NURS 355 Chapter 14
A father calls the clinic because he found his young daughter squirting Visine eyedrops into her mouth. What is the most appropriate nursing action?
Direct him to seek immediate medical treatment Visine is a sympathomimetic and if ingested may cause serious consequences. Medical treatment is necessary. Inducing vomiting is no longer recommended for ingestions. Dilution will not decrease risk.
The nurse is caring for a child with suspected ingestion of some type of poison. What action should the nurse take next after initiating cardiopulmonary resuscitation (CPR)?
Empty the mouth of pills, plants, or other material Emptying the mouth of any leftover pills, plants, or other ingested material is the next step after assessment and initiation of CPR if needed. Questioning the victim and witnesses, calling poison control, and placing the child in a side-lying position are follow-up steps.
What is probably the most important criterion on which to base the decision to report suspected child abuse?
Incompatibility between the history and injury observed Conflicting stories about the "accident" are the most indicative red flags of abuse. The child or caregiver may have an inappropriate response, but this is subjective. Parents should be questioned at some point during the investigation.
What is an important nursing consideration when a child is hospitalized for chelation therapy to treat lead poisoning?
Keep an accurate record of intake and output The iron chelates are excreted though the kidneys. Adequate hydration is essential. Periodic measurement of renal function is done. Bed rest is not necessary. Often the chelation therapy is done on an outpatient basis. Chelation therapy is not infectious or dangerous. Isolation is not indicated. Skeletal weakness does not result from high levels of lead.
An awake, alert 4-year-old child has just arrived at the emergency department after an ingestion of aspirin at home. The practitioner has ordered activated charcoal. The nurse administers charcoal in which manner?
Mixing with a flavorful beverage in an opaque container with a straw Although activated charcoal can be mixed with a flavorful sugar-free beverage, it will be black and resemble mud. When it is served in an opaque container, the child will not have any preconceived ideas about its being distasteful. The ability to see the charcoal solution may affect the child's desire to drink the solution. The child should be encouraged to drink the solution all at once. The nasogastric tube would be traumatic. It should be used only in children who cannot be cooperative or those without a gag reflex.
A child is admitted with a suspected diagnosis of Munchausen syndrome by proxy (MSBP). What is an important consideration in the care of this child?
Monitoring the parents whenever they are with the child MSBP refers to an illness that one person fabricates or induces in another. The child must be continuously observed for development of symptoms to determine the cause. MSBP is caused by an individual harming the child for the purpose of gaining attention. Nursing staff should obtain all specimens for analyzing. This minimizes the possibility of the abuser contaminating the sample. The child must be supported through the diagnosis of MSBP. The abuser must be identified and the child protected from that individual.
A child with acetaminophen (Tylenol) poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed?
N-acetylcysteine (Mucomyst) The antidote for acetaminophen (Tylenol) poisoning is N-acetylcysteine (Mucomyst). Carnitine (Carnitor) is an antidote for valproic acid (Depakote), fomepizole (Antizol) is the antidote for methanol poisoning, and deferoxamine (Desferal) is the antidote for iron poisoning.
What is a significant secondary prevention nursing activity for lead poisoning?
Screening children for blood lead levels Screening children for lead poisoning is an important secondary prevention activity. Screening does not prevent the initial exposure of the child to lead. It can lead to identification and treatment of children who are exposed. Chelation therapy is treatment, not prevention. Removing lead-based paints from older homes before children are affected is primary prevention. Questioning parents about ethnic remedies containing lead is part of the assessment to determine the potential source of lead.
A child with corrosive poisoning is being admitted to the emergency department. What clinical manifestation does the nurse expect to assess on this child?
Severe burning pain in the mouth, throat, and stomach Severe burning pain in the mouth, throat, and stomach is a clinical manifestation of corrosive poisoning. Nausea and vomiting; alterations in sensorium, such as lethargy; and respiratory symptoms of acute pulmonary involvement are clinical manifestations of hydrocarbon poisoning.
A 3-month-old infant dies shortly after arrival to the emergency department. The infant has subdural and retinal hemorrhages but no external signs of trauma. What should the nurse suspect?
Shaken baby syndrome Shaken baby syndrome causes internal bleeding but may have no external signs. Unintentional injury would not cause these injuries. With unintentional injuries, external signs are usually present. Congenital neurologic problems would usually have signs of abnormal neurologic anatomy. SIDS does not usually have identifiable injuries.
What do inflicted immersion burns often appear as?
Sharply demarcated, symmetrical burns Immersion burns are sharply demarcated symmetrical burns. Asymmetrical burns and splash burns are often accidental.
A parent asks the nurse about the "characteristics of a sleep terror." What response should the nurse give to the parent? (Select all that apply.)
The child screams during the sleep terror. The child has no memory of the dream with a sleep terror. The child is not aware of another's presence during a sleep terror. During sleep terrors, the child screams and has no memory of the dream. The child is not aware of another's presence during a sleep terror. Return to sleep is usually rapid with a sleep terror, but it is delayed with a nightmare. The sleep terror occurs usually within 1 to 4 hours of sleep, but nightmares occur during the second half of night.
When only one child is abused in a family, the abuse is usually a result of what?
The parent is unable to deal with the child's behavioral style. The child unintentionally contributes to the abuse. The "fit" or compatibility between the child's temperament and the parent's ability to deal with that behavior style is an important predictor. Birth order and gender can contribute to abuse, but there is not a specific birth order or gender relationship that is indicative of abuse. Being the firstborn or the same gender as the abuser is not linked to child abuse. Avoidance of favoritism is not usually a cause of abuse.
What statement is correct about young children who report sexual abuse?
They may exhibit various behavioral manifestations. Victims of sexual abuse have no typical profile. The child may exhibit various behavioral manifestations, none of which is diagnostic for sexual abuse. When children report potentially sexually abusive experiences, their reports need to be taken seriously. Other children in the household also need to be evaluated. In children who are sexually abused, it is often difficult to identify other evidence. In one study, approximately 96% of children who were sexually abused had normal genital and anal findings. The ability to retell the story is partly dependent on the child's cognitive level. Children who repeatedly tell identical stories may have been coached.
The nurse is teaching parents of a preschool child strategies to implement when the child delays going to bed. What strategy should the nurse recommend?
Use consistent bedtime rituals For children who delay going to bed, a recommended approach involves a consistent bedtime ritual and emphasizing the normalcy of this type of behavior in young children. Parents should ignore attention-seeking behavior, and the child should not be taken into the parents' bed or allowed to stay up past a reasonable hour.
The nurse is teaching parents of preschool children consequences of inadequate sleep. What should the nurse include in the teaching session? (Select all that apply.)
behavior changes difficulty concentrating poor control of emotions impaired learning ability Consequences of inadequate sleep include daytime tiredness, behavior changes, hyperactivity, difficulty concentrating, impaired learning ability, poor control of emotions and impulses, and strain on family relationships. Increased appetite is not a consequence of inadequate sleep.
What can the nurse suggest to families to reduce blood lead levels? (Select all that apply.)
do not store food in open cans ensure the child eats regular meals wash and dry the child's hands and face frequently To reduce blood lead levels, the family should ensure the child eats regular meals because more lead is absorbed on an empty stomach. The child's hands and face should be washed and dried frequently, especially before eating. Food should not be stored in open cans, particularly if cans are imported. Hot water dissolves lead more quickly than cold water and thus contains higher levels of lead. Hot water should not be used to mix formula. Hard-surfaced floors or window sills or wells should not be vacuumed because this spreads dust.
What are symptoms of abusive head trauma (AHT) in the more severe form that may be present? (Select all that apply.)
seizures posturing altered level of consciousness In more severe forms, presenting symptoms of abusive head trauma may include seizures, posturing, alterations in level of consciousness, apnea, bradycardia, or death.
What identified characteristics occur more frequently in parents who abuse their children? (Select all that apply.)
socially isolated single-parent families few supportive relationships Abusive families are often socially isolated and have few supportive relationships. Single-parent families are at higher risk for abuse. Younger parents more often are abusers of their children. Abusive parents have stressors such as low-income circumstances, with little education, and are not middle class parents.
A child with cyanide poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed for the child?
Amyl nitrate Amyl nitrate is the antidote for cyanide poisoning. Atropine is an antidote for organophosphate poisoning, glucagon is an antidote for a beta-blocker poisoning, and naloxone (Narcan) is an antidote for an opioid poisoning.
A child with diazepam (Valium) poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed?
Flumazenil (Romazicon) The antidote for diazepam (Valium) poisoning is flumazenil (Romazicon). Succimer (Chemet) and EDTA (Versenate) are antidotes for heavy metal poisoning. Octreotide acetate (Sandostatin) is an antidote for sulfonylurea poisoning.
What are classified as hydrocarbon poisons? (Select all that apply.)
gasoline turpentine lighter fluid Gasoline, turpentine, and lighter fluid are classified as hydrocarbon poisons. Bleach and oven cleaners are classified as corrosive poisons.
What are classified as corrosive poisons? (Select all that apply.)
batteries drain cleaners mildew remover Batteries, drain cleaners, and mildew removers are classified as corrosive poisons. Paint thinner and mineral seed oil are classified as hydrocarbon poisons.
A parent asks the nurse about the "characteristics of a nightmare." What response should the nurse give to the parent? (Select all that apply.)
nightmares are scary dreams the child can describe the nightmare the child is reassured by your presence Nightmares are scary dreams, the child can describe the nightmare, and the child is reassured by a parent's presence. Sleep terrors occur usually 1 to 4 hours after falling asleep, but nightmares occur in the second half of sleep. Sleep terrors occur during non-rapid eye movement sleep, but nightmares occur during rapid eye movement sleep.
A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The nurse taking the call should know that the primary danger is what?
Bronchitis and chemical pneumonia Lighter fluid is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose, not hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger. Esophageal stricture is a late or chronic consequence of hydrocarbon ingestion.
The nurse suspects that a child has ingested some type of poison. What clinical manifestation would be most suggestive that the poison was a corrosive product?
Edema of the lips, tongue, and pharynx Edema of the lips, tongue, and pharynx indicates a corrosive ingestion. Tinnitus is indicative of aspirin ingestion. Corrosives do not act on the central nervous system.
A child has been admitted to the hospital with a blood lead level of 72 mcg/dL. What treatment should the nurse anticipate?
Initiation of chelation therapy Severe lead toxicity (lead level ?5=70 mcg/dL) requires immediate inpatient chelation treatment. Referral to social service and follow-up in 1 month are prescribed for lead levels of 15 to 19 mcg/dL. Aggressive environmental intervention would be initiated after chelation treatments.
What is a clinical manifestation of acetaminophen poisoning?
Hepatic involvement Hepatic involvement is the third stage of acetaminophen poisoning. Hyperpyrexia is a severe elevation in body temperature and is not related to acetaminophen poisoning. Acetaminophen does not cause burning pain in stomach and does not pose an airway threat.
A child with acetylsalicylic acid (aspirin) poisoning is being admitted to the emergency department. What early clinical manifestation does the nurse expect to assess on this child?
Hyperventilation An early clinical manifestation of acetylsalicylic acid (aspirin) poisoning is hyperventilation. Hematemesis, hematochezia, and hyperglycemia are clinical manifestations of iron poisoning.
The parents of a 7-year-old boy tell the nurse that lately he has been cruel to their family pets and actually caused physical harm. The nurse's recommendation should be based on remembering what?
This is a warning sign of a serious problem. Cruelty to family pets is not an expected behavior. Hurting animals can be one of the earliest symptoms of a conduct disorder. Abusing animals does not dissipate violent emotions; rather, the acts may fuel the abusive behaviors. Referral for evaluation is essential. This behavior may be seen in emotional abuse or neglect, not physical abuse
A child is admitted to the hospital with lesions on his abdomen that appear like cigarette burns. What should accurate documentation by the nurse include?
Two round 4-mm lesions are on the child's lower abdomen. Burn documentation should include the location, pattern, demarcation lines, and presence of eschar or blisters. The option that includes the size of the lesions is the most accurate.
The nurse is administering activated charcoal to a preschool child with acetaminophen (Tylenol) poisoning. What potential complications from the use of activated charcoal should the nurse plan to assess for? (Select all that apply.)
vomiting intestinal obstruction Potential complications from the use of activated charcoal include vomiting and possible aspiration, constipation, and intestinal obstruction. Diarrhea and fluid retention are not potential complications of activated charcoal administration.
The nurse is teaching parents of preschoolers about plants that are poisonous. What plant should the nurse include in the teaching session?
Azalea All parts of the azalea are poisonous. Begonias, Boston ferns, and asparagus ferns are nonpoisonous plants
The nurse is teaching parents of preschool-aged children strategies to prevent sexual abuse. What should the nurse include in the teaching session? (Select all that apply.)
Back up a child's right to say no. Take a second look at signals of potential danger. Remind children that even "nice" people sometimes do mean things. To provide protection and preparation from sexual abuse, parents should back up a child's right to say no, take a second look at signals of potential danger, and remind children that even "nice" people sometimes do mean things. Parents should take what children say seriously and they should give specific definitions and examples of sexual assault.
What is the most common form of child maltreatment?
Child neglect Child neglect, which is characterized by the failure to provide for the child's basic needs, is the most common form of child maltreatment. Sexual abuse, physical abuse, and emotional abuse are individually not as common as neglect.
