Peds Exam 4
The nurse advises a mother with a 2-year-old child to avoid encouraging excessive milk consumption by the toddler because excess milk consumption can lead to which problem? - vitamin C deficiency - iron deficiency - biotin deficiency - folate deficiency
Fe deficiency Explanation: Excessive milk consumption can lead to the displacement of iron-rich foods in the diet. This can result in iron deficiency anemia. Drinking excess milk will not cause vitamin C, biotin, or folate deficiencies.
Which toxic adverse reaction should the nurse monitor in a toddler taking digoxin? - weight gain - tachycardia - nausea and vomiting - seizures
N/V Explanation: Digoxin toxicity in infants and children may present with nausea, vomiting, anorexia, or a slow, irregular heart rate. Weight gain, tachycardia, and seizures are not findings in digoxin toxicity.
A child has a seizure while a nurse is performing a bed bath. Which of the following are priority actions for the nurse to implement? Select all that apply: - Time the length of the seizure. - Observe the stages of the seizure. - Place a tongue depressor in the child's mouth. - Turn the child to a side-lying position. - Restrain the twitching extremities.
Time the length of the seizure, observe the stages of the seizure, turn the child to a side-lying position Explanation: It is important to assess the characteristics of the seizure to help the physician diagnose the type of seizure. Turning the child to a side-lying position may prevent aspiration of secretions. Placing a tongue depressor in the mouth or restraining extremities can cause injury to the child and is contraindicated.
When teaching the parents of a child diagnosed with tetralogy of Fallot about the cardiac defects involved with this condition, which defects should the nurse describe? Select all that apply: - right ventricular hypertrophy - aortic valve stenosis - ventricular septal defect - overriding aorta - atrial septal defect - pulmonary stenosis
VSD, overriding aorta, pulmonary stenosis, R ventricular hypertrophy Explanation: Tetralogy of Fallot involves four defects: right ventricular hypertrophy, ventricular septal defect, overriding aorta, and pulmonary stenosis.Aortic valve stenosis and atrial septal defect are not components associated with this condition.
A nurse on the pediatric unit is caring for a group of preschool children. Which situation takes priority? - a child who develops a fever during a blood transfusion - a child admitted from the postanesthesia care unit who has a blood-saturated surgical dressing - a physician waiting on the telephone to give the nurse a verbal order - a child with asthma who is wheezing with an oxygen saturation level of 96%
a child who develops a fever during a blood transfusion Explanation: A fever indicates an adverse reaction to the blood transfusion and requires immediate intervention. The post-surgical child is losing blood through the surgical incision, which also requires attention. However, managing the bleeding may take significant time. Between these two priorities, stopping the transfusion and beginning normal saline should be accomplished first and takes minimal time. Postponing stopping the blood to manage the bleeding from the post-op patient will cause potentially life threatening complications for the blood transfusion patient. The telephone call is important for medication changes and to prevent a delay in treatment. Airway management is also a high priority. At this point, the child is compensating with a reasonable oxygen saturation. In this scenario, the most critical situation is the blood transfusion reaction, which requires the quickest intervention to stop potential complications.
The nurse is providing postoperative care for an infant who had a ventriculoperitoneal shunt placed to correct hydrocephalus. Which clinical finding warrants immediate intervention? - abdominal distension - lethargy - facial edema - headache
abdominal distension Explanation: Abdominal distension in a pediatric client with a ventriculoperitoneal shunt can be an indication of peritonitis and requires intervention. Lethargy may be present for several days following surgery for a ventriculoperitoneal shunt. Facial and eye edema is common during the postoperative period and can be reduced by utilizing a cold compress to the eyes. Infants commonly have pain in the postoperative period that should be treated with analgesics; however, infants cannot convey that they specifically have a headache.
A physician orders digoxin elixir for a client with heart failure. Immediately before administering this drug, the nurse must check the client's - serum sodium level. - urine output. - weight. - apical pulse.
apical pulse Explanation: Because digoxin may reduce the heart rate and heart failure may cause a pulse deficit, the nurse should measure the client's apical pulse before administering the drug to prevent further slowing of the heart rate. The serum sodium level doesn't affect digoxin's action. For a client with heart failure, the nurse should check urine output and measure weight regularly, but not necessarily just before digoxin administration.
A 13-year-old with anorexia nervosa is admitted to the facility for I.V. fluid therapy and nutritional management. The client is worried that the I.V. fluids will cause weight gain. Which nursing diagnosis is most appropriate? - noncompliance (dietary regimen) - disturbed body image - complicated grieving - grieving
disturbed body image Explanation: A client with anorexia nervosa has a body image disturbance and views the client's body as fat despite physical evidence to the contrary. One goal of nursing care is to help the client develop realistic body self perceptions. Although this adolescent has expressed concern about weight gain from I.V. fluids, no information suggests refusal of treatment; therefore, a nursing diagnosis of noncompliance isn't warranted. Likewise, no evidence supports the nursing diagnoses of complicated grieving and grieving.
A nurse is assessing an infant for signs of increased intracranial pressure (ICP). What is the earliest sign of increased ICP in an infant? - vomiting - papilledema - vital sign changes - irritability
irritability Explanation: An infant with increased ICP is commonly fussy, irritable, and restless at first as a result of a headache cause by the ICP. Vomiting occurs later. Papilledema is a late sign of increased ICP that may not be evident. Changes in vital signs occur later; pressure on the brainstem slows pulse and respiration.
The parents of a child with sickle cell anemia ask about the chances of sickle cell disease occurring in future children. What does the nurse determine is the family's risk of having another child with sickle cell anemia? - one chance in five for each pregnancy - one chance in four for each pregnancy - one chance in three for each pregnancy - one chance in two for each pregnancy
one chance in four for each pregnancy Explanation: Sickle cell disease is an autosomal recessive Mendelian disorder. Therefore, if both parents have the trait, there is a one-in-four chance that any child (each pregnancy) will have the disease and a one-in-two chance that a child (each pregnancy) will have the trait.
A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to - place ice packs on the client's painful joints. - administer antibiotics. - provide oral and I.V. fluids. - administer folic acid supplements.
provide PO and IVF Explanation: Initial nursing interventions for the child in a sickle cell crisis include providing hydration and oxygenation to prevent more sickling. Pain relief is also a concern. However, painful joints are treated with analgesics and warm packs because cold packs may increase sickling. Antibiotics will be given to treat a sickle cell crisis if it's thought to be bacterial but only after hydration and oxygenation have been addressed. Daily supplements of folic acid will help counteract anemia but aren't a priority during sickle cell crisis.
A toddler with a ventricular septal defect is receiving digoxin to treat heart failure. Which assessment finding should be the nurse's priority concern? - bradycardia - tachycardia - hypertension - hyperactivity
bradycardia Explanation: Digoxin enhances cardiac efficiency by increasing the force of contraction and decreasing the heart rate. An early sign of digoxin toxicity is bradycardia (an abnormally slow heart rate). To help detect digoxin toxicity, the nurse always should measure the apical heart rate before administering each digoxin dose. Other signs and symptoms of digoxin toxicity include arrhythmias, vomiting, hypotension, fatigue, drowsiness, and visual halos around objects. Tachycardia, hypertension, and hyperactivity aren't associated with digoxin toxicity.
A child with a brain tumor has a decreased respiratory rate and is less responsive to verbal commands than he was when the nurse assessed the client the previous hour. What should the nurse do next: - Raise the head of the bed. - Notify the health care provider (HCP). - Implement seizure precaution - Obtain an oximeter reading.
notify the HCP Explanation: A decreasing level of consciousness, decerebrate positioning, or Cushing's triad (elevated systolic blood pressure, decreased pulse, and decreased respiratory rate) indicates that there is pressure on the brain stem and the client could require intubation and cardiac resuscitation unless the health care provider (HCP) can prescribe a medication or surgical procedure to reduce the intracranial pressure. Raising the head of the bed could offer some reduction in the intracranial pressure by increasing venous blood return from the head, but it is not the priority at this time. While brain tumors can cause seizures in children, they often manifest early in the disease process. The impending risk of seizure is not as great as the potential for respiratory arrest. An oximeter would measure the oxygen level in the blood but not necessarily in the brain.
A child diagnosed with tetralogy of Fallot becomes upset, cries, and thrashes around when a blood specimen is obtained. The child becomes cyanotic and the respiratory rate increases to 44 breaths/min. Which action should the nurse do first? - Obtain an order for sedation for the child. - Assess for an irregular heart rate and rhythm. - Explain to the child that it will only hurt for a short time. - Place the child in a knee-to-chest position.
Place the child in a knee-to-chest position Explanation: The child is experiencing TET or hypoxic episode. Therefore the nurse should place the child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from the lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of Fallot. As a result, the blood then entering the systemic circulation has higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position in the crib, or the mother learns to put the infant over her shoulder while holding the child in a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may need a sedative. Once the child is in the position, the nurse may assess for an irregular heart rate and rhythm. Explaining to the child that it will only hurt for a short time does nothing to alleviate the hypoxia.
A 6-year-old child with a history of varicella and aspirin intake is brought to the emergency department. The nurse suspects Reye's syndrome. Which assessment findings are consistent with this syndrome? - fever, decreased level of consciousness (LOC), and impaired liver function - joint inflammation, red macular rash with a clear center, and low-grade fever - peripheral edema, fever for 5 or more days, and "strawberry tongue" - red, raised "bull's eye" rash, malaise, and joint pain
fever, decreased level of consciousness (LOC), and impaired liver function Explanation: Reye's syndrome occurs in children with a history of a viral infection, varicella, or influenza. It's commonly associated with the administration of aspirin. The child presents with fever and decreased LOC, which can lead to coma and death. As the disease progresses, the child also develops impaired liver function. A child with joint pain, a red macular rash with a clear center, and a low-grade fever probably has rheumatic fever. A child presenting with peripheral edema, fever for more than 5 days, and a "strawberry tongue" probably has Kawasaki disease. A child with a red, raised "bull's eye" rash, malaise, and joint pain should be tested for Lyme disease.
A school-age child with leukemia is taking immunosuppressive drugs. What health maintenance recommendation should the nurse include in the teaching plan? - Monitor the child's temperature at school. - Avoid any live attenuated vaccines. - Take daily vitamin and mineral supplements. - Stay away from other children.
Avoid any live attenuated vaccines Explanation: Children who are immunosuppressed should not receive any live attenuated vaccines. Clients who are immunosuppressed and are given live attenuated vaccines such as measles, mumps, rubella, and oral polio vaccine can develop severe forms of the diseases for which they are being immunized, which can result in death. Inactivated vaccines may be given if necessary, but the client is not able to adequately produce needed antibodies, and it is recommended that immunizations be delayed for 3 months after the immunosuppressive drugs have been discontinued. It is unnecessary to monitor the child's temperature at school unless the child shows symptoms of an illness. Vitamin and mineral supplements are not normally given in conjunction with immunosuppressive drugs. When the client is immunosuppressed, the client should avoid only persons who have an infection.
The nurse is assessing an adolescent 1 hour after admission for a head injury. The nurse identifies that there have been changes since the baseline assessment, including apnea, bradycardia, and a widening pulse pressure. What is the primary reason for the nurse to notify the healthcare provider? - The healthcare provider should be notified of significant condition changes. - The changes suggest that the client's intracranial pressure is increasing. - The client may require additional diagnostic testing and imaging. - The healthcare provider will want to change fluids and narcotics prescribed.
The changes suggest that the client's intracranial pressure is increasing. Explanation: Cushing's triad (apnea, bradycardia, and widening pulse pressure) is a hallmark of increasing intracranial pressure, which indicates that the adolescent's condition is deteriorating. It is correct that the healthcare provider must be alerted to significant changes and may need to change orders. The client may need additional testing. However, the primary reason to notify the healthcare provider is so the obvious increase in intracranial pressure can be managed using a holistic and emergent approach.
A child is admitted to the hospital with a febrile seizure. What action should the nurse take? - Keep the child supine. - Place the child in isolation. - Keep the room temperature low and bedclothes to a minimum. - Place a padded tongue blade at the bedside.
Keep the room temperature low and bedclothes to a minimum Explanation: One nursing goal for a child with febrile seizures is to maintain the child's temperature at a level low enough to prevent recurrence of seizures. Decreasing the environmental temperature and removing excess clothing and blankets will help decrease the child's temperature.There is no reason to keep the child supine; a side-lying position would be acceptable and help decrease intracranial pressure. A febrile seizure, though, results from abnormal electrical activity in the brain due to elevated body temperature.Isolation precautions are not necessary unless the child has a condition that warrants such an isolation.Using a tongue blade to separate the teeth in the upper jaw from the lower jaw in an attempt to prevent the child from biting the tongue has proven to be ineffective and may result in broken teeth.
The nurse is providing an education program to a group of adolescents on the importance of testicular self-examinations. One of the participants asks the nurse, "when is the best time to do the examination?" What is the best response by the nurse? - when you first arise in the morning - when you are in the shower or immediately after - in the evening prior to going to bed - prior to urinating in the morning
when you are in the shower or immediately after Explanation: Testicular cancer occurs most frequently between the ages of 15 and 34; therefore, boys should begin doing testicular self-examinations at age 12, which will help them become familiar with the normal contours and consistency of their genital structures. The nurse should inform the group that the best time to perform a testicular self-examination is in the shower or immediately afterward because the scrotum is relaxed. When the male first rises in the morning, in the evening, or prior to urinating, the scrotum is not in the optimal condition for the examination.
Which action should the nurse include in the plan of care for a child with leukemia who has an absolute neutrophil count of 400/mm3 (0.4 X 109/L)? - Restrict staff and visitors with active infections. - Place the child in strict isolation. - Consult with the primary care provider to administer an antiemetic. - Increase the child's oral fluid intake.
Restrict staff and visitors with active infections Explanation: The child's neutrophil count is low (the normal range is 3,000 to 5,000 cells/mm3 [3 to 5 X 109/L]), predisposing the child to infection. If an infection occurs, the child will have difficulty combating it. Therefore, staff and visitors should be restricted to those without an active infection. Typically neutropenic precautions, not strict isolation, would be used to protect the child from exposure to infection. The hospitalized child would be placed in a private room with visitors and staff screened for illnesses. Temperature would be monitored every 4 hours. Low neutrophil counts do not increase the likelihood of vomiting; therefore, an antiemetic is not needed. Increasing the child's oral fluid intake may be necessary; however, doing so is unrelated to the child's neutrophil count.
The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arches the back (see figure). What action should the nurse take first? - Notify the health care provider (HCP). - Stroke the back to release the arching. - Pad the side rails of the crib. - Place the child prone.
Notify the health care provider (HCP) Explanation: The infant has opisthotonos, an indication of brain stem herniation; the nurse should notify the HCP immediately and have resuscitation equipment ready. Stroking the back will not relieve the herniation or release the arching. Although the infant may also have a seizure, and padded side rails will prevent injury, the first action is to notify the HCP. Placing the child in a prone position will not relieve the herniation or release the arching.
The 17-year-old client with a diagnosis of bulimia nervosa is hospitalized. The client weighs 5 lb (2.26 kg) less than her ideal weight for her height. She tells the nurse, "I do not have a problem. I am not really underweight." The nurse should respond by saying: - "Your parents told the health care provider that you do have a problem." - "Even though your weight is almost ideal for your height, purging and using laxatives are harmful to your body." - "We'll find out if you do have a problem while you're here." - "It's often difficult to acknowledge our imperfections."
"Even though your weight is almost ideal for your height, purging and using laxatives are harmful to your body." Explanation: The nurse acknowledges the client's perception and does not challenge the client and her expression of feeling. Telling the client that purging and using laxatives are harmful behaviors is honest and accurate information. Stating, "Your parents told the health care provider that you do have a problem," places blame for the client's hospitalization on the parents, which may foster angry feelings in the client. Stating, "We'll find out if you do have a problem while you're here," is trite and instills blame and guilt toward the client for not being perfect. It also belittles the client. Suggesting that the client has imperfections is inappropriate and challenges the client to defend her beliefs.
An adolescent at a mental health clinic tells the nurse about feeling an overwhelming sadness and isolation for several months. The adolescent states a lack of interest in school and family life and proclaims, "No one cares about me. I wish I were dead." Which information would be most important for the nurse to obtain in order to plan appropriate care? - Determine whether the adolescent has had trouble adjusting to a stressful event. - Determine whether the adolescent has had intermittent episodes of euphoria. - Determine whether the adolescent's mood is related to a lack of sun exposure. - Determine whether the adolescent has developed a plan for committing suicide.
Determine whether the adolescent has developed a plan for committing suicide Explanation: The adolescent is experiencing a major depression, which is a type of mood disturbance that lasts over 2 weeks. Symptoms may include overwhelming feelings of sadness and grief, loss of interest or pleasure in activities that are usually enjoyed, and feelings of worthlessness or guilt. It may result in poor sleep, a change in appetite, severe fatigue, and difficulty concentrating. It increases the risk of suicide. The nurse needs to determine whether the adolescent has a plan for suicide, which would increase the likelihood that a suicide would occur.
A nurse has received report on her clients and notices that they're of varying ages. To prepare for the shift, the nurse reviews Erik Erikson's five stages of psychosocial development. Place the stages in chronological order from infancy to adolescence: Autonomy versus shame and doubt Trust versus mistrust Industry versus inferiority Identity versus role confusion Initiative versus guilt
Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion Explanation: During the first stage of Erikson's five stages of psychosocial development, trust versus mistrust (birth to age 1), the child develops trust as the primary caregiver meets his needs. In the second stage, autonomy versus shame and doubt (ages 1 to 3), the child gains control of body functions and becomes increasingly independent. In the third stage, initiative versus guilt (ages 3 to 6), the child develops a conscience and learns about the world through play. In the fourth stage, industry versus inferiority (ages 6 to 12), the child enjoys working on projects with others, follows rules, and forms social relationships. As body changes begin to take place, the child enters the fifth stage, identity versus role confusion (ages 12 to 19), and becomes preoccupied with looks, how others view him, meeting peer expectation, and establishing his own identity.
During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which intervention would be most appropriate to institute? - limiting conversation with the child - keeping extraneous noise to a minimum - allowing the child to play in the bathtub - performing treatments quickly
keeping extraneous noise to a minimum Explanation: A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Although treatments need to be completed as quickly as possible to prevent overstressing the child, they should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.
