Unit 3
A child is seen in the emergency department. The nurse hears a high-pitched squeal every time the child inhales. The parent states that the child's fever is very high and, in addition, the child is gasping for breath and sitting in the tripod position. Which of the following actions would be appropriate for the nurse to perform at this time? 1. Provide the child with warm liquids to drink. 2. Inspect the throat with a flashlight and tongue blade. 3. Check the child's vital signs and lung fields. 4. Get immediate medical attention for the child.
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A child is being admitted to the hospital to be tested for cystic fibrosis (CF). Which tests should the nurse expect? a. Sweat chloride test, stool for fat, chest radiograph films b. Stool test for fat, gastric contents for hydrochloride, chest radiograph films c. Sweat chloride test, bronchoscopy, duodenal fluid analysis d. Sweat chloride test, stool for trypsin, biopsy of intestinal mucosa
ANS: A A sweat test result of greater than 60 mEq/L is diagnostic of CF, a high level of fecal fat is a gastrointestinal (GI) manifestation of CF, and a chest radiograph showing patchy atelectasis and obstructive emphysema indicates CF. Gastric contents contain hydrochloride normally; it is not diagnostic. Bronchoscopy and duodenal fluid are not diagnostic. Stool test for trypsin and intestinal biopsy are not helpful in diagnosing CF
Which is instituted for the therapeutic management of minimal change nephrotic syndrome? a. Corticosteroids b. Antihypertensive agents c. Long-term diuretics d. Increased fluids to promote diuresis
ANS: A Corticosteroids are the first line of therapy for minimal change nephrotic syndrome. Response is usually seen within 7 to 21 days. Antihypertensive agents and long-term diuretic therapy are usually not necessary. A diet that has fluid and salt restrictions may be indicated.
Which should the nurse recommend to prevent urinary tract infections in young girls? a. Wear cotton underpants. b. Limit bathing as much as possible. c. Increase fluids; decrease salt intake. d. Cleanse perineum with water after voiding.
ANS: A Cotton underpants are preferable to nylon underpants. No evidence exists that limiting bathing, increasing fluids/decreasing salt intake, or cleansing the perineum with water after voiding decrease urinary tract infections in young girls.
An infant's parents ask the nurse about preventing OM. Which should be recommended? a. Avoid tobacco smoke. b. Use nasal decongestant. c. Avoid children with OM. d. Bottle-feed or breastfeed in supine position.
ANS: A Eliminating tobacco smoke from the child's environment is essential for preventing OM and other common childhood illnesses. Nasal decongestants are not useful in preventing OM. Children with uncomplicated OM are not contagious unless they show other upper respiratory tract infection (URI) symptoms. Children should be fed in an upright position to prevent OM.
The nurse is administering an IV chemotherapeutic agent to a child with leukemia. The child suddenly begins to wheeze and have severe urticaria. Which is the most appropriate nursing action? a. Stop drug infusion immediately. b. Recheck rate of drug infusion. c. Observe child closely for next 10 minutes. d. Explain to child that this is an expected side effect.
ANS: A If an allergic reaction is suspected, the drug should be immediately discontinued. Any drug in the line should be withdrawn, and a normal saline infusion begun to keep the line open. Rechecking the rate of drug infusion, observing the child closely for next 10 minutes, and explaining to the child that this is an expected side effect can all be done after the drug infusion is stopped and the child is evaluated.
The nurse closely monitors the temperature of a child with minimal change nephrotic syndrome. The purpose of this assessment is to detect an early sign of which possible complication? a. Infection b. Hypertension c. Encephalopathy d. Edema
ANS: A Infection is a constant source of danger to edematous children and those receiving corticosteroid therapy. An increased temperature could be an indication of an infection. Temperature is not an indication of hypertension or edema. Encephalopathy is not a complication usually associated with minimal change nephrotic syndrome. The child will most likely have neurologic signs and symptoms.
The nurse is teaching nursing students about normal physiologic changes in the respiratory system of toddlers. Which best describes why toddlers have fewer respiratory tract infections as they grow older? a. The amount of lymphoid tissue decreases. b. Repeated exposure to organisms causes increased immunity. c. Viral organisms are less prevalent in the population. d. Secondary infections rarely occur after viral illnesses.
ANS: B Children have increased immunity after exposure to a virus. The amount of lymphoid tissue increases as children grow older. Viral organisms are not less prevalent, but older children have the ability to resist invading organisms. Secondary infections after viral illnesses include Mycoplasma pneumoniae and group A β-hemolytic streptococcal infections.
9) A child is diagnosed with a Wilms tumor. Which nursing action is most appropriate prior to surgery? 1. Careful bathing and handling 2. Monitoring of behavioral status 3. Maintenance of strict isolation 4. Administration of packed RBCs
Answer: 1 Explanation: 1. The tumor should never be palpated; careful bathing and handling are an important nursing consideration. Palpating the tumor can cause a piece of the tumor to dislodge. The child's behavior will not be affected with a Wilms tumor. The tumor does not cause excessive lowering of WBCs or RBCs, so strict isolation or administration of packed RBCs is not usually a nursing intervention.
Which characteristic best describes the gross motor skills of a 24-month-old child? a. Skips and can hop in place on one foot b. Rides tricycle and broad jumps c. Jumps with both feet and stands on one foot momentarily d. Walks up and down stairs and runs with a wide stance
ANS: D The 24-month-old child can go up and down stairs alone with two feet on each step and runs with a wide stance. Skipping and hopping on one foot are achieved by 4-year-old children. Jumping with both feet and standing on one foot momentarily are achieved by 30-month-old children. Tricycle riding and broad jumping are achieved at age 3.
Which may be given to high-risk children after exposure to chickenpox to prevent varicella? a. Acyclovir (Zovirax) b. Varicella globulin c. Diphenhydramine hydrochloride (Benadryl) d. VCZ immune globulin (VariZIG)
ANS: D VariZIG is given to high-risk children to prevent the development of chickenpox. Acyclovir decreases the severity, not the development, of chickenpox. Varicella globulin is not effective because it is not the immune globulin. Diphenhydramine may help pruritus but not the actual chickenpox.
3) A lumbar puncture is performed on an infant suspected of having meningitis. Which finding does the nurse expect in the cerebral spinal fluid if the infant has meningitis? 1. Elevated WBC count 2. Elevated RBC count 3. Normal glucose 4. Decreased WBC count
Answer: 1 Explanation: 1. The lumbar puncture is done to obtain cerebral spinal fluid (CSF). Elevated WBC count is seen with bacterial meningitis. The RBC count is not elevated, and the glucose is decreased in meningitis.
A young child has just arrived at the emergency department after ingestion of aspirin at home. The practitioner has ordered activated charcoal. The nurse administers charcoal in which way? a. Administer through a nasogastric tube because the child will not drink it because of the taste. b. Serve in a clear plastic cup so the child can see how much has been drunk. c. Give half of the solution, and then give the other half in 1 hour. d. Serve in an opaque container with a straw.
ANS: D Although the activated charcoal can be mixed with a flavorful beverage, it will be black and resemble mud. When it is served in an opaque container, the child does not have any preconceived ideas about its being distasteful. The nasogastric tube should be used only in children without a gag reflex. The ability to see the charcoal solution may affect the child's desire to drink it. The child should be encouraged to drink the solution all at once.
A child with nephrotic syndrome has been prescribed prednisone. The nurse should monitor the child for which of the following medication side effects? 1. Gastric distress 2. Bradycardia 3. Hypoglycemia 4.Weight loss
1
2-year-old child with nephrotic syndrome is admitted to the pediatric unit. The following orders have been written in the child's medical record. Which of the actions is highest priority for the nurse to perform? 1. Place child on alternating pressure mattress. 2. Administer intravenous albumin. 3. Weigh all wet diapers. 4. Administer oral antibiotics.
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A 7-year-old child has just had a lumbar puncture in the emergency department for complaints of elevated temperature and a stiff neck. Which of the following cerebral spinal fluid findings would indicate that this child has bacterial meningitis? 1. Markedly lower than normal pressure 2. Glucose 20 mg/dL 3. White blood cell count 3 cells/mm3 4. Clear fluid
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8. A 6-year-old child with antistreptolysin antibodies and negative cultures is admitted to the pediatric unit with a diagnosis of acute poststreptococcal glomerular nephritis. It would be most appropriate for the nurse to admit the child into which of the following rooms? 1. Isolation room on droplet isolation with no roommate 2. Isolation room on droplet and contact isolation with a child with bronchiolitis 3. Regular patient room with 8-year-old child in traction for a broken femur 4. Regular patient room with 6-year-old child with diabetes for insulin control
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An 11-month-old child is receiving chemotherapy for a diagnosis of acute lymphoblastic leukemia (ALL). Which of the following vaccinations is safe for the nurse to administer to the child? 1. Var (varicella) 2. MMR (measles, mumps, rubella) 3. LAIV (live attenuated influenza vaccine) 4. PCV (pneumococcal)
A:4
A child has been diagnosed with acute lymphoblastic leukemia (ALL). With which of the following signs/symptoms did the child likely present to the primary health-care provider? Select all that apply. 1. Bruising 2. Lethargy 3. Jaundice 4. Leukopenia 5. Erythema
A:1,2
A nurse is caring for a 3½-year-old child who consumed a bottle of aspirin 10 minutes earlier. Which of the following findings would the nurse expect to see? 1. Hyperglycemia 2. Hyperpnea 3. Hyperthermia 4. Hypernatremia
Answer 2
A child has been diagnosed with acute glomerular nephritis. Which of the following changes would the nurse expect to see in the child's laboratory reports? 1. Urine white blood cell count: elevated 2. Urine specific gravity: decreased 3. Urine creatinine clearance: decreased 4. Urine red blood cell count: elevated
Answer:4
18) The child is diagnosed with an upper urinary tract infection (UTI). The family asks the nurse what is the difference in the symptoms of an upper versus a lower urinary tract infection? Match each symptom (1-8 below) with the appropriate infection. A. Lower UTI B. Upper UTI 1. High fever 2. Diarrhea 3. Chills 4. Hematuria 5. Costovertebral angle tenderness 6. Cloudy urine 7. Suprapubic or flank pain 8. Moderate/severe dehydration
1/B, 2/A, 3/B, 4/A, 5/B, 6/A, 7/A, 8/B 1. Upper UTI 2. Lower UTI 3. Upper UTI 4. Lower UTI 5. Upper UTI 6. Lower UTI 7. Lower UTI 8. Upper UTI Explanation: Lower UTI: Fever, diarrhea, vomiting, irritability, lethargy, foul smelling and cloudy urine, dehydration, abdominal pain, enuresis, suprapubic or flank pain, and urgency. Upper UTI: high fever, chills abdominal pain, nausea, vomiting, flak pain, costo-vertebral angle tenderness, moderate to severe dehydration.
The parents of a Hispanic American child who has been diagnosed with Wilms' tumor ask the nurse about the origin of the tumor. Which of the following information should the nurse provide the parents? 1. "Nephroblastoma is a cancer that originated in another part of your child's body." 2. "The tumor often starts growing in the kidney while the baby is still in the uterus." 3. "Wilms' tumor is especially prevalent in the Hispanic population." 4. "The cancer is often seen in children who live in areas near nuclear reactors."
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A child has had tympanostomy tubes inserted. Before discharging the child from the hospital, which of the following should be included in the nurse's discharge teaching? 1. Elevate the head of the child's bed 30 degrees for the next week. 2. Bright-red bleeding may drain from the ears for remainder of the day. 3. Administer narcotic analgesic every 4 hours for the next two days. 4. Not to allow the child's head to be submerged in bath or pool water.
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A neonate has been diagnosed with cystic fibrosis. The nurse should educate the parents regarding which of the following dietary needs of their baby? 1. The baby must receive a dose of folic acid three times each day. 2. The baby must never consume any milk or milk products. 3. The baby must receive pancreatic enzymes before bedtime every night. 4. The baby must consume a predigested formula that is high in calories.
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The mother of a child with acute lymphoblastic leukemia (ALL) states that their family is employing complementary therapies to improve the child's chances of survival. The child is also receiving chemotherapy. The nurse should discuss with the mother that which of the following therapies may actually be in conflict with the child's medical care? 1. Therapeutic touch 2. Healing meals 3. Pet therapy 4. Folic acid supplements
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The nurse encourages the mother of a toddler with acute laryngotracheobronchitis (LTB) to stay at the bedside as much as possible. The nurse's rationale for this action is described primarily in which statement? a. Mothers of hospitalized toddlers often experience guilt. b. The mother's presence will reduce anxiety and ease child's respiratory efforts. c. Separation from mother is a major developmental threat at this age. d. The mother can provide constant observations of the child's respiratory efforts.
ANS: B The family's presence will decrease the child's distress. It is true that mothers of hospitalized toddlers often experience guilt but this is not the best answer. The main reason to keep parents at the child's bedside is to ease anxiety and therefore respiratory effort. The child should have constant monitoring by cardiorespiratory monitor and noninvasive oxygen saturation monitoring, but the parent should not play this role in the hospital.
A boy with leukemia screams whenever he needs to be turned or moved. Which is the most probable cause of this pain? a. Edema b. Bone involvement c. Petechial hemorrhages d. Changes within the muscles
ANS: B The invasion of the bone marrow with leukemic cells gradually causes a weakening of the bone and a tendency toward fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain. Edema, petechial hemorrhages, and changes within the muscles would not cause severe pain.
Which is an objective of care for a 10-year-old child with minimal change nephrotic syndrome? a. Reduce blood pressure. b. Reduce excretion of urinary protein. c. Increase excretion of urinary protein. d. Increase ability of tissues to retain fluid.
ANS: B The objectives of therapy for the child with minimal change nephrotic syndrome include reduction of the excretion of urinary protein, reduction of fluid retention, prevention of infection, and minimization of complications associated with therapy. Blood pressure is usually not elevated in minimal change nephrotic syndrome. Excretion of urinary protein and fluid retention are part of the disease process and must be reversed.
Which statement is correct about toilet training? a. Bladder training is usually accomplished before bowel training. b. Wanting to please the parent helps motivate the child to use the toilet. c. Watching older siblings use the toilet confuses the child. d. Children must be forced to sit on the toilet when first learning.
ANS: B Voluntary control of the anal and urethral sphincters is achieved sometime after the child is walking. The child must be able to recognize the urge to let go and to hold on. The child must want to please parent by holding on rather than pleasing self by letting go. Bowel training precedes bladder training. Watching older siblings provides role modeling and facilitates imitation for the toddler. The child should be introduced to the potty chair or toilet in a nonthreatening manner.
A nurse is teaching parents about caring for their child with chickenpox. The nurse should let the parents know that the child is considered to be no longer contagious when which occurs? a. When fever is absent b. When lesions are crusted c. 24 hours after lesions erupt d. 8 days after onset of illness
ANS: B When the lesions are crusted, the chickenpox is no longer contagious. This may be a week after onset of disease. Chickenpox is still contagious when child has fever. Children are contagious after lesions erupt. If lesions are crusted at 8 days, the child is no longer contagious.
Which should the nurse teach to parents of toddlers about accidental poison prevention? (Select all that apply.) a. Keep toxic substances in the garage. b. Discard empty poison containers. c. Know the number of the nearest poison control center. d. Remove colorful labels from containers of toxic substances. e. Caution child against eating nonedible items, such as plants.
ANS: B, C, E To prevent accidental poisoning, parents should be taught to promptly discard empty poison containers, know the number of the nearest poison control center and to caution the child against eating nonedible items, such as plants. Parents should place all potentially toxic agents, including cosmetics, personal care items, cleaning products, pesticides, and medications in a locked cabinet, not in the garage. Parents should be taught to never remove labels from containers of toxic substances.
A school-age child has been admitted to the hospital with an exacerbation of nephrotic syndrome. Which clinical manifestations should the nurse expect to assess? (Select all that apply.) a. Weight loss b. Facial edema c. Cloudy smoky brown-colored urine d. Fatigue e. Frothy-appearing urine
ANS: B, D, E A child with nephrotic syndrome will present with facial edema, fatigue, and frothy-appearing urine (proteinuria). Weight gain, not loss, is expected because of the fluid retention. Cloudy smoky brown-colored urine is seen with acute glomerulonephritis but not with nephrotic syndrome because there is no gross hematuria associated with nephrotic syndrome.
In terms of language and cognitive development, a 4-year-old child would be expected to have which traits? (Select all that apply.) a. Think in abstract terms. b. Follow directional commands. c. Understand conservation of matter. d. Use sentences of eight words. e. Tell exaggerated stories. f. Comprehend another person's perspective.
ANS: B, E Children ages 3 to 4 years can give and follow simple commands and tell exaggerated stories. Children cannot think abstractly at age 4 years. Conservation of matter is a developmental task of the school-age child. Five-year-old children use sentences with eight words with all parts of speech. A 4-year-old child cannot comprehend another's perspective.
The nurse is preparing to give oral care to a school-age child with mucositis secondary to chemotherapy administered to treat leukemia. Which preparations should the nurse use for oral care on this child? (Select all that apply.) a. Chlorhexidine gluconate (Peridex) b. Lemon glycerin swabs c. Antifungal troches (lozenges) d. Lip balm (Aquaphor) e. Hydrogen peroxide
ANS: A, C, D Preparations that may be used to prevent or treat mucositis include chlorhexidine gluconate (Peridex) because of its dual effectiveness against candidal and bacterial infections, antifungal troches (lozenges) or mouthwash, and lip balm (e.g., Aquaphor) to keep the lips moist. Agents that should not be used include lemon glycerin swabs (irritate eroded tissue and can decay teeth), hydrogen peroxide (delays healing by breaking down protein), and milk of magnesia (dries mucosa).
The nurse is caring for an infant with a suspected urinary tract infection. Which clinical manifestations should be expected? (Select all that apply.) a. Vomiting b. Jaundice c. Failure to gain weight d. Swelling of the face e. Back pain f. Persistent diaper rash
ANS: A, C, F Vomiting, failure to gain weight, and persistent diaper rash are clinical manifestations observed in an infant with a UTI.
A school-age child is admitted to the hospital with acute glomerulonephritis and oliguria. Which dietary menu items should be allowed for this child? (Select all that apply.) a. Apples b. Bananas c. Cheese d. Carrot sticks e. Strawberries
ANS: A, D, E Moderate sodium restriction and even fluid restriction may be instituted for children with acute glomerulonephritis. Foods with substantial amounts of potassium are generally restricted during the period of oliguria. Apples, carrot sticks, and strawberries would be items low in sodium and allowed. Bananas are high in potassium and cheese is high in sodium. Those items would be restricted.
A child is admitted with acute glomerulonephritis. The nurse should expect the urinalysis during this acute phase to show: a. bacteriuria, hematuria. b. hematuria, proteinuria. c. bacteriuria, increased specific gravity. d. proteinuria, decreased specific gravity.
ANS: B
Which best describes acute glomerulonephritis? a. Occurs after a urinary tract infection b. Occurs after a streptococcal infection c. Associated with renal vascular disorders d. Associated with structural anomalies of genitourinary tract
ANS: B
Acyclovir (Zovirax) is given to children with chickenpox to: a. minimize scarring. b. decrease the number of lesions. c. prevent aplastic anemia. d. prevent spread of the disease.
ANS: B Acyclovir decreases the number of lesions; shortens duration of fever; and decreases itching, lethargy, and anorexia. Treating pruritus and discouraging itching minimizes scarring. Aplastic anemia is not a complication of chickenpox. Strict isolation until vesicles are dried prevents spread of disease.
A child has been admitted to the emergency department with an acetaminophen (Tylenol) poisoning. An antidote is being prescribed by the health care provider. Which antidote should the nurse prepare to administer? a. Naloxone (Narcan) b. N-acetylcysteine (Mucomyst) c. Flumazenil (Romazicon) d. Digoxin immune Fab (Digibind)
ANS: B Antidotes available to treat toxin ingestion include N-acetylcysteine for acetaminophen poisoning, naloxone for opioid overdose, flumazenil (Romazicon) for benzodiazepines (diazepam [Valium], midazolam [Versed]) overdose, and digoxin immune Fab (Digibind) for digoxin toxicity.
The nurse is caring for a child with carbon monoxide poisoning associated with smoke inhalation. Which is essential in this child's care? a. Monitor pulse oximetry. b. Monitor arterial blood gases. c. Administer oxygen if respiratory distress develops. d. Administer oxygen if child's lips become bright, cherry red.
ANS: B Arterial blood gases are the best way to monitor carbon monoxide poisoning. Pulse oximetry is contraindicated in the case of carbon monoxide poisoning because the PaO2 may be normal. The child should receive 100% oxygen as quickly as possible, not only if respiratory distress or other symptoms develop.
A nurse is beginning chelation therapy on a child for lead poisoning. Which intervention should the nurse implement during the time the child is receiving chelation therapy? a. Calorie counts b. Strict intake and output c. Telemetry monitoring d. Contact isolation
ANS: B Because calcium disodium edetate (EDTA) and lead are toxic to the kidneys, a nurse should keep strict records of intake and output to monitor renal functioning. Adequate hydration is essential during therapy because the chelates are excreted via the kidneys. Calorie counts, telemetry, or contact isolation would not be nursing interventions appropriate for a child undergoing chelation therapy.
The most effective way to clean a toddler's teeth is for the: a. child to brush regularly with a toothpaste of his or her choice. b. parent to stabilize the chin with one hand and brush with the other. c. parent to brush the mandibular occlusive surfaces, leaving the rest for the child. d. parent to brush the front labial surfaces, leaving the rest for the child.
ANS: B For young children, the most effective cleaning of teeth is by the parents. Different positions can be used if the child's back is to the adult. The adult should use one hand to stabilize the chin and the other to brush the child's teeth. The child can participate in brushing, but for a thorough cleaning, adult intervention is necessary.
Which is a clinical manifestation of acetaminophen poisoning? a. Hyperpyrexia b. Hepatic involvement c. Severe burning pain in stomach d. Drooling and inability to clear secretions
ANS: B Hepatic involvement is the third stage of acetaminophen poisoning. Hyperpyrexia is a severe elevation in body temperature and is not related to acetaminophen poisoning. Acetaminophen does not cause burning pain in stomach or pose an airway threat.
The nurse is assessing a child with acute epiglottitis. Examining the child's throat by using a tongue depressor might precipitate which symptom or condition? a. Inspiratory stridor b. Complete obstruction c. Sore throat d. Respiratory tract infection
ANS: B If a child has acute epiglottitis, examination of the throat may cause complete obstruction and should be performed only when immediate intubation can take place. Stridor is aggravated when a child with epiglottitis is supine. Sore throat and pain on swallowing are early signs of epiglottitis. Epiglottitis is caused by H. influenzae in the respiratory tract.
A nurse is assessing a child and notes Koplik spots. In which of these communicable diseases are Koplik spots present? a. Rubella b. Measles (rubeola) c. Chickenpox (varicella) d. Exanthema subitum (roseola)
ANS: B Koplik spots are small irregular red spots with a minute, bluish white center found on the buccal mucosa 2 days before systemic rash. Rubella occurs with rash on the face, which rapidly spreads downward. Varicella appears with highly pruritic macules, followed by papules and vesicles. Roseola is seen with rose-pink macules on the trunk, spreading to face and extremities.
The single parent of a 3-year-old child who has just been diagnosed with chickenpox tells the nurse that she cannot afford to stay home with the child and miss work. The parent asks the nurse if some medication will shorten the course of the illness. Which is the most appropriate nursing intervention? a. Reassure the parent that it is not necessary to stay home with the child. b. Explain that no medication will shorten the course of the illness. c. Explain the advantages of the medication acyclovir (Zovirax) to treat chickenpox. d. Explain the advantages of the medication VCZ immune globulin (VariZIG) to treat chickenpox.
ANS: C Acyclovir is effective in treating the number of lesions; shortening the duration of fever; and decreasing itching, lethargy, and anorexia. It is important the parent stay with the child to monitor fever. Acyclovir lessens the severity of chickenpox. VariZIG is given only to high-risk children.
The child of 15 to 30 months is likely to be struggling with which developmental task? a. Trust b. Initiative c. Autonomy d. Intimacy
ANS: C Autonomy vs shame and doubt is the developmental task of toddlers. Trust vs mistrust is the developmental stage of infancy. Initiative vs guilt is the developmental stage of early childhood. Intimacy and solidarity vs isolation is the developmental stage of early adulthood.
The nurse is preparing a child for possible alopecia from chemotherapy. Which should be included? a. Explain to child that hair usually regrows in 1 year. b. Advise child to expose head to sunlight to minimize alopecia. c. Explain to child that wearing a hat or scarf is preferable to wearing a wig. d. Explain to child that when hair regrows, it may have a slightly different color or texture.
ANS: D Alopecia is a side effect of certain chemotherapeutic agents. When the hair regrows, it may be a different color or texture. The hair usually grows back within 3 to 6 months after cessation of treatment. The head should be protected from sunlight to avoid sunburn. Children should choose the head covering they prefer.
A mother asks the nurse what would be the first indication that acute glomerulonephritis is improving. The nurse's best response should be that the: a. blood pressure will stabilize. b. the child will have more energy. c. urine will be free of protein. d. urinary output will increase.
ANS: D An increase in urinary output may signal resolution of the acute glomerulonephritis. If blood pressure is elevated, stabilization usually occurs with the improvement in renal function. The child having more energy and the urine being free of protein are related to the improvement in urinary output.
The nurse suspects that a child has ingested some type of poison. Which clinical manifestation would be most suggestive that the poison was a corrosive product? a. Tinnitus b. Disorientation c. Stupor, lethargy, coma d. Edema of lips, tongue, pharynx
ANS: D Edema of lips, tongue, and pharynx indicates a corrosive ingestion. Tinnitus is indicative of aspirin ingestion. Corrosives do not act on the central nervous system (CNS).
Pancreatic enzymes are administered to the child with cystic fibrosis (CF). Nursing considerations should include to: a. not administer pancreatic enzymes if child is receiving antibiotics. b. decrease dose of pancreatic enzymes if child is having frequent, bulky stools. c. administer pancreatic enzymes between meals if at all possible. d. pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.
ANS: D Enzymes may be administered in a small amount of cereal or fruit at the beginning of a meal or swallowed whole. Pancreatic enzymes are not a contraindication for antibiotics. The dosage of enzymes should be increased if child is having frequent, bulky stools. Enzymes should be given just before meals and snacks.
A child with leukemia is receiving triple intrathecal chemotherapy consisting of methotrexate, cytarabine, and hydrocortisone. The purpose of this is to prevent: a. infection. b. brain tumor. c. drug side effects. d. central nervous system (CNS) disease.
ANS: D For certain children, CNS prophylactic therapy is indicated. This drug regimen is used to prevent CNS leukemia and will not prevent infection or drug side effects. If the child has a brain tumor in addition to leukemia, additional therapy would be indicated.
The nurse recommends to parents that peanuts are not a good snack food for toddlers. The nurse's rationale for this action is that they: a. are low in nutritive value. b. are high in sodium. c. cannot be entirely digested. d. can be easily aspirated.
ANS: D Foreign-body aspiration is common during the second year of life. Although they chew well, this age child may have difficulty with large pieces of food, such as meat and whole hot dogs, and with hard foods, such as nuts or dried beans. Peanuts have many beneficial nutrients, but should be avoided because of the risk of aspiration in this age group. The sodium level may be a concern, but the risk of aspiration is more important. Many foods pass through the gastrointestinal tract incompletely undigested. This is not necessarily detrimental to the child.
Which is the causative agent of scarlet fever? a. Enteroviruses b. Corynebacterium organisms c. Scarlet fever virus d. Group A â-hemolytic streptococci (GABHS)
ANS: D GABHS infection causes scarlet fever. Enteroviruses do not cause the same complications. Corynebacterium organisms cause diphtheria. Scarlet fever is not caused by a virus.
Parents have understood teaching about prevention of childhood otitis media if they make which statement? a. "We will only prop the bottle during the daytime feedings." b. "Breastfeeding will be discontinued after 4 months of age." c. "We will place the child flat right after feedings." d. "We will be sure to keep immunizations up to date."
ANS: D Parents have understood the teaching about preventing childhood otitis media if they respond they will keep childhood immunizations up to date. The child should be maintained upright during feedings and after. Otitis media can be prevented by exclusively breastfeeding until at least 6 months of age. Propping bottles is discouraged to avoid pooling of milk while the child is in the supine position.
Which is a common childhood communicable disease that may cause severe defects in the fetus when it occurs in its congenital form? a. Erythema infectiosum b. Roseola c. Rubeola d. Rubella
ANS: D Rubella causes teratogenic effects on the fetus. There is a low risk of fetal death to those in contact with children affected with fifth disease. Roseola and rubeola are not dangerous to the fetus.
The psychosocial developmental tasks of toddlerhood include which characteristic? a. Development of a conscience b. Recognition of sex differences c. Ability to get along with age-mates d. Ability to delay gratification
ANS: D If the need for basic trust has been satisfied, then toddlers can give up dependence for control, independence, and autonomy. One of the tasks that the toddler is concerned with is the ability to delay gratification. Development of a conscience occurs during the preschool years. The recognition of sex differences occurs during the preschool years. The ability to get along with age-mates develops during the preschool and school-age years.
A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The nurse taking the call should know that the primary danger is which result? a. Hepatic dysfunction b. Dehydration secondary to vomiting c. Esophageal stricture and shock d. Bronchitis and chemical pneumonia
ANS: D Lighter fluid is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose, not hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger. Esophageal stricture is a late or chronic issue of hydrocarbon ingestion.
Although a 14-month-old girl received a shock from an electric outlet recently, her parent finds her about to place a paper clip in another outlet. Which is the best interpretation of this behavior? a. Her cognitive development is delayed. b. This is typical behavior because toddlers are not very developed. c. This is typical behavior because of the inability to transfer knowledge to new situations. d. This is not typical behavior because toddlers should know better than to repeat an act that caused pain.
ANS: C During the tertiary circular reactions stage, children have only a rudimentary sense of the classification of objects. The appearance of an object denotes its function for these children. The slot of an outlet is for putting things into. Her cognitive development is appropriate for her age. Trying to put things into an outlet is typical behavior for a toddler. Only some awareness exists of a causal relation between events.
Chronic otitis media with effusion (OME) is differentiated from acute otitis media (AOM) because it is usually characterized by: a. a fever as high as 40° C (104° F). b. severe pain in the ear. c. nausea and vomiting. d. a feeling of fullness in the ear.
ANS: D OME is characterized by feeling of fullness in the ear or other nonspecific complaints. Fever is a sign of AOM. OME does not cause severe pain. This may be a sign of AOM. Nausea and vomiting are associated with otitis media.
During the preschool period, injury prevention efforts should emphasize: a. constant vigilance and protection. b. punishment for unsafe behaviors. c. education for safety and potential hazards. d. limitation of physical activities.
ANS: C Education for safety and potential hazards is appropriate for preschoolers because they can begin to understand dangers. Constant vigilance and protection is not practical at this age because preschoolers are becoming more independent. Punishment may make children scared of trying new things. Limitation of physical activities is not appropriate.
Which is the most appropriate nursing diagnosis for the child with acute glomerulonephritis? a. Risk for Injury related to malignant process and treatment b. Fluid Volume Deficit related to excessive losses c. Fluid Volume Excess related to decreased plasma filtration d. Fluid Volume Excess related to fluid accumulation in tissues and third spaces
ANS: C Glomerulonephritis has a decreased filtration of plasma, which results in an excessive accumulation of water and sodium that expands plasma and interstitial fluid volumes, leading to circulatory congestion and edema. No malignant process is involved in acute glomerulonephritis. A fluid volume excess is found. The fluid accumulation is secondary to the decreased plasma filtration.
Which is the most frequent source of acute childhood lead poisoning? a. Folk remedies b. Unglazed pottery c. Lead-based paint d. Cigarette butts and ashes
ANS: C Lead-based paint in houses built before 1978 is the most frequent source of lead poisoning. Some folk remedies and unglazed pottery may contain lead, but they are not the most frequent source. Cigarette butts and ashes do not contain lead.
Which snack should the nurse recommend parents offer to their slightly overweight preschool child? a. Carbonated beverage b. 10% fruit juice c. Low fat chocolate milk d. Whole milk
ANS: C Milk and dairy products are excellent sources of calcium and vitamin D (fortified). Low-fat milk may be substituted, so the quantity of milk may remain the same while limiting fat intake overall. Parents should be educated regarding non-nutritious fruit drinks, which usually contain less than 10% fruit juice yet are often advertised as healthy and nutritious; sugar content is dramatically increased and often precludes an adequate intake of milk by the child. In young children, intake of carbonated beverages that are acidic or that contain high amounts of sugar is also known to contribute to dental caries. Low fat milk should be substituted for whole milk if the child is slightly overweight.
A 4-year-old child tells the nurse that she does not want another blood sample drawn because "I need all my insides, and I don't want anyone taking them out." Which is the nurse's best interpretation of this? a. Child is being overly dramatic. b. Child has a disturbed body image. c. Preschoolers have poorly defined body boundaries. d. Preschoolers normally have a good understanding of their bodies.
ANS: C Preschoolers have little understanding of body boundaries, which leads to fears of mutilation. The child is not capable of being dramatic at 4 years of age. She truly has fear. Body image is just developing in the school-age child. Preschoolers do not have good understanding of their bodies.
A toddler's parent asks the nurse for suggestions on dealing with temper tantrums. Which is the most appropriate recommendation? a. Punish the child. b. Leave the child alone until the tantrum is over. c. Remain close by the child but without eye contact. d. Explain to child that this is wrong.
ANS: C The parent should be told that the best way to deal with temper tantrums is to ignore the behaviors, provided that the actions are not dangerous to the child. Tantrums are common in toddlers as the child becomes more independent and overwhelmed by increasingly complex tasks. The parents and caregivers need to have consistent and developmentally appropriate expectations. Punishment and explanations will not be beneficial. The parent's presence is necessary both for safety and to provide a feeling of control and security to the child when the tantrum is over.
The nurse notes that a child has lost 8 pounds after 4 days of hospitalization for acute glomerulonephritis. This is most likely the result of: a. poor appetite. b. increased potassium intake. c. reduction of edema. d. restriction to bed rest.
ANS: C This amount of weight loss in this period is a result of the improvement of renal function and mobilization of edema fluid. Poor appetite and bed rest would not result in a weight loss of 8 pounds in 4 days. Foods with substantial amounts of potassium are avoided until renal function is normalized.
A preschool child is being admitted to the hospital with dehydration and a urinary tract infection (UTI). Which urinalysis result should the nurse expect with these conditions? a. WBC <1; specific gravity 1.008 b. WBC <2; specific gravity 1.025 c. WBC >2; specific gravity 1.016 d. WBC >2; specific gravity 1.030
ANS: D
Cystic fibrosis (CF) is suspected in a toddler. Which test is essential in establishing this diagnosis? a. Bronchoscopy b. Serum calcium c. Urine creatinine d. Sweat chloride test
ANS: D A sweat chloride test result greater than 60 mEq/L is diagnostic of CF. Bronchoscopy, although helpful for identifying bacterial infection in children with CF, is not diagnostic. Serum calcium is normal in children with C35.
4) The nurse is planning care for a school-age child diagnosed with bacterial meningitis. Which intervention is most appropriate? 1. Keeping environmental stimuli at a minimum 2. Avoiding giving pain medications that could dull sensorium 3. Measuring head circumference to assess developing complications 4. Having the child move the head from side to side at least every two hours
Answer: 1 Explanation: 1. A quiet environment should be maintained because noise can disturb a child with meningitis. Pain medications are appropriate to give and should be used when needed. Measuring head circumference would only be appropriate for a child less than 2 years. Excessive head movement should be avoided because it can increase irritation of the meninges.
3) A child is admitted to the hospital with the diagnosis of laryngotracheobronchitis (LTB). Which nursing intervention is the priority for this child? 1. Administer nebulized epinephrine and oral or IM dexamethasone. 2. Administer antibiotics and assist with possible intubation. 3. Swab the throat for a throat culture. 4. Obtain a sputum specimen.
Answer: 1 Explanation: 1. Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.
12) An adolescent client who is diagnosed with Duchenne muscular dystrophy is seen in the clinic for a routine health visit. Which nursing diagnosis is the priority for this client? 1. Risk for Impaired Mobility Related to Hypertrophy of Muscles 2. Risk for Infection Related to Altered Immune System 3. Risk for Impaired Skin Integrity Related to Paresthesia 4. Risk for Altered Comfort Related to Effects of the Illness
Answer: 1 Explanation: 1. Nursing care for muscular dystrophy (MD) focuses on promoting independence and mobility for this progressive, incapacitating disease. Risk for Infection, Risk for Impaired Skin Integrity, and Risk for Altered Comfort are not as high a priority as Risk for Impaired Mobility.
6) The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. To administer this injection safely, the nurse chooses which needle, size and length, injection type, and injection site? 1. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh. 2. 22-gauge, 1/2-inch needle; IM (intramuscular); ventrogluteal. 3. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid. 4. 25-gauge, 3/4-inch needle; SQ (subcutaneous); anterolateral thigh.
Answer: 1 Explanation: 1. The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, 5/8- to 3/4-inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh.
11) The nurse is providing care to a toddler client who is diagnosed with osteogenesis imperfecta. Which nursing intervention is appropriate for this client? 1. Support of the trunk and extremities when moving 2. Traction care 3. Cast care 4. Postop spinal surgery care
Answer: 1 Explanation: 1. With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones are fragile, the entire body must be supported when the child is moved. Traction, casts, and spinal surgery are not routinely done for osteogenesis.
16) The nurse teaches a group of parents' strategies to reduce the risk of lead exposure for their children. Which statements indicate an appropriate understanding of the content presented? Select all that apply. 1. "We will provide our child with frequent snacks high in iron and calcium." 2. "We will wash any surfaces that have peeling paint." 3. "We will store leftovers in a ceramic pot." 4. "We can continue to use our traditional-medicine treatment, Azarcon, for any GI upset." 5. "We will sand the windowsills to remove the lead-based paint."
Answer: 1, 2 Explanation: 1. Snacks and meals high in iron and calcium should be encouraged. Lead is absorbed more readily on an empty stomach. Any surface with peeling paint should be washed with a damp sponge. Ceramic pots, if fired improperly, could contain lead. Food should not be prepared or stored in them. Azarcon, a traditional medicine used to treat a colic-like illness, may contain large amounts of lead. Sanding the windowsills will cause the lead to be dispersed in the air, leading to lead poisoning.
17) The parents of a child with Duchenne muscular dystrophy are in the clinic after diagnosis and ask the nurse if the family should have genetic testing completed. Who should the nurse suggest to have genetic testing? Select all that apply. 1. Female cousins 2. Aunts 3. Sisters 4. Brothers 5. Uncles and male cousins
Answer: 1, 2, 3
15) The nurse educator is teaching a group of nursing students the pathophysiologic reasons related to genitourinary (GU) disorders in the pediatric population. Which statements are appropriate for the nurse educator to include in the teaching session? Select all that apply. 1. "Incomplete organ development during fetal development is the cause of many GU disorders." 2. "Improper placement of the urethra in vagina is one cause of GU disorders." 3. "GU disorders in the pediatric population can be caused by hydronephrosis." 4. "GU disorders in the pediatric population are not caused by infections." 5. "Anatomic obstruction or incomplete nerve innervation can cause GU disorders."
Answer: 1, 3, 5 Explanation: 1. Pathophysiologic causes of GU disorders in the pediatric population include incomplete organ development during fetal development; hydronephrosis; and anatomic obstruction or incomplete nerve innervations. Improper placement of the urethra in the penis, not the vagina, is another pathophysiologic cause of GU disorders. GU disorders can also be caused by infection.
8) The nurse teaches parents how to care for their child who has tympanostomy tubes inserted. Which actions by the parents indicate appropriate understanding of the teaching session? Select all that apply. 1. Encouraging the child to drink generous amounts of fluids 2. Administering a decongestant for 1 to 2 weeks following surgery 3. Restricting the child to quiet activities after surgery 4. Limiting diet to soft, bland foods 5. Avoiding getting water in ears during bath time
Answer: 1, 3, 5 Explanation: 1. The correct responses include encouraging the child to drink generous amount of water, restricting the child to quiet activities after surgery, and avoiding water in the child's ears at bath time. Incorrect responses include administering a decongestant for 1 to 2 weeks following surgery and limiting diet to soft, bland foods-decongestants are not needed after surgery, and a regular diet should be resumed.
Vitamin A supplementation may be recommended for the young child who has which disease? a. Mumps b. Rubella c. Measles (rubeola) d. Erythema infectiosum
ANS: C Evidence shows vitamin A decreases morbidity and mortality in measles. Mumps is treated with analgesics for pain and antipyretics for fever. Rubella is treated similarly to mumps. Erythema infectiosum is treated similarly to mumps and rubella.
Chelation therapy for lead poisoning is initiated when a child's blood level is _____ g/dl. a. 10 to 14 b. 15 to 19 c. 20 to 44 d. >45
ANS: D Chelation therapy is initiated if the child's blood level is greater than 45 g/dl. At 10 to 14 g/dl, the family should have lead-poisoning education and follow-up level. At 15 to 19 g/dl, the family should have lead-poisoning education and follow-up level but if it persists, initiate environmental investigation. At 20 to 44 g/dl environmental investigation and lead hazard control are necessary.
7) A child undergoing chemotherapeutic treatment for cancer is being admitted to the hospital for fever of 102 degrees F and possible sepsis. Cultures, antibiotics, and acetaminophen (Tylenol) along with bed rest have been ordered for this child. Place the following steps in order from first to last. Response 1 Administer the antibiotics. Response 2 Administer the acetaminophen (Tylenol). Response 3 Obtain the cultures. Response 4 Ensure the child has bed rest.
Answer: 2, 3, 1, 4
A nurse is reviewing the results of a genetic analysis performed on a child with Duchenne muscular dystrophy (DMD). Which of the following results would the nurse expect to see? 1. 46 XY, X-linked recessive inheritance 2. 46 XX, autosomal dominant inheritance 3. 46 XY, autosomal recessive inheritance 4. 46 XX, mitochondrial inheritance
1
A child is admitted to the pediatric unit with a diagnosis of meningitis. Which of the following actions should the nurse perform? Select all that apply. 1. Raise the head of the bed. 2. Dim the lights in the room. 3. Place the child on droplet isolation. 4. Administer intravenous antibiotics, as prescribed. 5. Perform passive range-of-motion exercises of the neck.
A:1,2,3,4
A child is receiving chemotherapy for a diagnosis of acute lymphoblastic leukemia (ALL). The nurse monitors the child for which of the following common side effects? Select all that apply. 1. Malaise 2. Alopecia 3. Priapism 4. Anorexia 5. Epistaxis
A:1,2,4,5
Which is included in the diet of a child with minimal change nephrotic syndrome? a. High protein b. Salt restriction c. Low fat d. High carbohydrate
ANS: B
Which type of croup is always considered a medical emergency? a. Laryngitis b. Epiglottitis c. Spasmodic croup d. Laryngotracheobronchitis (LTB)
ANS: B Epiglottitis is always a medical emergency needing antibiotics and airway support for treatment. Laryngitis is a common viral illness in older children and adolescents, with hoarseness and URI symptoms. Spasmodic croup is treated with humidity. LTB may progress to a medical emergency in some children.
A 3-year-old child's blood lead level measures 12 micrograms/dL. The nurse would expect the child to exhibit which of the following signs/symptoms? 1. Hyponatremia 2. Polycythemia 3. Aggression 4. Polyphagia
Answer 3. Alters CNS
1) A child diagnosed with a Wilms tumor is prescribed chemotherapy. Which laboratory test will the nurse monitor prior to administering the chemotherapy to determine the child's infection-fighting capability? 1. Hemoglobin 2. RBC count 3. Absolute neutrophil count (ANC) 4. Platelets
Answer: 3 Explanation: 1. The absolute neutrophil count uses both the segmented (mature) and bands (immature) neutrophils as a measure of the body's infection-fighting capability. RBC count, hemoglobin, and platelets cannot determine infection-fighting capabilities.
The mother of a 3-year-old child who has been diagnosed with an ear infection states, "I can't understand why you won't give my child antibiotics. Can't you see that she is sick?" Which of the following responses by the nurse is appropriate at this time? 1. "I know how you feel, but the best medicine for your daughter right now is acetaminophen." 2. "Your child will get better on her own in a few days." 3. "I am also very surprised that the pediatrician didn't order antibiotics." 4. "It is likely that the ear infection is caused by a virus, and antibiotics do not kill viruses."
A,4
The nurse is conducting an assessment on a school-age child with urosepsis. Which assessment finding should the nurse expect? a. Fever with a positive blood culture b. Proteinuria and edema c. Oliguria and hypertension d. Anemia and thrombocytopenia
ANS: A Symptoms of urosepsis include a febrile UTI coexisting with systemic signs of bacterial illness; blood culture reveals presence of urinary pathogen. Proteinuria and edema are symptoms of minimal change nephrotic syndrome (MCNS). Oliguria and hypertension are symptoms of acute glomerulonephritis (AGN). Anemia and thrombocytopenia are symptoms of hemolytic uremic syndrome (HUS).
3) A preschool child is seen in the clinic, and the nurse anticipates a diagnosis of leukemia. Which reaction does the nurse anticipate this child will exhibit upon diagnosis? 1. Acceptance, especially if able to discuss the disease with children their own age 2. Thoughts that they caused their illness and are being punished 3. Understanding of what cancer is and how it is treated 4. Unawareness of the illness and its severity
Answer: 2 Explanation: 1. Preschool-age children may think they caused their illness. Adolescents find contact with others who have gone through their experience helpful. School-age children can understand a diagnosis of cancer. Infants and toddlers are unaware of the severity of the disease.
13) A mother brings her 4-month-old infant in for a routine checkup and vaccinations. The mother reports that the infant was exposed to a brother who has the flu. Which action by the nurse is most appropriate based on these assessment findings? 1. Withhold the vaccinations. 2. Give the vaccinations as scheduled. 3. Withhold the DTaP vaccination but give the others as scheduled. 4. Give the infant the flu vaccination but withhold the others.
Answer: 2 Explanation: 1. Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old.
4) The nurse is teaching a group of mothers of infants about the benefits of immunization. Which immunization will the nurse teach to the mothers that can assist in preventing the life-threatening disease epiglottitis? 1. Measles, mumps, and rubella (MMR) 2. Haemophilus influenzae type B (HIB) 3. Hepatitis B 4. Polio
Answer: 2 Explanation: 1. The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.
A school nurse is making rounds in the kindergarten classrooms of an elementary school. The nurse, who interviews 5 of the boys, suspects that which of the boys is a victim of child neglect? The child who: Select all that apply. 1. is wearing shorts and a tee shirt on a cold winter day. 2. steals some breakfast cereal from a closet in the nurse's office. 3. states that his mother is going to buy fast-food hamburgers for supper. 4. is upset because his parents will not let him learn how to play hockey. 5. states that his parents are waiting for the two teeth with cavities to fall out.
A:1,2,5
The oncologist caring for a child immediately postsurgery for Wilms' tumor reports: the child is in Stage III. The child will go through a series of chemotherapy. Based on the proposed therapy, which of the following patient-care goals should be included in the child's nursing care plan? Select all that apply. 1. The child will be free of infection. 2. The child will experience no tissue damage. 3. The child will have regular bowel movements. 4. The child will not complain of nausea and will not vomit. 5. The child will regress to the previous level of growth and development.
A:1234
1. The mother of an 11-month-old remarks to a nurse at the pediatric clinic, "We are so lucky. Our daughter has never had an ear infection!" Which of the following factors can the nurse tell the mother have protected her daughter from the disease? Select all that apply. 1. The family owns no pets. 2. No one in the family smokes. 3. The mother breastfeeds her daughter. 4. Child attends day care only two mornings a week. 5. The family lives in the southern part of the country.
A:2,3,4
A 2-year-old child's blood lead level is 4 micrograms per dL. Based on the data, which of the following actions should the nurse take? 1. Notify the department of health regarding the value. 2. Recommend to the primary health-care provider that the child receive chelation therapy. 3. Educate the child's teacher regarding ways to prevent another incident. 4. Remind the parents of the importance of frequently washing their child's hands, especially prior to eating.
A:4
A nurse working in a preschool discovers that a 2½-year-old child has drunk a bottle of red paint. Place the following nursing actions in the correct order of priority. 1. Notify the child's parents. 2. Question the child's teacher regarding the incident. 3. Call the poison control center. 4. Assess the child for adverse effects from the ingestion.
A:4312
12) The hospital admitting nurse is taking a history of a child's illness from the parents. The nurse concludes that the parents treated their 6-year-old child appropriately for a fever related to otitis media. Which action by the parents brought the nurse to this conclusion? 1. Used aspirin every four hours to reduce the fever 2. Alternated acetaminophen with ibuprofen every two hours 3. Put the child in a tub of cold water to reduce the fever 4. Offered generous amounts of fluids frequently
Answer: 4
Which is a common characteristic of those who sexually abuse children? a. Pressure victim into secrecy b. Are usually unemployed and unmarried c. Are unknown to victims and victims' families d. Have many victims that are each abused once only
ANS: A Sex offenders may pressure the victim into secrecy regarding the activity as a "secret between us" that other people may take away if they find out. The offender may be anyone, including family members and persons from any level of society. Sex offenders are usually trusted acquaintances of the victims and victims' families. Many victims are abused many times over a long period.
4) The nurse is monitoring the urine specific gravity and pH on a child receiving chemotherapy. Which urinalysis result is the goal for this child? 1. Spec gravity 1.030; pH 6 2. Spec gravity 1.030; pH 7.5 3. Spec gravity 1.005; pH 6 4. Spec gravity 1.005; pH 7.5
Answer: 4
4) Which symptoms are characteristic of a preschool-age client who is diagnosed with a urinary tract infection? 1. Foul-smelling urine, elevated blood pressure, and hematuria 2. Severe flank pain, nausea, headache 3. Headache, hematuria, vertigo 4. Urgency, dysuria, fever
Answer: 4 Explanation: 1. Clinical manifestations of a urinary tract infection (UTI) in a preschool-age client include fever, urgency, and dysuria. While hematuria may be present, there is no elevated blood pressure, headache, or vertigo.
A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. Which is an appropriate nursing goal related to this? a. Prevent infection. b. Stimulate appetite. c. Detect evidence of edema. d. Ensure compliance with prophylactic antibiotic therapy.
ANS: A
A child with cystic fibrosis (CF) receives aerosolized bronchodilator medication. When should this medication be administered? a. Before chest physiotherapy (CPT) b. After CPT c. Before receiving 100% oxygen d. After receiving 100% oxygen
ANS: A Bronchodilators should be given before CPT to open bronchi and make expectoration easier. Aerosolized bronchodilator medications are not helpful when used after CPT. Oxygen administration is necessary only in acute episodes with caution because of chronic carbon dioxide retention.
Parents of a child with cystic fibrosis ask the nurse about genetic implications of the disorder. Which statement, made by the nurse, expresses accurately the genetic implications? a. If it is present in a child, both parents are carriers of this defective gene. b. It is inherited as an autosomal dominant trait. c. It is a genetic defect found primarily in non-Caucasian population groups. d. There is a 50% chance that siblings of an affected child also will be affected.
ANS: A CF is an autosomal recessive gene inherited from both parents and is inherited as an autosomal recessive, not autosomal dominant, trait. CF is found primarily in Caucasian populations. An autosomal recessive inheritance pattern means that there is a 25% chance a sibling will be infected but a 50% chance a sibling will be a carrier
Which describes a child who is abused by the parent(s)? a. Unintentionally contributes to the abusing situation b. Belongs to a low socioeconomic population c. Is healthier than the nonabused siblings d. Abuses siblings in the same way as child is abused by the parent(s)
ANS: A Child's temperament, position in the family, additional physical needs, activity level, or degree of sensitivity to parental needs unintentionally contribute to the abusing situation. Abuse occurs among all socioeconomic levels. Children who are ill or have additional physical needs are more likely to be abused. The abused child may not abuse siblings.
In providing nourishment for a child with cystic fibrosis (CF), which factor should the nurse keep in mind? a. Diet should be high in carbohydrates and protein. b. Diet should be high in easily digested carbohydrates and fats. c. Most fruits and vegetables are not well tolerated. d. Fats and proteins must be greatly curtailed.
ANS: A Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired intestinal absorption. Enzyme supplementation helps digest foods; other modifications are not necessary. A well-balanced diet containing fruits and vegetables is important. Fats and proteins are a necessary part of a well-balanced diet.F. Urine creatinine is not diagnostic of CF.
Which explains why cool-mist vaporizers rather than steam vaporizers are recommended in home treatment of childhood respiratory tract infections? a. They are safer. b. They are less expensive. c. Respiratory secretions are dried. d. A more comfortable environment is produced.
ANS: A Cool-mist vaporizers are safer than steam vaporizers, and little evidence exists to show any advantages to steam. The cost of cool-mist and steam vaporizers is comparable. Steam loosens secretions, not dries them. Both may promote a more comfortable environment, but cool-mist vaporizers present decreased risk for burns and growth of organisms.
A 4-year-old child has just been diagnosed with pseudohypertrophic (Duchenne) muscular dystrophy. The management plan should include which action? a. Recommend genetic counseling. b. Explain that the disease is easily treated. c. Suggest ways to limit use of muscles. d. Assist family in finding a nursing facility to provide his care.
ANS: A Pseudohypertrophic (Duchenne) muscular dystrophy is inherited as an X-linked recessive gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring. No effective treatment exists at this time for childhood muscular dystrophy. Maintaining optimal function of all muscles for as long as possible is the primary goal. It has been found that children who remain as active as possible are able to avoid wheelchair confinement for a longer time. Assisting the family in finding a nursing facility to provide his care is inappropriate at the time of diagnosis. When the child becomes increasingly incapacitated, the family may consider home-based care, a skilled nursing facility, or respite care to provide the necessary care.
Parents are concerned that their child is showing aggressive behaviors. Which suggestion should the nurse make to the parents? a. Supervise television viewing. b. Ignore the behavior. c. Punish the child for the behavior. d. Accept the behavior if the child is male.
ANS: A Television is also a significant source for modeling at this impressionable age. Research indicates there is a direct correlation between media exposure, both violent and educational media, and preschoolers exhibiting physical and relational aggression (Ostrov, Gentile, and Crick, 2006). Therefore, parents should be encouraged to supervise television viewing. The behavior should not be ignored because it can escalate to hyperaggression. The child should not be punished because it may reinforce the behavior if the child is seeking attention. For example, children who are ignored by a parent until they hit a sibling or the parent learn that this act garners attention. The behavior should not be accepted from a male child; this is using a "double standard" and aggression should not be equated with masculinity.
The parents of a 2-year-old tell the nurse that they are concerned because the toddler has started to use "baby talk" since the arrival of their new baby. The nurse should recommend which intervention? a. Ignore the "baby talk." b. Explain to the toddler that "baby talk" is for babies. c. Tell the toddler frequently, "You are a big kid now." d. Encourage the toddler to practice more advanced patterns of speech.
ANS: A The baby talk is a sign of regression in the toddler. It should be ignored, while praising the child for developmentally appropriate behaviors. Regression is children's way of expressing stress. The parents should not introduce new expectations and allow the child to master the developmental tasks without criticism.
Which technique is best for dealing with the negativism of the toddler? a. Offer the child choices. b. Remain serious and intent. c. Provide few or no choices for child. d. Quietly and calmly ask the child to comply.
ANS: A The child should have few opportunities to respond in a negative manner. Questions and requests should provide choices. This allows the child to be in control and reduces opportunities for negativism. The child will continue trying to assert control. The toddler is too young for verbal explanations. The negativism is the child testing limits. These should be clearly defined by structured choices.
The nurse is admitting a child with a Wilms tumor. Which is the initial assessment finding associated with this tumor? a. Abdominal swelling b. Weight gain c. Hypotension d. Increased urinary output
ANS: A The initial assessment finding with a Wilms (kidney) tumor is abdominal swelling. Weight loss, not weight gain, may be a finding. Hypertension occasionally occurs with a Wilms tumor. Urinary output is not increased, but hematuria may be noted.
Decongestant nose drops are recommended for a 10-month-old infant with an upper respiratory tract infection. Instructions for nose drops should include which action? a. Avoid using for more than 3 days. b. Keep drops to use again for nasal congestion. c. Administer drops until nasal congestion subsides. d. Administer drops after feedings and at bedtime.
ANS: A Vasoconstrictive nose drops such as phenylephrine (Neo-Synephrine) should not be used for more than 3 days to avoid rebound congestion. Drops should be discarded after one illness because they may become contaminated with bacteria. Vasoconstrictive nose drops can have a rebound effect after 3 days of use. Drops administered before feedings are more helpful.
Which assessment findings should the nurse note in a school-age child with Duchenne muscular dystrophy (DMD)? (Select all that apply.) a. Lordosis b. Gower sign c. Kyphosis d. Scoliosis e. Waddling gait
ANS: A, B, E Difficulties in running, riding a bicycle, and climbing stairs are usually the first symptoms noted in Duchenne muscular dystrophy. Typically, affected boys have a waddling gait and lordosis, fall frequently, and develop a characteristic manner of rising from a squatting or sitting position on the floor (Gower sign). Lordosis occurs as a result of weakened pelvic muscles, and the waddling gait is a result of weakness in the gluteus medius and maximus muscles. Kyphosis and scoliosis are not assessment findings with DMD.
A nurse is teaching parents methods to reduce lead levels in their home. Which should the nurse include in the teaching? (Select all that apply.) a. Plant bushes around the outside of the house. b. Ensure your child eats frequent meals. c. Use hot water from the tap when boiling vegetables. d. Food can be stored in ceramic in the refrigerator. e. Ensure that your child's diet contains sufficient iron and calcium.
ANS: A, B, E Methods to reduce lead levels in homes include: planting bushes around the outside of the house, if soil is contaminated with lead, so children cannot play there; ensuring that children eat regular meals because more lead is absorbed on an empty stomach; and ensuring that children's diets contain sufficient iron and calcium. Cold water should only be used for drinking, cooking, and reconstituting powder infant formula. Hot water dissolves lead more quickly than cold water and thus contains higher levels of lead. Do not use pottery or ceramic ware that was inadequately fired or is meant for decorative use for food storage or service.
The nurse is caring for a 5-year-old child who is scheduled for a tonsillectomy in 2 hours. Which action should the nurse include in the child's postoperative care plan? (Select all that apply.) a. Notify the surgeon if the child swallows frequently. b. Apply a heat collar to the child for pain relief. c. Place the child on the abdomen until fully wake. d. Allow the child to have diluted juice after the procedure. e. Encourage the child to cough frequently.
ANS: A, C, D Frequent swallowing is a sign of bleeding in children after a tonsillectomy. The child should be placed on the abdomen or the side to facilitate drainage. The child can drink diluted juice, cool water, or popsicles after the procedure. An ice collar should be used after surgery. Frequent coughing and nose blowing should be avoided.
The nurse is educating the parents and their 10-year-old child regarding home care for the child's diagnosis of acute glomerular nephritis. Which of the following statements by the child indicate that the child understood the teaching? Select all that apply. 1. "I can't eat any potato chips or other salty foods." 2. "I can't go to school for a week because I am contagious." 3. "I won't be able to go back to soccer practice for a long time." 4. "I'm going to have to go to the doctor's office a lot during the next few months." 5. "When I get home, I will have to stay in bed, except when I need to go to the bathroom."
ANSWER: 1, 3, and 4 Rationale: 1. This statement is true. Children with AGN are usually on salt restricted diets. 2. This is not correct. It is rare for children with AGN still to be contagious. If they are still S. pyogenes positive, they will be prescribed penicillin. Once they have been on the medication for one full day, they are no longer contagious. 3. This statement is correct. Until the urinalyses are normal, children are restricted from participating in contact sports.
A preschool child was administered activated charcoal in the emergency department after a poisoning event. The child is being discharged home. Which of the following adverse reactions to the medication should the parent be advised to report to the child's primary health-care provider? 1. Rash 2. Conjunctivitis 3. Lethargy 4. Constipation
Answer 4.
6) A school-age client diagnosed with nephrotic syndrome is severely edematous. The primary healthcare provider has placed the child on bed rest. Which nursing intervention is a priority for this client? 1. Reposition the child every 2 hours. 2. Monitor BP every 30 minutes. 3. Encourage fluids. 4. Limit visitors.
Answer: 1 Explanation: 1. A child with severe edema, on bed rest, is at risk for altered skin integrity. To prevent skin breakdown, the child should be repositioned every 2 hours. Vital signs are taken every 4 hours, fluids need to be monitored and should not be encouraged, and the child needs social interaction, so visitors should not be limited.
18) The family and school-age child are at the healthcare clinic for immunizations. The nurse takes the time to talk with the child and family about reducing the transmission of infection. What practices should the nurse suggest for the family? Select all that apply. 1. Do not share dishes, utensils, and cups. 2. Sanitize toys every week with Lysol. 3. Use alcohol-based hand sanitizer with the child after eating and toileting. 4. Cough or sneeze into cloth tissue 5. Dispose of diapers in a closed container.
Answer: 1, 5 Explanation: 1. Teach families to reduce transmission of infection among family members with the following practices: use disposable tissues and dispose immediately after using, wash hands thoroughly with soap/water after all contact with diapers/tissues/mucous, sneeze/cough into elbow, wash hands with soap/water after eating and toileting, do not share dishes/utensils/cups, wash hands thoroughly before preparing food and again several times during the preparation process, use soapy warm water to wash dishes/cutting boards, wipe counters/surfaces that are used for diaper changes or that the child touches with disinfectant, make sure diaper changing area is well away from food prep areas, dispose of diapers in closed containers. This is a practice that the nurse should suggest for the family.
14) A child is admitted to the hospital unit with physical injuries. The nurse is taking the child's history. Which statement by the parent would arouse suspicion of abuse? 1. "I did not realize that my baby was able to roll over yet, and I was just gone a minute to check on dinner when the baby rolled off of the couch and onto our tile floor." 2. "The baby's 18-month-old brother was trying to pull the baby out of the crib and dropped the baby on the floor." 3. "I placed the baby in the infant swing. His 6-year-old brother was running through the house and tripped over the swing, causing it to fall." 4. "I was walking up the steps and slipped on the ice, falling while carrying my baby."
Answer: 2 Explanation: 1. All of the statements made by the parent are plausible from a developmental perspective except the statement "The baby's 18-month-old brother was trying to pull the baby out of the crib and dropped the baby on the floor." Developmentally, it would be very difficult for an 18-month-old child to pull an infant out of a crib.
7) An infant is diagnosed with acute otitis media. Which intervention is most appropriate for the nurse to teach the infant's parents? 1. Keep the baby in a flat lying position during sleep. 2. Administer acetaminophen (Tylenol) to relieve discomfort. 3. Administer a decongestant. 4. Place baby to sleep with a pacifier.
Answer: 2 Explanation: 1. An infant with a bulging tympanic membrane because of acute otitis media will have pain. Parents are taught to administer acetaminophen (Tylenol) to relieve the discomfort associated with acute otitis media. A flat lying position may exacerbate the discomfort. Elevating the head slightly is recommended. Decongestants are not recommended for treatment of acute otitis media. Placing infants to sleep with a pacifier may increase the incidence of otitis media.
9) A child diagnosed with acute glomerulonephritis is in the playroom and experiences blurred vision and headache. Which action by the nurse is the most appropriate? 1. Check the urine to see if hematuria has increased. 2. Obtain a blood pressure on the child; notify the healthcare provider. 3. Reassure the child, and encourage bed rest until the headache improves. 4. Obtain serum electrolytes, and send a urinalysis to the lab.
Answer: 2 Explanation: 1. Blurred vision and headache may be signs of encephalopathy, a complication of acute glomerulonephritis. A blood pressure (BP) should be obtained and the healthcare provider notified. The healthcare provider may decide to order an antihypertensive to bring down the BP. This is a serious complication, and delay in treatment could mean lethargy and seizures. Therefore, the other options (checking urine for hematuria, encouraging bed rest, and obtaining serum electrolytes) do not directly address the potential problem of encephalopathy.
14) A parent brings her school-age child to the clinic because the child has a temperature of 100.2°F. The child remains active without other symptoms. Which statement by the nurse to the parents is most appropriate? 1. "Take the child's temperature every 2 hours and call the clinic if it reaches 102°F or above." 2. "Unless the fever bothers the child, it is best to let the natural body defenses respond to the infection." 3. "Keep the child warm, because shivering often occurs with fever." 4. "Alternate acetaminophen and ibuprofen to help keep the fever down and keep the child comfortable."
Answer: 2 Explanation: 1. Fever is the body's response to an infection, and is not a disease. Allowing the body's natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, and so on. Taking the child's temperature more than every 4 to 6 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.
13) A preschool-age child is brought to the clinic by the mother, who says the child has been lethargic and anorexic lately and complains of bone pain. On exam, the nurse notes petechiae, joint pain, and an enlarged liver. Which diagnosis does the nurse anticipate for this child? 1. Hodgkin disease 2. Leukemia 3. Rhabdomyosarcoma 4. Ewing sarcoma
Answer: 2 Explanation: 1. Hodgkin disease, rhabdomyosarcoma, and Ewing sarcoma are all childhood cancers, but they do not have the clinical manifestations listed. Leukemia is one of the most common childhood cancers, and has those clinical symptoms.
15) The nurse is providing care to a toddler-age child. Which assessment finding is indicative of abuse? 1. Parents indicating that they did not see the event occur 2. Inconsistency of stories between caregivers 3. Bruising noted on the knees and shins 4. Acting out behavior of the child
Answer: 2 Explanation: 1. Inconsistency of stories is a red flag for abuse. All other answers are logical explanations for this age group.
13) The pediatric nurse is working with a parent who is suspected of Münchausen Syndrome by Proxy. Which action by the nurse is the priority? 1. Confront the parent with concerns of possible abuse. 2. Carefully document parent-child interactions. 3. Try to keep the parent separated from the child as much as possible. 4. Explain to the child that the parent is causing the illness and that the health team will prevent the child from being harmed.
Answer: 2 Explanation: 1. Münchausen Syndrome by Proxy is very difficult to prove, and evidence provided by the careful documentation of the nursing staff can be very influential. Care must be taken not to make the parent suspicious and to keep the child in the hospital until enough evidence is collected. Confronting the parent or separating the parent from the child may alienate the parent and cause him or her to leave with the child. Talking to the child about the health-care team's suspicions may be confusing and frightening for the child.
4) While working at a weekend "free clinic," the nurse is assessing a toddler when the mother of the child confides that it has been very difficult providing for her family of four children on her limited budget. She is not sure that she has enough money to buy food for the rest of the month and the antibiotic that is needed for the child's ear infection. Which intervention would be the most beneficial for this family? 1. Giving the mother enough free samples of the antibiotic for the recommended course of treatment 2. Putting the mother in contact with a local agency that provides food on a regular basis to needy families and helps them access other resources in the community 3. Talking with the mother about the factors that increase a child's risk of acquiring an ear infection 4. Talking with the mother about the importance of a balanced diet in the growth and development of children and providing her with a list of inexpensive, nutritious foods
Answer: 2 Explanation: 1. While most of these are good interventions, putting the mother in contact with a local agency is most likely to meet the family's basic need for food and possibly connect the mother to a resource that could supply her with the antibiotic for her child. Also, many uncomplicated ear infections can resolve without antibiotic treatment. Giving antibiotics will only benefit the child, and the question asks what will benefit the child and family.
16) A nurse working in a pediatric clinic is responsible for monitoring and maintaining the vaccinations on site. Which actions are appropriate for this nurse to implement? Select all that apply. 1. Fluctuate refrigerator and freezer temperatures each day. 2. Store vaccines in the center of the unit. 3. Check and record the temperature of the unit twice each day. 4. Have a plan for power outages. 5. Place bottles of water in each unit to help keep temperatures consistent.
Answer: 2, 3, 4, 5 Explanation: 1. Appropriate interventions for the nurse to implement in order to maintain the potency of vaccines include storing the vaccines in the center of the unit, checking and recording the temperature of the storage unit twice a day, having a plan for power outages, and placing bottles of water in each unit to help keep temperatures consistent. The temperature of the refrigerator and freezer should be consistent and not fluctuate.
11) The nurse is teaching a prenatal class about infant care. Under which circumstances should the nurse emphasize that parents should call their healthcare provider immediately? Select all that apply. 1. Child 4 months old, received a DTaP immunization yesterday, and has a temperature of 38.0°C (100.4°F) 2. Child under 3 months old and has a temperature over 40.1°C (104.2°F) 3. Child difficult to awaken and has a pulsing fontanel 4. Child has purple spots on the skin and is lethargic. 5. Child has a stiff neck and has been irritable for three days.
Answer: 2, 3, 4, 5 Explanation: 1. Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1°C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for 3 days in infants and children of any age may indicate meningitis. A mild fever of 38.0°C (100.4°F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.
10) A nurse notes blue sclera during a newborn assessment. Which item will the newborn require further assessment for based on this finding? 1. Marfan syndrome 2. Achondroplasia 3. Osteogenesis imperfecta 4. Muscular dystrophy
Answer: 3 Explanation: 1. Clinical manifestations of osteogenesis imperfecta include blue sclera. This is not present in Marfan syndrome, achondroplasia, or muscular dystrophy.
5) A child is admitted to the hospital unit with a diagnosis of minimal-change nephrotic syndrome (MCNS). Which clinical manifestations does the nurse anticipate when conducting the admission assessment? 1. Hematuria, bacteriuria, weight gain 2. Gross hematuria, albuminuria, fever 3. Massive proteinuria, hypoalbuminemia, edema 4. Hypertension, weight loss, proteinuria
Answer: 3 Explanation: 1. Nephrotic syndrome is an alteration in kidney function secondary to increased glomerular basement membrane permeability to plasma protein. It is characterized by massive proteinuria, hypoalbuminemia, and edema. While hematuria and hypertension may be present, they are not pronounced. Gross hematuria and hypertension are associated with glomerulonephritis. Bacteriuria and fever are associated with a urinary tract infection. Because of the edema, a weight gain, not a weight loss, would be seen.
10) A newborn is suspected of having cystic fibrosis. As the child is being prepared for transfer to a pediatric hospital, the mother asks the nurse which symptoms made the practitioner suspect cystic fibrosis. Which response by the nurse is the most appropriate? 1. Steatorrheic stools 2. Constipation 3. Meconium ileus 4. Rectal prolapse
Answer: 3 Explanation: 1. Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child.
10) The school nurse is trying to prevent the spread of a flu virus through the school. Which infection-control strategies can be employed to prevent the spread of the flu virus? Select all that apply. 1. Teaching parents safe food preparation and storage 2. Withholding immunizations for children with compromised immune systems 3. Sanitizing toys, telephones, and door knobs to kill pathogens 4. Separating children with infections from children who are well 5. Teaching children to wash their hands after using the bathroom
Answer: 3, 4, 5 Explanation: 1. To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.
4) A mother refuses to have her child be immunized with measles, mumps, and rubella (MMR) vaccine because she believes that letting her infant get these diseases will help him fight off other diseases later in life. Which response by the nurse is most appropriate? 1. Honor her request because she is the parent. 2. Explain that antibodies can fight many diseases. 3. Tell her that not immunizing her infant may protect pregnant women. 4. Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases.
Answer: 4 Explanation: 1. Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Honoring her request is not correct because the nurse has a professional duty to explain that the mother's belief about immunizations is erroneous and may result in harm to her infant. Explaining that antibodies can fight many diseases is not correct because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease. Telling her that not immunizing her infant may protect pregnant women is not correct because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.
5) A parent reports that her school-age child, who has had all recommended immunizations, had a mild fever one week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. Which disease process does the nurse suspect based on the parent's description? 1. Chicken pox (varicella) 2. German measles (rubella) 3. Roseola (exanthem subitum) 4. Fifth disease (erythema infectiosum)
Answer: 4 Explanation: 1. Fifth disease manifests first with a flulike illness, followed by a red "slapped-cheek" sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. The rash of varicella progresses from papules to vesicles to pustules. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.
3) The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis (DTaP) and second inactivated polio vaccine (IPV) immunization injections for an infant who is 4 months old. The nurse may also give which of immunizations during the same well-child-care appointment? 1. Var (varicella) 2. TIV (influenza) 3. MMR (measles, mumps, rubella) 4. Haemophilus influenza type B (HIB)
Answer: 4 Explanation: 1. Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 12 to 15 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 12 to 15 months and 4 to 6 years of age (two doses). Varicella (Var) is given at 12 to 18 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 4 to 8 weeks apart.
7) Reducing the number of preventable childhood illnesses is a major national goal in Healthy People 2020. What will the school nurse teach families regarding immunizations in order to reach this goal? 1. A minor illness with a low-grade fever is a contraindication to receiving an immunization according to Healthy People 2020. 2. Vaccines should be given one at a time for optimum active immunity in the prevention of illness and disease. 3. Premature infants and low-birth-weight infants should receive half doses of vaccines for protection from communicable diseases. 4. It is important to maintain vaccination coverage for recommended vaccines in early childhood and to maintain them through kindergarten.
Answer: 4 Explanation: 1. The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.