Chapter 22: The Child with Gastrointestinal Dysfunction Hockenberry: Wong's Essentials of Pediatric Nursing, 10th Edition Exam 2

What offers the best chance of survival for a child with cirrhosis? a. Liver transplantation b. Treatment with corticosteroids c. Treatment with immune globulin d. Provision of nutritional support

ANS: A The only successful treatment for end-stage liver disease and liver failure may be liver transplantation, which has improved the prognosis for many children with cirrhosis. Liver transplantation has revolutionized the approach to cirrhosis. Liver failure and cirrhosis are indications for transplantation. Liver transplantation reflects the failure of other medical and surgical measures to prevent or treat cirrhosis. DIF: Cognitive Level: Understand REF: p. 719 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

Which is an important nursing consideration in the care of a child with celiac disease? a. Refer to a nutritionist for detailed dietary instructions and education. b. Help child and family understand that diet restrictions are usually only temporary. c. Teach proper hand washing and standard precautions to prevent disease transmission. d. Suggest ways to cope more effectively with stress to minimize symptoms.

ANS: A The main consideration is helping the child adhere to dietary management. Considerable time is spent explaining to the child and parents about the disease process, the specific role of gluten in aggravating the condition, and foods that must be restricted. Referral to a nutritionist would help in this process. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible or stress related. DIF: Cognitive Level: Apply REF: p. 732 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

Which condition in a child should alert a nurse for increased fluid requirements? a. Fever b. Mechanical ventilation c. Congestive heart failure d. Increased intracranial pressure (ICP)

ANS: A Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid overload in children. Increased ICP does not lead to increased fluid requirements in children. DIF: Cognitive Level: Understand REF: p. 689 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. What should therapeutic management of this child begin with? a. Intravenous (IV) fluids b. ORS c. Clear liquids, 1 to 2 ounces at a time d. Administration of antidiarrheal medication

ANS: A In children with severe dehydration, IV fluids are initiated. ORS is acceptable therapy if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth. These fluids have a high carbohydrate content, low electrolyte content, and high osmolality. Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea. DIF: Cognitive Level: Apply REF: p. 706 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

Which type of dehydration is defined as "dehydration that occurs in conditions in which electrolyte and water deficits are present in approximately balanced proportion"? a. Isotonic dehydration b. Hypotonic dehydration c. Hypertonic dehydration d. All types of dehydration in infants and small children

ANS: A Isotonic dehydration is the correct term for this definition and is the most frequent form of dehydration in children. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. Hypertonic dehydration results from water loss in excess of electrolyte loss and is usually caused by a proportionately larger loss of water or a larger intake of electrolytes. This definition is specific to isotonic dehydration. DIF: Cognitive Level: Understand REF: p. 694 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

A nurse is admitting an infant with biliary atresia. Which is the earliest clinical manifestation of biliary atresia the nurse should expect to assess? a. Jaundice b. Vomiting c. Hepatomegaly d. Absence of stooling

ANS: A Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in the sclera and may be present at birth but is usually not apparent until age 2 to 3 weeks. Vomiting is not associated with biliary atresia. Hepatomegaly and abdominal distention are common but occur later. Stools are large and lighter in color than expected because of the lack of bile. DIF: Cognitive Level: Understand REF: p. 719 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. Which nursing action is the most appropriate? a. Notify practitioner b. Measure abdominal girth c. Auscultate for bowel sounds d. Take vital signs, including blood pressure

ANS: A Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic-therapeutic care plan. The first action would be to report the normal stool to the practitioner. DIF: Cognitive Level: Apply REF: p. 728 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

Which is a high-fiber food that the nurse should recommend for a child with chronic constipation? a. Raisins b. Pancakes c. Muffins d. Ripe bananas

ANS: A Raisins are a high-fiber food. Pancakes and muffins do not have significant fiber unless made with fruit or bran. Raw fruits, especially those with skins and seeds, other than ripe bananas, have high fiber. DIF: Cognitive Level: Apply REF: p. 703 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

A child has recurrent abdominal pain (RAP) and a dairy-free diet has been prescribed for 2 weeks. Which explanation is the reason for prescribing a dairy-free diet? a. To rule out lactose intolerance b. To rule out celiac disease c. To rule out sensitivity to high sugar content d. To rule out peptic ulcer disease

ANS: A Treatment for RAP involves providing reassurance and reducing or eliminating symptoms. Dietary modifications may include removal of dairy products to rule out lactose intolerance. Fructose is eliminated to rule out sensitivity to high sugar content, and gluten is removed to rule out celiac disease. A dairy-free diet would not rule out peptic ulcer disease. DIF: Cognitive Level: Understand REF: p. 734 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

The nurse is caring for a neonate with a suspected tracheoesophageal fistula. What nursing care should be included? a. Elevate the head but give nothing by mouth. b. Elevate the head for feedings. c. Feed glucose water only. d. Avoid suctioning unless infant is cyanotic.

ANS: A When a newborn is suspected of having a tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. Feedings should not be given to infants suspected of having tracheoesophageal fistulas. The oral pharynx should be kept clear of secretion by oral suctioning. This is to prevent the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx. DIF: Cognitive Level: Apply REF: p. 725 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

A child who has just had definitive repair of a high rectal malformation is to be discharged. Which should the nurse address in the discharge preparation of this family? (Select all that apply.) a. Perineal and wound care b. Necessity of firm stools to keep suture line clean c. Bowel training beginning as soon as child returns home d. Reporting any changes in stooling patterns to practitioner e. Use of diet modification to prevent constipation

ANS: A, D, E Wound care instruction is necessary in a child who is being discharged after surgery. The parents are taught to notify the practitioner if any signs of an anal stricture or other complications develop. Constipation is avoided, since a firm stool will place strain on the suture line. Fiber and stool softeners are often given to keep stools soft and avoid tension on the suture line. The child needs to recover from the surgical procedure. Then bowel training may begin, depending on the child's developmental and physiologic readiness. DIF: Cognitive Level: Apply REF: p. 732 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. Which is appropriate to relieve the abdominal discomfort? a. Place in Trendelenburg position. b. Allow to assume position of comfort. c. Apply moist heat to the abdomen. d. Administer a saline enema to cleanse bowel.

ANS: B The child should be allowed to take a position of comfort, usually with the legs flexed. The Trendelenburg position will not help with the discomfort. In any instance in which appendicitis is a possibility, there is a danger in administering a laxative or enemas or applying heat to the area. Such measures stimulate bowel motility and increase the risk of perforation. DIF: Cognitive Level: Apply REF: p. 709 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

Parents call the clinic and report that their toddler has had acute diarrhea for 24 hours. The nurse should further ask the parents if the toddler has which associated factor that is causing the acute diarrhea? a. Celiac disease b. Antibiotic therapy c. Immunodeficiency d. Protein malnutrition

ANS: B Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy. Celiac disease is a problem with gluten intolerance and may cause chronic diarrhea if not identified and managed appropriately. Immunodeficiency would occur with chronic diarrhea. Protein malnutrition or kwashiorkor causes chronic diarrhea from lowered resistance to infection. DIF: Cognitive Level: Apply REF: p. 691 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

An infant with short bowel syndrome will be discharged home on total parenteral nutrition (TPN) and gastrostomy feedings. What should be included in the discharge teaching? a. Prepare family for impending death. b. Teach family signs of central venous catheter infection. c. Teach family how to calculate caloric needs. d. Secure TPN and gastrostomy tubing under diaper to lessen risk of dislodgment.

ANS: B During TPN therapy, care must be taken to minimize the risk of complications related to the central venous access device, such as catheter infections, occlusions, or accidental removal. This is an important part of family teaching. The prognosis for patients with short bowel syndrome depends in part on the length of residual small intestine. It has improved with advances in TPN. Although parents need to be taught about nutritional needs, the caloric needs and prescribed TPN and rate are the responsibility of the health care team. The tubes should not be placed under the diaper due to risk of infection. DIF: Cognitive Level: Apply REF: p. 727 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease. What enema solution should be used? a. Tap water b. Normal saline c. Oil retention d. Phosphate preparation

ANS: B Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid overload. Oil-retention enemas will not achieve the "until clear" result. Phosphate enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the phosphate enema can result in diarrhea, which can lead to metabolic acidosis. DIF: Cognitive Level: Apply REF: p. 703 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

A 4-month-old infant has gastroesophageal reflux (GER) but is thriving without other complications. Which should the nurse suggest to minimize reflux? a. Place in Trendelenburg position after eating. b. Thicken formula with rice cereal. c. Give continuous nasogastric tube feedings. d. Give larger, less frequent feedings.

ANS: B Small, frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula have been recommended. Milk-thickening agents have been shown to decrease the number of episodes of vomiting and to increase the caloric density of the formula. This may benefit infants who are underweight as a result of GER disease. Placing the child in a Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive. DIF: Cognitive Level: Apply REF: p. 726 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

A mother who intended to breastfeed has given birth to an infant with a cleft palate. What nursing interventions should be included? a. Giving medication to suppress lactation. b. Encouraging and helping mother to breastfeed. c. Teaching mother to feed breast milk by gavage. d. Recommending use of a breast pump to maintain lactation until infant can suck.

ANS: B The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infant's oral cavity so that the tongue action facilitates milk expression. Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation. Because breastfeeding can usually be accomplished, gavage feedings are not indicated. The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex. DIF: Cognitive Level: Apply REF: p. 724 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

The nurse is caring for an infant whose cleft lip was repaired. What important aspects of this infant's postoperative care should be included? a. Arm restraints, postural drainage, mouth irrigations b. Cleansing the suture line, supine and side-lying positions, arm restraints c. Mouth irrigations, prone position, cleansing the suture line d. Supine and side-lying positions, postural drainage, arm restraints

ANS: B The suture line should be cleansed gently after feeding. The child should be positioned on the back, on the side, or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. There is no reason to perform mouth irrigations, and the child should not be placed in the prone position where injury to the suture site can occur. DIF: Cognitive Level: Apply REF: p. 725 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

Which vaccine is now recommended for the immunization of all newborns? a. Hepatitis A vaccine b. Hepatitis B vaccine c. Hepatitis C vaccine d. Hepatitis A, B, and C vaccines

ANS: B Universal vaccination for hepatitis B is now recommended for all newborns. A vaccine is available for hepatitis A, but it is not yet universally recommended. No vaccine is currently available for hepatitis C. Only hepatitis B vaccine is recommended for newborns. DIF: Cognitive Level: Understand REF: p. 717 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Health Promotion and Maintenance

Which is true concerning hepatitis B? (Select all that apply.) a. Hepatitis B cannot exist in carrier state. b. Hepatitis B can be prevented by HBV vaccine. c. Hepatitis B can be transferred to an infant of a breastfeeding mother. d. Onset of hepatitis B is insidious. e. Principal mode of transmission for hepatitis B is fecal-oral route. f. Immunity to hepatitis B occurs after one attack.

ANS: B, C, D, F The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is protective against hepatitis B. Hepatitis B can be transferred to an infant of a breastfeeding mother, especially if the mother's nipples are cracked. The onset of hepatitis B is insidious. Immunity develops after one exposure to hepatitis B. Hepatitis B has a carrier state. The fecal-oral route is the principal mode of transmission for hepatitis A. Hepatitis B is transmitted through the parenteral route. DIF: Cognitive Level: Understand REF: p. 717 TOP: Integrated Process: Nursing Process: Diagnosis MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

Which type of hernia has an impaired blood supply to the herniated organ? a. Hiatal hernia b. Incarcerated hernia c. Omphalocele d. Strangulated hernia

ANS: D A strangulated hernia is one in which the blood supply to the herniated organ is impaired. Hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus. Incarcerated hernia is a hernia that cannot be reduced easily. Omphalocele is the protrusion of intra-abdominal viscera into the base of the umbilical cord. The sac is covered with peritoneum, not skin. DIF: Cognitive Level: Understand REF: p. 728 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

What are the results of excessive vomiting in an infant with pyloric stenosis? a. Hyperchloremia b. Hypernatremia c. Metabolic acidosis d. Metabolic alkalosis

ANS: D Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Chloride ions and sodium are lost with vomiting. Metabolic alkalosis, not acidosis, is likely. DIF: Cognitive Level: Understand REF: p. 728 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

What is invagination of one segment of bowel within another called? a. Atresia b. Stenosis c. Herniation d. Intussusception

ANS: D Intussusception occurs when a proximal section of the bowel telescopes into a more distal segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction. Invagination of one segment of bowel within another is the definition of intussusception, not atresia, stenosis, or herniation. DIF: Cognitive Level: Understand REF: p. 728 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

Which therapeutic management treatment is implemented for children with Hirschsprung disease? a. Daily enemas b. Low-fiber diet c. Permanent colostomy d. Surgical removal of affected section of bowel

ANS: D Most children with Hirschsprung disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery. The colostomy that is created in Hirschsprung disease is usually temporary. DIF: Cognitive Level: Understand REF: p. 703 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

A child is admitted with bacterial gastroenteritis. Which lab results of a stool specimen confirm this diagnosis? a. Eosinophils b. Occult blood c. pH less than 6 d. Neutrophils and red blood cells

ANS: D Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance and parasitic infections are suspected in the presence of eosinophils. Occult blood may indicate pathogens such as Shigella, Campylobacter, or hemorrhagic Escherichia coli strains. A pH of less than 6 may indicate carbohydrate malabsorption or secondary lactase insufficiency. DIF: Cognitive Level: Understand REF: p. 700 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

Which clinical manifestation would be the most suggestive of acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Abdominal pain that is most intense at McBurney point

ANS: D Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain localizes to the right lower quadrant at McBurney point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Bright red or dark red rectal bleeding and abdominal pain that is relieved by eating are not signs of acute appendicitis. DIF: Cognitive Level: Understand REF: p. 709 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

Which pathogen is the viral pathogen that frequently causes acute diarrhea in young children? a. Giardia organisms b. Shigella organisms c. Rotavirus d. Salmonella organisms

ANS: C Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia (parasite) and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial pathogen that is uncommon in the United States. DIF: Cognitive Level: Understand REF: p. 697 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

Which observation made of the exposed abdomen is most indicative of pyloric stenosis? a. Abdominal rigidity b. Substernal retraction c. Palpable olive-like mass d. Marked distention of lower abdomen

ANS: C The diagnosis of pyloric stenosis is often made after the history and physical examination. The olive-like mass is easily palpated when the stomach is empty, the infant is quiet, and the abdominal muscles are relaxed. Abdominal rigidity and substernal retraction are usually not present. The upper abdomen, not lower abdomen, is distended. DIF: Cognitive Level: Understand REF: p. 728 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

A nurse is conducting an in-service on childhood gastrointestinal disorders. Which statement is most descriptive of Meckel diverticulum? a. It is more common in females than in males. b. It is acquired during childhood. c. Intestinal bleeding may be mild or profuse. d. Medical interventions are usually sufficient to treat the problem.

ANS: C Bloody stools are often a presenting sign of Meckel diverticulum. It is associated with mild to profuse intestinal bleeding. It is twice as common in males as in females, and complications are more frequent in males. Meckel diverticulum is the most common congenital malformation of the GI tract and is present in 1% to 4% of the general population. The standard therapy is surgical removal of the diverticulum. DIF: Cognitive Level: Apply REF: p. 709 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

An infant is brought to the emergency department with dehydration. Which physical assessment finding does the nurse expect? a. Weight gain b. Bradycardia c. Poor skin turgor d. Brisk capillary refill

ANS: C Clinical manifestations of dehydration include poor skin turgor, weight loss, lethargy, and tachycardia. The infant would have prolonged capillary refill, not brisk. DIF: Cognitive Level: Understand REF: p. 691 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

Constipation has recently become a problem for a school-age girl. She is healthy except for seasonal allergies that are being treated with antihistamines. What should the nurse suspect caused the constipation? a. Diet b. Allergies c. Antihistamines d. Emotional factors

ANS: C Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids, antiepileptics, and iron. Because this is the only known change in her habits, the addition of antihistamines is most likely the cause of the diarrhea. With a change in bowel habits, the role of any recently prescribed medications should be assessed. DIF: Cognitive Level: Analyze REF: p. 702 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

Which is used to treat moderate to severe inflammatory bowel disease? a. Antacids b. Antibiotics c. Corticosteroids d. Antidiarrheal medications

ANS: C Corticosteroids, such as prednisone and prednisolone, are used in short bursts to suppress the inflammatory response in inflammatory bowel disease. Antacids and antidiarrheal medications are not drugs of choice in the treatment of inflammatory bowel disease. Antibiotics may be used as an adjunctive therapy to treat complications. DIF: Cognitive Level: Understand REF: p. 713 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

Which is a parasite that causes acute diarrhea? a. Shigella organisms b. Salmonella organisms c. Giardia lamblia d. Escherichia coli

ANS: C G. lamblia is a parasite that represents 10% of non-dysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens. DIF: Cognitive Level: Understand REF: p. 697 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

Which statement best characterizes hepatitis A? a. Incubation period is 6 weeks to 6 months. b. Principal mode of transmission is through the parenteral route. c. Onset is usually rapid and acute. d. There is a persistent carrier state.

ANS: C Hepatitis A is the most common form of acute hepatitis in most parts of the world. It is characterized by a rapid and acute onset. The incubation period is approximately 3 weeks for hepatitis A, and the principal mode of transmission for it is the fecal-oral route. Hepatitis A does not have a carrier state. DIF: Cognitive Level: Understand REF: p. 717 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

The nurse is explaining to a parent how to care for a school-age child with vomiting associated with a viral illness. Which action should the nurse include? a. Avoid carbohydrate-containing liquids. b. Give nothing by mouth for 24 hours. c. Brush teeth or rinse mouth after vomiting. d. Give plain water until vomiting ceases for at least 24 hours.

ANS: C It is important to emphasize the need for the child to brush the teeth or rinse the mouth after vomiting to dilute the hydrochloric acid that comes in contact with the teeth. Ad libitum administration of glucose- electrolyte solution to an alert child will help restore water and electrolytes satisfactorily. It is important to include carbohydrate to spare body protein and avoid ketosis. DIF: Cognitive Level: Apply REF: p. 709 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

A nurse is conducting an in-service on gastrointestinal disorders. The nurse includes that melena, the passage of black, tarry stools, suggests bleeding from which area? a. Perianal or rectal area b. Hemorrhoids or anal fissures c. Upper gastrointestinal (GI) tract d. Lower GI tract

ANS: C Melena is denatured blood from the upper GI tract or bleeding from the right colon. Blood from the perianal or rectal area, hemorrhoids, or lower GI tract would be bright red. DIF: Cognitive Level: Apply REF: p. 696 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

Which therapeutic management should the nurse prepare to initiate first for a child with acute diarrhea and moderate dehydration? a. Clear liquids b. Adsorbents, such as kaolin and pectin c. Oral rehydration solution (ORS) d. Antidiarrheal medications such as paregoric

ANS: C ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended. Antidiarrheals are not recommended because they do not get rid of pathogens. DIF: Cognitive Level: Apply REF: p. 700 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

During the first few days after surgery for cleft lip, which intervention should the nurse do? a. Leave infant in crib at all times to prevent suture strain. b. Keep infant heavily sedated to prevent suture strain. c. Remove restraints periodically to cuddle infant. d. Alternate position from prone to side-lying to supine.

ANS: C Remove restraints periodically, while supervising the infant, to allow him or her to exercise arms and to provide cuddling and tactile stimulation. The infant should not be left in the crib, but should be removed for appropriate holding and stimulation. Analgesia and sedation are administered for pain. Heavy sedation is not indicated. The child should not be placed in the prone position. DIF: Cognitive Level: Apply REF: p. 725 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

When caring for a child with probable appendicitis, the nurse should be alert to recognize that which condition or symptom is a sign of perforation? a. Bradycardia b. Anorexia c. Sudden relief from pain d. Decreased abdominal distention

ANS: C Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical manifestation of appendicitis. Abdominal distention usually increases. DIF: Cognitive Level: Understand REF: p. 709 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child psychologically is: a. not necessary because of child's age. b. not necessary because colostomy is temporary. c. necessary because it will be an adjustment. d. necessary because the child must deal with a negative body image.

ANS: C The child's age dictates the type and extent of psychological preparation. When a colostomy is performed, the child who is at least preschool age is told about the procedure and what to expect in concrete terms, with the use of visual aids. It is necessary to prepare a 3-year-old child for procedures. The preschooler is not yet concerned with body image. DIF: Cognitive Level: Understand REF: p. 705 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Psychosocial Integrity: Coping and Adaptation

A histamine-receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is ordered for an infant with GER. What is the purpose of this medication? a. Prevent reflux b. Prevent hematemesis c. Reduce gastric acid production d. Increase gastric acid production

ANS: C The mechanism of action of histamine-receptor antagonists is to reduce the amount of acid present in gastric contents and perhaps prevent esophagitis. Preventing reflux or hematemesis and increasing gastric acid production are not the modes of action of histamine-receptor antagonists. DIF: Cognitive Level: Understand REF: p. 707 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis? a. Abdominal rigidity and pain on palpation b. Rounded abdomen and hypoactive bowel sounds c. Visible peristalsis and weight loss d. Distention of lower abdomen and constipation

ANS: C Visible gastric peristaltic waves that move from left to right across the epigastrium and weight loss are observed in pyloric stenosis. Abdominal rigidity and pain on palpation or a rounded abdomen and hypoactive bowel sounds are usually not present. The upper abdomen, not lower abdomen, is distended. DIF: Cognitive Level: Apply REF: p. 728 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

A nurse is conducting dietary teaching on high-fiber foods for parents of a child with constipation. Which foods should the nurse include as being high in fiber? (Select all that apply.) a. White rice b. Avocados c. Whole grain breads d. Bran pancakes e. Raw carrots

ANS: C, D, E High-fiber foods include whole grain breads, bran pancakes, and raw carrots. Unrefined (brown) rice is high in fiber, but white rice is not. Raw fruits, especially those with skins or seeds, other than ripe banana or avocado, are high in fiber. DIF: Cognitive Level: Understand REF: p. 732 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance

What should be included in caring for the newborn with a cleft lip and palate before surgical repair? a. Gastrostomy feedings b. Keeping infant in near-horizontal position during feedings c. Allowing little or no sucking d. Providing satisfaction of sucking needs

ANS: D Using special or modified nipples for feeding techniques helps meet the infant's sucking needs. Gastrostomy feedings are usually not indicated. Feeding is best accomplished with the infant's head in an upright position. The child requires both nutritive and nonnutritive sucking. DIF: Cognitive Level: Apply REF: p. 723 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

A child has an NG tube to continuous low intermittent suction. The physician's prescription is to replace the previous 4-hour NG output with a normal saline piggyback over a 2- hour period. The NG output for the previous 4 hours totaled 50 ml. What milliliter/hour rate should the nurse administer to replace normal saline piggyback? (Record your answer in a whole number.)

ANS:25 The previous total 4-hour output was 50 ml. To run the 50 ml over a 2-hour period, the nurse woulddivide 50 by 2 = 25. The normal saline replacement fluid would be run at 25 ml per hour.DIF_ Cognitive Level_ Apply REF_ p. 693TOP_ Integrated Process_ Nursing Process_ PlanningMSC_ Area of Client Needs_ Physiologic Integrity_ Pharmacologic and Parenteral Therapies

A nurse is receiving report on a newborn admitted yesterday after a gastroschisis repair. In the report, the nurse is told the newborn has a physician's prescription for an NG tube to low intermittent suction. The reporting nurse confirms that the NG tube is to low intermittent suction and draining light green stomach contents. Upon initial assessment, the nurse notes that the newborn has pulled the NG tube out. Which is the priority action the nurse should take? a. Replace the NG tube and continue the low intermittent suction. b. Leave the NG tube out and notify the physician at the end of the shift. c. Leave the NG tube out and monitor for bowel sounds. d. Replace the NG tube, but leave to gravity drainage instead of low wall suction.

ANS: A A newborn with a gastroschisis performed the day before will require bowel decompression with an NG tube to low wall intermittent suction. The nurse's priority action is to replace the NG tube and continue with the low wall intermittent suctioning. The NG tube cannot be left out this soon after surgery. The physician's prescription was to have the NG tube to low wall intermittent suction, so the tube cannot be placed to gravity drainage. DIF: Cognitive Level: Apply REF: p. 729 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

A mother calls the clinic nurse about her 4-year-old son who has acute diarrhea. She has been giving him the antidiarrheal drug loperamide (Imodium A-D). The nurse's response should be based on what knowledge about this drug? a. Not indicated b. Indicated because it slows intestinal motility c. Indicated because it decreases diarrhea d. Indicated because it decreases fluid and electrolyte losses

ANS: A Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea. These medications have adverse effects and toxicity, such as worsening of the diarrhea because of slowing of motility and ileus, or a decrease in diarrhea with continuing fluid losses and dehydration. Antidiarrheal medications are not recommended in infants and small children. DIF: Cognitive Level: Analyze REF: p. 701 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A nurse is admitting a child with Crohn disease. Parents ask the nurse, "How is this disease different from ulcerative colitis?" Which statement should the nurse make when answering this question? a. "With Crohn disease the inflammatory process involves the whole GI tract." b. "There is no difference between the two diseases." c. "The inflammation with Crohn disease is limited to the colon and rectum." d. "Ulcerative colitis is characterized by skip lesions."

ANS: A The chronic inflammatory process of Crohn disease involves any part of the GI tract from the mouth to the anus but most often affects the terminal ileum. Crohn disease involves all layers of the bowel wall in a discontinuous fashion, meaning that between areas of intact mucosa, there are areas of affected mucosa (skip lesions). The inflammation found with ulcerative colitis is limited to the colon and rectum, with the distal colon and rectum the most severely affected. Inflammation affects the mucosa and submucosa and involves continuous segments along the length of the bowel with varying degrees of ulceration, bleeding, and edema. DIF: Cognitive Level: Apply REF: p. 713 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

Why are bismuth subsalicylate, clarithromycin, and metronidazole prescribed for a child with a peptic ulcer? a. Eradicate Helicobacter pylori b. Coat gastric mucosa c. Treat epigastric pain d. Reduce gastric acid production

ANS: A The drug therapy combination of bismuth subsalicylate, clarithromycin, and metronidazole is effective in the treatment of H. pylori and is prescribed to eradicate it. DIF: Cognitive Level: Understand REF: p. 716 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

A nurse is planning preoperative care for a newborn with tracheoesophageal fistula (TEF). Which interventions should the nurse plan to implement? (Select all that apply.) a. Positioning with head elevated on a 30-degree plane b. Feedings through a gastrostomy tube c. Nasogastric tube to continuous low wall suction d. Suctioning with a Replogle tube passed orally to the end of the pouch e. Gastrostomy tube to gravity drainage

ANS: A, D, E The most desirable position for a newborn who has TEF is supine (or sometimes prone) with the head elevated on an inclined plane of at least 30 degrees. This positioning minimizes the reflux of gastric secretions at the distal esophagus into the trachea and bronchi, especially when intra-abdominal pressure is elevated. It is imperative to immediately remove any secretions that can be aspirated. Until surgery, the blind pouch is kept empty by intermittent or continuous suction through an indwelling double-lumen or Replogle catheter passed orally or nasally to the end of the pouch. In some cases, a percutaneous gastrostomy tube is inserted and left open so that any air entering the stomach through the fistula can escape, thus minimizing the danger of gastric contents being regurgitated into the trachea. The gastrostomy tube is emptied by gravity drainage. Feedings through the gastrostomy tube and irrigations with fluid are contraindicated before surgery in an infant with a distal TEF. A nasogastric tube to low intermittent suctioning could not be accomplished because the esophagus ends in a blind pouch in TEF. DIF: Cognitive Level: Apply REF: p. 725 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

Parents of a child undergoing an endoscopy to rule out peptic ulcer disease (PUD) from H. pylori ask the nurse, "If H. pylori is found, will my child need another endoscopy to know that it is gone?" Which is the nurse's best response? a. "Yes, the only way to know the H. pylori has been eradicated is with another endoscopy." b. "We can collect a stool sample and confirm that the H. pylori has been eradicated." c. "A blood test can be done to determine that the H. pylori is no longer present." d. "Your child will always test positive for H. pylori because after treatment it goes into remission but can't be completely eradicated."

ANS: B An upper endoscopy is the procedure initially performed to diagnose PUD. A biopsy can determine the presence of H. pylori. Polyclonal and monoclonal stool antigen tests are an accurate, noninvasive method to confirm H. pylori has been eradicated after treatment. A blood test can identify the presence of the antigen to this organism, but because H. pylori was already present, it would not be as accurate as a stool sample to determine whether it has been eradicated. H. pylori can be treated and, once the treatment is complete, the stool sample can determine that it was eradicated. DIF: Cognitive Level: Apply REF: p. 716 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. What is the initial therapeutic approach for the mother? a. Restating what the physician has told her about plastic surgery. b. Encouraging her to express her feelings. c. Emphasizing the normalcy of her baby and the baby's need for mothering. d. Recognizing that negative feelings toward the child continue throughout childhood.

ANS: B For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must emphasize not only the infant's physical needs but also the parents' emotional needs. The mother needs to be able to express her feelings before she can accept her child. Although the nurse will restate what the physician has told the mother about plastic surgery, it is not part of the initial therapeutic approach. As the mother expresses her feelings, the nurse's actions should convey to the parents that the infant is a precious human being. The nurse emphasizes the child's normalcy and helps the mother recognize the child's uniqueness. DIF: Cognitive Level: Apply REF: p. 723 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Psychosocial Integrity

What is the best description of pyloric stenosis? a. Dilation of the pylorus b. Hypertrophy of the pyloric muscle c. Hypotonicity of the pyloric muscle d. Reduction of tone in the pyloric muscle

ANS: B Hypertrophic pyloric stenosis occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel. Dilation of the pylorus, hypotonicity of the pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis. DIF: Cognitive Level: Understand REF: p. 728 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

The home care nurse has been visiting an adolescent with recently acquired tetraplegia. The teen's mother tells the nurse, "I'm sick of providing all the care while my husband does whatever he wants to, whenever he wants to do it." Which should be the initial action of the nurse? a. Refer mother for counseling. b. Listen and reflect mother's feelings. c. Ask father, in private, why he does not help. d. Suggest ways the mother can get her husband to help.

ANS: B It is appropriate for the nurse to reflect with the mother about her feelings, exploring issues such as an additional home health aide to help care for the child and provide respite for the mother. It is inappropriate for the nurse to agree with the mother that her husband is not helping enough. It is a judgment beyond the role of the nurse and can undermine the family relationship. Counseling is not necessary at this time. A support group for caregivers may be indicated. Asking the father why he does not help and suggesting ways to the mother to get her husband to help are interventions based on the mother's assumption of minimal contribution to the child's care. The father may have a full-time job and other commitments. The parents need to have an involved third person help them through the negotiation of responsibilities for the loss of their normal child and new parenting responsibilities. DIF: Cognitive Level: Apply REF: p. 708 TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Psychosocial Integrity

One of the supervisors for a home health agency asks the nurse to give the family a survey evaluating the nurses and other service providers. How should the nurse interpret this request? a. Inappropriate, unless nurses are able to evaluate family. b. Appropriate to improve quality of care. c. Inappropriate, unless nurses and other providers agree to participate. d. Inappropriate, because family lacks knowledge necessary to evaluate professionals.

ANS: B Quality assessment and improvement activities are essential for virtually all organizations. Family involvement is essential in evaluating a home care plan and can occur on several levels. The nurse can ask the family open-ended questions at regular intervals to assess their opinion of the effectiveness of care. Families should also be given an opportunity to evaluate the individual home care nurses, the home care agency, and other service providers periodically. The nurse is the care provider. The evaluation is of the provision of care to the patient and family. The nurse's role is not to evaluate the family. Quality- monitoring activities are required by virtually all health care agencies. During the evaluation process, the family is requested to provide their perceptions of care. DIF: Cognitive Level: Apply REF: p. 708 TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care

The nurse is preparing to care for an infant returning from pyloromyotomy surgery. Which prescribed orders should the nurse anticipate implementing? (Select all that apply.) a. NPO for 24 hours b. Administration of analgesics for pain c. Ice bag to the incisional area d. IV fluids continued until tolerating PO e. Clear liquids as the first feeding

ANS: B, D, E Feedings are usually instituted soon after a pyloromyotomy surgery, beginning with clear liquids and advancing to formula or breast milk as tolerated. IV fluids are administered until the infant is taking and retaining adequate amounts by mouth. Appropriate analgesics should be given around the clock because pain is continuous. Ice should not be applied to the incisional area as it vasoconstricts and would reduce circulation to the incisional area and impair healing. DIF: Cognitive Level: Apply REF: p. 728 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

A school-age child with diarrhea has been rehydrated. The nurse is discussing the child's diet with the family. Which statement by the parent would indicate a correct understanding of the teaching? a. "I will keep my child on a clear liquid diet for the next 24 hours." b. "I should encourage my child to drink carbonated drinks but avoid food for the next 24 hours." c. "I will offer my child bananas, rice, applesauce, and toast for the next 48 hours." d. "I should have my child eat a normal diet with easily digested foods for the next 48 hours."

ANS: D Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness. Clear liquids and carbonated drinks have high carbohydrate content and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. The BRAT diet has little nutritional value and is high in carbohydrates. DIF: Cognitive Level: Apply REF: p. 700 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

A nurse is admitting an infant with dehydration caused from water loss in excess of electrolyte loss. Which type of dehydration is this infant experiencing? a. Isotonic b. Isosmotic c. Hypotonic d. Hypertonic

ANS: D Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion and is another term for isomotic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. DIF: Cognitive Level: Understand REF: p. 694 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

A family wants to begin oral feeding of their 4-year-old son, who is ventilator- dependent and currently tube-fed. They ask the home health nurse to feed him the baby food orally. The nurse recognizes a high risk of aspiration and an already compromised respiratory status. What is the most appropriate nursing action? a. Refuse to feed him orally because the risk is too high. b. Explain the risks involved, and then let the family decide what should be done. c. Feed him orally because the family has the right to make this decision for their child. d. Acknowledge their request, explain the risks, and explore with the family the available options.

ANS: D Parents want to be included in the decision making for their child's care. The nurse should discuss the request with the family to ensure this is the issue of concern, and then they can explore potential options together. Merely refusing to feed the child orally does not determine why the parents wish the oral feedings to begin and does not involve them in the problem solving. The decision to begin or not change feedings should be a collaborative one, made in consultation with the family, nurse, and appropriate member of the health care team. DIF: Cognitive Level: Analyze REF: p. 735 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care