Peds Chapter 22
The nurse is providing care to a preschool-age client who is diagnosed with acquired immune deficiency syndrome (AIDS). In planning the client's care, which vaccine is inappropriate for the client to receive? 1. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) 2. Haemophilus influenzae type B (HIB conjugate vaccine) 3. Varicella vaccine 4. Hepatitis B vaccine (Hep B)
Answer: 3 A child with an immune disorder should not be immunized with a live varicella vaccine because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines and should be given on schedule.
A child is prescribed Didanosine (Videx), a nucleoside reverse transcriptase inhibitor, for human immunodeficiency virus (HIV). Which lab value will the nurse monitor closely for this child? 1. Potassium 2. Sodium 3. RBC count 4. Glucose
Answer: 3 Didanosine (Videx) causes bone-marrow suppression with resulting anemia. RBC counts are monitored at least monthly for changes. Potassium and sodium are electrolytes, and glucose is a laboratory test for checking diabetes. Didanosine (Videx) does not affect these values.
A nurse begins an infusion of intravenous immune globulin (IVIG) to a child who has combined immunodeficiency disease. Which assessment finding indicates that the nurse should stop the infusion? 1. A mild headache 2. Clear yellow urine 3. Severe shaking, chills, and fever 4. Complaints of being "thirsty"
Answer: 3 Hypersensitivity reaction can be seen with IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction. A mild headache is an adverse side effect of IVIG but not a severe reaction. Thirst is not an indication of a reaction. Voiding clear yellow urine is a normal finding
The nurse is providing care to an adolescent client diagnosed with systemic lupus erythematosus (SLE). Which action by the client indicates acceptance of body changes associated with SLE? 1. She refuses to attend school. 2. She doesn't want to attend any social functions. 3. She discusses the body changes with a peer. 4. She discusses the body changes with healthcare personnel only.
Answer: 3 Peer interaction is important to the teen. Being able to discuss the changes to her body with a peer indicates acceptance of the change in body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to body-image changes. Refusing to go to school or not going to social functions indicates nonacceptance of the changes to body image.
A school-age child diagnosed with rheumatoid arthritis asks the nurse to recommend an exercise activity. Which activity is most appropriate for this child? 1. Softball 2. Football 3. Swimming 4. Basketball
Answer: 3 Swimming helps to exercise all of the extremities without putting undue stress on joints. Softball, football, and basketball could exacerbate joint discomfort.
The nurse is providing discharge teaching to a school-age client who was recently diagnosed with a latex allergy. Which product will the nurse educate the client and family to avoid? 1. Plastic bottles 2. Footballs 3. Chewing gum 4. Paper bags
Answer: 3 When a child is diagnosed with a latex allergy, it is essential for the nurse to educate both the child and the family regarding sources of latex within the home and the community. The child and family should be educated to avoid chewing gum as it contains latex. The other items do not contain latex and do not pose a risk for this child in the community.
A nurse is planning care for a child with human immunodeficiency virus (HIV). Which nursing diagnosis is the highest priority for this child? 1. Risk for Infection 2. Risk for Fluid-Volume Deficit 3. Ineffective Thermoregulation 4. Ineffective Tissue Perfusion, Peripheral
Answer: 1 A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for FluidVolume Deficit, Ineffective Thermoregulation, and Ineffective Tissue Perfusion, Peripheral would not be priority problems with this disease process.
The nurse is caring for an adolescent client diagnosed with rheumatoid arthritis. Which nonpharmacological measure to reduce joint pain is most appropriate for the nurse to recommend to this client? 1. Moist heat 2. Elevation of extremity 3. Massage 4. Immobilization
Answer: 1 Moist heat can promote relief of pain and decrease joint stiffness. Elevation of extremity would not have an effect on reducing pain in rheumatoid arthritis. Massage of extremities should be avoided because of a potential risk for emboli. Immobilization can lead to contractures, and range of motion to the involved joint should be maintained
An HIV-positive mother states she is relieved after the birth of her child to hear that the child is HIV-negative. Which response by the nurse is the most appropriate? 1. "Symptoms could still appear over the next 2 years." 2. "You took good care of yourself, so your child did not get HIV." 3. "We will assess for signs of pneumonia to be sure." 4. "The test will be repeated in 1 week to verify the negative status."
Answer: 1 Symptoms of HIV could still manifest within the first 2 years. An infant is retested 1 to 2 months after the initial negative result. The HIV-positive mother can infect the newborn regardless of how well she takes care of herself once she is HIV-positive. There is no reason to assess for signs of pneumonia if the newborn is HIV-negative.
A child with human immunodeficiency virus (HIV) also has oral candidiasis. Which type of mouth care solution will the nurse teach the child to use? 1. Normal saline 2. Listerine 3. Scope 4. Viscous lidocaine
Answer: 1 The mouth care should be with a non-alcohol base. Normal saline can keep the child's lips and mouth moist. Listerine and Scope are commercial mouth rinses that can have an alcohol base and cause drying of the membranes. Viscous lidocaine causes numbing and could depress the gag reflex in a younger child
A child comes to the clinic for an assessment 20 days post-bone marrow transplant. Which system should receive the highest priority during the nursing assessment? 1. Integumentary 2. Gastrointestinal 3. Respiratory 4. Cardiovascular
Answer: 1 The skin is most commonly affected in graft-versus-host disease after a transplant. A pruritic, macular papular rash and a blistering, burning sensation can occur. The other systems are important to assess, but are not the highest priority
A preschool-age child has just had a moderate reaction to latex. When teaching the parents about latex allergy, the nurse should inform the parents of what common household items that contain latex? Select all that apply. 1. Rubber bands 2. Sneakers 3. Toothbrushes 4. Big Wheel® tricycle 5. Water toys
Answer: 1, 2, 3, 5 Rubber bands, sneakers, toothbrushes, and water toys are household items that might contain latex. A Big Wheel® tricycle is plastic and does not contain latex.
A nurse is administering an intramuscular vaccination to an infant diagnosed with WiskottAldrich syndrome (WAS). Which reaction is the infant more at risk for due to the diagnosis of WAS? 1. Pain at injection site 2. Bleeding at injection site 3. Redness and swelling at injection site 4. Mild rash at injection site
Answer: 2 Wiskott-Aldrich syndrome is characterized by thrombocytopenia, with bleeding tendencies appearing during the neonatal period. The syndrome would not put the child at higher risk for pain, redness, swelling, or rash at the injection site
The nurse is providing care to a school-age client with a documented immunodeficiency who is admitted to the general pediatric unit for intravenous medication administration. Which interventions are appropriate for this client? Select all that apply. 1. Institute droplet precautions. 2. Place in a positive-pressure room. 3. Avoid live vaccines. 4. Perform frequent handwashing. 5. Recommend fresh fruits brought in by the family.
Answer: 2, 3, 4 Pediatric clients with documented immunodeficiency require specific interventions to decrease their risk for developing infections while in the hospital environment. Appropriate interventions for this client include a positive-pressure room, avoiding live vaccines, and meticulous handwashing from staff and visitors. This client would require standard precautions, not droplet precautions. Because of the risk of infection with fresh fruit, the family would not be allowed to bring this to the client during their hospital stay.
The nurse is caring for the adolescent with systemic lupus erythematosus (SLE). What nursing diagnoses would the nurse address? Select all that apply. 1. Activity intolerance 2. Risk for impaired skin integrity 3. Body image disturbed 4. Ineffective breathing pattern 5. Risk for infection
Answer: 2, 3, 5 Nursing diagnoses that may apply to the adolescent with SLE are: risk for impaired skin integrity, risk for activity intolerance, disturbed body image, risk for infection, acute pain, and ineffective family therapeutic regimen management.
Parents of a child who experienced a moderately severe allergic reaction after eating peanuts ask the nurse what they can do to help if it happens again. Which response by the nurse is the most appropriate? 1. "If it happens again, I will teach you what to do." 2. "You should have an antihistamine like Benadryl with you at all times." 3. "We can start a desensitization process to take the allergy away." 4. "I will teach you how to use an Epi-Pen."
Answer: 4 An Epi-Pen is the appropriate treatment if this reaction occurs again. Benadryl is fine, but most likely is not strong enough in light of the serious reaction the child had. Desensitization is not the appropriate instruction at this time. Telling the parents that they will be taught if it happens again is brushing off the seriousness of the situation.
