CH 34?'s

When developing the plan of care for a 10-month-old infant in septic shock, which of the following would the nurse most likely include? a) Administering intravenous saline as ordered b) Administering intravenous dopamine as ordered c) Giving blood if saline provides inadequate response d) Inserting a urinary catheter for monitoring urinary output

B Explanation: Although isotonic intravenous solutions such as saline, blood transfusion, and urinary catheter insertion are important for any child with shock, children experiencing septic shock often require larger volumes of fluid as a result of the increased capillary permeability. Thus, fluid alone may not improve the status of a child with septic shock, necessitating the use of vasoactive medications such as dopamine. Saline is the first choice for restoring fluid volume, but this child will most likely need vasoactive medications. Children in shock from trauma may require blood transfusions to restore volume. Once fluids are given, a urinary catheter will be placed to monitor urine output.

The nurse is caring for a patient hospitalized after a crushing chest injury, leading to development of blood surrounding the pericardium. The nurse notes tachycardia, tachypnea, muffled heart sounds, weakened peripheral pulses, and delayed capillary refill. Which form of shock is the patient likely experiencing? a. Septic shock b. Cardiogenic shock c. Distributive shock d. Hypovolemic shock

b. Cardiogenic shock Cardiogenic shock results when the patient's heart cannot pump effectively to meet the patient's metabolic needs. In the early stages of cardiogenic shock, the child is able to compensate with tachycardia, tachypnea, and vasoconstriction to maintain cardiac output.

The nurse is caring for a 10-year-old child in hypovolemic shock after a liver laceration from a bicycle injury. The nurse notes delayed capillary refill, lethargy, BP 74/48, and SpO2 88%. Which orders are most important for the nurse to complete first? Select all that apply. a. Administer IV antibiotics b. Give IV normal saline bolus c. Provide oxygen via nasal cannula d. Refer parents to hospital chaplain e. Perform range-of-motion exercises

b. Give IV normal saline bolus c. Provide oxygen via nasal cannula d. Refer parents to hospital chaplain The nurse should administer IV fluid to replace fluid volume loss.The nurse should provide supplemental oxygen to help maintain the patient's tissue perfusion. Referring patients to the hospital chaplain can help provide the emotional support necessary to cope with the child's condition.Range-of-motion exercises can help maintain muscle function in patients who are hospitalized, but it is not a priority action.

A 16-year-old boy is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to which of the following? a) Play-related injuries b) Falls from beds c) Automobile accidents d) Falls from staircases

c. Automobile accidents Explanation: Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-aged children, and falling from staircases is a common injury among toddlers.

A 10-year-old boy with congenital heart disease is in shock. Which nursing intervention would be most appropriate for this child? a) Assessing for changes in mental status and alertness b) Monitoring urine output with a goal of 1 to 2 mL/kg/hour c) Palpating for pulses and capillary refill d) Assessing for pulmonary edema from fluid overload

d) Assessing for pulmonary edema from fluid overload Explanation:Assessing for pulmonary edema from fluid overload is the most appropriate intervention. Pulmonary edema is rare but may occur in children with preexisting cardiac conditions or severe chronic pulmonary disease. Assessing for changes in mental status and alertness, monitoring urine output, and palpating for improved pulses and capillary refill are valid interventions for managing shock of any kind.

A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which of the following actions should the nurse take first? a) Provide oral analgesics as ordered. b) Draw blood for type and cross-match. c) Begin hyperventilation. d) Establish a suitable IV site.

d. Establish a suitable IV site. Explanation: The goal of treating shock is to restore circulating blood volume. This requires that vascular access be obtained to administer fluids and vasoactive drugs. Hyperventilation is reserved for temporary treatment of severe intracranial pressure. Analgesics should not be administered prior to neurologic and cardiovascular examination being performed. Chelation therapy is a treatment for metallic poisoning.

The nurse is caring for an infant brought in with a high fever, cough, labored breathing, and tachypnea. Which general appearance finding would be most concerning for the nurse? a. Diarrhea b. Poor feeding c. Weak, continuous cry d. Skin is cool and mottled

d. Skin is cool and mottled Cool, mottled skin is a sign of poor tissue perfusion and can indicate shock in an infant with labored breathing and tachypnea.

When assessing a young child who is experiencing decompensated shock, what would the nurse expect to find? a) Normal blood pressure b) Tachycardia c) Tachypnea d) Irritability

C

The nurse is caring for a patient in hypovolemic shock. The patient has a patent airway, unlabored breathing, and capillary refill less than 4 seconds. Which prescription should the nurse anticipate receiving first from the health care practitioner? a. Obtain vascular access b. Administer oral antibiotics c. Prepare patient for surgery d. Begin hemodynamic monitoring

a. Obtain vascular access Once the airway, breathing, and circulation are established, the next priority for the nurse is adequate vascular access.

The nurse is caring for a 3 year old diagnosed with pneumonia one week previously. The parents report the child has become lethargic and appears to have more difficulty breathing. The nurse notes delayed capillary refill, tachycardia, and tachypnea. Which prescription should the nurse implement first? a. Supplemental oxygen b. Hemodynamic monitoring c. IV fluid bolus of normal saline d. Parenteral antibiotic therapy

a. Supplemental oxygen Supplemental oxygen should be initiated first for a patient with signs of shock, hypoxia, and poor tissue perfusion.

A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 bpm. Which intervention is priority? a) Give three doses of epinephrine b) Administer two consecutive defibrillator shocks c) Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR) d) Initiate cardiac compressions

d) Initiate cardiac compressions

A 5-year-old child presents to the emergency department and begins to exhibit neurological side effects after ingesting an unknown poison at home. Which action should the nurse take after assessing that the airway is stable? a. Gastric lavage b. Administer naloxone c. Initiate IV fluid resuscitation d. Prepare for seizure precautions

d. Prepare for seizure precautions Patients with neurological or metabolic side effects are prone to seizures and precautions are necessary.

The nurse is caring for an infant with vomiting and diarrhea for the past week. The nurse notes a depressed anterior fontanel, decreased urine output, and lack of tears. Which prescription should the nurse complete first? a. Initiate oxygen b. Give an IV fluid bolus c. Administer oral antiemetic d. Apply barrier cream to the buttocks

b. Give an IV fluid bolus The patient's symptoms are indicative of hypovolemic shock. IV fluid resuscitation is the most important action.

The nurse is examining a 10-year-old boy with tachypnea and increased work of breathing. Which finding is a late sign that the child is in shock? a) Delayed capillary refill with cool extremities b) Blood pressure slightly less than normal c) Significantly decreased skin elasticity d) Equally strong central and distal pulses

c) Significantly decreased skin elasticity Decrease skin turgor is a late sign of shock.-Blood pressure is not a reliable method of evaluating for shock in children because they tend to maintain normal or slightly below normal blood pressure in compensated shock.- Equal central and distal pulses are not a sign of shock.- Delayed capillary refill with cool extremities are signs of shock that occur earlier than changes in skin turgor.

A 3-year-old girl had a near-drowning incident when she fell into a wading pool. Which intervention would be of the highest priority? a) Inserting a nasogastric tube to decompress stomach b) Assuring the child stays still during an X-ray c) Suctioning the upper airway to ensure airway patency d) Covering the child with warming blankets

c. Suctioning the upper airway to ensure airway patency Explanation: Due to the potentially devastating effects of drowning-related hypoxia on a child's brain, airway interventions must be initiated immediately. The child's airway should be suctioned to ensure patency. Other interventions such as covering the child with blankets, inserting a nasogastric tube, and assuring that the child remains still during X-ray are interventions that are appropriate once airway patency is achieved and maintained.

Administration of which medication reverses histamine release and hypotension that are seen in anaphylaxis? a) Atropine b) Epinephrine c) Benadryl d) Zantac

b. Epinephrine Explanation: Epinephrine reverses histamine release and hypotension due to anaphylaxis.

When developing the plan of care for a 10-month-old infant in septic shock, which intervention would the nurse most likely include? a) Administering intravenous saline as ordered b) Giving blood if saline provides inadequate response c) Inserting a urinary catheter for monitoring urinary output d) Administering intravenous dopamine as ordered

d) Administering intravenous dopamine as ordered

The nurse is providing care to a child experiencing shock. Which intravenous solution would the nurse expect to administer? A) Lactated ringers B) Dextrose 5% and water C) Dextrose 5% and normal saline D) Dextrose 10% and water

Ans: A Feedback: Isotonic fluids, such as Lactated ringers or normal saline, are the fluids of choice given rapidly to children experiencing shock. Dextrose solutions are contraindicated in shock because of the risk of complications such as osmotic diuresis, hypokalemia, hyperglycemia, and worsening of ischemic brain injury

After teaching a group of nursing students about shock in children, the instructor determines that the teaching was successful when the students identify which type of shock as most common? A) Septic B) Cardiogenic C) Hypovolemic D) Distributive

Ans: C Feedback: Although septic, cardiogenic, hypovolemic, and distributive shock can occur in children, hypovolemic shock is the most common type of shock that occurs in children.

A 6-year-old girl in shock is receiving dobutamine. What would the nurse most likely do? a) Give adequate fluids prior to administration. b) Monitor for hypotension or seizures. c) Monitor for ventricular arrhythmias. d) Assess for shortness of breath and dyspnea.

c) Monitor for ventricular arrhythmias.

A 13-year-old boy has had a near-drowning experience. The nurse notices he has labored breathing and a cough. Which of the following is the priority intervention? a) Provide sedation as ordered. b) Check his capillary refill time. c) Administer 100% oxygen by mask. d) Have the child sit up straight in a chair.

C Explanation: Management of the near-drowning victim focuses on assessing his airway, breathing, and circulation (ABCs) and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the child assume the most comfortable position for him. Checking capillary refill time helps determine ineffective tissue perfusion. Providing sedation is an intervention for pain that will be assessed after effective breathing is established.

The nurse is caring for a pediatric patient admitted with severe nausea and vomiting for several days. Which finding will help the nurse quickly evaluate peripheral tissue perfusion? a. Oral temp 102.3 F b. Flat anterior fontanel c. Bowel sounds hyperactive d. Capillary refill greater than 5 seconds

d. Capillary refill greater than 5 seconds Capillary refill is the best assessment method to quickly assess tissue perfusion.

A child who weighs 53 lb is receiving fluid volume replacement as part of the treatment for shock. The nurse is evaluating the child's hourly urinary output to determine if the child's condition is improving. Which output would the nurse interpret as most indicative of improvement? A) 12 mL B) 15 mL C) 22 mL D) 30 mL

Ans: D Feedback: Improved urinary output of 1 to 2 mL/kg/hour is the goal. The child weighs 53 pounds, which is equivalent to 24 kg. Thus, improvement in this child would be noted by an hourly urinary output between 24 and 48 mL/hour.

The nurse is receiving a pediatric patient in shock who was just involved in an accident and has lost a large amount of blood. The patient should be assessed for which type of shock first? a. Septic shock b. Distributive shock c. Cardiogenic shock d. Hypovolemic shock

d. Hypovolemic shock This patient should be first assessed for hypovolemic shock because this is characterized by an overall decrease in circulating blood or fluid volume.

The nurse is caring for a child who is unresponsive after being struck by a vehicle. The child sustained multiple injuries and was diagnosed with cardiogenic shock. The child's parents are tearful and refuse to speak with the provider about the child's prognosis. Which action would the nurse take to enhance family coping? Select all that apply. a. Ask the parents to refrain from staying at the child's bedside b. Provide concise, accurate information to the parents at frequent intervals c. Give information in a calm, relaxed, and empathetic manner d. Encourage parents to participate in the child's care as appropriate e. Provide simple explanations to the child and parents of procedures before initiating them f. Provide detailed information, using correct medical terminology so parents will understand

b. Provide concise, accurate information to the parents at frequent intervals c. Give information in a calm, relaxed, and empathetic manner d. Encourage parents to participate in the child's care as appropriate e. Provide simple explanations to the child and parents of procedures before initiating them The nurse's action of providing concise, accurate information to parents at frequent intervals enhances family coping. Children older than 24 months: 70 mm Hg plus the number that is double the child's age in years. (9-year-old child: 70 + 18 = 88 mm Hg) The nurse's action of giving information in a calm, relaxed, and empathetic manner enhances family coping.The nurse's action of encouraging parents to participate in the child's care as appropriate provides them with some degree of control.The nurse's action of providing simple explanations to the child and parents before initiating them enhances family coping.