Nurse 140 Ch. 28

The nurse is monitoring a 2-year old child for signs of dehydration. Which of the following techniques of monitoring body temperature is appropriate? (Select all that apply) 1. Axillary 2. Rectal 3. Tympanic 4. Temporal artery 5. Stroking the forehead

1. Axillary 3. Tympanic 4. Temporal artery Elevations in temperature also increase the rate of water loss, therefore the temperature must be monitored. A rectal temperature technique is no longer an accepted practice unless specifically ordered by the health care provider. However, the temporal artery, axillary, and tympanic techniques are acceptable methods of measuring body temperatures. REF: Dehydration

Priority teaching for a parent of a child who ingested a foreign body includes: 1.) encouraging the use of a mild laxative every night 2.) slicing each stool passed to observe for the foreign body 3.) encouraging a daily enema until the foreign body is passed 4.) keeping the child NPO until the foreign body is passed

2.) slicing each stool passed to observe for the foreign body Unless an ingested foreign body is sharp or large, passage through the GI tract may be possible and can take 4 to 6 days. The child is cared for at home, and the nurse should emphasize the importance of cutting and examining each stool until the object is passed successfully. REF: Foreign body ingestion

How are pinworms diagnosed? 1.) seeing the worm in the stool 2.) a blood antigen level 3.) A "Scotch tape test" in the early morning 4.) a stool laboratory examination obtained at the hour of sleep

3. A "Scotch tape test" in the early morning A special pinworm diagnostic tape or paddle, or a tongue blade covered with cellophane tape with the sticky side out, may be placed against the anal region to obtain pinworm eggs (the "Scotch tape test"). This is done early in the morning, before the child has a bowel movement, bathes, or scratches the area with the fingers. The tape is put on a glass slide and examined under a microscope. The eggs are typical of pinworms. REF: Enterobiasis (pinworms)

The pathologic disturbance of pyloric stenosis results from: 1. edema of the pyloric muscle 2. ischemia of pyloric muscle 3. hypertrophy of the pyloric muscle 4. neoplastic

3. hypertrophy of the pyloric muscle Pyloric stenosis (narrowing) is an obstruction at the lower end of the stomach (pylorus) caused by an overgrowth (hypertrophy) of the circular muscles of the pylorus or by spasms of the sphincter. REF: Pyloric stenosis

Which menu selections are best for a child diagnosed with celiac disease? 1. Pizza and chocolate cake 2. Spaghetti and blueberry muffin 3. Chicken sandwich on whole-wheat bread 4. Corn tortilla and fresh fruit

4. Corn tortilla and fresh fruit Celiac disease is also known as gluten enteropathy and sprue, and it is the leading malabsorption problem in children. Repeated exposure to gluten damages the villi in the mucous membranes of the intestine. Gluten is found in wheat, barley, oats, and rye. Foods containing these are restricted for those with the disease. REF: Celiac disease

A mother reports that her child has been scratching the anal area and complaining of itching. What does the nurse suspect based on this information? a. Pinworms b. Giardiasis c. Ringworm d. Roundworm

a. Pinworms With pinworms, the nurse or parent may notice that the child scratches the anal area and complains of itchiness. The other choices do not cause this reaction. REF: Page 678

What sign(s) indicate(s) moderate dehydration? (Select all that apply.) a. 10% weight loss b. Dry mucous membranes c. Normal anterior fontanel d. Increased urinary output e. Lethargy

a. 10% weight loss b. Dry mucous membranes c. Normal anterior fontanel The child that is moderately dehydrated will have lost 10% of his body weight, will have dry mucous membranes, normal (non sunken) anterior fontanelle, decreased urine output, and will be irritable. REF: Page 673

Which assessment would the nurse report to the physician immediately? a. 2-month-old with a urine output of 150 mL in 24 hours b. 3-year-old with a urine output of 650 mL in 24 hours c. 8-year-old with a urine output of over 1000 mL in 24 hours d. 14-year-old with a urine output of 800 mL in 24 hours

a. 2-month-old with a urine output of 150 mL in 24 hours The urine output of a 2-month-old should be between 400 and 500 mL/24 hours. REF: Page 673

What description of a child's stool characteristic leads the nurse to suspect intussusception? a. Currant jelly b. Black and tarry c. Green liquid d. Greasy and foul-smelling

a. Currant jelly Bowel movements of blood and mucus that contain no feces (currant jelly stools) are common about 12 hours after the onset of the obstruction. REF: Page 665

What assessment(s) would lead a nurse to suspect Hirschsprungs disease in a 1-month-old infant? (Select all that apply.) a. Ribbon-like stools b. Fever c. Failure to thrive d. Vomiting e. Diminished peristalsis

a. Ribbon-like stools b. Fever c. Failure to thrive d. Vomiting e. Diminished peristalsis All options are significant indicators of Hirschsprungs disease. REF: Page 664

A child has been diagnosed with ascariasis (roundworm). Which statement made by her mother that may suggest a cause for her condition? a. I've been airing out the house on these nice breezy days. b. My child often goes out to the garden and pulls up a carrot to eat. c. She runs barefoot so much I have to wash her feet at least twice a day. d. We just remodeled our bathroom at home.

b. My child often goes out to the garden and pulls up a carrot to eat. The child can ingest roundworm eggs from contaminated soil. REF: Page 678

A newborn does not pass meconium within the first 48 hours after birth. Which diagnosis does the nurse suspect? a. An abdominal wall defect b. Intussusception c. Hirschsprung's disease d. Celiac disease

c. Hirschsprung's disease Hirschsprung's disease, or aganglionic megacolon, occurs when there is an absence of ganglionic innervation to the muscle of a segment of the bowel. Because of the absence of nerve cells, there is a lack of normal peristalsis. This results in chronic constipation. In the newborn, failure to pass meconium stools within 24 to 48 hours may be a symptom of Hirschsprung's disease. REF: p. 665

The nurse is teaching a parent about pyrvinium (Povan). What would be included in regard to potential side effects? a. Diarrhea b. Skin rash c. Red stool d. Metallic taste

c. Red stool The nurse should advise parents that pyrvinium stains clothing and turns stools red. REF: Page 678

The nurse is instructing a mother how to administer oral nystatin suspension prescribed to treat thrush. What will the nurse include? a. Pour the prescribed amount into a nipple and have the infant suck the medication. b. Squirt the prescribed dose into the back of the mouth and have the infant swallow. c. Give the medication mixed with a small amount of juice in a bottle. d. Use a sterile applicator to swab the medication on the oral mucosa.

d. Use a sterile applicator to swab the medication on the oral mucosa. An appropriate way to administer nystatin is to moisten a sterile applicator with the medication and then swab it on the inside of the mouth. REF: Page 677

What instruction will the nurse give to parents about preventing the spread and reinfection of pinworms? a. Keep children's nails short. b. Dress child in loose-fitting underwear. c. Clean the bathroom with bleach solution. d. Wash bed linens in cold water.

a. Keep children's nails short. One intervention to prevent the further spread of pinworms is to keep the child's fingernails short. Pinworms are not spread from person to person. REF: Page 678

What may be included in the treatment of salicylate poisoning? a. Vitamin K b. Mucomyst c. Acetaminophen d. Chelating agents e. Syrup of ipecac

a. Vitamin K Vitamin K is administered to control bleeding. The other treatments are not used for treatment of salicylate poisoning. REF: p. 682

Which statement by a mother may indicate a cause of her sons vitamin C deficiency? a. We get our fruits from homemade preserves. b. We use milk from our own goats. c. We grow all our own vegetables. d. Were not big meat eaters.

a. We get our fruits from homemade preserves. Vitamin C is destroyed by heat. REF: Page 676

What is the treatment of choice for a child with intussusception? a. A barium enema b. Immediate surgery c. IV fluids until the spasms subside d. Gastric lavage

a. A barium enema A barium enema is the treatment of choice for intussusception because the passage of the barium frequently un-telescopes the bowel. Surgery is scheduled only if reduction is not achieved. REF: Page 665

An infant is admitted to the hospital with severe dehydration. Laboratory results show pH 7.32, PaCO2 40, HCO3 21. How does the nurse interpret these values? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

a. Metabolic acidosis A pH lower than 7.35 indicates acidosis. If the childs pH falls in the same line as the HCO3, the problem is metabolic (see Table 27-4). REF: Page 674

What signs and symptoms would alert the nurse to the possibility of intussusception? (Select all that apply.) a. Onset is sudden b. Kicking and drawing of legs c. Failure to thrive d. Bile stained vomit e. Currant jelly stools

a. Onset is sudden b. Kicking and drawing of legs d. Bile stained vomit e. Currant jelly stools All of these are signs of intussusception except failure to thrive. This diagnosis is an acute condition and it will be diagnosed before a child has the opportunity to develop a diagnosis of failure to thrive. REF: p. 665

Which is the most appropriate intervention for a 3-month-old infant who has gastroesophageal reflux? a. Position the infant in the crib on his or her abdomen, with the head elevated. b. Administer medication as ordered to stimulate the pyloric sphincter. c. Give thin rice cereal with formula before feeding solid foods. d. Place the infant in an infant seat after feedings.

a. Position the infant in the crib on his or her abdomen, with the head elevated. After feedings, the infant is placed in a prone position to avoid increased intraabdominal pressure. REF: Page 667

A 7-month-old infant is admitted to the hospital with a diagnosis of acute gastroenteritis. What will be the nurse's priority goal of the infants care? a. Prevent fluid and electrolyte imbalance. b. Prevent nutritional deficiency. c. Prevent skin breakdown. d. Prevent malabsorption.

a. Prevent fluid and electrolyte imbalance. The priority goal of care in gastroenteritis is preventing fluid and electrolyte imbalance. REF: Page 666

On the second day of hospitalization for a 3-month-old brought in for treatment for gastroenteritis, the nurse makes all of the assessments listed below. Which assessment finding indicates ineffectiveness of treatment? a. Weight loss of 4 ounces b. Dry mucous membranes c. Decreased skin turgor d. Depressed fontanelle

a. Weight loss of 4 ounces Weight loss is the most significant indicator of dehydration because an infants weight comprises 77% water. REF: Page 672

What would the nurse expect to find in a child admitted to the hospital for nonorganic failure to thrive? a. Cry to be picked up b. Be limp like a rag doll c. Be responsive to cuddling d. Weigh in the 10th percentile for age

b. Be limp like a rag doll Some children with failure to thrive have rag-doll limpness (hypotonia) and appear wary of their caregivers. REF: Page 675

What interventions will the nurse perform when feeding a child with pyloric stenosis? (Select all that apply.) a. Give a formula thinned with water. b. Burp the infant before and during feeding. c. Give the feeding slowly. d. Refeed if the infant vomits. e. Position infant on left side after feeding.

b. Burp the infant before and during feeding. c. Give the feeding slowly. d. Refeed if the infant vomits. Children with pyloric stenosis are given formula thickened with cereal; the infant is burped before and during feeding to get rid of any gas in the stomach; the infant is fed slowly and refed if vomiting occurs. The infant is positioned on the right side to allow the weight of the feeding to stay in the stomach against the pyloric valve. REF: Page 661

Which finding in a newborn is suggestive of tracheoesophageal fistula? a. Failure to pass meconium in 24 hours b. Choking on the first feeding c. Palpable mass in the sternal area d. Visible peristalsis across abdomen

b. Choking on the first feeding After birth, a newborn with tracheoesophageal fistula will vomit and choke when the first feeding is introduced. REF: Page 660

A child is admitted to the emergency department with suspected intussusception. What significant assessment supports this diagnosis? a. A gradual onset of pain b. Currant jelly stools c. Frothy, bulky stools d. Vague abdominal pain

b. Currant jelly stools In typical cases the onset is sudden. The child feels severe pain in the abdomen. The child vomits. The stomach contents are green or greenish yellow (bilious). Movements of blood and mucus that contain no feces are common about 12 hours after the onset of the obstruction; these are termed currant jelly stools. REF: p. 666

A child is brought into the ED with suspected appendicitis. What signs and symptoms does the nurse expect to assess? (Select all that apply.) a. Left lower quadrant pain b. Guarding c. Rebound tenderness d. Decreased C-reactive protein e. Pain on lifting thigh when supine

b. Guarding c. Rebound tenderness e. Pain on lifting thigh when supine With appendicitis on examination, characteristic tenderness in the right lower quadrant known as McBurney's point will occur. Other diagnostic signs include guarding (tightening of the abdominal muscles or rigidity of the abdomen on palpation); rebound tenderness (pressing the RLQ with rapid release of pressure causes severe pain); pain on lifting the thigh while in the supine position is caused by muscle irritation. C-reactive protein levels will be increased after 12 hours if any infection is present REF: Page 676

Which is the earliest sign of esophageal atresia? a. Mother develops gestational diabetes. b. Mother develops unexplained polyhydramnios. c. Infant does not pass meconium within 48 hours. d. Infant appears to drool during feedings.

b. Mother develops unexplained polyhydramnios. The mother will develop polyhydramnios in pregnancy. Gestational diabetes does not factor into this diagnosis. If an infant does not pass meconium, it is more pertinent at 24 hours, and it could be a sign of an imperforate anus. The infant does begin to drool during feeding for the diagnosis; however, the polyhydramnios is an earlier sign. REF: p. 660

A child is brought to the emergency department because he ingested an unknown quantity of acetaminophen (Tylenol). What does the nurse expect this child to receive following gastric lavage? a. Activated charcoal b. N-acetylcysteine c. Vitamin K d. Syrup of ipecac

b. N-acetylcysteine Gastric lavage is followed by N-acetylcysteine (Mucomyst), the antidote for acetaminophen. REF: Page 679

What clinical manifestation is most suggestive of pyloric stenosis? a. Regurgitation b. Projectile vomiting c. Bloody stool d. Steatorrhea

b. Projectile vomiting Vomiting is the outstanding symptom of pyloric stenosis. The force progresses until most of the food is ejected a considerable distance from the mouth. This is termed projectile vomiting. REF: p. 661

The nurse is interviewing parents of an infant with pyloric stenosis. What would the nurse expect the parents to report? a. Diarrhea b. Projectile vomiting c. Poor appetite d. Constipation

b. Projectile vomiting Vomiting is the outstanding symptom of pyloric stenosis. Food is ejected with considerable force, which is described as projectile vomiting. REF: Page 661

A frightened mother calls the pediatricians office because her child swallowed dishwashing detergent. What is the most appropriate action? a. Induce vomiting by giving the child syrup of ipecac. b. Take the child to the local emergency department. c. Give the child activated charcoal mixed with juice. d. Give the child milk to soothe affected mucous membranes.

b. Take the child to the local emergency department. Inducing vomiting is no longer recommended because it may pose additional problems. The child should be taken immediately to the nearest emergency department along with the packaging of the ingested substance. REF: Page 678

Parents have adopted a child with the diagnosis of kwashiorkor. What is most likely to be observed when assessing this child? (Select all that apply.) a. Hyperactivity b. White streak in hair c. Edematous abdomen d. Slowed growth e. Thick, oily hair

b. White streak in hair c. Edematous abdomen d. Slowed growth Kwashiorkor means, in native dialect, the disease of the deposed baby when the next one is born, indicating that the child no longer breastfeeds because a sibling is born and takes over the breast of the mother. Oral intake then is deficient in protein. The child fails to grow normally. The muscles become weak and wasted. There is edema of the abdomen that may become generalized. Diarrhea, skin infections, irritability, anorexia, and vomiting may be present. The hair becomes thin and dry. Because protein is the basis of melanin, a substance that provides color to hair, melanin becomes deficient. This is the reason the earliest sign of this protein malnutrition is a white streak in the hair of the child (depigmentation). The child looks apathetic and weak. REF: Page 676

Why are infants more vulnerable to fluid and electrolyte imbalances than adults? a. They have a smaller surface area than adults in proportion to body weight. b. Water needs and losses per kilogram are lower than those for adults. c. A greater percentage of body water in infants is extracellular. d. Infants have a lower metabolic turnover of water.

c. A greater percentage of body water in infants is extracellular. A greater percentage of body water is contained in the extracellular compartment of children under 2 years of age. REF: Page 672

Parents ask the nurse how their infant developed a Meckel's diverticulum. What condition, will the nurse explain, is present causing this diagnosis? a. The yolk sac remains connected to the intestine. b. There is inflammation of the ileocecal valve. c. A pouch forms when the vitelline duct fails to disappear. d. There is a weakness in the abdominal wall.

c. A pouch forms when the vitelline duct fails to disappear. If the vitelline duct fails to disappear completely after birth, a blind pouch may form. REF: Page 665

The nurse is speaking to the parent of a 3-year-old child who has mild diarrhea. What dietary modification would the nurse advise? a. Soft foods with rice, bananas, toast, and applesauce b. Small amounts of clear fluids such as gelatin c. An oral rehydrating solution, such as Pedialyte d. Chicken soup because it is high in sodium

c. An oral rehydrating solution, such as Pedialyte An oral rehydrating solution is recommended to replace fluids and electrolytes lost from frequent bowel movements. REF: Page 668

What does the nurse expect the appearance of the stools of a child with celiac disease to be? a. Ribbon like b. Hard, constipated c. Bulky, frothy d. Loose, foul-smelling

c. Bulky, frothy Celiac disease causes malabsorption. Stools that are large, bulky, and frothy may indicate malabsorption. REF: Page 663

The nurse is planning a parent education program about lead poisoning prevention. What will be included regarding primary sources of lead in the community? a. Increased lead content of air b. Use of aluminum cookware c. Deteriorating paint in older buildings d. Inhaling smog

c. Deteriorating paint in older buildings The primary source of lead is paint from old, deteriorating buildings. REF: Page 682

Which statement made by a parent alerts the nurse to the need for additional education about poison prevention? a. I keep the poison control center phone number easily accessible. b. All medication is kept out of reach in a locked cabinet. c. I keep a bottle of syrup of ipecac handy. d. Our garden is free from marigolds.

c. I keep a bottle of syrup of ipecac handy. Traditionally, syrup of ipecac was the treatment of choice to remove some types of poisons from a child's system and parents were advised to keep a supply on hand in the home. However, the American Academy of Pediatrics (AAP) revised this policy in 2003. Parents are now advised to call the poison control center and bring the container of the substance ingested to the hospital emergency department as quickly as possible because stomach lavage is rarely effective 1 hour or more after ingestion. Ipecac syrup should not be kept in the home. Uncontrolled vomiting can cause serious complications. REF: Page 679

Why are rapid respirations a possible cause of dehydration? a. They prevent the child from drinking. b. They increase circulation, thus increasing urine production. c. They cause evaporation of fluid on the mucous membranes. d. They often lead to vomiting.

c. They cause evaporation of fluid on the mucous membranes. Rapid respirations cause increased insensible fluid loss. REF: Page 672

A mother reports that her 2-year-old child experiences constipation frequently. Which food would the nurse recommend to include in the child's diet? a. Cooked vegetables b. Pretzels c. Whole-grain cereal d. Yogurt

c. Whole-grain cereal Dietary modifications for constipation include eating more high-roughage foods such as whole-grain breads and cereals. REF: Page 670

The nurse is caring for an 18-pound child who has had one stool of diarrhea. The nurse knows that the child needs to consume how many milliliters of oral fluid to make up for the fluid loss? a. 18 b. 36 c. 64 d. 81

d. 81 The formula for oral fluid replacement is 10 mL/kg. 18 pounds = 8.1 kg 10 = 81 mL. REF: Page 671

A child is brought to the pediatric clinic because he has been vomiting for the past 2 days. What acid-base imbalance would the nurse expect to occur from this persistent vomiting? a. Hyperkalemia b. Hypernatremia c. Acidosis d. Alkalosis

d. Alkalosis Hydrochloric acid and sodium chloride from the stomach are lost from persistent vomiting. This results in alkalosis. REF: Page 666

Following surgery for pyloric stenosis, an infant awoke from anesthesia hungry and crying. What is the most appropriate nursing action? a. Delay feeding the child for 6 hours. b. Offer regular formula thinned with water. c. Give small amounts of regular formula thickened with cereal. d. Allow 1 ounce of glucose water at frequent intervals.

d. Allow 1 ounce of glucose water at frequent intervals. Small oral feedings of glucose water are given after recovery from anesthesia. Feedings are gradually increased to larger amounts of regular formula. REF: Page 661

A child is admitted to the hospital with dehydration. The physician orders potassium to be added to the child's IV. What is the nurse's priority assessment? a. Skin integrity b. Mucous membranes c. Bowel status d. Genitourinary status

d. Genitourinary status Potassium is lost in almost all degrees of dehydration. Replacement potassium is administered only after normal urinary excretion is confirmed. The nurse must document that at least one void has occurred before IV potassium is administered. REF: p. 674

The nurse has reviewed dietary restrictions for celiac disease with concerned parents. Which grain will the nurse explain can be eaten with celiac disease? a. Wheat b. Oats c. Barley d. Rice

d. Rice Rice is a gluten-free grain that can be eaten by children afflicted with celiac disease. These children will have a lifelong restriction of wheat, oats, barley, and rye. REF: Page 663

An infant is admitted to the hospital with severe isotonic dehydration. For what is this child at the highest risk? a. Metabolic alkalosis b. Hypocalcemia c. Sepsis d. Shock

d. Shock Shock is the greatest threat to life in isotonic dehydration. REF: Page 673

Which nursing interventions will be implemented for the mother of a 10-month-old infant with nonorganic failure to thrive? a. Pointing out errors that the nurse observes when the mother is caring for the infant b. Discussing negative characteristics of the infant with the mother c. Having the nurse provide as much of the infants care as possible d. Teaching the mother about the developmental milestones to expect in the next few months

d. Teaching the mother about the developmental milestones to expect in the next few months The nurse can increase parents knowledge of growth and development by providing anticipatory guidance about normal developmental milestones. REF: Page 675