Lippincott the child with health problems of the urinary system

12. The nurse is caring for an infant with hypospadias. Identify the area where the nurse would assess for this condition.

12. In hypospadias, the urethral opening is on the ventral side of the penis.

1. A father brings his 4-week-old son to the clinic for a checkup, stating that he believes his son's testicle is missing. Which of the following explanations would be most appropriate? 1. "Although the testes should have descended by now, it is not a cause for worry." 2. "The testes often do not descend until age 6 months, but let's check to see whether the testes are present." 3. "The testes are present in the scrotal sac at birth, but surgery can remedy the situation." 4. "Although the testes normally descend by 1 year of age, I can understand your concern."

1. 4. Normally the testes descend by 1 year of age ; failure to do so may indicate a problem with patency or a hormonal imbalance. By age 4 weeks, descent may not have occurred. However, telling the father that lack of descent is not a cause for worry is inappropriate and uncaring. Additionally, a statement such as this may be false reassurance. By acknowledging the father's concern, the nurse indicates acceptance of his feelings. If the testes have not descended, then they will not be palpable in the scrotal sac. Surgery is not discussed until after a full

10. Shortly after an infant is returned to his room following hydrocele repair , the infant's mother tells the nurse that the child's scrotum looks swollen and bruised. Which of the following responses by the nurse would be most appropriate? 1. "Let me see if the doctor has prescribed aspirin for him. If he did, I'll get it right away." 2. "Why don't you wait in his room? Then you can ask me any questions when I get there." 3. "What you are describing is unusual after this type of surgery. I'll let the doctor know." 4. "This is normal after this type of surgery. Let's look at it together just to be sure."

10. 4. Some swelling and bruising are normal postoperatively. By assessing the area with the mother, the nurse is conveying acceptance of the mother's concern. In addition, the nurse needs to inspect the area to determine if what the mother is describing is accurate. Doing so also provides an opportunity for teaching. Aspirin is not usually prescribed for children because of the link between aspirin and Reye's syndrome . Acetaminophen is commonly administered for fever or pain relief . Asking the mother to wait in the child's room ignores the mother's concerns. There is no need to notify the doctor at this time.

11. The parents of a neonate with hypospadias and chordee wish to have him circumcised. Which of the following explanations should the nurse incorporate into the discussion with the parents concerning the recommendation to delay circumcision? 1. The associated chordee is difficult to remove during circumcision. 2. The foreskin is used to repair the deformity surgically. 3. The meatus can become stenosed, leading to urinary obstruction. 4. The infant is too small to have a circumcision.

11. 2. The condition in which the urethral opening is on the ventral side of the penis or below the glans penis is referred to as hypospadias. Chordee refers to a ventral curvature of the penis that results from a fibrous band of tissue that has replaced normal tissue. Circumcision is delayed because the foreskin, which is removed with a circumcision, often is used toreconstruct the urethra. The chordee is corrected when the hypospadias is repaired. Circumcision is performed at the same time. Urethral meatal stenosis, which can occur in circumcised infants , results from meatal ulceration, possibly leading to urinary obstruction. It is not associated with hypospadias or circumcision. The infant is not too small to have a circumcision, which is commonly performed on the first or the second day of life.

13. A 1-year-old child is scheduled for surgery tocorrect hypospadias and chordee. The nurse explains to the parents that this is the preferred time for surgical repair based on which of the following? 1. At this age, the child will experience less pain. 2. The child is too young to have developed castration anxiety. 3. The child will not remember the surgical experience. 4. The repair is easier to perform after the child is toilet trained.

13. 2. The preferred time for surgery is between the ages of 6 and 18 months, before the child develops castration and body image anxiety. Children learn early on about society's emphasis on the importance of genitals. Pain is different for each child and is not related to the preferred time for repair of the hypospadias or chordee. Although the child will probably not remember the experience, this is not the basis for having the surgery at this age. If the condition is not repaired, the child will have difficulty with toilet training because urine is not eliminated through the tip of the penis.

14. A 6-month-old child is discharged with a urinary stent after a procedure to repair a hypospadias. The nurse should tell the parents to: 1. Avoid tub baths until the stent is removed. 2. Measure output in the urinary bag. 3. Avoid drinking fruit juice. 4. Clean the tip of the penis three times a day with soap and water.

14. 1. The parents should keep the penis as dry as possible until the stent is removed. Soaking in a tub bath is not recommended . Children this age typically go home voiding directly into a diaper. Infants may be started on juice at 6 months of age. Parents are advised to keep their child well hydrated after a hypospadius repair. Therefore, there is no reason to avoid juice. Cleaning the tip of the penis three times a day may cause unnecessary irritation.

15. After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which of the following? 1. Decreases pain at the surgical site. 2. Keeps the new urethra from closing. 3. Measures his urine correctly. 4. Prevents bladder spasms.

15. 2. The main purpose of the urethral catheter is to maintain patency of the reconstructed urethra. The catheter prevents the new tissue inside the urethra from healing on itself. However, the urethral catheter can cause bladder spasms. Recently, stents have been used instead of catheters . The urethral catheter will have no effect on the child's pain level. In fact, because bladder spasms are associated with its use , the child's problems of pain may actually increase . Urine output can be measured through the suprapubic catheter because it provides an alternative route for urinary elimination , thus keeping the bladder empty and pressure-free.

16. While assessing the penis of a child who has had surgery for repair of a hypospadias, the nurse observes the appearance of the penis. The nurse should report which aspect to the surgeon? 1. Swollen. 2. Dusky blue at the tip. 3. Somewhat misshapen. 4. Pink.

16. 2. A dusky blue color at the tip of the penis may indicate a problem with circulation, and the nurse should notify the surgeon. Following surgery, it is normal for the penis to be swollen and pink. The penis may be misshapen and is unlikely to look normal even after reconstruction.

17. When developing the teaching plan for the parents of a 12-month-old infant with hypospadias and chordee repair, which of the following should the nurse expect to include as most important? 1. Assisting the child to become familiar with hisdressings so he will leave them alone. 2. Encouraging the child to ambulate as soon as possible by using a favorite push toy. 3. Forcing fluids to at least 2,500 mL/ day by offering his favorite juices. 4. Preventing the child from disrupting the catheters by using soft restraints.

17. 4. The most important consideration for a successful outcome of this surgery is maintenance of the catheters or stents. A 12-month-old infant likes to explore his environment but must be prevented from manipulating his dressings or catheters through the use of soft restraints. Allowing the infant to become familiar with the dressings will not prevent him from pulling at them. After surgery the child is allowed limited activity, possibly with sitting in the parent's lap. A 12-month-old infant may or may not be walking. If he is, most likely he will be clumsy and possibly injure himself. Although increasing fluids is important, 2,500 mL/ day is an excessive amount for a 12-month-old. Fluid requirements would be 115 mL/ kg.

18. The physician prescribes a urinalysis for a child who has undergone surgical repair of a hypospadias. Which of the following results should the nurse report to the physician? 1. Urine specific gravity of 1.017. 2. Ten red blood cells per high-powered field. 3. Twenty-five white blood cells per high-powered field. 4. Urine pH of 6.0.

18. 3. A normal white blood cell count in aurinalysis is 1 to 2 cells/ mL . A white blood cell count of 25 per high-powered field indicates a urinary tract infection. A urine specific gravity of 1.017 is within the normal range of 1.002 to 1.030. After urologic surgery, it is not unusual for a small number of red blood cells to appear in the urine. The child's urine pH is within the normal range of 4.6 to 8.

19. A 4-year-old with a history of urinary reflux returned from surgery for bilateral urethral reimplants 2 days ago. Which assessment finding is most concerning? 1. Intermittent bladder spasms. 2. Small amounts of blood-tinged urine. 3. Decreased oral intake. 4. Continuous drainage from a Foley catheter.

19. 3. Children with bilateral ureteral implants often have pain with urination due to bladder spasms. Some children will avoid drinking in order to avoid the pain associated with urination, thus putting the child at risk for dehydration. Intermittent bladder spasms are common after ureteral reimplant surgery and can be treated with Ditropan (oxybutynin) to decrease discomfort. Small amounts of blood tinged urine, bladder spasms, urinary frequency, and urinary incontinence are common following ureteral reimplant surgery.

2. While preparing to examine a 6-week-old infant's scrotal sac and testes for possibleundescended testes, which of the following would be most important for the nurse to do? 1. Check the diaper for recent urination. 2. Give the infant a pacifier. 3. Ensure that the room is kept warm. 4. Tap lightly on the left inguinal ring.

2. 3. A cold environment can cause the testes to retract. Cold and touch stimulate the cremasteric reflex, which causes a normal retraction of the testes toward the body. Therefore, the nurse should warm the hands and make sure that the environment also is warm. Checking the diaper for urination provides information about the infant's voiding and urinary function, not information about the testes. Giving the infant a pacifier may help to calm the infant and possibly make the examination easier, but the concern here is with the temperature of the environment. Tapping on the inguinal ring would not be helpful in assessing the infant.

20. The health care provider has prescribed a sterile urine specimen on a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized the procedure was very painful and traumatic. The nurse should tell the family: 1. "I will request a prescription for a sedative to help him relax." 2. "I can't do anything to reduce the pain, but you can hold him during the procedure." 3. "I will get a prescription for a lidocaine-based lubricant to make the procedure more comfortable."4. "I can apply a topical anesthetic 20 minutes before placing the catheter."

20. 3. Two percent lidocaine lubricants have been found to significantly reduce the pain of urinary catheter insertion in children. If the unit does not have a standing protocol to use the lubricant, the nurse should request a prescription. A sedative would carry with it additional risks that could be avoided with the use of other methods to reduce pain. The parents should be encouraged to hold the child in addition to other pain relief methods. Frequent urination would make the use of topical anesthetics that must be left in place for a period of time impractical.

21. The parents of a child on sulfamethoxazole and trimethoprim for a urinary tract infection report that the child has a red, blistery rash. The nurse should tell the parents to: 1. Apply lotion to the affected areas. 2. Discontinue the medicine and come for immediate further evaluation. 3. Use sunblock while on the medication. 4. Increase the child's fluid intake.

21. 2. Sulfonamides have been associated with severe adverse reactions. A blistering rash may be a sign of Stevens-Johnson syndrome, a severe allergic reaction that manifests as skin lesions. This reaction is life threatening and requires immediate attention. Lotion should not be applied to skin with blisters.Sulfamethoxazole and trimethoprim may cause photosensitivity, but this usually appears as a mild red rash, not blisters. Increasing the child's fluid intake may help the urinary tract infection, but does not address the rash.

22. A recent history of which of the following should alert the nurse to gather additional information about the possibility of a urinary tract infection in a 2-year-old child who is exhibiting fever and fussiness? 1. Abdominal pain. 2. Swollen lymph glands. 3. Skin rash. 4. Back pain.

22. 1. Abdominal pain frequently accompanies urinary tract infection in children 2 years of age and older. Other associated signs and symptoms include decreased appetite , vomiting, fever, and irritability . The presence of swollen lymph glands (lymphadenopathy) is unrelated to urinary tract infections. Lymphadenopathy is associated with a systemic infection or possibly cancer. Skin rash is associated with exposure to allergens or irritants ( eg, poison ivy or harsh soaps); prolonged contact with urine (eg, diaper dermatitis); or illnesses such as measles, rheumatic fever, or juvenile rheumatoid arthritis. Flank or back pain is associated with urinary tract infection in children older than 2 years of age and in adults.

23. A father of a child with a urinary tract infection calls the clinic and explains, "My wife and I are concerned because our child refuses to obey us concerning the preventions you told us about. Our child refuses to take the medication unless we buy a present. We don't want to use discipline because of the illness, but we're worried about the behavior." Which response by the nurse is best? 1. "I sympathize with your difficulties, but just ignore the behavior for now." 2. "I understand it's hard to discipline a child who is ill, but things need to be kept as normal as possible." 3. "I understand that things are difficult for you right now, but your child is ill and deserves special treatment." 4. "I understand your concern, but this type of behavior happens all the time; your child will get over it when feeling better."

23. 2. To ensure appropriate psychosocial development, a child needs to have normal patterns maintained as much as possible during illness. It is tempting to give ill children special treatment and to relax discipline. However, family routines and discipline should be kept as normal as possible. The child needs to know the limits to ensure feelings of security. When they are ill, children commonly attempt to stretch the rules and limits. If this occurs , returning to the previous well-behavior patterns will take time.

24. A nurse is teaching the parents of a child diagnosed with a urinary tract infection secondary tovesicoureteral reflux. How should the nurse explain how the reflux contributes to the infection? 1. "It prevents complete emptying of the bladder." 2. "It causes urine backflow into the kidney." 3. "It results in painful bladder spasms." 4. "It causes painful urination."

24. 1. The reason that urinary tract infections are a problem in children with vesicoureteral reflux is that urine flows back up the ureter, past the incompetent valve, and back into the bladder after the child has finished voiding. This incomplete emptying of thebladder results in stasis of urine, providing a good medium for bacterial growth and subsequent infection. Vesicoureteral reflux does not cause bladder spasms or painful urination. However, the child may experience painful urination with a urinary tract infection.

25. A 15-year-old has been diagnosed with acute glomerulonephritis and has been in the hospital for 1 day. Which of the following findings requires immediate action? 1. Large amount of generalized edema. 2. Urine specific gravity of 1.030. 3. Large amount of albumin in the urine. 4. 24-hour output of 1,500 mL.

25. 2. An adolescent with acute glomerulonephritis has a high urine specific gravity related to oliguria caused by inflammation of the glomeruli. The client will have periorbital edema, but not the generalized edema that occurs in nephrotic syndrome. In glomerulonephritis, there is some albumin in the urine, but there are large amounts of red blood cells, giving the urine a brown color. The urine in glomerulonephritis is scanty, averaging about 400 mL in 24 hours, which leads to fluid volume excess and hypertension.

26. Which of the following meals would be most appropriate for a 15-year-old with glomerulonephritis with severe hypertension? 1. Egg noodles, hamburger, canned peas, milk. 2. Baked ham, baked potato, pear, canned carrots, milk. 3. Baked chicken, rice, beans, orange juice. 4. Hot dog on a bun, corn chips, pickle, cookie, milk.

26. 3. The best selection of food would include no added salt or salty food. Because sodium cannot be excreted due to the oliguria and to avoid increasing the hypertension, a low-salt diet is recommended. Most canned foods have sodium added as a preservative. Hamburger, ham, hot dogs, canned peas, canned carrots, corn chips, pickles, and milk are high in sodium.

27. A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should immediately: 1. Put the client to bed. 2. Obtain the child's blood pressure. 3. Notify the physician. 4. Administer acetaminophen (Tylenol).

27. 2. Hypertension occurs with acute glomerulonephritis. The symptoms of headache and blurred vision may indicate an elevated blood pressure. Hypertension in acute glomerulonephritis occurs due to the inability of the kidneys to remove fluid and sodium; the fluid is reabsorbed, causing fluid volume excess. The nurse must verify that these symptoms are due to hypertension. Calling the physician before confirming the cause of the symptoms would not assist the physician intreatment. Putting the client to bed may help treat an elevated blood pressure, but first the nurse must establish that high blood pressure is the cause of the symptoms. Administering Tylenol for high blood pressure is not recommended.

28. Which of the following questions should the nurse ask first when obtaining a history from the mother of a 10-year-old child with a fever, malaise, and swelling around the eyes? 1. "Has the child had a sore throat recently?" 2. "Is the child playing with friends as usual?" 3. "Does the child urinate as much as usual?"4. "Is the urine pale in color?"

28. 3. Most likely, the nurse suspects that the child is exhibiting signs and symptoms of glomerulonephritis, such as periorbital edema and fever. Other signs and symptoms include loss of appetite, dark-colored urine, pallor, headaches, and abdominal pain . To confirm this suspicion, the nurse would ask about the child's urinary elimination patterns. Typically the child with glomerulonephritis experiences a decrease in urine output. Asking about any recent sore throat would provide additional information to confirm the suspicion of glomerulonephritis, because the most common type is acute poststreptococcal glomerulonephritis, which follows a strep throat by 10 to 14 days. Frequently , the children have only mild cold symptoms and do not realize they have a streptococcal infection. Asking whether the child plays with friends as usual is important and gives the nurse information about how the child feels in general. However, this is a general question that would be appropriate to ask later on in the history. Although asking the mother about the color of the child's urine is important, the nurse needs to determine whether there is any change in the child's urinary output first.

29. A school-age client admitted to the hospital because of decreased urine output and periorbital edema is diagnosed with acute poststreptococcal glomerulonephritis. Which of the following actions should receive the highest priority? 1. Assessing vital signs every 4 hours. 2. Monitoring intake and output every 12 hours. 3. Obtaining daily weight measurements. 4. Obtaining serum electrolyte levels daily.

29. 3. The child with acute poststreptococcal glomerulonephritis experiences a problem with renal function that ultimately affects fluid balance. Because weight is the best indicator of fluid balance, obtaining daily weights would be the highest priority.

3. While the nurse is examining the infant for presence of testes, the father paces around the room shaking his head. Which of the following would be the most appropriate response by the nurse? 1. "I'm sure everything will work out for the best, and he'll be fine." 2. "You seem upset; please tell me how you're feeling." 3. "Don't worry ; his testes will probably descend on their own." 4. "Would you like to talk with a parent of a child who has the same problem?"

3. 2. The nurse needs more information about the father's perceptions and feelings before providing any information or taking action . Determining the exact nature of the father's concern rather than making an assumption about it is essential. Therefore, the nurse should identify what is observed and ask the father how he is feeling. Telling the father that everything will be fine or not to worry is inappropriate and provides false reassurance. It also devalues the father's concern. Later on, it may be appropriate for the father to talk to a parent of a child with the same problem for support.

30. When developing the plan of care for a school-age child with acute poststreptococcal glomerulonephritis who has a fluid restriction of 1,000 mL/ day, which of the following fluids should the nurse consider as most appropriate for the client's condition and effective for preventing excessive thirst? 1. Diet cola. 2. Ice chips. 3. Lemonade. 4. Tap water.

30. 2. The most appropriate and effective choice would be ice chips, because they help moisten the mouth and lips while keeping fluid intake low . However, ice chips must still be counted as intakewith the fluid restriction. Sweet beverages, such as diet cola or lemonade, commonly increase thirst. Tap water effectively relieves thirst but does not help keep fluid intake low.

31. The nurse is planning interventions for a school-aged child in need of diversional activity. Which of the following activities should the nurse expect to include? 1. Playing a card game with someone the same age. 2. Putting together a puzzle with mother. 3. Playing video games with a 4-year-old. 4. Watching a movie with a younger brother.

31. 1. Generally, school-age children enjoy activities with their peers first, then family members, and lastly younger children . School-age children like to be busy but also to accomplish something. This helps to meet their task of industry versus inferiority, feeling good about what they are able to accomplish.

32. A 10 -year-old child hospitalized with acute poststreptococcal glomerulonephritis during the acute stage has elevated blood pressure and low urine output for 14 hours. The nurse should next: 1. Assess the child's neurologic status. 2. Encourage the child to drink more water. 3. Advise the child to eat a low-sodium breakfast. 4. Help the client to ambulate in the hallway.

32. 1. The nurse should assess the child's neurologic status, because hypertensive encephalopathy is a major potential complication of the acute phase of glomerulonephritis. Seizure precautions also should be instituted. Hypertensive encephalopathy can result in transient loss of vision , hemiparesis, disorientation, and grand mal seizures. Encouraging the child to drink more water is inappropriate because the child has had a low urine output for 14 hours. Typically, in this situation, fluids would be restricted. Although a low-sodium diet is encouraged, it is not the priority action at this time. Initially, bed rest, not ambulation, is advocated during the acute phase of glomerulonephritis.

33. When developing the discharge plan for a school-age child diagnosed with acute poststreptococcal glomerulonephritis, which instruction should the nurse plan to discuss?1. Restricting dietary protein. 2. Monitoring pulse rate and rhythm. 3. Preventing respiratory infections. 4. Restricting foods high in potassium.

33. 3. Children recovering from glomerulonephritis need to avoid exposure to all types of infections. Glomerulonephritis is caused by group A beta-hemolytic streptococcus, a common cause of sore throat. As the child recovers, he or she may be susceptible to a recurrence if exposed to the organism again. During convalescence from glomerulonephritis, fluid and dietary restrictions are no longer indicated because the kidneys are now functioning normally. There is no need for the parents to assess the child's vital signs.

An adolescent with a history of losing weight and fatigue is admitted to the hospital with a diagnosis of stage I chronic renal failure. The chart shows: Based on these findings, the nurse should: 1. Continue monitoring intake and output. 2. Notify the physician. 3. Restrict the client's fluids. 4. Increase the client's fluids.

34. 2. The nurse would expect a person with a normal GFR to have approximately equal inputs and outputs. Chronic renal failure has five stages. In stage I, the glomerular filtration rate (GFR) is approximately ≥ 90 mL/ min/ 1.73 m2. In stage II, the GFR decreases to approximately 60 to 89 mL/ min/ 1.73 m2. The decreased urine output may indicate worsening disease and should be reported. Assessing the client's intake and output is still important, but notifying the provider is the priority . Fluids are restricted based on decreased sodium . Clients are encouraged to drink to thirst. Therefore, there is not enough information to suggest increasing or restricting fluids.

35. A parent of a child with acute poststreptococcal glomerularnephritis (APSGN) asks how a strep infection caused their child to have a kidney problem. What is the nurse's best response? 1. "The streptococcal infection spread through the bloodstream to your child's kidneys." 2. "Your child made excessive antibodies to fight the infection that are now attacking the kidneys." 3. "By-products of immune complexes that fought the infection are depositing in the kidneys." 4. "The strep infection weakened your child's immune system, making him susceptible to a secondary infection."

35. 3. APSGN is an immune complex disease. Large antigen-antibody complexes are formed that deposit in the glomerular capillary loops leading to obstruction. APSGN is considered an autoimmune disorder, not an infection . Antibodies do not attack the kidneys in this disorder.

36. A child with nephrosis is taking prednisone. The nurse should teach the caregivers to report which of the following adverse effects? Select all that apply. 1. Increased urinary output. 2. Hematemesis. 3. Respiratory infection. 4. Bleeding gums.5. Vision problems.

36. 2, 3. Adverse effects of steroid therapy include edema of the face and trunk , increased susceptibility to infection, gastric and intestinal mucosal bleeding, sodium and water retention , and hypertension. Urinary output is decreased due to the retention of sodium. Bleeding gums do not result from steroids . Steroid therapy does not cause vision problems.

The nurse is caring for a 5-year-old boy who is taking prednisolone for nephrotic syndrome. The child is at the 75th percentile for height and has a blood pressure of 114/ 73. The nurse compares the reading to the below blood pressure levels for boys age and height percentiles. The nurse determines that the blood pressure represents a change and notifies the primary care provider of the assessment of: 1. Hypotension. 2. Prehypertension. 3. Hypertension. 4. Hypertension stage II.

37. 3. Reading at or above the 95th percentile are considered indicative of hypertension. Here, both the systolic and diastolic readings are at the 95th percentile for a boy who is at the 75th percentile for height. This blood pressure may be a side effect of the medication or part of the disease process and needs to be reported. The charts do not define hypotension. Readings below the 90th percentile are considerednormal. Blood pressures at the 90th percentile, but below the 95th are considered prehypertension. Blood pressures at the 99th percentile are considered stage II hypertension and are most likely to need antihypertensive medications.

38. Which of the following statements by the mother of a toddler diagnosed with nephrotic syndrome indicates that the mother has understood the nurse's teaching about this disease? 1. "My child really likes chips and bologna. I guess we'll have to find something else." 2. "We'll have to encourage lots of liquids. Did you say about 4 L every day?" 3. "We worry about the surgery. Do you think we should do direct donation of blood?" 4. "We understand the need for antibiotics. I just wish the antibiotics could be given by mouth."

38. 1. Children with nephrotic syndrome usually require sodium restriction. Because potato chips and bologna are high in sodium, the mother's statement about finding something else reflects understanding of this need. Although fluid intake is not restricted in children with nephrotic syndrome, 4 L is an excessive amount for a toddler. The typical fluid requirement for a toddler is 115 mL/ kg. Surgical intervention and antibiotic therapy are not parts of the treatment plan for nephrotic syndrome.

39. A toddler diagnosed with nephrotic syndrome has a fluid volume excess related to fluid accumulation in the tissues. Which measure should the nurse anticipate including in the child's plan of care? 1. Limiting visitors to 2 to 3 hours a day. 2. Maintaining strict bed rest. 3. Testing urine specific gravity every shift. 4. Weighing the child before breakfast.

39. 4. The best indicator of fluid balance is weight. Therefore, daily weight measurements help determine fluid losses and gains. Although limiting visitors to 2 to 3 hours per day or maintaining strict bed rest would help to ensure that the child gets adequate rest, this is unrelated to the child's fluid balance. In nephrotic syndrome, urine is tested for protein, not specific gravity.

4. When assessing an infant with an undescended testis, the nurse should be alert for which of the following? 1. Abnormal lower extremity reflexes. 2. A history of frequent emesis. 3. A bulging in the inguinal area. 4. Poor weight gain.

4. 3. When an anomaly is found in one system, such as the genitourinary system, that system requires a more focused assessment to reveal other conditions that also may be occurring. A bulging in the inguinal area may suggest an inguinal hernia . Also, hydrocele or an upper urinary tract anomaly may occur on the same side as the undescended testis. A neuromuscular problem, not a genitourinary problem such as undescended testes, would most likely be the cause of abnormal lower extremityreflexes. A history of frequent emesis may be caused by pyloric stenosis or viral gastroenteritis. Poor weight gain might suggest a metabolic or a feeding problem.

40. The mother of a toddler with nephroticsyndrome asks the nurse what can be done about the child's swollen eyes. Which measure should the nurse suggest? 1. Applying cool compresses to the child's eyes. 2. Elevating the head of the child's bed. 3. Applying eye drops every 8 hours. 4. Limiting the child's television watching.

40. 2. The child's swollen eyes are caused by fluid accumulation. Elevating the head of the bed allows gravity to increase the downward flow of fluids in the body, away from the face. Applying cool compresses or eye drops, or limiting television, may be comforting but will not relieve the swelling.

41. The nurse determines that interventions for decreasing fluid retention have been effective when the child with nephrotic syndrome demonstrates evidence of which of the following? 1. Decreased abdominal girth. 2. Increased caloric intake. 3. Increased respiratory rate. 4. Decreased heart rate.

41. 1. Fluid accumulates in the abdomen and interstitial spaces owing to hydrostatic pressure changes. Increased abdominal fluid is evidenced by an increase in abdominal girth. Therefore, decreased abdominal girth is a sign of reduced fluid in the third spaces and tissues. When fluid accumulates in the abdomen and interstitial spaces, the child does notfeel hungry and does not eat well. Although increased caloric intake may indicate decreased intestinal edema, it is not the best and most accurate indicator of fluid retention. Increased respiratory rate may be an indication of increasing fluid in the abdomen (ascites) causing pressure on the diaphragm. Heart rate usually stays in the normal range even with excessive fluid volume.

42. The toddler with nephrotic syndrome exhibits generalized edema. Which of the following measures should the nurse institute for this child with impaired skin integrity related to edema? 1. Ambulate every shift while awake. 2. Apply lotion on opposing skin surfaces. 3. Apply powder to skinfolds. 4. Separate opposing skin surfaces with soft cloth.

42. 4. Placing soft cloth between opposing skin surfaces absorbs moisture and keeps the area dry, thus preventing any further breakdown. The child with nephrotic syndrome and severe edema is usually maintained on bed rest. Therefore , ambulation is not appropriate. Applying lotion or powder to edematous surfaces that touch increases moisture and can lead to maceration, causing further breakdown.

A child with nephrosis is placed on prednisone. The dose is 2 mg/ kg/ day to be administered twice a day. The child weighs 25 lb (11.3 kg). How many milligrams will the child receive at each dose? ______________________ mg.

43. 11.3 mg

44. The toddler with nephrotic syndrome responds to treatment and is ready to go home. When helping the family plan for home care, which of the following instructions should the nurse include in the teaching? 1. Administer pain medication as needed. 2. Keep the child away from others with an infection. 3. Notify the physician if there is an increase in the child's urine output. 4. Administer acetaminophen (Tylenol) daily.

44. 2. A child recovering from nephrotic syndrome should be protected from infection. Therefore, the nurse would teach the parents to keep the child away from others with an infection. Because pain is not associated with this disorder, pain medication typically is not needed. The physician should be notified if urine output decreases, not increases. In children recovering from nephrotic syndrome, there is no reason to administer acetaminophen daily.

45. The nurse is planning care with the parents of a child who requires continuous peritoneal dialysis. Which finding should be discussed with the physician? 1. The family lives a long distance from the medical facility. 2. The child attends a large public school. 3. The child reports having a previous surgery for a ruptured appendix. 4. The family feels the child cannot self-regulate to wake at night and change bags.

45. 3. A client who has had a ruptured appendix may have peritoneal scarring that may alter the effectiveness of treatment. Living a long distance from a medical facility is typically a reason to select peritoneal dialysis. Attending a large school is not a problem, but the school nurse needs to be included aspart of the health care team. Typically the treatment schedule can be planned to allow for uninterrupted sleep at night.

46. While performing daily peritoneal dialysis and catheter exit site care with the mother of a child with chronic renal failure, which of the following would be an important step to emphasize to the mother? 1. Applying an occlusive dressing after cleaning the site. 2. Changing the dressing when the peritoneal space is dry. 3. Examining the site for signs of infection while cleaning the area. 4. Pulling on the catheter to hold taut while cleaning the skin.

46. 3. Until it heals, the catheter exit site is particularly vulnerable to invasion by pathogenic organisms. Therefore, the site must be monitored for signs of infection. An occlusive dressing is not needed because there is no danger of air being sucked in or out of the peritoneal space. Furthermore, the catheter used is designed with a cuff, so that the skin grows around the catheter, sealing off the area. Site care may be done at any time, but the child may experience abdominal discomfort if the peritoneal space is dry during site care. Holding the catheter taut or pulling on it may cause irritation of the skin at the exit site, which could lead to infection.

47. When developing the discharge teaching plan for a child with chronic renal failure and the family, the nurse should emphasize restriction of which of the following nutrients? 1. Ascorbic acid. 2. Calcium. 3. Magnesium. 4. Phosphorus.

47. 4. With minimal or absent kidney function, the serum phosphate level rises, and the ionized calcium level falls in response. This causes increased secretion of parathyroid hormone, which releases calcium from the bones. Therefore, the intake of foods high in phosphorus is restricted. Because renal failure results in decreased erythropoietin production, an increase in ascorbic acid intake is needed . Because magnesium is minimally affected by renal failure, its intake need not be restricted.

48. After emphasizing to an adolescent with renal failure the importance of maintaining a positive self -concept, which of the following behaviors by the adolescent should the nurse identify as an indicator that the plan is working? 1. Reports of headaches, abdominal pain, and2. Insistence on making diet choices even if the foods chosen are restricted. 3. Verbalization of plans to quit all after-school activities when returning home. 4. Demonstration of desire to do the dressing changes and take care of the medications.

48. 4. Demonstration of desire to do the dressing changes and manage medications implies compliance with the medical regimen and acceptance of the condition, thereby indicating a positive self-image . Diffuse somatic symptoms could indicate anxiety or problems with coping, with a negative effect on self-concept. Insistence on choosing restricted foods implies that the adolescent has not accepted the diagnosis and is noncompliant, possibly indicating a negative self-concept. Social withdrawal from activities may indicate depression, possibly negatively

49. Which of the following diet plans would be appropriate for the nurse to discuss with the family of a child with acute renal failure? 1. High carbohydrate and protein. 2. High fat and carbohydrate. 3. Low fat and protein. 4. Low in carbohydrate and fat.

49. 2. The child with acute renal failure needs extra calories to reduce tissue catabolism, metabolic acidosis, and uremia. Using a high-fat and carbohydrate diet helps to supply the necessary extra calories. If the child is able to tolerate oral foods , concentrated food sources that are high in carbohydrate and fat but low in protein, potassium, and sodium may be provided.

52. After teaching the mother of a young child with a peritoneal catheter about the signs and symptoms of peritonitis, the nurse determines that the mother has understood the teaching when she identifies which of the following as an importantsign? 1. Cloudy dialysate drainage return. 2. Distended abdomen. 3. Shortness of breath. 4. Weight gain of 3 lb (1.36 kg) in 2 days.

52. 1. Normally, dialysate drainage return should be clear. With peritonitis, large numbers of bacteria , white blood cells, and fibrin cause the dialysate to appear cloudy. Abdominal distention is unrelated toperitonitis. However, it might suggest an obstruction. Weight gain and shortness of breath are associated with fluid excess, not infection.

50. An adolescent with chronic renal failure is scheduled to go home with a peritoneal dialysis catheter in place. When developing the discharge teaching plan for the client and the family focusing on psychosocial needs, which of the following areas should be a top priority to include? 1. Advantages of limiting social activities and contacts for the first few months. 2. Not disclosing information about the peritoneal dialysis to people outside the family. 3. Possible effect on body image of the presence of an abdominal catheter. 4. Importance of relying on parents to do the dialysis and dressing changes.

50. 3. For an adolescent, body image is a major concern. The presence of an abdominal catheter can greatly affect the client's body image. The adolescent needs opportunities to discuss feelings about altered body image due to the catheter. Adolescents need to be with their peers and to maintain social activities and contacts in order to meet the developmental tasks for this age group. The adolescent client may choose to confide in friends for both psychological health and physical safety. Because peers are most important to adolescents , they will confide in their peers before confiding in family members. Another major developmental need of the adolescent is achieving independence. Relying on the parents would interfere with the adolescent's ability to do so.

51. During a home visit, the public health nurse assesses the peritoneal catheter exit site of a child with chronic renal failure. Which of the following findings should lead the nurse to determine a client has an infection? 1. Dialysate leakage. 2. Granulation tissue. 3. Increased time for drainage. 4. Tissue swelling.

51. 4. Tissue swelling, pain, redness, and exudate indicate infection. Dialysate leakage is associated with improper catheter function, incomplete healing at the insertion site, or excessive instillation of dialysate. Granulation tissue indicates healing around the exit site, not infection. Increased time for drainage may indicate that the tube is kinked, suggesting an obstruction.

53. The nurse assesses the child with chronic renal failure who is receiving peritoneal dialysis for edema. Which finding is expected for this child? 1. Absence of pulmonary crackles. 2. Increased dialysate outflow. 3. Normal blood pressure. 4. Pallor.

53. 4. With edema, pallor can occur owing to hemodilution as intestinal fluid moves to the vascular space. The child would exhibit pulmonary crackles secondary to pulmonary congestion and edema . Dialysate outflow would decrease, not increase, as the body attempts to conserve fluid. The child's blood pressure would be increased because of excessive fluid volume.

54. The mother of a child with chronic renal failure who is receiving peritoneal dialysis at home asks the nurse what she can do if both inflow and drain times are increased. Which of the following instructions would be most appropriate for the nurse to include when responding to the mother? 1. Assess the child for constipation. 2. Decrease the amount of dialysate infused for each dwell. 3. Incorporate the increased inflow and drain times into the dialysis schedule. 4. Monitor the child for shoulder pain during inflow and drain times.

54. 1. Accumulation of hard stool in the bowel can cause the distended intestine to block the holes of the catheter. Consequently, the dialysate cannot flow freely through the catheter. Decreasing the dialysate infusion may make the dialysis less effective. Altering fluid, electrolyte , and waste product removal can cause fluid and electrolyte imbalance and increased levels of blood urea nitrogen and creatinine . Incorporating the increased times into the dialysis may make the dialysis less effective because fewer cycles can be scheduled. Shoulder pain, which may occur occasionally, can be caused by air in the peritoneal space and diaphragmatic irritation. However, it is unrelated to inflow and drain times.

55. The nurse judges that the mother understands the diet restrictions for her child with chronic renal failure who is receiving peritoneal dialysis when she reports providing a diet involving which of the following? 1. Sodium and water restrictions. 2. High protein and carbohydrates. 3. High potassium and iron. 4. Protein and phosphorous restrictions.

55. 4. Regulation of the diet is the most effective means, besides dialysis, for reducing renal excretion . Dietary phosphorus is restricted, which reduces the protein load on the kidneys. Clients are also given substances to bind phosphorus in the intestines to prevent absorption . Limited protein in the diet should include foods high in essential amino acids. Foods high in fat and carbohydrate are used to increase caloric intake. Sodium and water may not be restricted because of the continual loss of sodium and water through the dialysate. Iron-rich foods are commonly high in protein.

56. A 3-year-old child receiving chemotherapy after surgery for a Wilms' tumor has developed neutropenia. The parent is trying to encourage thechild to eat by bringing extra foods to the room . Which food would not be appropriate for this child? 1. Fudge. 2. French fries. 3. Fresh strawberries. 4. A milk shake.

56. 3. When a client receiving chemotherapy develops neutropenia, eating uncooked fruits and vegetables may pose a health risk due to possible bacterial contamination. All other foods are either cooked or pasteurized and would not produce a health risk.

57. When assessing a 2-year-old child with Wilms' tumor, the nurse should avoid? 1. Measuring the child's chest circumference. 2. Palpating the child's abdomen. 3. Placing the child in an upright position. 4. Measuring the child's occipitofrontal circumference.

57. 2. The abdomen of the child with Wilms' tumor should not be palpated because of the danger of disseminating tumor cells. Techniques such as measuring the occipitofrontal circumference (which is done in children younger than 18 months of age because the anterior fontanel closes between 12 and 18 months of age), upright positioning, and measuring chest circumference are not necessarily contraindicated; however, the child with Wilms ' tumor should always be handled gently and carefully.

58. Which statement by the mother of a child with Wilms' tumor tells the nurse that the mother understands what stage II tumor means? 1. "The tumor has extended beyond the kidney but was completely removed." 2. "Although the tumor was in the kidney, it has spread to the lung, liver, and bone." 3. "The tumor has extended outside the kidney to the lungs and the liver." 4. "The tumor was solely located in the kidney but it was totally removed."

58. 1. A stage II tumor is one that extends beyond the kidney but is completely resected. The tumor staging is verified during surgery to maximize treatment protocols. The following criteria for staging are commonly used: stage I, tumor is limited to the kidney and completely resected; stage II, tumor extends beyond the kidney but is completely resected ; stage III, residual nonhematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis occurs, with deposits beyond stage III (lung, bone and brain, liver); stage V, bilateral renal involvement is present at diagnosis.

59. A child diagnosed with Wilms' tumor undergoes successful surgery for removal of the diseased kidney. When the child returns to the room, the nurse should place the child in which position? 1. Modified Trendelenburg. 2. Sims'. 3. Semi-Fowler's. 4. Supine.

59. 3. The child who has undergone abdominal surgery is usually placed in a semi-Fowler's position to facilitate draining of abdominal contents and promote pulmonary expansion. The modified Trendelenburg position is used for clients in shock. The Sims' position is likely to be uncomfortable for this child because of the large transabdominal incision. The supine position, without the headelevated, puts the child at increased risk for aspiration.

6. When developing the preoperative teaching plan for a 14 -month-old child with an undescended testis who is scheduled to have surgery, which of the following methods is appropriate? 1. Telling the child that his penis and scrotum will be "fixed." 2. Explaining to the parents how the defect will becorrected. 3. Telling the child that he will not see any incisions after surgery. 4. Using an anatomically correct doll to show the child what will be "fixed."

6. 2. Preoperative teaching would be directed at the parents, because the child is too young to understand the teaching . Telling the child that his penis and scrotum will be "fixed," telling the child he will not see incisions after surgery, and using a doll to illustrate the surgery are appropriate interventions for a preschool-age child.

60. After a child undergoes nephrectomy for a Wilms' tumor , the nurse should assess the child postoperatively for which early sign of a complication? 1. Increased abdominal distention. 2. Elevated blood pressure. 3. Increased respiratory rate. 4. Increased urine output.

60. 1. Children who have undergone abdominal surgery are at risk for intestinal obstruction from a dynamic ileus . Indications of intestinal obstruction include abdominal distention, decreased or absent bowel sounds, and vomiting. Later signs of intestinal obstruction include tachycardia, fever, hypotension, increased respirations, shock, and decreased urinary output.

61. When developing the discharge plan forchild who had a nephrectomy for a Wilms' tumor, the nurse identifies outcomes to prevent damage to the child's remaining kidney and accomplish which of the following? 1. Minimize pain. 2. Prevent dependent edema. 3. Prevent urinary tract infection. 4. Minimize sodium intake.

61. 3. Because the child has only one kidney , measures should be recommended to prevent urinary tract infection and injury to the remaining kidney . Severe pain and dependent edema are not associated with surgery for Wilms' tumor. Dietary sodium is not restricted because function in the remaining kidney is not impaired.

The nurse reads the new medications prescriptions for a 4-year-old child with nephrotic syndrome on the chart below: The nurse should: 1. Discontinue the prednisolone 40 mg and give the 30-mg dose today. 2. Check the medication record first to see when the last dose of prednisolone was given. 3. Start the 30-mg dose tomorrow. 4. Contact the prescriber for clarification.

62. 4. There are many problems with this medication prescription. The abbreviation QOD is ambiguous and open to various interpretations. The abbreviation D/ C may be interpreted as "discontinue" or "discharge." The prescriber should have specifically stated when to start the lower dose because the nurse could reason beginning the medication that day, the next, or even the day after that. The only safe thing to do is call for clarification.

63. The charge nurse finds the mother of a child with a chronic bladder condition requiring clean intermittent catheterization (CIC) visibly upset. The mother states, "That other nurse said parents are not allowed to perform CIC in the hospital because of increased infection risk." The charge nurse should tell the parent: 1. "Your child is exposed to additional bacterial in the hospital that makes CIC unsafe." 2. "You can catheterize your child as long as you use sterile technique." 3. "You can use CIC on your child. I will talk with your nurse to clarify the policy." 4. "I can tell you are having a conflict with this nurse. I will switch assignments."

63. 3. The charge nurse should assure the parent that it is okay to use CIC and discuss the conversation with the nurse. It is possible that the nurse was unaware of current research findings or unit policies. The charge nurse should also determine if the parent has the supplies and uses a new catheter each time, but the insertion principles would not change . Parents are frequently taught how to do CIC while achild is in the hospital. Therefore, the rationale that it now becomes unsafe, or that sterile technique is needed, is faulty. Switching nurses will not solve the underlying problem.

64. The parent of an 18-year-old with chronic renal disease states, "My son has so many problems. I'm really worried that he will not get the right care if he gets sick at college." The nurse should tell the parent: 1. "I can have his records sent to the school's health center." 2. "Make sure your son always carries his nephrologist's phone number." 3. "Your son can make an e-health history to facilitate his care if he gets sick away from home." 4. "Your son is going to need to learn to manage his own disease."

64. 3. Access to a well-constructed e-history will facilitate care if the adolescent becomes ill while at college. Because the client is 18, legally the nurse cannot transfer the records to the school without permission. Also, the adolescent may need to seek treatment in facilities other than the health center. Instructing the adolescent to always carry the nephrologist's phone number is not bad advice, but compliance may vary and there is no guarantee the provider will be available in all instances. Telling the parent that the son must learn to manage his own disease does not address the parent's concern.

7. An adolescent with a history of surgical repair for an undescended testis comes to the clinic for a sports physical . Anticipatory guidance for the parents and adolescent should focus on which of the following as most important? 1. The adolescent's sterility. 2. The adolescent's future plans. 3. Technique for monthly testicular self-examinations. 4. Need for a lot of psychological support.

7. 3. Because the incidence of testicular cancer is increased in adulthood among children who have had undescended testes, it is extremely important to teach the adolescent how to perform the testicular self -examination monthly. The undescended testicle is removed to reduce the risk of cancer in that testicle. Removal of a testis would not necessarily make the adolescent sterile because the other testicle remains. Although discussing the adolescent's future plans is important, it is not the priority at this time. Because the adolescent has been dealing with the situation for a long time, the need for a sports physical at this time should not be a cause of emotional distress requiring a lot of psychological support.

8. When explaining to the parents of a child with a hydrocele about the possible cause of the condition, the nurse bases this explanation on the interpretation that a hydrocele is most likely the result of which condition? 1. Blockage in the inguinal canal that allows fluid to accumulate in epididymis and ductus deferens. 2. Failure of the upper part of the processus vaginalis to atrophy, allowing accumulation of fluid in the testicle and the peritoneal cavity. 3. A patent processus vaginalis that results in the collection of fluid along the spermatic cord or tunica vaginalis of the testicle. 4. An obliterated processus vaginalis that allows fluid to accumulate in the scrotal sac.

8. 3. A hydrocele is a collection of fluid in the tunica vaginalis of the testicle or along the spermatic cord that results from a patent processus vaginalis . Failure of the upper part of the processus vaginalis to atrophy allows the accumulation of fluid in the testicle and the peritoneal cavity, causing an inguinal hernia.

9. During a clinic visit, the mother of an infant with hydrocele states that the infant's scrotum is smaller now than when he was born. After teaching the mother about the infant's condition, which of the following statements by the mother indicates that the teaching has been effective? 1. "I guess keeping his bottom up has helped." 2. "Massaging his groin area is working."3. "It seems like the fluid is being reabsorbed." 4. "Keeping him quiet and in an infant seat has helped."

9. 3. A hydrocele is a collection of fluid in the tunica vaginalis of the testicle or along the spermatic cord that results from a patent processus vaginalis . Because scrotal size is decreasing, the fluid is being absorbed. Elevation of the infant's bottom, massage , or keeping the infant quiet or in an infant seat would have no effect in promoting fluid reabsorption in hydrocele.

5. When explaining the plan of care to the parents of an infant with an undescended testis, the nurse should tell the parents about which of the following as a nonsurgical treatment method? 1. A trial of human chorionic gonadotrophic hormone. 2. A trial of adrenocorticotropic hormone. 3. Frequent stimulation of the cremasteric reflex. 4. Use of several warm baths each day.

may be given to stimulate descent of the affected testis. A trial of adrenocorticotropic hormone will not cause the testis to descend. The cremasteric reflex results in the testis being drawn up, the opposite of the intended effect. Application of warmth, such as warm baths, although soothing and relaxing for the infant, would have little or no effect on stimulating the testis to descend.