Exam 3 N332: Wong Chapter 31, 23, 24, 25, 19
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. DIF: Cognitive Level: Understand REF: p. 743 TOP: Integrated Process: Nursing Process: Assessment 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. DIF: Cognitive Level: Analyze REF: p. 791 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
A pediatric client is hospitalized with a severe case of impetigo contagiosa. Which antibiotic does the nurse anticipate the healthcare provider will order for this client? 1. Dicloxacillin (Pathocil) 2. Rifampin (Rifadin) 3. Sulfamethoxazole and trimethoprim (Bactrim) 4. Metronidazole (Flagyl)
Answer: 1 Rationale 1: A systemic antibiotic will be given for severe impetigo because it is a bacterial infection. Dicloxacillin is used in treatment of skin and soft-tissue infections. It is specific for treating staphylococcal infections. Rifampin is an antitubercular agent, sulfamethoxazole and trimethoprim are used as a prophylaxis against Pneumocystis carinii pneumonia (PCP), and metronidazole is used to treat anaerobic and protozoic infections.
The nurse is caring for a pediatric client diagnosed with eczema. Which topical medication order does the nurse anticipate for this client? 1. Corticosteroids 2. Retinoids 3. Antifungals 4. Antibacterials
Answer: 1 Rationale 1: Topical corticosteroids are used to reduce inflammation when the child has eczema. Topical retinoids are used for acne. Topical antifungals are used for dermatophytoses. Topical antibacterials would be used for problems such as burns.
The nurse is providing care to a pediatric client who is diagnosed with psoriasis. Which clinical manifestations does the nurse anticipate upon assessment of this client? (Select all that apply.) 1. Thick, silvery, scaly erythematous plaque 2. Pruritus 3. Dry skin, likely to crack and fissure 4. Fragile skin and blisters 5. Irregular border surrounded by normal skin
Answer: 1,2,5 Rationale 1: Clinical manifestations that support the diagnosis of psoriasis include thick, silvery, scaly erythematous plaque; pruritis; and irregular border surrounded by normal skin. Dry skin that is likely to crack and fissure is a clinical manifestation of atopic dermatitis. Fragile skin and blisters are clinical manifestations of epidermolysis bullosa.
The nurse is teaching a group of adolescents about care for acne vulgaris. Which interventions will the nurse include in the teaching session? (Select all that apply.) 1. Wash skin with mild soap and water twice a day. 2. Use astringents and vigorous scrubbing. 3. Avoid picking or squeezing the lesions. 4. Apply tretinoin (Retin-A) liberally. 5. Avoid sun exposure if on tetracycline.
Answer: 1,3,5 Rationale 1: The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline. Using astringents and scrubbing vigorously can exacerbate acne. Tretinoin (Retin-A) should be applied sparingly (pea-size doses).
The nurse is teaching a group of students about wound healing. Which items will the nurse include as occurring during the hemostasis and inflammation stage of wound healing? (Select all that apply.) 1. Clot formation to seal the wound 2. Production of collagen and granulation tissue 3. Scar formation and strengthening 4. Release of inflammatory mediators by platelets 5. Swelling as a result of increased capillary permeability
Answer: 1,4,5 Rationale 1: During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation.
The nurse is examining a 12-month-old who is brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with bright red scaly plaques and small papules. Satellite lesions are also present. What is the most likely cause of this client's diaper rash? 1. Impetigo (staph) 2. Candida albicans (yeast) 3. Urine and feces 4. Infrequent diapering
Answer: 2 Rationale 1: Candida albicans is frequently the underlying cause of severe diaper rash. When a primary or secondary infection with Candida albicans occurs, the rash has bright red scaly plaques with sharp margins. Small papules and pustules may be seen, along with satellite lesions. Even though diaper dermatitis can be caused by impetigo, urine and feces, and infrequent diapering, the lesions and persistent characteristics are common for Candida.
The nurse explains to the parents of a child with a severe burn that wearing of an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help with the prevention of which complication? 1. Poor circulation 2. Hypertrophic scarring 3. Pain 4. Formation of thrombus in the burn area
Answer: 2 Rationale 1: During the rehabilitation stage, Jobst stockings or pressure garments are used to reduce development of hypertrophic scarring and contractures.
A pediatric client sustains a minor burn. When teaching the family the treatment for this burn, the nurse would teach that the client's diet should be high in which substance? 1. Fats 2. Protein 3. Minerals 4. Carbohydrates
Answer: 2 Rationale 1: Parents should be taught that management of a minor burn requires a high-calorie, high-protein diet. This is necessary to meet the increased nutritional requirements of healing.
A nurse is caring for a toddler client who is diagnosed with scabies and prescribed a 5 percent permethrin lotion. How will the nurse apply this lotion when administering it to the toddler? 1. To the scalp only 2. Over the entire body from the chin down, as well as on the scalp and forehead 3. Only on the areas with evidence of scabies activity 4. Only on the hands
Answer: 2 Rationale 1: Treatment of scabies involves application of a scabicide, such as 5 percent permethrin lotion, over the entire body from the chin down. The scabicide is also applied to the scalp and forehead of younger children, avoiding the rest of the face.
The nurse is providing care for a pediatric client who has a third-degree circumferential burn of the right arm. Which nursing diagnosis is the priority for this client? 1. Risk for Infection 2. Risk for Altered Tissue Perfusion 3. Risk for Altered Nutrition: Less than Body Requirements 4. Impaired Physical Mobility
Answer: 2 Rationale 1: When the burn is circumferential, blood flow can become restricted due to edema and result in tissue hypoxia; therefore, the priority diagnosis is Risk for Altered Tissue Perfusion to the Extremity. Infection, Nutrition, and Mobility would have second priority in this case.
An infant has a severe case of oral thrush (Candida albicans). Which nursing diagnosis is the priority for this infant? 1. Activity Intolerance Related to Oral Thrush 2. Ineffective Airway Clearance Related to Mucus 3. Ineffective Infant Feeding Pattern Related to Discomfort 4. Ineffective Breathing Pattern Related to Oral Thrush
Answer: 3 Rationale 1: An infant with oral thrush may refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. Activity intolerance, ineffective airway clearance, and ineffective breathing patterns are not usual associated problems.
During the recovery-management phase of burn treatment, which is the most common complication seen in children? 1. Shock 2. Metabolic acidosis 3. Burn-wound infection 4. Asphyxia
Answer: 3 Rationale 1: Infection of the burned area is a frequent complication in the recovery-management phase. A goal of burn-wound care is protection from infection.
The nurse is planning care for a 3-month-old infant diagnosed with eczema. Which should be the focus of the nurse's care for this infant? 1. Maintaining adequate nutrition 2. Keeping the baby content 3. Preventing infection of lesions 4. Applying antibiotics to lesions
Answer: 3 Rationale 1: Nursing care should focus on preventing infection of lesions. Due to impaired skin-barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Maintaining adequate nutrition and keeping the infant content are not as high a priority. Antibiotics are not routinely applied to the lesions.
17. 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
a. Abdominal swelling 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. DIF: Cognitive Level: Understand REF: p. 820 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
18. What is the most common clinical manifestation(s) of brain tumors in children? a. Irritability b. Seizures c. Headaches and vomiting d. Fever and poor fine motor control
ANS: C Headaches, especially on awakening, and vomiting that is not related to feeding are the most common clinical manifestation(s) of brain tumors in children. Irritability, seizures, and fever and poor fine motor control are clinical manifestations of brain tumors, but headaches and vomiting are the most common. DIF: Cognitive Level: Understand REF: p. 831 TOP: Integrated Process: Nursing Process: Assessment 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
a. Administering penicillin 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. DIF: Cognitive Level: Apply REF: p. 768 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
26. The nurse is caring for an adolescent with osteosarcoma being admitted to undergo chemotherapy. The adolescent had a right above-the-knee amputation 2 months ago and has been experiencing "phantom limb pain." Which prescribed medication is appropriate to administer to relieve phantom limb pain? a. Amitriptyline (Elavil) b. Hydrocodone (Vicodin) c. Oxycodone (OxyContin) d. Alprazolam (Xanax)
a. Amitriptyline (Elavil) ANS: A Amitriptyline (Elavil) has been used successfully to decrease phantom limb pain. Opioids such as Vicodin or OxyContin would not be prescribed for this pain. A benzodiazepine, Xanax, would not be prescribed for this type of pain. DIF: Cognitive Level: Apply REF: p. 836 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
What are supportive interventions that can assist a toddler with a chronic illness to meet developmental milestones? (Select all that apply.) a. Give choices. b. Provide sensory experiences. c. Avoid discipline and limit setting. d. Discourage negative and ritualistic behaviors. e. Encourage independence in as many areas as possible.
a. Give choices. b. Provide sensory experiences. e. Encourage independence in as many areas as possible. -To encourage autonomy, choices should be given and independence encouraged in as many areas as possible. Sensory experiences should be encouraged to help the toddler to learn through sensorimotor experiences. Age-appropriate discipline and limit setting should be initiated. Negative and ritualistic behaviors are normal and should be allowed.
What nursing intervention is most appropriate in promoting normalization in a school-age child with a chronic illness? a. Give the child as much control as possible. b. Ask the child's peer to make the child feel normal. c. Convince the child that nothing is wrong with him or her. d. Explain to parents that family rules for the child do not need to be the same as for healthy siblings.
a. Give the child as much control as possible. -The school-age child who is ill may be forced into a period of dependency. To foster normalcy, the child should be given as much control as possible. It is unrealistic for one individual to make the child feel normal. The child has a chronic illness, so it would be unacceptable to convince the child that nothing is wrong. The family rules should be similar for each of the children in a family. Resentment and hostility can arise if different standards are applied to each child.
What manifestation observed by the nurse is suggestive of parental overprotection? a. Gives inconsistent discipline. b. Facilitates the child's responsibility for self-care of illness. c. Persuades the child to take on activities of daily living even when not able. d. Encourages social and educational activities not appropriate to the child's level of capability.
a. Gives inconsistent discipline. -Parental overprotection is manifested when the parents fear letting the child achieve any new skill, avoid all discipline, and cater to every desire to prevent frustration. Overprotective parents do not allow the child to assume responsibility for self-care of the illness. The parents prefer to remain in the role of total caregiver. The parents do not encourage the child to participate in social and educational activities.
The potential effects of chronic illness or disability on a child's development vary at different ages. What developmental alteration is a threat to a toddler's normal development? a. Hindered mobility. b. Limited opportunities for socialization. c. Child's sense of guilt that he or she caused the illness or disability. d. Limited opportunities for success in mastering toilet training.
a. Hindered mobility. -Toddlers are acquiring a sense of autonomy, developing self-control, and forming symbolic representation through language acquisition. Mobility is the primary tool used by toddlers to experiment with maintaining control. Loss of mobility can create a sense of helplessness. Toddlers do not socialize. They are sensitive to changes in family routines. A sense of guilt is more likely to occur in a preschooler. Toilet training is not usually mastered until the end of the toddler period.
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.
a. It decreases edema 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. DIF: Cognitive Level: Understand REF: p. 752 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies.
The nurse is teaching coping strategies to parents of a child with a chronic illness. What coping strategies should the nurse include? (Select all that apply.) a. Listen to the child. b. Accept the child's illness. c. Establish a support system. d. Learn to care for the child's illness one day at a time. e. Do not share information with the child about the illness.
a. Listen to the child. b. Accept the child's illness. c. Establish a support system. d. Learn to care for the child's illness one day at a time. -Coping strategies for parents caring for a child with a chronic illness include listening to the child, accepting the child's illness, establishing a support system, and learning to care for the child's illness one day at a time. Information should be shared with the child about the illness.
13. Why is meperidine (Demerol) not recommended for children in sickle cell crisis? a. May induce seizures b. Is easily addictive c. Not adequate for pain relief d. Given by intramuscular injection
a. May induce seizures 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. DIF: Cognitive Level: Understand REF: p. 795 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
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
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. DIF: Cognitive Level: Apply REF: p. 741 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
What intervention is most appropriate for fostering the development of a school-age child with disabilities associated with cerebral palsy? a. Provide sensory experiences. b. Help develop abstract thinking. c. Encourage socialization with peers. d. Give choices to allow for feeling of control.
c. Encourage socialization with peers. -Peer interaction is especially important in relation to cognitive development, social development, and maturation. Cognitive development is facilitated by interaction with peers, parents, and teachers. The identification with those outside the family helps the child fulfill the striving for independence. Sensory experiences are beneficial, especially for younger children. School-age children are too young for abstract thinking. Giving school-age children choices is always an important intervention. Providing structured choices allows for a feeling of control.
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)
c. Epinephrine (Adrenalin) 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. DIF: Cognitive Level: Apply REF: p. 780 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
44. What clinical manifestation is included in toxic shock syndrome? a. Severe hypertension b. Subnormal temperature c. Erythematous macular rash d. Papular rash over extremities
c. Erythematous macular rash 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. DIF: Cognitive Level: Understand REF: p. 783 TOP: Integrated Process: Nursing Process: Assessment 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
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. DIF: Cognitive Level: Understand REF: p. 779 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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. What is the priority nursing action? a. Notify physician b. Apply new bandage with more pressure c. Place the child in Trendelenburg position d. Apply direct pressure above catheterization site
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.
32. Which is a common, serious complication of rheumatic fever? a. Seizures b. Cardiac arrhythmias c. Pulmonary hypertension d. Cardiac valve damage
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. DIF: Cognitive Level: Understand REF: p. 767 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
6. A child with leukemia is receiving triple intrathecal chemotherapy consisting of methotrexate, cytarabine, and hydrocortisone. What will the triple intrathecal chemotherapy prevent? a. Infection b. Brain tumor c. Drug side effects d. Central nervous system (CNS) disease
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. DIF: Cognitive Level: Analyze REF: p. 831 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
The nurse outlines short- and long-term goals for a 10-year-old child with many complex health problems. Who should agree on these goals? a. Family and nurse. b. Child, family, and nurse. c. All professionals involved. d. Child, family, and all professionals involved.
d. Child, family, and all professionals involved. -In the home, the family is a partner in each step of the nursing process. The family priorities should guide the planning process. Both short- and long-term goals should be outlined and agreed on by the child, family, and professionals involved. Elimination of any of these groups can potentially create a care plan that does not meet the needs of the child and family.
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.
a. Milk is a poor source of iron. 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. DIF: Cognitive Level: Understand REF: p. 789 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. 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.
a. Relax any eating pressures. 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. DIF: Cognitive Level: Apply REF: p. 826 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. 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.
a. Stop drug infusion immediately.
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."
b. "I have to stay on strict bed rest for 3 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. DIF: Cognitive Level: Analyze REF: p. 740 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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
b. 70 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. DIF: Cognitive Level: Apply REF: p. 752 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
Families progress through various stages of reactions when a child is diagnosed with a chronic illness or disability. After the shock phase, a period of adjustment usually follows. This is often characterized by what response? a. Denial. b. Guilt and anger. c. Social reintegration. d. Acceptance of the childs limitations.
b. Guilt and anger. -For most families, the adjustment phase is accompanied by several responses, including guilt, self-accusation, bitterness, and anger. The initial diagnosis of a chronic illness or disability is met with intense emotion and characterized by shock and denial. Social integration and acceptance of the child's limitations are the culmination for the adjustment process.
2. Which is the usual presenting symptom for testicular cancer? a. Hard, painful mass b. Hard, painless mass c. Epididymis easily palpated d. Scrotal swelling and pain
b. Hard, painless mass ANS: B The usual presenting symptom for testicular cancer is a heavy, hard, painless mass that is either smooth or nodular and palpated on the testes. A hard, painful mass, an epididymis easily palpated, and scrotal swelling and pain are not the clinical presentations of testicular cancer. DIF: Cognitive Level: Understand REF: p. 842 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
b. Increased cardiac output 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. DIF: Cognitive Level: Understand REF: p. 779 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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 the 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.
b. Let the child hear the sounds of an ECG monitor. 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. DIF: Cognitive Level: Analyze REF: p. 763 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance
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 which nutrient? a. Chlorides b. Potassium c. Sodium d. Vitamins
b. Potassium 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. DIF: Cognitive Level: Understand REF: p. 754 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
A feeling of guilt that the child caused the disability or illness is especially common in which age group? a. Toddler. b. Preschooler. c. School-age child. d. Adolescent.
b. Preschooler. -Preschoolers are most likely to be affected by feelings of guilt that they caused the illness or disability or are being punished for wrongdoings. Toddlers are focused on establishing their autonomy. The illness fosters dependency. School-age children have limited opportunities for achievement and may not be able to understand limitations. Adolescents face the task of incorporating their disabilities into their changing self-concept.
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
b. Prevent dehydration 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. DIF: Cognitive Level: Analyze REF: p. 759 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse asks the mother of a child with a chronic illness many questions as part of the assessment. The mother answers several questions, then stops and says, "I don't know why you ask me all this. Who gets to know this information?" The nurse should respond in what manner? a. Determine why the mother is so suspicious. b. Determine what the mother does not want to tell. c. Explain who will have access to the information. d. Explain that everything is confidential and that no one else will know what is said.
c. Explain who will have access to the information. -Communication with the family should not be invasive. The nurse needs to explain the importance of collecting the information, its applicability to the childs care, and who will have access to the information. The mother is not being suspicious and is not necessarily withholding important information. She has a right to understand how the information she provides will be used. The nurse will need to share, through both oral and written communication, clinically relevant information with other involved health professionals.
What is a major premise of family-centered care? a. The child is the focus of all interventions. b. Nurses are the authorities in the childs care. c. Parents are the experts in caring for their child. d. Decisions are made for the family to reduce stress.
c. Parents are the experts in caring for their child. -As parents become increasingly responsible for their children, they are the experts. It is essential that the health care team recognize the family's expertise. In family-centered care, consistent attention is given to the effects of the child's chronic illness on all family members, not just the child. Nurses are adjuncts in the child's care. The nurse builds alliances with parents. Family members are involved in decision making about the child's physical care.
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
c. Peripheral edema 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. DIF: Cognitive Level: Understand REF: p. 744 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
What behavior seen in children should be addressed by the nurse who is providing care to a child with a chronic illness? a. An infant who is uncooperative. b. A toddler who expresses loneliness. c. A preschooler who refuses to participate in self-care. d. An adolescent who is showing independence.
c. A preschooler who refuses to participate in self-care. -Preschoolers thrive on being independent and are in the phase of gaining autonomy, so they want to perform as many self-care tasks as possible. If a preschooler is refusing to participate in self-care activities, then the home health nurse should address this. Infants are uncooperative by nature, and toddlers do not understand the concept of loneliness, so these are not observations that would need to be addressed. Adolescents are always striving for independence, so this is a normal observation; if the adolescent were becoming more dependent on family, it might require intervention.
What does the surgical closure of the ductus arteriosus do? 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
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.
20. The nurse is teaching nursing students about childhood nervous system tumors. Which best describes a neuroblastoma? a. Diagnosis is usually made after metastasis occurs. b. Early diagnosis is usually possible because of the obvious clinical manifestations. c. It is the most common brain tumor in young children. d. It is the most common benign tumor in young children.
ANS: A Neuroblastoma is a silent tumor with few symptoms. In more than 70% of cases, diagnosis is made after metastasis occurs, with the first signs caused by involvement in the nonprimary site. In only 30% of cases is diagnosis made before metastasis. Neuroblastomas are the most common malignant extracranial solid tumors in children. The majority of tumors develop in the adrenal glands or the retroperitoneal sympathetic chain. They are not benign but metastasize. DIF: Cognitive Level: Apply REF: p. 835 TOP: Integrated Process: Teaching/Learning 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. DIF: Cognitive Level: Understand REF: p. 743 TOP: Integrated Process: Nursing Process: Assessment 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. The child needs opportunities to play with peers. b. The 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. DIF: Cognitive Level: Analyze REF: p. 760 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Psychosocial Integrity
3. The treatment of brain tumors in children consists of which therapies? (Select all that apply.) a. Surgery b. Bone marrow transplantation c. Chemotherapy d. Stem cell transplantation e. Radiation f. Myelography
ANS: A, C, E Treatment for brain tumors in children may consist of surgery, chemotherapy, and radiotherapy alone or in combination. Bone marrow and stem cell transplantation therapies are used for leukemia, lymphoma, and other solid tumors where myeloablative therapies are used. Myelography is a radiographic examination after an intrathecal injection of contrast medium. It is not a treatment. DIF: Cognitive Level: Understand REF: p. 831 TOP: Integrated Process: Nursing Process: Assessment
17. Chelation therapy is begun on a child with b-thalassemia major. What is the purpose of this therapy? 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. DIF: Cognitive Level: Understand REF: p. 799 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
7. 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. DIF: Cognitive Level: Understand REF: p. 824 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. A clinic nurse is conducting a staff in-service for other clinic nurses about signs and symptoms of a rhabdomyosarcoma tumor. Which should be included in the teaching session? (Select all that apply.) a. Bone fractures b. Abdominal mass c. Sore throat and ear pain d. Headache e. Ecchymosis of conjunctiva
ANS: B, C, E The initial signs and symptoms of rhabdomyosarcoma tumors are related to the site of the tumor and compression of adjacent organs. Some tumor locations, such as the orbit, manifest early in the course of the illness. Other tumors, such as those of the retroperitoneal area, only produce symptoms when they are relatively large and compress adjacent organs. Unfortunately, many of the signs and symptoms attributable to rhabdomyosarcoma are vague and frequently suggest a common childhood illness, such as "earache" or "runny nose." An abdominal mass, sore throat and ear pain, and ecchymosis of conjunctiva are signs of a rhabdomyosarcoma tumor. Bone fractures would be seen in osteosarcoma, and a headache is a sign of a brain tumor. DIF: Cognitive Level: Apply REF: p. 840 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. José is a 4-year-old child scheduled for a cardiac catheterization. What should be included in preoperative teaching? 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 d. Adapted to his level of development so that he can understand 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. DIF: Cognitive Level: Apply REF: p. 739 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance
23. A nurse is conducting a staff in-service on childhood cancers. Which is the primary site of osteosarcoma? a. Femur b. Humerus c. Pelvis d. Tibia
a. Femur ANS: A Osteosarcoma is the most frequently encountered malignant bone cancer in children. The peak incidence is between ages 10 and 25 years. More than half occur in the femur. After the femur, most of the remaining sites are the humerus, tibia, pelvis, jaw, and phalanges. DIF: Cognitive Level: Understand REF: p. 836 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
The nurse is providing teaching to a community group regarding preventative strategies to reduce the risk of burn injury. Which topics will the nurse include in the teaching session? (Select all that apply.) 1. Avoid contact with unknown animals and wild animals. 2. Layer children's clothing for warmth. 3. Keep infants and toddlers off the lap when drinking hot beverages or eating soup. 4. Lower the temperature settings for hot water heaters. 5. Wear light-colored clothes and avoid eating sweetened foods and beverages when outside.
Answer: 3,4 Rationale 1: In order to decrease the risk of burn injury, the nurse would tell the group to keep infants and toddlers off the lap while drinking hot beverages or eating soup and to lower the temperature settings for the hot water heaters. Avoiding contact with unknown animals and wild animals along with wearing light-colored clothes and avoiding eating sweetened foods and beverages when outside are strategies to prevent bites and stings. Layering children's clothing for warmth is a strategy to prevent hypothermia.
A 2-month-old client has a candidal diaper rash. Which medication does the nurse anticipate will be prescribed for this client? 1. Bacitracin ointment 2. Hydrocortisone ointment 3. Desitin 4. Nystatin given topically and orally
Answer: 4 Rationale 1: Diaper candidiasis is treated with an antifungal cream (Nystatin). An oral antifungal agent may be given to clear the candidiasis from the intestines. Bacitracin is for an infection caused by staphylococcus. Mild diaper rash is treated with a barrier such as Desitin. Moderate diaper rash is treated with hydrocortisone ointment.
The school nurse is conducting pediculosis capitis (head lice) checks. Which findings would indicate a "positive" head check? 1. White, flaky particles throughout the entire scalp region 2. Maculopapular lesions behind the ears 3. Lesions in the scalp that extend to the hairline or neck 4. White sacs attached to the hair shafts in the occipital area
Answer: 4 Rationale 1: Evidence of pediculosis capitis includes white sacs (nits) that are attached to the hair shafts, frequently in the occiput area. Lesions may be present from itching, but the positive sign is evidence of nits. Lice and nits must be distinguished from dandruff, which appears as white, flaky particles.
The nurse is providing education to the parents of a pediatric client who is diagnosed with tinea capitis (ringworm of the scalp). Which statement made the parents indicates an appropriate understanding of the teaching session? 1. "We will give the griseofulvin on an empty stomach." 2. "We're glad ringworm isn't transmitted from person to person." 3. "Once the lesion is gone, we can stop the griseofulvin." 4. "We will give the griseofulvin with milk or peanut butter."
Answer: 4 Rationale 1: Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. The medication must be used for the entire prescribed period even if the lesions are gone. All members of the family and household pets should be assessed for fungal lesions because person-to-person transmission is common.
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."
a. "You may need to increase the caloric density of your infant's formula." 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. DIF: Cognitive Level: Apply REF: p. 754 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
25. An adolescent with osteosarcoma is scheduled for a leg amputation in 2 days. The nurse's approach should include which action? a. Answering questions with straightforward honesty b. Avoiding discussing the seriousness of the condition c. Explaining that, although the amputation is difficult, it will cure the cancer d. Assisting the adolescent in accepting the amputation as better than a long course of chemotherapy
a. Answering questions with straightforward honesty ANS: A Honesty is essential to gain the child's cooperation and trust. The diagnosis of cancer should not be disguised with falsehoods. The adolescent should be prepared for the surgery so he or she has time to reflect on the diagnosis and subsequent treatment. This allows questions to be answered. To accept the need for radical surgery, the child must be aware of the lack of alternatives for treatment. Amputation is necessary, but it will not guarantee a cure. Chemotherapy is an integral part of the therapy with surgery. The child should be informed of the need for chemotherapy and its side effects before surgery. DIF: Cognitive Level: Apply REF: p. 836 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance
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
a. Aplastic 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. DIF: Cognitive Level: Understand REF: p. 800 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
One of the supervisors for a home health agency asks the nurse to give a family of a child with a chronic illness a survey evaluating the nurses and other service providers. How should the nurse recognize this request? a. Appropriate to improve quality of care b. Improper because it is an invasion of privacy c. Inappropriate unless nurses and other providers agree to participate d. Not acceptable because the family lacks remembering necessary to evaluate professionals
a. Appropriate to improve quality of care -Quality assessment and improvement activities are essential for virtually all organizations. Family involvement in evaluating a home care plan can occur on several levels. The nurse can ask the family open-ended questions at regular intervals to assess their opinion of the effectiveness of care. Families should also be given an opportunity to evaluate the individual home care nurses, the home care agency, and other service providers periodically. Evaluation of the provision of care to the patient and family requires evaluation of the care provider, that is, the nurse. Quality-monitoring activities are required by virtually all health care agencies. During the evaluation process, the family is asked to provide their perceptions of care.
14. A nurse is preparing to administer an angiotensin-converting enzyme (ACE) inhibitor. Which drug should the nurse administer? a. Captopril (Capoten) b. Furosemide (Lasix) c. Spironolactone (Aldactone) d. Chlorothiazide (Diuril)
a. Captopril (Capoten) ANS: A Captopril is an ACE inhibitor. Furosemide is a loop diuretic. Spironolactone blocks the action of aldosterone. Chlorothiazide works on the distal tubules. DIF: Cognitive Level: Remember REF: p. 752 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
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
a. Cardiac arrhythmia 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. DIF: Cognitive Level: Apply REF: p. 739 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
26. 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.
a. Carefully follow universal precautions. 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. DIF: Cognitive Level: Apply REF: p. 807 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
1. 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
a. Chlorhexidine gluconate (Peridex) c. Antifungal troches (lozenges) d. Lip balm (Aquaphor) 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). DIF: Cognitive Level: Apply REF: p. 819 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. A young child with human immunodeficiency virus (HIV) is receiving several antiretroviral drugs. What is the purpose of these drugs? a. Cure the disease b. Delay disease progression c. Prevent spread of disease d. Treat Pneumocystis carinii pneumonia
b. Delay disease progression 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. DIF: Cognitive Level: Understand REF: p. 806 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Inte
The parents of a child on a ventilator tell the nurse that their insurance company wants the child to be discharged. They explain that they do not want the child home under any circumstances. What principle should the nurse consider when working with this family? a. Desire to have the child home is essential to effective home care. b. Parents should not be expected to care for a technology-dependent child. c. Having a technology-dependent child at home is better for both the child and the family. d. Parents are not part of the decision-making process because of the costs of hospitalization.
a. Desire to have the child home is essential to effective home care. -Home care requires the family to manage the child's illness, including providing daily hands-on care, monitoring the child's medical condition, and educating others to care for the child. The child's home environment with the child's family is perceived as the best place for the child to be cared for. If the family does not want to or is not able to assume these responsibilities, other arrangements need to be investigated. The family is an essential part of the decision-making process. Without family involvement and support, the technology-dependent child will not be care for well at home.
19. What is a possible cause of acquired aplastic anemia in children? a. Drugs b. Injury c. Deficient diet d. Congenital defect
a. Drugs 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. DIF: Cognitive Level: Understand REF: p. 800 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
What are supportive interventions that can assist an adolescent with a chronic illness to meet developmental milestones? (Select all that apply.) a. Encourage activities appropriate for age. b. Avoid discussing planning for the future. c. Provide instruction on interpersonal and coping skills. d. Emphasize good appearance and wearing of stylish clothes. e. Understand that the adolescent will not have the same sexual needs.
a. Encourage activities appropriate for age. c. Provide instruction on interpersonal and coping skills. d. Emphasize good appearance and wearing of stylish clothes. -To achieve independence from family, instruction on interpersonal and coping skills should be provided. To promote heterosexual relationships, activities appropriate for age should be encouraged, and a good appearance and wearing of stylish clothes should be emphasized. Plans for the future should be discussed, and the adolescent will have the same sexual needs as adolescents without a chronic illness.
What are supportive interventions that can assist an infant with a chronic illness to meet developmental milestones? (Select all that apply.) a. Encourage consistent caregivers. b. Encourage periodic respite from demands of care. c. Encourage one family member to be the primary caretaker. d. Encourage parental rooming in during hospitalization. e. Withhold age-appropriate developmental tasks until the child is older.
a. Encourage consistent caregivers. b. Encourage periodic respite from demands of care. d. Encourage parental rooming in during hospitalization. -To develop trust, consistent caretakers and parents rooming in should be encouraged. To develop a sense of separateness from parents, periodic respites from caregiving should be encouraged. All members of the family, not one primary caretaker, should be encouraged to participate in care. Age-appropriate developmental tasks should be encouraged, not withheld until an older age.
The nurse is planning care for a 3-year-old boy who has Down syndrome and is on continuous oxygen. He recently began walking around furniture. He is spoon fed by his parents and eats some finger foods. What goal is the most appropriate to promote normal development? a. Encourage mobility. b. Encourage assistance in self-care. c. Promote oral-motor development. d. Provide opportunities for socialization.
a. Encourage mobility. -A major principle for developmental support in children with complex medical issues is that it should be flexible and tailored to the individual child's abilities, interests, and needs. This child is exhibiting readiness for ambulation. It is an appropriate time to provide activities that encourage mobility, for example, longer oxygen tubing. Parents should provide decreasing amounts of assistance with self-care as he is able to develop these skills. The boy is receiving oral foods and is eating finger foods. He has acquired this skill. Mobility is a new developmental task. Opportunities for socialization should be ongoing.
What are supportive interventions that can assist a preschooler with a chronic illness to meet developmental milestones? (Select all that apply.) a. Encourage socialization. b. Encourage mastery of self-help skills. c. Provide devices that make tasks easier. d. Clarify that the cause of the child's illness is not his or her fault. e. Discuss planning for the future and how the condition can affect choices.
a. Encourage socialization. b. Encourage mastery of self-help skills. c. Provide devices that make tasks easier. d. Clarify that the cause of the child's illness is not his or her fault. -To encourage initiative, mastery of self-help skills should be encouraged, and devices should be provided that make tasks easier. To develop peer relationships, socialization should be encouraged. To develop body image, the fact that the cause of the child's illness is not the fault of the child should be emphasized. Discussing planning for the future and how the condition can affect choices is appropriate for an adolescent.
What are supportive interventions that can assist a school-age child with a chronic illness to meet developmental milestones? (Select all that apply.) a. Encourage socialization. b. Discourage sports activities. c. Encourage school attendance. d. Provide instructions on assertiveness. e. Educate teachers and classmates about the child's condition.
a. Encourage socialization. c. Encourage school attendance. e. Educate teachers and classmates about the child's condition. -To develop a sense of accomplishment, school attendance should be encouraged, and teachers and classmates should be educated about the child's condition. To form peer relationships, socialization should be encouraged. Sports activities should be encourages (e.g., Special Olympics), not discouraged. Providing instructions on assertiveness is appropriate for adolescence.
The parents of a child born with disabilities ask the nurse for advice about discipline. The nurse's response should be based on remembering that discipline is which? a. Essential for the child. b. Not needed unless the childs behavior becomes problematic. c. Best achieved with punishment for misbehavior. d. Too difficult to implement with a special needs child.
a. Essential for the child. -Discipline is essential for the child. It provides boundaries on which she can test out her behavior and teachers her socially acceptable behaviors. The nurse should teach the parents ways to manage the child's behavior before it becomes problematic. Punishment is not effective in managing behavior.
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.
a. Normal adult hemoglobin is replaced by abnormal hemoglobin 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, depth, and color of hemoglobin. DIF: Cognitive Level: Apply REF: p. 791 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation.
For case management to be most effective, who should be recognized as the most appropriate case manager? a. Nurse. b. Panel of experts. c. Multidisciplinary team. d. Insurance company.
a. Nurse. -Nursing case managers are ideally suited to provide the care coordination necessary. Care coordination is most effective if a single person works with the family to accomplish the many tasks and responsibilities that are necessary. The family retains the role as primary decision maker. Most likely the insurance company will have a case manager focusing on the financial aspects of care. This does not include coordination of care to assist the family.
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
a. Osler 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. DIF: Cognitive Level: Understand REF: p. 766 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse notes that the parents of a critically ill child spend a large amount of time talking with the parents of another child who is also seriously ill. They talk with these parents more than with the nurses. How should the nurse interpret this situation? a. Parent-to-parent support is valuable. b. Dependence on other parents in crisis is unhealthy. c. This is occurring because the nurses are unresponsive to the parents. d. This has the potential to increase friction between the parents and nursing staff.
a. Parent-to-parent support is valuable. -Veteran parents share experiences that cannot be supplied by other support systems. They have known the stress related to diagnosis, have weathered the many transition times, and have a practical remembering of resources. The parents can be mutually supportive during times of crisis. Nursing staff cannot provide the type of support that is realized from other parents who are experiencing similar situations. Friction should not exist between the nursing staff and the family of the child who is critically ill.
The nurse is assessing coping behaviors of a family with a child with a chronic illness. What indicates approach coping behaviors? (Select all that apply.) a. Plans realistically for the future. b. Verbalizes possible loss of the child. c. Uses magical thinking and fantasy. d. Realistically perceives the child's condition. e. Does not share the burden of the disorder with others.
a. Plans realistically for the future. b. Verbalizes possible loss of the child. d. Realistically perceives the child's condition. -Approach coping behaviors include planning realistically for the future, verbalizing possible loss of a child, and realistically perceiving the child's behavior. Using magical thinking and fantasy is an avoidance behavior. The family should share the burden of the disorder with others as an approach behavior.
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
a. Polyarthritis 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. DIF: Cognitive Level: Apply REF: p. 767 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
25. 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
a. Preventing 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. DIF: Cognitive Level: Apply REF: p. 806 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
The nurse is assessing coping behaviors of a family with a child with a chronic illness. What indicates avoidance coping behaviors? (Select all that apply.) a. Refuses to agree to treatment. b. Avoids staff, family members, or child. c. Is unable to discuss possible loss of the child. d. Recognizes own growth through a passage of time. e. Makes no change in lifestyle to meet the needs of other family members.
a. Refuses to agree to treatment. b. Avoids staff, family members, or child. c. Is unable to discuss possible loss of the child. e. Makes no change in lifestyle to meet the needs of other family members. -Avoidance coping behaviors include refusing to agree to treatment; avoiding staff, family members, or child; unable to discuss possible loss of the child; and making no change in lifestyle to meet the needs of other family members. Recognizing ones own growth through a passage of time is an approach behavior.
A childs parents ask the nurse many questions about their child's illness and its management. The nurse does not know enough to answer all the questions. What nursing action is most appropriate at this time? a. Tell them, "I dont know, but I will find out." b. Suggest that they ask the physician these questions. c. Explain that the nurse cannot be expected to know everything. d. Answer questions vaguely so they do not lose confidence in the nurse.
a. Tell them, "I dont know, but I will find out." -Questions from parents should be answered in a straightforward manner. Stating "I don't know" or "I'll find out," is better than pretending to know or giving excuses. Suggesting that they ask the physician these questions if not supportive of the family. The nurse's role is to assist the parents in obtaining accurate information about their child's illness and its management. Although the nurse cannot be expected to know everything, it is an unprofessional attitude to state this. Nurse's must provide accurate information to the extent possible. Vague answers are not helpful to the family.
27. 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.
a. There is a deficit in both the humoral and cellular immunity 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. DIF: Cognitive Level: Understand REF: p. 809 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24. The nurse is taking care of an adolescent with osteosarcoma. The parents ask the nurse about treatment. The nurse should make which accurate response about treatment for osteosarcoma? a. Treatment usually consists of surgery and chemotherapy. b. Amputation of the affected extremity is rarely necessary. c. Intensive irradiation is the primary treatment. d. Bone marrow transplantation offers the best chance of long-term survival.
a. Treatment usually consists of surgery and chemotherapy. ANS: A The optimal therapy for osteosarcoma is a combination of surgery and chemotherapy. Intensive irradiation and bone marrow transplantation are usually not part of the therapeutic management. DIF: Cognitive Level: Understand REF: p. 836 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse is talking to the parent of a child with special needs. The parent has expressed worry about how to support the siblings at home. What suggestion is appropriate for the nurse to give to the parent? a. You should help the siblings see the similarities and differences between themselves and your child with special needs. b. You should explain that your child with special needs should be included in all activities that the siblings participate in even if they are reluctant. c. You should give the siblings many caregiving tasks for your child with special needs so the siblings feel involved. d. You should intervene when there are differences between your child with special needs and the siblings.
a. You should help the siblings see the similarities and differences between themselves and your child with special needs. -Appropriate information to give to a parent who wants to support the siblings of a child with special needs includes helping the siblings see the differences and similarities between themselves and the child with special needs to promote an understanding environment. The parent should be encouraged to allow the siblings to participate in activities that do not always include the child with special needs, to limit care giving responsibilities, and to allow the children to settle their own differences rather than step in all the time.
14. A school-age child is admitted in vasoocclusive sickle cell crisis. What should be included in the child's care? 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
b. Adequate hydration and pain management 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 are 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. DIF: Cognitive Level: Apply REF: p. 796 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse is assessing the coping behaviors of the parents of a child recently diagnosed with a chronic illness. What behavior should the nurse consider an approach behavior that results in movement toward adjustment? a. Being unable to adjust to a progression of the disease or condition. b. Anticipating future problems and seeking guidance and answers. c. Looking for new cures without a perspective toward possible benefit. d. Failing to recognize the seriousness of the child's condition despite physical evidence.
b. Anticipating future problems and seeking guidance and answers. -The parents who anticipate future problems and seek guidance and answers are demonstrating approach behaviors. These are positive signs in caring for their child. Being unable to adjust, looking for new cures, and failing to recognize the seriousness of the child's condition are avoidance behaviors. The parents are moving away from adjustment or exhibiting maladaptation to the crisis of a child with chronic illness or disability.
What is the single most prevalent cause of disability in children and responsible for the recent increase in childhood disability? a. Cancer. b. Asthma. c. Seizures. d. Heart disease.
b. Asthma. -Asthma is the single most prevalent cause of disability in children and has been largely responsible for much of the recent increase in childhood disability.
39. The nurse is teaching nursing students about shock that occurs in children. What is one of the most frequent causes of hypovolemic shock in children? a. Sepsis b. Blood loss c. Anaphylaxis d. Congenital heart disease
b. Blood loss 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. DIF: Cognitive Level: Understand REF: p. 778 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. 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
b. Bone involvement 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. DIF: Cognitive Level: Analyze REF: p. 826 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
What is the major health concern of children in the United States? a. Acute illness. b. Chronic illness. c. Congenital disabilities. d. Nervous system disorders.
b. Chronic illness. -An estimated 18% of children in the US have a chronic illness or disability that warrants health care services beyond those usually required by children. Chronic illness has surpassed acute illness as the major health concern for children. Congenital disabilities exist from birth but may not be hereditary. These represent a portion of the number of children with chronic illness. Mental and nervous system disorders account for approx. 17% of chronic illnesses in children.
The parent of a child with a chronic illness tells the nurse, "I feel so hopeless in this situation." The nurse should take which actions to foster hopefulness for the family? (Select all that apply.) a. Avoid topics that are lighthearted. b. Convey a personal interest in the child. c. Be honest when reporting on the child's condition. d. Do not initiate any playful interaction with the child. e. Demonstrate competence and gentleness when delivering care.
b. Convey a personal interest in the child. c. Be honest when reporting on the child's condition. e. Demonstrate competence and gentleness when delivering care. -To foster hopefulness, the nurse should convey a personal interest in the child, be honest when reporting a child's condition, and demonstrate competence and gentleness when delivering care. The nurse should introduce conversations on neutral, nondisease-related, or less sensitive topics (discuss the child's favorite sports, tell stories). The nurse should be lighthearted and initiate or respond to teasing or other playful interactions with the child.
31. What is the primary nursing intervention to prevent bacterial endocarditis? 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.
b. Counsel parents of high-risk children about prophylactic antibiotics. 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. DIF: Cognitive Level: Apply REF: p. 765 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
33. The home care nurse has been visiting an adolescent with recently acquired tetraplegia. The teen's mother tells the nurse, "I'm sick of providing all the care while my husband does whatever he wants to, whenever he wants to do it." Which should be the initial action of the nurse? a. Refer mother for counseling. b. Listen and reflect mother's feelings. c. Ask father, in private, why he does not help. d. Suggest ways the mother can get her husband to help. \
b. Listen and reflect mother's feelings. ANS: B It is appropriate for the nurse to reflect with the mother about her feelings, exploring issues such as an additional home health aide to help care for the child and provide respite for the mother. It is inappropriate for the nurse to agree with the mother that her husband is not helping enough. It is a judgment beyond the role of the nurse and can undermine the family relationship. Counseling is not necessary at this time. A support group for caregivers may be indicated. Asking the father why he does not help and suggesting ways to the mother to get her husband to help are interventions based on the mother's assumption of minimal contribution to the child's care. The father may have a full-time job and other commitments. The parents need to have an involved third person help them through the negotiation of responsibilities for the loss of their normal child and new parenting responsibilities. DIF: Cognitive Level: Apply REF: p. 842 TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Psychosocial Integrity
The nurse has been visiting an adolescent with recently acquired tetraplegia. The teen's mother tells the nurse, "I'm sick of providing all the care while my husband does whatever he wants to, whenever he wants to do it." What reaction should be the nurses initial response? a. Refer the mother for counseling. b. Listen and reflect the mother's feelings. c. Ask the father in private why he does not help. d. Suggest ways the mother can get her husband to help.
b. Listen and reflect the mother's feelings. -It is appropriate for the nurse to reflect with the mother about her feelings, exploring solutions such as an additional home health aide to help care for the child and provide respite for the mother. It is inappropriate for the nurse to agree with the mother that her husband is not helping enough. This judgment is beyond the role of the nurse and can undermine the family relationship. Counseling, if indicated, would be necessary for both parents. A support group for caregivers may be indicated. The nurse should not ask the father in private why he does not help or suggest way the mother can get her husband to help. These interventions are based on the mothers perceptions; the father may have a full-time job and other commitments. The parents may need an unbiased third person to help them through the negotiation of their new parenting responsibilities.
22. In which position should the nurse place a 10-year-old child after a large tumor was removed through a supratentorial craniotomy? a. On the inoperative side with the bed flat b. On the inoperative side with the head of bed elevated 20 to 30 degrees c. On the operative side with the bed flat and pillows behind the head d. On the operative side with the head of bed elevated 45 degrees
b. On the inoperative side with the head of bed elevated 20 to 30 degrees ANS: B If a large tumor was removed, the child is not placed on the operative side because the brain may suddenly shift to that cavity, causing trauma to the blood vessels, linings, and the brain itself. The child with an infratentorial procedure is usually positioned on either side with the bed flat. When a supratentorial craniotomy is performed, the head of bed is elevated 20 to 30 degrees with the child on either side or on the back. In a supratentorial craniotomy, the head elevation facilitates CSF drainage and decreases excessive blood flow to the brain to prevent hemorrhage. Pillows should be placed against the child's back, not head, to maintain the desired position. DIF: Cognitive Level: Apply REF: p. 831 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
21. An 8-month-old infant has a hypercyanotic spell while blood is being drawn. What is the priority nursing action? a. Assess for neurologic defects b. Place the child in the knee-chest position c. Begin cardiopulmonary resuscitation d. Prepare family for imminent death
b. Place the child in the knee-chest position 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. DIF: Cognitive Level: Apply REF: p. 759 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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 the answer using lowercase letters separated by commas (e.g., a, b, c, d). a. Administer 100% oxygen by blow-by. b. Place the infant in knee-chest position. c. Remain calm. d. Give morphine subcutaneously or by an existing intravenous line.
b. Place the infant in knee-chest position. a. Administer 100% oxygen by blow-by. d. Give morphine subcutaneously or by an existing intravenous line. c. Remain calm. 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. DIF: Cognitive Level: Apply REF: p. 741 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. Which is often administered to prevent or control hemorrhage in a child with cancer? a. Nitrosoureas b. Platelets c. Whole blood d. Corticosteroids
b. Platelets 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. DIF: Cognitive Level: Apply REF: p. 826 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
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
b. Rarely cause addiction because they are medically indicated 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. DIF: Cognitive Level: Apply REF: p. 796 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
37. Which is the leading cause of death after heart transplantation? a. Infection b. Rejection c. Cardiomyopathy d. Heart failure
b. Rejection 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. DIF: Cognitive Level: Remember REF: p. 775 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse has been assigned as a home health nurse for a child who is technology dependent. The nurse recognizes that the familys background differs widely from the nurse's own. The nurse believes some of their lifestyle choices are less than ideal. What nursing intervention is most appropriate to institute? a. Change the family. b. Respect the differences. c. Assess why the family is different. d. Determine whether the family is dysfunctional.
b. Respect the differences. -Respect for varied family structures and for racial, ethnic, cultural, and socioeconomic diversity among families is essential in home care. The nurse must assess and respect the family's background and lifestyle choices. It is not appropriate to attempt to change the family. The nurse is a guest in the home and care of the child. The family and the values held by the cultural group prevail. The nurse may assess why the family is different to help the nurse and other health professions understand the difference. It is not appropriate to determine whether the family is dysfunctional.
A 16-year-old boy with a chronic illness has recently become rebellious and is taking risks such as missing doses of his medication. What should the nurse explain to his parents? a. That he needs more discipline. b. That this is a normal part of adolescence. c. That he needs more socialization with peers. d. That this is how he is asking for more parental control.
b. That this is a normal part of adolescence. -Risk taking, rebelliousness, and lack of cooperation are normal parts of adolescence, during which young adults are establishing independence. If the parents increase the amount of discipline, he will most likely be more rebellious. More socialization with peers does not address the problem of risk-taking behaviors.
2. Which expected appearance will the nurse explain to parents of an infant returning from surgery after an enucleation was performed to treat retinoblastoma? (Select all that apply.) a. A lot of drainage will come from the affected socket. b. The face may be edematous or ecchymotic. c. The eyelids will be sutured shut for the first week. d. There will be an eye pad dressing taped over the surgical site. e. The implanted sphere is covered with conjunctiva and resembles the lining of the mouth.
b. The face may be edematous or ecchymotic. d. There will be an eye pad dressing taped over the surgical site. e. The implanted sphere is covered with conjunctiva and resembles the lining of the mouth. ANS: B, D, E After enucleation surgery, the parents are prepared for the child's facial appearance. An eye patch is in place, and the child's face may be edematous or ecchymotic. Parents often fear seeing the surgical site because they imagine a cavity in the skull. A surgically implanted sphere maintains the shape of the eyeball, and the implant is covered with conjunctiva. When the eyelids are open, the exposed area resembles the mucosal lining of the mouth. The dressing, consisting of an eye pad taped over the surgical site, is changed daily. The wound itself is clean and has little or no drainage. So expecting a lot of drainage is not accurate to tell parents. The eyelids are not sutured shut after enucleation surgery. DIF: Cognitive Level: Apply REF: p. 839 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance
The nurse is planning to use an interpreter with a nonEnglish-speaking family. What should the nurse plan with regard to the use of an interpreter? (Select all that apply.) a. Use a family member. b. The nurse should speak slowly. c. Use an interpreter familiar with the family's culture. d. The nurse should speak only a few sentences at a time. e. The nurse should speak to the interpreter during interactions.
b. The nurse should speak slowly. c. Use an interpreter familiar with the family's culture. d. The nurse should speak only a few sentences at a time. -When parents who do not speak English are informed of their child's chronic illness, interpreters familiar with both their culture and language should be used. The nurse should speak slowly and only use a few sentences at a time. Children, family members, and friends of the family should not be used as translators because their presence may prevent parents from openly discussing the issues. The nurse should speak to the family, not the interpreter.
A 5-year-old child will be starting kindergarten next month. She has cerebral palsy, and it has been determined that she needs to be in a special education classroom. Her parents are tearful when telling the nurse about this and state that they did not realize her disability was so severe. What is the best interpretation of this situation? a. This is a sign the parents are in denial. b. This is a normal anticipated time of parental stress. c. The parents need to learn more about cerebral palsy. d. The parents expectations are too high.
b. This is a normal anticipated time of parental stress. -Parenting a child with a chronic illness can be stressful. At certain anticipated times, parental stress increases. One of these identified times is when the child begins school. Nurses can help parents recognize and plan interventions to work through these stressful periods. The parents are not in denial; rather, they are responding to the child's placement in school. The parents are not exhibiting signs of a remembering deficit; this is their first interaction with the school system with this child.
35. A ventilator-dependent child is cared for at home by his parents. Nurses come for 4 hours each day giving the parents some relief. Which other strategy should the nurse recommend to give the parents a break from the responsibilities of caring for a ventilator-dependent child? a. Encourage members from the parent's church group to provide some relief care. b. Train a trusted grandparent to provide an occasional break from the responsibilities of care. c. Encourage the parents to pay out of pocket for additional private duty nurses. d. Suggest the parents place the child in a care facility.
b. Train a trusted grandparent to provide an occasional break from the responsibilities of care. ANS: B Respite care provides temporary relief to parents and allows a break from the responsibilities of caring for the ventilator-dependent child on a daily basis. For example, a trusted and trained grandparent or extended family member may be called in to give the family a break from caring for the child. Members of the parent's church group would not have the training necessary to care for a ventilator-dependent child. Asking the parents to pay out of pocket for additional care would put a financial burden on the family. Suggesting the family place the child in a care facility is inappropriate. DIF: Cognitive Level: Apply REF: p. 842 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Psychosocial Integrity
19. A 5-year-old boy is being prepared for surgery to remove a brain tumor. Nursing actions should be based on which statement? a. Removal of tumor will stop the various symptoms. b. Usually the postoperative dressing covers the entire scalp. c. He is not old enough to be concerned about his head being shaved. d. He is not old enough to understand the significance of the brain.
b. Usually the postoperative dressing covers the entire scalp. ANS: B The child should be told what he will look and feel like after surgery. This includes the size of the dressing. The nurse can demonstrate on a doll the expected size and shape of the dressing. Some of the symptoms may be alleviated by the removal of the tumor, but postsurgical headaches and cerebellar symptoms such as ataxia may be aggravated. Children should be prepared for the loss of their hair, and it should be removed in a sensitive, positive manner if the child is awake. Children at this age have poorly defined body boundaries and little knowledge of internal organs. Intrusive experiences are frightening, especially those that disrupt the integrity of the skin. DIF: Cognitive Level: Apply REF: p. 831 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance
24. 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)
b. Varicella 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. DIF: Cognitive Level: Apply REF: p. 806 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
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
b. Vomiting 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. DIF: Cognitive Level: Understand REF: p. 754 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
32. One of the supervisors for a home health agency asks the nurse to give the family a survey evaluating the nurses and other service providers. The nurse should recognize this as: a. inappropriate, unless nurses are able to evaluate family. b. appropriate to improve quality of care. c. inappropriate, unless nurses and other providers agree to participate. d. inappropriate, because family lacks knowledge necessary to evaluate professionals.
b. appropriate to improve quality of care ANS: B Quality assessment and improvement activities are essential for virtually all organizations. Family involvement is essential in evaluating a home care plan and can occur on several levels. The nurse can ask the family open-ended questions at regular intervals to assess their opinion of the effectiveness of care. Families should also be given an opportunity to evaluate the individual home care nurses, the home care agency, and other service providers periodically. The nurse is the care provider. The evaluation is of the provision of care to the patient and family. The nurse's role is not to evaluate the family. Quality- monitoring activities are required by virtually all health care agencies. During the evaluation process, the family is requested to provide their perceptions of care. DIF: Cognitive Level: Apply REF: p. 842 TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
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."
c. "Your child must lie quietly; sometimes a mild sedative is administered before the procedure." 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. DIF: Cognitive Level: Apply REF: p. 740 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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
c. 90 to 110 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. Sixty 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. DIF: Cognitive Level: Apply REF: p. 752 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
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. What should the nurse explain? a. The venipuncture discomfort is very brief b. Only one venipuncture will be needed c. A 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
c. A topical application of local anesthetic can eliminate venipuncture pain 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. DIF: Cognitive Level: Apply REF: p. 789 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance
22. 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
c. Acquired immunodeficiency syndrome (AIDS) 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. DIF: Cognitive Level: Remember REF: p. 806 TOP: Integrated Process: Nursing Process: Assessment 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.
c. Adequate dosage will turn the stools a tarry green color. 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. DIF: Cognitive Level: Apply REF: p. 789 TOP: Integrated Process: Teaching/Learning
12. 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.
c. Administer an antiemetic before chemotherapy begins 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. Waiting 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. DIF: Cognitive Level: Apply REF: p. 826 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies.
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 the procedure. d. Expect bright red drainage for several hours after removal.
c. Administer analgesics before the procedure. 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. DIF: Cognitive Level: Apply REF: p. 764 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
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.
c. Administer supplemental oxygen before and after 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. DIF: Cognitive Level: Apply REF: p. 764 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
An adolescent with long-term, complex health care needs will soon be discharged from the hospital. The nurse case manager has been assigned to the teen and family. The adolescent's care involves physical therapy, occupational therapy, and speech therapy in addition to medical and nursing care. Who should be the decision maker in the adolescents care? a. Adolescent. b. Nurse case manager. c. Adolescent and family. d. Multidisciplinary health care team.
c. Adolescent and family. -The extent to which children are involved in their own care and decision making depends on many factors, including the child's developmental age, level of interest, physical ability, and parental support. If the adolescent is developmentally age appropriate, then decision making should be the responsibility of the child and family. Family needs need to be involved because they will be caring for the adolescent in the home. Health care providers have necessary input into the care of the child, but ultimate decision making rests with the adolescent and family.
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.
c. Assess the affected extremity for temperature and color. 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. DIF: Cognitive Level: Apply REF: p. 748 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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
c. Atrial septal defect 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.
The nurse observes that a seriously ill child passively accepts all painful procedures. The nurse should recognize that this is most likely an indication that the child is experiencing what emotional response? a. Hopefulness. b. Chronic sorrow. c. Belief that procedures are a deserved punishment. d. Understanding that procedures indicate impending death.
c. Belief that procedures are a deserved punishment. -The nurse should be particularly alert to a child who withdraws and passively accepts all painful procedures. This child may believe that such acts are inflicted as deserved punishment for being less worthy. A child who is hopeful is mobilized into goal-directed actions. This child would actively participate in care. Chronic sorrow is the feeling of sorrow and loss that recurs in waves over time. It is usually evident in the parents, not in the child. The seriously ill child would actively participate in care. Nursing interventions should be used to minimize pain.
21. The nurse is monitoring a 7-year-old child post surgical resection of an infratentorial brain tumor. Which vital sign findings indicate Cushing's triad? a. Increased temperature, tachycardia, tachypnea b. Decreased temperature, bradycardia, bradypnea c. Bradycardia, hypertension, irregular respirations d. Bradycardia, hypotension, tachypnea
c. Bradycardia, hypertension, irregular respirations ANS: C Cushing's triad is a hallmark sign of increased intracranial pressure (ICP). The triad includes bradycardia, hypertension, and irregular respirations. Increased or decreased temperature is not a sign of Cushing's triad. DIF: Cognitive Level: Understand REF: p. 831 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
30. The home health nurse is caring for a child who requires complex care. The family expresses frustration related to obtaining accurate information about their child's illness and its management. Which is the best action for the nurse? a. Determine why family is easily frustrated. b. Refer family to child's primary care practitioner. c. Clarify family's request, and provide information they want. d. Answer only questions that family needs to know about.
c. Clarify family's request, and provide information they want. ANS: C The philosophic basis for family-centered practice is the recognition that the family is the constant in the child's life. It is essential and appropriate that the family have complete and accurate information about their child's illness and management. The nurse may first have to clarify what information the family believes has not been communicated. The family's frustration arises from their perception that they are not receiving information pertinent to their child's care. Referring the family to the child's primary care practitioner does not help the family. The home health nurse should have access to the necessary information. Questions about what they need and want to know concerning their child's care should be addressed. DIF: Cognitive Level: Apply REF: p. 842 TOP: Integrated Process: Communication and Documentation
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 preterm addition of solid foods.
c. Clinical manifestations are similar regardless of the cause of the anemia. 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. DIF: Cognitive Level: Apply REF: p. 789 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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
c. Cool extremities and decreased skin turgor d. Confusion and somnolence 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. DIF: Cognitive Level: Analyze REF: p. 779 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
28. The home health nurse asks a child's mother many questions as part of the assessment. The mother answers many questions and then stops and says, "I don't know why you ask me all this. Who gets to know this information?" The nurse should take which action? a. Determine why the mother is so suspicious. b. Determine what the mother does not want to tell. c. Explain who will have access to the information. d. Explain that everything is confidential and that no one else will know what is said.
c. Explain who will have access to the information. ANS: C Communication with the family should not be invasive. The nurse needs to explain the importance of collecting the information, its applicability to the child's care, and who will have access to the information. The mother is not being suspicious and is not necessarily withholding important information. She has a right to understand how the information she provides will be used. The nurse will need to share, through both oral and written communication, clinically relevant information with other involved health professionals. DIF: Cognitive Level: Apply REF: p. 842 TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
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
c. Heart failure 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. DIF: Cognitive Level: Understand REF: p. 744 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
16. 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
c. IV 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. DIF: Cognitive Level: Apply REF: p. 818 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. The nurse is caring for a child after heart surgery. What should the nurse do if evidence of cardiac tamponade is found? a. Increase analgesia b. Apply warming blankets c. Immediately report this to physician d. Encourage child to cough, turn, and breathe deeply
c. Immediately report this to physician 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. DIF: Cognitive Level: Apply REF: p. 764 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
16. Which statement best describes b-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.
c. Increased incidence occurs in families of Mediterranean extraction. 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. DIF: Cognitive Level: Understand REF: p. 799 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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.
c. Increased red blood cell destruction 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. DIF: Cognitive Level: Apply REF: p. 791 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
7. Iron dextran is ordered for a young child with severe iron-deficiency anemia. What nursing considerations should be included? 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
c. Inject deeply into a large muscle 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. DIF: Cognitive Level: Apply REF: p. 790 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
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 the answer using lowercase letters separated by commas (e.g., a, b, c). a. Administer epinephrine. b. Keep the child warm and calm. c. Obtain vascular access.
c. Obtain vascular access a. Administer epinephrine. b. Keep the child warm and calm. 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. DIF: Cognitive Level: Apply REF: p. 781 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
1. A chest radiograph film is ordered for a child with suspected cardiac problems. Thechild's parent asks the nurse, "What will the radiograph show about the heart?" What knowledge about the x-ray should the nurse include in the response to the parents? 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
c. Permanent record of heart size and configuration 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. DIF: Cognitive Level: Understand REF: p. 738 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
27. Home care is being considered for a young child who is ventilator-dependent. Which factor is most important in deciding whether home care is appropriate? a. Level of parents' education b. Presence of two parents in the home c. Preparation and training of family d. Family's ability to assume all health care costs
c. Preparation and training of family ANS: C One of the essential elements is the family's training and preparation. The family must be able to demonstrate all aspects of care for the child. In many areas, it cannot be guaranteed that nursing care will be available on a continual basis, and the family will have to care for the child. The amount of formal education reached by the parents is not the important issue. The determinant is the family's ability to care adequately for the child in the home. At least two family members should learn and demonstrate all aspects of the child's care in the hospital, but it does not have to be two parents. Few families can assume all health care costs. Creative financial planning, including negotiating arrangements with the insurance company and/or public programs, may be required. DIF: Cognitive Level: Analyze REF: p. 842 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
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
c. Puppet play in the child's room 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. DIF: Cognitive Level: Apply REF: p. 789 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
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.
c. Refer children with sore throats for throat cultures. ANS: C Nurses have a role in prevention—primarily in screening school-age children for sore throats caused by group A b-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 b-hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses. DIF: Cognitive Level: Apply REF: p. 768 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
When communicating with other professionals about a child with a chronic illness, what is important for nurses to do? a. Ask others what they want to know. b. Share everything known about the family. c. Restrict communication to clinically relevant information. d. Recognize that confidentiality is not possible in home care.
c. Restrict communication to clinically relevant information. -The nurse needs to share, through both oral and written communication, clinically relevant information with other involved health professionals. Asking others what they want to know and sharing everything known about the family are inappropriate measures. Patients have a right to confidentiality. Confidentiality permits the disclosure of information to other health professionals on a need-to-know basis.
1. The school nurse is discussing testicular self-examination with adolescent boys. Why is this important? a. Epididymitis is common during adolescence. b. Asymptomatic sexually transmitted diseases may be present. c. Testicular tumors during adolescence are generally malignant. d. Testicular tumors, although usually benign, are common during adolescence.
c. Testicular tumors during adolescence are generally malignant. ANS: C Tumors of the testes are not common, but when manifested in adolescence, they are generally malignant and demand immediate evaluation. Epididymitis is not common in adolescence. Asymptomatic sexually transmitted disease would not be evident during testicular self-examination. The focus of this examination is on testicular cancer. Testicular tumors are most commonly malignant. DIF: Cognitive Level: Apply REF: p. 842 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. 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.
c. Unrestricted proliferation of immature white blood cells (WBCs) occurs 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. DIF: Cognitive Level: Understand REF: p. 826 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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
c. X-linked recessive inherited disorder in which a blood-clotting factor is deficient 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. DIF: Cognitive Level: Understand REF: p. 801 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
34. A mother of a 5-year-old child, with complex health care needs and cared for at home, expresses anxiety about attending a kindergarten graduation exercise of a neighbor's child. The mother says, "I wish it could be my child graduating from kindergarten." The nurse recognizes that the mother is experiencing: a. abnormal anxiety. b. ineffective coping. c. chronic sorrow. d. denial.
c. chronic sorrow. ANS: C Home care nurses should be aware that parents may experience chronic sorrow as a parental stressor. Chronic sorrow as a normal grief response is associated with a living loss (the loss of a healthy child) that is cyclical in nature. This is a normal response and does not indicate abnormal anxiety, ineffective coping, or denial. DIF: Cognitive Level: Understand REF: p. 842 TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Psychosocial Integrity
29. When communicating with other professionals, it is important for home care nurses to: a. ask others what they want to know. b. share everything known about the family. c. restrict communication to clinically relevant information. d. recognize that confidentiality is not possible.
c. restrict communication to clinically relevant information. ANS: C The nurse will need to share, through both oral and written communication, clinically relevant information with other involved health professionals. Asking others what they want to know and sharing everything known about the family is inappropriate. Patients have a right to confidentiality. The nurse is not permitted to share information about clients, except clinically relevant information that pertains to the child's care. Confidentiality permits the disclosure of information to other health professionals on a need- to-know basis. DIF: Cognitive Level: Apply REF: p. 842 TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
30. 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."
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. DIF: Cognitive Level: Apply REF: p. 805 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
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
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. DIF: Cognitive Level: Understand REF: p. 789 TOP: Integrated Process: Nursing Process: Assessment 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
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. DIF: Cognitive Level: Understand REF: p. 804 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
29. 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. Of what are these manifestations most suggestive? a. Air emboli b. Allergic reaction c. Hemolytic reaction d. Circulatory overload
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. DIF: Cognitive Level: Apply REF: p. 811 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
d. Confusion and somnolence ANS: D Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock. DIF: Cognitive Level: Understand REF: p. 779 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. 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
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. DIF: Cognitive Level: Apply REF: p. 824 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
What nursing intervention is especially helpful in assessing feelings of parental guilt when a disability or chronic illness is diagnosed? a. Ask the parents if they feel guilty. b. Observe for signs of overprotectiveness. c. Talk about guilt only after the parents mention it. d. Discuss the meaning of the parents' religious and cultural background.
d. Discuss the meaning of the parents' religious and cultural background. -Guilt may be associated with cultural or religious beliefs. Some parents are convinced that they are being punished for some previous misdeed. Others may see the disorder as a trail sent by God to test their religious beliefs. The nurse can help the parents explore their religious beliefs. On direct questioning, the parents may not be able to identify the feelings of guilt. It would be appropriate for the nurse to explore their adjustment responses. Overprotectiveness is a parental response during the adjustment phase. The parents feat letting the child achieve any new skill and avoid all discipline.
15. 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
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. DIF: Cognitive Level: Understand REF: p. 829 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
14. 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.
d. Explain to child that when hair regrows, it may have a slightly different color or 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. DIF: Cognitive Level: Apply REF: p. 819 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
What should the nurse determine to be the priority intervention for a family with an infant who has a disability? a. Focus on the child's disabilities to understand care needs. b. Institute age-appropriate discipline and limit setting. c. Enforce visiting hours to allow parents to have respite care. d. Foster feelings of competency by helping parents learn the special care needs of the infant.
d. Foster feelings of competency by helping parents learn the special care needs of the infant. -It is important that the parents learn how to care for their infant so they feel competent. The nurse facilitates this by teaching special holding techniques, supporting breastfeeding, and encouraging frequent visiting and rooming in. The focus should be on the infant's capabilities and positive features. Infants do not usually require discipline. As the child gets older, this is necessary, but it is not a priority intervention at this time. The nursing staff negotiates with the family about the need for respite care.
36. When discussing hyperlipidemia with a group of adolescents, which high level labs should the nurse explain can prevent cardiovascular disease? a. Cholesterol b. Triglycerides c. Low-density lipoproteins (LDLs) d. High-density lipoproteins (HDLs)
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.
A child with a serious chronic illness will soon go home. The case manager requests that the family provide total care for the child for a couple of days while the child is still hospitalized. How should the request be viewed? a. Improper because of legal issues. b. Supportive because families are usually eager to get involved. c. Unacceptable because the family will have to assume the care soon enough. d. Important because it can be beneficial to the transition from hospital to home.
d. Important because it can be beneficial to the transition from hospital to home. -This type of groundwork is essential for the family. Adequate family training and preparation will assist in the child's transition home. The nursing staff in the hospital is responsible for the child's care. The family will provide the care with assistance as needed. Although parents are eager to be involved, the purpose of this intervention is the development of family competency and confidence that they are capable. Arrangements for respite care are important for the family both during hospitalization and while the child is at home.
Parents ask for help for their other children to cope with the changes in the family resulting from the special needs of their sibling. What strategy does the nurse recommend? a. Explain to the siblings that embarrassment is unhealthy. b. Encourage the parents not to expect siblings to help them care for the child with special needs. c. Provide information to the siblings about the child's condition only as requested. d. Invite the siblings to attend meetings to develop plans for the child with special needs.
d. Invite the siblings to attend meetings to develop plans for the child with special needs. -Siblings should be invited to attend meetings to be part of the care team for the child. They can learn about an individualized education plan and help design strategies that will work at home. Embarrassment may be associated with having a sibling with a chronic illness or disability. Parents must be able to respond in an appropriate manner without punishing the sibling. The parents may need assistance with the care of the child. Most siblings are positive about the extra responsibilities. Parents need to inform the siblings about the child's condition before a non family member does so. The parents do not want the siblings to fantasize about what is wrong with the child.
8. The nurse is recommending how to prevent iron-deficiency anemia in a healthy, term, breastfed 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
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 breastfed 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. DIF: Cognitive Level: Apply REF: p. 789 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
9. 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
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. DIF: Cognitive Level: Apply REF: p. 825 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
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
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. DIF: Cognitive Level: Understand REF: p. 791 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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.
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. DIF: Cognitive Level: Apply REF: p. 754 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
What finding by the nurse is most characteristic of chronic sorrow? a. Lack of acceptance of child's limitation. b. Lack of available support to prevent sorrow. c. Periods of intensified sorrow when experiencing anger and guilt. d. Periods of intensified sorrow at certain landmarks of the child's development.
d. Periods of intensified sorrow at certain landmarks of the child's development. -Chronic sorrow is manifested by feelings of sorrow and loss that recur in waves over time. The sorrow is a response to the recognition of the child's limitations. The family should be assessed in an ongoing manner to provide appropriate support as their needs change. The sorrow is not preventable. The chronic sorrow occurs during the reintegration and acknowledgement stage.
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.
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. DIF: Cognitive Level: Apply REF: p. 763 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
29. Which is the most common causative agent of bacterial endocarditis? a. Staphylococcus albus b. Streptococcus hemolyticus c. Staphylococcus albicans d. Streptococcus viridans
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. DIF: Cognitive Level: Remember REF: p. 765 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
28. 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
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. DIF: Cognitive Level: Understand REF: p. 810 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.
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. DIF: Cognitive Level: Apply REF: p. 776 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
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.
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.
31. A family wants to begin oral feeding of their 4-year-old son, who is ventilator- dependent and currently tube-fed. They ask the home health nurse to feed him the baby food orally. The nurse recognizes a high risk of aspiration and an already compromised respiratory status. The most appropriate nursing action is to: a. refuse to feed him orally because the risk is too high. b. explain the risks involved, and then let the family decide what should be done. c. feed him orally because the family has the right to make this decision for their child. d. acknowledge their request, explain the risks, and explore with the family the available options.
d. acknowledge their request, explain the risks, and explore with the family the available options. ANS: D Parents want to be included in the decision making for their child's care. The nurse should discuss the request with the family to ensure this is the issue of concern, and then they can explore potential options together. Merely refusing to feed the child orally does not determine why the parents wish the oral feedings to begin and does not involve them in the problem solving. The decision to begin or not change feedings should be a collaborative one, made in consultation with the family, nurse, and appropriate member of the health care team. DIF: Cognitive Level: Analyze REF: p. 823 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
5. 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..
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. DIF: Cognitive Level: Apply REF: p. 828 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
