Wong's Pediatrics Chp. 24,25,26,27

Chapter 24: The Child with Gastrointestinal Dysfunction MULTIPLE CHOICE 1. Which condition in a child should alert a nurse for increased fluid requirements? a. Fever b. Mechanical ventilation c. Congestive heart failure d. Increased intracranial pressure (ICP) ANS: A Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid overload in children. Increased ICP does not lead to increased fluid requirements in children. PTS: 1 DIF: Cognitive Level: Understand REF: 763 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 2. A nurse is conducting an in-service on gastrointestinal disorders. The nurse includes that melena, the passage of black, tarry stools, suggests bleeding from which area? a. Perianal or rectal area b. Hemorrhoids or anal fissures c. Upper gastrointestinal (GI) tract d. Lower GI tract ANS: C Melena is denatured blood from the upper GI tract or bleeding from the right colon. Blood from the perianal or rectal area, hemorrhoids, or lower GI tract would be bright red. PTS: 1 DIF: Cognitive Level: Apply REF: 792 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 3. Which type of dehydration is defined as "dehydration that occurs in conditions in which electrolyte and water deficits are present in approximately balanced proportion"? a. Isotonic dehydration b. Hypotonic dehydration c. Hypertonic dehydration d. All types of dehydration in infants and small children ANS: A Isotonic dehydration is the correct term for this definition and is the most frequent form of dehydration in children. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. Hypertonic dehydration results from water loss in excess of electrolyte loss and is usually caused by a proportionately larger loss of water or a larger intake of electrolytes. This definition is specific to isotonic dehydration. PTS: 1 DIF: Cognitive Level: Understand REF: 767 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 4. A nurse is admitting an infant with dehydration caused from water loss in excess of electrolyte loss. Which type of dehydration is this infant experiencing? a. Isotonic b. Isosmotic c. Hypotonic d. Hypertonic ANS: D Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion and is another term for isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. PTS: 1 DIF: Cognitive Level: Understand REF: 767 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 5. An infant is brought to the emergency department with dehydration. Which physical assessment finding does the nurse expect? a. Weight gain b. Bradycardia c. Poor skin turgor d. Brisk capillary refill ANS: C Clinical manifestations of dehydration include poor skin turgor, weight loss, lethargy, and tachycardia. The infant would have prolonged capillary refill, not brisk. PTS: 1 DIF: Cognitive Level: Understand REF: 767 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 6. Parents call the clinic and report that their toddler has had acute diarrhea for 24 hours. The nurse should further ask the parents if the toddler has which associated factor that is causing the acute diarrhea? a. Celiac disease b. Antibiotic therapy c. Immunodeficiency d. Protein malnutrition ANS: B Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy. Celiac disease is a problem with gluten intolerance and may cause chronic diarrhea if not identified and managed appropriately. Immunodeficiency would occur with chronic diarrhea. Protein malnutrition or kwashiorkor causes chronic diarrhea from lowered resistance to infection. PTS: 1 DIF: Cognitive Level: Apply REF: 772 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 7. Which pathogen is the viral pathogen that frequently causes acute diarrhea in young children? a. Giardia organisms b. Shigella organisms c. Rotavirus d. Salmonella organisms ANS: C Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia (parasite) and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial pathogen that is uncommon in the United States. PTS: 1 DIF: Cognitive Level: Understand REF: 772 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 8. Which is a parasite that causes acute diarrhea? a. Shigella organisms b. Salmonella organisms c. Giardia lamblia d. Escherichia coli ANS: C G. lamblia is a parasite that represents 10% of non-dysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens. PTS: 1 DIF: Cognitive Level: Understand REF: 775 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 9. A child is admitted with bacterial gastroenteritis. Which lab results of a stool specimen confirm this diagnosis? a. Eosinophils b. Occult blood c. pH less than 6 d. Neutrophils and red blood cells ANS: D Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance and parasitic infections are suspected in the presence of eosinophils. Occult blood may indicate pathogens such as Shigella, Campylobacter, or hemorrhagic Escherichia coli strains. A pH of less than 6 may indicate carbohydrate malabsorption or secondary lactase insufficiency. PTS: 1 DIF: Cognitive Level: Understand REF: 775 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 10. Which therapeutic management should the nurse prepare to initiate first for a child with acute diarrhea and moderate dehydration? a. Clear liquids b. Adsorbents, such as kaolin and pectin c. Oral rehydration solution (ORS) d. Antidiarrheal medications such as paregoric ANS: C ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended. Antidiarrheals are not recommended because they do not get rid of pathogens. PTS: 1 DIF: Cognitive Level: Apply REF: 775 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 11. A school-age child with diarrhea has been rehydrated. The nurse is discussing the child's diet with the family. Which statement by the parent would indicate a correct understanding of the teaching? a. "I will keep my child on a clear liquid diet for the next 24 hours." b. "I should encourage my child to drink carbonated drinks but avoid food for the next 24 hours." c. "I will offer my child bananas, rice, applesauce, and toast for the next 48 hours." d. "I should have my child eat a normal diet with easily digested foods for the next 48 hours." ANS: D Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness. Clear liquids and carbonated drinks have high carbohydrate content and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. The BRAT diet has little nutritional value and is high in carbohydrates. PTS: 1 DIF: Cognitive Level: Apply REF: 775-776 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 12. A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child should begin with: a. intravenous (IV) fluids. b. ORS. c. clear liquids, 1 to 2 ounces at a time. d. administration of antidiarrheal medication. ANS: A In children with severe dehydration, IV fluids are initiated. ORS is acceptable therapy if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth. These fluids have a high carbohydrate content, low electrolyte content, and high osmolality. Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea. PTS: 1 DIF: Cognitive Level: Apply REF: 776 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 13. A mother calls the clinic nurse about her 4-year-old son who has acute diarrhea. She has been giving him the antidiarrheal drug loperamide (Imodium A-D). The nurse's response should be based on knowledge that this drug is: a. not indicated. b. indicated because it slows intestinal motility. c. indicated because it decreases diarrhea. d. indicated because it decreases fluid and electrolyte losses. ANS: A Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea. These medications have adverse effects and toxicity, such as worsening of the diarrhea because of slowing of motility and ileus, or a decrease in diarrhea with continuing fluid losses and dehydration. Antidiarrheal medications are not recommended in infants and small children. PTS: 1 DIF: Cognitive Level: Analyze REF: 777 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 14. Constipation has recently become a problem for a school-age girl. She is healthy except for seasonal allergies that are being treated with antihistamines. The nurse should suspect that the constipation is most likely caused by: a. diet. b. allergies. c. antihistamines. d. emotional factors. ANS: C Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids, antiepileptics, and iron. Because this is the only known change in her habits, the addition of antihistamines is most likely the cause of the diarrhea. With a change in bowel habits, the role of any recently prescribed medications should be assessed. PTS: 1 DIF: Cognitive Level: Analyze REF: 778 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 15. Which is a high-fiber food that the nurse should recommend for a child with chronic constipation? a. Popcorn b. Pancakes c. Muffins d. Ripe bananas ANS: A Popcorn is a high-fiber food. Pancakes and muffins do not have significant fiber unless made with fruit or bran. Raw fruits, especially those with skins and seeds, other than ripe bananas, have high fiber. PTS: 1 DIF: Cognitive Level: Apply REF: 779-780 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 16. Which therapeutic management treatment is implemented for children with Hirschsprung disease? a. Daily enemas b. Low-fiber diet c. Permanent colostomy d. Surgical removal of affected section of bowel ANS: D Most children with Hirschsprung disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery. The colostomy that is created in Hirschsprung disease is usually temporary. PTS: 1 DIF: Cognitive Level: Understand REF: 781 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 17. Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease. The enema solution should be: a. tap water. b. normal saline. c. oil retention. d. phosphate preparation. ANS: B Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid overload. Oil-retention enemas will not achieve the "until clear" result. Phosphate enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the phosphate enema can result in diarrhea, which can lead to metabolic acidosis. PTS: 1 DIF: Cognitive Level: Apply REF: 781 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 18. A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child psychologically is: a. not necessary because of child's age. b. not necessary because colostomy is temporary. c. necessary because it will be an adjustment. d. necessary because the child must deal with a negative body image. ANS: C The child's age dictates the type and extent of psychological preparation. When a colostomy is performed, the child who is at least preschool age is told about the procedure and what to expect in concrete terms, with the use of visual aids. It is necessary to prepare a 3-year-old child for procedures. The preschooler is not yet concerned with body image. PTS: 1 DIF: Cognitive Level: Understand REF: 781 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Psychosocial Integrity: Coping and Adaptation 19. The nurse is explaining to a parent how to care for a school-age child with vomiting associated with a viral illness. Which action should the nurse include? a. Avoid carbohydrate-containing liquids. b. Give nothing by mouth for 24 hours. c. Brush teeth or rinse mouth after vomiting. d. Give plain water until vomiting ceases for at least 24 hours. ANS: C It is important to emphasize the need for the child to brush the teeth or rinse the mouth after vomiting to dilute the hydrochloric acid that comes in contact with the teeth. Ad libitum administration of glucose-electrolyte solution to an alert child will help restore water and electrolytes satisfactorily. It is important to include carbohydrate to spare body protein and avoid ketosis. PTS: 1 DIF: Cognitive Level: Apply REF: 782 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 20. A 4-month-old infant has gastroesophageal reflux (GER) but is thriving without other complications. Which should the nurse suggest to minimize reflux? a. Place in Trendelenburg position after eating. b. Thicken formula with rice cereal. c. Give continuous nasogastric tube feedings. d. Give larger, less frequent feedings. ANS: B Small, frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula has been recommended. Milk-thickening agents have been shown to decrease the number of episodes of vomiting and to increase the caloric density of the formula. This may benefit infants who are underweight as a result of GER disease. Placing the child in a Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive. PTS: 1 DIF: Cognitive Level: Apply REF: 783 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 21. A histamine-receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is ordered for an infant with GER. The purpose of this is to: a. prevent reflux. b. prevent hematemesis. c. reduce gastric acid production. d. increase gastric acid production. ANS: C The mechanism of action of histamine-receptor antagonists is to reduce the amount of acid present in gastric contents and perhaps prevent esophagitis. Preventing reflux or hematemesis and increasing gastric acid production are not the modes of action of histamine-receptor antagonists. PTS: 1 DIF: Cognitive Level: Understand REF: 783 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 22. Which clinical manifestation would be the most suggestive of acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Abdominal pain that is most intense at McBurney point ANS: D Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain localizes to the right lower quadrant at McBurney point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Bright red or dark red rectal bleeding and abdominal pain that is relieved by eating are not signs of acute appendicitis. PTS: 1 DIF: Cognitive Level: Understand REF: 785 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 23. When caring for a child with probable appendicitis, the nurse should be alert to recognize that which condition or symptom is a sign of perforation? a. Bradycardia b. Anorexia c. Sudden relief from pain d. Decreased abdominal distention ANS: C Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical manifestation of appendicitis. Abdominal distention usually increases. PTS: 1 DIF: Cognitive Level: Understand REF: 786 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 24. The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. Which is appropriate to relieve the abdominal discomfort? a. Place in Trendelenburg position. b. Allow to assume position of comfort. c. Apply moist heat to the abdomen. d. Administer a saline enema to cleanse bowel. ANS: B The child should be allowed to take a position of comfort, usually with the legs flexed. The Trendelenburg position will not help with the discomfort. In any instance in which appendicitis is a possibility, there is a danger in administering a laxative or enemas or applying heat to the area. Such measures stimulate bowel motility and increase the risk of perforation. PTS: 1 DIF: Cognitive Level: Apply REF: 787 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 25. A nurse is conducting an in-service on childhood gastrointestinal disorders. Which statement is most descriptive of Meckel diverticulum? a. It is more common in females than in males. b. It is acquired during childhood. c. Intestinal bleeding may be mild or profuse. d. Medical interventions are usually sufficient to treat the problem. ANS: C Bloody stools are often a presenting sign of Meckel diverticulum. It is associated with mild to profuse intestinal bleeding. It is twice as common in males as in females, and complications are more frequent in males. Meckel diverticulum is the most common congenital malformation of the GI tract and is present in 1% to 4% of the general population. The standard therapy is surgical removal of the diverticulum. PTS: 1 DIF: Cognitive Level: Apply REF: 788 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 26. A nurse is admitting a child with Crohn disease. Parents ask the nurse, "How is this disease different from ulcerative colitis?" Which statement should the nurse make when answering this question? a. "With Crohn's the inflammatory process involves the whole GI tract." b. "There is no difference between the two diseases." c. "The inflammation with Crohn's is limited to the colon and rectum." d. "Ulcerative colitis is characterized by skip lesions." ANS: A The chronic inflammatory process of Crohn disease involves any part of the GI tract from the mouth to the anus but most often affects the terminal ileum. Crohn disease involves all layers of the bowel wall in a discontinuous fashion, meaning that between areas of intact mucosa, there are areas of affected mucosa (skip lesions). The inflammation found with ulcerative colitis is limited to the colon and rectum, with the distal colon and rectum the most severely affected. Inflammation affects the mucosa and submucosa and involves continuous segments along the length of the bowel with varying degrees of ulceration, bleeding, and edema. PTS: 1 DIF: Cognitive Level: Apply REF: 789 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 27. Which is used to treat moderate to severe inflammatory bowel disease? a. Antacids b. Antibiotics c. Corticosteroids d. Antidiarrheal medications ANS: C Corticosteroids, such as prednisone and prednisolone, are used in short bursts to suppress the inflammatory response in inflammatory bowel disease. Antacids and antidiarrheal medications are not drugs of choice in the treatment of inflammatory bowel disease. Antibiotics may be used as an adjunctive therapy to treat complications. PTS: 1 DIF: Cognitive Level: Understand REF: 790 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 28. Bismuth subsalicylate, clarithromycin, and metronidazole are prescribed for a child with a peptic ulcer to: a. eradicate Helicobacter pylori. b. coat gastric mucosa. c. treat epigastric pain. d. reduce gastric acid production. ANS: A The drug therapy combination of bismuth subsalicylate, clarithromycin, and metronidazole is effective in the treatment of H. pylori and is prescribed to eradicate it. PTS: 1 DIF: Cognitive Level: Understand REF: 793 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 29. Which statement best characterizes hepatitis A? a. Incubation period is 6 weeks to 6 months. b. Principal mode of transmission is through the parenteral route. c. Onset is usually rapid and acute. d. There is a persistent carrier state. ANS: C Hepatitis A is the most common form of acute hepatitis in most parts of the world. It is characterized by a rapid and acute onset. The incubation period is approximately 3 weeks for hepatitis A and the principal mode of transmission for it is the fecal-oral route. Hepatitis A does not have a carrier state. PTS: 1 DIF: Cognitive Level: Understand REF: 795 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 30. Which vaccine is now recommended for the immunization of all newborns? a. Hepatitis A vaccine b. Hepatitis B vaccine c. Hepatitis C vaccine d. Hepatitis A, B, and C vaccines ANS: B Universal vaccination for hepatitis B is now recommended for all newborns. A vaccine is available for hepatitis A, but it is not yet universally recommended. No vaccine is currently available for hepatitis C. Only hepatitis B vaccine is recommended for newborns. PTS: 1 DIF: Cognitive Level: Understand REF: 797 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Health Promotion and Maintenance 31. The best chance of survival for a child with cirrhosis is: a. liver transplantation. b. treatment with corticosteroids. c. treatment with immune globulin. d. provision of nutritional support. ANS: A The only successful treatment for end-stage liver disease and liver failure may be liver transplantation, which has improved the prognosis for many children with cirrhosis. Liver transplantation has revolutionized the approach to cirrhosis. Liver failure and cirrhosis are indications for transplantation. Liver transplantation reflects the failure of other medical and surgical measures to prevent or treat cirrhosis. PTS: 1 DIF: Cognitive Level: Understand REF: 798 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 32. A nurse is admitting an infant with biliary atresia. Which is the earliest clinical manifestation of biliary atresia the nurse should expect to assess? a. Jaundice b. Vomiting c. Hepatomegaly d. Absence of stooling ANS: A Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in the sclera, may be present at birth, but is usually not apparent until age 2 to 3 weeks. Vomiting is not associated with biliary atresia. Hepatomegaly and abdominal distention are common but occur later. Stools are large and lighter in color than expected because of the lack of bile. PTS: 1 DIF: Cognitive Level: Understand REF: 798-799 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 33. A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. Initial therapeutic approach to the mother should be: a. restating what the physician has told her about plastic surgery. b. encouraging her to express her feelings. c. emphasizing the normalcy of her baby and the baby's need for mothering. d. recognizing that negative feelings toward the child continue throughout childhood. ANS: B For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must place emphasize not only the infant's physical needs but also the parents' emotional needs. The mother needs to be able to express her feelings before she can accept her child. Although the nurse will restate what the physician has told the mother about plastic surgery, it is not part of the initial therapeutic approach. As the mother expresses her feelings, the nurse's actions should convey to the parents that the infant is a precious human being. The nurse emphasizes the child's normalcy and helps the mother recognize the child's uniqueness. Maternal-infant attachment was not negatively affected at age 1 year. PTS: 1 DIF: Cognitive Level: Apply REF: 800 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Psychosocial Integrity 34. Caring for the newborn with a cleft lip and palate before surgical repair includes: a. gastrostomy feedings. b. keeping infant in near-horizontal position during feedings. c. allowing little or no sucking. d. providing satisfaction of sucking needs. ANS: D Using special or modified nipples for feeding techniques helps meet the infant's sucking needs. Gastrostomy feedings are usually not indicated. Feeding is best accomplished with the infant's head in an upright position. The child requires both nutritive and nonnutritive sucking. PTS: 1 DIF: Cognitive Level: Apply REF: 801 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 35. A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing interventions should include: a. giving medication to suppress lactation. b. encouraging and helping mother to breastfeed. c. teaching mother to feed breast milk by gavage. d. recommending use of a breast pump to maintain lactation until infant can suck. ANS: B The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infant's oral cavity so that the tongue action facilitates milk expression. Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation. Because breastfeeding can usually be accomplished, gavage feedings are not indicated. The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex. PTS: 1 DIF: Cognitive Level: Apply REF: 801 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 36. The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infant's postoperative care include: a. arm restraints, postural drainage, mouth irrigations. b. cleansing the suture line, supine and side-lying positions, arm restraints. c. mouth irrigations, prone position, cleansing suture line. d. supine and side-lying positions, postural drainage, arm restraints. ANS: B The suture line should be cleansed gently after feeding. The child should be positioned on the back, on the side, or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. There is no reason to perform mouth irrigations, and the child should not be placed in the prone position where injury to the suture site can occur. PTS: 1 DIF: Cognitive Level: Apply REF: 802 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 37. During the first few days after surgery for cleft lip, which intervention should the nurse do? a. Leave infant in crib at all times to prevent suture strain. b. Keep infant heavily sedated to prevent suture strain. c. Remove restraints periodically to cuddle infant. d. Alternate position from prone to side-lying to supine. ANS: C Remove restraints periodically, while supervising the infant, to allow him or her to exercise arms and to provide cuddling and tactile stimulation. The infant should not be left in the crib, but should be removed for appropriate holding and stimulation. Analgesia and sedation are administered for pain. Heavy sedation is not indicated. The child should not be placed in the prone position. PTS: 1 DIF: Cognitive Level: Apply REF: 802 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 38. The nurse is caring for a neonate with a suspected tracheoesophageal fistula. Nursing care should include: a. elevating the head but give nothing by mouth. b. elevating the head for feedings. c. feeding glucose water only. d. avoiding suctioning unless infant is cyanotic. ANS: A When a newborn is suspected of having a tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. Feedings should not be given to infants suspected of having tracheoesophageal fistulas. The oral pharynx should be kept clear of secretion by oral suctioning. This is to prevent the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx. PTS: 1 DIF: Cognitive Level: Apply REF: 803-804 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 39. Which type of hernia has an impaired blood supply to the herniated organ? a. Hiatal hernia b. Incarcerated hernia c. Omphalocele d. Strangulated hernia ANS: D A strangulated hernia is one in which the blood supply to the herniated organ is impaired. Hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus. Incarcerated hernia is a hernia that cannot be reduced easily. Omphalocele is the protrusion of intra-abdominal viscera into the base of the umbilical cord. The sac is covered with peritoneum, not skin. PTS: 1 DIF: Cognitive Level: Understand REF: 805 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 40. Pyloric stenosis can best be described as: a. dilation of the pylorus. b. hypertrophy of the pyloric muscle. c. hypotonicity of the pyloric muscle. d. reduction of tone in the pyloric muscle. ANS: B Hypertrophic pyloric stenosis occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel. Dilation of the pylorus, hypotonicity of the pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis. PTS: 1 DIF: Cognitive Level: Understand REF: 805 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 41. Which observation made of the exposed abdomen is most indicative of pyloric stenosis? a. Abdominal rigidity b. Substernal retraction c. Palpable olive-like mass d. Marked distention of lower abdomen ANS: C The diagnosis of pyloric stenosis is often made after the history and physical examination. The olive-like mass is easily palpated when the stomach is empty, the infant is quiet, and the abdominal muscles are relaxed. Abdominal rigidity and substernal retraction are usually not present. The upper abdomen, not lower abdomen, is distended. PTS: 1 DIF: Cognitive Level: Understand REF: 806 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 42. The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis? a. Abdominal rigidity and pain on palpation b. Rounded abdomen and hypoactive bowel sounds c. Visible peristalsis and weight loss d. Distention of lower abdomen and constipation ANS: C Visible gastric peristaltic waves that move from left to right across the epigastrium and weight loss are observed in pyloric stenosis. Abdominal rigidity and pain on palpation or a rounded abdomen and hypoactive bowel sounds are usually not present. The upper abdomen, not lower abdomen, is distended. PTS: 1 DIF: Cognitive Level: Apply REF: 808 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 43. An infant with pyloric stenosis experiences excessive vomiting that can result in: a. hyperchloremia. b. hypernatremia. c. metabolic acidosis. d. metabolic alkalosis. ANS: D Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Chloride ions and sodium are lost with vomiting. Metabolic alkalosis, not acidosis, is likely. PTS: 1 DIF: Cognitive Level: Understand REF: 808 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 44. Invagination of one segment of bowel within another is called: a. atresia. b. stenosis. c. herniation. d. intussusception. ANS: D Intussusception occurs when a proximal section of the bowel telescopes into a more distal segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction. Invagination of one segment of bowel within another is the definition of intussusception, not atresia, stenosis, or herniation. PTS: 1 DIF: Cognitive Level: Understand REF: 809 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 45. The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. Which nursing action is the most appropriate? a. Notify practitioner. b. Measure abdominal girth. c. Auscultate for bowel sounds. d. Take vital signs, including blood pressure. ANS: A Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic-therapeutic care plan. The first action would be to report the normal stool to the practitioner. PTS: 1 DIF: Cognitive Level: Apply REF: 809 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 46. Which is an important nursing consideration in the care of a child with celiac disease? a. Refer to a nutritionist for detailed dietary instructions and education. b. Help child and family understand that diet restrictions are usually only temporary. c. Teach proper hand washing and standard precautions to prevent disease transmission. d. Suggest ways to cope more effectively with stress to minimize symptoms. ANS: A The main consideration is helping the child adhere to dietary management. Considerable time is spent explaining to the child and parents about the disease process, the specific role of gluten in aggravating the condition, and foods that must be restricted. Referral to a nutritionist would help in this process. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible or stress related. PTS: 1 DIF: Cognitive Level: Apply REF: 814 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 47. An infant with short bowel syndrome will be discharged home on total parenteral nutrition (TPN) and gastrostomy feedings. Nursing care should include: a. preparing family for impending death. b. teaching family signs of central venous catheter infection. c. teaching family how to calculate caloric needs. d. securing TPN and gastrostomy tubing under diaper to lessen risk of dislodgment. ANS: B During TPN therapy, care must be taken to minimize the risk of complications related to the central venous access device, such as catheter infections, occlusions, or accidental removal. This is an important part of family teaching. The prognosis for patients with short bowel syndrome depends in part on the length of residual small intestine. It has improved with advances in TPN. Although parents need to be taught about nutritional needs, the caloric needs and prescribed TPN and rate are the responsibility of the health care team. The tubes should not be placed under the diaper due to risk of infection. PTS: 1 DIF: Cognitive Level: Apply REF: 815 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 48. A nurse is receiving report on a newborn admitted yesterday after a gastroschisis repair. In the report, the nurse is told the newborn has a physician's prescription for an NG tube to low intermittent suction. The reporting nurse confirms that the NG tube is to low intermittent suction and draining light green stomach contents. Upon initial assessment, the nurse notes that the newborn has pulled the NG tube out. Which is the priority action the nurse should take? a. Replace the NG tube and continue the low intermittent suction. b. Leave the NG tube out and notify the physician at the end of the shift. c. Leave the NG tube out and monitor for bowel sounds. d. Replace the NG tube, but leave to gravity drainage instead of low wall suction. ANS: A A newborn with a gastroschisis performed the day before will require bowel decompression with an NG tube to low wall intermittent suction. The nurse's priority action is to replace the NG tube and continue with the low wall intermittent suctioning. The NG tube cannot be left out this soon after surgery. The physician's prescription was to have the NG tube to low wall intermittent suction so the tube cannot be placed to gravity drainage. PTS: 1 DIF: Cognitive Level: Apply REF: 807 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 49. Parents of a child undergoing an endoscopy to rule out peptic ulcer disease (PUD) from H. pylori ask the nurse, "If H. pylori is found will my child need another endoscopy to know that it is gone?" Which is the nurse's best response? a. "Yes, the only way to know the H. pylori has been eradicated is with another endoscopy." b. "We can collect a stool sample and confirm that the H. pylori has been eradicated." c. "A blood test can be done to determine that the H. pylori is no longer present." d. "Your child will always test positive for H. pylori because after treatment it goes into remission, but can't be completely eradicated." ANS: B An upper endoscopy is the procedure initially performed to diagnose PUD. A biopsy can determine the presence of H. pylori. Polyclonal and monoclonal stool antigen tests are an accurate, noninvasive method to confirm H. pylori has been eradicated after treatment. A blood test can identify the presence of the antigen to this organism, but because H. pylori was already present it would not be as accurate as a stool sample to determine whether it has been eradicated. H. pylori can be treated and, once the treatment is complete, the stool sample can determine that it was eradicated. PTS: 1 DIF: Cognitive Level: Apply REF: 793 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 50. A child has recurrent abdominal pain (RAP) and a dairy-free diet has been prescribed for 2 weeks. Which explanation is the reason for prescribing a dairy-free diet? a. To rule out lactose intolerance b. To rule out celiac disease c. To rule out sensitivity to high sugar content d. To rule out peptic ulcer disease ANS: A Treatment for RAP involves providing reassurance and reducing or eliminating symptoms. Dietary modifications may include removal of dairy products to rule out lactose intolerance. Fructose is eliminated to rule out sensitivity to high sugar content and gluten is removed to rule out celiac disease. A dairy-free diet would not rule out peptic ulcer disease. PTS: 1 DIF: Cognitive Level: Understand REF: 784 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. A child who has just had definitive repair of a high rectal malformation is to be discharged. Which should the nurse address in the discharge preparation of this family? (Select all that apply.) a. Perineal and wound care b. Necessity of firm stools to keep suture line clean c. Bowel training beginning as soon as child returns home d. Reporting any changes in stooling patterns to practitioner e. Use of diet modification to prevent constipation ANS: A, D, E Wound care instruction is necessary in a child who is being discharged after surgery. The parents are taught to notify the practitioner if any signs of an anal stricture or other complications develop. Constipation is avoided, since a firm stool will place strain on the suture line. Fiber and stool softeners are often given to keep stools soft and avoid tension on the suture line. The child needs to recover from the surgical procedure. Then bowel training may begin, depending on the child's developmental and physiologic readiness. PTS: 1 DIF: Cognitive Level: Apply REF: 812 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 2. Which is true concerning hepatitis B? (Select all that apply.) a. Hepatitis B cannot exist in carrier state. b. Hepatitis B can be prevented by HBV vaccine. c. Hepatitis B can be transferred to an infant of a breastfeeding mother. d. Onset of hepatitis B is insidious. e. Principal mode of transmission for hepatitis B is fecal-oral route. f. Immunity to hepatitis B occurs after one attack. ANS: B, C, D, F The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is protective against hepatitis B. Hepatitis B can be transferred to an infant of a breastfeeding mother, especially if the mother's nipples are cracked. The onset of hepatitis B is insidious. Immunity develops after one exposure to hepatitis B. Hepatitis B has a carrier state. The fecal-oral route is the principal mode of transmission for hepatitis A. Hepatitis B is transmitted through the parenteral route. PTS: 1 DIF: Cognitive Level: Understand REF: 795 TOP: Integrated Process: Nursing Process: Diagnosis MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 3. A nurse is planning preoperative care for a newborn with tracheoesophageal fistula (TEF). Which interventions should the nurse plan to implement? (Select all that apply.) a. Positioning with head elevated on a 30-degree plane b. Feedings through a gastrostomy tube c. Nasogastric tube to continuous low wall suction d. Suctioning with a Replogle tube passed orally to the end of the pouch e. Gastrostomy tube to gravity drainage ANS: A, D, E The most desirable position for a newborn who has TEF is supine (or sometimes prone) with the head elevated on an inclined plane of at least 30 degrees. This positioning minimizes the reflux of gastric secretions at the distal esophagus into the trachea and bronchi, especially when intraabdominal pressure is elevated. It is imperative to immediately remove any secretions that can be aspirated. Until surgery, the blind pouch is kept empty by intermittent or continuous suction through an indwelling double-lumen or Replogle catheter passed orally or nasally to the end of the pouch. In some cases, a percutaneous gastrostomy tube is inserted and left open so that any air entering the stomach through the fistula can escape, thus minimizing the danger of gastric contents being regurgitated into the trachea. The gastrostomy tube is emptied by gravity drainage. Feedings through the gastrostomy tube and irrigations with fluid are contraindicated before surgery in an infant with a distal TEF. A nasogastric tube to low intermittent suctioning could not be accomplished because the esophagus ends in a blind pouch in TEF. PTS: 1 DIF: Cognitive Level: Apply REF: 804 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 4. The nurse is preparing to care for an infant returning from pyloromyotomy surgery. Which prescribed orders should the nurse anticipate implementing? (Select all that apply.) a. NPO for 24 hours b. Administration of analgesics for pain c. Ice bag to the incisional area d. IV fluids continued until tolerating PO e. Clear liquids as the first feeding ANS: B, D, E Feedings are usually instituted soon after a pyloromyotomy surgery, beginning with clear liquids advancing to formula or breast milk as tolerated. IV fluids are administered until the infant is taking and retaining adequate amounts by mouth. Appropriate analgesics should be given around the clock because pain is continuous. Ice should not be applied to the incisional area as it vasoconstricts and would reduce circulation to the incisional area and impair healing. PTS: 1 DIF: Cognitive Level: Apply REF: 809 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 5. A nurse is conducting dietary teaching on high-fiber foods for parents of a child with constipation. Which foods should the nurse include as being high in fiber? (Select all that apply.) a. White rice b. Avocados c. Whole grain breads d. Bran pancakes e. Raw carrots ANS: C, D, E High-fiber foods include whole grain breads, bran pancakes, and raw carrots. Unrefined (brown) rice is high in fiber but not white rice. Raw fruits, especially those with skins or seeds, other than ripe banana or avocado are high in fiber. PTS: 1 DIF: Cognitive Level: Understand REF: 780 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance SHORT ANSWER 1. A child has an NG tube to continuous low intermittent suction. The physician's prescription is to replace the previous 4-hour NG output with a normal saline piggyback over a 2-hour period. The NG output for the previous 4 hours totaled 50 ml. What milliliter/hour rate should the nurse administer to replace normal saline piggyback? (Record your answer in a whole number.) ANS: 25 The previous total 4-hour output was 50 ml. To run the 50 ml over a 2-hour period, the nurse would divide 50 by 2 = 25. The normal saline replacement fluid would be run at 25 ml per hour. PTS: 1 DIF: Cognitive Level: Apply REF: 775 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

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Chapter 25: The Child with Cardiovascular Dysfunction MULTIPLE CHOICE 1. A chest radiograph film is ordered for a child with suspected cardiac problems. The child's parent asks the nurse, "What will the radiograph show about the heart?" The nurse's response should be based on knowledge that the x-ray film will show: a. bones of chest but not the heart. b. measurement of electrical potential generated from heart muscle. c. permanent record of heart size and configuration. d. computerized image of heart vessels and tissues. ANS: C A chest radiograph will provide information on the heart size and pulmonary blood-flow patterns. It will provide a baseline for future comparisons. The heart will be visible, as well as the sternum and ribs. Electrocardiography (ECG) measures the electrical potential generated from heart muscle. Echocardiography will produce a computerized image of the heart vessels and tissues by using sound waves. PTS: 1 DIF: Cognitive Level: Understand REF: 835 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 2. The nurse is assessing a child after a cardiac catheterization. Which complication should the nurse be assessing for? a. Cardiac arrhythmia b. Hypostatic pneumonia c. Heart failure d. Rapidly increasing blood pressure ANS: A Because a catheter is introduced into the heart, a risk exists of catheter-induced dysrhythmias occurring during the procedure. These are usually transient. Hypostatic pneumonia, heart failure, and rapidly increasing blood pressure are not risks usually associated with cardiac catheterization. PTS: 1 DIF: Cognitive Level: Apply REF: 853 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 3. José is a 4-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be: a. directed at his parents because he is too young to understand. b. detailed in regard to the actual procedures so he will know what to expect. c. done several days before the procedure so that he will be prepared. d. adapted to his level of development so that he can understand. ANS: D Preoperative teaching should always be directed at the child's stage of development. The caregivers also benefit from the same explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. Preschoolers will not understand in-depth descriptions and should be prepared close to the time of the cardiac catheterization. PTS: 1 DIF: Cognitive Level: Apply REF: 822 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 4. Which explanation regarding cardiac catheterization is appropriate for a preschool child? a. Postural drainage will be performed every 4 to 6 hours after the test. b. It is necessary to be completely "asleep" during the test. c. The test is short, usually taking less than 1 hour. d. When the procedure is done, you will have to keep your leg straight for at least 4 hours. ANS: D The child's leg will have to be maintained in a straight position for approximately 4 hours. Younger children can be held in the parent's lap with the leg maintained in the correct position. Postural drainage will not be performed unless the child has corresponding pulmonary problems. The child should be sedated to lie still, but being completely asleep is not necessary. The test will vary in length of time from start to finish. PTS: 1 DIF: Cognitive Level: Apply REF: 823 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 5. The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is to: a. notify physician. b. apply new bandage with more pressure. c. place the child in Trendelenburg position. d. apply direct pressure above catheterization site. ANS: D If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure over the vessel puncture. Notifying a physician and applying a new bandage can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. It is not a helpful intervention to place the girl in the Trendelenburg position. It would increase the drainage from the lower extremities. PTS: 1 DIF: Cognitive Level: Apply REF: 823 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 6. The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the adolescent would indicate a need for further teaching? a. "I should avoid tub baths but may shower." b. "I have to stay on strict bed rest for 3 days." c. "I should remove the pressure dressing the day after the procedure." d. "I may attend school but should avoid exercise for several days." ANS: B The child does not need to be on strict bed rest for 3 days. Showers are recommended; children should avoid a tub bath. The pressure dressing is removed the day after the catheterization and replaced by an adhesive bandage to keep the area clean. Strenuous activity must be avoided for several days, but the child can return to school. PTS: 1 DIF: Cognitive Level: Analyze REF: 823 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 7. Surgical closure of the ductus arteriosus would: a. stop the loss of unoxygenated blood to the systemic circulation. b. decrease the edema in legs and feet. c. increase the oxygenation of blood. d. prevent the return of oxygenated blood to the lungs. ANS: D The ductus arteriosus allows blood to flow from the higher-pressure aorta to the lower-pressure pulmonary artery, causing a right-to-left shunt. If this is surgically closed, no additional oxygenated blood (from the aorta) will return to the lungs through the pulmonary artery. The aorta carries oxygenated blood to the systemic circulation. Because of the higher pressure in the aorta, blood is shunted into the pulmonary artery and the pulmonary circulation. Edema in the legs and feet is usually a sign of heart failure. This repair would not directly affect the edema. Increasing the oxygenation of blood would not interfere with the return of oxygenated blood to the lungs. PTS: 1 DIF: Cognitive Level: Analyze REF: 825 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 8. Which defect results in increased pulmonary blood flow? a. Pulmonic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries ANS: C Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles. Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow. PTS: 1 DIF: Cognitive Level: Understand REF: 825 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 9. The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes tetralogy of Fallot? a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy ANS: A Tetralogy of Fallot has these four characteristics: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not atrial stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular hypertrophy, is present in tetralogy of Fallot. Tetralogy of Fallot has right ventricular hypertrophy, not left ventricular hypertrophy, and an atrial septal defect, not aortic hypertrophy. PTS: 1 DIF: Cognitive Level: Understand REF: 830 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 10. A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow? a. Atrial septal defect b. Tetralogy of Fallot c. Ventricular septal defect d. Patent ductus arteriosus ANS: B Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis increases the pressure in the right ventricle, causing the blood to go from right to left across the ventricular septal defect. Atrial and ventricular septal defects and patent ductus arteriosus result in increased pulmonary blood flow. PTS: 1 DIF: Cognitive Level: Understand REF: 830 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 11. Which is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures? a. Pulmonary congestion b. Congenital heart defect c. Heart failure d. Systemic venous congestion ANS: C The definition of heart failure is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body's metabolic demands. Pulmonary congestion is an excessive accumulation of fluid in the lungs. Congenital heart defect is a malformation of the heart present at birth. Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature. PTS: 1 DIF: Cognitive Level: Understand REF: 830 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 12. Which is a clinical manifestation of the systemic venous congestion that can occur with heart failure? a. Tachypnea b. Tachycardia c. Peripheral edema d. Pale, cool extremities ANS: C Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous congestion. Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale, cool extremities are clinical manifestations of impaired myocardial function. PTS: 1 DIF: Cognitive Level: Understand REF: 835 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 13. The nurse is preparing to administer a dose of digoxin (Lanoxin) to a child in heart failure (HF). Which is a beneficial effect of administering digoxin (Lanoxin)? a. It decreases edema. b. It decreases cardiac output. c. It increases heart size. d. It increases venous pressure. ANS: A Digoxin has a rapid onset and is useful for increasing cardiac output, decreasing venous pressure, and, as a result, decreasing edema. Cardiac output is increased by digoxin. Heart size and venous pressure are decreased by digoxin. PTS: 1 DIF: Cognitive Level: Understand REF: 835 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 14. A nurse is preparing to administer an angiotensin-converting enzyme (ACE) inhibitor. Which drug should the nurse be administering? a. Captopril (Capoten) b. Furosemide (Lasix) c. Spironolactone (Aldactone) d. Chlorothiazide (Diuril) ANS: A Captopril is an ACE inhibitor. Furosemide is a loop diuretic. Spironolactone blocks the action of aldosterone. Chlorothiazide works on the distal tubules. PTS: 1 DIF: Cognitive Level: Remember REF: 835 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 15. An 8-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than _____ beats/min. a. 60 b. 70 c. 90 d. 100 ANS: B If a 1-minute apical pulse is less than 70 beats/min for an older child, the digoxin is withheld; 60 beats/min is the cut-off for holding the digoxin dose in an adult. A pulse below 90 to 110 beats/min is the determination for not giving a digoxin dose to infants and young children. PTS: 1 DIF: Cognitive Level: Apply REF: 836 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 16. A 6-month-old infant is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than _____ beats/min. a. 60 b. 70 c. 90 to 110 d. 110 to 120 ANS: C If the 1-minute apical pulse is below 90 to 110 beats/min, the digoxin should not be given to a 6-month-old. 60 beats/min is the cut-off for holding the digoxin dose in an adult. 70 beats/min is the determining heart rate to hold a dose of digoxin for an older child. 110 to 120 beats/min is an acceptable heart rate to administer digoxin to a 6-month-old. PTS: 1 DIF: Cognitive Level: Apply REF: 836 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 17. The nurse is teaching parents about signs of digoxin (Lanoxin) toxicity. Which is a common sign of digoxin toxicity? a. Seizures b. Vomiting c. Bradypnea d. Tachycardia ANS: B Vomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin toxicity. The child will have a slower heart rate, not respiratory rate. The heart rate will be slower, not faster. PTS: 1 DIF: Cognitive Level: Understand REF: 839 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 18. The parents of a young child with heart failure tell the nurse that they are "nervous" about giving digoxin (Lanoxin). The nurse's response should be based on which statement? a. It is a safe, frequently used drug. b. It is difficult to either overmedicate or undermedicate with digoxin. c. Parents lack the expertise necessary to administer digoxin. d. Parents must learn specific, important guidelines for administration of digoxin. ANS: D Digoxin has a narrow therapeutic range. The margin of safety between therapeutic, toxic, and lethal doses is very small. Specific guidelines are available for parents to learn how to administer the drug safely and to monitor for side effects. Digoxin is a frequently used drug, but it has a narrow therapeutic range. Small amounts of the liquid are given to infants, making it easy to overmedicate or undermedicate. Parents may lack the necessary expertise to administer the drug at first, but with discharge preparation, they should be prepared to administer the drug safely. PTS: 1 DIF: Cognitive Level: Apply REF: 839 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 19. The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which statement about feeding the child is correct? a. "You may need to increase the caloric density of your infant's formula." b. "You should feed your baby every 2 hours." c. "You may need to increase the amount of formula your infant eats with each feeding." d. "You should place a nasal oxygen cannula on your infant during and after each feeding." ANS: A The metabolic rate of infants with heart failure is greater because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of the average infants, yet their ability to take in the calories is diminished by their fatigue. Infants with heart failure should be fed every 3 hours; a 2-hour schedule does not allow for enough rest, and a 4-hour schedule is too long. Fluids must be carefully monitored because of the heart failure. Infants do not require supplemental oxygen with feedings. PTS: 1 DIF: Cognitive Level: Apply REF: 838-839 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 20. As part of the treatment for heart failure, the child takes the diuretic furosemide (Lasix). As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in: a. chlorides. b. potassium. c. sodium. d. vitamins. ANS: B Diuretics that work on the proximal and distal renal tubules contribute to increased losses of potassium. The child's diet should be supplemented with this electrolyte. With this type of diuretic, potassium must be monitored and supplemented as needed. PTS: 1 DIF: Cognitive Level: Understand REF: 840 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 21. An 8-month-old infant has a hypercyanotic spell while blood is being drawn. The nurse's first action should be to: a. assess for neurologic defects. b. place the child in the knee-chest position. c. begin cardiopulmonary resuscitation. d. prepare family for imminent death. ANS: B The first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. The child should be assessed for airway, breathing, and circulation. Often, calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell. PTS: 1 DIF: Cognitive Level: Apply REF: 841-842 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 22. The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk exists of cerebrovascular accidents (strokes). Which is an important objective to decrease this risk? a. Minimize seizures. b. Prevent dehydration. c. Promote cardiac output. d. Reduce energy expenditure. ANS: B In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents. PTS: 1 DIF: Cognitive Level: Analyze REF: 841 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 23. Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should be based on which statement? a. Child needs opportunities to play with peers. b. Child needs to understand that peers' activities are too strenuous. c. Parents can meet all of the child's needs. d. Constant parental supervision is needed to avoid overexertion. ANS: A The child needs opportunities for social development. Children usually limit their activities if allowed to set their own pace. The child will limit activities as necessary. Parents must be encouraged to seek appropriate social activities for the child, especially before kindergarten. The child needs to have activities that foster independence. The child will be able to regulate activities. PTS: 1 DIF: Cognitive Level: Analyze REF: 843 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Psychosocial Integrity 24. Which should the nurse consider when preparing a school-age child and the family for heart surgery? a. Unfamiliar equipment should not be shown. b. Let child hear the sounds of an ECG monitor. c. Avoid mentioning postoperative discomfort and interventions. d. Explain that an endotracheal tube will not be needed if the surgery goes well. ANS: B The child and family should be exposed to the sights and sounds of the intensive care unit (ICU). All positive, nonfrightening aspects of the environment are emphasized. The child should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous (IV) lines, incision, and endotracheal tube. PTS: 1 DIF: Cognitive Level: Analyze REF: 845 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 25. Seventy-two hours after cardiac surgery, a young child has a temperature of 101° F. Which action should the nurse take? a. Keep child warm with blankets. b. Apply a hypothermia blanket. c. Record temperature on nurses' notes. d. Report findings to physician. ANS: D In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7° C (100° F) as part of the inflammatory response to tissue trauma. If the temperature is higher or continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. Hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique. PTS: 1 DIF: Cognitive Level: Apply REF: 846 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 26. Which is an important nursing consideration when suctioning a young child who has had heart surgery? a. Perform suctioning at least every hour. b. Suction for no longer than 30 seconds at a time. c. Administer supplemental oxygen before and after suctioning. d. Expect symptoms of respiratory distress when suctioning. ANS: C If suctioning is indicated, supplemental oxygen is administered with a manual resuscitation bag before and after the procedure to prevent hypoxia. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique. PTS: 1 DIF: Cognitive Level: Apply REF: 846 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 27. The nurse is caring for a child after heart surgery. Which should the nurse do if evidence is found of cardiac tamponade? a. Increase analgesia. b. Apply warming blankets. c. Immediately report this to physician. d. Encourage child to cough, turn, and breathe deeply. ANS: C If evidence is noted of cardiac tamponade, which is blood or fluid in the pericardial space constricting the heart, the physician is notified immediately of this life-threatening complication. Increasing analgesia may be done before the physician drains the fluid, but the physician must be notified. Warming blankets are not indicated at this time. Encouraging the child to cough, turn, and breathe deeply should be deferred till after the evaluation by the physician. PTS: 1 DIF: Cognitive Level: Apply REF: 846 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 28. Which is an important nursing consideration when chest tubes will be removed from a child? a. Explain that it is not painful. b. Explain that only a Band-Aid will be needed. c. Administer analgesics before procedure. d. Expect bright red drainage for several hours after removal. ANS: C It is appropriate to prepare the child for the removal of chest tubes with analgesics. Short-acting medications can be used that are administered through an existing IV line. A sharp, momentary pain is felt. This should not be misrepresented to the child. A petroleum gauze, air-tight dressing will be needed, but it is not a pain-free procedure. Little or no drainage should be found on removal. PTS: 1 DIF: Cognitive Level: Apply REF: 846 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 29. Which is the most common causative agent of bacterial endocarditis? a. Staphylococcus albus b. Streptococcus hemolyticus c. Staphylococcus albicans d. Streptococcus viridans ANS: D S. viridans is the most common causative agent in bacterial (infective) endocarditis. Staphylococcus albus, Streptococcus hemolyticus, and Staphylococcus albicans are not common causative agents. PTS: 1 DIF: Cognitive Level: Remember REF: 848 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 30. Which painful, tender, pea-sized nodules may appear on the pads of the fingers or toes in bacterial endocarditis? a. Osler nodes b. Janeway lesions c. Subcutaneous nodules d. Aschoff nodes ANS: A Osler nodes are red, painful, intradermal nodes found on pads of the phalanges in bacterial endocarditis. Janeway lesions are painless hemorrhagic areas on palms and soles in bacterial endocarditis. Subcutaneous nodules are nontender swellings, located over bony prominences, commonly found in rheumatic fever. Aschoff nodules are small nodules composed of cells and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis. PTS: 1 DIF: Cognitive Level: Understand REF: 848 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 31. The primary nursing intervention to prevent bacterial endocarditis is to: a. institute measures to prevent dental procedures. b. counsel parents of high-risk children about prophylactic antibiotics. c. observe children for complications, such as embolism and heart failure. d. encourage restricted mobility in susceptible children. ANS: B The objective of nursing care is to counsel the parents of high-risk children about both the need for prophylactic antibiotics for dental procedures and the necessity of maintaining excellent oral health. The child's dentist should be aware of the child's cardiac condition. Dental procedures should be done to maintain a high level of oral health. Prophylactic antibiotics are necessary. Children should be observed for complications such as embolism and heart failure and restricted mobility should be encouraged in susceptible children, but maintaining good oral health and prophylactic antibiotics is important. PTS: 1 DIF: Cognitive Level: Apply REF: 848 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 32. Which is a common, serious complication of rheumatic fever? a. Seizures b. Cardiac arrhythmias c. Pulmonary hypertension d. Cardiac valve damage ANS: D Cardiac valve damage is the most significant complication of rheumatic fever. Seizures, cardiac arrhythmias, and pulmonary hypertension are not common complications of rheumatic fever. PTS: 1 DIF: Cognitive Level: Understand REF: 849 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 33. The nurse is conducting a staff in-service on childhood-acquired heart diseases. Which is a major clinical manifestation of rheumatic fever? a. Polyarthritis b. Osler nodes c. Janeway spots d. Splinter hemorrhages of distal third of nails ANS: A Polyarthritis, which is swollen, hot, red, and painful joints, is a major clinical manifestation of rheumatic fever. The affected joints will change every 1 to 2 days. Primarily the large joints are affected. Osler nodes, Janeway spots, and splinter hemorrhages are characteristic of infective endocarditis. PTS: 1 DIF: Cognitive Level: Apply REF: 850 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 34. The nurse is admitting a child with rheumatic fever. Which therapeutic management should the nurse expect to implement? a. Administering penicillin b. Avoiding salicylates (aspirin) c. Imposing strict bed rest for 4 to 6 weeks d. Administering corticosteroids if chorea develops ANS: A The goal of medical management is the eradication of the hemolytic streptococci. Penicillin is the drug of choice. Salicylates can be used to control the inflammatory process, especially in the joints, and reduce the fever and discomfort. Bed rest is recommended for the acute febrile stage, but it does not need to be strict. The chorea is transient and will resolve without treatment. PTS: 1 DIF: Cognitive Level: Apply REF: 849 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 35. Which action by the school nurse is important in the prevention of rheumatic fever? a. Encourage routine cholesterol screenings. b. Conduct routine blood pressure screenings. c. Refer children with sore throats for throat cultures. d. Recommend salicylates instead of acetaminophen for minor discomforts. ANS: C Nurses have a role in prevention—primarily in screening school-age children for sore throats caused by group A -hemolytic streptococci. They can achieve this by actively participating in throat culture screening or by referring children with possible streptococcal sore throats for testing. Cholesterol and blood pressure screenings do not facilitate the recognition and treatment of group A -hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses. PTS: 1 DIF: Cognitive Level: Apply REF: 849-850 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 36. When discussing hyperlipidemia with a group of adolescents, the nurse should explain that cardiovascular disease can be prevented by high levels of: a. cholesterol. b. triglycerides. c. low-density lipoproteins (LDLs). d. high-density lipoproteins (HDLs). ANS: D HDLs contain very low concentrations of triglycerides, relatively little cholesterol, and high levels of proteins. It is thought that HDLs protect against cardiovascular disease. Cholesterol, triglycerides, and LDLs are not protective against cardiovascular disease. PTS: 1 DIF: Cognitive Level: Apply REF: 851 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 37. Which is the leading cause of death after heart transplantation? a. Infection b. Rejection c. Cardiomyopathy d. Heart failure ANS: B The posttransplant course is complex. The leading cause of death after cardiac transplantation is rejection. Infection is a continued risk secondary to the immunosuppression necessary to prevent rejection. Cardiomyopathy is one of the indications for cardiac transplant. Heart failure is not a leading cause of death. PTS: 1 DIF: Cognitive Level: Remember REF: 856 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 38. When caring for the child with Kawasaki disease, the nurse should know which information? a. A child's fever is usually responsive to antibiotics within 48 hours. b. The principal area of involvement is the joints. c. Aspirin is contraindicated. d. Therapeutic management includes administration of gamma globulin and aspirin. ANS: D High-dose IV gamma globulin and aspirin therapy is indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. The fever of Kawasaki disease is unresponsive to antibiotics and antipyretics. Mucous membranes, conjunctiva, changes in the extremities, and cardiac involvement are seen. Aspirin is part of the therapy. PTS: 1 DIF: Cognitive Level: Apply REF: 859 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 39. The nurse is teaching nursing students about shock that occurs in children. One of the most frequent causes of hypovolemic shock in children is: a. sepsis. b. blood loss. c. anaphylaxis. d. congenital heart disease. ANS: B Blood loss is the most frequent cause of hypovolemic shock in children. Sepsis causes septic shock, which is overwhelming sepsis and circulating bacterial toxins. Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Congenital heart disease contributes to hypervolemia, not hypovolemia. PTS: 1 DIF: Cognitive Level: Understand REF: 860 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 40. Which type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy? a. Neurogenic b. Cardiogenic c. Hypovolemic d. Anaphylactic ANS: D Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission that occurs from a spinal cord injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure. PTS: 1 DIF: Cognitive Level: Understand REF: 862-863 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 41. Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock? a. Thirst b. Irritability c. Apprehension d. Confusion and somnolence ANS: D Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock. PTS: 1 DIF: Cognitive Level: Understand REF: 861 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 42. Which occurs in septic shock? a. Hypothermia b. Increased cardiac output c. Vasoconstriction d. Angioneurotic edema ANS: B Increased cardiac output, which results in warm, flushed skin, is one of the manifestations of septic shock. Fever and chills are characteristic of septic shock. Vasodilation is more common than vasoconstriction. Angioneurotic edema occurs as a manifestation in anaphylactic shock. PTS: 1 DIF: Cognitive Level: Understand REF: 864 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 43. A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, the nurse should prepare which medication for immediate administration? a. Diphenhydramine (Benadryl) b. Dobutamine (Dobutarex) c. Epinephrine (Adrenalin) d. Calcium chloride (calcium chloride) ANS: C After the first priority of establishing an airway, administration of epinephrine is the drug of choice. Diphenhydramine, an antihistamine, is usually not used for severe reactions. Dobutamine and calcium chloride are not appropriate drugs for this type of reaction. PTS: 1 DIF: Cognitive Level: Apply REF: 862 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 44. Clinical manifestations of toxic shock syndrome include: a. severe hypertension. b. subnormal temperature. c. erythematous macular rash. d. papular rash over extremities. ANS: C One of the diagnostic criteria for toxic shock syndrome is a diffuse macular erythroderma. Hypotension is one of the manifestations. Fever of 38.9° C or higher is a characteristic. Desquamation of the palms and soles of the feet occurs in about 1 to 2 weeks. PTS: 1 DIF: Cognitive Level: Understand REF: 864 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 45. A preschool child is scheduled for an echocardiogram. Parents ask the nurse whether they can hold the child during the procedure. The nurse should answer with which response? a. "You will be able to hold your child during the procedure." b. "Your child can be active during the procedure, but can't sit in your lap." c. "Your child must lie quietly; sometimes a mild sedative is administered before the procedure." d. "The procedure is invasive so your child will be restrained during the echocardiogram." ANS: C Although an echocardiogram is noninvasive, painless, and associated with no known side effects, it can be stressful for children. The child must lie quietly in the standard echocardiographic positions; crying, nursing, or sitting up often leads to diagnostic errors or omissions. Therefore, infants and young children may need a mild sedative; older children benefit from psychological preparation for the test. The distraction of a video or movie is often helpful. PTS: 1 DIF: Cognitive Level: Apply REF: 821 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 46. The nurse is caring for an infant with congestive heart disease (CHD). The nurse should plan which intervention to decrease cardiac demands? a. Organize nursing activities to allow for uninterrupted sleep. b. Allow the infant to sleep through feedings during the night. c. Wait for the infant to cry to show definite signs of hunger. d. Discourage parents from rocking the infant ANS: A The infant requires rest and conservation of energy for feeding. Every effort is made to organize nursing activities to allow for uninterrupted periods of sleep. Whenever possible, parents are encouraged to stay with their infant to provide the holding, rocking, and cuddling that help children sleep more soundly. To minimize disturbing the infant, changing bed linens and complete bathing are done only when necessary. Feeding is planned to accommodate the infant's sleep and wake patterns. The child is fed at the first sign of hunger, such as when sucking on fists, rather than waiting until he or she cries for a bottle because the stress of crying exhausts the limited energy supply. Because infants with CHD tire easily and may sleep through feedings, smaller feedings every 3 hours may be helpful. PTS: 1 DIF: Cognitive Level: Apply REF: 839 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 47. The nurse is admitting a child with coarctation of the aorta. Which figure depicts this congenital heart defect? a. c. b. d. ANS: A The figure that depicts a narrowing of the aortic arch is coarctation of the aorta. It typically occurs past the ductal area but can occur in other areas along the aortic arch. The figure that depicts an opening between the atria is atrial septal defect. The figure that depicts an opening between the ventricles is ventricular septal defect. The figure that depicts an opening from the atrium to the pulmonary artery is patent ductus arteriosus. PTS: 1 DIF: Cognitive Level: Analyze REF: 827 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Nursing interventions for the child after a cardiac catheterization should include which actions? (Select all that apply.) a. Allow ambulation as tolerated. b. Monitor vital signs every 2 hours. c. Assess the affected extremity for temperature and color. d. Check pulses above the catheterization site for equality and symmetry. e. Remove pressure dressing after 4 hours. f. Maintain a patent peripheral intravenous catheter until discharge. ANS: C, F The extremity that was used for access for the cardiac catheterization must be checked for temperature and color. Coolness and blanching may indicate arterial occlusion. The child should have a patent peripheral intravenous line (PIV) to ensure adequate hydration. The child should remain on bed rest with the leg extended for a minimum of 4 hours. Initially vital signs are taken every 15 minutes, with emphasis on a heart rate counted for 1 minute. Pulses above the catheterization site should not be affected by the catheterization. Pulses distal to the site should be monitored. The pressure dressings should not be removed for 24 hours. PTS: 1 DIF: Cognitive Level: Apply REF: 822-823 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 2. Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock? (Select all that apply.) a. Thirst and diminished urinary output b. Irritability and apprehension c. Cool extremities and decreased skin turgor d. Confusion and somnolence e. Normal blood pressure and narrowing pulse pressure f. Tachypnea and poor capillary refill time ANS: C, D, F Cool extremities, decreased skin turgor, confusion, somnolence, tachypnea, and poor capillary refill time are beginning signs of decompensated shock. Thirst, diminished urinary output, irritability, apprehension, normal blood pressure, and narrowing pulse pressure are signs of compensated shock. PTS: 1 DIF: Cognitive Level: Analyze REF: 861 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 3. The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include? (Select all that apply.) a. Warm flushed extremities b. Weight loss c. Decreased urinary output d. Sweating (inappropriate) e. Fatigue ANS: C, D, E The signs and symptoms of heart failure include decreased urinary output, sweating, and fatigue. Other signs include pale, cool extremities, not warm and flushed, and weight gain, not weight loss. PTS: 1 DIF: Cognitive Level: Apply REF: 844 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation SHORT ANSWER 1. Which is the acceptable mg/dl level, or below this level, low density lipoprotein (LDL) cholesterol for a child from a family with heart disease? (Record your answer in a whole number.) ANS: 110 The low-density lipoproteins (LDLs) contain low concentrations of triglycerides, high levels of cholesterol, and moderate levels of protein. LDL is the major carrier of cholesterol to the cells. Cells use cholesterol for synthesis of membranes and steroid production. Elevated circulating LDL is a strong risk factor in cardiovascular disease. For children from families with a history of heart disease, the LDL should be <110. PTS: 1 DIF: Cognitive Level: Apply REF: 831 | 851 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation ESSAY 1. An infant with an unrepaired tetralogy of Fallot defect is becoming extremely cyanotic during a routine blood draw. Which interventions should the nurse implement? Place in order from the highest-priority intervention to the lowest-priority intervention. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d). a. Administer 100% oxygen by blow-by. b. Place infant in knee-chest position. c. Remain calm. d. Give morphine subcutaneously or by an existing intravenous line. ANS: b, a, d, c Hypercyanotic spells, also referred to as blue spells or tet spells because they are often seen in infants with tetralogy of Fallot, may occur in any child whose heart defect includes obstruction to pulmonary blood flow and communication between the ventricles. The infant becomes acutely cyanotic and hyperpneic because sudden infundibular spasm decreases pulmonary blood flow and increases right-to-left shunting. Because profound hypoxemia causes cerebral hypoxia, hypercyanotic spells require prompt assessment and treatment to prevent brain damage or possibly death. The infant should first be placed in the knee-chest position to reduce blood returning to the heart. Next 100% oxygen is given to alleviate the hypoxemia. Morphine is next administered to reduce infundibular spasms. Last, the nurse should remain calm. PTS: 1 DIF: Cognitive Level: Apply REF: 842 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 2. A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. Once the airway is established, the nurse should do which action? Place in correct sequence. Provide answer using lowercase letters separated by commas (e.g., a, b, c). a. Administer epinephrine. b. Keep child warm and calm. c. Obtain vascular access. ANS: c, a, b The correct sequence of actions is to obtain vascular access, administer epinephrine, and then to keep the child warm and calm. PTS: 1 DIF: Cognitive Level: Apply REF: 841 | 863 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

Chapter 25

Chapter 26: The Child with Hematologic or Immunologic Dysfunction MULTIPLE CHOICE 1. Which child should the nurse document as being anemic? a. 7-year-old child with a hemoglobin of 11.5 g/dl b. 3-year-old child with a hemoglobin of 12 g/dl c. 14-year-old child with a hemoglobin of 10 g/dl d. 1-year-old child with a hemoglobin of 13 g/dl ANS: D Anemia is a condition in which the number of red blood cells, or hemoglobin concentration, is reduced below the normal values for age. Anemia is defined as a hemoglobin level below 10 or 11 g/dl. The child with a hemoglobin of 10 g/dl would be considered anemic. The normal hemoglobin for a child after 2 years of age is 11.5 to 15.5 g/dl. PTS: 1 DIF: Cognitive Level: Understand REF: 869 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 2. Several blood tests are ordered for a preschool child with severe anemia. The child is crying and upset because of memories of the venipuncture done at the clinic 2 days ago. The nurse should explain: a. venipuncture discomfort is very brief. b. only one venipuncture will be needed. c. topical application of local anesthetic can eliminate venipuncture pain. d. most blood tests on children require only a finger puncture because a small amount of blood is needed. ANS: C Preschool children are concerned with both pain and the loss of blood. When preparing the child for venipuncture, the nurse will use a topical anesthetic to eliminate any pain. This is a traumatic experience for preschool children. They are concerned about their bodily integrity. A local anesthetic should be used, and a bandage should be applied to maintain bodily integrity. The nurse should not promise one attempt in case multiple attempts are required. Both finger punctures and venipunctures are traumatic for children. Both require preparation. PTS: 1 DIF: Cognitive Level: Apply REF: 871 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 3. The nurse is planning activity for a 4-year-old child with anemia. Which activity should the nurse plan for this child? a. Game of "hide and seek" in the children's outdoor play area b. Participation in dance activities in the playroom c. Puppet play in the child's room d. A walk down to the hospital lobby ANS: C Because the basic pathologic process in anemia is a decrease in oxygen-carrying capacity, an important nursing responsibility is to assess the child's energy level and minimize excess demands. The child's level of tolerance for activities of daily living and play is assessed, and adjustments are made to allow as much self-care as possible without undue exertion. Puppet play in the child's room would not be overly tiring. Hide and seek, dancing, and walking to the lobby would not conserve the anemic child's energy. PTS: 1 DIF: Cognitive Level: Apply REF: 871 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 4. The nurse is teaching parents about the importance of iron in a toddler's diet. Which explains why iron deficiency anemia is common during toddlerhood? a. Milk is a poor source of iron. b. Iron cannot be stored during fetal development. c. Fetal iron stores are depleted by age 1 month. d. Dietary iron cannot be started until age 12 months. ANS: A Children between the ages of 12 and 36 months are at risk for anemia because cow's milk is a major component of their diet and it is a poor source of iron. Iron is stored during fetal development, but the amount stored depends on maternal iron stores. Fetal iron stores are usually depleted by age 5 to 6 months. Dietary iron can be introduced by breastfeeding, iron-fortified formula, and cereals during the first 12 months of life. PTS: 1 DIF: Cognitive Level: Understand REF: 872 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 5. The nurse is teaching parents of an infant about the causes of iron deficiency anemia. Which statement best describes iron deficiency anemia in infants? a. It is caused by depression of the hematopoietic system. b. It is easily diagnosed because of an infant's emaciated appearance. c. Clinical manifestations are similar regardless of the cause of the anemia. d. Clinical manifestations result from a decreased intake of milk and the premature addition of solid foods. ANS: C In iron deficiency anemia, the child's clinical appearance is a result of the anemia, not the underlying cause. Usually the hematopoietic system is not depressed in iron deficiency anemia. The bone marrow produces red cells that are smaller and contain less hemoglobin than normal red cells. Children who are iron deficient from drinking excessive quantities of milk are usually pale and overweight. They are receiving sufficient calories, but are deficient in essential nutrients. The clinical manifestations result from decreased intake of iron-fortified solid foods and an excessive intake of milk. PTS: 1 DIF: Cognitive Level: Apply REF: 872 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 6. Which should the nurse include when teaching the mother of a 9-month-old infant about administering liquid iron preparations? a. They should be given with meals. b. They should be stopped immediately if nausea and vomiting occur. c. Adequate dosage will turn the stools a tarry green color. d. Allow preparation to mix with saliva and bathe the teeth before swallowing. ANS: C The nurse should prepare the mother for the anticipated change in the child's stools. If the iron dose is adequate, the stools will become a tarry green color. The lack of the color change may indicate insufficient iron. The iron should be given in two divided doses between meals when the presence of free hydrochloric acid is greatest. Iron is absorbed best in an acidic environment. Vomiting and diarrhea may occur with iron administration. If these occur, the iron should be given with meals, and the dosage reduced, then gradually increased as the child develops tolerance. Liquid preparations of iron stain the teeth. They should be administered through a straw and the mouth rinsed after administration. PTS: 1 DIF: Cognitive Level: Apply REF: 873 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 7. Iron dextran is ordered for a young child with severe iron deficiency anemia. Nursing considerations include to: a. administer with meals. b. administer between meals. c. inject deeply into a large muscle. d. massage injection site for 5 minutes after administration of drug. ANS: C Iron dextran is a parenteral form of iron. When administered intramuscularly, it must be injected into a large muscle. Iron dextran is for intramuscular or intravenous (IV) administration. The site should not be massaged to prevent leakage, potential irritation, and staining of the skin. PTS: 1 DIF: Cognitive Level: Apply REF: 873 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 8. The nurse is recommending how to prevent iron deficiency anemia in a healthy, term, breast-fed infant. Which should be suggested? a. Iron (ferrous sulfate) drops after age 1 month b. Iron-fortified commercial formula by age 4 to 6 months c. Iron-fortified infant cereal by age 2 months d. Iron-fortified infant cereal by age 4 to 6 months ANS: D Breast milk supplies inadequate iron for growth and development after age 5 months. Supplementation is necessary at this time. The mother can supplement the breastfeeding with iron-fortified infant cereal. Iron supplementation or the introduction of solid foods in a breast-fed baby is not indicated. Providing iron-fortified commercial formula by age 4 to 6 months should be done only if the mother is choosing to discontinue breastfeeding. PTS: 1 DIF: Cognitive Level: Apply REF: 873 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 9. Parents of a child with sickle cell anemia ask the nurse, "What happens to the hemoglobin in sickle cell anemia?" Which statement by the nurse explains the disease process?" a. Normal adult hemoglobin is replaced by abnormal hemoglobin. b. There is a lack of cellular hemoglobin being produced. c. There is a deficiency in the production of globulin chains. d. The size and depth of the hemoglobin are affected. ANS: A Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being produced. Thalassemia major refers to a variety of inherited disorders characterized by deficiencies in production of certain globulin chains. Iron deficiency anemia affects the size and depth of the color. PTS: 1 DIF: Cognitive Level: Apply REF: 873 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 10. When both parents have sickle cell trait, which is the chance their children will have sickle cell anemia? a. 25% b. 50% c. 75% d. 100% ANS: A Sickle cell anemia is inherited in an autosomal recessive pattern. If both parents have sickle cell trait (one copy of the sickle cell gene), then for each pregnancy, a 25% chance exists that their child will be affected with sickle cell disease. With each pregnancy, a 50% chance exists that the child will have sickle cell trait. Percentages of 75% and 100% are too high for the children of parents who have sickle cell trait. PTS: 1 DIF: Cognitive Level: Analyze REF: 874 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 11. The nurse is conducting a staff in-service on sickle cell anemia. Which describes the pathologic changes of sickle cell anemia? a. Sickle-shaped cells carry excess oxygen. b. Sickle-shaped cells decrease blood viscosity. c. Increased red blood cell destruction occurs. d. Decreased adhesion of sickle-shaped cells occurs. ANS: C The clinical features of sickle cell anemia are primarily the result of increased red blood cell destruction and obstruction caused by the sickle-shaped red blood cells. Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low oxygen tension. When the sickle cells change shape, they increase the viscosity in the area where they are involved in the microcirculation. Increased adhesion and entanglement of cells occurs. PTS: 1 DIF: Cognitive Level: Apply REF: 874 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 12. Which clinical manifestation should the nurse expect when a child with sickle cell anemia experiences an acute vasoocclusive crisis? a. Circulatory collapse b. Cardiomegaly, systolic murmurs c. Hepatomegaly, intrahepatic cholestasis d. Painful swelling of hands and feet; painful joints ANS: D A vasoocclusive crisis is characterized by severe pain in the area of involvement. If in the extremities, painful swelling of the hands and feet is seen; if in the abdomen, severe pain resembles that of acute surgical abdomen; and if in the head, stroke and visual disturbances occur. Circulatory collapse results from sequestration crises. Cardiomegaly, systolic murmurs, hepatomegaly, and intrahepatic cholestasis result from chronic vasoocclusive phenomena. PTS: 1 DIF: Cognitive Level: Understand REF: 874 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 13. Meperidine (Demerol) is not recommended for children in sickle cell crisis because it: a. may induce seizures. b. is easily addictive. c. is not adequate for pain relief. d. is given by intramuscular injection. ANS: A A metabolite of meperidine, normeperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Patients with sickle cell disease are particularly at risk for normeperidine-induced seizures. Meperidine is no more addictive than other narcotic agents. Meperidine is adequate for pain relief. It is available for IV infusion. PTS: 1 DIF: Cognitive Level: Understand REF: 876 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 14. A school-age child is admitted in vasoocclusive sickle cell crisis. The child's care should include: a. correction of acidosis. b. adequate hydration and pain management. c. pain management and administration of heparin. d. adequate oxygenation and replacement of factor VIII. ANS: B The management of crises includes adequate hydration, minimization of energy expenditures, pain management, electrolyte replacement, and blood component therapy if indicated. Hydration and pain control are two of the major goals of therapy. The acidosis will be corrected as the crisis is treated. Heparin and factor VIII is not indicated in the treatment of vasoocclusive sickle cell crisis. Oxygen may prevent further sickling, but it is not effective in reversing sickling because it cannot reach the clogged blood vessels. PTS: 1 DIF: Cognitive Level: Apply REF: 875-876 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 15. The parents of a child hospitalized with sickle cell anemia tell the nurse that they are concerned about narcotic analgesics causing addiction. Which is appropriate for the nurse to explain about narcotic analgesics? a. Are often ordered but not usually needed b. Rarely cause addiction because they are medically indicated c. Are given as a last resort because of the threat of addiction d. Are used only if other measures, such as ice packs, are ineffective ANS: B The pain of sickle cell anemia is best treated by a multidisciplinary approach. Mild to moderate pain can be controlled by ibuprofen and acetaminophen. When narcotics are indicated, they are titrated to effect and are given around the clock. Patient-controlled analgesia reinforces the patient's role and responsibility in managing the pain and provides flexibility in dealing with pain. Few, if any, patients who receive opioids for severe pain become behaviorally addicted to the drug. Narcotics are often used because of the severe nature of the pain of vasoocclusive crisis. Ice is contraindicated because of its vasoconstrictive effects. PTS: 1 DIF: Cognitive Level: Apply REF: 879 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 16. Which statement best describes -thalassemia major (Cooley anemia)? a. All formed elements of the blood are depressed. b. Inadequate numbers of red blood cells are present. c. Increased incidence occurs in families of Mediterranean extraction. d. Increased incidence occurs in persons of West African descent. ANS: C Individuals who live near the Mediterranean Sea and their descendants have the highest incidence of thalassemia. An overproduction of red cells occurs. Although numerous, the red cells are relatively unstable. Sickle cell disease is common in persons of West African descent. PTS: 1 DIF: Cognitive Level: Understand REF: 881 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 17. Chelation therapy is begun on a child with -thalassemia major. The purpose of this therapy is to: a. treat the disease. b. eliminate excess iron. c. decrease risk of hypoxia. d. manage nausea and vomiting. ANS: B A complication of the frequent blood transfusions in thalassemia is iron overload. Chelation therapy with deferoxamine (an iron-chelating agent) is given with oral supplements of vitamin C to increase iron excretion. Chelation therapy treats the side effect of the disease management. Decreasing the risk of hypoxia and managing nausea and vomiting are not the purposes of chelation therapy. PTS: 1 DIF: Cognitive Level: Understand REF: 882 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 18. In which of the conditions are all the formed elements of the blood simultaneously depressed? a. Aplastic anemia b. Sickle cell anemia c. Thalassemia major d. Iron deficiency anemia ANS: A Aplastic anemia refers to a bone marrow-failure condition in which the formed elements of the blood are simultaneously depressed. Sickle cell anemia is a hemoglobinopathy in which normal adult hemoglobin is partly or completely replaced by abnormal sickle hemoglobin. Thalassemia major is a group of blood disorders characterized by deficiency in the production rate of specific hemoglobin globin chains. Iron deficiency anemia results in a decreased amount of circulating red cells. PTS: 1 DIF: Cognitive Level: Understand REF: 882 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 19. A possible cause of acquired aplastic anemia in children is: a. drugs. b. injury. c. deficient diet. d. congenital defect. ANS: A Drugs, such as chemotherapeutic agents and several antibiotics (e.g., chloramphenicol), can cause aplastic anemia. Injury, deficient diet, and congenital defect are not causative agents in acquired aplastic anemia. PTS: 1 DIF: Cognitive Level: Understand REF: 883 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 20. Parents of a hemophiliac child ask the nurse, "Can you describe hemophilia to us?" Which response by the nurse is descriptive of most cases of hemophilia? a. Autosomal dominant disorder causing deficiency in a factor involved in the blood-clotting reaction b. X-linked recessive inherited disorder causing deficiency of platelets and prolonged bleeding c. X-linked recessive inherited disorder in which a blood-clotting factor is deficient d. Y-linked recessive inherited disorder in which the red blood cells become moon-shaped ANS: C The inheritance pattern in 80% of all of the cases of hemophilia is X-linked recessive. The two most common forms of the disorder are factor VIII deficiency, hemophilia A or classic hemophilia; and factor IX deficiency, hemophilia B or Christmas disease. The inheritance pattern is X-linked recessive. The disorder involves coagulation factors, not platelets, and does not involve red cells or the Y chromosomes. PTS: 1 DIF: Cognitive Level: Understand REF: 883-884 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 21. The nurse is conducting a staff in-service on childhood blood disorders. Which describes the pathology of idiopathic thrombocytopenic purpura? a. Bone marrow failure in which all elements are suppressed b. Deficiency in the production rate of globin chains c. Diffuse fibrin deposition in the microvasculature d. An excessive destruction of platelets ANS: D Idiopathic thrombocytopenic purpura is an acquired hemorrhagic disorder characterized by an excessive destruction of platelets, discolorations caused by petechiae beneath the skin, and a normal bone marrow. Aplastic anemia refers to a bone marrow-failure condition in which the formed elements of the blood are simultaneously depressed. Thalassemia major is a group of blood disorders characterized by deficiency in the production rate of specific hemoglobin globin chains. Disseminated intravascular coagulation is characterized by diffuse fibrin deposition in the microvasculature, consumption of coagulation factors, and endogenous generation of thrombin and plasma. PTS: 1 DIF: Cognitive Level: Understand REF: 886 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 22. Which is most descriptive of the pathophysiology of leukemia? a. Increased blood viscosity occurs. b. Thrombocytopenia (excessive destruction of platelets) occurs. c. Unrestricted proliferation of immature white blood cells (WBCs) occurs. d. First stage of coagulation process is abnormally stimulated. ANS: C Leukemia is a group of malignant disorders of the bone marrow and lymphatic system. It is defined as an unrestricted proliferation of immature WBCs in the blood-forming tissues of the body. Increased blood viscosity may occur secondary to the increased number of WBCs. Thrombocytopenia may occur secondary to the overproduction of WBCs in the bone marrow. The coagulation process is unaffected by leukemia. PTS: 1 DIF: Cognitive Level: Understand REF: 889 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 23. 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. PTS: 1 DIF: Cognitive Level: Analyze REF: 889 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 24. Myelosuppression, associated with chemotherapeutic agents or some malignancies such as leukemia, can cause bleeding tendencies because of a(n): a. decrease in leukocytes. b. increase in lymphocytes. c. vitamin C deficiency. d. decrease in blood platelets. ANS: D The decrease in blood platelets secondary to the myelosuppression of chemotherapy can cause an increase in bleeding. The child and family should be alerted to avoid risk of injury. Decrease in leukocytes, increase in lymphocytes, and vitamin C deficiency would not affect bleeding tendencies. PTS: 1 DIF: Cognitive Level: Apply REF: 890 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 25. 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. PTS: 1 DIF: Cognitive Level: Analyze REF: 889 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 26. A young boy will receive a bone marrow transplant (BMT). This is possible because one of his older siblings is a histocompatible donor. Which is this type of BMT called? a. Syngeneic b. Allogeneic c. Monoclonal d. Autologous ANS: B Allogeneic transplants are from another individual. Because he and his sibling are histocompatible, the BMT can be done. Syngeneic marrow is from an identical twin. There is no such thing as a monoclonal BMT. Autologous refers to the individual's own marrow. PTS: 1 DIF: Cognitive Level: Understand REF: 899 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 27. Which is the most effective pain-management approach for a child who is having a bone marrow aspiration? a. Relaxation techniques b. Administration of an opioid c. EMLA cream applied over site d. Conscious or unconscious sedation ANS: D Effective pharmacologic and nonpharmacologic measures should be used to minimize pain associated with procedures. For bone marrow aspiration, conscious or unconscious sedation should be used. Relaxation, opioids, and EMLA can be used to augment the conscious or unconscious sedation. PTS: 1 DIF: Cognitive Level: Apply REF: 890 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 28. Which immunization should not be given to a child receiving chemotherapy for cancer? a. Tetanus vaccine b. Inactivated poliovirus vaccine c. Diphtheria, pertussis, tetanus (DPT) d. Measles, rubella, mumps ANS: D The vaccine used for measles, mumps, and rubella is a live virus and can result in an overwhelming infection. Tetanus vaccine, inactivated poliovirus vaccine, and diphtheria, pertussis, tetanus (DPT) are not live virus vaccines. PTS: 1 DIF: Cognitive Level: Apply REF: 890 | 896 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 29. Which is often administered to prevent or control hemorrhage in a child with cancer? a. Nitrosoureas b. Platelets c. Whole blood d. Corticosteroids ANS: B Most bleeding episodes can be prevented or controlled with the administration of platelet concentrate or platelet-rich plasma. Nitrosoureas, whole blood, and corticosteroids would not prevent or control hemorrhage. PTS: 1 DIF: Cognitive Level: Apply REF: 890 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 30. 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. PTS: 1 DIF: Cognitive Level: Apply REF: 891 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 31. A school-age child with leukemia experienced severe nausea and vomiting when receiving chemotherapy for the first time. Which is the most appropriate nursing action to prevent or minimize these reactions with subsequent treatments? a. Encourage drinking large amounts of favorite fluids. b. Encourage child to take nothing by mouth (remain NPO) until nausea and vomiting subside. c. Administer an antiemetic before chemotherapy begins. d. Administer an antiemetic as soon as child has nausea. ANS: C The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy is to administer the antiemetic before the chemotherapy is begun. The goal is to prevent anticipatory symptoms. Drinking fluids will add to the discomfort of the nausea and vomiting. Remaining until nausea and vomiting subside will help with this episode, but the child will have the discomfort and be at risk for dehydration. Administering an antiemetic as soon as the child has nausea does not prevent anticipatory nausea. PTS: 1 DIF: Cognitive Level: Apply REF: 891 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 32. A young child with leukemia has anorexia and severe stomatitis. The nurse should suggest that the parents try which intervention? a. Relax any eating pressures. b. Firmly insist that child eat normally. c. Begin gavage feedings to supplement diet. d. Serve foods that are either hot or cold. ANS: A A multifaceted approach is necessary for children with severe stomatitis and anorexia. First, the parents should relax eating pressures. The nurse should suggest that the parents try soft, bland foods; normal saline or bicarbonate mouthwashes; and local anesthetics. The stomatitis is a temporary condition. The child can resume good food habits as soon as the condition resolves. PTS: 1 DIF: Cognitive Level: Apply REF: 892 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 33. 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. PTS: 1 DIF: Cognitive Level: Apply REF: 892 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 34. Which is a common clinical manifestation of Hodgkin disease? a. Petechiae b. Bone and joint pain c. Painful, enlarged lymph nodes d. Enlarged, firm, nontender lymph nodes ANS: D Asymptomatic, enlarged, cervical or supraclavicular lymphadenopathy is the most common presentation of Hodgkin disease. Petechiae are usually associated with leukemia. Bone and joint pain are not likely in Hodgkin disease. The enlarged nodes are rarely painful. PTS: 1 DIF: Cognitive Level: Understand REF: 893 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 35. Which is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4+ T cells? a. Wiskott-Aldrich syndrome b. Idiopathic thrombocytopenic purpura c. Acquired immunodeficiency syndrome (AIDS) d. Severe combined immunodeficiency disease ANS: C AIDS is caused by the human immunodeficiency virus (HIV), which primarily attacks the CD4+ T cells. Wiskott-Aldrich syndrome, idiopathic thrombocytopenic purpura, and severe combined immunodeficiency disease are not viral illnesses. PTS: 1 DIF: Cognitive Level: Remember REF: 895 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 36. A young child with human immunodeficiency virus (HIV) is receiving several antiretroviral drugs. The purpose of these drugs is to: a. cure the disease. b. delay disease progression. c. prevent spread of disease. d. treat Pneumocystis carinii pneumonia. ANS: B Although not a cure, these antiviral drugs can suppress viral replication, preventing further deterioration of the immune system and delaying disease progression. At this time, cure is not possible. These drugs do not prevent the spread of the disease. P. carinii prophylaxis is accomplished with antibiotics. PTS: 1 DIF: Cognitive Level: Understand REF: 895 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 37. Which immunization should be given with caution to children infected with human immunodeficiency virus (HIV)? a. Influenza b. Varicella c. Pneumococcal d. Inactivated poliovirus (IPV) ANS: B The children should be carefully evaluated before being given live viral vaccines such as varicella, measles, mumps, and rubella. The child must be immunocompetent and not have contact with other severely immunocompromised individuals. Influenza, pneumococcal, and inactivated poliovirus (IPV) are not live vaccines. PTS: 1 DIF: Cognitive Level: Apply REF: 896 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 38. The nurse is planning care for an adolescent with AIDS. Which is the priority nursing goal? a. Preventing infection b. Preventing secondary cancers c. Restoring immunologic defenses d. Identifying source of infection ANS: A Because the child is immunocompromised in association with HIV infection, the prevention of infection is paramount. Although certain precautions are justified in limiting exposure to infection, these must be balanced with the concern for the child's normal developmental needs. Preventing secondary cancers is not currently possible. Current drug therapy is affecting the disease progression; although not a cure, these drugs can suppress viral replication, preventing further deterioration. Case finding is not a priority nursing goal. PTS: 1 DIF: Cognitive Level: Apply REF: 896 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 39. The school nurse is informed that a child with human immunodeficiency virus (HIV) will be attending school soon. Which is an important nursing intervention? a. Carefully follow universal precautions. b. Determine how the child became infected. c. Inform the parents of the other children. d. Reassure other children that they will not become infected. ANS: A Universal precautions are necessary to prevent further transmission of the disease. It is not the role of the nurse to determine how the child became infected. Informing the parents of other children and reassuring children that they will not become infected is a violation of the child's right to privacy. PTS: 1 DIF: Cognitive Level: Apply REF: 897 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 40. The nurse is conducting a staff in-service on inherited childhood blood disorders. Which statement describes severe combined immunodeficiency syndrome (SCIDS)? a. There is a deficit in both the humoral and cellular immunity with this disease. b. Production of red blood cells is affected with this disease. c. Adult hemoglobin is replaced by abnormal hemoglobin in this disease. d. There is a deficiency of T and B lymphocyte production with this disease. ANS: A Severe combined immunodeficiency syndrome (SCIDS) is a genetic disorder that results in deficits of both humoral and cellular immunity. Wiskott-Aldrich is an X-linked recessive disorder with selected deficiencies of T and B lymphocytes. Fanconi syndrome is a hereditary disorder of red cell production. Sickle cell disease is characterized by the replacement of adult hemoglobin with an abnormal hemoglobin S. PTS: 1 DIF: Cognitive Level: Understand REF: 897 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 41. Several complications can occur when a child receives a blood transfusion. Which is an immediate sign or symptom of an air embolus? a. Chills and shaking b. Nausea and vomiting c. Irregular heart rate d. Sudden difficulty in breathing ANS: D Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Air emboli should be avoided by carefully flushing all tubing of air before connecting to patient. Chills, shaking, nausea, and vomiting are associated with hemolytic reactions. Irregular heart rate is associated with electrolyte disturbances and hypothermia. PTS: 1 DIF: Cognitive Level: Understand REF: 897-898 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 42. An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough. These manifestations are most suggestive of: a. air emboli. b. allergic reaction. c. hemolytic reaction. d. circulatory overload. ANS: D The signs of circulatory overload include distended neck veins, hypertension, crackles, dry cough, cyanosis, and precordial pain. Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Allergic reactions are manifested by urticaria, pruritus, flushing, asthmatic wheezing, and laryngeal edema. Hemolytic reactions are characterized by chills, shaking, fever, pain at infusion site, nausea, vomiting, tightness in chest, flank pain, red or black urine, and progressive signs of shock and renal failure. PTS: 1 DIF: Cognitive Level: Apply REF: 898 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 43. An adolescent will receive a bone marrow transplant (BMT). The nurse should explain that the bone marrow will be administered by which route? a. Bone grafting b. Bone marrow injection c. IV infusion d. Intra-abdominal infusion ANS: C Bone marrow from a donor is infused intravenously, and the transfused stem cells will repopulate the marrow. Because the stem cells migrate to the recipient's marrow when given intravenously, this is the method of administration. PTS: 1 DIF: Cognitive Level: Apply REF: 883 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 44. The nurse is reviewing first aid with a group of school nurses. Which statement made by a participant indicates a correct understanding of the information? a. "If a child loses a tooth due to injury, I should place the tooth in warm milk." b. "If a child has recurrent abdominal pain, I should send him or her back to class until the end of the day." c. "If a child has a chemical burn to the eye, I should irrigate the eye with normal saline." d. "If a child has a nosebleed, I should have the child sit up and lean forward." ANS: D If a child has a nosebleed, the child should lean forward, not lie down. A tooth should be placed in cold milk or saliva for transporting to a dentist. Recurrent abdominal pain is a physiologic problem and requires further evaluation. If a chemical burn occurs in the eye, the eye should be irrigated with water for 20 minutes. PTS: 1 DIF: Cognitive Level: Apply REF: 888 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. The nurse is planning care for a school-age child admitted to the hospital with hemophilia. Which interventions should the nurse plan to implement for this child? (Select all that apply.) a. Finger sticks for blood work instead of venipunctures b. Avoidance of IM injections c. Acetaminophen (Tylenol) for mild pain control d. Soft tooth brush for dental hygiene e. Administration of packed red blood cells ANS: B, C, D Nurses should take special precautions when caring for a child with hemophilia to prevent the use of procedures that may cause bleeding, such as IM injections. The subcutaneous route is substituted for IM injections whenever possible. Venipunctures for blood samples are usually preferred for these children. There is usually less bleeding after the venipuncture than after finger or heel punctures. Neither aspirin nor any aspirin-containing compound should be used. Acetaminophen is a suitable aspirin substitute, especially for controlling mild pain. A soft toothbrush is recommended for dental hygiene to prevent bleeding from the gums. Packed red blood cells are not administered. The primary therapy for hemophilia is replacement of the missing clotting factor. The products available are factor VIII concentrates. PTS: 1 DIF: Cognitive Level: Apply REF: 885 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 2. Parents of a school-age child with hemophilia ask the nurse, "Which sports are recommended for children with hemophilia?" Which sports should the nurse recommend? (Select all that apply.) a. Soccer b. Swimming c. Basketball d. Golf e. Bowling ANS: B, D, E Because almost all persons with hemophilia are boys, the physical limitations in regard to active sports may be a difficult adjustment, and activity restrictions must be tempered with sensitivity to the child's emotional and physical needs. Use of protective equipment, such as padding and helmets, is particularly important, and noncontact sports, especially swimming, walking, jogging, tennis, golf, fishing, and bowling, are encouraged. Contact sport such as soccer and basketball are not recommended. PTS: 1 DIF: Cognitive Level: Apply REF: 885 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 3. Which should the nurse teach about prevention of sickle cell crises to parents of a preschool child with sickle cell disease? (Select all that apply.) a. Limit fluids at bedtime. b. Notify the health care provider if a fever of 38.5° C (101.3° F) or greater occurs. c. Give penicillin as prescribed. d. Use ice packs to decrease the discomfort of vasoocclusive pain in the legs. e. Notify the health care provider if your child begins to develop symptoms of a cold. ANS: B, C, E The most important issues to teach the family of a child with sickle cell anemia are to (1) seek early intervention for problems, such as a fever of 38.5° C (101.3° F) or greater; (2) give penicillin as ordered; (3) recognize signs and symptoms of splenic sequestration, as well as respiratory problems that can lead to hypoxia; and (4) treat the child normally. The nurse emphasizes the importance of adequate hydration to prevent sickling and to delay the adhesion-stasis-thrombosis-ischemia cycle. It is not sufficient to advise parents to "force fluids" or "encourage drinking." They need specific instructions on how many daily glasses or bottles of fluid are required. Many foods are also a source of fluid, particularly soups, flavored ice pops, ice cream, sherbet, gelatin, and puddings. Increased fluids combined with impaired kidney function result in the problem of enuresis. Parents who are unaware of this fact frequently use the usual measures to discourage bedwetting, such as limiting fluids at night. Enuresis is treated as a complication of the disease, such as joint pain or some other symptom, to alleviate parental pressure on the child. Ice should not be used during a vasoocclusive pain crisis because it vasoconstricts and impairs circulation even more. PTS: 1 DIF: Cognitive Level: Apply REF: 878 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 4. 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). PTS: 1 DIF: Cognitive Level: Apply REF: 892 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation SHORT ANSWER 1. A toddler with leukemia is on intravenous chemotherapy treatments. The toddler's lab results are WBC: 1000; neutrophils: 7%; nonsegmented neutrophils (bands): 7%. What is this child's absolute neutrophil count (ANC)? (Record your answer in a whole number.) ANS: 140 To calculate an ANC for a WBC = 1000; neutrophils = 7%; and nonsegmented neutrophils (bands) = 7%, the steps are Step 1: 7% + 7% = 14%. Step 2: 0.14 1000 = 140 ANC. PTS: 1 DIF: Cognitive Level: Analyze REF: 890 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation ESSAY 1. The nurse has initiated a blood transfusion on a preschool child. The child begins to exhibit signs of a transfusion reaction. Place in order the interventions the nurse should implement sequencing from the highest priority to the lowest. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d). a. Take the vital signs. b. Stop the transfusion. c. Notify the practitioner. d. Maintain a patent IV line with normal saline. ANS: b, a, d, c If a blood transfusion reaction of any type is suspected, stop the transfusion, take vital signs, maintain a patent IV line with normal saline and new tubing, notify the practitioner, and do not restart the transfusion until the child's condition has been medically evaluated. PTS: 1 DIF: Cognitive Level: Apply REF: 899 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

Chapter 26

Chapter 27: The Child with Genitourinary Dysfunction MULTIPLE CHOICE 1. The nurse is conducting a staff in-service on renal ultrasounds. Which statement describes this diagnostic test? a. Computed tomography uses external radiation to visualize the renal system. b. Visualization of the renal system is accomplished without exposure to radiation or radioactive isotopes. c. Contrast medium and x-rays allow for visualization of the renal system. d. External radiation for x-ray films is used to visualize the renal system, before, during, and after voiding. ANS: A A renal ultrasound transmits ultrasonic waves through the renal parenchyma allowing for visualization of the renal system without exposure to external beam radiation or radioactive isotopes. Computed tomography uses external radiation and sometimes contrast media to visualize the renal system. An intravenous pyelogram uses contrast medium and external radiation for x-ray films. The voiding cystourethrogram visualizes the renal system with injection of a contrast media into the bladder through the urethral opening and use of x-ray before, during, and after voiding. PTS: 1 DIF: Cognitive Level: Understand REF: 908 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 2. The nurse is admitting a school-age child in acute renal failure with reduced glomerular filtration rate. Which urine test is the most useful clinical indication of glomerular filtration rate? a. pH b. Osmolality c. Creatinine d. Protein level ANS: C The most useful clinical indication of glomerular filtration is the clearance of creatinine. It is a substance that is freely filtered by the glomerulus and secreted by the renal tubule cells. The pH and osmolality are not estimates of glomerular filtration. Although protein in the urine demonstrates abnormal glomerular permeability, it is not a measure of filtration rate. PTS: 1 DIF: Cognitive Level: Understand REF: 904 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 3. 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). PTS: 1 DIF: Cognitive Level: Analyze REF: 906 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 4. The nurse is teaching parents about prevention of urinary tract infections in children. Which factor predisposes the urinary tract to infection? a. Increased fluid intake b. Short urethra in young girls c. Prostatic secretions in males d. Frequent emptying of the bladder ANS: B The short urethra in females provides a ready pathway for invasion of organisms. Increased fluid intake and frequent emptying of the bladder offer protective measures against urinary tract infections. Prostatic secretions have antibacterial properties that inhibit bacteria. PTS: 1 DIF: Cognitive Level: Understand REF: 908 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 5. 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. PTS: 1 DIF: Cognitive Level: Apply REF: 910 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 6. The nurse is admitting a newborn with hypospadias to the nursery. The nurse expects which finding in this newborn? a. Absence of a urethral opening is noted. b. Penis appears shorter than usual for age. c. The urethral opening is along the dorsal surface of the penis. d. The urethral opening is along the ventral surface of the penis. ANS: D Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis. The urethral opening is present, but not at the glans. Hypospadias refers to the urethral opening, not to the size of the penis. Urethral opening along ventral surface of penis is known as epispadias. PTS: 1 DIF: Cognitive Level: Understand REF: 912 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 7. The nurse is conducting a staff in-service on newborn defects of the genitourinary system. Which describes the narrowing of the preputial opening of the foreskin? a. Chordee b. Phimosis c. Epispadias d. Hypospadias ANS: B Phimosis is the narrowing or stenosis of the preputial opening of the foreskin. Chordee is the ventral curvature of the penis. Epispadias is the meatal opening on the dorsal surface of the penis. Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis. PTS: 1 DIF: Cognitive Level: Remember REF: 912 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 8. 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. PTS: 1 DIF: Cognitive Level: Apply REF: 914 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 9. 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. PTS: 1 DIF: Cognitive Level: Apply REF: 914 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 10. Which is a common side effect of short-term corticosteroid therapy? a. Fever b. Hypertension c. Weight loss d. Increased appetite ANS: D Side effects of short-term corticosteroid therapy include an increased appetite. Fever is not a side effect of therapy. It may be an indication of infection. Hypertension is not usually associated with initial corticosteroid therapy. Weight gain, not weight loss, is associated with corticosteroid therapy. PTS: 1 DIF: Cognitive Level: Understand REF: 914 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 11. 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. PTS: 1 DIF: Cognitive Level: Understand REF: 914 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 12. 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 High-dose steroid therapy has an immunosuppressant effect. These children are particularly vulnerable to upper respiratory tract infections. A priority nursing goal is to minimize the risk of infection by protecting the child from contact with infectious individuals. Appetite is increased with prednisone therapy. The amount of edema should be monitored as part of the disease process, not necessarily related to the administration of prednisone. Antibiotics would not be used as prophylaxis. PTS: 1 DIF: Cognitive Level: Apply REF: 914 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 13. 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 Salt is usually restricted (but not eliminated) during the edema phase. The child has little appetite during the acute phase. Favorite foods are provided (with the exception of high-salt ones) in an attempt to provide nutritionally complete meals. PTS: 1 DIF: Cognitive Level: Understand REF: 914 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 14. 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 Acute glomerulonephritis is an immune-complex disease that occurs after a streptococcal infection with certain strains of the group A â-hemolytic streptococcus. Acute glomerulonephritis usually follows streptococcal pharyngitis and is not associated with renal vascular disorders or genitourinary tract structural anomalies. PTS: 1 DIF: Cognitive Level: Understand REF: 915 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 15. 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 Urinalysis during the acute phase characteristically shows hematuria and proteinuria. Bacteriuria and changes in specific gravity are not usually present during the acute phase. PTS: 1 DIF: Cognitive Level: Understand REF: 915 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 16. 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. PTS: 1 DIF: Cognitive Level: Apply REF: 916 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 17. 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. PTS: 1 DIF: Cognitive Level: Understand REF: 916 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 18. The nurse is teaching the parent about the diet of a child experiencing severe edema associated with acute glomerulonephritis. Which information should the nurse include in the teaching? a. "You will need to decrease the number of calories in your child's diet." b. "Your child's diet will need an increased amount of protein." c. "You will need to avoid adding salt to your child's food." d. "Your child's diet will consist of low-fat, low-carbohydrate foods." ANS: C For most children, a regular diet is allowed, but it should contain no added salt. The child should be offered a regular diet with favorite foods. Severe sodium restrictions are not indicated. PTS: 1 DIF: Cognitive Level: Apply REF: 916 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 19. 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. PTS: 1 DIF: Cognitive Level: Analyze REF: 915 TOP: Integrated Process: Nursing Process: Nursing Diagnosis MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 20. 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. PTS: 1 DIF: Cognitive Level: Understand REF: 917 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 21. Which is the most common cause of acute renal failure in children? a. Pyelonephritis b. Tubular destruction c. Urinary tract obstruction d. Severe dehydration ANS: D The most common cause of acute renal failure in children is dehydration or other causes of poor perfusion that may respond to restoration of fluid volume. Pyelonephritis and tubular destruction are not common causes of acute renal failure. Obstructive uropathy may cause acute renal failure, but it is not the most common cause. PTS: 1 DIF: Cognitive Level: Understand REF: 919 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 22. The nurse is conducting an admission assessment on a school-age child with acute renal failure. Which are the primary clinical manifestations the nurse expects to find with this condition? a. Oliguria and hypertension b. Hematuria and pallor c. Proteinuria and muscle cramps d. Bacteriuria and facial edema ANS: A The principal feature of acute renal failure is oliguria; hypertension is a nonspecific clinical manifestation. Hematuria and pallor, proteinuria and muscle cramps, and bacteriuria and facial edema are not principal features of acute renal failure. PTS: 1 DIF: Cognitive Level: Understand REF: 919 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 23. The nurse is caring for a child with acute renal failure. Which clinical manifestation should the nurse recognize as a sign of hyperkalemia? a. Dyspnea b. Seizure c. Oliguria d. Cardiac arrhythmia ANS: D Hyperkalemia is the most common threat to the life of the child. Signs of hyperkalemia include electrocardiograph anomalies such as prolonged QRS complex, depressed ST segments, peaked T waves, bradycardia, or heart block. Dyspnea, seizure, and oliguria are not manifestations of hyperkalemia. PTS: 1 DIF: Cognitive Level: Apply REF: 920 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 24. When a child has chronic renal failure, the progressive deterioration produces a variety of clinical and biochemical disturbances that eventually are manifested in the clinical syndrome known as: a. uremia. b. oliguria. c. proteinuria. d. pyelonephritis. ANS: A Uremia is the retention of nitrogenous products, producing toxic symptoms. Oliguria is diminished urinary output. Proteinuria is the presence of protein, usually albumin, in the urine. Pyelonephritis is an inflammation of the kidney and renal pelvis. PTS: 1 DIF: Cognitive Level: Remember REF: 921 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 25. Which is a major complication in a child with chronic renal failure? a. Hypokalemia b. Metabolic alkalosis c. Water and sodium retention d. Excessive excretion of blood urea nitrogen ANS: C Chronic renal failure leads to water and sodium retention, which contributes to edema and vascular congestion. Hyperkalemia, metabolic acidosis, and retention of blood urea nitrogen are complications of chronic renal failure. PTS: 1 DIF: Cognitive Level: Understand REF: 921 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 26. Which clinical manifestation would be seen in a child with chronic renal failure? a. Hypotension b. Massive hematuria c. Hypokalemia d. Unpleasant "uremic" breath odor ANS: D Children with chronic renal failure have a characteristic breath odor resulting from the retention of waste products. Hypertension may be a complication of chronic renal failure. With chronic renal failure, little or no urinary output occurs. Hyperkalemia is a concern in chronic renal failure. PTS: 1 DIF: Cognitive Level: Understand REF: 922 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 27. One of the clinical manifestations of chronic renal failure is uremic frost. Which best describes this term? a. Deposits of urea crystals in urine b. Deposits of urea crystals on skin c. Overexcretion of blood urea nitrogen d. Inability of body to tolerate cold temperatures ANS: B Uremic frost is the deposition of urea crystals on the skin. The urea crystals are present on the skin, not in the urine. The kidneys are unable to excrete blood urea nitrogen, leading to elevated levels. There is no relation between cold temperatures and uremic frost. PTS: 1 DIF: Cognitive Level: Understand REF: 922 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 28. Calcium carbonate is given with meals to a child with chronic renal disease. The purpose of this is to: a. prevent vomiting. b. bind phosphorus. c. stimulate appetite. d. increase absorption of fat-soluble vitamins. ANS: B Oral calcium carbonate preparations combine with phosphorus to decrease gastrointestinal absorption and the serum levels of phosphate. Serum calcium levels are increased by the calcium carbonate, and vitamin D administration is necessary to increase calcium absorption. Calcium carbonate does not prevent vomiting, stimulate appetite, or increase the absorption of fat-soluble vitamins. PTS: 1 DIF: Cognitive Level: Apply REF: 922 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 29. Which should the nurse recommend for the diet of a child with chronic renal failure? a. High in protein b. Low in vitamin D c. Low in phosphorus d. Supplemented with vitamins A, E, and K ANS: C Dietary phosphorus is controlled by the reduction of protein and milk intake to prevent or control the calcium-phosphorus imbalance. Protein should be limited in chronic renal failure to decrease intake of phosphorus. Vitamin D therapy is administered in chronic renal failure to increase calcium absorption. Supplementation of vitamins A, E, and K is not part of dietary management in chronic renal disease. PTS: 1 DIF: Cognitive Level: Apply REF: 922 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 30. The nurse is caring for an adolescent who has just started dialysis. The child seems always angry, hostile, or depressed. The nurse should recognize that this is most likely related to: a. neurologic manifestations that occur with dialysis. b. physiologic manifestations of renal disease. c. adolescents having few coping mechanisms. d. adolescents often resenting the control and enforced dependence imposed by dialysis. ANS: D Older children and adolescents need control. The necessity of dialysis forces the adolescent into a dependent relationship, which results in these behaviors. These are a function of the child's age, not neurologic or physiologic manifestations of the dialysis. Feelings of anger, hostility, and depression are functions of the child's age, not neurologic or physiologic manifestations of the dialysis. Adolescents do have coping mechanisms, but they need to have some control over their disease management. PTS: 1 DIF: Cognitive Level: Analyze REF: 923 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Health Promotion and Maintenance 31. Which is an advantage of peritoneal dialysis? a. Treatments are done in hospitals. b. Protein loss is less extensive. c. Dietary limitations are not necessary. d. Parents and older children can perform treatments. ANS: D Peritoneal dialysis is the preferred form of dialysis for parents, infants, and children who wish to remain independent. Parents and older children can perform the treatments themselves. Treatments can be done at home. Protein loss is not significantly different. The dietary limitations are necessary, but they are not as stringent as those for hemodialysis. PTS: 1 DIF: Cognitive Level: Analyze REF: 923 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 32. Which statement is descriptive of renal transplantation in children? a. It is an acceptable means of treatment after age 10 years. b. It is the preferred means of renal replacement therapy in children. c. Children can receive kidneys only from other children. d. The decision for transplantation is difficult because a relatively normal lifestyle is not possible. ANS: B Renal transplant offers the opportunity for a relatively normal life and is the preferred means of renal replacement therapy in end-stage renal disease. Renal transplantation can be done in children as young as age 6 months. Both children and adults can serve as donors for renal transplant purposes. Renal transplantation affords the child a more normal lifestyle than dependence on dialysis. PTS: 1 DIF: Cognitive Level: Understand REF: 925 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 33. 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 WBC count in a routine urinalysis should be <1 or 2. Over that amount indicates a urinary tract inflammatory process. The urinalysis specific gravity for children with normal fluid intake is 1.016 to 1.022. When the specific gravity is high, dehydration is indicated. A low specific gravity is seen with excessive fluid intake, distal tubular dysfunction, or insufficient antidiuretic hormone secretion. PTS: 1 DIF: Cognitive Level: Analyze REF: 907 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 34. The nurse is conducting teaching for an adolescent being discharged to home after a renal transplant. The adolescent needs further teaching if which statement is made? a. "I will report any fever to my primary health care provider." b. "I am glad I only have to take the immunosuppressant medication for two weeks." c. "I will observe my incision for any redness or swelling." d. "I won't miss doing kidney dialysis every week." ANS: B The immunosuppressant medications are taken indefinitely after a renal transplant, so they should not be discontinued after two weeks. Reporting a fever and observing an incision for redness and swelling are accurate statements. The adolescent is correct in indicating dialysis will not need to be done after the transplant. PTS: 1 DIF: Cognitive Level: Apply REF: 925 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 35. The nurse is teaching parents of a child with chronic renal failure (CRF) about the use of recombinant human erythropoietin (rHuEPO) subcutaneous injections. Which statement indicates the parents have understood the teaching? a. "These injections will help with the hypertension." b. "We're glad the injections only need to be given once a month." c. "The red blood cell count should begin to improve with these injections." d. "Urine output should begin to improve with these injections." ANS: C Anemia in children with CRF is related to decreased production of erythropoietin. Recombinant human erythropoietin (rHuEPO) is being offered to these children as thrice-weekly or weekly subcutaneous injections and is replacing the need for frequent blood transfusions. The parents understand the teaching if they say that the red blood cell count will begin to improve with these injections. PTS: 1 DIF: Cognitive Level: Apply REF: 916 | 923 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 36. A school-age child with chronic renal failure is admitted to the hospital with a serum potassium level of 5.2 mEq/L. Which prescribed medication should the nurse plan to administer? a. Spironolactone (Aldactone) b. Sodium polystyrene sulfonate (Kayexalate) c. Lactulose (Cephulac) d. Calcium carbonate (Calcitab) ANS: B Normal serum potassium levels in a school-age child are 3.5 to 5 mEq/L. Sodium polystyrene sulfonate is administered to reduce serum potassium levels. Spironolactone is a potassium sparing diuretic and should not be used if the serum potassium is elevated. Lactulose is administered to reduce ammonia levels in patients with liver disease. Calcium carbonate may be prescribed as a calcium supplement, but it will not reduce serum potassium levels. PTS: 1 DIF: Cognitive Level: Apply REF: 920 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy MULTIPLE RESPONSE 1. 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. PTS: 1 DIF: Cognitive Level: Understand REF: 909 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 2. 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. PTS: 1 DIF: Cognitive Level: Apply REF: 916 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 3. 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. PTS: 1 DIF: Cognitive Level: Apply REF: 914 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 4. A 6-year-old child is scheduled for an IV urography (IVP) in the morning. Which preparatory interventions should the nurse plan to implement? (Select all that apply.) a. Clear liquids in the morning before the procedure b. Cathartic in the evening before the procedure c. Soapsuds enema the morning of the procedure d. Insertion of a Foley catheter before the procedure e. Teaching with regard to insertion of an intravenous catheter before the procedure ANS: B, C, E The IV urography is a test done to provide information about the integrity of the kidneys, ureters, and bladder. It requires an IV injection of a contrast medium with X-ray films made 5, 10, and 15 minutes after injection. Delayed films (30, 60 minutes, and so on) are also obtained. The preparation for children ages 2 to 14 years includes cathartic on the evening before examination, nothing orally after midnight, and an enema (soapsuds) on the morning of examination. Teaching about the insertion of an intravenous catheter should be part of the preoperative preparation. Insertion of a Foley catheter is not part of the preparation for an IVP. PTS: 1 DIF: Cognitive Level: Apply REF: 905 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential SHORT ANSWER 1. The nurse is performing a pH dipstick test on a urine specimen. Which is the average pH expected for this test? (Record your answer in a whole number.) ANS: 6 The average pH for urine is 6. The normal range is 4.8 to 7.8. Abnormal pH levels are associated with urinary infection and metabolic alkalosis or acidosis. PTS: 1 DIF: Cognitive Level: Analyze REF: 907 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

Chapter 27