Nurs 341 exam 3 prepu review

The nurse is discussing acne vulgaris with a group of adolescents. The teenagers make the following statements regarding the topic. Which statement is the most accurate regarding acne vulgaris?

"Sometimes I get acne when I use my sister's makeup." Irritation and irritating substances, such as vigorous scrubbing and cosmetics with a greasy base, can cause acne vulgaris. Increased hormone levels, hereditary factors, and anaerobic bacteria can cause acne vulgaris as well. Eating chocolate and fatty foods does not cause acne, but a well-balanced, nutritious diet does promote healing.

The student nurse is preparing a presentation on celiac disease. What information should be included? Select all apply.

"Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "The only treatment for celiac disease is a strict gluten-free diet." "Gluten is found in most wheat products, rye, barley and possibly oats."

Coarctation of the aorta demonstrates few symptoms in newborns. What is an important assessment to make on all newborns to help reveal this condition?

Assessing for the presence of femoral pulses Coarctation of the aorta is a defect where there is narrowing of the aorta, which is the largest vessel carrying oxygenated blood to the body. As a result of this narrowing, blood flow is impeded causing pressure to increase in the area proximal to the defect and decrease distal to the defect. As a result, the blood pressure will be higher in the upper part of the body and decreased in the lower part of the body. The pulses will be full or bounding in the upper part of the body and weak or absent in the lower part of the body. When assessing an infant with coarctation there may be weak or absent femoral pulses. There will also be differences in the blood pressure readings. These infants may or may not have a murmur and will be no more fussy than other babies.

When examining a child with congenital heart disease, an organ in the upper right quadrant of the abdomen can be palpated at 4 cm below the rib cage. What would most likely explain this assessment finding?

The liver size increases in right-sided heart failure. The liver increases in size due to right-sided heart failure. This is one of the cardinal signs of congestive heart failure. The spleen is in the upper left quadrant of the abdomen and would increase in size under certain circumstances, but this is asking for the upper right quadrant information. There are certain medications that can affect the liver, but this would not be the most likely reason for hepatomegaly.

A 6-week-old infant is diagnosed with pyloric stenosis. When taking a health history from the parent, which symptom would the nurse expect to hear described?

Vomiting immediately after feeding With pyloric stenosis the circular muscle pylorus is hypertrophied. This thickness causes gastric outlet obstruction. The condition is seen in younger infants starting at 3 to 6 weeks of age. The infant has projectile nonbilious vomiting. It occurs directly after eating and is not related to the feeding position. The infant is hungry shortly after eating. There is weight loss and/or dehydration. The treatment is a pyloromyotomy to reduce the increased size and increase the opening. Diarrhea is not associated with the disorder.

A group of nursing students is discussing terminology related to the genitourinary system during a post-conference setting. One of the students asks what mittelschmerz is or what it means. A classmate of this student correctly answers that mittelschmerz is:

a dull, aching abdominal pain at ovulation. Mittelschmerz is a dull, aching abdominal pain at the time of ovulation (hence the name, which means "midcycle"). The beginning of menstruation is called menarche. Symptoms include edema (resulting in weight gain), headache, increased anxiety, mild depression, and mood swings. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) inhibit prostaglandins and are the treatment of choice for primary dysmenorrhea, which is painful menstruation.

The nurse assesses that the client is at risk for an infection related to chemotherapy-induced immunosuppression. What will the nurse include in the teaching plan for the child and parents to help reduce this risk? Select all that apply.

-Have the child sleep in a single bed and room. -Encourage frequent, thorough handwashing. To reduce the risk of infection, the nurse should teach the child and parents about minimizing the child's exposure to potentially infectious situations. The nurse should encourage the parents to arrange for the child to sleep in a single bed and room and, if possible, avoid close contact with other family members who may be developing upper respiratory tract infections. Thorough and frequent handwashing, especially after using the bathroom and before eating, is essential. A high-calorie, high-protein diet helps to rebuild white blood cells and should be encouraged. If possible, the child's exposure to large crowds and visitors should be limited because of the increased risk of infection from these individuals. Fresh flowers and plants should be avoided because they could harbor mold spores.

The parent of a school-age child comments to the nurse, "Every time my child eats enchiladas at our local Mexican restaurant the child gets a rash. It just does not make sense to me." How should the nurse respond?

"Has your child ever been tested for a peanut allergy?" Enchilada sauce is an unexpected food that may contain a form of peanuts (such as peanut oil) that may be causing an allergic reaction in the child.

The nurse is speaking with a teenager who has requested HIV testing. Which is the best statement by the nurse regarding HIV testing?

"The ELISA method detects antibodies so a person may have a false negative test for up to six months after exposure. ELISA method detects only antibodies, so the test may remain negative for several weeks up to 6 months (false-negative) after exposure. A false-positive may result with autoimmune disease. The ELISA test requires serial testing. HIV test results are confidential.

The nurse caring for a 14-year-old scheduled for magnetic resonance imaging (MRI) explains to a family how the test works. Which response accurately describes this test?

"The MRI uses radio waves and magnets to produce a computerized image of the body." The MRI uses radio waves and magnets to produce a computerized image of the body. The bone scan is a nuclear scanning test to rule out cancer involving the bones or determine extent of bone involvement. The ultrasound uses sound waves to create images that visualize body structures and locate masses. Radiography uses radiation to examine soft tissue and bony structures of the body.

The nurse is caring for child who present to the emergency department with reports of a fever for 5 days. The nurse notes a diffuse maculopapular rash, reddened cracked lips, erythema of hands, and bilateral conjunctivitis and suspects Kawasaki disease. Which nursing action is priority?

Initiate intravenous access. A child with signs of Kawasaki disease is at risk for dehydration due to a prolonged fever and oral pain. The priority for the nurse is to establish intravenous access to begin IV fluids. Placing the child on a soft diet will be done after ensuring IV access. Pain is not a priority, and children with Kawasaki disease are given aspirin because of the anti-inflammatory properties of aspirin, instead of acetaminophen. Because the child already has the required four signs of Kawasaki disease, assessing cervical lymph nodes is minimally helpful and could be performed later.

The nurse is caring for an 11-year-old presenting with tenderness in the shoulder. He is the pitcher for his baseball team and reports shoulder pain with active internal rotation but is able to continue past the pain with full range of motion. Based on these reported symptoms, the nurse is aware that the disorder is most likely to be:

epiphysiolysis of the proximal humerus. Epiphysiolysis of the proximal humerus is an overuse disorder that occurs with rigorous upper extremity activity such as pitching and causes tenderness in the shoulder. Osgood-Schlatter disease causes knee pain and painful swelling or prominence of the anterior portion of the tibial tubercle. Sever disease (calcaneal apophysitis) causes pain over the posterior aspect of the calcaneus. Epiphysiolysis of the distal radius is an overuse disorder that causes wrist pain. It is common in gymnasts.

The health care provider suspects an infant may have a ventricular septal defect. The parents ask the nurse what diagnostic tests the infant will need to have to determine this diagnosis. For what test(s) should the nurse provide education to the family? Select all that apply.

magnetic resonance imaging (MRI) echocardiogram cardiac catheterization A ventricular septal defect (VSD) is an abnormal opening between the right and left ventricles. An MRI or echocardiogram with color-flow Doppler may reveal the opening as well as the extent of left-to-right shunting. These studies also may identify right ventricular hypertrophy and dilation of the pulmonary artery resulting from the increased blood flow. Cardiac catheterization may be used to evaluate the extent of blood flow being pumped to the pulmonary circulation and to evaluate hemodynamic pressures. Neither a CT nor stress test are used in the diagnosis of the VSD. A chest x-ray may also be used to determine if there is an enlargement of the heart.

The parents of a 6-year-old child with idiopathic thrombocytopenic purpura (ITP) ask the nurse conducting an assessment of the child what causes the disease. What is the nurse's best response?

"ITP is primarily an autoimmune disease in which the immune system attacks and destroys the body's own platelets, for an unknown reason." Idiopathic thrombocytopenic purpura (ITP) is primarily an autoimmune disease, which is an acquired, self-limiting disorder of hemostasis characterized by destruction and decreased numbers of circulating platelets. The child will exhibit symptoms of excessive petechiae, purpura, and bruising. Hemophilia A and hemophilia B are distinguished by the particular procoagulant factor that is decreased, absent, or dysfunctional. Iron-deficiency anemia occurs when the body's iron stores are depleted. Hereditary spherocytosis (HS) is characterized by loss of surface area on the red blood cell membrane.

The nurse is speaking with the mother of a child diagnosed with contact dermatitis from poison ivy. Which statement by the mother indicates a need for further education?

"As long as he takes a shower as soon as he gets inside, he shouldn't get this again." Prevention of contact dermatitis from poison ivy, poison oak, or poison sumac includes wearing long pants and long sleeves on outings in the wood. If contact occurs, wash vigorously with soap and water within 10 minutes of contact. The plant's oil residue may be on clothes, pets, toys, and other objects, so these must be washed well with soap and water. Ivy Block is the only preventive treatment approved by the US FDA. It is applied to the skin before exposure.

The parents of an adolescent tell the nurse, "Our child seems to have allergy symptoms every time we visit our favorite cafe. I don't understand since the only allergy indicated in the testing was to eggs?" How should the nurse respond?

"Does your child get a whipped cream or foam topping on their favorite drink?" Albumin, globulin, ovalbumin should be avoided if allergic to eggs. Some foam toppings for drinks contain these substances and would cause an allergic reaction to the person allergic to eggs. This would be important information to ascertain from the family as they would likely not be aware of this.

A 3-year-old child has sustained injuries from a fall. Once the airway is secured, what interventions would be next?

Stabilize the cervical spine.

The clinic nurse is assessing a 12-year-old client. The client reports having dandruff and asks the nurse what can be done for it. Which response by the nurse is best?

"Wash your hair with a gentle shampoo daily."

An infant has presented at the clinic with impetigo. Which organism usually causes impetigo in infants?

Staphylococcus aureus Staphylococcus aureus is the most common cause of impetigo in infants. MRSA is a hospital-associated infection (HAI), group A beta hemolytic strep is seen in older children, and Escherichia coli is not frequently associated with impetigo.

The pediatric nurse has digoxin ordered for each of five children. The nurse should withhold digoxin for which children? Select all that apply. 4-month-old child with an apical heart rate of 102 beats per minute 12-year-old child whose digoxin level was 0.9 ng/ml on a blood draw this morning 16-year-old child with a heart rate of 54 beats per minute 2-year-old child whose digoxin level was 2.4 ng/ml from a blood draw this morning 5-year-old child who developed vomiting and diarrhea, and is difficult to arouse

16-year-old child with a heart rate of 54 beats per minute 2-year-old child whose digoxin level was 2.4 ng/ml from a blood draw this morning 5-year-old child who developed vomiting and diarrhea, and is difficult to arouse The nurse should not administer digoxin to children with the following issues: apical pulse under 60 beats per minute, digoxin level above 2 ng/ml, and signs of digoxin toxicity.

The nurse is caring for a 7-year-old with burns. Which finding would be highly suggestive of a burn induced by child abuse (child maltreatment)?

stocking-glove pattern on hands or feet

Which assessment finding by the nurse would warrant immediate action?

A child with periorbital cellulitis reports changes in vision and pain with eye movement. In a child with periorbital cellulitis, the nurse musty notify the health care provider immediately if signs of progression to orbital cellulitis occur, such as conjunctival redness, change in vision, pain with eye movement, eye muscle weakness or paralysis, or proptosis. This assessment finding warrants immediate action. In nonbullous impetigo, a honey-colored exudate when the vesicles or pustules rupture may be noted on the skin. This assessment finding would be expected. A localized cellulitis will present with erythema, pain, edema, and warmth at the site of the skin disruption (such as a cut or spider bite). This assessment finding warrants further follow-up but not immediate attention. Fever may occur with bullous impetigo or cellulitis and is common with scalded skin syndrome; therefore, this assessment finding also warrants further, but not immediate, follow-up.

Which nursing diagnosis would best apply to a child with rheumatic fever?

Activity intolerance related to inability of heart to sustain extra workload Acute rheumatic fever affects the joints, central nervous system, skin, and soft tissue. It causes chronic, progressive damage to the heart and valves. Children with rheumatic fever need to reduce activity to relieve stress on the heart and joints during the course of the illness. Rheumatic fever does not produce cardiomegaly nor does it interfere with respirations or the ability to oxygenate the body. Children with rheumatic fever may develop chorea. These movements are involuntary and are not related to hyperexcitability.

The nurse is admitting to an examination room a child with the diagnosis of "probable acute lymphoblastic leukemia (ALL)." What will confirm this diagnosis?

Bone marrow aspiration Bone marrow aspiration and biopsy are diagnostic. An abnormal white blood count and symptoms of lethargy, bruising, and pallor only create suspicion of leukemia; a twin may or may not be affected.

The nurse is preparing a discharge teaching plan for the parents of an 8-year-old girl with leukemia. Which instruction would be the priority?

Calling the doctor if the child gets a sore throat Calling the doctor if the child gets a sore throat is the priority. Because of the child's impaired immune system, any sign of potential infection, such as sore throat, must be evaluated by a physician. Using acetaminophen if the child needs an analgesic, writing down phone numbers and appointments, and keeping a written copy of the treatment plan are important teaching points—but secondary to guarding against infection.

The nurse is assessing an 11-year-old child diagnosed with acute myeloid leukemia (AML) who came to the emergency department. What would alert the nurse to the need for immediate intervention?

Child reports a headache and vision problems. About 25% of children with acute myeloid leukemia present with blood counts greater than 100,000 × 109/L. This is called hyperleukocytosis, and it is a medical emergency requiring leukapheresis to decrease hyperviscosity by quickly decreasing the number of circulating blasts. Lymphadenopathy, headache, visual disturbance, weight loss, and muscle wasting are signs and symptoms common to both types of leukemia. Lymphadenopathy, headache and vision problems, as well as weight loss and muscle wasting are common manifestations associated with AML. They do not require immediate intervention.

The nurse is caring for a child with a second-degree (partial-thickness) burn. What assessment findings would the nurse expect to observe?

Edema with wet blistering skin Partial-thickness or second-degree burns are very painful and edematous and have a wet appearance or the presence of blisters. Third-degree (full-thickness) burns appear red, edematous, leathery, dry, or waxy and may display red or charred skin (eschar).

The nurse is helping the parents of a toddler identify foods that are causing allergic symptoms in the child. Which strategy should the nurse encourage the parents to use?

Elimination diet An elimination diet is a traditional method to detect food allergens. Parents feed the child only foods that rarely cause allergy, such as rice, lamb, carrots, peas, and sweet potatoes, for about 7 days. Then they add, one by one, at 2- to 3-day intervals, foods that are suspected of causing allergy. When a food is introduced this way, the child must be encouraged to eat a lot of it that day. If symptoms occur, the food is then eliminated from the child's meals on a permanent basis. If no symptoms occur, the child can continue to eat the food. Hyposensitivity testing is unreliable with food allergies. Corticosteroids delay hypersensitivity reactions. It is difficult to totally eliminate protein from the diet, and this is not a method to determine the cause of food allergies in the toddler.

he nurse cares for adolescents with cancer. Which recommended psychosocial interventions will the nurse use to help the adolescents cope with their disease? Select all that apply. Encourage adolescents to engage in their usual activities. Encourage the adolescents to make plans for the future. Control the amount of information given out about an adolescent's condition. Discourage relationships with other adolescents who have cancer. Be an advisor as well as a friend to the adolescents to promote cooperation in the care plan. Postpone return to school for as long as possible to ensure an eventual successful

Encourage adolescents to engage in their usual activities. Encourage the adolescents to make plans for the future. Control the amount of information given out about an adolescent's condition. Be an advisor as well as a friend to the adolescents to promote cooperation in the care plan. Adolescents need as normal a life as possible to experience things other peers engage in. The nurse should encourage usual activities and plans for the future and control the amount of information outsiders know about the adolescent's condition. Relationships with other children with cancer should be encouraged as well as an early return to school. Children should attend school as long as their white blood cells are not dangerously low. They can participate in activities if their platelets are adequate to prevent any bleeding from accidents while playing sports. The nurse should be a friend as well as an advisor to the adolescent.

The nurse is caring for a 6-year-old child with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority?

Place the child in a knee-to-chest position. The priority nursing action is to place the child in a knee-to-chest position. Once the child has been placed in this position, the nurse should provide supplemental oxygen or administer medication as prescribed. A calm, comforting approach should be used but is not the priority action.

When reviewing the record of a child with tetralogy of Fallot, what would the nurse expect to discover?

Polycythemia Tetralogy of Fallot is a congenital heart defect causing decreased pulmonary blood flow. This causes mild to severe oxygen desaturation. To compensate for the low blood oxygenation the kidneys produce erythropoietin to stimulate the bone marrow to make more red blood cells (RBCs). The increased amount of RBCs is known as polycythemia. This increased blood volume causes more workload on the heart. It also does not increase the amount of blood reaching the lungs so the child remains desaturated. Leukopenia, increased platelets, and anemia are not associated with tetralogy of Fallot.

Which intervention is the most beneficial for a burn client undergoing a skin graft?

Provide around-the-clock pain medication as soon as pain is reported.

A caregiver brings her 7-year-old son to the pediatrician's office, concerned about the child's bedwetting after being completely toilet trained even at night for over 2 years. The caregiver further reports that the child has wet the bed every night since returning home from a 1-week fishing trip. The child refuses to talk about the bedwetting. The nurse notes the child is shy, skittish, and will not make eye contact. Further evaluation needs to be done to rule out what possible explanation for the bedwetting?

The child has been sexually abused, maybe on the fishing trip. Enuresis may have a physiologic or psychological cause and may indicate a need for further exploration and treatment. Enuresis in the older child may be an expression of resentment toward family caregivers or of a desire to regress to an earlier level of development to receive more care and attention. Emotional stress can be a precipitating factor. The health care team also needs to consider the possibility that enuresis can be a symptom of sexual abuse. Bruising, bleeding, or lacerations on the external genitalia, especially in the child who is extremely shy and frightened, may be a sign of child abuse (child mistreatment) and should be further explored.

A newborn is diagnosed with hypospadias and the parents want the newborn to be circumcised. What would be the best response by the nurse?

The foreskin is needed for repair. Hypospadias occurs when the meatal opening is on the ventral surface of the penis rather than at the end of the penis. The newborn with this condition is not circumcised at birth because the excess skin may be needed to reconstruct the meatus during surgical repair. Once the hypospadias is repaired, a circumcision can be performed as part of the procedure. Hypospadias repair is usually done after the newborn is 1 year or older. Meatal stenosis has to do with the urethral opening diameter, not the placement. Circumcision or hypospadias repair does not affect the functioning of the renal system so neither would predispose the newborn to renal failure.

The nurse is conducting an educational class regarding the use of the intraosseous site for administration of fluid to the pediatric client experiencing an emergency, such as shock. What would the nurse include in this educational presentation?

The intraosseous site is preferred if peripheral access cannot be attained rapidly. The intraosseous site is preferred if peripheral access cannot be obtained in 90 seconds. The child would be positioned so the nurse can readily access the bone rather than in a position with the spine flexed. The access site is not related to the spine. The intraosseous needles are generally 15 to 18 gauge. Any fluids or medications that can be infused via a peripheral site can be given via an intraosseous site.

The nurse is preparing to assess and intubate a school-aged child who presents via ambulance to the emergency department. The child has been manually ventilated prior to arrival. The nurse obtains a nasogastric tube in preparation to care for the child for what reason?

The nasogastric tube will alleviate any accumulation of air in the stomach Children who are manually ventilated typically have some abdominal distention as some air passes into the stomach. The nasogastric tube will not assist the ET to be secured properly or allow a quick intubation. The child will be NPO while intubated and may require a nasogastric tube for feeding in the future, but the purpose of the emergency need is to alleviate the accumulation of air.

The nurse is caring for a child admitted to the hospital for an open fracture of the femur following a motor vehicle accident. The nurse notes the following lab values: white blood cells 10,000/mm3, hemoglobin 7.9 g/dl (79 g/L), hematocrit 28%, platelets 151,000/mm3. Which nursing action is priority?

Transfuse 1 unit of packed red blood cells. In a situation where the child exhibits signs of anemia related to acute hemorrhage, the nurse should anticipate administering a transfusion of packed red blood cells to improve oxygenation and circulation. Administration of antibiotics, pain assessment, and family education can be performed after the beginning the blood transfusion.

What would be the most important measure to implement for an infant who develops heart failure?

placing the infant in a semi-Fowler position Placing an infant with heart failure in a semi-Fowler position reduces the pressure of the abdominal contents against the chest and allows for better lung expansion. Keeping the infant supine would cause more pressure on the heart and lungs and increase the work of the heart and lungs. Infants with heart disease need calories to grow. They are given formula or breast milk which is fortified with extra nutrients. Thus the infant can have an intake of the same amount of fluid but receive extra nutrients.

The nurse is providing preoperative care for a newborn with myelomeningocele. Which action is the central nursing priority?

prevent rupture or leaking of cerebrospinal fluid The central nursing priority is to prevent rupture or leaking of cerebrospinal fluid. Keeping the infant in a prone position will help prevent pressure on the lesion. Keeping the lesion free from fecal matter or urine is important as well, but the priority is to prevent rupture or leakage. The nurse should consider the lesion first when maintaining the infant's body temperature.

The nurse is providing care to a child with acute kidney injury. What assessment is priority for the nurse to determine if this child is developing hyperkalemia?

pulse rate and rhythm

A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting several feet from his mouth. He is always hungry again just after vomiting. At the physician's office, the nurse holds the child and offers him a bottle. While he drinks, the nurse notes an olive-size lump in his right abdomen. Which condition should the nurse suspect in this child?

pyloric stenosis With pyloric stenosis, at 4 to 6 weeks of age, infants typically begin to vomit almost immediately after each feeding. The vomiting grows increasingly forceful until it is projectile, possibly projecting as much as 3 to 4 feet. Infants are usually hungry immediately after vomiting because they are not nauseated. A definitive diagnosis can be made by watching the infant drink. If pyloric stenosis is present, the sphincter feels round and firm, approximately the size of an olive in the right abdomen. Peptic ulcer disease in neonates usually presents with hematemesis (blood in vomitus) or melena (blood in the stool). Gastroesophageal reflux involves a small (1-2 tsp) volume and is not forceful. Appendicitis typically begins with anorexia for 12 to 24 hours; children do not eat and do not act like their usual selves. Nausea and vomiting may then occur, followed by diffuse abdominal pain.

A client has been admitted to the emergency department with nausea, vomiting, and severe scrotal pain. These findings indicate what condition?

testicular torsion A hydrocele is a collection of fluid that collects in the fold of the scrotum, requiring no treatment. A varicocele is an abnormal dilation (dilatation) of the veins of the spermatic cord. Testicular torsion is evidenced by severe scrotal pain, nausea, and vomiting and is a surgical emergency. Testicular infection is not indicated.

After a cardiac catheterization, the nurse monitors the child's fluid balance closely based on the understanding that:

the contrast material used has a diuretic effect. The contrast material has a diuretic effect so the nurse assesses the child closely for signs and symptoms of dehydration and hypovolemia. Although blood loss can occur, this is not the reason for monitoring the child's fluid balance. Catheter insertion into the heart does not initiate a diuretic response. Typically, food and fluid is withheld for 4 to 6 hours before the procedure.

Testing is being performed to confirm the presence of Meckel diverticulum. Which findings are consistent with this condition? Select all that apply. hemoglobin 9.4 g/dl (94 g/L) white blood cell count 8 g/dl Stool test reveals occult blood. platelet count 200,000 hematocrit 37% (0.37)

white blood cell count 8 g/dl Stool test reveals occult blood. platelet count 200,000 Meckel diverticulum is a disorder where there are weaknesses on the intestine resulting in pouchlike areas. Test findings that are consistent with this disorder are anemia and the presence of occult blood. The values listed for white blood cell count, platelet levels, and hematocrit levels are within normal limits.

The nurse is doing a presentation for a group of nursing students about the topic of menstrual disorders. After discussing the disorder secondary amenorrhea, the students make the following statements. Which statement made by the nursing students is the most accurate regarding the cause of secondary amenorrhea?

"Emotional stress can be a cause of this disorder." Secondary amenorrhea can be the result of discontinuing contraceptives, a sign of pregnancy, the result of physical or emotional stress, or a symptom of an underlying medical condition. A complete physical examination, including gynecologic screening, is necessary to help determine the cause. Primary amenorrhea occurs when a girl has had no previous menstruation. A spontaneous abortion (miscarriage) does not cause secondary amenorrhea.

The nursing instructor has completed a presentation on normal immune function. Which statement by a student would suggest a need for further education?

"Humoral immunity is generally functional at birth." Normal immune function is a complex process involving phagocytosis (process by which phagocytes swallow up and break down microorganisms), humoral immunity (immunity mediated by antibodies secreted by B cells), cellular immunity (cell-mediated immunity controlled by T cells), and activation of the complement system. Cellular immunity is generally functional at birth, and as the infant is exposed to various substances over time, humoral immunity develops.

The nurse has performed client education for a 15-year-old boy with Crohn disease and his parents regarding the cobblestone lesions in his small intestine. Which comment by the family indicates learning has occurred?

"I have to be careful because I am prone to not absorbing nutrients."

The nurse is caring for a child with a prescription for PO prednisone. Which statement by the child's mother would indicate a need for further education?

"I will give it to ny child at least 1 hour before all meals." Systemic corticosteroids such as prednisone should be administered with food to decrease gastrointestinal upset. These medications may mask signs of infection. This medication may increase blood sugar levels. Corticosteroid doses should be tapered and should not be stopped abruptly.

The nurse is caring for a 4-year-old with oral vesicles and ulcers from herpangina. The child is refusing fluids due to the pain and the mother is concerned about his hydration status. Which of the suggestions would be most appropriate?

"Offer 'magic mouthwash' followed by a popsicle." Children are more likely to cooperate with interventions if play is involved. "Magic" analgesic mouthwash followed by a popsicle is most likely to alleviate some pain and then provide hydration. Soda should be avoided because it can cause stinging and burning. Orange juice should be avoided because it can cause stinging and burning. Anbesol might be helpful but it will likely be difficult to apply. Additionally, oral analgesics are often necessary.

A nurse is providing discharge teaching to the parent of a child hospitalized after experiencing respiratory arrest. The parent expresses concerns about the child's well-being. Which action(s) is appropriate for the nurse take? Select all that apply. -Reassure the parent that the child's infection has been cured. -Reinforce when the health care provider should be called. -Encourage the parent to discuss specific concerns about the child. -Tell the parent that the child's provider will address any concerns during the follow-up visit. -Review signs and symptoms of respiratory distress with the parent.

-Reinforce when the health care provider should be called. -Encourage the parent to discuss specific concerns about the child. -Review signs and symptoms of respiratory distress with the parent.

A 13-year-old boy has had a near-drowning experience. The nurse notices he has labored breathing and a cough. Which of the following would be the priority?

Administer 100% oxygen by mask. Management of the near-drowning victim focuses on assessing the ABCs and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the child assume his own most comfortable position. Checking capillary refill time helps determine ineffective tissue perfusion. Providing sedation is an intervention for pain that will be assessed after effective breathing is established.

The nurse observes the interactions of parents with their infant who was born with a cleft lip. The mother is attempting to feed the baby, but does not make eye contact. The father is watching television with his back turned to the mother and baby. What psychosocial nursing intervention would be most helpful to this family?

Ask the parents if they have any questions regarding the care of their child. The family's emotional response to the birth of a child with cleft lip, palate, or both may range from grief to anger to denial. The nurse should encourage the parents to express their feelings and provide the parents with opportunities and support for normal infant-parent interactions.

When providing discharge instructions to a child who was admitted to the hospital following stridor, wheezing, and urticaria after taking penicillin, which nursing action is priority?

Encourage the child to wear a medical alert bracelet for penicillin. Oral medications most likely to cause an allergic reaction include antibiotics, acetylsalicylic acid (aspirin), and NSAIDs. Children experiencing stridor, wheezing, and urticaria after taking a medication most likely have an allergy to that medication. The priority nursing action for discharge education is to prevent the child from being exposed to penicillin again, which could be accomplished by encouraging the child to wear a medical alert bracelet. Although children with atopic diseases are more likely to have medication allergies, requesting parents have the child evaluated is not a priority. Questioning the child about the amount of penicillin taken and educating parents about the side effects of penicillin is not a priority.

A 10-year-old has been bitten on the lower posterior arm by a dog, requiring several stitches. The child was just admitted to the hospital for 3 days of antibiotic therapy. When developing the care plan, the nurse identifies which nursing diagnoses as being the top 2 priorities? Impaired skin integrity Risk for infection Disturbed body image Risk for fluid volume deficit Knowledge deficit regarding care of wound

Impaired skin integrity Risk for infection

An 8-month-old infant has a ventricular septal defect. Which nursing diagnosis would best apply?

Ineffective tissue perfusion related to inefficiency of the heart as a pump

The parents of a preschool child are distraught as they carry their limp child into the emergency room. The parents report the child fell approximately 10 feet from a large slide and hit his head "hard enough to knock him out." What is the nurse's next action?

Perform a jaw-thrust technique to assess the patency of the airway.

A 3-month-old boy is found to have undescended testes. The parents are concerned. What should the nurse anticipate as the next step for this client?

Reassess the client's testes at 6 months of age. Because the testes sometimes descend spontaneously during the first year of life, treatment is usually delayed until at least 6 months of age. If testes have not descended between 6 and 12 months of age, the client may be given a short course of chorionic gonadotropin hormone to see if testicular descent can be stimulated. If this is not successful, surgical intervention (orchiopexy) will be needed to correct the condition to prevent infertility. Karyotyping is not needed in this situation, because the client's gender is already established.

The nurse is instructing a group of women of childbearing age about human immunodeficiency virus (HIV) during pregnancy. What would be a priority recommendation in this setting?

Screening for HIV No screening mandate has been put forth for HIV, but all pregnant women should be encouraged to undergo this test. Prophylactic treatment would be initiated only once the woman has been screened. Screening for STIs and ensuring proper nutrition are also part of health promotion for women in this age group, but they are of lower priority than identifying HIV-positive individuals.

An adolescent comes to the clinic reporting vaginal discharge. When assessing the vaginal discharge, what would lead the nurse to suspect that the adolescent has candidiasis?

Thick, white cheese-like discharge With candidiasis, the vaginal discharge is thick, white, and cheese-like. A frothy, gray-green discharge is noted with trichomoniasis. A milky, gray discharge with a fishy odor suggests gardnerella. A yellow-green vaginal discharge suggests gonorrhea.

The nurse is caring for a 3-year-old boy with a fracture of the humerus. His chart indicates "fracture is partially through the physis extending into the metaphysis." The nurse identifies this as which Salter-Harris classification?

Type II According to the Salter-Harris classification, a type II fracture is partially through the physis extending into the metaphysis. A type I fracture is through the physis, widening it. A type IV fracture is through the metaphysis, physis, and epiphysis. A type V fracture is a crushing injury to the physis.

While assessing a child with end-stage kidney disease, the nurse notes that the child has fallen into a coma. The nurse interprets this finding as resulting from which complication?

Uremia Uremia may result in 1331of the central nervous system leading to symptoms such as headache or coma or gastrointestinal or neuromuscular disturbances. Metabolic acidosis causes lethargy, dull headache, and confusion. Immunosuppression is not involved with end-stage kidney disease. Hypocalcemia is manifested by muscle twitching, or tetany.

A nurse is providing care to a child with Kawasaki disease. Which medication(s) would the nurse expect the health care provider to prescribe? Select all that apply. aspirin ibuprofen abciximab IV immunoglobulin corticosteroids

aspirin IV immunoglobulin Management of the child with Kawasaki disease includes a high dose of IV immunoglobulin therapy to relieve the symptoms and prevent coronary artery abnormalities, along with aspirin to control inflammation and fever. Aspirin may be continued for as long as 1 year in lower doses as an antiplatelet.

A nurse is developing a teaching plan for the parents of an 8-year-old experiencing nocturnal enuresis. The nurse determines that additional teaching is needed when the parents state which as an appropriate measure?

encouraging fluid intake after dinner In many children, limiting fluids after dinner can be helpful for nocturnal enuresis. Bladder-stretching exercises also can be helpful. If these measures are ineffective, desmopressin may be prescribed. Stress factors may be contributing to the child's condition. Therefore, measures to address stress and promote coping are appropriate.

The nurse is monitoring the labs of a child admitted for an exacerbation of juvenile pauciarticular arthritis. Which lab result does the nurse expect to be elevated?

erythrocyte sedimentation rate (ESR) The erythrocyte sedimentation rate (ESR) is an indicator of inflammation; it would likely be elevated during an exacerbation of arthritis. Immunoglobulin electrophoresis determines the level of individual immunoglobulins; it would not be elevated in an autoimmune disease. Lymphocyte immunophenotyping T-cell quantification measures T-cells; this would be used to monitor immunosuppressive disorders. The radioallergosorbent test measures minute quantities of IgE in the blood; it is used for asthma and food allergy testing.

A nurse examining a neonate is unable to identify the fetal stomach. The nurse knows that this sign strongly indicates which condition?

esophageal atresia (EA)

A nurse taking a health history of a newborn notes that there is a maternal history of polyhydramnios. What GI condition might this history precipitate?

esophageal atresia (EA) A maternal history of polyhydramnios is usually present in one-third of cases of EA and in some cases of tracheoesophageal fistula (TEF).

The nurse is caring for a newborn with a cleft palate. Which findings in the maternal medical record are considered to be contributing factors? Select all that apply. maternal tobacco use moderate maternal alcohol use prior to pregnancy maternal age less than 18 years anticonvulsant therapy used to manage a seizure disorder reports of marijuana use in early pregnancy

maternal tobacco use anticonvulsant therapy used to manage a seizure disorder

The caregiver of a child diagnosed with celiac disease tells the nurse that the child has large amounts of bulky stools and what looks like fat in the stools. The clinical manifestation this caregiver is describing is:

steatorrhea Celiac disease is an immunologic response to gluten, which causes damage to the small intestine. Steatorrhea (fatty stools) is a classic symptom of celiac disease. Symptoms also include abdominal distention or bloating, constipation, and nutritional deficiencies. Currant jelly stools are a sign of intussusception. Projectile vomiting is a sign of pyloric stenosis. Severe diarrhea could be caused by a bacteria or virus. Projectile stools represent severe diarrhea.

A nurse is providing discharge teaching to the parent of a child hospitalized after experiencing respiratory arrest. The parent expresses concerns about the child's well-being. Which action(s) is appropriate for the nurse take? Select all that apply. Reinforce when the health care provider should be called. Encourage the parent to discuss specific concerns about the child. Tell the parent that the child's provider will address any concerns during the follow-up visit. Review signs and symptoms of respiratory distress with the parent.

Encourage the parent to discuss specific concerns about the child. Tell the parent that the child's provider will address any concerns during the follow-up visit. Review signs and symptoms of respiratory distress with the parent.

The nurse is assessing a child with a suspected head injury. The child opens the eyes only in response to the nurse placing pressure in the child's nail bed. What score on the Glasgow coma scale for eye opening should the nurse assign based on this assessment finding?

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The nurse is preparing to administer the child's dose of intravenous immune globulin (IVIG). Which actions should the nurse take? Select all that apply.

Take baseline vital signs and monitor the vital signs during the infusion. Prepare to give acetaminophen to the child. Prepare to give diphenhydramine to the child.

The nurse is assessing a 10-day-old infant for dehydration. Which finding indicates severe dehydration?

Tenting of skin Tenting of skin is an indicator of severe dehydration. Soft and flat fontanels (fontanelles) indicate mild dehydration. Pale and slightly dry mucosa indicates mild or moderate dehydration. Blood pressure of 80/42 mm Hg is a normal finding for an infant.

The nurse caring for a client diagnosed with muscular dystrophy would expect which laboratory values to be most abnormal?

creatine kinase Serum creatine kinase levels are elevated early in the disorder, when significant muscle wasting is actively occurring. Bilirubin is a by-product of liver function. Potassium and sodium levels can change due to various factors and aren't indicators of muscular dystrophy.

When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure?

Tachycardia Heart failure occurs when the heart has the inability to pump effectively to provide adequate blood, oxygen, and nutrients to the body's organs and tissues. Symptoms occur because of three factors. The neurohormonal influences cause symptoms of tachycardia, pallor, decreased urine output, sweating, hypertension, weight gain and edema. The symptoms seen from systolic dysfunction are dyspnea on exertion, increased work of breathing, and feeding difficulties. Diastolic influences produce hepatomegaly, jugular vein distention and periorbital edema.

A nurse is palpating the pulse of a child with suspected aortic regurgitation. Which assessment finding should the nurse expect to note?

bounding pulse A bounding pulse is characteristic of patent ductus arteriosus or aortic regurgitation. Narrow or thready pulses may occur in children with heart failure or severe aortic stenosis. A normal pulse would not be expected with aortic regurgitation.

The student nurse is preparing a presentation on celiac disease. What information should be included? Select all apply. Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "Most children with celiac disease are diagnosed within the first year of life." "The only treatment for celiac disease is a strict gluten-free diet." "Gluten is found in most wheat products, rye, barley and possibly oats." "The entire family will need to eat a gluten-free diet."

Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "The only treatment for celiac disease is a strict gluten-free diet." "Gluten is found in most wheat products, rye, barley and possibly oats." Celiac disease is an immunologic disorder in which gluten causes damage to the small intestine. The only treatment currently is consuming a gluten-free diet. While the child needs to have a gluten-free diet, the rest of the family does not. Most children present by the age of 2 for evaluation. Symptoms of celiac disease include diarrhea, constipation, steatorrhea, weight loss, poor muscle tone, anemia and dental disorders. Gluten is found in most grains, like wheat, rye, barley and possibly oats.

The nurse is preparing to administer the child's dose of intravenous immune globulin (IVIG). Which actions should the nurse take? Select all that apply. Prepare to administer the medication in the ventrogluteal site as an intramuscular injection. Take baseline vital signs and monitor the vital signs during the infusion. Prepare to give acetaminophen to the child. Prepare to give diphenhydramine to the child. Mix the medication with the child's intravenous antibiotic.

Take baseline vital signs and monitor the vital signs during the infusion. Prepare to give acetaminophen to the child. Prepare to give diphenhydramine to the child.

A child is scheduled for a urea breath test. The nurse understands that this test is being performed for which reason?

detect Helicobacter pylori Urea breath test is used to detect the presence of H. pylori in the exhaled breath. This test does not evaluate gastric pH. Serum amylase and lipase levels are used to confirm pancreatitis. Esophageal manometry is used to evaluate esophageal contractile activity and effectiveness.

The nurse in a pediatric cardiovascular clinic is talking with the father of a 5-year-old child who underwent cardiac surgery for a heart defect at the age of 3. The father reports that the child has been having increased shortness of breath, tires easily after playing, and has been gaining weight. The nurse is aware that the child is most likely demonstrating symptoms of which acquired cardiovascular disorder?

heart failure Infective endocarditis would present with intermittent, unexplained low-grade fever, fatigue, anorexia, weight loss, or flu-like symptoms. Characteristics of cardiomyopathy include respiratory distress, fatigue, poor growth (dilated), chest pain, dizziness, and syncope. Abdominal pain, joint pain, fever, and irritability are signs of Kawasaki disease.