Module #6 PEDS

The pediatric nurse examines the radiographs of a client that indicate lesions on the bone. This finding is indicative of:

Ewing sarcoma. Explanation: Radiographs that show lesions on the bone may indicate tumors (e.g., Ewing sarcoma, osteosarcoma) or metastasis of tumors. Osteosarcoma is the most common type of bone malignancy in children. It occurs primarily in the long bones. Ewing sarcoma is a highly malignant bone cancer. It occurs in the pelvis, chest wall, vertebrae, and midshaft of the long bones. Neuroblastomas are seen in children younger than 5 years old and arise from immature nerve cells and the adrenal glands. Hodgkin disease develops from the immune system. Non-Hodgkin lymphoma is a blood cancer

3. A patient, with a history of gastric bypass surgery 6 months ago, reports feeling very fatigued and is having food cravings for clay and dirt. On assessment, you note the patient has nail changes that look "spoon-shaped". This spoon-shaped appearance of the nails is called? A. Terry's Nails B. Onychoschizia C. Koilonychias D. Leukonychia

The answer is C. Koilonychias is the medial term for a spoon-shaped appearance of nails found in iron-deficiency anemia.

The young boy was involved in a motor vehicle accident and was admitted to the pediatric intensive care unit with changes in level of consciousness and a high-pitched cry. Which are late signs of increased intracranial pressure? Select all that apply.

The child's toes are pointed downward, his head and neck are arched backwards, and his arms and legs are extended. The child's heart rate is 56 beats per minute. The child's pupils are fixed and dilated. Explanation: Late signs of increased intracranial pressure are: decerebrate posturing, bradycardia, and pupils that are fixed and dilated. The other options are early signs of increased intracranial pressure.

The nurse is administering meperidine as ordered for pain management for a 10-year-old boy in sickle cell crisis. The nurse would be alert for:

seizures. Explanation: Repeated use of meperidine for pain management during sickle cell crisis increases the risk of seizures when used in children with sickle cell anemia. Behavioral addiction is rarely a concern in the child with sickle cell anemia if the opioid is used for the alleviation of severe pain. Priapism is a complication of sickle cell anemia unrelated to meperidine administration. Leg ulcers are a complication of sickle cell anemia unrelated to meperidine administration.

Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n):

steroid. Explanation: Increased intracranial pressure (ICP) may be caused by several factors: head trauma, birth trauma, hydrocephalus, infection, and/or tumors. Whatever the reason, the brain swells and becomes inflamed. Dexamethasone is a steroid. A steroid may be prescribed to reduce inflammation and pressure on vital centers of the brain. The diuretic mannitol may be used to decrease edema. An anticonvulsant is used with increased ICP to prevent seizures. An antihistamine would not be warranted for the treatment of a head injury.

An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the father would indicate to the nurse that additional teaching should be done?

"I always keep phenobarbital with me in case of a fever." Explanation: Anticonvulsants, such as phenobarbital, are administered to children with prolonged seizures or neurologic abnormalities. Ibuprofen, not phenobarbital, is given for fever. Febrile seizures usually occur after age 6 months and are unusual after age 5. Treatment is to decrease the temperature because seizures occur as the temperature rises.

The nurse is caring for a toddler taking ferrous sulfate for severe iron-deficiency anemia. Which report by the parent is most concerning?

"I mix ferrous sulfate with milk in a bottle." Explanation: Ferrous sulfate may not be absorbed if taken with milk or tea, and if the parent mixes the medicine with milk in a bottle, there is also concern that if the child does not drink the entire amount of medication. Ferrous sulfate may be taken after meals to prevent gastrointestinal irritation. Dark stools are a common side effect of ferrous sulfate. Parents should be encouraged to brush the child's teeth thoroughly to prevent teeth staining.

A child is receiving chemotherapy and develops stomatitis. The nurse identifies a nursing diagnosis of Impaired oral mucous membranes related to the effects of chemotherapy. What instructions would the nurse include in the child's plan of care? Select all that apply.

Provide various soft and bland foods to minimize further irritation. Have the child rinse the mouth with lukewarm water three times a day. Apply a lip balm or petroleum jelly to prevent cracking. Explanation: For the child with stomatitis, the nurse should provide soft foods to prevent further abrasions, have the child rinse the mouth three times a day with lukewarm water to promote comfort and healing, avoid giving the child acidic foods that would further irritate the tissue, and apply a lip balm or petroleum jelly to prevent cracking of the lips. The nurse should offer a soft toothbrush to minimize discomfort.

9. During an outpatient well visit with a patient who has sickle cell anemia, you make it PRIORITY to assess the patient's? A. hemoglobin A1C level B. heart rate C. reflexes D. vaccination history

The answer is D. Patients will sickle cell anemia are at risk for infection because of spleen compromise. Many patients with SCA experience splenomegaly because blood flow is compromised to the spleen due to sickling of RBCs and the spleen is overworked from recycling the old RBCs (remember a patient with sickle cell anemia does NOT have long-living RBCs...the RBCs tend to die in 20 days rather than 120 days). Therefore, vaccination history is very important. The patient should be up-to-date with the flu, pneumococcal, and meningococcal vaccines.

The nurse is caring for an adolescent who suffered an injury during a diving accident. During assessment the client is demonstrating the posturing in the figure. The nurse is aware that this type of posturing is the result of injury to what area?

brain stem Explanation: Decerebrate posturing is seen with injuries occurring at the level of the brain stem. Decorticate posturing occurs with damage of the cerebral cortex. Both types of posturing are characterized by extremely rigid muscle tone. Injuries to the frontal lobe of the brain and the mid-cervical spine would not cause these types of posturing.

The nurse is providing care for a 13-year-old child diagnosed with iron-deficiency anemia. The client's current hemoglobin level is 11 g/dL (110 g/L). Which intervention will the nurse anticipate including in the client's care?

giving ferrous sulfate with orange juice between meals Explanation: Treatment for iron-deficiency anemia is the administration of ferrous sulfate for a 13-year-old client with a hemoglobin at 11 g/dL (110 g/L). It should be administered with orange juice, because vitamin C helps absorb iron. It should not be taken with milk. It can cause teeth staining in children and should be given with a straw. Intravenous immunoglobulin would be administered for idiopathic thrombocytopenic purpura. The client's hemoglobin level is not severe enough to warrant blood transfusions at this time. There is also no indication the child is symptomatic. Anemia is generally diagnosed for a hemoglobin less than 12 g/dL (120 g/L) in children 12 to 14 years of age. The normal level for children 12 to 18 years of age is 14 g/dL (140 g/L). While increasing fresh fruits and vegetables is good for the client's overall health, this client needs foods specifically high in iron. These include broccoli, bananas, tomatoes, spinach, liver, nuts, dates, legumes, beef, eggs, and pork.

A school nurse is teaching a group of parents about signs and symptoms of cancer in children. Which symptom is an early sign of a brain tumor?

headache, vision changes, and vomiting Explanation: Children with any form of brain tumor develop symptoms of increased intracranial pressure: headache, vision changes, vomiting, an enlarging head circumference, or papilledema. Lethargy, projectile vomiting, and coma are late signs. Epistaxis is not usually related to a brain tumor. A growing tumor produces specific localized signs, such as nystagmus (constant horizontal movement of the eye) or visual field defects. As tumor growth continues, symptoms of ataxia, personality change (e.g., emotional lability, irritability), and seizures may occur. These would be later symptoms

A child is brought to the emergency department after experiencing a series of continuous seizures. The nurse is reviewing the orders for care and treatment. Which order would be of the highest priority?

serum glucose level Explanation: Status epilepticus is the occurrence of repetitive seizures in an individual. This is a neurological emergency. The events of the repetitive seizures greatly expend energy. This will result in rapid drops in serum glucose level, making this the priority laboratory value to review.

The nurse is preparing a care plan for a toddler diagnosed with cerebral palsy (CP). Which intervention would be appropriate for the nursing diagnosis of Risk for disuse syndrome related to spasticity of muscle groups? Select all that apply.

Administer carbidopa/levodopa as prescribed. Administer benzodiazepines as prescribed. Teach parents exercises and games to help prevent contractures. Explanation: Dopaminergic drugs such as carbidopa/levodopa can help to reduce muscle rigidity and spasticity. Benzodiazepines also help with smoother muscle movement and reduce spasticity. Exercises and games, done daily, can help to prevent contractures from disuse. Interventions such as education about the disease and speech therapy are appropriate for clients with cerebral palsy but are not appropriate for the nursing diagnosis of Risk for disuse syndrome related to spasticity of muscle groups.

A nurse is preparing a 7-year-old girl for bone marrow aspiration. Which site should she prepare?

Illac crest

Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis?

Signs of increased intracranial pressure (ICP) Explanation: Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessment for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who's ill from nearly any cause but doesn't pose a great danger to life.

6. A 14 year-old female has sickle cell anemia. Which factors below can increase the patient's risk for developing sickle cell crisis? Select all that apply: A. Shellfish B. Infection C. Dehydration D. Hypoxia E. Low altitudes F. Hemorrhage G. Strenuous exercise

The answers are B, C, D, F and G. Sickle cell crisis can occur when the body experiences low amounts of oxygen in the body (so think about something that increases the body's need for oxygen or affects how oxygen is being transported). Therefore, infection (especially respiratory infections), dehydration, hypoxia, HIGH (not low) altitudes, hemorrhage (blood loss), or strenuous exercise can lead to a sickle cell crisis.

The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)?

While assessing the child's pupils, there is no change in diameter in response to a light. Explanation: To perform the child's eye reflex examination, the nurse will shine a penlight into the eyes and observe if the pupils constrict, which is a normal response. Lack of pupillary light reflex can indicate increased intracranial pressure (ICP). To perform the "doll's eye" reflex examination, the nurse will place the child in a supine position and move the head gently but rapidly to one side. During this movement, it is normal for the child's eye to move to the opposite side. If the child has increased ICP, this response will be absent. While the other options are potential signs of increased ICP, they do not demonstrate the child's eye reflex examination.

The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client?

use of anticonvulsant medications Explanation: Complete control of seizures can be achieved for most people through the use of anticonvulsant drug therapy. These medications are typically used first as treatment for seizure disorders. Frequent temperature assessment would only be useful in febrile seizures. Ketogenic diets (high in fat, low in carbohydrates, and adequate in protein) cause the child to have high levels of ketones, which help to reduce seizure activity. Diet is generally used when medications cannot control a child's seizure activity. Stimulating the left vagus nerve intermittently with electrical pulses may reduce seizure frequency. This requires surgically implanting a stimulator under the skin and is approved for children 12 and older.

The nurse is providing preoperative care for a 7-year-old boy with a brain tumor, as well as his parents. Which intervention is a priority?

Assessing the child's level of consciousness. Explanation: The priority intervention is to monitor for increases in intracranial pressure because brain tumors may block cerebral fluid flow or cause edema in the brain. A change in the level of consciousness is just one of several subtle changes that can occur indicating a change in intracranial pressure. Lower priority interventions include providing a tour of the ICU to prepare the child and parents for after the surgery, and educating the child and parents about shunts.

Which nursing action should be included in the care plan to promote comfort in a 4-year-old child hospitalized with meningitis?

Avoid making noise when in the child's room. Explanation: Meningeal irritation may cause seizures and heightens a child's sensitivity to all stimuli, including noise, lights, movement, and touch. Frequent rocking, presence of a younger sibling, and bright lights would increase stimulation.

Antibiotic therapy to treat meningitis should be instituted immediately after which event?

Collection of cerebrospinal fluid (CSF) and blood for culture Explanation: Antibiotic therapy should always begin immediately after the collection of CSF and blood cultures. After the specific organism is identified, bacteria-specific antibiotics can be administered if the initial choice of antibiotic therapy isn't appropriate. Admission and initiation of IV therapy aren't, by themselves, appropriate times to begin antibiotic therapy.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan?

Decrease environmental stimulation Explanation: A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.

A nurse is teaching a school-aged child with iron-deficiency anemia and her parents about dietary measures to increase iron intake. The nurse determines that the teaching was successful when they state which food is high in iron? Select all that apply.

Eggs Fortified cereal Green leafy vegetables Explanation: Foods high in iron include meat, cheese, eggs, green leafy vegetables, and fortified cereal. Citrus fruits and milk are not iron-rich foods

The young child has been diagnosed with bacterial meningitis. Which nursing interventions are appropriate? Select all that apply

Initiate droplet isolation. Identify close contacts of the child who will require post-exposure prophylactic medication. Administer antibiotics as ordered. Initiate seizure precautions. Explanation: The child with bacterial meningitis should be placed in droplet isolation until 24 hours following the administration of antibiotics. Close contacts of the child should receive antibiotics to prevent them from developing the infection. The nurse should administer antibiotics and initiate seizure precautions. Children with bacterial meningitis have an increased risk of developing problems associated with increased intracranial pressure.

The nurse is caring for a preschooler who has developed a high fever and has just had a seizure. What is the best action by the nurse?

Remove any blankets or heavy clothing and replace with a thin sheet Explanation: The child should not have any blankets or clothing that would elevate the temperature further. Removing them is helpful in allowing the heat to dissipate. The child should not be placed in a bathtub because he or she may suffer another seizure and slip underwater. Using ice packs or alcohol can be a shock to an immature nervous system. Antipyretics should be administered as a suppository rather than PO to reduce the risk of aspiration while the child is in the postictal or drowsy state following the seizure.

The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status?

She has been irritable for the last hour....seems like she is just upset for some reason." Explanation: Irritability in an infant can be a sign of declining neurological function. Because infants are not able to answer questions pertaining to person, place and time, their neurological assessment must be catered to their level of development. The other responses would be typical and normal for an infant.

The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply.

eye opening verbal response motor response Explanation: The pediatric Glasgow Coma Scale assesses level of consciousness using three parts: eye opening, verbal response, and motor response. Reference:

A child with a seizure disorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included? Select all that apply.

oxygen gauge and tubing suction at bedside padding for side rails Explanation: When planning the client's environment it is imperative that both safety items and those to manage the seizure are present. The side rails should be padded to prevent injury during seizure activity. Oxygen setup should be provided. Suction may be needed. Tongue blades and smelling salts are not employed.

A nurse is providing care to a toddler with nephroblastoma and is being evaluated. Which nursing action would be most important?

Placing a "no abdominal palpation" sign above the child's bed Explanation: Nephroblastoma (Wilms tumor) metastasizes rapidly, so it is important that the child's abdomen not be palpated any more than necessary for diagnosis, because handling appears to aid metastasis. There is no need to restrict the child's visitors. Ensuring nothing by mouth would be appropriate prior to surgery. Preventing weight-bearing activities would be appropriate for a child with Ewing sarcoma

2. Select all the patients who are at MOST risk for iron-deficiency anemia: A. A 55 year old male who reports taking Ferrous Sulfate regularly. B. A 25 year old female who was recently diagnosed with Celiac Disease. C. A 35 year old female who is 36 weeks pregnant that reports craving ice. D. A 67 year old female with a Hemoglobin level of 14.

The answers are B and C. Patients who have GI issues, such as Celiac Disease, are at risk for iron-deficiency anemia due to damage to the intestines, which play a huge role in absorbing iron. In addition, females who are pregnant are at risk for this condition because of fetal demands on the body for iron. Also, this patient is craving ice which is a sign that the body is low on iron. Option A is wrong because Ferrous Sulfate is an iron supplement, therefore decreasing the patient's chances of developing this condition, and option D is wrong because the patient's hemoglobin level is normal (normal Hgb level for a female is 12 to 15.5 women & 13.5-17.5 for men.

7. A 6 year-old is admitted with sickle cell crisis. The patient has a FACE scale rating of 10 and the following vital signs: HR 115, BP 120/82, RR 18, oxygen saturation 91%, temperature 101.4'F. Select all the appropriate nursing interventions for this patient at this time? A. Administer IV Morphine per MD order B. Administer oxygen per MD order C. Keep NPO D. Apply cold compresses E. Start intravenous fluids per MD order F. Administer iron supplement per MD order G. Keep patient on bed rest H. Remove restrictive clothing or objects from the patient

The answers are A, B, E, G, and H. When a patient is in sickle cell crisis, the abnormal RBCs are sickling and sticking together, which blocks blood flow. To help alleviate the RBCs from clumping together and sickling, oxygen and hydration are priority. This will help dilute the blood (hence decrease the sticking of RBCs) and help supply oxygen to the RBCs (remember abnormal RBCs with hemoglobin S are very sensitive to low oxygen levels and will sickle when there is low oxygen). In addition, pain needs to be addressed. Opioid medication is the best on a scheduled basis rather than PRN (as needed). Avoid keeping patient NPO unless needed (remember patient needs hydration). Avoid cold compresses (can lead to more sickling) but instead use warm compresses. The patient will need FOLIC ACID supplements to help with RBC creation rather than iron (iron can actually build up in the body and collect in the organs in patients with sickle cell disease). Patients definitely need to be on bedrest, and restrictive clothing or objects (blood pressure cuff etc.) should be removed to help blood flow.

The nurse develops a meal plan for a child with iron-deficiency anemia. Which meal would the nurse teach the parent has the highest amount of iron?

red meat, eggs, oatmeal, and dried fruit Explanation: Iron-deficiency anemia occurs when the blood does not have enough iron to produce hemoglobin. The anemia can be corrected via iron supplementation, nutrition, and even blood transfusion if the anemia is severe. Foods that have the highest sources of iron include red meat, tuna, eggs, tofu, enriched grains, dried beans and peas, dried fruits, green leafy vegetables and iron-fortified breakfast cereals. The nurse should teach the meal containing red meat, eggs, oatmeal, and dried fruit has the highest amount of iron. Chicken has less iron than red meat, and corn has only a small amount. All the fruits listed have iron, but when dried, the iron levels increase. Pork has a limited amount of iron, and white rice contains almost no iron. Brown rice and whole grains contain higher iron amounts.