Focus on Child Health Exam
The nurse is caring for a 3-year-old with leukemia. The child is not eating and is losing weight as a result of nausea and mucositis stemming from the chemotherapy. Which interventions are appropriate? Select all that apply.
Providing small, frequent high-protein foods Providing cool liquids and soft foods at room temperature Applying a solution of Benadryl (diphenhydramine) and Maalox as prescribed to the mouth Rationale: High-protein, high-calorie foods should be given to the child. Protein promotes tissue healing, and calories are needed for growth. Small, frequent meals are easier for a child to handle. Viscous lidocaine is not recommended for young children, because it may depress the gag reflex and increase the risk of aspiration. Local anesthetics without alcohol, such as a solution of diphenhydramine (Benadryl) and Maalox, may be recommended. Favorite foods should not be given to a child who is nauseated, because the child will associate these foods with being sick. Cool liquids are soothing and reduce the risk of burning fragile mucosa. Soft foods are gentler on inflamed mucosa.
A nurse is developing a plan of care for a child at risk for seizures. Which interventions should be carried out if a seizure occurs? Select all that apply.
Turning the child on her side Monitoring the child's movements Loosening the clothing around the child's neck Rationale: When a seizure begins, it is important to note the child's movements and keep track how long the seizure lasts. This information will help the health care provider treat the seizure. Positioning the child on the side will help prevent aspiration because saliva will drain from the child's mouth. Clothing around the child's neck is loosened to help maintain a patent airway. The nurse would not restrain the child's arms or legs, because this could cause injury. The nurse would not insert any object into the child's mouth. Forcing an object into the child's mouth may cause injury to the child's mouth, gums, or teeth.
A nurse is monitoring a school-age child who is being treated for dehydration. The nurse notes that the child's urine output has been 1 mL/kg/hr over the past 3 hours and that the specific gravity of the urine is 1.020. Which is the appropriate nursing action?
Document the findings Rationale: Urine output of less than 2 to 3 mL/kg/hr in infants and toddlers, 1 to 2 mL/kg/hr in preschoolers and young school-age children, and 0.5 to 1 mL/kg/hr in school-age children or adolescents indicates dehydration. A specific gravity of the urine above 1.020 may indicate dehydration. The nurse would document the findings, because they are normal.
A nurse is monitoring a child who sustained a head injury. Which assessment finding is an early sign of increased intracranial pressure (ICP)?
Change in behavior Rationale: A change in the child's normal behavior is an important early sign of increased ICP. The Cushing response — which consists of an increased systolic blood pressure with widening pulse pressure, bradycardia, and a change in respiratory rate and pattern, usually apparent just before or at the time of brainstem herniation —is a late sign of increased ICP.
A child has a plaster of Paris cast applied to his arm after fracturing the arm in a fall. The nurse should tell the mother which about the cast?
Takes 24 hours or more to dry Rationale: Plaster of Paris is a heavy material that molds easily to the extremity and is less expensive than synthetic cast materials. It takes 24 hours or longer to dry. Plaster of Paris is not water resistant; when wet, a cast made of plaster will begin to disintegrate.
The nurse is providing home care instructions to the parents of a child with immune thrombocytopenic purpura (ITP) whose platelet count is 195 × 103/μL (195 × 109/L). Which statements by the parents indicate that they understand the instructions? Select all that apply.
"We need to avoid giving him aspirin." "He should use an extra-soft toothbrush." "We need to watch for signs of bleeding." Rationale: Immune thrombocytopenic purpura is a hematologic disorder resulting in the reduction and destruction of platelets. A decreased platelet count places the child at risk for bleeding. The normal platelet count is 150-400 × 103/μL (150-400 × 109/L). If the platelet count falls below 20 × 103/μL (20 × 109/L)., high-risk activities such as contact sports, bicycle riding, roller skating, and diving are avoided. The child should also use an extra-soft toothbrush to prevent mucosal trauma. Parents are instructed to monitor the child for signs of bleeding. Medications that may affect platelet function, such as aspirin and nonsteroidal antiinflammatory drugs (NSAIDs, e.g., iboprophen are avoided. Acetaminophen is an acceptable alternative to aspirin and NSAIDs.
A nurse is caring for an infant with Hirschsprung's disease. Which manifestation of the disease should the nurse expect to note?
Foul-smelling, ribbon-like stools Rationale: The child with Hirschsprung's disease will have constipation that has been present since the neonatal period and the frequent passage of foul-smelling, ribbon-like or pellet stools. Non-bilious projectile vomiting is a manifestation of pyloric stenosis. Bloody, mucousy "currant jelly" stools and a sausage-shaped abdominal mass are manifestations of intussusception.
A child being seen in the clinic is found to have rubeola (measles), and the father asks the nurse how to care for the child. The nurse should provide which instruction to the father?
Keep the child in a room with dim lights Rationale: One nursing consideration in rubeola is eye care. The affected child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas. Children with viral infections are not to be given aspirin because of the risk of Reye syndrome. Warm baths and sunlight will aggravate itching. Additionally, the child needs rest.
A nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions?
Droplet Rationale: The child is also placed in a private room, with droplet-transmission precautions, for at least 24 hours after antibiotics are given. Enteric, contact, and neutropenic precautions are not implemented to prevent the spread of meningitis. Enteric precautions are instituted when the mode of transmission involves the gastrointestinal tract. Contact precautions are instituted when contact with infectious items or materials is likely. Neutropenic precautions are instituted when a child has a low neutrophil count.
The nurse assesses a child with suspected meningitis for the presence of the Kernig sign. Which finding is the Kernig sign?
Pain with extension of the leg and knee Rationale: The Kernig sign is pain that occurs with extension of the leg and knee. The Brudzinski sign is flexion of the hips and knees when the head is flexed. Both the Kernig and Brudzinski signs are noted in meningitis. Calf pain that occurs with dorsiflexion of the foot or when the calf muscle is squeezed against the tibia are not manifestations of meningitis.
A nurse reviews the prescriptions for a child with Kawasaki disease and notes that the health care provider has prescribed intravenous immune globulin (IVIG). The nurse should tell the child's mother that this medication has been prescribed for which purpose?
Prevent coronary artery damage Rationale: Therapeutic management of Kawasaki disease is directed at preventing or reducing the coronary artery damage that may occur. High-dose IVIG has been shown to reduce the prevalence of coronary artery abnormalities when given within 10 days of fever onset. IVIG is not specifically administered to reduce a fever or to alleviate pain. Kawasaki disease is not communicable
The nurse should contact the health care provider with concerns about a prescription for valproic acid for an adolescent who has a history of which disorder?
Hepatitis Rationale: Valproic acid, an anticonvulsant used to treat seizures, is principally used as an adjunct to other anticonvulsant agents. It is also used as prophylaxis against migraine headaches. Valproic acid is contraindicated in hepatic disease and used with caution in persons with a history of hepatic disease or bleeding abnormalities. It is not contraindicated in clients with diabetes mellitus.
A nurse, providing information to the mother of a child with irritable bowel syndrome should tell the mother what about the syndrome?
Treatment is aimed at relieving the symptoms Rationale: There is no definitive treatment for irritable bowel syndrome. Instead, treatment is aimed at relieving the symptoms. The primary nursing intervention is reassurance that irritable bowel syndrome is a self-limiting, intermittent problem. Unless lactose intolerance is suspected, a healthy, well-balanced, moderate-fiber diet should be followed. The child is encouraged to eat slowly. Surgery and creation of a permanent colostomy are not necessary
A nurse is caring for an infant with hypospadias. The nurse makes a priority of assessing which in the infant?
Urinary output Rationale: Hypospadias is a congenital anomaly in which the actual opening of the urethral meatus is below the normal placement on the glans of the penis. The nurse would make a priority of assessing urinary function in the infant. Blood pressure, level of consciousness, and gastrointestinal function are unrelated to this disorder.
The use of a Pavlik harness has been prescribed for an infant with developmental dysplasia of the hip, and the nurse provides instructions to the mother about the use of the harness. Which statement by the mother indicates the need for further instruction?
"The harness is placed against the skin to provide support." Rationale: When the infant is in a Pavlik harness, the skin under the harness must be protected. The parents are instructed to place a shirt and socks on the infant under the harness to reduce rubbing. The diaper should go on under the harness as well. The harness straps should be secure enough to keep the child's hips flexed but not tight. The harness should be worn 23 hours a day and should be removed only in accordance with the health care provider's recommendation. The infant's hips and buttocks should be carefully supported whenever the infant is out of the harness.
A child has been in the hospital for several days for treatment of severe vomiting related his HIV-positive status. Which assessment finding is the best indication that the child's condition is improving?
Weight increase of 1 lb (0.45 kg) over 3 days Rationale: Vomiting results in fluid volume deficit. The most accurate method of evaluating fluid volume increase (the desired outcome) is weight. A temperature decrease is not reflective of fluid volume increase. Increasing capillary refill time is indicative of a fluid volume decrease, not an increase. The absence of mouth ulcers would allow the child to drink without pain but does not reflect a fluid volume increase.
A nurse is providing information to the parents of a child with suspected Hirschsprung's disease. The nurse informs the parents that diagnosis is definitively confirmed by the findings of which?
Rectal biopsy Rationale: The definitive diagnosis of Hirschsprung's disease is made by means of rectal biopsy. During biopsy, a small core or punch sample that contains all layers of the bowel mucosa is removed. Absence of ganglionic cells in the sample confirms the diagnosis of Hirschsprung's disease. Blood tests are not used to diagnose the disease. A barium enema and a rectal examination will detect significant characteristics of the disease but will not confirm the diagnosis.
Which medication is essential for the nurse to have available before administering an allergy injection to a child?
Epinephrine Rationale: Emergency epinephrine should be available, when allergy injections are being administered, to treat a hypersensitivity reaction if one occurs. Immune globulin is an immune serum used to provide passive immunity or prevent acute infection in immunocompromised clients. Ibuprofen is a nonsteroidal antiinflammatory drug, and acetaminophen is an analgesic; neither is an appropriate treatment for a hypersensitivity reaction.
The mother of a child admitted to the hospital with Kawasaki disease asks the nurse about the disease. The nurse responds that it is characterized by which?
It is a disease that affects the smooth muscle cells of the vascular walls Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is an acute febrile exanthematous illness of children with a generalized vasculitis of unknown origin. A generalized immune response affects the smooth muscle cells of the vascular walls. It is not a communicable disease and is not caused by exposure to an individual with rheumatic fever. Kawasaki disease is diagnosed most often in late winter and early spring. It is not associated with swimming.
Which laboratory result would the nurse expect to see in a child admitted to the hospital with acute glomerulonephritis?
2+ protein in the urine Rationale: History, presenting symptoms, and laboratory results can establish the diagnosis of acute poststreptococcal glomerulonephritis. Urinalysis reveals macroscopic or microscopic hematuria with red cast cells, which indicate glomerular injury. Proteinuria is also present. Blood chemistry values are usually within the normal ranges. If renal insufficiency is severe, however, the blood urea nitrogen and creatinine levels are increased. The complete blood count usually demonstrates normal a WBC count and mild anemia. The lower hemoglobin and hematocrit values reflect the dilutional effect of extra fluid in the blood, a result of decreased glomerular filtration. Electrolyte disturbances such as a high serum potassium level and low serum bicarbonate level may result from inadequate glomerular filtration. All laboratory values identified in the options are normal, with the exception of the urinary protein level.
A nurse provides instructions on the administration of oral iron to the mother of a child with iron-deficiency anemia. The nurse determines that the mother understands the instructions if the mother states that she will administer the iron with which item?
Orange juice Rationale: Oral iron is administered with a vitamin C-rich food to aid its absorption. Milk, cereal, and formula are avoided with the administration of iron because these foods may impede absorption.
A nurse provides home care instructions to the mother of an infant with gastroesophageal reflux disease (GERD). Which statement by the mother indicates a need for further instruction?
"I shouldn't give the baby a pacifier." Rationale: Small, frequent feedings of a predigested formula will reduce the amount of formula in the stomach, ease distension, and minimize reflux. These smaller, more frequent feedings with frequent burping are often tried as the first line of treatment. Thickened feedings tend to decrease the chances of reflux, vomiting, and aspiration. Placing the affected infant in a 30-degree head-elevated prone or right-side-lying position helps prevent reflux. The use of a pacifier allows the infant to practice swallowing. Pacifier use also decreases the incidence of crying and reflux episodes and may increase clearance of reflux stomach contents.
A nurse is caring for a child scheduled for a tonsillectomy. To reduce the risk of aspiration during surgery the nurse should assess the child for which?
Loose teeth Rationale: In the preoperative period, the child is checked for loose teeth to reduce the risk of aspiration during surgery. Throat redness and exudate in the tonsillar area are signs of active infection. Other signs of active infection include fever and an increased white blood cell count.
A nurse provides instructions to the mother of a child with cystic fibrosis (CF) on the correct procedure for administering pancrelipase. The nurse tells the child's mother that the medication may be administered with which item?
Applesauce Rationale: Pancrelipase is a pancreatic enzyme preparation used to reduce fat in the stool and to aid the digestion of protein, carbohydrates, and fat. Because these enzymes may be inactivated by heat, the preparation should not be administered with hot foods.
What instruction should the nurse provide to a parent regarding the prevention of urinary tract infection in his child?
Avoid giving the child bubble baths Rationale: Bubble baths should be avoided because they may irritate the urinary tract and lead to urinary tract infections. Tight clothing or diapers are avoided, and cotton underwear, rather than a synthetic fabric, should be used to prevent irritation that could lead to infection. The child should be encouraged to avoid holding urine and to urinate at least four times per day, emptying the bladder completely.
The nurse is assigned a child who has been admitted to the hospital with suspected cystic fibrosis (CF). Which tests does the nurse anticipate will be prescribed to diagnosis CF? Select all that apply.
Chest x-ray Sweat chloride assay Rationale: The diagnosis of CF is established with the use of several tests findings: a quantitative sweat chloride test result of more than 60 mEq/L (60 mmol/L),, a chest x-ray showing patchy atelectasis, and a stool analysis revealing fat. The barium swallow is used to diagnosis gastrointestional disorders such as pyloric stenosis but not CF. Intestinal biopsy is not used to diagnose CF. Stool examination for ova and parasites is used to diagnose parasitic infestation; CF is not caused by a parasite.
A nurse is providing home care instructions to the mother of a child with juvenile idiopathic arthritis. Which action should the nurse tell the parents to take during a painful exacerbation?
Encouraging the child to perform simple isometric exercises Rationale: During an exacerbation of the disease, the child's natural reaction is to rest the painful joint, but such inactivity could lead to muscle wasting and flexion deformity. Therefore it is important for the child to perform simple isometric exercises. These exercises are appropriate during exacerbations of the disease because they do not involve joint movement. Exercises that involve joint movement are avoided during an exacerbation of the disease.
A nurse reviews the health care provider's prescriptions for the care of a child who has just undergone tonsillectomy. Which prescription should the nurse question?
Suction every 2 hours. Rationale: After tonsillectomy, suction equipment should be available for emergency use. The child is not suctioned unless there is an airway obstruction, because suctioning may disrupt the surgical site, leading to bleeding. The child is positioned on the side to facilitate drainage of secretions. Clear, cool liquids are offered once the child is awake. An ice collar can alleviate discomfort.
A nurse is monitoring a 3-year-old with diarrhea for signs of dehydration. The child now weighs 42 lb (19 kg), a decrease from his weight of 44 lb (20 kg) 24 hours ago. In addition to dry mucous membranes and lack of tears, what assessment finding would the nurse find?
Bilateral 1+ pedal pulses Rationale: The minimum urine output for a child is 1 mL/kg/hour. The child weighs 42 lb, or 19 kg, so 80 mL in the last 4 hours is within the minimum range. A child with dehydration will have a rapid, weak, thready pulse. Blood pressure may be decreased in moderate and severe dehydration, but it is a late sign of hypovolemia. A child with dehydration will exhibit 1+ pedal pulses: difficult to palpate, weak, and thready.
A nurse is monitoring a child for complications after spinal fusion for scoliosis. The nurse suspects the presence of superior mesenteric artery syndrome if the child exhibits which?
Vomits and exhibits abdominal distension Rationale: One complication of the surgical treatment of scoliosis is superior mesenteric artery syndrome, the result of mechanical changes in the position of the client's abdominal contents caused by lengthening of the body. It results in a syndrome of emesis and abdominal distention. Therefore postoperative vomiting warrants attention. Lethargy and headache with fever are not symptoms of superior mesenteric artery syndrome. The nurse would need more information about the client's pain to determine whether it is the result of superior mesenteric artery syndrome. Additionally, pain is expected in the postoperative period.
An HIV-positive woman delivers an infant. The pediatrician prescribes testing for the newborn, and the nurse prepares for which action?
Ask the laboratory to perform virologic testing Rationale: Traditional HIV antibody measurement by ELISA or Western-blot assay is not accurate in infants younger than 18 months because of the persistence of maternal antibodies. Because of the potential for maternal contamination during delivery, umbilical cord blood should not be used for testing. HIV-exposed infants should undergo virologic testing within 48 hours of birth and follow-up testing, depending on the initial results.
The mother of a child who underwent myringotomy with the insertion of tympanostomy tubes 1 day ago calls the surgeon's office and reports to the nurse that the child has a small amount of reddish drainage coming from the ears. The nurse should provide which information to the mother?
Continue to monitor the drainage, because this is a normal finding Rationale: After myringotomy with insertion of tympanostomy tubes, the child is monitored for ear drainage. A small amount of reddish drainage is normal for the first few days after surgery, but the mother should report any heavier bleeding or bleeding that occurs after 3 days. Having the surgeoncheck the child is unnecessary. Irrigating the ears with warm water and pushing the tubes further into the ear canal are inappropriate and could cause harm to the child.
Which pediatric client is at least risk for otitis media?
A breastfed infant Rationale: Breastfeeding offers some protection against ear infection by providing maternal antibodies and by decreasing the incidence of allergy. Also, the more upright the position of the infant during nursing, the greater the protection against ear infection. Bottle feeding contributes to ear infection because of the position of the infant during feeding. Also, reflux of formula into the eustachian tube from the nasopharynx may occur when the infant swallows while in a supine position. Attendance at a daycare center predisposes a child to otitis media. Exposure to environmental smoke is a risk factor.
A child with severe respiratory distress is seen in the emergency department and treated for an acute asthmatic episode. Which assessment finding indicates that the child's condition is improving?
Increased wheezing Rationale: A child in severe respiratory distress may not demonstrate wheezing during an acute asthma attack because of decreased air movement. Decreased wheezing in a child who is not improving clinically may signal an inability to move air. This is referred to as a "silent chest" and is an ominous sign during an asthma episode. With treatment, increased wheezing may actually signal that the child's condition is improving. Shortness of breath, dyspnea on exertion, and stridor are manifestations of an asthmatic episode that indicate airway obstruction.
A newborn is found to have esophageal atresia (EA) with tracheoesophageal fistula (TEF). In which position does the nurse immediately place the infant?
Supine, with the head of the bed elevated Rationale: EA and TEF are congenital malformations in which the esophagus terminates before it reaches the stomach, a fistula forms an unnatural connection with the trachea, or both. Keeping the infant supine, with the head of the bed elevated, decreases the likelihood that gastric secretions will enter the lungs. Placing the child in the Trendelenburg position, flat and side-lying, or prone with the head of the bed flat is incorrect; any of these positions could result in the aspiration of gastric secretions.
A nurse reviews a child's record and notes documentation that the child is obtunded. On the basis of this documentation, which finding would the nurse expect to note while conducting a neurological assessment?
The child sleeps unless aroused and, once aroused, has limited interaction with the environment. Rationale: A child is considered obtunded when he or she sleeps unless aroused and, once aroused, has limited interaction with the environment. A lethargic child awakens easily but demonstrates limited responsiveness. A child in a stupor requires considerable stimulation to be aroused. A child who is awake, alert, oriented and interacts with the environment is fully conscious.
A child is admitted to the hospital with suspected infective endocarditis. Place in order of priority how the nurse will carry out the health care provider's prescriptions for the child, with 1 being the first prescription to be carried out and 4 the last.
The correct order is: Obtaining blood for cultures Starting an IV line Administering intravenous (IV) antibiotics Scheduling an echocardiogram Rationale: The diagnosis of infective endocarditis is established primarily on the basis of blood cultures that yield the causative organism. The nurse would prepare to obtain blood cultures first so that the diagnosis could be confirmed. An IV line would then be initiated and the antibiotics started. The echocardiogram should be scheduled once the antibiotics have been started. The visualization of a vegetation (an abnormal growth of infected tissue) on echocardiographic studies helps establish the diagnosis.
A nurse is conducting an assessment on a child admitted with suspected von Willebrand's disease (VWD). Which question does the nurse ask to elicit information specific to the manifestations associated with this disease?
"How many times have you had a nosebleed?" Rationale: VWD is an inherited bleeding disorder. In the child with VWD, von Willebrand protein is either underproduced or dysfunctional. The von Willebrand protein is the carrier protein for coagulation factor VIII, and it is also a cofactor for the binding of platelets to damaged endothelial cells. The clinical manifestations of VWD include a history of epistaxis, bleeding from the gums, prolonged bleeding from cuts, excessive bleeding after surgery or trauma, and menorrhagia (excessive menstrual bleeding) in females. Urinary problems, thirst, and headaches are not clinical manifestations of VWD.
A nurse is providing instructions on the use of a metered-dose inhaler (MDI) to an adolescent with asthma. Which statements by the adolescent indicates an understanding of the instructions? Select all that apply.
"I need to shake the inhaler well before I use it." "I really need to use the spacer when I inhale the corticosteroid." "I have to put my lips tightly around the mouthpiece, press down on the inhaler, and breathe in slowly." Rationale: If the health care provider has prescribed two inhalations, the nurse teaches the adolescent to wait at least 2 minutes after the first inhalation before taking the second. The adolescent is also taught to shake the inhaler before repeating the dose. The client should hold his or her breath for as long as possible, at least 5 to10 seconds, to allow the medicine to penetrate deep into the lungs. A spacer must be utilized with the MDI when corticosteroids are being inhaled to prevent yeast infection of the mouth
Which test result specifically indicates that a child with an immunosuppressive condition has been exposed to tuberculosis?
A 7-mm area of induration after administration of a tuberculin skin test Rationale: The tuberculin skin test is administered as a screen for tuberculosis. Purified protein derivative (PPD) is administered by way of intradermal injection and the skin reaction is read by a professional 48 to 72 hours after administration. An induration measuring 5 mm or larger is considered a positive finding in the highest-risk groups, such as children with immunosuppressive conditions or HIV infection. The ELISA and Western blot are used to diagnose HIV. An increased WBC count occurs with infections in general but is not specific to tuberculosis.
A nurse is reviewing the results of an infant's serum digoxin test. The digoxin level is 0.6 ng/mL (0.77 nmol/L). In light of this finding, which action should the nurse take?
Administering the prescribed dose because the level is within the therapeutic range Rationale: Digoxin is a cardiac glycoside that increases cardiac output and improves cardiac contractility. The effectiveness of digoxin depends on achieving and maintaining a therapeutic serum drug level. The difference between a therapeutic and a toxic level is narrow, the optimal therapeutic range as 0.5 to 0.8 ng/mL. (0.64 to 1.02 nmol/L). A digoxin level of 0.6 ng/dL (0.77 nmol/L) is therapeutic. A level greater than 0.8 ng/mL (1.02 nmol/L) exceeds the therapeutic range. Therefore the nurse should administer the prescribed dose. The remaining options are incorrect actions.
A nurse is assigned to care for an infant with congenital diaphragmatic hernia (CDH). Which clinical finding supports this diagnosis?
Auscultation of cardiac sounds on the right side of the chest Rationale: CDH is an opening in the diaphragm through which abdominal contents herniate into the thoracic cavity during prenatal development. Clinical findings depend on the severity of the defect but may include the presence of abdominal organs in the chest (revealed by fetal ultrasonography), diminished breath sounds or an absence of such sounds on the affected side, auscultation of bowel sounds over the chest, auscultation of cardiac sounds on the right side of the chest, respiratory distress, and a scaphoid abdomen. The presence of an anal membrane and failure to pass meconium stool are findings noted in imperforate anus. The presence of viscera outside the abdominal cavity is noted in gastroschisis.
A nurse is caring for several children who have been fitted with a variety of traction devices. Which child should be monitored most closely for signs and symptoms of osteomyelitis?
B Rationale: The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used for traction. Osteomyelitis may occur with any open fracture. Clinical manifestations include localized pain, swelling, warmth, tenderness, and unusual odor. An increased temperature may accompany the symptoms. Balanced suspension traction may be used with or without skin and skeletal traction. When it is used with skeletal traction, however, the client is at risk for osteomyelitis. Buck's extension and Russell traction are types of skin traction. Crutchfield tongs are inserted in the skull and as a result are less likely to give rise to osteomyelitis.
A nurse is reviewing the chart of a child with a brain tumor. Which symptom(s) would the nurse expect to note in the history and physical?
Headache and morning vomiting related to the child's getting out of bed Rationale: Manifestations of brain tumors vary with tumor location and the age and development of the child, but the hallmark symptoms of a brain tumor in a child are headache and morning vomiting related to the child's getting out of bed. The sudden increase in intracranial pressure that occurs with the change of position causes the vomiting. Nausea at bedtime, dizziness that occurs late in the day, and fatigue after activity are not symptoms specifically associated with brain tumors.
The mother of a child with hemophilia calls the clinic nurse and reports that her child has hit his knee on the corner of a coffee table and that the joint appears swollen. The nurse should tell the mother immediately to take which action?
Immobilize the affected joint Rationale: If a muscle or joint injury occurs in the child with hemophilia, the affected part is immobilized, elevated, and treated with ice and compression. Initial immobilization will help prevent further injury until the bleeding resolves. There is no information in the question indicating that bringing the child to the emergency department is necessary. Heat will increase circulation to the site and increase bleeding. The physician should be notified if a blunt injury, especially that involving a joint, occurs, but it is not necessary to immediately bring the child to the primary healthcare provider.
A nurse is providing information to parents about the transmission of hepatitis. The nurse should tell the parents that hepatitis A virus (HAV) is primarily transmitted in which way?
In contaminated food or water Rationale: HAV is transmitted by way of the fecal-oral route and in food or water contaminated with HAV. Hepatitis B virus is transmitted by way of blood, blood products, and secretions; prenatally or perinatally; during sexual contact; and in breast milk. Hepatitis C virus is transmitted perinatally or through blood and blood products.
A pediatric community health nurse is conducting a screening program to identify children at risk for a hematologic disorder. The nurse determines that the child at most risk for beta-thalassemia is which child?
Of Mediterranean descent Rationale: The thalassemias are a group of inherited disorders characterized by an abnormality in hemoglobin synthesis that results from a reduction in or absence of one of the chains found in normal hemoglobin. They are primarily found among people of Mediterranean descent. Beta-thalassemia, also known as thalassemia major or Cooley's anemia, is the most common and severe form of thalassemia. Poor dietary intake of iron is associated with iron-deficiency anemia. Factor VIII deficiency is associated with hemophilia. An abnormal HbS trait is associated with sickle cell disease.
In which position should the nurse place the child who has just undergone tonsillectomy to facilitate drainage?
Prone Rationale: After tonsillectomy, the child should be placed in a prone or side-lying position to facilitate drainage. The supine, high Fowler and semi-Fowler positions will not facilitate drainage and may, in fact, increase the risk for aspiration.
Oral nystatin suspension is prescribed for an infant with thrush (oral candidiasis). Which instruction should the nurse provide to the motherZ?
Rub the suspension onto the mucous membranes with a gloved finger Rationale: Thrush is a superficial fungal infection of the oral mucous membranes. It occurs as a result of overgrowth of Candida albicans. Cotton-tipped applicators tend to absorb the medication; a more effective method of administration is to rub the suspension onto the mucous membranes, using a gloved finger. To increase the amount of time the medication is in contact with the mucous membranes, nystatin should be applied after feedings. Breastfeeding does not need to be avoided. If the infant is breastfed, the mother's breasts should also be treated with nystatin.
A nurse is providing home care instructions to the parents of a child with bacterial conjunctivitis. The nurse should provide which information to the parents?
That the child's towels and washcloths should not be used by other members of the household Rationale: Bacterial conjunctivitis is highly contagious, and infection control measures should be taught. These include practicing good handwashing and not sharing towels and washcloths with others. The child should be kept home from school until 24 hours after antibiotics have been started. Bottles of eye medication should never be shared with others. Crusted material may be wiped from the eye with a cotton ball soaked in warm water, starting at the inner aspect of the eye and moving toward the outer aspect.
A nurse provides home care instructions to the mother of a child who has undergone myringotomy with the insertion of tympanostomy tubes. Which statement by the mother indicates a need for further instruction?
"A fever is normal after this procedure." Rationale: The mother should be instructed to report any fever or increased pain, which could indicate a postoperative infection. It is not an emergency if the tubes fall out, but the surgeon should be notified. Nose-blowing should be avoided for 7 to 10 days after the procedure. The child's ears need to be kept dry during baths and showers. The usual recommendation is to place ear plugs or cotton balls covered with petroleum jelly in the ears during baths and showers.
A nurse is providing home care instructions to the mother of a child with sinusitis. Which statement by the mother indicates a need for further instruction?
"Breathing cool, moist air will help drain his sinuses." Rationale: Breathing warm (not cool) mist in a shower can help liquefy and mobilize nasal mucus. Acetaminophen (Tylenol) is given to reduce fever and alleviate discomfort. Sinus drainage is facilitated by increasing the child's intake of clear fluids. Warm, moist compresses applied two or three times a day help ease swelling and pain.
What discharge instructions are important to provide the parents after their child undergoes cardiac catheterization? Select all that apply.
Contact sports should be avoided for 1 week after the procedure. Acetaminophen or ibuprofen may be given to ease pain or discomfort Rationale: The parents are instructed that the health care provider must be notified if a fever higher than 38° C (101° F) develops, if bleeding or drainage (pus) from the catheter insertion site is noted, or if the child exhibits pallor, coolness, or numbness of the affected extremity. Acetaminophen or ibuprofen is recommended for mild pain as needed. Bathing should be limited to a shower, sponge bath, or brief tub bath (no soaking) for the first 1 to 3 days. The parents are also instructed to keep the child from engaging in strenuous exercise (e.g., climbing trees, swimming, contact sports) for 1 week after the procedure.
A nurse is caring for an infant scheduled for a pyloromyotomy. In which position should the nurse place the infant for the preoperative period?
Head elevated Rationale: In the preoperative period, the infant's head of the bed is elevated to reduce the risk of aspiration. The nurse would use blankets or towel rolls to maintain this position. Prone, supine, and Trendelenburg are incorrect positions because they increase the risk of aspiration.
A pancreatic enzyme preparation is prescribed for a child with cystic fibrosis (CF). The nurse instructs the child's mother to administer the pancreatic enzyme in what way?
With meals and snacks Rationale: Pancreatic enzyme preparations are administered to ease the steatorrhea that occurs in CF as a result of digestive system involvement. These preparations are administered with every meal and snack to supplement and replace pancreatic enzymes and aid digestion
A nurse is preparing to administer digoxin (Lanoxin) to an infant. The nurse notes that the infant's heart rate is 110 beats/min. The appropriate response on the part of the nurse is to take which action?
Administer the prescribed dose Rationale: Before administering digoxin, the nurse counts the infant's heart rate for 1 full minute. The nurse would withhold the dose and contact the health care provider if the heart rate were slower than 100 beats/min in an infant. Therefore the appropriate action on the part of the nurse would be to administer the prescribed dose. Contacting the health care provider , obtaining a blood sample to check the digoxin level, and withholding the dose and reassessing the heart rate in 1 hour are incorrect on the basis of the information in the question.
A nurse is providing information to the mother of a child with newly diagnosed celiac disease. What piece of information should the nurse include?
An infection can precipitate a celiac crisis. Rationale: Celiac disease is the result of an inability to digest fully the gliadin, or protein, part of wheat, barley, rye, and oats. This lifelong deficiency requires dietary modifications to prevent chronic maldigestion and malabsorption; dietary management is the mainstay of treatment. All wheat, barley, rye, and oats (i.e., pasta, baked products, and many breakfast cereals) should be eliminated from the diet and replaced with corn and rice. Celiac crisis is marked by profuse, watery diarrhea and vomiting and can quickly lead to severe dehydration and metabolic acidosis.
The nurse is discharging a child with primarynocturnal enuresis. Which statements by the parents indicate that they understand the techniques used to manage this disorder? Select all that apply.
"An alarm system might help prevent the bedwetting." "We need to be sure that he urinates just before bedtime." "We've already developed a reward system for when he stays dry for a certain number of consecutive nights." Rationale: Treatment of primary nocturnal enuresis includes limiting fluids after supper (not throughout the day) and encouraging the child to urinate before bedtime. A reward system of some type may be helpful, and the child and parents can decide on a special reward when the child has achieved a certain number of consecutive dry nights. Behavioral conditioning with the use of alarms may be helpful. One such alarm system includes a device worn on the child's pajamas that contains a moisture-sensitive alarm. As the child starts to void, the alarm goes off, awakening the child. Kegel or pelvic muscle exercises may be helpful for daytime enuresis but are not useful in preventing nocturnal enuresis.
A nurse is performing an assessment of a school-age child admitted with acute poststreptococcal glomerulonephritis. Which question would help determine the cause of this acute condition?
"Did you have a sore throat a few weeks ago?" Rationale: Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Acute poststreptococcal glomerulonephritis, the most common type, is characterized by hematuria, proteinuria, edema, and renal insufficiency. It occurs as an immune reaction to a group A beta-hemolytic streptococcal infection of the throat or skin. Falling off a bicycle, contracting chickenpox, and eating shellfish are not causes of acute glomerulonephritis.
A nurse provides information to new parents about measures to reduce the risk of sudden infant death syndrome (SIDS). The nurse should tell the parents to implement which measure?
Place the infant in a supine position for sleep Rationale: As a means of reducing the risk of SIDS, the infant should be positioned on his or her back rather than in the prone (face-down) position to sleep. The use of soft bedding is also a risk factor. Infants may suffocate by rebreathing carbon dioxide-laden expired air when sleeping face down on soft bedding. SIDS occurs most frequently between the second and fourth months of life, with most of cases occurring before the age of 2 to 3 months.
A nurse provides home care instructions to the mother of a child with pediculosis capitis (head lice). Which statement by the mother indicates a need for further instruction?
"I need to use an antilice spray on her and on anything that she's been in contact with." Rationale: Antilice sprays should be used on furniture and other environmental objects but are never used on a child. Also, floors, play areas, and furniture should be vacuumed to remove any hairs carrying live nits. The child's clothing and bedding should be washed in hot water and dried on a hot setting. Items that cannot be washed should be dry cleaned or sealed in plastic bags and kept in a warm place for 2 to 3 weeks. Combs and brushes must be boiled or soaked in antilice shampoo or hot water for at least 10 minutes. Lice and nits may be removed from the child's eyelashes with the application of petrolatum to the eyelashes twice a day for 8 days.
A nurse provides home care instructions to the mother of a child with impetigo. Which statement by the mother indicates the need for further instruction?
"It's OK for him to go to school tomorrow." Rationale: Impetigo is an extremely contagious bacterial skin infection, and close contact contributes to its spread. The child should not attend school or daycare for 24 hours after treatment with antibiotics is started. Gloves should be worn by anyone caring for the child. Towels or eating utensils used by the child should not be shared with anyone else. The crusts should be soaked and then washed off with a warm, soapy washcloth three times a day. Additionally, the child should be bathed daily with an antibacterial soap. The child's fingernails should be kept short, and the hands should be washed frequently with an antibacterial soap to help prevent cross-contamination
The health care provider prescribes the following interventions for a child with suspected meningitis. Prioritize these interventions by numbering them in the order in which they should be performed, with 1 as the first prescription to be carried out and 4 as the last.
1. Respiratory isolation 2. Lumbar puncture 3. Administer antibiotics 4. Continued neurologic assessments every 2 hours Rationale: It is important that nurses protect themselves and others from possible infection, so the child should immediately be placed in isolation if meningitis is suspected. The next priority is setting up for the lumbar puncture so that specimens for culture may be obtained. Once this is done, antibiotics are administered. Antibiotics given before lumbar puncture has been performed and cultures have been obtained could kill the causative bacteria and lead to a misdiagnosis. A neurological assessment is conducted every 2 hours and should have been part of the admission criteria. It is the lowest priority of the four options based on the timeframe identified in the question.
A nurse has provided dietary instructions to the mother of a child with Crohn's disease. Which statements by the mother indicate an understanding of the instructions? Select all that apply.
"I won't give him high-fiber vegetables like corn." "Snacks such as nuts will help provide the extra protein he needs." "I'll make sure that he takes a multivitamin and iron supplement every day." Rationale: A well-balanced, high-protein, high-calorie diet is recommended in Crohn's disease; a multivitamin and iron supplement should also be taken. Meat is high in protein and necessary for optimal growth and development. High-fiber foods such as corn, nuts, and seeds can produce obstructions in children with intestinal strictures and should be avoided. Ice cream is a milk product and should be avoided. Test-Taking Strategy: Focus on the subject, a child with Crohn's disease. Recalling that Crohn's disease is an inflammatory bowel disease will direct you to the correct options. Review the dietary measures for Crohn's disease.
A nurse provides instructions to the parents of an infant with bronchopulmonary dysplasia about the safe use of oxygen at home. Which statement by a parent indicates a need for further instruction?
"We can put petroleum jelly on her lips to relieve the dryness." Rationale: If oxygen is being used at home, the parents are instructed to avoid using alcohol-based substances or oil, which are flammable and increase the risk for fire, around the infant's mouth. Products that should be avoided include petroleum jelly, vitamin A and D ointment, and baby oil. The remaining statements reflect correct use of oxygen at home.
A nurse is assigned to care for a child with a severe burn injury. The nurse plans care, remembering which about a child?
A child has a larger body surface area than an adult and is therefore at increased risk for fluid and heat loss Rationale: A child has a larger body surface area than an adult and is therefore at increased risk for fluid and heat loss. Children are also at increased risk for dehydration and metabolic acidosis stemming from diarrhea, evaporative water loss, and increased fluid requirements. A child's skin is thinner than an adult's; therefore lower burn temperatures and shorter exposure to heat or chemicals can result in a more severe burn. The higher proportion of body fluid to mass in children increases the risk of cardiovascular problems because of the less effective cardiovascular response to changing intravascular volume. Children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and lower body fat than do adults.
Which high-calcium food does the nurse direct the parents of a child with lactose intolerance to include in the child's diet?
Broccoli Rationale: Yogurt, ice cream, and broccoli are high in calcium, but the child with lactose intolerance should avoid all high-lactose foods, such as milk, yogurt, and ice cream. Foods that are high in calcium and will be tolerated by a child with lactose intolerance include egg yolk, dried beans, cauliflower, and molasses. Raisins are high in magnesium and phosphorus.
A nurse is preparing a child admitted from the emergency department with a diagnosis of acute appendicitis for an appendectomy, to be performed in an hour. The child tells the nurse that the acute abdominal pain has suddenly subsided. The priority nursing intervention is which?
Contact the surgeon Rationale: In appendicitis, sudden relief of pain may indicate that the appendix has ruptured. The temporary relief from pain is followed by an increase in pain, a rigid abdomen, and early shock symptoms. If a ruptured appendix is suspected, the nurse must immediately contact the surgeon. The nurse would document the findings but would contact the surgeon first, because a ruptured appendix is an emergency. The surgery will not be canceled. This manifestation is not a result of gastroenteritis.
A nurse is conducting a neurovascular assessment of a child who has just had a cast applied to her leg. The nurse notes that the capillary refill time distal to the cast is 4 seconds. In light of this finding, which action by the nurse is appropriate?
Contacting the health care provider Rationale: To assess capillary refill time, the nurse would apply pressure to the child's nail bed and count how long it takes for the color to return (should be no longer than 2 seconds). A sluggish capillary refill time indicates neurovascular impairment; if such impairment is suspected, the health care provider is notified. Although the nurse would document the findings and continue the assessments, it would be most important to contact the health care provider . Elevation of the extremity on pillows helps prevent edema at the fracture site and subsequent neurovascular impairment.
What manifestation of hypertrophic pyloric stenosis should the nurse reviewing the record of an infant with this disorder expect to see documented?
Olive-shaped mass palpated in the right upper abdominal quadrant Rationale: Progressive non-bilious projectile vomiting in a previously healthy infant is the major manifestation of pyloric stenosis. The vomitus may become blood-tinged if esophageal irritation occurs. A movable, palpable, firm, olive-shaped mass is felt in the right upper quadrant. This mass is most easily palpated when the stomach is empty and the infant is relaxed. Deep gastric peristaltic waves from the left upper quadrant to the right upper quadrant may be visible immediately before vomiting commences. If the condition progresses, the infant may become dehydrated and experience metabolic alkalosis. Fever, profuse diarrhea, and alternating constipation and diarrhea and fecal impaction are not manifestations of this disorder.
A nurse is conducting an assessment of a 12-year-old with Osgood-Schlatter disease. Which question does the nurse ask the child to elicit data regarding the cause of the disease?
"Do you participate in sports?" Rationale: Osgood-Schlatter disease is believed to result from repetitive stress in sports, combined with overuse of immature muscles and tendons over an extended period, and an imbalance in the strength of the quadriceps muscle during adolescent growth. The classic picture is bilateral knee pain that is exacerbated by running, jumping, or climbing stairs in a very active boy or girl who is involved in sports. The child will point to the tibial tubercle as the site of pain. The disease occurs in boys and girls between the ages of 8 and 16 years, although it is more common in boys. Usually both knees are involved. The assessment questions noted in the remaining options are unrelated to the cause of this disease.
A 9-year-old is found to have type 1 diabetes mellitus. The nurse discusses with the child's parents the self-care tasks that may be delegated to the child. In light of the developmental characteristics of the school-age child, which task does the nurse tell the mother may be delegated to the child as long as the child is supervised?
Choosing the injection site in accordance with the rotation schedule Rationale: The school-age child is beginning to develop a self-concept. Appropriate self-care tasks include choosing the injection site in accordance with a rotation schedule, performing fingersticks and blood glucose testing, pushing the plunger on the insulin syringe after the needle has been inserted by a parent or administering one's own injection, and performing ketone testing. Drawing up insulin is a task appropriate for a client in early adolescence. Recognizing when to test for ketones and looking for patterns in the blood glucose level are also tasks for the adolescent.
A lumbar puncture is performed on a child with suspected bacterial meningitis, and the cerebrospinal fluid (CSF) obtained for analysis. The nurse determines that the diagnosis is confirmed if which findings are noted?
Cloudy CSF Rationale: The diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. Findings usually include cloudy CSF (in the case of bacterial meningitis), a low glucose level, increased CSF pressure, and a high protein concentration.
A nurse is assessing a child after tonsillectomy. Which finding is indicative of postoperative bleeding?
Frequent swallowing Rationale: Monitoring the child for postoperative bleeding is most important. Because the operative site in this procedure is not as readily visible as other surgical sites, the nurse must be alert to excessive or frequent swallowing, an increased pulse and decreasing blood pressure, signs of fresh bleeding in the back of the throat, vomiting of bright-red blood, and restlessness that does not seem to be associated with pain. Pain is not an indication of postoperative bleeding.
A nurse is providing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse should tell the mother to take which action?
Pad crib rails and table corners Rationale: Establishment of an age-appropriate safe environment is of paramount importance for the hemophiliac client. Providing a safe environment for an infant includes padding table corners and crib rails, providing extra joint padding in clothes, and keeping items that could be pulled down onto the infant out of reach. The use of a soft toothbrush is an appropriate measure for a child with hemophilia but is not typically necessary for an infant. Rectal temperature measurements and the use of aspirin are contraindicated in hemophilia because of the risk of bleeding.
A nurse is performing an assessment of a child with nephrotic syndrome. Which manifestation would the nurse most likely note?
Periorbital edema Rationale: Nephrotic syndrome is a kidney disorder characterized by proteinuria, hypoalbuminemia, and edema. Manifestations include edema (first noted in the periorbital spaces and dependent areas of the body), anorexia, fatigue, abdominal pain, respiratory infection, and increased weight. The child with nephrotic syndrome usually has a normal blood pressure. Fever may occur if an infection is present.
A nurse provides home care instructions to the parents of a child with acute spasmodic croup. The nurse should tell the parents that if stridor at rest occurs, they should take which action?
Take the child to the emergency department Rationale: Children who experience stridor at rest, cyanosis, severe agitation or fatigue, or moderate to severe retractions and children who are unable to take oral fluids should be seen in the emergency department, because these manifestations may indicate airway obstruction. An analgesic will not alleviate the stridor. Although a cool-mist humidifier and steam produced by hot running water are measures used to treat acute spasmodic croup, they are not useful in this situation, which involves stridor, indicating airway obstruction and representing a medical emergency.
The mother of a child with iron-deficiency anemia who is receiving an oral iron supplement calls the nurse and reports that the child is having black stools. Which response by the nurse is appropriate?
"Black, tarry stools are a normal finding when oral iron supplements are being administered." Rationale: Black, tarry stools are a harmless side effect of the administration of iron supplements. The child does not need to be brought to the emergency department, and it is not necessary to obtain a stool specimen to check for blood. It is inappropriate to tell the mother not to worry. It is appropriate to provide an accurate explanation for the mother's concern.
A nurse provides instruction to an adolescent client with exercise-induced asthma. Which statement by the adolescent indicates a need for further instruction?
"I should use the bronchodilator after I finish working out." Rationale: Exercise-induced asthma may be triggered by the rapid breathing of large volumes of cool, dry air, such as that taken in with mouth breathing during exercise. The symptoms of exercise-induced asthma usually begin after 5 to 10 minutes of exercise and often last 30 to 60 minutes. Measures to prevent exercise-induced asthma include warming the air by breathing through the nose or covering the mouth and nose with a scarf when exercising in cold weather, using an inhaled bronchodilator before exercise, and practicing techniques to decrease hyperventilation, such as progressive muscle relaxation and diaphragmatic breathing.
A nurse is providing home care instructions to the mother of a child who has undergone cleft lip repair. Which statements by the mother indicate an understanding of these instructions? Select all that apply.
"I shouldn't brush her teeth for 1 to 2 weeks." "I should rinse her mouth with water after feeding her." "I should watch signs of infection like drainage or fever." Rationale: "I shouldn't brush her teeth for 1 to 2 weeks," "I should rinse her mouth with water after feeding her," and "I should watch for signs of infection like drainage or fever" are all accurate statements. Gentle aspiration of oral secretions may be needed to prevent respiratory complications, and bulb syringes are often sent home with the family for removal of these secretions. After cleft lip repair the child should be kept supine, on the side opposite the repair, or in an infant seat. The prone position could result in contact of the suture line with the bed linens, leading to disruption of the suture line.
A nurse providing home care instructions to a mother of a HIV-positive child discusses measures to prevent transmission of the virus. Which statement by the mother indicates a need for further instruction?
"I'll wash up blood spills with soap and hot water and allow them to air dry." Rationale: The correct method of cleaning up blood spills is to wash the area with soap and water, rinse with bleach, and let the area air dry. The remaining statements by the mother reflect correct measures to prevent transmission of the virus.
A nurse provides home care instructions to the parents of a child who has undergone heart surgery. The nurse should provide which information to the parents?
Contact the health care provider if the child's appetite decreases Rationale: After discharge, the child's appetite normally will improve, so the nurse instructs the parents to contact the health care provider if the child's appetite decreases. The parents should also notify the health care provider if the child's breathing becomes faster and harder than normal at rest; if the temperature rises above 100° F (37.7° C); if new or frequent coughing develops; if the child becomes cyanotic; if redness, swelling, or drainage at the incision site occurs; if the child experiences frequent vomiting or diarrhea; or if the child's pain increases. The use of creams, lotions, and powders on the incision line are avoided until the incision is completely healed and without scabs. Adequate fluid intake is encouraged. The child should avoid outside play and activities in which falls are a risk for several weeks.
A child is admitted to the hospital, where Wilms' tumor is diagnosed. Which is the primary nursing intervention?
Posting a sign over the bed reading, "Do not palpate abdomen" Rationale: Wilms' tumor, or nephroblastoma, is the most common renal tumor in children. The most common clinical presentation is an asymptomatic, mobile abdominal mass. The tumor mass should not be palpated because of the high risk of rupturing the protective capsule. Excessive manipulation may result in seeding of the tumor. The nurse places a sign in the child's room warning against palpating the abdomen. Hypertension may occur as a result of increased production of renin by the kidneys; therefore the blood pressure needs to be checked regularly (more frequently than once a day). Placing the child in a high Fowler position and keeping the room dark are not interventions specific to Wilms' tumor.
A nurse is providing discharge dietary instructions to the mother of a child who has undergone tonsillectomy. Which items should the nurse tell the mother that it is safe to give the child? Select all that apply.
Water Scrambled eggs Mashed potatoes Rationale: Adequate fluid and food intake promotes healing and maintains hydration. Clear, cool liquids are encouraged. Water will maintain hydration. Red liquids and foods, such as cherry gelatin, are avoided because they will give the appearance of blood if the child vomits. Rough foods such as toast could irritate the throat. Soft foods such as mashed potatoes and scrambled eggs will not irritate the throat.
A nurse is admitting a child with respiratory syncytial virus (RSV) infection to the hospital. The nurse tells the parents that the best way to prevent the spread of the infection isto implement which measure?
Washing the hands meticulously Rationale: RSV infection, which is easily communicable, is acquired mainly through contact with contaminated surfaces. RSV can live on skin or paper for as long as 1 hour and on cribs and other nonporous surfaces for as long as 6 hours. It is usually transferred on inadequately washed hands. Meticulous handwashing decreases the spread of organisms. Maintaining contact precautions (e.g., wearing a gown and gloves) reduces nosocomial transmission of RSV. RSV infection is not airborne, so goggles and masks are unnecessary. Restriction of visitors is not necessary.
A nurse is planning diversional activities for a school-age child hospitalized with acute febrile rheumatic fever. Which activity is appropriate?
Board games Rationale: A child with rheumatic fever requires bed rest during the acute febrile stage of the illness. When the child's activities are restricted, the nurse and family should limit visitors and arrange for quiet yet enjoyable activities based on the child's age and developmental level. Visits to the playroom are also restricted during the acute stage of the illness. Board and computer games, movies, puzzles, and crafts are all appropriate for the school-age child.
A cardiac catheterization is performed on an infant. After the procedure, the nurse should tell the mother which about the infant?
Can be held in a prone position on the mother's lap Rationale: After cardiac catheterization, the affected leg is kept straight for 4 to 6 hours. Keeping the infant in the crib does not ensure that the affected leg will remain in a straight position. The infant may be held prone on a parent's lap. Older children remain in bed, with the head of the bed raised just 20 degrees.
Intravenous potassium chloride in 0.9% sodium chloride solution has been prescribed for a child who is severely dehydrated. Before administering the solution, the nurse must take which priority action?
Check urine output Rationale: Potassium chloride is not administered if the urine output is not adequate. If the child is anuric, potassium will be retained, causing an increased potassium level. Although skin turgor, capillary refill, and blood pressure may be checked, they are not essential assessments in this situation.
Hydrostatic reduction is performed in a hospitalized child with a diagnosis of intussusception. Which outcome indicates that the procedure was successful?
Passage of stool without blood Rationale: Intussusception is an invagination of a section of the intestines into the distal bowel that results in bowel obstruction. In children, this condition most often occurs as a section of the terminal ileum telescopes into the ascending colon through the ileocecal valve. The goal of treatment is to restore the bowel to its normal position and function as quickly as possible. In children who do not show symptoms of shock or sepsis, attempts at hydrostatic reduction are made with the use of a barium or air enema until a free flow of barium into the terminal ileum is evident. The passage of stool without blood is a successful outcome. The nurse watches for the passage of barium after this procedure, but it does not indicate a successful procedure. Visible peristalsis across the abdomen is a manifestation of Hirschprung's disease. Presence of a sausage-shaped abdominal mass is a sign of intussusception.
A nurse is assigned to care for a child with diarrhea. Which intervention should the nurse avoid in caring for the child?
Taking a rectal temperature every 4 hours Rationale: Rectal temperatures are avoided in the child with diarrhea because inserting a thermometer in the rectum stimulates peristalsis and may damage excoriated tissue. Gloves are worn when caring for the child. Clean gloves are sufficient; sterile gloves are not necessary in this situation. The child is turned every 2 hours to reduce pressure on irritated skin and to prevent skin breakdown. Protective moisture barriers, such as creams or ointments, are useful in protecting the skin from diarrhea stools.
An immunocompromised child who never had chickenpox is exposed to a child with varicella. The nurse should provide which information to the mother of the immunocompromised child?
The child will receive varicella zoster immune globulin Rationale: Immunocompromised children are unable to fight varicella adequately. If a child who has not had chickenpox is exposed to someone with varicella, the child should receive the varicella zoster immune globulin within 96 hours of exposure. Stating that there is no need to be concerned about exposure to varicella, placing the child on respiratory isolation, and monitoring for signs chickenpox are all incorrect.
A child has been found to have pharyngitis. The most reliable method of determining whether the infection is bacterial or viral in origin is by which method?
Throat culture Rationale: Although signs and symptoms differ between viral and bacterial pharyngitis, the only reliable means of determining whether a case of pharyngitis is viral or bacterial in origin is a throat culture. Not all children with pharyngitis complain of a sore throat, particularly if they are of preschool age. Instead, the child may complain of a stomachache or simply refuse to eat. Although a rapid streptococcal antigen test can be used to screen for group A streptococcal infection, it is not the most reliable means of determining whether a case of pharyngitis is viral or bacterial in origin. This test has an approximately 20% incidence of false-negative results.
A child with a history of sickle cell disease is seen in the emergency department, where acute sequestration crisis is diagnosed. The nurse should immediately prepare to take which action?
Start an intravenous (IV) line Rationale: Acute sequestration crisis is a complication of sickle cell disease. It is characterized by pooling of blood in the spleen, resulting in splenic enlargement. Acute sequestration crisis is a life-threatening condition if hypovolemic shock occurs. Emergency treatment involves restoring circulating blood volume with a crystalloid and colloid (blood) infusion. Therefore an IV line is needed immediately. Pain is not a priority concern with this type of crisis. Splenectomy may be necessary in cases in which the condition recurs frequently. Placing a cold pack on the abdomen over the area of the spleen will not stop the pooling of blood and might cause more discomfort for the child, so this is not an appropriate measure.
A child who is experiencing wheezing during an acute asthma episode is brought to the emergency department by the parents. Which intervention does the nurse prepare to implement first?
Administration of a bronchodilator Rationale: A child who is experiencing an episode of wheezing along with other symptoms of an acute asthma attack will first receive a bronchodilator by way of nebulizer or metered-dose inhaler. If the symptoms do not improve, a dose of an oral corticosteroid is usually prescribed. If the child's condition still does not improve, hospitalization may be necessary. Once the child is hospitalized, humidified oxygen is administered to keep the oxygen saturation at 95% or greater. An IV line is initiated to deliver fluids and provide venous access for parenteral medications as prescribed. Chest radiography, arterial blood gas determinations, or pulse oximetry may be performed as a means of further evaluating the child's oxygenation status.
Hemosiderosis develops in a child with beta-thalassemia as a result of long-term transfusion therapy. The child is being treated with deferoxamine. The nurse assesses the effectiveness of this therapy by monitoring which?
Serum iron level Rationale: One major complication of long-term transfusion therapy is hemosiderosis, the deposition of hemosiderin, an iron-containing pigment, in the organs. As a means of preventing iron overload-induced organ damage, chelation therapy with deferoxamine (administered subcutaneously or intravenously) is instituted. The nurse would assess the effectiveness of therapy by monitoring the serum iron level. Therapy is continued until the iron level returns to an acceptable level. Lung sounds, blood pressure, and the serum erythrocyte level not indicators of the effectiveness of this therapy.
The health care provider prescribes oral amoxicillin 60 mg 3 times daily for a child who weighs 12.5 lb. The safe pediatric dosage is 20 to 40 mg/kg/day in 3 equal doses. The medication label reads, "Amoxicillin 125 mg/5 mL." How many milliliters will the nurse administer per dose?
2.4 Rationale: First, change the child's weight in pounds to kilograms: Divide the child's weight in pounds (12.5) by 2.2 (1 kg = 2.2 lb). This yields 5.7 kg. Next check safe dosing parameters by multiplying the child's weight in kilograms by the minimum and maximum daily doses (20 to 40 mg/kg/day in 3 equal doses) of the medication. Therefore 20 mg/kg/day × 5.7 kg = 114 mg/day and 40 mg/kg/day × 5.7 kg = 228 mg/day. Therefore the recommended safe dose is between 114 and 228 mg/day. Next, multiply the prescribed dosage (60 mg 3 times daily) by the frequency to determine the daily dose. The prescription for oral amoxicillin 60 mg 3 times daily means that three doses will be given per day; 60 mg × 3 doses = 180 mg. Because the daily dose of amoxicillin (180 mg) falls within the recommended range (114 to 228 mg/day), it is considered a safe dose. Finally, use the formula for determining the number of milliliters per dose. Ratio and proportion: 125 mg : 5 mL :: 60 mg : X mL. 125 X = 300 = 2.4 mL. The nurse would administer 2.4 mL per dose.
A child's mother tells the nurse that during a seizure the child has a blank expression and exhibits eyelid fluttering lasting just 5 to 10 seconds. The nurse determines that the child is experiencing which type of seizure?
Absence seizures Rationale: Absence seizures, formerly called petit mal seizures, are characterized by brief episodes of altered consciousness. There is no muscle activity except for eyelid fluttering, twitching, or head bobbing, and the child has a blank expression. Absence seizures last only 5 to 10 seconds but may occur one after another, several times a day. Atonic seizures are marked by an abrupt loss of postural tone, impairment of consciousness, confusion, lethargy, and sleep. Myoclonic seizures are brief, random contractions of a muscle group that may occur on both sides of the body and may occur singly or in clusters. Tonic-clonic seizures, formerly called grand mal seizures, consist of a tonic phase (a sustained, generalized stiffening of muscles lasting a few seconds) and a clonic phase (symmetric and rhythmic, consisting of alternating contraction and relaxation of major muscle groups).
A girl with systemic lupus erythematosus (SLE) wants to go to the beach with her friends on the day after their junior prom. The girl asks the nurse for guidance regarding sun exposure. The nurse should provide which information to the girl?
Waterproof sunscreen with a minimum sun protection factor (SPF) of 15 is a necessity Rationale: SLE, a chronic multi-system autoimmune disease characterized by inflammation of the connective tissue, varies in severity and is marked by remissions and exacerbations. Although the origin of SLE is not known, genetic, environmental, hormonal, and immune response factors are likely responsible. These factors include exposure to sun and other UV light, stress, fatigue, viruses, bacteria, certain medications, and some food additives. Avoiding triggers that set off exacerbation is essential, so wearing appropriate sunscreen is a necessity. The sunscreen should contain an SPF higher than 15 and should be waterproof. The remaining options present incorrect information.
A nurse is performing an assessment of a child admitted to the hospital with suspected rheumatic fever. About which recent occurrence should the nurse ask the parents as a means of eliciting data relevant to the cause of illness?
A sore throat Rationale: Rheumatic fever characteristically appears 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. Therefore the nurse would ask the parents about the recent occurrence of a sore throat in the child. A blunt chest injury is not associated with rheumatic fever. A swollen knee joint and loss of appetite may be manifestations of this disorder but are not the cause.
A nurse is reviewing the health care provider's preoperative prescriptions for a child who is scheduled for an appendectomy. Which prescription should the nurse question?
Administer a Fleet enema before surgery. Rationale: Enemas or laxatives are not administered to the client with appendicitis because of the risk of rupturing the appendix. IV fluid therapy is started to prepare the child for surgery and correct any fluid or electrolyte imbalance related to vomiting and diarrhea. Vital signs are taken as a means of monitoring the child for sepsis or shock. Comfort measures, including topical cold application, pain medication, encouragement of positions of comfort, are instituted. Heat is not applied to the abdomen, because vasodilation increases the risk of perforation.
