Peds prep
The nurse is providing care to a preschool-age client who is diagnosed with celiac disease. Which interventions will the nurse include in the client's plan of care? Select all that apply. 1. Avoiding processed foods 2. Adding oat products to the diet 3. Obtaining a dietary prescription 4. Adding wheat products to the diet 5. Administering a fat-soluble vitamin supplement
1, 2, 3, 5 A preschool-age client who is diagnosed with celiac disease should avoid processed foods (hidden sources of gluten), add oat products to the diet (often tolerated), obtain a dietary prescription (insurance payments for the purchase of specialized food), and receive fat-soluble vitamin supplements. Wheat products contain gluten; therefore, these should be avoided.
A child is admitted to the pediatric intensive care unit with acute bacterial meningitis. What is the nurse's priority intervention? 1. Offering clear fluids whenever the child is awake 2. Checking the child's level of consciousness hourly 3. Assessing the child's blood pressure every four hours 4. Administering the prescribed oral antibiotic medication
2. Checking the level of consciousness is part of a total neurological check. It can reveal increasing intracranial pressure, which may occur as a result of cerebral inflammation. The child is too ill to ingest anything by mouth; also, vomiting is likely. Hydration is maintained intravenously. Taking the blood pressure and other vital signs every four hours is insufficient monitoring; many changes can occur in this time span. Intravenous antibiotics have a rapid systemic effect and are preferable to those administered by way of the oral route.
A nurse is caring for a child with meningococcal meningitis. What clinical finding does the nurse expect to encounter during a physical assessment? 1. Severe glossitis 2. Low-grade fever 3. Purpuric skin rash 4. Tremors of the extremities
3. Meningococcal meningitis is identified by its epidemic nature and purpuric skin rash. Glossitis and tremors are not characteristic of meningococcal meningitis, and the fever of meningitis is usually high.
A child is admitted to the hospital with a tentative diagnosis of meningitis, and a lumbar puncture is performed to confirm the diagnosis. What finding from the spinal fluid report should lead the nurse to conclude that bacterial meningitis is present? 1. Increased protein 2. Increased glucose 3. Decreased specific gravity 4. Decreased white blood cell count
1. A child is admitted to the hospital with a tentative diagnosis of meningitis, and a lumbar puncture is performed to confirm the diagnosis. What finding from the spinal fluid report should lead the nurse to conclude that bacterial meningitis is present?
Because of a measles epidemic, a 6-month-old infant receives measles immunoglobulin. The nurse should help the parents understand that to ensure continuous protection against measles, the infant should be revaccinated around what age? 1. 8 months 2. 10 months 3. 12 months 4. 18 months
3. The optimal age for measles vaccination is between 12 and 15 months; if prophylaxis is given earlier because of exposure to a person with measles, it is not counted as one of the two required doses. Eight months and 10 months are too early; the infant will still have antibodies from the previous vaccination. Eighteen months is not the optimal time; the measles immunization should be given between 12 and 15 months.
A nurse is caring for a 3-month-old infant with congenital hypothyroidism. What should the parents be taught about the probable long-term effect of the condition if treatment is not begun immediately? 1. Myxedema 2. Thyrotoxicosis 3. Spastic paralysis 4. Cognitive impairment
4. Congenital hypothyroidism is the result of insufficient secretion by the thyroid gland because of an embryonic defect. A decreased level of thyroid hormone affects the fetus before birth during cerebral development, so it is likely that there will be some cognitive impairments at birth. Treatment before 3 months of age will prevent further damage. Congenital hypothyroidism does not become myxedema. Thyrotoxicosis is another term for hyperthyroidism. Although it is not expected, it may occur with an overdose of exogenous thyroid hormone, but it is too soon to discuss this possibility with the parents. Spastic paralysis occurs only if the infant has cerebral palsy.
A nurse is caring for an infant with meningitis. When the nurse extends the baby's leg, the hamstring muscles go into spasm and the infant begins to cry. What sign or reflex is the infant exhibiting? 1. Kernig sign 2. Babinski reflex 3. Chvostek sign 4. Cremasteric reflex
1. The Kernig sign is indicative of meningitis; it is demonstrated by a spasm of the hamstring muscles when the legs are extended. The Babinski reflex is dorsiflexion and fanning of the toes when the sole is stroked; adults with neuromuscular impairment and healthy infants exhibit this sign. The Chvostek sign is elicited by tapping on the facial nerve in the region of the parotid gland; spasm indicates tetany. In a male, the cremasteric reflex is elicited by stroking the inner thigh; this should cause the testes to retract into the scrotal sac.
When explaining the occurrence of febrile seizures to a parents' class, what information should the nurse include? 1. They may occur in minor illnesses. 2. The cause is usually readily identified. 3. They usually do not occur during the toddler years. 4. The frequency of occurrence is greater in females than males.
1. Febrile seizures are usually not associated with major neurologic problems. Between 95% and 98% of these children do not experience epilepsy or other neurologic problems. The cause of febrile seizures is still uncertain. Most febrile seizures occur after 6 months of age and before age 3 years, with the average age of onset between 18 and 22 months. Boys are affected about twice as frequently as girls.
A child with meningitis suddenly assumes an opisthotonic position. In what position should the nurse position the child? 1. Side-lying 2. Knee-chest 3. High-Fowler 4. Trendelenburg
1. Maximal safety and comfort are ensured with the side-lying position because the child's neck and back are hyperextended. The knee-chest position is impossible because the child is in a rigid opisthotonic position, with the neck and back hyperextended. The high-Fowler is impossible because the child is in a rigid position with the neck and back hyperextended. The Trendelenburg position increases intracranial pressure and is contraindicated in meningitis.
On a visit to the well-baby clinic the parents are upset because their 9-month-old infant has severe diaper rash; one parent wants to know how to treat it and prevent it from recurring. What cause of diaper dermatitis should the nurse include when answering the parent's question? 1. Use of disposable diapers 2. Prolonged contact with an irritant 3. Decreased pH of the infant's urine 4. Too-early introduction of solid foods
2. Diaper dermatitis is caused by prolonged repetitive contact with an irritant (e.g., urine, feces, soaps, detergents, ointments, friction). Both cloth and disposable diapers can cause diaper dermatitis if they are not changed frequently. An increased pH (i.e., alkaline) of the urine can contribute to diaper dermatitis. A change in diet may contribute, but there is no evidence that this is directly related.
A nurse is caring for a 2-year-old child with meningitis. For which clinical manifestations of increasing intracranial pressure should the nurse assess the child? Select all that apply. 1. Seizures 2. Vomiting 3. Bulging fontanels 4. Subnormal temperature 5. Decreased respiratory rate
1, 2, 5 Irritation of cerebral tissue can cause seizures. Pressure on vital centers can cause vomiting. Pressure on the respiratory center results in a decreased respiratory rate. A 2-year-old child's fontanels are closed, so bulging fontanels are not a sign of increased intracranial pressure in this case. The inflammatory process of meningitis causes an increase in temperature.
The nurse is inspecting the abdomen of an 18-month-old child. Which methods should the nurse adopt to inspect for inguinal hernia? Select all that apply. 1. Have the child blow up a balloon 2. Palpate the umbilicus for abdominal contents 3. Get the child to laugh so as to raise the intraabdominal pressure 4. Place the index finger of the right hand on the child's right femoral pulse 5. Slide the little finger into the external inguinal ring while having the child cough
1, 3 Typically, to locate an inguinal hernia, the nurse positions his or her finger at the proper site and asks the child to cough. However, if the child is too young to cough, such as at 18 months of age, the nurse can have the child blow up a balloon or laugh to raise the intraabdominal pressure sufficiently to demonstrate the presence of an inguinal hernia. In case of umbilical hernias, the nurse palpates the sac for abdominal contents and estimates the approximate size of the opening. In case of a femoral hernia, is felt or seen as a small mass on the anterior surface of the thigh just below the inguinal ligament in the femoral canal, the nurse should feel for a hernia by placing the index finger of the right hand on the child's right femoral pulse and the middle finger flat against the skin toward the midline. For a child who is old enough to cough when instructed, the nurse can slide the little finger into the external inguinal ring at the base of the scrotum and ask the child to cough. If a hernia is present, it will hit the tip of the finger.
A nurse is discussing an infant's diet with a mother who is breastfeeding. Why should the nurse recommend that the infant be offered solid foods by 5 or 6 months of age? Select all that apply. 1. Solid foods help control weight. 2. Fetal iron reserves are depleted. 3. Food can be taken from a spoon. 4. Bone marrow activity has diminished. 5. Breast milk lacks nutrients after 5 months.
2, 3 Fetal iron reserves are depleted by the fifth to sixth month. Although breast milk or formula is the major form of nutrition during the second half of the first year, exogenous iron should be introduced in the form of foods, such as iron-fortified cereal. Exogenous iron prevents iron-deficiency anemia. Formula-fed infants can receive iron in iron-fortified formula and may be offered foods later in the first year. Because the extrusion reflex has disappeared by this age, breastfed infants should be offered foods that contain iron. Although overingestion of milk can cause weight gain, so can overingestion of solid food. It is not the bone marrow production of cells but the decreased production of hemoglobin that can cause iron-deficiency anemia. Breast milk still provides adequate nutrients. The American Academy of Pediatrics (Canada: Public Health Agency of Canada) recommends continuation of breastfeeding until at least 12 months of age.
A nurse is assessing and obtaining the health history of a 6-year-old child with celiac disease. Which characteristic signs of this disorder does the nurse expect the child to exhibit? Select all that apply. 1. Hunger 2. Diarrhea 3. Muscle wasting 4. Edema 5. Abdominal distention
2, 3,4,5 Children with celiac disease have general malaise, as evidenced by decreased appetite and irritability. Diarrhea, especially steatorrhea, is observed because atrophy of the intestinal villi results in loose stools, inadequate absorption of nutrients, and malnutrition. Because of the severe diarrhea there is muscle wasting resulting from malnutrition, specifically protein deficiency. Edema, especially in the ankles and feet, is seen and is related to protein deficiency and third space fluid shifting. Peripheral edema is a sign of cardiac or kidney disease, not malnutrition.
An infant with hypertrophic pyloric stenosis is admitted to the pediatric unit. What does the nurse expect to find when palpating the infant's abdomen? 1. A distended colon 2. Marked tenderness around the umbilicus 3. An olive-sized mass in the right upper quadrant 4. Rhythmic peristaltic waves in the lower abdomen
3. The olive-like mass is caused by the thickened muscle (hypertrophy) of the pyloric sphincter. The obstruction is above the intestinal area; the colon is not involved. There is no significant tenderness in the abdomen. There is little or no peristalsis in the intestines.
After a 5-year-old child's tonsillectomy, the nurse notes that the child swallows frequently. What should the nurse conclude about the child's behavior? 1. This is a sign of respiratory distress. 2. The child is experiencing throat pain. 3. The child is bleeding from the surgical site. 4. This is a reaction from the general anesthesia.
3. A trickle of blood from the surgical site will cause the child to swallow frequently; usually this is the first sign of hemorrhage. If the child were experiencing respiratory distress the clinical manifestations would include dyspnea, tachycardia, and changes in behavior or skin color. The child with a sore throat tries not to swallow. Frequent swallowing is not a usual response on awakening from general anesthesia.
The nurse is reviewing the problems that may occur after frequent episodes of otitis media in infants. What complications may be precipitated by this infection? Select all that apply. 1. Mastoiditis 2. Heart failure 3. Hearing loss 4. Gastroenteritis 5. Bacterial meningitis
1, 3, 5 Mastoiditis is an inflammation of the mastoid gland; it may occur as a complication of otitis media because of the mastoid gland's proximity to the ear. Hearing loss is a common complication of otitis media; the child should be assessed frequently for this problem. The closeness of the infant's structures results in infections of surrounding organs; meningitis is a complication of otitis media. Heart failure and gastroenteritis are not complications of otitis media.
The mother of a 5-year-old girl child reports to a nurse that her daughter has a genital discharge and recurrent urinary tract infections. What should the nurse suspect from the mother's statement? 1. The child may be a victim of sexual abuse. 2. The child may be a victim of physical abuse. 3. The child may be a victim of physical neglect. 4. The child may be a victim of emotional neglect.
1. Genital discharge and recurrent urinary tract infections are signs of sexual abuse. Bruises, burns, fractures, or dislocation may indicate physical abuse. Malnutrition and poor hygiene may indicate physical neglect. Enuresis and sleep disorders may indicate emotional neglect.
A parent expresses concern that the adolescent child is not ingesting enough calcium because of an allergy to milk. What alternative foods or liquids should the nurse suggest? Select all that apply. 1. Cottage cheese 2. Green leafy vegetables 3. Black or baked beans 4. Yogurt 5. Oranges 6. Salmon and sardines
2, 3, 5, 6 Green leafy vegetables, black and baked beans, oranges, and salmon and sardines are all good sources of calcium even though they do not contain milk or milk products. Cottage cheese and yogurt both contain milk and therefore must be eliminated.
A father calls the clinic because he wants information about how to care for his child's severe diaper rash. The nurse asks the father what he has been doing so far and determines that the father needs further teaching when he says what? 1. "I expose the buttocks to the air." 2. "I direct a heat lamp at the buttocks." 3. "I don't use soap to clean the diaper area." 4. "I apply a medicated ointment to the diaper area."
2. Heat lamps are not used because of the potential for burns. Exposing the diaper area will promote drying and healing. Soap may irritate excoriated skin. Ointment protects the buttocks from the irritating contents of stool.
After many episodes of otitis media a 3-year-old child is to undergo myringotomy and have tubes implanted surgically. What should the nurse include in the discharge preparation for this family? 1. Keep the child at home for 1 week. 2. Insert earplugs during the child's bath. 3. Apply an ointment to the ear canal daily. 4. Use cotton swabs to clean the inner ears.
2. Water in the ears after myringotomy may be a source of infection. There is no reason that the child cannot be around other children, because there is no infectious process. Applying an ointment to the ear canal daily will clog the ear canal and serves no purpose. Cotton swabs may be used occasionally in the outer ear, but should not be inserted into the ear.
What findings should a nurse expect when examining the laboratory report of a preschooler with rheumatic fever? 1. Negative C-reactive protein 2. Increased reticulocyte count 3. Positive antistreptolysin titer 4. Decreased sedimentation rate
3. A positive antistreptolysin titer is present with rheumatic fever because of the previous infection with streptococci. An increased reticulocyte count is usually related to a decrease in mature red blood cells caused by hemorrhage or blood dyscrasias; it is unrelated to an infectious or inflammatory process. A positive, not a negative, C-reactive protein will be present; this is indicative of an inflammatory process. The erythrocyte sedimentation rate will be increased, not decreased, indicating the presence of an inflammatory process.
Surgery to correct hypertrophic pyloric stenosis is performed on a 3-week-old infant who has been fed formula. Which postoperative feeding regimen is most appropriate? 1. Thickened formula 24 hours after surgery 2. Withholding of feedings for the first 24 hours 3. Regular formula feeding within 24 hours of the surgery 4. Additional glucose feedings as desired after the first 24 hours
3. An initial feeding of glucose and electrolytes in water or breast milk is given 4 to 6 hours after surgery. Once clear fluids are being retained, formula feedings are begun within 24 hours. Thickened formula 24 hours after surgery is not necessary. Regular formula should be started within 24 hours after surgery in an attempt to gradually return the infant to a full feeding schedule. Withholding feedings for the first 24 hours and providing additional glucose feedings as desired after the first 24 hours are not necessary.`
A nurse is planning the discharge of a 9-year-old child who has undergone tonsillectomy. The nurse informs the parents that their child may have a mouth odor, slight ear pain, and a low-grade fever for a few days. In addition to the prescribed analgesic, what should the nurse recommend to ease their child's pain? 1. Warm saline gargles 2. Heating pad to the neck 3. Light-colored ice pops 4. Peppermint candy for sucking
3. Ice pops or ice chips provide a cool liquid that may be soothing to the oropharynx. Red, orange, or brown liquids are contraindicated because they mask bleeding. Gargling is contraindicated because it may traumatize the surgical site, resulting in bleeding; also, warm fluids promote capillary dilation, which may cause bleeding. A heating pad produces vasodilation, which may increase pain and promote bleeding. Hard candies can traumatize the surgical site and cause bleeding.
An infant is being admitted to a pediatric unit with bacterial meningitis. What is the priority nursing action? 1. Assessing the infant's neurologic status 2. Beginning intravenous fluids and antibiotics 3. Implementing respiratory isolation precautions 4. Teaching the parents the importance of maintaining a quiet environment
3. The infant's illness is contagious, and the nurse, as well as other clients, must first be protected with the implementation of respiratory isolation precautions. Assessment of neurologic status would be performed after implementing isolation. Parental teaching and implementation of prescribed fluids and antibiotics may be done after assessment. Also, antibiotics are usually not administered until after all cultures have been obtained.
The nurse is counseling the parents of a 12-year-old child with Duchenne muscular dystrophy about problems that may develop during adolescence. What body system does the nurse expect will be affected? 1. Neurological 2. Integumentary 3. Gastrointestinal 4. Cardiopulmonary
4. Muscle degeneration is advanced in the adolescent with Duchenne muscular dystrophy. The disease process involves the diaphragm, auxiliary muscles of respiration, and the heart, resulting in life-threatening respiratory infections and heart failure. Central nervous system function is not affected by Duchenne muscular dystrophy; nor is the integumentary system. Nutritional problems related to the gastrointestinal system are less significant than cardiopulmonary problems.
The parents of a 4-month-old infant with a diagnosis of acute otitis media and fever ask the nurse about the use of antibiotics to treat this condition. What is the best response by the nurse? 1. "Anti-inflammatory medications are recommended for this condition." 2. "Typically antiviral medications are given to treat acute otitis media." 3. "Current practice is to wait 72 hours to see whether the condition resolves." 4. "Antibiotics are recommended for infants younger than 6 months with acute otitis media."
4. All cases of acute otitis media (AOM) in infants younger than 6 months should be treated with antibiotics because of their immature immune systems and the potential for infection with bacteria. Current literature indicates that waiting up to 72 hours for spontaneous resolution is safe and appropriate management of AOM in healthy infants older than 6 months and children. However, the watchful waiting approach is not recommended for children younger than 2 years of age who have persistent acute symptoms of fever and severe ear pain. Antiviral or antiinflammatory medications would not be recommended in an acute case of otitis media.
What is most important for a nurse to teach the parents of a child with Duchenne muscular dystrophy to do for their school-aged child? 1. Maintain a high-calorie diet 2. Institute seizure precautions 3. Restrict the use of larger muscles 4. Perform range-of-motion exercises
4. Range-of-motion exercises are essential to help achieve the primary objectives of maintaining optimal muscle function for as long as possible and preventing the development of contractures. A high-calorie diet may result in obesity, which could cause the child to need a wheelchair sooner rather than as late as possible. Seizures are not associated with Duchenne muscular dystrophy. Restricting the use of large muscles could result in disuse atrophy and contractures.
A child undergoes tonsillectomy and adenoidectomy for numerous recurrent respiratory tract infections. After the surgery, what should the nurse teach the parents to do? 1. Offer crushed ice chips. 2. Encourage the intake of ice cream. 3. Keep the child in the supine position. 4. Gargle with a diluted mouthwash solution.
1. Ice chips are soothing and promote vasoconstriction. Cool water, flavored ice pop, or diluted fruit juice may be given but fluids with a red or brown color should be avoided to distinguish fresh or old blood in emesis from the ingested liquid. Milk and milk products coat the mouth, causing the child to clear the throat, which may precipitate bleeding. The supine position promotes edema and does not allow oral secretions to drain from the mouth. The head of the bed should be elevated and the child should be positioned on the side. Mouthwash solution is too caustic; a warm, saltwater solution is preferred.
Which between-meal snack should a nurse tell the parents of a preschooler with a urinary tract infection to offer their child? 1. Skim milk 2. Fresh fruit 3. Hard candy 4. Cream soup
1. A high-protein, high-carbohydrate snack provides additional nutrients to combat an infection and a fever. Also, fluid helps flush the urinary tract. Fruit does not provide the protein needed for the healing process. Candy provides empty calories. A cream soup is too heavy for a between-meal snack and does not provide the needed protein.
An adolescent with Duchenne muscular dystrophy has received care at the pediatric clinic since early childhood. Of which body system should the nurse perform a focused assessment to identify life-threatening complications as the child ages? 1. neurologic 2. gastrointestinal 3. musculoskeletal 4. cardiopulmonary
1. As muscular degeneration advances in the adolescent, the diaphragm, auxiliary muscles of respiration, and heart are affected, resulting in life-threatening respiratory infections and heart failure. Central nervous system functioning is not affected by Duchenne muscular dystrophy. Nutritional problems are less of a priority than cardiopulmonary problems. Although the musculoskeletal system will exhibit marked degeneration, it is second in priority to the cardiopulmonary changes.
A nurse bases the plan of care for a 15-month-old toddler with celiac disease on the pathophysiology of the disorder, which is characterized by what? 1. Inability to metabolize gluten 2. Absence of the enzyme phenylalanine 3. Excessive amount of salt in the sweat glands 4. Increase in the viscosity of mucous secretions
1. Children with celiac disease are unable to digest the gliadin component of gluten, resulting in fatty, foul-smelling diarrheal stools. Phenylketonuria is caused by the absence of phenylalanine; it is not related to celiac disease. Excessive salt in the sweat glands is a manifestation of cystic fibrosis. Increased viscosity of secretions from mucous glands is also related to cystic fibrosis.
When a 12-year-old boy who sustained several tick bites on a camping trip becomes ill, he is told that he may have Lyme disease. He asks the nurse, "What is Lyme disease?" What is the best response by the nurse? 1. "I can see that you're concerned. Tell me what you want to know." 2. "The infection is caused by a spirochete. It can be cured with penicillin." 3. "The tick bites gave you an infection. There is medication that will treat it." 4. "You sound upset. Don't worry—we have medicine that will make you better."
3 Telling the child that a tick bite caused the disease and that it is curable is a straightforward, truthful answer at a level that a 12-year-old child will comprehend. Just identifying the child's feelings disregards the fact that the child has asked a question that requires an answer. The child may not understand scientific terminology. Telling the child not to worry is demeaning and avoids answering the question.
A 3-week-old infant who has been vomiting for 3 days is admitted to the pediatric unit with a diagnosis of hypertrophic pyloric stenosis. What essential information should the nurse identify during the admission procedure? 1. Character and amount of vomitus 2. Size and shape of the abdominal mass 3. Respiratory status, amount and appearance of last voiding 4. Time of the last feeding, type of formula, and amount taken
3. Increased depth of respirations and scanty urine, in conjunction with prolonged vomiting, reflect dehydration and metabolic alkalosis. Metabolic alkalosis results from hydrochloric acid and potassium depletion. Although assessments of the vomitus are important, they are not the priority. Although assessment of the abdominal mass is important and the result should be documented, it is not the priority. Although assessments related to feedings are important and they should be documented, they are not the priority.
A mother reports feeding her infant immediately before arriving in the emergency department. After completing the assessment, the nurse reports which finding immediately to the primary healthcare provider because it likely indicates pyloric stenosis? 1. Loud bowel sounds 2. Sudden expulsion of diarrheal stool 3. Peristaltic waves that traverse the epigastrium 4. Regurgitation of a portion of the feeding when burped
3. Left-to-right peristalsis is noted as the stomach tries to force the feeding into the duodenum. Bowel activity is minimal, because little of the feeding passes through the pyloric sphincter; thus there are no loud bowel sounds. Sudden diarrhea is rare, because little of the feeding passes through the pyloric sphincter into the intestinal tract. Projectile vomiting, not regurgitation, is a classic manifestation of pyloric stenosis.
What does a nurse recognize as the most serious complication of meningitis in young children? 1. Epilepsy 2. Blindness 3. Peripheral circulatory collapse 4. Communicating hydrocephalus
3. Peripheral circulatory collapse (Waterhouse-Friderichsen syndrome) is a serious complication of meningococcal meningitis caused by bilateral adrenal hemorrhage. The resultant acute adrenocortical insufficiency causes profound shock, petechiae, ecchymotic lesions, vomiting, prostration, and hypotension. Although epilepsy or blindness may occur, neither condition is as serious a complication as peripheral circulatory collapse. Similarly, although hydrocephalus may occur, it is rare and not as serious as peripheral circulatory collapse.
A child with celiac disease is prescribed a gluten-restricted diet. Which lunch selection for the child indicates that the parent understands the dietary instruction provided by the nurse? 1. Frankfurter on a roll, cookies, fat-free milk 2. Macaroni and cheese, banana, pineapple juice 3. Beef taco, corn, canned peaches, chocolate milk 4. Peanut butter sandwich, oatmeal cookies, apple juice
3. Products that contain wheat, rye, barley, and oats are not tolerated by children with celiac disease. Beef tacos, corn, peaches, and milk are acceptable in a gluten-restricted diet; tortillas may be made with corn flour. Most frankfurters have fillers that contain gluten; the roll and most cookies contain wheat flour. Macaroni contains wheat flour. The bread used for the sandwich contains wheat flour, and oatmeal cookies contain oat and wheat flour.
A child is found to have celiac disease. When providing education to the family, what food will the nurse advise the family to eliminate from the child's diet? 1. Meat, poultry, and eggs 2. Processed sugar products 3. Milk and other dairy products 4. Wheat-based breads and cereals
4. Celiac disease, also known as gluten enteropathy, results from an inability to adequately digest grains such as wheat, barley, rye, and oats. Meat, poultry, and eggs; processed sugar products; and milk and other dairy products do not cause problems for clients with celiac disease.
A 2½-year-old toddler is admitted with a fever of 103° F (39.4° C), stiffness of the neck, and general malaise. The diagnosis is acute bacterial meningitis. What is the priority nursing intervention for this child? 1. Increasing fluids 2. Administering oxygen 3. Giving a tepid sponge bath 4. Instituting droplet precautions
4. Droplet precautions prevent the spread of infection to others; isolation is a priority and should be implemented immediately. There is no indication that the child is dehydrated; fluid maintenance is a continuing goal. There is no indication that the child needs oxygen. Oxygen is not given routinely; it is given if the child has a decreased oxygen saturation level. A sponge bath is not given because these children are sensitive to stimuli, and movement causes increased discomfort.
After treatment for Lyme disease, a child expresses fear of going camping again because of the ticks. What is the best response by the nurse? 1. "Tell me more about your fears about camping." 2. "Just think of all the fun you'll be missing if you don't go to camp." 3. "It's hard to believe you're afraid to go camping just because of a tick." 4. "I understand you are afraid. Frequently checking for ticks can help prevent re-infection."
4. Explaining the usefulness of frequent checks for ticks identifies the concern and presents an appropriate protective intervention. Detection and prompt removal of ticks decreases the chances of the spread of Lyme disease to human beings. Asking the child to tell the nurse more about fears related to camping is an inappropriate response because it focuses on the wrong fear. Telling the child to think of all the fun that would be missed is incorrect because the response focuses on camping, not on the fear of ticks. Also, it belittles the child's fears. Saying that it's hard to believe that the child is afraid to go camping also belittles the child's feelings.
A 17-year-old female who reports irregularity of menses and weight loss is diagnosed with hypothyroidism. Which type of menstrual disorder does this client have? 1. Primary amenorrhea 2. Primary dysmenorrhea 3. Secondary dysmenorrhea 4. Hypogonadotropic amenorrhea
4. Hypogonadotropic amenorrhea may be due to an interruption in the hypothalamic pituitary axis; this disruption results in endocrine disorders such as hypothyroidism and absence of menstruation. Primary amenorrhea is the absence of menses by 16.5 years regardless of normal growth and development. Dysmenorrhea, primary or secondary, is pain before or during menstruation.
A nurse is caring for an infant with bacterial meningitis. The parents ask how their baby could have contracted the illness. What does the nurse consider as the most likely route of transmission to the central nervous system? 1. Genitourinary tract 2. Gastrointestinal tract 3. Skin or mucous membranes 4. Cranial apertures or sinuses
4. Infections of cranial structures can cause meningitis because bacteria travel by way of direct anatomic route to the meninges and cerebrospinal fluid (CSF). The other parts of the body do not come into contact with CSF.
The nurse provides nutritional counseling to the parents of a 6-month-old formula-fed infant who will begin eating solid foods. Which statement by a parent indicates understanding of the nurse's advice? 1. "I'll keep giving him formula instead of regular cow's milk." 2. "I'll buy plenty of pureed spinach so she gets enough iron." 3. "Using a natural sweetener like honey is better than using table sugar." 4. "Baby food is sterilized, so it's better to feed directly from the jar than from a bowl."
1. Infants should receive formula or breast milk for a full year; cow's milk should not be introduced until 1 year of age. Commercially prepared spinach, collard greens, and certain other foods contain nitrates and so should be used very sparingly; if the infant is iron deficient, other sources should be used. Honey should not be given to infants because there is risk of botulism poisoning. Infants should not be fed from the jar because enzymes from saliva on the spoon will affect the quality of the food remaining in the jar.
A nurse is obtaining a health history from the mother of a 15-month-old toddler with celiac disease. The nurse expects the mother to indicate what about her toddler? 1. Has bulky, foul, frothy stools 2. Drinks large amounts of fluid 3. Is irritable throughout the day 4. Voids strong, concentrated urine
1. Steatorrhea (fatty, foul-smelling, frothy, bulky stools) occurs with celiac disease because of an intolerance to gluten; toxic substances, which can damage the intestinal mucosal cells, accumulate and cause diarrhea. Drinking large amounts of fluid is a response to dehydration. With celiac disease some thirst may occur, but it is not continuous. Although infants with celiac disease are irritable, this sign is too vague for accurate evaluation. Irritability is symptomatic of a variety of problems, ranging from cutting of teeth to leukemia. Concentrated urine is associated with a urinary tract infection or dehydration; this sign is too vague to permit accurate evaluation.
A nurse in the pediatric clinic is counseling the parents of a school-aged child with celiac disease. The child has extensive mucosal damage, and as a result the digestion of disaccharides is impaired. What substance should the nurse teach the parents to temporarily eliminate from their child's diet? 1. Salt 2. Milk 3. Rice 4. Honey
2. Milk contains lactose, a disaccharide, which is difficult for the damaged mucosa to absorb. Salt need not be restricted, because it is gluten-free and is not a disaccharide. Rice is a complex carbohydrate that does not contain gluten or a disaccharide. Honey, a monosaccharide, can be tolerated by the damaged mucosa.
The nurse is reviewing discharge instructions for a mother whose lactose intolerant school-aged child was recently found to have celiac disease. Which statements by the mother demonstrate understanding of the child's nutritional needs? Select all that apply. 1. "Rolled-up lunch meat with cheese is a good alternative to sandwiches." 2. "I'll try to provide meals that are lower in fats and higher in carbohydrates." 3. "I'll start giving her milk with meals so she gets enough calcium in her diet." 4. "She loves raw carrots for snacking, so I'll have to avoid those when the disease is worse." 5. "I'll be sure to look at the labels more closely from now on—we need to avoid hydrolyzed vegetable protein."
2, 4, 5 Celiac disease is characterized by bowel irritation on exposure to protein gluten. Dietary management generally consists of a diet high in protein and carbohydrates and low in fats. When the bowel is inflamed, high-fiber foods should be avoided; this includes carrots. Gluten is added to many foods as hydrolyzed vegetable protein; therefore the mother needs to read the ingredient list to identify the presence of this substance. Lunch meat should be avoided because it contains gluten. Since the child is also lactose intolerant, milk also needs to be avoided.
A nurse is conducting a physical assessment of an infant with pyloric stenosis. What clinical findings does the nurse expect? Select all that apply.A nurse is conducting a physical assessment of an infant with pyloric stenosis. What clinical findings does the nurse expect? Select all that apply. 1. Boardlike abdomen 2. Visible peristaltic waves 3. Decreased bowel sounds 4. Cramping movements in the lower abdomen 5. Olive-shaped mass in the right upper quadrant
2, 5 Gastric peristaltic waves are visible because the stomach is attempting to propel its contents through the stenotic pyloric sphincter. The hypertrophied muscle becomes elongated and is palpable as an olive-shaped mass. Because of its anatomic location, it is felt in the upper right quadrant of the abdomen. The upper abdomen may be distended, not boardlike, because food is unable to leave the stomach and progress through the remainder of the gastrointestinal tract. Transmission of ingested food is interrupted, but digestive processes are intact; therefore bowel sounds are heard. Gastric peristaltic waves, not cramping movements in the lower abdomen, may be observed.
A nurse is teaching the parents of a malnourished 6-year-old child with celiac disease about foods and nutrients that will help correct a problem related to celiac disease. Which foods and nutrients should the nurse recommend for this child? 1. High-calorie foods rich in protein and fat to correct weight loss 2. Foods high in folic acid, iron, and vitamin B12 to correct anemia 3. Supplements of vitamins A, D, E, and K to correct coagulation deficiencies 4. Foods high in potassium and magnesium to correct bone growth deficiencies
2. Children with celiac disease are anemic. Foods high in folic acid, iron, and vitamin B12 promote hemopoiesis. Fat is not adequately absorbed by children with celiac disease; therefore, a low-fat diet is indicated. Of these supplements, only vitamin K is related to blood coagulation. Celiac disease does not cause coagulation deficiencies. Potassium and magnesium are necessary elements that are lost during celiac crisis but are not related to bone growth.
A 3-year-old boy is found to have X-linked Duchenne muscular dystrophy. Neither parent has muscular dystrophy. Which statement indicates that the parents understand how the disorder is transmitted? 1. "Our sons or daughters may have the disease." 2. "Our daughters may be carriers of the disease." 3. "We each contributed a gene that gave our son the disease." 4. "We know that that our other son probably won't get the disease."
2. Duchenne muscular dystrophy follows an X-linked recessive inheritance pattern; when the father is unaffected and the mother is a carrier, there is a 50% chance that a son will be affected and a 50% chance that a daughter will be a carrier. Sex-linked transmission rarely results in females with the condition; males are predominantly affected, and females tend to be carriers. This sex-linked condition is transmitted by the recessive gene carried only by the mother. When the father is unaffected and the mother is a carrier, each son has a 50% chance of being affected.
The nurse is admitting an 8-month-old infant with suspected bacterial meningitis to the hospital. List in order of priority the nursing actions that should be taken. 1. Institute respiratory isolation 2. Insert an intravenous access device 3. Assist with a lumbar puncture 4. Administer the prescribed antibiotics 5. Monitor for signs of increased intracranial pressure (ICP)
Bacterial meningitis is transmitted through respiratory droplets. The nurse should first ensure that all who come in contact with the child are appropriately gowned, gloved, and masked. A circulatory access device provides an avenue to administer prescribed fluids and medications; also, it provides a circulatory access in case of an emergency. The next priority is to obtain a sample of cerebrospinal fluid (CSF). This will help determine whether the cause is viral or bacterial, permitting prescription of the appropriate pharmacological therapy by the healthcare provider. An antibiotic is usually not administered until the lumbar puncture is completed and CSF specimen is sent for culture. Complications, such as increased intracranial pressure and seizures, should be monitored for after the infant is admitted, placed on isolation, and antibiotics are started.
