Fall 2021 Nursing Level 3 Theory Test #2
With hyperpituitarism your bones would appear________ in the bone study
older
Piaget: Sensorimotor Stage for toddlers
pre-operational stage
At what Piaget stage do toddlers coordinate senses with motor abilities
sensorimotor
Growth __________after the first year of life
slows down
A patient has a dysfunction of the pituitary gland. Which hormone secretion may be altered in a patient with a dysfunction of the pituitary gland?
Prolactin
Which finding would the nurse assess in a patient with hyperthyroidism?
Protruding eyes (Exophthalmos) Weight loss High BP
What test are used to diagnose pyloric stenosis?
US abdomen
Which describes a child who is abused by the parent(s)?
Unintentionally contributes to the abusing situation
An infant is born with a cleft lip. What is the best way to assess for the presence of cleft palate?
Use your glove finger to feel the palate
Which rationale is accurate when explaining to a patient with hypothyroidism and coronary artery disease (CAD) as to why the use of an enema is contraindicated?
Vagus-nerve stimulation
The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?
Visible peristalsis and weight loss
Which characteristic best describes the gross motor skills of a 24-month-old child?
Walks up and down stairs and runs with a wide stance
Which statement about toilet training is correct?
Wanting to please the parent helps motivate the child to use the toilet.
Which statement is correct about toilet training?
Wanting to please the parent helps motivate the child to use the toilet.
Which skin condition would the nurse expect to assess in a patient diagnosed with hyperthyroidism?
Warm, smooth, moist skin
A child with hypoparathyroidism is receiving vitamin D therapy. The parents should be advised to watch for which sign of vitamin D toxicity?
Weakness and lassitude (lack of energy)
Which clinical manifestation would be most prominent in the assessment of a patient with suspected Cushing syndrome?
Weight gain, including truncal obesity buffalo hump
The nurse is planning care for a 17-month-old child. According to Piaget, in what stage would the nurse expect the child to be?
Tertiary circular reaction
ACTH (adrenocorticotropic hormone) tell us
if it is stimulated by the pituitary or the adrenal is been stimulated from an outside source (tumor) or takin too much steriods
which activity documented by the nurse describe the fine motor skills of a 2 yrs old?
imitates drawing a vertical line
During adrenal hormone replacement you _____________ the dose during stress
increase
Why is obesity considered a major problem in adolescence.
* Obvious to others * Difficult to treat * Long term psychological and physical effects
Treatment for hyperthyroidism
* PTU, methimazole * Large doses of Iodine
How does the pt with pyloric stenosis body compensate for his alkalotic state?
decrease RR
Patient is c/o pain which medication would be most appropriate after a lap chole?
ketorolac
Place sterile gauze dressing or transparent dressing over insertion site then_____.
label the dressing with date, time and your initials.
Target A1C for diabetics
less than 7.5 %
Proton Pump Inhibitors (PPIs) are used for
long-lasting reduction of gastric acid production.
What does exercise do for the child with diabetes
lowers blood glucose levels
Teaching for gastritis includes
maintaining non-irritating diet, six small meals
Nurse is caring for newborn w/ esophageal atresia, what would be in the mom's hx
maternal polyhydramnios (too much embryotic fluid)
Results from the incomplete fusion of the. oral cavity during intrauterine life
Cleft Lip
Which nursing intervention would be included in the plan of care for a patient with a diagnosis of hypothyroidism?
Patient teaching related to levothyroxine
The most effective way to clean a toddler's teeth is for the:
Parent to stabilize the chin with one hand and brush with the other.
Which prescribed medication should the nurse expect will have rapid effects on a patient admitted to the emergency department in thyroid storm?
Propranolol (Inderal)
Ketorolac
(Toradol) for pain management
a child builds a tower of four cubes by the age of
18 months
which child would need fluoride supplementation?
6 months or older
Which toy is the most developmentally appropriate for an 18- to 24-month-old child?
A push-pull toy
Which clinical manifestation would be the most suggestive of acute appendicitis?
Abdominal pain that is most intense at McBurney point
Which intervention should be included in planning the care of a client with Addison's disease.
Administered steroid medication
Juvenile autoimmune thyroiditis
Autoimmune thyroiditis is a frequent cause of goiter in children
To treat the symptoms of hyperthyroidism you give
Beta Blocker
Which is used to treat moderate to severe inflammatory bowel disease?
Corticosteroids
What is invagination of one segment of bowel within another called?
Intussusception
The pituitary gland would increase TSH to help stimulate
T3 and T4 by the thyroid
Which factor is most important in predisposing toddlers to frequent infections?
Toddlers have a short, straight internal ear canal and large lymph tissue.
motivation thinking
don't say NO!
Giagntism occurs when
too much growth hormones are released before the closure of the epiphyseal plates
What is the most common cause of death children older than one
unintentional death
Which is the most frequent source of acute childhood lead poisoning?
Lead-based paint
higher doses of corticosteroids more likely to be?
immunosuppressive
Which electrolyte do you restore in a pt with DKA
potassium
Cleft lip repair is usually recommended at
2-3 months
a result of excessive circulation of free cortisol.
Cushing syndrome
Over secretion of the adreno-cortical hormones leads to:
Cushing's syndrome
What stressor is common in a hospitalized toddler.
interrupted routine
Which organ is targeted by the hormone produced by the parathyroid glands?
Kidneys
Cleft lip repair will occur at what age?
6-12 weeks
You are working with a nurse who is new to your endocrine unit and has never worked with a infant born with congenital adrenal hyperplasia (CAH). You want to make sure he has full understanding of this diagnosis. Which statement by the nurse indicates a need for further teaching?
" Blood studies to identify elevated calcium levels and decreased phosphorus levels are routinely performed."
A Nurse is providing teaching about age appropriate activities to the parent of 2 year old. Which of the following statements by the parent indicates an understanding of the teaching?
" I will send my child's favorite stuffed animal when she will be napping away from home."
The parent of a 16-month-old toddler asks, "What is the best way to keep our son from getting into our medicines at home?" The nurse's best advice is:
"All medicines should be locked securely away."
Which condition is the goal for treating hypocalcemia?
Decreasing the pH
Which lab results identifies the cause of hypocalcemia?
PTH
procedures to suppress thyroid stimulation
RAIT Thyroid removal
Which should the nurse expect for a toddler's language development at age 18 months?
Increasing level of comprehension
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:
necessary because it will be an adjustment.
Addison's disease
occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone
Acromegaly most often occurs because
of a benign growth hormone (GH)-secreting pituitary adenoma.
Marasmus happens mostly before the age of
one
Which disorder is characterized by fat pads on the back of the neck, an increased abdominal girth, a "buffalo hump," and a "moon" face?
Cushing syndrome
Management for tracheoesophageal fistula
* NPO * Prevent pneumonia * Remove secretions * IVF * Broad spectrum antibiotics * Surgical repair
Cleft Palate repair is usually recommended at
6-12 months
What would not be taught to a pt who is dx with hyperthyroidism
Teach how to take levothyroxine properly
A toddler's parent asks the nurse for suggestions on dealing with temper tantrums. Which is the most appropriate recommendation?
Remain close by the child but without eye contact.
Which clinical manifestations does the nurse expect in a hospitalized patient diagnosed with Graves' disease? Select all that apply.
Dysrhythmia Systolic murmurs Systolic hypertension
Which condition is the 18-month old child at risk for when prolonging bottle feeding ?
Early childhood caries
A parent asks the nurse about negativism in toddlers. Which is the most appropriate recommendation?
Reduce the opportunities for a "no" answer.
Pt's with excessive, frothy saliva in the mouth or difficulty with secretion's and unexplained episode of cyanosis have
Tracheoesophageal fistula
Change central line transparent drsgs:
Transparent: q3-7 days
Which finding would the nurse assess in a patient admitted with Addison's disease?
"Bronze" skin tone
Which question from the nurse during a patient interview will provide focused information about a possible thyroid disorder?
"Have you had a recent unplanned weight gain or loss?"
Pt's with hyperthyroidism are at risk for
* Decrease perfusion * Dehydration * Dysrhythmias
a child creeps upstairs by the age of
15 months
The main nursing consideration and celiac disease is helping the child adhere to dietary management TRUE or FALSE
True to prevent autoimmune disease
What is helpful to tell a mother who is concerned about preventing sleep problems in her 2-year-old child?
Use a night-light in the child's room.
Which skin condition would the nurse expect to assess in a patient diagnosed with Addison's disease?
Darkened skin on the knuckles, elbows, and palmar creases
Which lab indicates that a pt has pancreatitis?
Lipase
cretinism (congenital hypothyroidism)
congenital absence or atrophy of the thyroid gland
For a toddler with sleep problems, the nurse should suggest that the parents
use a transitional object at bedtime.
cystoscopy
visual examination of the urinary bladder report if fever is > 101
A pt with pyloric stenosis lab shows that he has metabolic alkalosis. What is the underlying problem cause of the pt's metabolic alkalosis?
vomiting
*Clinical Manifestations of Adrenal Insufficiency (Addison's Disease)
weakness fatigue anorexia GI symptoms orthostatic hypotension hypotension salt craving hyperpigmentation Weight loss and malnutrition.
how do you determine hypothyroidism
with TSH levels
With hypopituitarism your bones would appear________ in the bone study
younger
Which statement made by a 50-yr-old female patient indicates to the nurse that further assessment of thyroid function may be needed?
"I feel a lump in my throat when I swallow."
which statement makes a nurse suspect the patient is experiencing hyperthyroidism.
"I have noticed that all my collars are getting tighter"
After receiving change-of-shift report about the following four patients, which patient should the nurse assess first?
A 70-year-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134
Define Kwashiorkor
A form of PEM characterized by a swollen appearance, especially in the abdomen. Usually caused by moving from breast milk to a low-protein diet/ high carb diet.
Which nursing interventions would be included in the plan of care for a patient exhibiting exophthalmos? Select all that apply.
Apply artificial tears. Tape the eyelids lightly for sleeping, if needed. Ask the patient to exercise the intraocular muscles. Teach the patient to eat a low-salt diet
main symptom of pyloric stenosis
projectile vomiting
Which clinical manifestations would the nurse assess in a patient with hyperthyroidism? Select all that apply.
A positive bruit upon auscultation of the thyroid gland A goiter Clubbing of the fingers
Exogenous or Iatrogenous Cushing's Syndrome
Taking or using glucocorticoids
A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The nurse taking the call should know that the primary danger is which result?
Bronchitis and chemical pneumonia
Which clinical manifestations would you expect with primary adrenal cortex insufficiency
Bronze pigmentation Hypotension Anorexia
Pt w/ acute exacerbation of Peptic Ulcer, double up in bed w/shallow/grunting respirations , the nurse first action is
Assess pt's abdomen and vital signs
A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first?
Assess the patient's respiratory effort.
Which disorder is associated with swollen salivary glands and macerated knuckles?
Bulimia nervosa
Adrenal Insufficiency (Addison's Disease) etiology
Autoimmune disease (leading), histoplasmosis, adrenal hemorrhage, met cancer or lymphoma, amyloidosis, hemochromatosis, familial glucocorticoid deficiency, & hypoplasia. Mycobacterium tuberculosis leading cause worldwide
The child of 15 to 30 months is likely to be struggling with which developmental task?
Autonomy
The psychosocial developmental tasks of toddlerhood include which characteristic?
Ability to delay gratification
The psychosocial developmental tasks of toddlerhood include:
Ability to withstand delayed gratification.
Which condition can result if hypersecretion of growth hormone (GH) occurs after epiphyseal plate closure?
Acromegaly
Which condition is associated with the symptoms of numbness and a "pins and needles" sensation in the thumb, middle, and index finger, especially at night?
Acromegaly
What is chronic adrenocortical insufficiency also called?
Addison disease
Under secretion of the adreno-cortical hormones leads to:
Addison's disease
A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next?
Administer IV calcium gluconate.
Which nursing interventions would the nurse implement for a patient status after a subtotal thyroidectomy? Select all that apply
Administer analgesics for postoperative pain Assess for signs of tetany. Assess the patient every two hours for signs of bleeding
A patient who has 20-year history of hypothyroidism was admitted to the intensive care unit (ICU) with a decreased level of consciousness and a temperature of 96° F. Which interventions would be included in the plan of care for this patient? Select all that apply.
Administering thyroid hormone IV Monitoring cardiovascular status continuously
A neonate born with ambiguous genitalia is diagnosed with congenital adrenogenital hyperplasia. What does therapeutic management include?
Administration of cortisone
What secretes glucocorticoids, mineralocorticoids, and sex steroids?
Adrenal cortex
How does a client develop iatrogenic Cushing's Syndrome
Taking steroid medications for an extended period of time
Which is characteristic of the immune-mediated type 1 diabetes mellitus?
Age at onset is usually younger than 20 years.
Which hormone is essential for the maintenance of fluid and electrolyte balance?
Aldosterone
Which hormone synthesis is inhibited by a serum potassium level of 3 mEq/L and a serum sodium level of 145 mEq/L?
Aldosterone
The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. Which is appropriate to relieve the abdominal discomfort?
Allow to assume position of comfort.
Which hormone levels would the nurse monitor in a patient with impaired adrenal cortex functioning? Select all that apply.
Androgens Glucocorticoids Mineralocorticoids
Which hormones are released by the adrenal cortex? Select all that apply
Androgens Glucocorticoids Mineralocorticoids
Steven, 16 months old, falls down a few stairs. He gets up and "scolds" the stairs as if they caused him to fall. This is an example of which of the following?
Animism
which behavior is described when a 2 1/2 year old child angrily says to the chair " Why you push me?"
Animism
A patient experiences hair loss, menstrual problems, dry skin, and constipation. The patient reports being extremely conscious about weight and appearance. The nurse recognizes that the assessment findings are indicative of which disorder?
Anorexia nervosa
Which is the target tissue of the releasing and inhibiting hormones secreted by the hypothalamus?
Anterior pituitary
Which information will the nurse teach a patient who has been newly diagnosed with Graves' disease?
Anti-thyroid medications may take several months for full effect.
A patient seen in the emergency department for severe headache and acute confusion has a serum sodium level of 118 mEq/L. The nurse should anticipate the need for which diagnostic test?
Antidiuretic hormone level
Which nursing assessment of a 70-year-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)?
Apical pulse rate= dysrhythmias.
cholecystectomy complications
Bile leakage purulent drainage infection
Pt is post operative lap chole, what potential complication can happen to this pt?
Bowel Obstruction
I nurse caring for an eight week old infant is evaluating for pylori stenosis what statement is typical for a child, with this diagnosis So what do they present like.
Baby has forceful vomiting episode 30 mins after eating
Which should the nurse expect of a healthy 3-year-old child?
Balance on one foot for a few seconds
The nurse is caring for a patient following an adrenalectomy. What is the highest priority in the immediate postoperative period?
Balancing fluids and electrolytes
What medication is given after a thyroidectomy
Calcium Gluconate
A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. What topic should the nurse plan to teach the patient?
Calcium supplements to normalize serum calcium levels
In case of a pt experiencing a thyroid storm crisis, what will the nurse do first?
Call the Rapid response team/Code team
The nurse recommends to parents that peanuts are not a good snack food for toddlers. What is the nurse's rationale for this action?
Can be easily aspirated
A nurse caring for a patient with hyperparathyroidism would monitor the patient for which complication?
Cardiac dysrhythmias
A 12-year-old male has short stature because of a constitutional growth delay. What should the nurse be the most concerned about?
Child's self-esteem and sense of competence
What is the preferred agent to clean a central line insertion site?
Chlorhexidine gluconate clean from inner to outer area of central line
A patient is being admitted with a diagnosis of Addison Disease. Which finding will the nurse expect during the assessment?
Chronically low blood pressureBronzed appearance of the skin
The nurse is caring for an infant whose cleft lip was repaired. What important aspects of this infant's postoperative care should be included?
Cleansing the suture line, supine and side-lying positions, arm restraints
Results from the incomplete fusion of the palates during intrauterine life
Cleft Palate
How are young people with anorexia nervosa often described?
Conforming
Which symptom would the nurse expect to see in a patient suspected of having hypothyroidism?
Constipation
Result as an effect of congenital hypothyroidism.
Cretinism
A nurse is reviewing the laboratory results on a school-age child with hypoparathyroidism. Which results are consistent with this condition?
Decreased serum calcium Increased serum phosphorus
Which assessment finding would the nurse document that correlates with the condition of hypoparathyroidism?
Decreased skin pigmentation Hypotension
Type one diabetes
Diabetes which is caused when the pancreas cannot make insulin.
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?
Encouraging her to express her feelings.
Which therapy is used to treat pyloric obstruction?
Endoscopic dilation
Which clinical manifestation is a classic finding in Graves' disease?
Exophthalmos
A patient develops carpopedal spasms and tingling of the lips following a parathyroidectomy. Which action will provide the patient with rapid temporary relief from the symptoms?
Have the patient rebreathe from a paper bag= increase Co2=increase in calcium levels
A nurse is assessing a 2 1/2 year-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider?
Head circumference exceeds chest circumference
Which is a clinical manifestation of acetaminophen poisoning?
Hepatic involvement
Which statement is correct about childhood obesity?
Heredity is an important factor in the development of obesity.
The nurse should expect to assess which clinical manifestations in an adolescent with Cushing syndrome? (Select all that apply.)
Hyperglycemia Cushingoid features Susceptibility to infections
Which condition is associated with a decrease in parathormone that in turn causes a decrease in serum calcium
Hyperparathyroidism
Which assessment finding would the nurse document that correlates with the condition of hyperparathyroidism?
Hypertension
What condition may cause exophthalmos (protruding eyeballs) in children?
Hyperthyroidism
When reviewing a patient's laboratory reports, the nurse notes increased aldosterone (blocks sodium) levels. Which electrolyte imbalance may be the cause of this finding? Select all that apply.
Hyponatremia Hyperkalemia
signs and symptoms of myxedema coma
Hypotension Hypothermia Hyponatremia Hypoglycemia Respiratory failure
Which symptom would the nurse assess in a patient with acromegaly?
Increase in shoe size
A patient has just arrived in the post-anesthesia recovery unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon?
Increasing neck swelling
Which finding indicates to the nurse that the current therapies are effective for a patient who has acute adrenal insufficiency (Addison disease) ?
Increasing serum sodium levels
The leading cause of death during the toddler period is:
Injuries
A toddler is admitted to the emergency room with a possible diagnosis of accidental poisoning. Which information if noted on the admission form would indicate a potential cause for this clinical diagnosis?
Mother has been taking Tylenol OTC for sinus headaches for several days and keeps medication in a tote handbag
How do treat H Pylori?
Multiple antibiotics
Which statement by a mom of an 18 month old would lead a nurse to refer child for further evaluation of developmental delay.
My child is able to stand, but not taking steps independently,
The cardiac telemetry unit charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first?
Patient with tetany who has a new order for IV calcium chloride= high calcium level=possible cardiac arrest
Pt admitted to the ER w/ profuse bright red hematemesis, the nurse first priority is
Perform a focus assessment of pt's status
A transsphenoidal hypophysectomy involves surgical resection of which gland?
Pituitary
which finding in the home should be addressed by the nurse
Placing a cough syrup in a child proof container at a high level
A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be helpful for the patient problem of disturbed body image related to changes in appearance?
Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery.
During the first few days after surgery for cleft lip, which intervention should the nurse do?
Remove restraints periodically to cuddle infant.
Proper care of CVCs includes which nursing action?
Replacing the dressing when it is damp, loose, or soiled
During d/c instructions for pt s/p lap chole, what should the nurse include in the teaching
Report any bile colored or purulent drainage from all four incisions
What is the best description of anorexia nervosa?
Results in severe weight loss in the absence of obvious physical causes
A father tells the nurse that his daughter wants the same plate and cup used at every meal, even if they go to a restaurant. What should the nurse explain to the father?
Ritualism, common at this age
A father tells the nurse that his daughter wants the same plate and cup used at every meal, even if they go to a restaurant. The nurse should explain that this is:
Ritualism, common at this age.
A hospitalized toddler clings to a worn, tattered blanket. The toddler screams when anyone tries to take it away. Which is the best explanation for the toddler's attachment to the blanket?
The blanket is an important transitional object.
A 9-year-old boy has several physical disabilities. His father explains to the nurse that his son concentrates on what he can, rather than cannot, do and is as independent as possible. What is the nurse's best interpretation of this statement?
The child is using an adaptive coping style
Based on developmental theories which important event is essential to the development of toddlers.
The child participates in potty-training (Autonomy)
The nurse is teaching the parent of a 2-year-old child how to care for the child's teeth. Which instruction should be included?
The parent should brush the toddler's teeth with plain water if he or she does not like toothpaste.
Which information about a patient who is scheduled for an oral glucose tolerance test should the nurse consider in interpreting the test results?
The patient takes oral corticosteroids for rheumatoid arthritis.
How would a nurse explain a bone age evaluation
The x-ray of a child's epiphyseal plate is compared with the hand x-ray of other children of the same age to determine how old that pt is
A patient who had surgery for the treatment of acromegaly asked about the possibility of becoming pregnant. The nurse's response would be based on which physiologic factor?
There will be a permanent loss of FSH hormones= problems with fertility
which information should the nurse give to parents of toddlers about the regular use of fluoridated water or beverages containing fluoride?
These drinks can cause stains and pits in the teeth
Come mom have a two year old six months child arrange a playdate with a two year old with nine months child. What would we see.
They're going to play alongside each other but not actively with one another= parallel play
A 4-month-old infant has gastroesophageal reflux (GER) but is thriving without other complications. Which should the nurse suggest to minimize reflux?
Thicken formula with rice cereal.
Two toddlers are playing in a sandbox when one child suddenly grabs a toy from the other child. The best interpretation of this behavior is that:
This is typical behavior because toddlers are egocentric.
Which instruction would the nurse give the patient and caregiver about managing hypothyroidism?
Use soap sparingly
The nurse is caring for a 4-year-old child immobilized by a fractured hip. Which complication should the nurse monitor related to the child's immobilization status?
Venous stasis leading to thrombi or emboli formation
Which clinical manifestations would the nurse assess in a patient with manifestation of hyperthyroidism? Select all that apply.
Weight loss Protrusion of the eyeballs Elevated BP
Which is descriptive of bulimia during adolescence?
Weight that can be normal, slightly above normal, or below normal
A nurse is taking a history of 11 yr-old with hypopituitarism. A important question to ask is
What time are you taking your Growth Hormone?
A pt with celiac disease should substitute_____,______, _______ and ______ with _____and ______
Wheat, rye, barley and oats rice and corn
For cleft palate repair we are going to put the pt in which position
prone (for drainage)
Celiac disease is an inflammation of
proximal small instestine
dermatologic uses for corticosteroids
pruritus (ACUTE onset) inflammation of skin/ear canals acute allergic/hypersensitivity reactions* IM/auto-immune skin diseases*
function of parathyroid hormone
raises blood calcium levels Stimulate the kidneys Activate vitamin D
A patient is diagnosed with hypothyroidism would present with the following.
a complaint of extreme fatigue
Non-organic failure to thrive
a disorder in which infants stop growing due to a lack of stimulation and attention as the result of inadequate parenting
A patient status post a hypophysectomy had drainage on the moustache dressing. Which complication is this patient at risk for if the glucose level of the drainage is 50 mg/dL?
a glucose level greater than 30 mg/dL indicates a CSF leak= meningitis
which statement made by the mother regarding minimizing sibling rivalry with the toddler needs further learning
a new playmate will come home soon
Which toy should be provided to a toddler to promote development.
a pail and shovel. finger painting play dress up
_________ should be over the insertion site. Either sterile gauze or or a sterile transparent semipermeable dressing.
a sterile dressing
Manifestations of crohns disease
abdominal pain fatigue diarrhea
ascites
abnormal accumulation of fluid in the abdomen
Cortisol is made in the:
adrenal cortex gland
Sudden cessation of corticosteroids after taking the medication for a week or more can lead to
adrenal insufficiency
celiac disease
an inherited autoimmune disorder due to decrease absorption of nutrients. Characterized by a severe reaction to foods containing gluten
An increase in thyroxine level would be expected with increased secretion of thyroid-stimulating hormone (TSH) by the
anterior pituitary.
lower doses of corticosteroids more likely to be?
anti-inflammatory
corticosteroid therapy effects (broad)
anti-inflammatory immunosuppressive, anti-mitotic (affect epithelial cell turnover & fibroblast proliferation)
Trousseau's sign
arm/carpal spasm associated with hypocalcemia
when do you give growth hormone injections
at night
Erikson psychosocial development for toddlers
autonomy vs shame
prostration
be overcome with extreme weakness
Growth homones subq injections are given at
bedtime
One of the major tasks of toddlerhood is toilet training. In teaching the parents about a child's readiness for toilet training, it is important for the nurse to emphasize that
bowel control is accomplished before bladder control, so the parent should focus on bowel training first.
what are the signs of hypoglycemia
bradycardia irritability shakiness pale skin
Which hormone is likely to be released when there is an increase in serum Ca+ levels?
calcitonin
What do you monitor with pt's with DKA?
cerebral edema
The primary reason for universal screening of young children for lead poisoning is that
children with lead poisoning rarely have symptoms.
A client with hypothyroidism is prescribed Levothyroxine which data and it indicates effectiveness.
client temperature is normal
Which assessment finding would the nurse document that correlates with the condition of hypothyroidism.?
cold intolerance
The inflammation found with ulcerative colitis is limited to the
colon and rectum
Patient is diagnosed with hypothyroidism would present with the following.
complains of extreme fatigue
Dressing changes should be documented along with site_____
condition and pt's response according to employing agency's policies and procedures.
Congenital Adrenal Hyperplasia (CAH)
condition during prenatal development in which the adrenal glands produce high levels of androgens; sometimes associated with masculinization of external genitalia in genetic females; and sometimes associated with higher rates of masculine-stereotyped play in genetic females
Diet for celiac disease
corn, rice and increase in vitamin and iron with small feedings
cortisol levels tells us if we are in
cushings
melena stool
dark tarry stools contained decomposing blood
Proton Pump Inhibitors
decrease the amount of acid produced by the stomach
secondary adrenal insufficiency (Addison Disease)
deficient ACTH secretion due to dysfunction of the pituitary-hypothalamic axis or a disorder of pituitary gland.
Primary Adrenal Insufficiency (Addison's Disease)
destruction or dysfunction of the cortex of the adrenal glands
A toddler is exploring the environment but returns to his mother within a few minutes of exploration. This finding would be noted as an example of
rapprochement. Rapprochement occurs when the child returns to the mother for reassurance following exploration of the environment
What should you be concerned with esophageal atresia
risk for aspiration
When using Chloraprep to cleanse the site, remember to
rub back and forth using friction for at least 30 seconds to clean the area working from the center to the outer area.
What to medication order will be questioned in a patient with untreated hypothyroidism.
sedatives
What basic strengths do children have in the autonomy versus shame and doubt.
self control, courage and will
Myxedema coma
severe hypothyroidism resulting in a decompensated metabolic state and mental status change
When assessing a pt with acute pancreatitis, the nurse would expect to find
severe midgastric or LUQ pain
myxedema
skin and tissue disorder due to severe prolonged hypothyroidism (thinned non pitting skin and puffy face)
Normally cortisol levels ________when you first wake up in the morning
spike
which instructions are appropriate when recommending fluoride supplements for the toddler
store fluoride supplements away from toddler
The nurse should teach parents of toddlers how to prevent poisoning by instructing them to
store poisonous substances in a locked cabinet.
Growth hormone is given
subcutaneous injections daily
Cleft lip repair, we want the pt in which position
supine
The operational child is characterized by
symbolic intuitive and ego centric thinking
cardiac symptom of Grave's disease
tachycardia
Nurses immediate action when a newborn begins to cough choke and become cyanotic during a feeding
take infant, admin blow by O2 levels while obtaining O2 stats
Therapeutic measures for Cushing can include?
* prepare to give insulin * potassium supplements
Inspect the site while cleaning. Observe for:
Erythema, edema, or drainage. Also assess for pain and tenderness at the site.
What should the nurse do to prevent separation anxiety and a hospitalized toddler
Establish a routine similar to that of the child's home
Chvostek sign (hypocalcemia)
Facial muscle spasm upon tapping
Tracheoesophageal atresia
Failure of the esophagus to connect to the stomach
Child fails below the 5% of the growth chart
Failure to thrive
Activity intolerance in a patient with hypothyroidism is related to which side effect?
Fatigue
signs and symptoms of thyroid storm
Fever (>103) tachycardia tachypnea dehydration profuse sweating agitation delirium psychosis coma
In which place in the birth order are feelings of sibling rivalry most pronounced?
First born
What is the most fatal type of burn in the toddler age group?
Flame burn from playing with matches
The most fatal type of burn in the toddler age-group is:
Flame burn from playing with matches.
Which complications are associated with hyperparathyroidism? Select all that apply.
Fractures Osteoporosis Kidney stones
The patient has been feeling tired lately and has gained weight and reports thickened, dry skin, and increased cold sensitivity, even though it is now summer. Which endocrine diagnostic test would be done first?
Free thyroxine (FT4)
Which is a parasite that causes acute diarrhea?
Giardia lamblia
Which condition can result if hypersecretion of growth hormone (GH) occurs before epiphyseal plate closure?
Gigantism
The nurse is teaching about home care to a patient with gastrointestinal reflux disease (GERD). Which statement made by the patient indicates the need for further teaching?
"I should lie down for two to three hours after eating."
A nurse is caring for a child who has Meckel's Diverticulum. Which of the following manifestations should the nurse expect? Select all that apply.
* Abdominal pain * Mucus, bloody stools
The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching?
"I had the flu earlier this week, so I couldn't take the hydrocortisone."
S/S of Cushing's Disease
* moon face * buffalo hump * Truncal obesity * Osteoporosis
The nurse is teaching the parents of a child who is receiving methimazole (Tapazole) for the treatment of hyperthyroidism (Graves disease). Which statement made by the parent indicates a correct understanding of the teaching?
"If my child develops a sore throat and fever, I should contact the physician immediately." Leukopenia!
The nurse is providing an in-service on thyroid disorders. One of the attendees asks the nurse, "Why don't the people in the United States get goiters as often?" Which statement by the nurse is the best response?
"Iodized salt helps prevent the development of goiters in the United States."
The mother of a 14-month-old child is concerned because the child's appetite has decreased. The best response for the nurse to make to the mother is:
"It is not unusual for toddlers to eat less."
Which comment should the parent of a two year old expect from a toddler about a new baby.
"It's time to put the baby away so that we can play."= egotistic nature
Which comments indicate that the mother of a toddler needs further teaching about dental care?
"My child will not need a dental checkup until his permanent teeth come in."
The parents of a newborn say that their toddler "hates the baby . . . he suggested that we put him in the trash can so the trash truck could take him away." The nurse's best reply is:
"That is a normal response to the birth of a sibling. Let's look at ways to deal with this."
The parents of a newborn say that their toddler "hates the baby; he suggested that we put him in the trash can so the trash truck could take him away." Which is the nurse's best reply?
"That is a normal response to the birth of a sibling. Let's look at ways to deal with this."
A patient scheduled for a thyroidectomy is placed on potassium iodine. When the patient's family asks the nurse why this medication is needed, which response by the nurse is accurate?
"This medication will decrease the vascularity of the thyroid gland."
What instruction would the nurse include in the teaching plan for a patient who is receiving radioactive iodine (RAI)?
"Towels that are used by you should not be used by other family members."
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?
"We can collect a stool sample and confirm that the H. pylori has been eradicated."
Parents need further teaching about the use of car safety seats if they make which statement?
"We won't need to use the car seat on short trips to the store."
Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter?
"What medications are you taking?"
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?
"With Crohn disease the inflammatory process involves the whole GI tract."
A patient diagnosed with acromegaly has developed speech difficulties and asks what is causing the problem. Which response by the nurse is accurate?
"You have developed the condition due to overgrowth of the tongue."
Cushingoid features
"moon face" and buffalo hump due to the redistribution of fat
decrease of absorption of intestinal nutrients causes
* Abdominal pain * Bloating * Cramping * Distention
Which should be included in the point of care for 14 month old who's cleft palate was repaired 12 hours ago.
* Allow infant to have familiar comfort items * Administer pain meds on a regular schedule as opposed to PRN
Indications when taking metronidazole?
* Avoid alcohol until 72 hours after finishing medication * Take with food to avoid GI upset
A nurse is assessing an infant who has intussusception. Which of the following findings should the nurse expect? Select all that apply
* Bloody mucus stools * Jelly stools * Telescoping intestine * Sausage shaped abdominal mass
Which 2 areas will be included in the nurses' focused assessment every 4 hrs after post lap chole?
* Bowel sounds * Pain
What intervention should the nurse make for a pt with hypocalcemia
* Call the provider * Closely monitor for cardiac arrhythmias * Reassess Chvostek and Trousseau signs * Check patency of IV line to administer calcium gluconate infusion
which action by the toddler indicates delayed fine motor development?
* Cannot build a block tower * Unable to release an object at will * Loses balance while throwing a ball * Cannot drop objects into a narrow necked bottle
signs and symptoms of peptic ulcer
* Chest pain/tightness/burning * Pain after a large meal or at night * Heartburn * Pain awakes him at night * Antacids do not help
If potential complications arise from a thyroidectomy, Which assessment will the nurse perform? Select all that apply
* Chvostek sign * Trousseau Sign
Three C's of Tracheoesophageal fistula (TEF) in newborn
* Coughing * Choking * Cyanosis
Which should the nurse teach to parents of toddlers about accidental poison prevention (select all that apply)?
* Discard empty poison containers. * Know the number of the nearest poison control center. * Caution child against eating nonedible items, such as plants.
symptoms of juvenile hypothyroidism
* Dry skin * constipation * Lethargy (sleepiness) * Mental decline. * Decreased growth
Teaching appropriate for a pt with PUD
* Eat normal, eliminate food that cause pain * Quit smoking * Use pillows to prop yourself up at night
A nurse is planning care for a hospitalized toddler in the preoperational thinking stage. Which characteristics should the nurse expect in this stage (select all that apply)?
* Egocentrism * Animism * Magical thinking
Select the appropriate cleft lip repair post-op nursing interventions
* Elbow restraints to both arms * Pain medications
Which nursing instruction is appropriate to help prevent dental caries in a family toddler? Select all that apply
* Eliminating the bedtime bottle * Never putting juice in the bottle * Substituting a bottle of water for milk or juice
12 yrs old girl dx with Graves disease. The nurse should discuss
* Emotional liability * Wearing a medical alert bracelet * Encourage the pt to take responsibility for OCT medications
Which meds are used to decrease gastric or hydrochloric acid secretions. Select all that apply
* Famotidine (Pepcid) * Omeprazole ( Prilosec) * Esomeprazole Magnesium (Nexium)
What are the three top priorities with infants born with a cleft lip and/or palate?
* Feeding practices * Caregiver bounding * Weight management
The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which symptoms are associated with this diagnosis? Select all that apply.
* Feeling cold * Loss of body hair * Persistent lethargy * Puffiness of the face
A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? Select all that apply.
* Fever * Nausea * Tremors *.Confusion
Which developmental behavior does a 18 month-old child possess? Select all that apply
* Fit smaller object into each other * Opens door and drawers to find objects
calcium gluconate precautions
* Give slow in central line or deep vein * Monitor VS frequently * Place on ECG * Monitor site for patency * Check calcium serum levels
Risk for developing thyrotoxicosis (thyroid storm) Select all that apply
* High stress * Recent illness
Medications for adrenal hormone replacement
* Hydrocortisone * Glucocorticoid (prednisone)
The nurse is caring for a school-age child with hyperthyroidism (Graves disease). Which clinical manifestations should the nurse monitor that may indicate a thyroid storm? (Select all that apply.)
* Hyperthermia* Tachycardia* Vomiting
What should a pt diagnosed with hyperthyroidism must notify to their provider
* If a weight loss of 3 lbs occurs within 2 days * Notify PCP before taking any OTC meds * Discuss ways to cope with the emotional lability
Function of Cortisol (hydrocortisone)
* Increase blood sugar * Aids in the metabolism of protein * Suppresses the immune system * Maintain BP and cardiac function * increase bone breakdown resulting in increased calcium levels
The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply.
* Instruct the client about thyroid replacement therapy * Encourage the client to consume fluids and high-fiber foods in the diet. * Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur
Which gross motor milestones should the nurse assess in an 18-month-old child (select all that apply)?
* Jumps in place with both feet * Throws ball overhand without falling * Pulls and pushes toys
Pt instructions after a thyroidectomy
* Keep head elevated while sleeping for 3-4 days * Keep all your f/u dr's app * Cover the incision with clothing or sun screen when pt is out in the sun.
Newborn just diagnosed with Tracheoesophageal fistula and is scheduled for surgery So what should the nurse expect and the pre op period.
* Keep the child upright at least 30 degrees, to help with drainage and prevent of aspiration * Administer IV fluids IV antibiotics
s/s of diabetic ketoacidosis
* Ketones in urine * Fruity scented breath * Acidosis * electrolyte imbalance * Deep rapid breathing
Diagnosis of Celiac disease is done by
* Lab * Stool sample * Endoscopy/biopsy * Diet change
Which assessment findings is of immediate concern for a pt with pyloric stenosis?
* Last urine was last night * Sunken anterior fontanel * Cap refill= 3sec
Which developmental task would a 30 month-age child would be able to do? Select all that apply
* Name many colors * Tell first and last name * Recognize gender differences
What treatments are most effective for treating pancreatitis? Select all that apply
* Pain medications * NPO
Bone age study is helpful to determine
* Parathyroidism * Hyperparathyroidism / hyperpituitarism (increased GH) * Hypoparathyroidism/ hypopituitarism (decreased GH)
Endogenous Cushing's Syndrome is caused by
* Pituitary tumor * Adrenal tumor * Ectopic tumor
Which nursing advice would be appropriate regarding nutritional needs of a child during a growth spurt? Select all that apply
* Plan for nutritionally balanced week * Serve food in various physical forms
clinical manifestation of type 2 diabetes
* Polyuria (urine) * Polyphagia (hunger) * Polydipsia (Thirst) * weight loss * Nocturia * Vision changes
A nurse is assessing an infant who has hypertrophic pyloric stenosis. Which of the following findings should the nurse expect? Select all that apply
* Projectile vomiting * Dry mucus membrane due to dehydration *. Constant hunger
Function of calcium
* Provide strength for bones * Provide electrical energy for nervous system/ muscular system
Patient has a nursing diagnosis of risk for injury related to hypoglycemia so what kind of nursing interventions will we do for a patient.
* Recognize the signs and symptoms of hypoglycemia early * 10-15g readily available carbs (OJ) initially to increase blood glucose * Complex carbs and protein (crackers w/BP) to maintain blood glucose
Which developmental task would a 24 month-age child would be able to do? Select all that apply
* Refer self by name * Dress self in simple clothing
Which are clinical manifestations commonly associated with cholelithiasis
* Residual tenderness 3-6 hrs after a meal * Flatulence * Heartburn
Motor vehicle injuries are a significant threat to young children. Knowing this, the nurse plans a teaching session with a toddler's parents on car safety. Which will she teach (select all that apply)?
* Secure in a rear-facing, upright, car safety seat. * Harness safety straps should be fit snugly. * After the age of 2 years, toddlers can be placed in a forward-facing car seat.
What must we take into consideration regarding children under 2 years old for risk for dehydration? Select all that apply
* Skin characteristics * Immature kidneys * Respiratory rate * Basal metabolic rate * Decreased thirst response
Risks for developing peptic ulcer
* Smoking and drinking alcohol * Increase stress * Frequent use of NSAIDS
function of growth hormone
* Stimulate cell growth, reproduction and regeneration * Increase protein production * Increase fat mobilization * Increase CHO use
What feeding practices are instituted for an infant with a cleft lip and/or palate?
* Stimulate sucking reflex * Resting during feeding * Squeeze bottle as infant sucks
Interventions for myxedema coma (severe hypothyroidism)
* Supportive (airway and rewarming) * Hydrocortisone * Levothyroxine (T4) * =/- T3 supplementation
Characteristic of Kwashiorkor
* Swollen abdomen * thin extremities * skin dry scaly depigmented
The nurse is assessing parental knowledge of temper tantrums. Which are true statements regarding temper tantrums (select all that apply)?
* Temper tantrums are a common response to anger and frustration in toddlers. * Temper tantrums often include screaming, kicking, throwing things, and head banging. * Children having temper tantrums should be safely isolated and ignored. * Parents can learn to anticipate times when tantrums are more likely to occur.
Which food activities would be considered to be normal adaptations for toddlers?
* They often pick up many types of foods, preferring snacking rather than eating just at mealtimes * Toddlers often exhibit "picky" eating behaviors which is considered to be a normal abnormal. * Foods should not be given to children during playtime.
A nurse is performing a developmental screening on an 18 month old. Which of the following skills should the toddler be able to perform? Select all that apply
* Throw a ball overhand * Use a spoon without rotation
What methods could they use to test pts for H. Pylori?
* Urine * Blood * Breath
What should the nurse include in teaching a pt on how to manage exophthalmos
* Wear sunglasses when outside * Report any changes in vision to provider * Use artificial tears to provide moisture * Tape the eyes closed at night with nonallergic tape
a 10 yr old with Graves disease would present with
* Weight loss * Difficulty sleeping * Heat sensitivity
Signs and symptoms of Cholecystitis
* antacids did not help * Pain is epigastric and RUQ * It started after lunch
Organic failure to thrive is caused by _____.
* congenital heart defects * UTI * Malabsorption * cystic fibrosis * endocrine disorders
treatment for peptic ulcer
* healthy diet * physical and emotional rest * don't smoke
Clinical manifestations of myxedema coma
**COLD** -Hallmarks = Decreased mental status/coma & hypothermia, hypoventilation -Other signs = Hypotension, *bradycardia*, *hyponatremia*, *hypoglycemia*, and hypoventilation
The nurse is caring for a 14 year old with celiac disease which meal choice shows understanding
*Cheese *Banana slices * Rice cakes * Whole milk
A patient with gastroesophageal reflux disease (GERD) reports severe heartburn. Which actions would the nurse suggest that the patient avoid? Select all that apply
*Drinking orange juice *Eating ice cream often *Drinking milk at bedtime
Type two diabetes
*Insulin resistance, in which the body fails to use insulin properly
A nurse is teaching a parent of an infant about GERD. Which of the following should the nurse include in the teaching? Select all that apply.
*Offer frequent feedings * Position baby upright after feedings
*Planning & Implementation for Adrenal Insufficiency (Addison's Disease)
-Restoration of extracellular fluid volume, reversal of shock, and replacement of corticosteroids and mineralocorticoids. -Monitor cardiovascular and respiratory status, urinary output, and neurological status every hour. -Correct hypoglycemia -Dietary assessment
To promote optimal absorption, the nurse would instruct a patient to take their levothyroxine at which time?
0600
PICC line assessment for possible infection
1) culture 2) change dressing 3) initials 4) EMR
anti-inflammatory effects of corticosteroids
1. vasoconstriction 2. stabilization of lysosomes 3. suppression of mitosis 4. interferes with cytokine enhancement 5. suppresses phospholipase A therefore decreasing synthesis of LTs and PGs
anterior fontanel closes at
18 months
Kimberly's parents have been using a rearward-facing, convertible car seat since she was born. Most car seats can be safely switched to the forward-facing position when the child reaches which age?
2
In teaching prospective parents about the emergence of gender identity, the nurse should instruct them that this concept emerges at about
24 months
a child engages in parallel play by the age of
24 months
Toddlers grow about ___ per year
3 inches
At what age should the nurse expect a child to give both first and last names when asked?
30 months
a child can jump with both feet by the age of
30 months
A young adult patient who is being seen in the clinic has excessive secretion of the anterior pituitary hormones. Which laboratory test result should the nurse expect?
Increased urinary cortisol
Change gauze on a central line every
48 hours
Parents tell the nurse that their toddler daughter eats little at mealtime, only sits at the table with the family briefly, and wants snacks "all the time." Which intervention should the nurse recommend?
Give her nutritious snacks.
Which clinical manifestations would the nurse document that correlate with the development of diabetes mellitus in a patient with a history of acromegaly? Select all that apply.
Increased thirst Increased urination
Which finding indicates to the nurse that the current therapies are effective for a patient who has acute adrenal insufficiency?
Increasing serum sodium levels
Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care provider before administering levothyroxine (Synthroid)?
Increased thyroxine (T4) level= decrease dose
Which complication would the nurse include in the teaching plan when educating a patient about possible postsurgical complications related to a hypophysectomy?
Infertility
Which is the leading cause of death during the toddler period?
Injuries
Parents tell the nurse that their toddler daughter eats little at mealtimes, only sits at the table with the family briefly, and wants snacks "all the time." The nurse should recommend that the parents:
Give her planned, frequent, and nutritious snacks.
A nurse reviewing the recent medical history of a patient with hypoparathyroidism expects to find a history of:
Thyroidectomy
Why are bismuth subsalicylate, clarithromycin, and metronidazole prescribed for a child with a peptic ulcer?
Eradicate Helicobacter pylori
An adolescent teen has bulimia. Which assessment finding should the nurse expect to assess?
Erosion of tooth enamel
Which nursing action is appropriate when a toddler refuses pasta because it does not taste good and when offered banana immediately after, will not try it?
Give the banana to the toddler later
A nurse places some x-ray contrast the toddler is to drink in a small cup instead of a large cup. Which concept of a toddler's preoperational thinking is the nurse using?
Inability to conserve
A patient with a goiter mentions losing 60 pounds in three months on a "raw food diet." Which foods, if eaten in great excess, would the nurse suspect as the cause of the goiter?
Broccoli
Define marasmus
Decrease in protein and calories intake
*Diagnostic Tests*:Adrenal Insufficiency (Addison's Disease)
Determine if primary or secondary adrenal insufficiency. -Deficiencies in thyroxin, testosterone, and GH [Not present in Primary, possible if pituitary or hypothalamus dysfunction is present in Secondary] -Plasma cortisol less than 5 mg/dL at 8 a.m. [Yes to both] -ACTH level changes [Primary; >200 pg/mL, in Secondary; low or normal -Antibodies [present in primary (Addison's Disease), in secondary may be present
The nurse is discussing with a parent group the importance of fluoride for healthy teeth. The nurse should recommend that the parents:
Determine whether water supply is fluoridated.
A nurse is providing anticipatory guidance to the parents of a toddler. Which of the following should the nurse include? Select all that apply.
Develop food habits that will prevent dental caries Expression of bedtime fears are common Expect behaviors associated with negativism and ritualism.
An 82-year-old patient in a long-term care facility is newly diagnosed with hypothyroidism. The nurse will need to consult with the health care provider before administering the prescribed
Diazepam (Valium)
Which should the nurse teach to parents of toddlers about accidental poison prevention? (Select all that apply.)
Discard empty poison containers. Know the number of the nearest poison control center. Caution child against eating non-edible items, such as plants.
What is the result of acute salicylate (ASA, aspirin) poisoning?
Disorientation and loss of consciousness
During the physical examination, the nurse cannot feel the patient's thyroid gland. What action should the nurse take?
Document that the thyroid was nonpalpable.
In terms of fine motor development, which should the 3-year-old child be expected to do?
Draw a circle and name what has been drawn
What should the nurse do to help reduce the risk of infection when drawing blood?
Draw all ordered samples at the same time, if possible.
The nurse is admitting a toddler with the diagnosis of juvenile hypothyroidism. Which is a common clinical manifestation of this disorder?
Dry skin
Myxedematous skin changes
Dry skin Sparse hair Periorbital edema (Puffy Eyes)
clinical manifestation of juvenile (toddler) hypothyroidism.
Dry skin mental decline myxedematous skin changes
Which condition can result if there is a deficiency of growth hormone (GH)
Dwarfism
Adrenal Insufficiency (Addison's Disease) *Patho*:
Dysfunction of all zones of adrenal cortex; deficiencies of adreno-cortical secretions, glucocorticoids, androgens & mineral-corticociods.
Developmentally, what should most children at age 12 months be able to do?
Eat the same food as the rest of the family
Developmentally, most children at age 12 months:
Eat the same food as the rest of the family.
The nurse suspects that a child has ingested some type of poison. Which clinical manifestation would be most suggestive that the poison was a corrosive product?
Edema of lips, tongue, pharynx
The nurse is caring for a neonate with a suspected tracheoesophageal fistula. What nursing care should be included?
Elevate the head but give nothing by mouth.
Which nursing intervention would be taken to provide relief to a patient who is complaining of a severe headache after a hypophysectomy?
Elevate the head of the bed to a 30-degree angle.
Which nursing action will be included in the plan of care for a patient with Graves' disease who has exophthalmos?
Elevate the head of the patient's bed to reduce periorbital fluid.
Which laboratory results would confirm overt hyperthyroidism? Select all that apply
Elevated triiodothyronine (T3) level Elevated free T4 level Low TSH level
A patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55mmol/L) and calcium of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care?
Encourage 4000 mL of fluids daily to avoid kidney stones
Which intervention will encourage a sense of autonomy in a toddler with disabilities?
Encourage independence in as many areas as possible.
A mother who intended to breastfeed has given birth to an infant with a cleft palate. What nursing interventions should be included?
Encouraging and helping mother to breastfeed.
Which treatment would be done for a patient diagnosed with hyperthyroidism who presents with nonmalignant neck nodules that are less than 3 cm in size?
Endoscopic thyroidectomy
What should the nurse recommend to the parents to help a toddler cope with the birth of a new sibling?
Give the toddler a doll with which he or she can imitate the parents.
which statement by the nurse is appropriate regarding the child throwing a temper tantrum after having a toy taken away that is usually given when the parents are away
Give the toy to the child to minimize loneliness
which information about childhood caries is appropriate for parents?
Giving a bottle of juice or milk at naptime or at bedtime predisposes the child to this syndrome
Which hormone stimulates the process of gluconeogenesis and glycogenolysis?
Glucagon
A nurse completes an assessment and notes that a patient's thyroid gland is enlarged. With which condition is this finding consistent?
Goiter
Which finding would the nurse assess in a patient with hypothyroidism?
Goiter
diseases involve the thyroid gland are
Graves and Hashimoto
Which hormone is secreting excessively if a patient with a pituitary tumor has developed excessive height and increased hat size and shoe size?
Growth hormone (GH)
Clinical Manifestations of cretinism
Growth retardation Large thickened tongue Mental retardation
A patient is diagnosed with anorexia nervosa. The nurse expects which clinical manifestations?
Hair loss, dry brittle nails, and stool retention
The nurse is caring for a patient who is suspected to be malnourished. Which components does the nurse assess while performing a nutritional screening of this patient? Select all that apply.
Handgrip strength Diet history Depression Serum albumin level Rate of weight change
associated with hypothyroidism
Hashimoto disease
Which condition is associated with decreased triiodothyronine (T3) and thyroxine (T4) levels and an increased TSH (thyroid-stimulating hormone) level?
Hypothyroidism
Nurse determines more d/c instruction needed when a pt with severe pancreatitis makes what statement
I should eat any salty foods or foods with high amount of salt
The parents of a 2-year-old tell the nurse that they are concerned because the toddler has started to use "baby talk" since the arrival of their new baby. The nurse should recommend that the parents:
Ignore the "baby talk."
The parents of a 2-year-old tell the nurse that they are concerned because the toddler has started to use "baby talk" since the arrival of their new baby. The nurse should recommend which intervention?
Ignore the "baby talk."
A toddler's parent asks the nurse for suggestions on dealing with temper tantrums. The most appropriate recommendation is to:
Ignore the behavior, provided that it is not injurious.
Which approach is appropriate when handling a toddler who, after the birth of a sibling, wants to drink from a bottle and demands the same toys as the baby?
Ignore this behavior and praise appropriate behavior
A nurse places some x-ray contrast the toddler is to drink in a small cup instead of a large cup. Which concept of a toddler's pre-operational thinking is the nurse using?
Inability to conserve
Uncontrolled hyperthyroidism can create a condition called
Thyrotoxicosis (thyroid storm)
Which nursing action would prevent the leakage of cerebrospinal fluid (CSF) after a transsphenoidal hypophysectomy?
Instructing the patient to avoid vigorous coughing, sneezing, and straining at stool
A nurse is conducting an in-service on childhood gastrointestinal disorders. Which statement is most descriptive of Meckel diverticulum?
Intestinal bleeding may be mild or profuse.
A patient is admitted with tetany. Which laboratory value should the nurse plan to monitor?
Ionized calcium
symptoms of celiac disease in a infant
Irritability failure to thrive abdominal pain
What is the primary purpose of a transitional object?
It is effective in decreasing anxiety in the toddler.
Which function of the hormone calcitonin is correct?
It regulates calcium balance
Pt is having RAI therapy for hyperthyroidism. The nurse would teach the client:
It would take about a month for s/s of hyperthyroidism to subside
Which gross motor milestones should the nurse assess in an 18-month-old child? (Select all that apply.)
Jumps in place with both feet Throws ball overhand without falling Pulls and pushes toys
What teaching should be included with a pt with Addison disease, with each monthly steroid injection?
Keep a month of extra steroids injections at all times
Which are initial symptoms of celiac disease and children aged five to seven.
Large pale oily fatty foul smelling stool Behavior changes. Abdominal distention, bloating and cramping
Which clinical manifestation may occur in the child who is receiving too much methimazole (Tapazole) for the treatment of hyperthyroidism (Graves disease)?
Lethargy and somnolence Enlargement of the salivary and cervical lymph glands occurs.
Which clinical manifestation would the nurse assess in a patient admitted with hyperparathyroidism?
Lethargy and weakness
Medications used for hypothyroidism
Levothyroxine sodium (T4) Liothyronine sodium (T3) Liotrix (T3-T4 combo)
Which symptoms should the nurse expect to observe during the physical assessment of an adolescent girl with severe weight loss and disrupted metabolism associated with anorexia nervosa?
Lowered body temperature and brittle nails
A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially?
Maintain a patent airway.
What is the nurse's highest priority to prevent life-threatening complications related to a CVAD?
Maintain aseptic care of the access device and system.
A patient who underwent surgery for acromegaly complains of postoperative headache and running nose. Which actions would the nurse take to resolve the problems within 72 hours? Select all that apply.
Maintain bed rest. Elevate head of the bed to 30 degrees
Which is descriptive of attention deficit hyperactivity disorder (ADHD)?
Manifestations affect every aspect of the child's life but are most obvious in the classroom.
What are the results of excessive vomiting in an infant with pyloric stenosis?
Metabolic alkalosis
medications used for hyperthyroidism
Methimazole (Tapazol) or Propylthiouracil (PTU)
Which medication is prescribed for the prevention of peptic ulcer caused by nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin?
Misoprostol
A nurse is planning interventions for a toddler with juvenile hypothyroidism. Which interventions should the nurse plan to implement for this child? (Select all that apply.)
Moisturizer for dry skin Implementation of thyroxine therapy
Which actions would the nurse take when caring for a patient status post a trans-sphenoidal hypophysectomy? Select all that apply.
Monitoring the pupillary response Elevating the head of the patient's bed Observing the patient for any signs of bleeding Monitoring extremity strength to detect neurologic complications
Which finding would the nurse assess in a patient with Cushing Disease?
Moon face Striae on skin
Treatment measures for management of acute pancreatitis
NG suction to prevent contents from entering duodenum
Treatment for acute cholecystitis to prevent further stimulation of gallbladder
NPO with NG suction
Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the health care provider?
Nausea and projectile vomiting= intracranial pressure
A child is admitted with bacterial gastroenteritis. Which lab results of a stool specimen confirm this diagnosis?
Neutrophils and red blood cells
Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action?
New-onset changes in the patient's voice= pressure on laryngeal nerve and possible airway obstruction
Which medications decrease lower esophageal sphincter pressure in elderly patients with a hiatal hernia and gastroesophageal reflux disease (GERD)? Select all that apply.
Nifedipine Imipramine Isosorbide dinitrate
For a patient who presents with an enlarged thyroid gland but has normal thyroid levels, which type of goiter would be documented in the patient's medical record?
Nontoxic
Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease. What enema solution should be used?
Normal saline
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?
Notify practitioner
A patient has redness, drainage, and pain at the CVC exit site as well as a fever. Which nursing intervention is the most appropriate?
Notify the practitioner and discuss
What statement would be included in discharge teaching for a client diagnosed with Cushing's?
Notify your healthcare provider if you develop a fever
Which discharge teaching would be a PRIORITY in a newborn with diagnosis of hypoparathyroidism
Observe for weakness, nausea, vomiting, and diarrhea
Which technique is best for dealing with the negativism of the toddler?
Offer the child choices.
Examples of PPIs are (ZOLES)
Omeprazole (Prilosec) Esomeprazole (Nexium) Lansoprazole (Prevacid) Rabeprazole (AcipHex) Pantoprazole (Protonix)
What topic should the nurse teach a patient who had a pituitary adenoma after the hypophysectomy?
Oral corticosteroids to replace endogenous cortisol
Complication with medications used for hypothyroidism (levothyroxine T4, Liothyronine T3 and Liotrix (combo T3 andT4)
Over medication=hyperthyroidism Take with a empty stomach
What is the history needed for overview of the endocrine system?
PMH (past endocrine disorder, changes in weight, hair distribution, muscle to fat, LOC, mod, behavior, heat and cold sensitivity) Meds (OTC, insulin, thyroid, corticosteroids) Surgery Treatments (chemo, radiation, especially above neck)
What are the characteristics unique to duodenal ulcer? Select all that apply
Pain relieved with eating food Increased gastric secretions occurs There is burning and cramping in the midepigastric area 24 hrs after meal
Which observation made of the exposed abdomen is most indicative of pyloric stenosis?
Palpable olive-like mass
which complication of acute pancreatitis requires prompt surgical drainage to prevent sepsis
Pancreatic abscess
Pts with H pylori will take which type of medications
Pantoprazole (protonix) PPI Metronidazole (antibiotics)
Which hormone is likely to be released when there is a decrease in serum Ca+ levels?
Parathormone (PTH)
A patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL. What should the nurse anticipate will be tested next?
Parathyroid hormone
Which hormone increases bone demineralization?
Parathyroid hormone
What is the most effective way to clean a toddler's teeth?
Parent to stabilize the chin with one hand and brush with the other
Which skin condition would the nurse expect to assess in a patient diagnosed with autoimmune endocrine disorders?
Patchy areas of light skin
Which information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone 40 mg daily for 3 weeks is most important to report to the health care provider?
Patient stopped taking the medication 2 days ago.
A very active, smart student is gaining weight and is depressed, and has low TSH levels. This may indicate
Pituitary disease Think!! What is causing the low TSH levels!!
Which action should the nurse take when changing a CVC dressing on a diaphoretic patient?
Place an occlusive gauze dressing over the catheter exit site.
A nurse is caring for an infant who is postoperative following cleft lip and palate repair. Which of the following actions should the nurse take?
Place the infant in an upright position
Which lab test are used to diagnose Cushing disease?
Plasma levels of ACTH and cortisol
s/s hyperglycemia: 3 Ps
Polyphagia Polydipsia Polyuria (also: hot and dry, sugar high)
The nurse is caring for a preschool child with suspected diabetes insipidus. Which clinical manifestation should the nurse expect to observe?
Polyuria and polydipsia (excessive urination and thirst)
What is a psychological effect of being obese during adolescence?
Poor body image
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.)
Positioning with head elevated on a 30-degree plane Suctioning with a Replogle tube passed orally to the end of the pouch Gastrostomy tube to gravity drainage
Stimulation of your adrenal glands right which tell the kidneys to keep water and sodium and excrete__________ which will cause hypokalemia
Potassium
A nurse is caring for a child who has Hirschsprung's disease. Which of the following actions should the nurse take?
Prepare for surgery to remove affected segment of the intestine.
The feeling of guilt that the child "caused" the disability or illness is especially critical in which child?
Preschooler
Which clinical manifestation would the nurse assess in a patient admitted with manifestation of hyperparathyroidism?
Presence of bruits upon auscultation of the thyroid gland Presence of goiter detected on palpation of the thyroid gland Presence of clubbed and swollen fingers
Which are characteristic of physical development of a 30-month-old child? (Select all that apply.)
Primary dentition is complete. Sphincter control is achieved.
Presenting symptoms of pylori stenosis.
Projectile non-bilious vomiting after feeding Olive like mass Failure to thrive or weight loss
an appropriate intervention for a patient with hyperthyroidism
Provide six well balanced small meals a day high calorie and high protein diet= high metabolism increase fluid intake= dehydration
A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving. Discharge is expected to occur in 2 days. Which teaching strategy is likely to result in effective patient self-management at home?
Provide written reminders of information taught
What should be included in caring for the newborn with a cleft lip and palate before surgical repair?
Providing satisfaction of sucking needs
A child with Graves disease is on PTU comes in with sore throat and fever. What concerns do you have
Pt may have leukopenia
A patient is being admitted with a diagnosis of Cushing syndrome. Which finding will the nurse expect during the assessment?
Purplish streaks on the abdomen
Which skin condition would the nurse expect to assess in a patient diagnosed with Cushing disease?
Purplish-red marks on the abdomen
What describes a toddler's cognitive development at age 20 months?
Realizes that "out of sight" is not out of reach
Which is descriptive of a toddler's cognitive development at age 20 months?
Realizes that "out of sight" is not out of reach
The nurse is assisting the family of a child with a history of encopresis. Which should be included in the nurse's discussion with this family?
Reassure the family that most problems are resolved successfully, with some relapses during periods of stress.
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?
Reduce gastric acid production
A parent asks the nurse about how to respond to negativism in toddlers. The most appropriate recommendation is to:
Reduce the opportunities for a "no" answer.
Which is an important nursing consideration in the care of a child with celiac disease?
Refer to a nutritionist for detailed dietary instructions and education.
Which pathogen is the viral pathogen that frequently causes acute diarrhea in young children?
Rotavirus
A blood sample is to be obtained through the CVAD. Which action should the nurse take before entering the system?
Scrub the needleless connector with an antiseptic and allow it to dry.
celiac crisis
Seen in young children with severe diarrhea leading to dehydration and metabolic acidosis
A nurse caring for a patient with hypoparathyroidism would monitor the patient for which complication?
Seizures Cataracts Dry, scaly skin
A young child has just arrived at the emergency department after ingestion of aspirin at home. The practitioner has ordered activated charcoal. The nurse administers charcoal in which way?
Serve in an opaque container with a straw.
An appropriate recommendation in preventing tooth decay in young children is to:
Serve sweets after a meal.
Which play item should the nurse bring from the playroom to a hospitalized toddler in isolation?
Set of large plastic building blocks
characteristic of Marasmus
Severe wasting Looks very skinny Skin flabby and wrinkled
Which factor is most important in predisposing toddlers to frequent infections such as otitis media, tonsillitis, and upper respiratory tract infections?
Short, straight internal ear/throat structures and large tonsil/adenoid lymph tissue are present.
Which medication is likely to be prescribed for a patient with hyperaldosteronism?
Spironolactone (Aldactone)
Pt w/ Addison's comes to the ER's on a hot day. He is lethargic, forgetful. Priority intervention?
Start IV and infuse NS rapidly while starting high dose of cortisol
Which is an appropriate recommendation for preventing tooth decay in young children?
Substitute sugarless gum for regular gum.
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?
Sudden relief from pain
Nursing care for cleft lip and cleft palate
Support and encourage parents in the general care of their child. Promote parent-infant bonding Promote healthy self-esteem throughout the child's development
Which therapeutic management treatment is implemented for children with Hirschsprung disease?
Surgical removal of affected section of bowel
A patient who has hyperthyroidism is treated with radioactive iodine (RAI). What information should the nurse include in discharge teaching?
Symptoms of hypothyroidism will occur as the RAI therapy takes effect.
s/s hypoglycemia: TIRED
T:tachycarida I: irritability R: restlessness E: excessive hunger D: diaphoresis (also: cold and clammy, need some candy)
which lab indicates malfunction of anterior pituitary gland
TSH
Which clinical manifestations would the nurse assess in a hospitalized patient experiencing exophthalmos? Select all that apply.
Tachypnea Increased appetite Bounding, rapid pulse
An infant with short bowel syndrome will be discharged home on total parenteral nutrition
Teach family signs of central venous catheter infection.
The nurse is teaching parents of toddlers about animal safety. Which should be included in the teaching session?
Teach your toddler not to disturb an animal that is eating.
Which assessment finding for an adult admitted with Graves' disease requires the most rapid intervention by the nurse?
Temperature 103.8° F (40.4° C)
A nurse is planning care for a 17-month-old child. According to Piaget, which stage should the nurse expect the child to be in cognitively?
Tertiary circular reaction
A registered nurse (RN) is caring for a patient with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching?
The RN palpates the neck to assess thyroid size
Which rationale is accurate for checking Trousseau's sign in a patient following a subtotal thyroidectomy?
To assess for parathyroid gland injury
if the adrenal corticotrophin levels are high and cortisol level are high then we can assume that the problem is which the
pituitary gland because over production of hormone
A parent of an 18-month-old boy tells the nurse that he says "no" to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. The nurse's best interpretation of this behavior is included in which statement?
This is normal behavior for his age.
Although a 14-month-old girl received a shock from an electrical outlet recently, her parents find her about to place a paper clip in another outlet. The best interpretation of this behavior is that:
This is typical behavior because of inability to transfer knowledge to new situations.
Although a 14-month-old girl received a shock from an electric outlet recently, her parent finds her about to place a paper clip in another outlet. Which is the best interpretation of this behavior?
This is typical behavior because of the inability to transfer knowledge to new situations.
Two toddlers are playing in a sandbox when one child suddenly grabs a toy from the other child. Which is the best interpretation of this behavior?
This is typical behavior because toddlers are egocentric.
A patient with a right upper extremity CVC reports pain, swelling, and tenderness of the extremity. No fluids are infusing through the catheter. The nurse knows that these signs and symptoms may indicate which CVC-associated complication?
Thrombophlebitis or venous thrombosis
A goiter is an enlargement or hypertrophy of which gland?
Thyroid
Which potential problem would the nurse assess in a patient who has made no significant dietary changes but still lost 25 lbs over the past six months?
Thyroid disorders (Hyperthyroidism)
A very active, smart student has low T3 and T4 but high TSH levels. This may indicate
Thyroid gland disease
Which laboratory value should the nurse review to determine whether a patient's hypothyroidism is caused by a problem with the anterior pituitary gland?
Thyroid-stimulating hormone (TSH) level
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?
To rule out lactose intolerance
In the clinic waiting room, a nurse observes a parent showing an 18-month-old child how to make a tower out of blocks. What should the nurse recognize in this situation?
Toddlers are capable of building a tower of blocks
In the clinic waiting room, a nurse observes a parent showing an 18-month-old child how to make a tower out of blocks. In this situation the nurse should recognize that:
Toddlers are capable of building a tower of blocks.
What usually triggers the weight loss of anorexia nervosa?
Traumatic interpersonal conflict
When explaining the proper restraint of toddlers in motor vehicles to a group of parents, the nurse should include
placing the car seat in the back seat of the car facing forward.
The nurse is conducting a staff in-service on childhood endocrine disorders. Diabetes insipidus is a disorder of:
posterior pituitary.
Intervention for risk for imbalanced body temperature and a patient with hyperthyroidism.
discourage use of electric blanket due to body inability to regulate temp= burns
which illustrates the fine motor skills of a typical toddler.
draw shapes on a paper
Why would the nurse place a pt undergoing a thyroid storm on oxygen
due to high metabolic rate
12 month old and eating should
eat the same food as family
Acromegaly may cause
enlarged hands and forehead issues with voicebox and soft tissues
Cushing disease/syndrome
excess cortisol or an ACTH-secreting tumor, causing an excess of cortisol
What is the most immediate nursing problem in the care of a new born with cleft lip and palate.
feeding
toddlers should weight _______times their birth weight
four
Which lab indicates hyperthyroidism
free T4
How can a caregiver respond to a toddler having a temper tantrum.
give calm consistent responses
adrenal cortex secretes
glucocorticoids mineralocorticoids sex hormones
(Cushing) causes increase release of _______as part of the increase of cortisol in the body in response to the fight and flight stress response
glucose
changes in the epiphyseal plate affects
growth
if the adrenal corticotrophin is low than the cortisol level is
high= adrenal tumor
Which s/s should make the nurse suspect the client is experiencing a thyroid storm?
hyperpyrexia and extreme tachycardia
What is the best description of pyloric stenosis?
hypertrophy of the pyloric muscle
Pt c/o numbness around his mouth, tingling at the tips of his fingers and jitteriness. This is a sign that the pt has
hypocalcemia
Which discharge teaching would be a priority in a newborn with diagnosis of hypoparathyroidism
hypoparathyroidism
a newborn develop tetany and has a seizure prior to discharge. Which diagnosis is likely
hypoparathyroidism
it reads the body's level of cortisol in the regulation of the adrenal glands
hypothalamus
Patient receiving aldosterone the nurse should monitor
increase potassium levels
Complication with medications used for hyperthyroidism (PTU, Tapazole)
increased WBC Agranulocytosis Fever/sore throat/ fatigue Take with meals
Acute pancreatitis diagnosed by which lab findings
increased amylase
which behavior is appropriate when describing a toddler's eating's habits of eating a lot then nothing at the next day or refusing favorite foods?
influenced by the psychologic components of food
Before putting a catheter you need to check for
iodine allergy
which condition would the nurse be concerned for in the toddler that drinks milk and fruit juice and consume little solid foods?
iron deficiency
signs and symptoms of Addison Disease
just two things you need to know. They are hyperpigmented and they don't adapt to stress. Fatigue weight-loss anorexia postural hypotension hypoglycemia hyponatremia hyperkalemia hyperpigmentation loss of body hair hypovolemia
language development of toddler
multiword sentences by combining two to three words
All of these are complications from a thyroidectomy except
myxedema coma
The excess GH in pts with Acromegaly results in
overgrowth of soft tissues and bones in the hands, feet, and face.
Endogenous Cushing's Syndrome
overproduction of cortisol
An NG tube is removed when
pain level decreases
Gastritis causing this anemia is related to an autoantibody to instrictic factor
pernicious anemia
