EXAM 3 nurse labs

Steve is diagnosed with celiac disease and experiences celiac crisis secondary to upper respiratory tract infection; which of the following would Nurse Nancy expect to assess? A. Lethargy B. Weight gain C. Respiratory distress D. Watery diarrhea

Correct Answer: D. Watery diarrhea Episodes of celiac crises are precipitated by infections, ingestion of gluten, prolonged fasting, or exposure to anticholinergics. Celiac crisis is typically characterized by severe watery diarrhea. Celiac crisis is a life-threatening syndrome in which patients with celiac disease have profuse diarrhea and severe metabolic disturbances.

The nurse is assessing a newborn who had undergone vaginal delivery. Which of the following findings is least likely to be observed in a normal newborn? A. uneven head shape B. respirations are irregular, abdominal, 30-60 bpm C. (+) Moro reflex D. heart rate is 80 bpm

Correct Answer D. Heart rate is 80 bpm Normal heart rate of the newborn is 120 to 160 bpm. The high heart rate (120 to 160 beats per minute) seen in newborn infants can be attributed to the high metabolic rate of activity to main breathing, feeding, and thermogenesis.

Which of the following should be included when developing a teaching plan to prevent urinary tract infection? Select all that apply. A. Maintaining adequate fluid intake B. Avoiding urination before and after intercourse C. Emptying bladder with urination D. Wearing underwear made of synthetic material such as nylon E. Keeping urine alkaline by avoiding acidic beverages F. Avoiding bubble baths and tight clothing

Correct Answer: A, C, & F Even with proper antibiotic treatment, most UTI symptoms can last several days. In women with recurrent UTIs, the quality of life is poor. About 25% of women experience such recurrences. Many cases of uncomplicated UTIs will resolve spontaneously, without treatment, but many patients seek therapy for symptom relief.

Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse in charge detects dry mucous membranes and lethargy. What other findings suggest a fluid volume deficit? A. A sunken fontanel B. Decreased pulse rate C. Increased blood pressure D. Low urine specific gravity

Correct Answer: A. A sunken fontanel In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels, increased pulse rate, and decreased blood pressure. They occur when the body can no longer maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to minimize fluid loss, which results in concentrated urine with high specific gravity.

12-year-old Caroline has recurring nephrotic syndrome. Which of the following areas of potential disturbances should be a prime consideration when planning ongoing nursing care? A. Body image B. Sexual maturation C. Muscle coordination D. Intellectual development

Correct Answer: A. Body image Because of edema associated with nephrotic syndrome, potential self-concept, and body image disturbances related to changes in appearance and social isolation should be considered. Nephrotic syndrome is a condition that causes the kidneys to leak large amounts of protein into the urine. This can lead to a range of problems, including swelling of body tissues and a greater chance of catching infections.

Patient S is a sexually active adolescent. Which of the following instructions would be included in the preventive teaching plan about urinary tract infections? A. Drinking acidic juices B. Avoiding urinating before intercourse C. Wearing nylon underwear D. Wiping back to front

Correct Answer: A. Drinking acidic juices Drinking acidic juices, such as cranberry juice, helps keep the urine at its desired pH and reduces the chance of infection. Pure cranberry juice, cranberry extract, or cranberry supplements may help prevent repeated UTIs in women, but the benefit is small. It helps about as much as taking antibiotics to prevent another UTI.

Nurse Elena is handling a 7-year-old child who has cystitis. Which of the following would Nurse Elena expect when assessing the child? A. Dysuria B. Costovertebral tenderness C. Flank pain D. High fever

Correct Answer: A. Dysuria Dysuria is a symptom of a lower urinary tract infection (UTI) such as cystitis. Common symptoms include frequency, dysuria, urgency, suprapubic pain, cloudy urine, hematuria, nausea, vomiting, and fever. A history is the most important tool for the diagnosis of acute uncomplicated cystitis, and it should be supported by a focused examination and urinalysis.

A female child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first? A. Heart rate, respiratory rate, and blood pressure B. Recent exposure to communicable diseases C. Number of immunizations received D. Height and weight

Correct Answer: A. Heart rate, respiratory rate, and blood pressure The most important data to obtain on a child's arrival in the emergency department are vital sign measurements. Salicylate toxicity is a medical emergency. Intentional ingestion or accidental overdose can cause severe metabolic derangements, making treatment difficult. In an acute salicylate overdose, the onset of symptoms will occur within 3 to 8 hours. The severity of symptoms is dependent on the amount ingested.

Nurse Chole is evaluating a female child with acute post-streptococcal glomerulonephritis for signs of improvement. Which finding typically is the earliest sign of improvement? A. Increased urine output B. Increased appetite C. Increased energy level D. Decreased diarrhea

Correct Answer: A. Increased urine output Increased urine output, a sign of improving kidney function, typically is the first sign that a child with acute post-streptococcal glomerulonephritis (APSGN) is improving. PSGN typically presents with features of the nephritic syndrome such as hematuria, oliguria, hypertension, and edema, though it can also present with significant proteinuria.

The nurse is evaluating a female child with acute post streptococcal glomerulonephritis for signs of improvement. Which finding typically is the earliest sign of improvement? A. Increased urine output B. Increased appetite C. Increased energy level D. Decreased diarrhea

Correct Answer: A. Increased urine output Increased urine output, a sign of improving kidney function, typically is the first sign that a child with acute post-streptococcal glomerulonephritis (APSGN) is improving. PSGN typically presents with features of the nephritic syndrome such as hematuria, oliguria, hypertension, and edema, though it can also present with significant proteinuria.

Which of the following situations increase the risk of lead poisoning in children? A. playing in the park with heavy traffic and with many vehicles passing by B. playing sand in the park C. playing plastic balls with other children D. playing with stuffed toys at home

Correct Answer: A. Playing in the park with heavy traffic and with many vehicles passing by. Lead poisoning may be caused by inhalation of dust and smoke from leaded gas. It may also be caused by lead-based paint, soil, water (especially from plumbings of old houses). Approximately 535000 children between 1 and 5 years of age have an elevated blood lead concentration, defined by the Advisory Committee on Childhood Lead Poisoning Prevention of the Centers for Disease Control and Prevention (CDC) as greater than or equal to 5mcg/dL based on the 97.5 percentile of blood lead concentrations in the most recent National Health and Nutrition Examination Survey (NHANES) dataset.

Will is being assessed by Nurse Lucas for possible intussusception. Which of the following would be least likely to provide valuable information? A. Abdominal palpation B. Family history C. Pain pattern D. Stool inspection

Correct Answer: B. Family history Because intussusception is not believed to have familial tendencies, obtaining a family history would provide the least amount of information. The causes of intussusception are not clearly known. About 90% of cases of intussusception in children arise from an unknown cause. They can include infections, anatomical factors, and altered motility.

In pediatric gastroesophageal reflux disease (GERD), the immaturity of lower esophageal sphincter function is manifested by frequent transient lower esophageal relaxations, which result in retrograde flow of gastric contents into the esophagus. Which statement about the esophagus is true? Select all that apply. A. It is a cartilaginous tube. B. It has upper and lower sphincters. C. It lies anterior to the trachea. D. It extends from the nasal cavity to the stomach. E. It is a highway for food and drinks to travel along to make it to the stomach. F. All statements describe the esophagus.

Correct Answer: B & E Upper and lower esophageal sphincters, located at the upper and lower ends of the esophagus, respectively, regulate the movement of food into and out of the esophagus. If the mouth is the gateway to the body, then the esophagus is a highway for food and drink to travel along to make it to the stomach.

Niklaus was born with hypospadias; which of the following should be avoided when a child has such condition? A. Surgery B. Circumcision C. Intravenous pyelography (IVP) D. Catheterization

Correct Answer: B. Circumcision Hypospadias refers to a condition in which the urethral opening is located below the glans penis or anywhere along the ventral surface (underside) of the penile shaft. The ventral foreskin is lacking, and the distal portion gives an appearance of a hood. Early recognition is important so that circumcision is avoided; the foreskin is used for surgical repair.

What is most likely the underlying physiology of primary enuresis? A. Psychogenic stress B. Delayed bladder maturation C. Urinary tract infection D. Vesicoureteral reflux

Correct Answer: B. Delayed bladder maturation The most likely cause of primary enuresis is delayed or incomplete maturation of the bladder. Primary enuresis is that which occurs in a child who has not been dry for at least 6 months, whereas secondary enuresis is the one that has an onset after a period of nocturnal dryness of at least 6 months.

Nurse Jeremy is evaluating a client's fluid intake and output record. Fluid intake and urine output should relate in which way? A. Fluid intake should double the urine output. B. Fluid intake should be approximately equal to the urine output. C. Fluid intake should be half the urine output. D. Fluid intake should be inversely proportional to the urine output.

Correct Answer: B. Fluid intake should be approximately equal to the urine output. Normally, fluid intake is approximately equal to the urine output. Any other relationship signals an abnormality. One general principle for all patient scenarios is to replace whatever fluid is being lost as accurately as possible. The strategy of managing a patient's fluid differs depending on each patient's clinical condition. If they can drink adequate fluid volumes by mouth, this should be the first choice. Some patients can tolerate other enteral options, such as feeding tubes. IV plus oral orders are effective for those unable to meet their total daily fluid requirements enterally.

An unconscious child is brought to the emergency room due to Tylenol poisoning. Which of the following is the most appropriate nursing action? A. Administer mucomyst P.O B. Gastric lavage with activated charcoal C. Gastric Lavage with activated charcoal and mucomyst D. Administer ethylenediaminetetraacetic acid (EDTA)

Correct Answer: B. Gastric lavage with activated charcoal. In an unconscious child with Tylenol poisoning, the priority intervention is to administer gastric lavage with activated charcoal to decrease the absorption of Tylenol. If the patient presents within 1 hour of ingestion, GI decontamination may be attempted. In alert patients, activated charcoal can be used. Orogastric lavage or whole bowel irrigation is not effective.

Baby Ellie is diagnosed with gastroesophageal reflux (GER). Which of the following nursing diagnoses would be inappropriate? A. Risk for aspiration B. Impaired oral mucous membrane C. Deficient fluid volume D. Imbalanced nutrition: Less than body requirements

Correct Answer: B. Impaired oral mucous membrane GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder.

When educating parents regarding known antecedent infections in acute glomerulonephritis, which of the following should the nurse cover? A. Scabies B. Impetigo C. Herpes simplex D. Varicella

Correct Answer: B. Impetigo Impetigo, a bacterial infection of the skin, may be caused by streptococci and may precede acute glomerulonephritis. Although most streptococcal infections do not cause acute glomerulonephritis, when they do, a latent period of 10 to 14 days occurs between the infection, usually of the skin (impetigo) or upper respiratory tract, and the onset of clinical manifestations.

Dustin who was diagnosed with Hirschsprung's disease has a fever and watery explosive diarrhea. Which of the following would Nurse Joyce do first? A. Administer an antidiarrheal. B. Notify the physician immediately. C. Monitor the child every 30 minutes. D. Nothing. (These findings are common in Hirschsprung's disease.)

Correct Answer: B. Notify the physician immediately. For the child with Hirschsprung's disease, fever and explosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physician should be notified directly. Further important pointers in the history of patients with suspected HD include clinical features of Hirschsprung's associated enterocolitis (HAEC), multiple episodes of overflow constipation, and soft distended abdomen.

The nurse is aware that the most common assessment finding in a child with ulcerative colitis is: A. Intense abdominal cramps B. Profuse diarrhea C. Anal fissures D. Abdominal distention

Correct Answer: B. Profuse diarrhea The most common assessment finding in a child with ulcerative colitis is profuse diarrhea. The main symptom of ulcerative colitis is bloody diarrhea, with or without mucus. Other symptoms include blood in the toilet, on toilet paper, or in the stool. Characteristically, it involves inflammation restricted to the mucosa and submucosa of the colon. Typically, the disease starts in the rectum and extends proximally in a continuous manner.

Nurse Kathy is aware that the most common assessment finding in a child with ulcerative colitis is: A. Intense abdominal cramps B. Profuse diarrhea C. Anal fissures D. Abdominal distention

Correct Answer: B. Profuse diarrhea Ulcerative colitis causes profuse diarrhea. The most common assessment finding in a child with ulcerative colitis is profuse diarrhea. The main symptom of ulcerative colitis is bloody diarrhea, with or without mucus. Other symptoms include blood in the toilet, on toilet paper, or in the stool. Characteristically, it involves inflammation restricted to the mucosa and submucosa of the colon. Typically, the disease starts in the rectum and extends proximally in a continuous manner.

Nurse Nancy is teaching Mr. and Mrs. Diaz about the early signs and symptoms of lead poisoning. Which of the following if stated by the couple would indicate the need for further understanding of the case? A. Anemia B. Seizures C. Irritability D. Anorexia

Correct Answer: B. Seizures Seizures usually are associated with encephalopathy, a late sign of lead poisoning. Typically, lead levels have already exceeded 70 mg/dl. In the appropriate clinical setting, lead encephalopathy should be considered in patients presenting with delirium, altered mental status, or seizures. As lead encephalopathy often presents with altered sensorium, obtaining a history directly from the patient can be challenging.

Which of the following parameters would Nurse Max monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux (GER)? A. Urine B. Vomiting C. Weight D. Stools

Correct Answer: B. Vomiting Thickened feedings are used with GER to stop the vomiting. Therefore, the nurse would monitor the child's vomiting to evaluate the effectiveness of using the thickened feedings. The feeding management strategy has been shown to represent an effective approach in otherwise healthy infants with both GER and GERD. It involves modifying feeding frequency and volume, ensuring the intake of feed per kilogram of weight is appropriate. There is some evidence for the efficacy of feed thickeners on reducing visible regurgitation

An 11-year-old girl with celiac disease was discharged from the hospital. An appropriate teaching was carried out by the nurse if the parents are aware of avoiding which of the following? A. Chicken B. Wheat C. Milk D. Rice

Correct Answer: B. Wheat Children with celiac disease cannot tolerate or digest gluten. Therefore, because of its gluten content, wheat and wheat-containing products must be avoided. Celiac disease is an autoimmune condition that causes severe damage to the lining of the small intestine. Gluten — a protein found in wheat, barley, and rye — triggers its symptoms.

Which of the following organisms is the most common cause of urinary tract infection (UTI) in children? A. Klebsiella B. Staphylococcus C. Escherichia coli D. Pseudomonas

Correct Answer: C. Escherichia coli E. coli is the most common organism associated with the development of UTI. Escherichia coli is the most common organism in uncomplicated UTI by a large margin. Pathogenic bacteria ascend from the perineum, causing the UTI. Women have shorter urethras than men and therefore are far more susceptible to UTI. Very few

Mr. and Ms. Byers' child failed to pass meconium within the first 24 hours after birth; this may indicate which of the following? A. Celiac disease B. Intussusception C. Hirschsprung's disease D. Abdominal-wall defect

Correct Answer: C. Hirschsprung's disease Failure to pass meconium within the first 24 hours after birth may be a sign of Hirschsprung's disease, a congenital anomaly resulting in mechanical obstruction due to weak motility in an intestinal segment. History of the colonic obstruction, which might occur during the early neonatal period till adulthood, along with failure to pass meconium during the first 48 hours of the life, which presents in up to 90% of the affected patients, is highly compatible with the impression of HD.

Nurse Karen is providing postoperative care for Dustin who had a cleft palate (CP) repair; the nurse should position the child in which of the following? A. In an infant seat B. In the supine position C. In the prone position D. On his side

Correct Answer: C. In the prone position Postoperatively, children with a cleft palate should be placed on their abdomens to facilitate drainage. A child who has had a cleft lip repair should be positioned on their side or back to keep them from rubbing their face in the bed. A child with only a cleft palate repair may sleep on their stomach. It is important to keep the stitches clean and without crusting.

The nurse is aware that the following laboratory values support a diagnosis of pyelonephritis? A. Myoglobinuria B. Ketonuria C. Pyuria D. Low white blood cell (WBC) count

Correct Answer: C. Pyuria (high level of leukocytes) Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. A urinary specimen should be obtained for a urinalysis. On urinalysis, one should look for pyuria as it is the most common finding in patients with acute pyelonephritis.

Baby Jonathan was born with cleft lip (CL); Nurse Barbara would be alert that which of the following will most likely be compromised? A. GI function B. Locomotion C. Sucking ability D. Respiratory status

Correct Answer: C. Sucking ability Because of the defect, the child will be unable to form a mouth adequately around the nipple, thereby requiring special devices to allow for feeding and sucking gratification. Patients with cleft lips inherently will have some degree of alveolar cleft with potential for collapse of the maxillary arch and class III malocclusion (the maxillary teeth sit posterior to the mandibular teeth). These hard and soft tissue anatomic changes translate to the various changes in appearance, speech, and swallowing/feeding seen in cleft lip patients.

Dr. Jones prescribes corticosteroids for a child with nephritic syndrome. What is the primary purpose of administering corticosteroids to this child? A. To increase blood pressure B. To reduce inflammation C. To decrease proteinuria D. To prevent infection

Correct Answer: C. To decrease proteinuria The primary purpose of administering corticosteroids to a child with nephritic syndrome is to decrease proteinuria. It helps relieve the inflammation in the kidney and promotes healing. The proteinuria usually ranges in the sub nephrotic range (less than 3.5 g/day), but it can go up to the nephrotic range. A 24-hours urinary protein assay is required if the attendant nephrotic syndrome is suspected.

The following are considered functions of the Urinary System, EXCEPT: A. Vitamin D synthesis B. Regulation of red blood cell synthesis C. Excretion D. Absorption of digested molecules E. Regulation of blood volume and pressure

Correct Answer: D. Absorption of digested molecules This is a function of the digestive system. The small molecules that result from digestion are absorbed through the walls of the intestine for use in the body. Digestion is the process of mechanically and enzymatically breaking down food into substances for absorption into the bloodstream.

Stephen was diagnosed with minimal-change nephrotic syndrome; which of the following signs and symptoms are characteristics of the said disorder? A. Hypertension, edema, hematuria B. Hypertension, edema, proteinuria C. Gross hematuria, fever, proteinuria D. Poor appetite, edema, proteinuria

Correct Answer: D. Poor appetite, edema, proteinuria Clinical manifestations of nephrotic syndrome include loss of appetite due to edema of the intestinal mucosa, proteinuria, and edema. The classic NS presentation is edema, in the early phase is located in the face in the morning on waking with puffiness of the eyelids and the impression of the folds of sheets on the skin and ankles at the end of the day.

Nurse Nancy is assessing a child with pyloric stenosis; she is likely to note which of the following? A. "Currant jelly" stools B. Regurgitation C. Steatorrhea D. Projectile vomiting

Correct Answer: D. Projectile vomiting Projectile vomiting is a key sign of pyloric stenosis. Pyloric stenosis, also known as infantile hypertrophic pyloric stenosis (IHPS), is an uncommon condition in infants characterized by abnormal thickening of the pylorus muscles in the stomach leading to gastric outlet obstruction. Clinically infants are well at birth. Then, at 3 to 6 weeks of age, the infants present with "projectile" vomiting, potentially leading to dehydration and weight loss.

A mother asks the nurse how to handle her 5-year-old child, who recently started wetting the pants after being completely toilet trained. The child just started attending nursery school 2 days a week. Which principle should guide the nurse's response? A. The child forgets previously learned skills B. The child experiences growth while regressing, regrouping, and then progressing C. The parents may refer less mature behaviors D. The child returns to a level of behavior that increases the sense of security.

Correct Answer: D. The child returns to a level of behavior that increases the sense of security. The stress of starting nursery school may trigger a return to a level of successful behavior from earlier stages of development. Parents may notice a change in their child's bathroom behaviors. They'll want to observe if the child is going more frequently or having accidents.