Health Problems in the Pediatric Patient

A baby is preoperative for closure of a myelomeningocele. Which of the following is the baby's priority nursing diagnosis? 1. Risk for Infection 2. Impaired Physical Mobility 3. Risk for Latex Allergy 4. Bowel Incontinence

ANSWER: 1 Rationale: 1. Risk for Infection is the baby's highest priority nursing diagnosis. 2. Impaired Physical Mobility is an appropriate nursing diagnosis, but it is not the priority diagnosis. 3. Risk for Latex Allergy is an appropriate nursing diagnosis, but it is not the priority diagnosis. 4. Bowel Incontinence is an appropriate nursing diagnosis, but it is not the priority diagnosis. TEST-TAKING TIP: Although babies born with meningomyelocele are at risk for latex allergy and have both impaired physical mobility of their lower extremities and bowel incontinence, their most significant problem is their risk for infection. The exposed sac is a direct portal for bacterial invasion. The sac must be protected with moist, sterile dressings until it is surgically closed. Content Area: Newborn-At-Risk Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Reduction of Risk Potential: Potential for Alterations in Body Systems Cognitive Level: Analysis

A nurse is educating a parent regarding the psychosocial stage of development of the infancy period. Which of the following information did the nurse include in the discussion? 1. Infants should have their needs met in a timely fashion. 2. Mothers should let their babies cry themselves to sleep each night. 3. Infants should be scolded for bad behavior whenever they break objects. 4. Mothers should sneak out of the room when they must leave their babies.

ANSWER: 1 Rationale: 1. This response is correct. Infants should have their needs met in a timely manner. 2. It is not recommended that infants cry themselves to sleep each night. 3. It is not recommended that infants be disciplined for breaking items. 4. Mothers who sneak out when they are leaving their children are not promoting a sense of trust in their children. TEST-TAKING TIP: The Eriksonian psychosocial stage of the infancy period is trust versus mistrust. Infants develop trust when they become assured that their parents will meet their needs (e.g., feed them when they are hungry, change their diapers when they are wet or soiled). Parents who meet their children's needs in a timely fashion are promoting a sense of trust in their children. Content Area: Pediatrics—Infant Integrated Processes: Nursing Process: Implementation; Teaching/Learning Client Need: Health Promotion and Maintenance: Developmental Stages and Transitions Cognitive Level: Application

A 9-year-old child is in the hospital in skin traction after sustaining a simple fracture of the femur. Which of the following assessments should the nurse make during rounds with the child's orthopedist? The nurse should assess the: (Select all that apply.) 1. child's level of pain. 2. child's bowel sounds. 3. capillary refill of the child's toes. 4. skin under the ace bandage for signs of skin breakdown. 5. wound for signs of redness, edema, ecchymosis, drainage, and approximation.

ANSWER: 1, 2, 3, and 4 Rationale: 1. The nurse should assess the child's level of pain. 2. The nurse should assess the child's bowel sounds. 3. The nurse should assess the capillary refill of the child's toes. 4. The nurse should assess the skin under the ace bandages for signs of skin breakdown. 5. There is no wound for the nurse to assess. TEST-TAKING TIP: A simple fracture is an internal fracture that is enclosed in intact skin. Skin traction is applied directly to the skin using ace bandages or other external devices. One of the complications of skin traction is impaired skin integrity. Children who are in traction are confined to the bed. A complication of immobility is impaired elimination secondary to decrease in peristalsis. Content Area: Pediatrics—Neuromuscular Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential: Potential for Complications of Diagnostic Test/ Treatments/Procedures Cognitive Level: Application

A 13-year-old adolescent is in hospital for reconstructive surgery after a severe automobile accident. During rounds, the nurse notes that the teen is watching television and playing a video game. Which of the following should the nurse assess regarding the patient's well-being? Select all that apply. 1. Teen's pain level 2. How often friends visit the teen 3. Level of healing of the teen's surgical site 4. Teen's progress on daily homework assignments 5. How well the teen is performing on the video games

ANSWER: 1, 2, 3, and 4 Rationale: 1. The teen's pain level should be assessed. 2. The nurse should assess how often friends visit the teen. 3. The nurse should assess the healing of the teen's surgical site. 4. The nurse should assess the teen's progress on daily homework assignments. 5. It is not important for the nurse to assess how well the teen is performing on the video games. TEST-TAKING TIP: When a nurse is performing holistic nursing care in the pediatric setting, he or she must assess not only the physiological aspects of the child's well-being but also the psychosocial aspects. Completion of the child's homework is one of those aspects. Content Area: Pediatrics Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation: Illness Management; Psychosocial Integrity: Behavioral Interventions Cognitive Level: Application

A child is admitted to the pediatric unit with a diagnosis of meningitis. Which of the following actions should the nurse perform? Select all that apply. 1. Raise the head of the bed. 2. Dim the lights in the room. 3. Place the child on droplet isolation. 4. Administer intravenous antibiotics, as prescribed. 5. Perform passive range-of-motion exercises of the neck.

ANSWER: 1, 2, 3, and 4 Rationale: 1. The head of the bed should be raised. 2. The room lights should be dimmed. 3. The child should be placed on droplet isolation. 4. The child will receive IV antibiotics. 5. The nurse should refrain from moving the child's neck. The movement is very painful. TEST-TAKING TIP: The bacteria that cause meningitis are transmitted via the respiratory route. The child, therefore, should be placed on droplet isolation. Once the child has been on antibiotics for a full 24 hr or if the culture report is negative for bacteria, he or she no longer needs to remain on isolation. Content Area: Pediatrics—Neuromuscular Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation: Illness Management Cognitive Level: Application

A child has been diagnosed with Hirschsprung's disease. Which of the following findings would the nurse expect the parents to report in the child's history? Select all that apply. 1. Ribbon-like stools 2. Chronic constipation 3. Black and tarry stools 4. Distended abdomen 5. Delayed meconium passage

ANSWER: 1, 2, 4, and 5 Rationale: 1. The nurse would expect the parents to report that the child has ribbon-like stools. 2. The nurse would expect the parents to report that the child has chronic constipation. 3. The nurse would not expect the parents to report that the child has black and tarry stools. 4. The nurse would expect the parents to report that the child has a distended abdomen. 5. The nurse would expect the parents to report that the child has delayed meconium passage. TEST-TAKING TIP: The lack of enervation to the rectum and/or lower intestine results in the absence of peristalsis in the affected bowel. As a result, in the neonatal period, meconium is passed very late. If the disease remains undiagnosed, the child develops a distended abdomen and chronic constipation with pellet or ribbon-like stools.

The nurse is developing a plan of care to prevent separation behaviors in children who are hospitalized for long periods of time. Which of the following items should the nurse include in the plan of care? Select all that apply. 1. Provide the child with the child's favorite transitional object. 2. When possible, assign the same nurse to care for the child each day. 3. Admit the child to the patient room that is closest to the nurse's station. 4. Tape pictures of the child's friends and family members to the walls of the child's hospital room. 5. Inform the parents that at least one person must stay with the child at all times during the hospitalization.

ANSWER: 1, 2, and 4 Rationale: 1. The nurse should provide the child with the child's favorite transitional object. 2. When possible, the same nurse should be assigned to care for the child each day. 3. The child need not be admitted to the patient room that is closest to the nurse's station. 4. The nurse should tape pictures of the child's friends and family members to the walls of the child's hospital room. 5. The nurse should not inform the parents that at least one person must stay with the child at all times during the hospitalization. TEST-TAKING TIP: Although it is ideal for at least one parent to stay with a child during the child's hospitalization, it is not always possible. For example, the parents may have to work, they may live miles away from the hospital, or they may need to be at home to care for the child's siblings. To maintain a strong relationship between the child and his or her parents, the nurse should implement actions as stated above as well as encourage direct communication via a number of routes (e.g., via telephone, texting, video conferencing). Content Area: Pediatrics Integrated Processes: Nursing Process: Implementation Client Need: Psychosocial Integrity: Coping Mechanisms Cognitive Level: Application

The nurse is developing a plan of care to prevent separation behaviors in children who are hospitalized for long periods of time. Which of the following items should the nurse include in the plan of care? Select all that apply. 1. Provide the child with the child's favorite transitional object. 2. When possible, assign the same nurse to care for the child each day. 3. Admit the child to the patient room that is closest to the nurse's station. 4. Tape pictures of the child's friends and family members to the walls of the child's hospital room. 5. Inform the parents that at least one person must stay with the child at all times during the hospitalization.

ANSWER: 1, 2, and 4 Rationale: 1. The nurse should provide the child with the child's favorite transitional object. 2. When possible, the same nurse should be assigned to care for the child each day. 3. The child need not be admitted to the patient room that is closest to the nurse's station. 4. The nurse should tape pictures of the child's friends and family members to the walls of the child's hospital room. 5. The nurse should not inform the parents that at least one person must stay with the child at all times during the hospitalization. TEST-TAKING TIP: Although it is ideal for at least one parent to stay with a child during the child's hospitalization, it is not always possible. For example, the parents may have to work, they may live miles away from the hospital, or they may need to be at home to care for the child's siblings. To maintain a strong relationship between the child and his or her parents, the nurse should implement actions as stated above as well as encourage direct communication via a number of routes (e.g., via telephone, texting, video conferencing). Content Area: Pediatrics Integrated Processes: Nursing Process: Implementation Client Need: Psychosocial Integrity: Coping Mechanisms Cognitive Level: Application

A 12-year-old boy with a history of sickle cell anemia and a diagnosis of vaso-occlusive crisis is being assessed by the admitting nurse in the emergency department. Which of the following signs/symptoms would the nurse expect to see? Select all that apply. 1. Priapism 2. Pain level of 2/10 3. Hematuria 4. Elevated liver enzymes 5. Hematocrit 39%

ANSWER: 1, 3, and 4 Rationale: 1. Priapism is symptom seen in males during a vaso- occlusive crisis. 2. The pain level is much higher during a vaso-occlusive crisis, often rated at 9/10 or 10/10 on a numeric pain rating scale. 3. Hematuria is a symptom seen during a vaso-occlusive crisis. 4. Elevated liver enzymes are seen during a vaso- occlusive crisis. 5. The nurse would expect to see a low hematocrit in a child with SCA. TEST-TAKING TIP: To remember signs and symptoms seen during vaso-occlusive crises, the test taker should remember the pathology of the attack (i.e., sickling and clumping of RBCs). Vascular organs, therefore, are most affected by the crisis. The blood becomes trapped in the vessels of the penis, resulting in a painful erection. The kidneys become ischemic, resulting in the loss of blood into the urine. The liver becomes ischemic, resulting in elevated liver enzymes. Patients in vaso-occlusive crisis experience severe pain. Content Area: Pediatrics—Hematological Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation: Alterations in Body Systems Cognitive Level: Application

A child with nonorganic failure to thrive (NOFTT) is being discharged from the hospital. The baby's mother, who is now exhibiting appropriate parenting behaviors, is providing the baby with needed nutritional supplementation. In addition, the mother does which of the following? 1. Feeds the baby through an enlarged hole in the nipple 2. Faces a blank wall while feeding the baby 3. Adds rice cereal to the baby's formula 4. Puts the baby to bed with a bottle of formula

ANSWER: 2 Rationale: 1. It is not recommended to feed babies with FTT through an enlarged hole in the nipple. 2. It is recommended to face a blank wall while feeding babies with NOFTT. 3. It is not recommended to add rice to a baby's bottle of formula because they can choke on the mixture. 4. It is not recommended to put babies to bed with a bottle of formula because they will be at high risk for developing dental caries. TEST-TAKING TIP: Some babies with NOFTT eat poorly because they become distracted by external stimuli and fail to attend to the primary caregiver who is feeding them. By facing a blank wall, distractions are markedly reduced. Content Area: Pediatrics Integrated Processes: Nursing Process: Evaluation Client Need: Health Promotion and Maintenance: Health Promotion/Disease Prevention Cognitive Level: Application

A nurse discovers an 8-month-old child face down in a puddle of water. The child is not breathing and has no pulse. Which of the following actions should the nurse perform at this time? 1. 5 back slaps followed by 5 cardiac compressions 2. 30 cardiac compressions followed by 2 rescue breaths 3. A series of rescue breaths every 3 to 5 seconds 4. Call 911 to activate the emergency response team.

ANSWER: 2 Rationale: 1. The nurse should begin CPR in a 30 compressions to 2 rescue breaths ratio. 2. The nurse should begin CPR in a 30 compressions to 2 rescue breaths ratio. 3. The acronym for emergency care is CAB—cardiac compressions, airway, breathing. The nurse, therefore, should begin CPR in a 30 compression to 2 rescue breath ratio. 4. The nurse should wait to call 911 to activate the emergency response team until he or she has performed CPR for approximately 2 min. TEST-TAKING TIP: Even though liquid is the most common cause of airway obstruction in infants, it is recommended that CPR be instituted when a drowning victim is discovered rather than performing actions to dislodge an obstruction. Content Area: Pediatrics Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation: Medical Emergencies Cognitive Level: Application

A young child is admitted to the emergency department in vaso-occlusive crisis. Which of the following orders is the highest priority for the nurse to perform? 1. Morphine 1 mg subcu STAT 2. IVD5W1⁄4NSat90mL/hr 3. Oxygen 2 L/min 4. Arterial blood gases STAT

ANSWER: 2 Rationale: 1. Administering the narcotic is an important action but not the priority action. 2. Infusing IV fluids is the priority action. 3. Administering oxygen is an important action but not the priority action. 4. Obtaining and assessing the arterial blood gases are important actions but not the priority action. TEST-TAKING TIP: When determining the priority action, nurses must consider which of the actions will be most apt to improve their client's condition. The pathology of a vaso-occlusive crisis results in clumping of the RBCs and poor blood flow. The only action that will improve circulation is the IV infusion that will increase the child's blood volume. Content Area: Pediatrics—Hematological Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment: Management of Care: Establishing Priorities Cognitive Level: Analysis

The nurse, who is admitting a neonate into the well-baby nursery, assesses the following: widely separated sagittal suture and enlarged anterior and posterior fontanels. Which of the following follow-up assessments is most important for the nurse to perform at this time? 1. Tonic neck reflex 2. Head and chest circumferences 3. Ortolani's sign 4. Red reflexes of both eyes

ANSWER: 2 Rationale: 1. It is important to assess the tonic neck reflex, but another response is more important. 2. It would be most important for the nurse to assess the child's head and chest circumferences carefully. 3. It is important to assess Ortolani's sign, but another response is more important. 4. It is important to assess for the red reflex in both of the baby's eyes, but another response is more important. TEST-TAKING TIP: Babies with widely separated sagittal sutures and enlarged fontanels may have heads that are larger than normal. The head circumference should be approximately 2 cm larger than the chest circumference. If it is markedly larger, the baby may be developing hydrocephalus. Content Area: Newborn-At-Risk Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation: Alterations in Body Systems Cognitive Level: Analysis

A nurse is providing counseling to parents regarding an important action they can take to prevent their children from developing meningitis. Which of the following actions did the nurse suggest? 1. Have children sleep in separate beds during sleepover parties. 2. Have children receive all recommended immunizations. 3. Teach children to wash their hands after toileting and before eating. 4. Teach children to cover their faces with a tissue when they sneeze.

ANSWER: 2 Rationale: 1. Sleeping in separate beds may help to prevent transmission if one child is harboring bacteria that cause meningitis, but it is not the best response. 2. Many of the vaccinations administered to children immunize children against bacteria that cause meningitis. 3. Teaching children to wash their hands after toileting and before eating helps to prevent many types of illnesses, most notably gastrointestinal illnesses. 4. Teaching children to cover their faces with a tissue when they sneeze helps to prevent the transmission of upper respiratory illnesses to other children. TEST-TAKING TIP: Immunizations against H. influenzae, N. meningitides, and S. pneumoniae have prevented many children from developing meningitis. Content Area: Child Health Integrated Processes: Nursing Process: Implementation; Teaching/Learning Client Need: Health Promotion and Maintenance: Health Promotion/Disease Prevention Cognitive Level: Analysis

A 4-year-old child, who is hospitalized with pneumonia, tells the nurse, "I got sick because I was bad. I yelled at my little sister yesterday." The nurse determines that which of the following is an accurate explanation for the child's comment? The child is: 1. Trying to get sympathy from the nurse. 2. Exhibiting an example of magical thinking. 3. Making up stories to entertain the nurse. 4. Expressing remorse for having yelled at her sister.

ANSWER: 2 Rationale: 1. This explanation is unlikely. 2. This is the likely explanation. The child is exhibiting an example of magical thinking. 3. Preschool children do make up stories, but the statement is consistent with a child who is expressing a form of magical thinking. 4. The child may feel bad about yelling at her sister, but the child likely truly believes that the sister became ill because the child was yelling at her sister. TEST-TAKING TIP: The Eriksonian psychosocial development stage of the preschool child is initiative versus guilt. Children during this stage of development often believe that their thoughts are powerful (i.e., that they can cause injury simply by having angry thoughts or expressing angry words and, unless they are told otherwise, they can become guilt-ridden). Content Area: Pediatrics—Preschool Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance: Developmental Stages and Transitions Cognitive Level: Application

The nurse is caring for a 14-year-old adolescent after a serious injury. A twice-daily dressing change has been ordered by the child's primary health-care provider. When planning care with the patient, which of the following statements would be best for the nurse to make? 1. "I'll be in to change your dressing twice today." 2. "When do you think will be the best times for me to change your dressing?" 3. "I'm going to have you help me when I change your dressing." 4. "Can you help me to figure out how best to change your dressing?"

ANSWER: 2 Rationale: 1. This is not the best statement for the nurse to make. 2. This is the best statement for the nurse to make. 3. This is not the best statement for the nurse to make.4. This is not the best statement for the nurse to make. TEST-TAKING TIP: During adolescence, teenagers are progressing through the Eriksonian psychosocial stage of identity versus role confusion. During this stage, adolescents are developing a sense of self as an independent individual. To become a unique individual, teens seek to become more and more independent. When the nurse solicits the teenager's help in determining when the dressing should be changed, the nurse is providing the teen with some independence. Content Area: Pediatrics Integrated Processes: Nursing Process: Implementation Client Need: Psychosocial Integrity: Therapeutic Communication Cognitive Level: Analysis

The neonatal cardiologist orders digoxin (Lanoxin) for a newborn in congestive heart failure. The baby weighs 7 lb 8 oz and is 21 inches long. The drug reference states: for full-term newborns, 8 to 10 mcg/kg/day in divided doses every 12 hr. Which of the following orders would be safe for the nurse to administer? 1. 10mcgPOevery12hr 2. 15mcgPOevery12hr 3. 20mcgPOevery12hr 4. 25mcgPOevery12hr

ANSWER: 2 Rationale: 1. Ten mcg PO every 12 hr is below the recommended dosage range for digoxin. 2. Fifteen mcg PO every 12 hr is between the minimum and the maximum recommended dosages for digoxin and is the correct response. 3. Twenty mcg PO every 12 hr is above the recommended dosage range for digoxin. 4. Twenty-five mcg PO every 12 hr is above the recommended dosage range for digoxin. TEST-TAKING TIP: Ratio and proportion method: The baby in the scenario weighs 7 lb 8 oz, or 71⁄2 lb (there are 16 oz per pound). 1 kg: 2.2 lb = x kg: 7.5 lb x = 3.409, or 3.41 kg Minimum safe dosage: 8 mcg: 1 kg = x mcg: 3.41 kg x = 27.28 mcg, per day dosage 27.28 ÷ 2 = 13.64 mcg, every 12 hr dosage (two doses per day) Maximum safe dosage: 10 mcg: 1 kg = x mcg: 3.41 kg x = 34.1 mcg, per day dosage 34.1 ÷ 2 = 17.05 mcg, every 12 hr dosage (two doses per day) Content Area: Pediatrics—CardiacIntegrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Pharmacological and Parental Therapies: Dosage CalculationCognitive Level: Synthesis

The mother of an 11-month-old remarks to a nurse at the pediatric clinic, "We are so lucky. Our daughter has never had an ear infection!" Which of the following factors can the nurse tell the mother have protected her daughter from the disease? Select all that apply. 1. The family owns no pets. 2. No one in the family smokes. 3. The mother breastfeeds her daughter. 4. Child attends day care only two mornings a week. 5. The family lives in the southern part of the country.

ANSWER: 2, 3, and 4 Rationale: 1. Pet ownership has not been shown to have any effect on the incidence of ear infections. 2. Cigarette smoke places children at high risk for ear infections. 3. Breastfeeding has been shown to have a protective effect on the incidence of ear infections. 4. Day-care attendance places children at high risk for ear infections. 5. Geographic location has not been shown to have an effect on the incidence of ear infections. TEST-TAKING TIP: Nurses working with pregnant women and with young children should encourage parents to promote healthful behaviors in the home. Babies who consume breast milk are less likely to develop ear infections as well as a number of other conditions. Content Area: Pediatrics—Respiratory Integrated Processes: Nursing Process: Implementation Client Need: Health Promotion and Maintenance: Health Promotion/Disease Prevention Cognitive Level: Application

An 8-year-old child, who is post-op appendectomy, is playing with a set of building blocks. The child's pulse and blood pressure are slightly elevated above their presurgery levels. When asked what level the child would rate the postoperative pain on a numeric pain scale, the child states that the pain is "8 on a scale of 1 to 10." The child's primary health-care provider has ordered Tylenol (acetaminophen) and morphine sulfate for pain. Which of the following actions should the nurse perform at this time? 1. Report the child's pain level to the child's primary health-care provider. 2. Administer acetaminophen to the child based on the child's behavior. 3. Administer morphine to the child based on the child's rating of the pain. 4. Query the child about how the child is able to play with such severe pain.

ANSWER: 3 Rationale: 1. It is not necessary to report the child's pain level to the child's primary health-care provider. 2. It would be inappropriate to administer acetaminophen to the child based on the child's behavior. 3. The nurse should administer morphine to the child based on the child's rating of the pain. 4. It is inappropriate for the nurse to question the child's veracity. TEST-TAKING TIP: A child's rating on a pain rating scale is more accurate than a nurse's interpretation of the child's pain based on the child's behavior. The nurse should always believe the child's rating of the pain. Content Area: Pediatrics Integrated Processes: Nursing Process: Implementation Client Need: Caring; Physiological Integrity; Pharmacological and Parenteral Therapies: Pharmacological Pain Management Cognitive Level: Application

A pediatric nurse is having a discussion with a father whose child has recently been diagnosed with spastic cerebral palsy. Which of the following statements by the nurse is appropriate? 1. "It must be very hard to know that your child's ability to move will decrease over time." 2. "I am sure that it is hard for you to know that your child has this disease, but at least the medicine will treat the underlying problem." 3. "The treatment plan for your child will focus on enabling him to have as normal movements as possible." 4. "The nerve stimulation of your child's legs will enable him to walk on his own when he is older."

ANSWER: 3 Rationale: 1. The symptoms of CP do not get worse over time. 2. Although medicines are available for some of the comorbidities associated with CP, there is no medication that treats the underlying cause of CP. 3. This statement is accurate. 4. This statement is false. The pathology of CP is in the brain. TEST-TAKING TIP: The signs and symptoms of CP result from a hypoxic insult to the brain. The therapeutic interventions are aimed at enabling the child to reach his or her highest potential. Content Area: Pediatrics—Neuromuscular Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation: Alterations in Body Systems Cognitive Level: Application

A 12-week-gestation African American woman asks her obstetrician's nurse whether her baby could be born with sickle cell disease. Which of the following replies is appropriate for the nurse to give? 1. It is possible because one out of every 500 African Americans is diagnosed with sickle cell anemia. 2. If either you or the baby's father has sickle cell anemia, your child may be born with the disease. 3. The baby could only have sickle cell anemia if both you and the baby's father carry a sickle cell gene. 4. If the child is a boy, he could have sickle cell anemia, but if the child is a girl, she will definitely be healthy.

ANSWER: 3 Rationale: 1. It is possible that the child could have SCA, but only if both parents carry a sickle cell gene. 2. This statement is incorrect. SCA is an autosomal recessive illness, not an autosomal dominant illness. 3. This statement is correct. The baby could only have sickle cell anemia if both the woman and the baby's father carry a sickle cell gene. 4. This statement is incorrect. SCA is an autosomal recessive illness, not an X-linked recessive illness. TEST-TAKING TIP: Test takers should be familiar with the inheritance patterns of common genetic illnesses such as the autosomal recessive inheritance of SCA. Those with the disease must carry affected genes on both of their chromosomes. Those with the carrier state have an affected gene on one of their chromosomes and a normal gene on their other chromosome. Content Area: Pediatrics—HematologicalIntegrated Processes: Nursing Process: Implementation; Teaching/LearningClient Need: Health Promotion and Maintenance: Health ScreeningCognitive Level: Application

A 6-year-old child is being assessed by a nurse for possible signs of dehydration. Which of the following assessments should the nurse perform? 1. Patellar reflexes 2. Anterior fontanel tension 3. Skin turgor 4. Pupil reactivity to light

ANSWER: 3 Rationale: 1. Patellar reflexes are not performed when assessing hydration status. 2. Anterior fontanelle tension should be assessed in infants and young toddlers. This child, however, is 6 years of age. 3. The child's skin turgor should be assessed. 4. Pupil reactivity to light is not checked when assessing hydration status. TEST-TAKING TIP: To assess skin turgor, the nurse should gently pinch the skin between two fingers. A well- hydrated child's skin should return to its original position without noticeable indentations. When a child is dehydrated, however, the skin will stay in the position where it was released in what appears to be a type of tent. This finding is called tenting. Content Area: Pediatrics—School Age Integrated Processes: Nursing Process: Assessment Client Need: Physiological Adaptation: Fluid and Electrolyte Imbalances Cognitive Level: Application

A primary health-care provider has ordered an IV of D5 1⁄2 NS for a child with a diagnosis of dehydration. The parent asks the nurse to explain why the child must receive the solution. Which of the following responses by the nurse is appropriate? 1. "The solution contains all of the substances that should be in your child's bloodstream." 2. "The solution will replace the most important electrolytes that your child is missing." 3. "The fluid contains some sugar and some salt. Those, in addition to the fluid, will help to make your child better." 4. "The fluid is the same as the water that you drink. Your child needs the water in order to get better."

ANSWER: 3 Rationale: 1. The solution only contains dextrose and saline that is one-half the concentration of the blood. 2. Because this response is made using medical terminology, it will be difficult for the parent to understand. In addition, only sodium and chloride are being replaced. 3. This is an appropriate response for the nurse to provide. 4. This statement is not accurate. The fluid is not the same as drinking water. It contains saline one-half the100 mL of water. TEST-TAKING TIP: The solution, D5 1⁄2 NS, is comprised of 77 mEq of both sodium and chloride for every 1,000 mL, and 5 g of dextrose for every 100 mL of water. It is providing the child, therefore, with saline that is one-half the concentration of saline of the blood as well as some dextrose for calories. Content Area: PediatricsIntegrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation: Fluid and Electrolyte Imbalances Cognitive Level: Application

A nurse is interviewing a group of 4th grade children. It would be appropriate for the nurse to diagnose the child who made which of the following statements as at "Risk for Altered Coping related to poor psychosocial development"? 1. "My teacher put the picture I drew up on the board." 2. "I made a goal during our soccer game yesterday." 3. "I strike out every time I bat when we play softball in gym class." 4. "My teacher let me read out loud last week and again this week."

ANSWER: 3 Rationale: 1. This child is exhibiting positive psychosocial development. 2. This child is exhibiting positive psychosocial development. 3. This child may be at risk of poor psychosocial development. 4. This child is exhibiting positive psychosocial development. TEST-TAKING TIP: The Eriksonian stage of the school-age period is called industry versus inferiority. Children try hard to succeed, but when they repeatedly are unable to achieve what they consider to be a successful result, they may develop a feeling of inferiority. It is important to note that it is a rare child who is successful in all that he or she endeavors. Rather, he or she should feel capable in at least one aspect of life. Parents who praise their children's achievements are fostering a belief in their children that if they work hard, they will perform their best. Content Area: Pediatrics—School Age Integrated Processes: Nursing Process: Analysis Client Need: Health Promotion and Maintenance: Developmental Stages and Transitions Cognitive Level: Application

The nurse is admitting a newly delivered neonate with meningocele into the nursery. Which of the following assessments is priority for the nurse to perform? 1. Assessment of the red reflexes 2. Hard palate assessment 3. Trunk incurvation reflex 4. Head and chest circumferences

ANSWER: 4 Rationale: 1. Assessment of the red reflex is important, but it is not the priority assessment. 2. Hard palate assessment is important, but it is not the priority assessment. 3. Assessment of the trunk incurvation reflex is important, but it is not the priority assessment. 4. It is priority for the nurse to assess the baby's head and chest circumferences. TEST-TAKING TIP: Over 90% of babies born with meningocele and myelomeningocele will also have hydrocephalus. It is priority, therefore, for the nurse to assess the circumferences to determine whether the baby is suffering from that complication. Content Area: Newborn-At-Risk Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation: Alterations in Body Systems Cognitive Level: Analysis

A child who is experiencing high fever and neck pain is diagnosed with viral meningitis. Which of the following should the nurse include in the discharge teaching? 1. Keep the child isolated until the temperature returns to normal. 2. Pad the child's bed headboard. 3. Rent a commode for the child to use at home. 4. Administer over-the-counter analgesics as needed.

ANSWER: 4 Rationale: 1. It is unnecessary to be in isolation for viral meningitis. 2. It is rare for children with viral meningitis to seize. 3. The child will be able to walk to the bathroom. A commode will not be needed. 4. Children with meningitis often have headaches. Over-the-counter analgesics are administered for the pain. TEST-TAKING TIP: Viral meningitis is much more benign than is the bacterial disease. Palliative care is provided to the child until the meningeal inflammation diminishes. Content Area: Pediatrics—Neuromuscular Integrated Processes: Nursing Process: Implementation; Teaching/Learning Client Need: Physiological Integrity: Physiological Adaptation: Illness Management Cognitive Level: Application

A child is seen in the emergency department. The nurse hears a high-pitched squeal every time the child inhales. The parent states that the child's fever is very high and, in addition, the child is gasping for breath and sitting in the tripod position. Which of the following actions would be appropriate for the nurse to perform at this time? 1. Provide the child with warm liquids to drink. 2. Inspect the throat with a flashlight and tongue blade. 3. Check the child's vital signs and lung fields. 4. Get immediate medical attention for the child.

ANSWER: 4 Rationale: 1. With the signs and symptoms listed, it would be inappropriate to provide the child with something to drink. 2. Inspecting the throat of a child with the noted signs and symptoms could result in total occlusion of the trachea. 3. Vital signs and lung sounds are appropriate, but not at this time. 4. The nurse should obtain immediate medical attention for the child. TEST-TAKING TIP: This child is exhibiting three signs/ symptoms of epiglottitis. Inspiratory stridor is especially concerning. The child should be examined immediately by a primary health-care provider. Content Area: Pediatrics—Respiratory Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation: Illness Management Cognitive Level: Application

A school-age child has sickle cell anemia. The child's parents ask the school nurse regarding the high-risk nature of 4 activities the child is requesting to participate in. Which of the following activities should the nurse advise the parents is most high risk for the child to perform? 1. Perform the lead role in the school play. 2. Play the violin in the school orchestra. 3. Create an oil painting in art class. 4. Join the after-school wrestling team.

ANSWER: 4 Rationale: 1. It is unlikely that acting in the school play would precipitate a vaso-occlusive crisis. 2. It is unlikely that playing the violin would precipitate a vaso-occlusive crisis. 3. It is unlikely that painting would precipitate a vaso- occlusive crisis. 4. Wrestling most likely would precipitate a vaso- occlusive crisis. TEST-TAKING TIP: Vaso-occlusive crises occur when children are dehydrated, hypoxic, and/or acidotic. The child could become hot and sweaty while wrestling, which could lead to dehydration, hypoxia, and acidosis. The child would need to drink quantities of fluid in excess of his maintenance needs and take frequent rest breaks during wrestling practice. Content Area: Pediatrics—Hematological Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential: Potential for Alterations in Body Systems Cognitive Level: Analysis

A mother of a 21⁄2-year-old calls the health-care provider and states, "I don't know what to do. My son keeps taking off his diaper in public and playing with his penis." Which of the following responses by the nurse is appropriate? 1. "Slap his hand, and tell him that that behavior is unacceptable." 2. "He should be given a time out every time he does that." 3. "Laugh at him, and say that you understand that it feels good to play with his penis." 4. "Simply put his diaper back on, and tell him that he should do that in his own bedroom."

ANSWER: 4 Rationale: 1. This response is not recommended. 2. This response is not recommended. 3. This response is not recommended. 4. This is an appropriate response. TEST-TAKING TIP: The Eriksonian stage of the toddler period is autonomy versus shame and doubt. The child who is able to remove his diaper and masturbate is exhibiting autonomous behavior that, to him, is pleasurable. When reprimanded and disciplined, the child believes that the action is wrong and he may develop feelings of guilt or shame. Masturbating in public is not socially acceptable; however, parents should simply advise the child that it is something that one does in private. Content Area: Pediatrics—Toddlers Integrated Processes: Nursing Process: Implementation Client Need: Health Promotion and Maintenance: Health Promotion/Disease Prevention Cognitive Level: Application

The parents of a 2-year-old child state that their child begins nursery school in one week. Which of the following actions should the nurse advise the parents to perform on the child's first day of school? 1. When dropping the child off at school, quickly leave the classroom when the child is not looking. 2. When preparing the child for the first day of school, tell the child that teachers do not like bad boys and girls. 3. Tell the child that big boys and girls never cry on their first day of school. 4. Make sure to let the child take to school any special object the child is attached to.

ANSWER: 4 Rationale: 1. This action would be inappropriate. 2. This action would be inappropriate. 3. This action would be inappropriate. 4. The nurse should advise the parents to allow the child to take his or her transition object to school. TEST-TAKING TIP: Toddlers are engaged in the Eriksonian stage of autonomy versus shame and doubt. Although they strive for independence, the process can be very stressful for them. Holding a transition object during a new experience can help them to make the transition from the safe environment of home to a new environment. Content Area: Pediatrics—Toddlers Integrated Processes: Nursing Process: Implementation Client Need: Health Promotion and Maintenance: Health Promotion/Disease Prevention Cognitive Level: Application

A newborn baby is receiving digoxin (Lanoxin) and furosemide (Lasix) for congestive heart failure. Which of the following actions would be appropriate for the nurse to perform? 1. Hold digoxin if the apical heart rate is 170 bpm. 2. Hold digoxin for a digoxin level of 1 ng/mL. 3. Hold both the digoxin and furosemide for a weight increase of 5% in one day. 4. Hold both the digoxin and the furosemide for a potassium 3.2 mEq/L.

ANSWER: 4 Rationale: 1. Tachycardia is one sign of CHF and is an indication for the administration of digoxin. 2. A dig level of 1 ng/mL is within the therapeutic range of the medication (0.8 to 2 ng/mL). 3. Fluid retention is a sign of CHF and is an indication for the administration of both digoxin and furosemide. 4. A serum potassium level of 3.2 mEq/L is well below the normal for a newborn of 3.7 to 5.9 mEq/L. The nurse should hold both medications and notify the health-care provider who ordered them. TEST-TAKING TIP: Hypokalemia, or a serum potassium level that is lower than normal, places the body at high risk for cardiac arrhythmias. In addition, when digoxin is taken, the potential for the cardiac arrhythmias increases. Furosemide increases the excretion of potassium. It is essential, therefore, that the nurse not administer the medications until the hypokalemia has been reported and action has been taken to return the electrolyte level to normal. Content Area: Pediatrics—Cardiac Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies: Medication Administration Cognitive Level: Application

A child has had tympanostomy tubes inserted. Before discharging the child from the hospital, which of the following should be included in the nurse's discharge teaching? 1. Elevate the head of the child's bed 30 degrees for the next week. 2. Bright-red bleeding may drain from the ears for remainder of the day. 3. Administer narcotic analgesic every 4 hours for the next two days. 4. Not to allow the child's head to be submerged in bath or pool water.

ANSWER: 4 Rationale: 1. The child may sleep flat in bed. 2. Little to no blood loss is expected after a myringotomy procedure. 3. Pain medication may be administered, but it is unlikely that the baby will need narcotics for 48 hr. 4. The child's head should not be allowed to submerge in bath or pool water. TEST-TAKING TIP: Tympanostomy tubes are inserted through the eardrum to enable fluid to drain from the middle ear. Unfortunately, fluid can also travel into the middle ear. To prevent fluid from entering the middle ear, children should refrain from submerging their heads in water. Content Area: Pediatrics—RespiratoryIntegrated Processes: Nursing Process: Implementation; Teaching/LearningClient Need: Physiological Integrity: Reduction of Risk Potential: Potential for Complications of Diagnostic Tests/ Treatments/ProceduresCognitive Level: Application

The mother of a 3-year-old child who has been diagnosed with an ear infection states, "I can't understand why you won't give my child antibiotics. Can't you see that she is sick?" Which of the following responses by the nurse is appropriate at this time? 1. "I know how you feel, but the best medicine for your daughter right now is acetaminophen." 2. "Your child will get better on her own in a few days." 3. "I am also very surprised that the pediatrician didn't order antibiotics." 4. "It is likely that the ear infection is caused by a virus, and antibiotics do not kill viruses."

ANSWER: 4 Rationale: 1. This statement is correct, but it does not provide the mother with an explanation of why antibiotics have not been prescribed. 2. This statement is likely correct, but it does not provide the mother with an explanation of why antibiotics have not been prescribed. 3. This statement is not correct. Antibiotics are not prescribed for illnesses that are likely viral in origin. 4. This is an appropriate statement for the nurse to make. TEST-TAKING TIP: The nurse should provide the patient with a clear rationale for the health-care provider's treatment plan. Content Area: Pediatrics—Respiratory Integrated Processes: Nursing Process: Implementation; Teaching/Learning Client Need: Physiological Integrity: Physiological Adaptation: Illness Management Cognitive Level: Application

The nurse is caring for a 6-month-old infant diagnosed with meningitis. When the child is placed in the supine position and flexes his neck, the nurse notes he flexes his knees and hips. This is referred to as: 1. Brudzinski sign. 2. Cushing triad. 3. Kernig sign. 4. Nuchal rigidity.

Correct: 1. Brudzinski sign occurs when the child responds to a flexed neck with an involuntary flexion of the hips and/or knees. 2. Cushing triad is a sign of increased ICP and is manifested with an increase in systolic blood pressure, decreased heart rate, and irregular respirations. 3. Kernig sign occurs when there is resistance or pain in response to raising the child's flexed leg. 4. Nuchal rigidity occurs when there is a resistance to neck flexion.

A nursing action that promotes ideal nutrition in an infant with congestive heart failure (CHF) is: 1. Feeding formula that is supplemented with additional calories. 2. Allowing the infant to nurse at each breast for 20 minutes. 3. Providing large feedings every 5 hours. 4. Using firm nipples with small openings to slow feedings.

Correct 1. Formula can be supplemented with extra calories, either from a commercial supplement, such as Polycose, or from corn syrup. Calories in formula could increase from 20 kcal/oz to 30 kcal/oz or more. 2. The infant would get too tired while feeding, which increases cardiac demand. Limit breastfeeding to a half hour, or 15 minutes per side. 3. Smaller feedings more often, such as every 2 to 3 hours, would decrease cardiac demand. 4. Soft nipples that are easy for the infant to suck would make for less work getting nutrition. TEST-TAKING HINT: Allow the child to get the most nutrition most effectively.

The nurse is caring for clients in a pediatric emergency department (ED). Which client should the nurse assess first? 1. The child with a dog bite on the left hand who is bleeding. 2. The child who has a laceration on the right side of the forehead. 3. The child with a fractured tibia who will not move the foot. 4. The child who has ingested a bottle of prenatal vitamins.

Correct 4 A child who ingested a bottle of prenatal vitamins presents a medication poisoning that is a potentially life threatening situation. This child must be assessed first to determine how many vitamins were taken, how long ago were they taken, and whether or not the vitamins contained iron. The child's neurological status must also be assessed. 1. A dog bite is an emergency, but it is not life threatening 2. The child diagnosed with a head laceration must be assessed, but not before a child who might die of medication poisoning. 3. The child diagnosed with a fractured tibia would not be expected to move the foot.

The charge nurse has assigned a staff nurse to care for an 8-year-old client diagnosed with cerebral palsy. Which nursing action by the staff nurse would warrant immediate intervention by the charge nurse? 1. The staff nurse performs gentle range-of-motion (ROM) exercises to extremities. 2. The staff nurse puts the client's bed in the lowest position possible. 3. The staff nurse takes the client in a wheelchair to the activity room. 4. The staff nurse places the child in semi-Fowler's position to eat lunch.

Correct 4 The child should be positioned upright to prevent aspiration during meals 1. It is appropriate for the nurse to perform ROM exercises to help prevent contractures, specifically scissoring of the legs 2. Safety issues should always be addressed, and keeping the bed in the lowest position may prevent injury to the child. 3. Taking the child to the activity room is being a client advocate and would not warrant intervention.

Which assessments indicate that the parent of a 7-year-old is following the prescribed treatment for congestive heart failure (CHF)? Select all that apply. 1. HR of 56 beats per minute. 2. Elevated red blood cell count. 3. 50th percentile height and weight for age. 4. Urine output of 0.5 cc/kg/hr.5. Playing basketball with other children his age.

Correct: 3, 5. 1. HR of 56 beats per minute is likely the result of digoxin (Lanoxin) toxicity. 2. Elevated count of red blood cells indicates polycythemia secondary to hypoxemia. 3. The 50th percentile height and weight for age shows good growth, indicating good nutrition and perfusion. 4. Urine output of 0.5 cc/kg/hr indicates that furosemide (Lasix) is not being given as ordered; the output is too low. 5. Playing basketball with children his age indicates he is following the prescribed treatment and responding well to it. TEST-TAKING HINT: The test taker should know the expected responses of medications used to treat CHF and indications of doing well.

The pediatric clinic nurse is triaging telephone calls. Which client's parent should the nurse call first? 1. The 4-month-old child who had immunizations yesterday and the parent is report- ing a high-pitched cry and a 103°F fever. 2. The 8-month-old whose parent is reporting the child is pulling on the right ear and has a fever. 3. The 2-year-old child who has patent ductus arteriosis whose parent reports running out of digoxin. 4. The 3-year-old child whose mother called and reported her daughter may have chickenpox.

Correct: 1 A high fever and high-pitched crying may indicate a reaction to the immunizations; therefore this parent needs to be called first to bring the child to the clinic 2. This child probably has an ear infection, which needs to be seen but is not a priority over a reaction to immunizations. 3. The nurse needs to call in a prescription for the digoxin but not before calling the parent whose child is having a reaction to an immunization 4. The child may need to be seen but primarily kept in isolation, so this parent does not need to be called first CLINICAL JUDGMENT GUIDE: The test taker must determine if the signs and symptoms are normal for the disease process; if the signs and symptoms are not normal, then the nurse should call the parent.

The pediatric nurse on the surgical unit has just received a.m. shift report. Which client should the nurse assess first? 1. The 3-week-old child 1 day postoperative with surgical repair of a myelomeningo-cele who has bulging fontanels. 2. The 3-month-old child 2 days postoperative temporary colostomy secondary to Hirschsprung's disease who has a moist, pink stoma. 3. The 9-month-old child with a cleft palate repair who is spitting up formula and refusing to eat. 4. The 4-year-old child 1 day postoperative for repair of hypospadias who has clear amber urine draining from indwelling catheter.

Correct: 1 Bulging fontanels is a sign of increased intracranial pressure, which is a complication of neurological surgery; therefore this should be assessed first. 2. A moist, pink stoma is normal; therefore this child does not need to be assessed first. 3. This child needs to be assessed but it it not a priority over a child with a surgical, possibly life threatening, complication. 4. The child will have an indwelling urinary catheter and clear amber urine is normal, so this child does not need to be assessed first. CLINICAL JUDGMENT GUIDE: The test taker must determine if the signs and symptoms are expected for the surgical procedure. If the signs and symptoms are not expected, this child should be assessed first. If two clients have signs and symptoms that are not expected, then the child diagnosed with a life-threatening complication should be assessed first.

Which child should the charge nurse assess first? 1. The 1 month old infant who is crying, is inconsolable, and has inspiratory retractions 2. The 4 year old toddler diagnosed with cystic fibrosis who has a pulse oximeter reading of 93% 3. The 6 year old child diagnosed with gastroenteritis who has a potassium level of 3.6 mEq/L 4. The 14 year old child diagnosed with type 2 diabetes with a blood glucose level os 210 mg/dL

Correct: 1 The child who is having respiratory difficulty, inspiratory retractions, should be assessed first. Remember Maslow's Hierarchy of Needs 2. A pulse ox reading of 93% is within normal limits. It is on the low side because CF causes chronic hypoxia and low arterial oxygen is expected. 3. This is a normal potassium level; therefore the nurse would not assess this child first 4. A 20 mg/dL glucose for a child diagnosed with type 2 diabetes is not life-threatening and the nurse would not assess this child first.

Hypoxic spells in the infant with a congenital heart defect (CHD) can cause which of the following? Select all that apply. 1. Polycythemia. 2. Blood clots. 3. Cerebrovascular accident (CVA). 4. Developmental delays. 5. Viral pericarditis. 6. Brain damage. 7. Alkalosis.

Correct: 1, 2, 3, 4, 6. 1. Hypoxia causes polycythemia, which can lead to increased blood viscosity, which can lead to blood clots and a stroke (CVA). 2. Hypoxia causes polycythemia, which can lead to increased blood viscosity, which can lead to blood clots and a stroke (CVA). 3. Hypoxia causes polycythemia, which can lead to increased blood viscosity, which can lead to blood clots and a stroke (CVA). 4. Developmental delays can be caused by multiple hospitalizations and surgeries. The child usually catches up to the appropriate level. 5. Hypoxia can increase the risk for bacterial endocarditis, not viral pericarditis. 6. Brain damage can be caused by hypoxia, blood clots, and stroke (CVA). 7. Hypoxic episodes cause acidosis, not alkalosis. TEST-TAKING HINT: Hypoxic episodes in a child with CHD ("tet spells") can cause polycythemia and strokes (CVAs).

The nurse is evaluating an 18-month-old child in the pediatric clinic. Which data would indicate to the nurse that the child is not meeting tasks according to Erikson's Stages of Psychosocial Development? Select all that apply. 1. The child stamps his or her foot and says "no" frequently. 2. The child does not interact with the mother. 3. The child cries when the mother leaves the room. 4. The child responds when called by name. 5. The child smiles when successful at toilet training.

Correct: 1, 3, 4, 5 An 18 month old child should be throwing temper tantrums. This indicates the child is developing a sense of autonomy. An 18 month old child should cling to the mother and interact continuously with the primary caregiver. A child not interacting with the mother is not meeting the task of developing a sense of autonomy. The child has met the task of trust when he or she cries if the mother leaves the room. When a child responds to his or her name, it indicates a sense of identity; therefore the task is met. When a child is smiling and happy with successful toilet training, it indicates development of autonomy and independence.

Which interventions decrease cardiac demands in an infant with congestive heart failure (CHF)? Select all that apply. 1. Allow parents to hold and rock their child. 2. Feed only when the infant is crying. 3. Keep the child uncovered to promote low body temperature. 4. Make frequent position changes. 5. Feed the child when sucking the fists. 6. Change bed linens only when necessary. 7. Organize nursing activities.

Correct: 1, 4, 5, 6, 7. 1. Rocking by the parents will comfort the infant and decrease demands. 2. The infant would not be fed when crying because crying increases cardiac demands. The infant might choke if the nipple is placed in the mouth and the child inhales when trying to swallow. 3. Keep the child normothermic to reduce metabolic demands. 4. Frequent position changes will decrease the risk for infection by avoiding immobility with its potential for skin breakdown. 5. An infant sucking the fists could indicate hunger. 6. Change bed linens only when necessary to avoid disturbing the child. 7. Organize nursing activities to avoid disturbing the child. TEST-TAKING HINT: Do all that can be done to decrease demands on the child.

The parents of a 12-month-old with cerebral palsy (CP) ask the nurse if they should teach their child sign language because he has not begun to vocalize. The nurse bases the response on the knowledge that sign language: 1. May be a very beneficial way to help children with CP communicate. 2. May cause confusion and further delay vocalization. 3. Is difficult to learn for most children with CP. 4. Is beneficial to learn, but it would be best to wait until the child is older.

Correct: 1. Sign language may help the child with CP communicate and ultimately decrease frustration. Children with CP may have difficulty verbalizing because of weak tongue and jaw muscles. They may be able to have sufficient motor skills to communicate with their hands. 2. Sign language does not cause confusion and may help reinforce vocabulary and vocalization. 3. CP is manifested differently in all children; therefore, generalizations cannot be made. 4. The earlier sign language is taught, the more it will be beneficial. TEST-TAKING HINT: The test taker can immediately eliminate answer 3 because it makes a generalization. All forms of language are beneficial and well tolerated by children, especially young children.

The parents of a child with cerebral palsy (CP) are learning how to feed their child and avoid aspiration. The nurse would question which of the following when reviewing the teaching plan? 1. Place the food on the tip of the tongue. 2. Place the child in an upright position during feedings. 3. Feed the child soft and blended foods. 4. Feed the child slowly.

Correct: 1. The food should be placed far back in the mouth to avoid tongue thrust. 2. The child should be placed in an upright position. 3. Soft and blended foods minimize the risk of aspiration. 4. Allowing the child time to feed minimizes the risk of aspiration. TEST-TAKING HINT: The test taker should consider which methods will decrease the risk of aspiration. Answers 2, 3, and 4 all decrease the risk of choking and should be eliminated.

The 13-year- old child is admitted to the emergency department with nucal rigidity, a positive Kernig's sign, a positive Brudzinki's sign, and an elevated temperature. Which intervention should the charge nurse implement first? 1. Administer acetaminophen (tylenol) PO with water 2. Place the young teenage child in droplet isolation 3. Prepare the teenager for a lumbar puncture 4. Notify the hospital infection control nurse about this client.

Correct: 2 The charge nurse should suspect bacterial meningitis and place the young teenage child in isolation until definitive diagnosis is made. The nurse must protect the child but also all the other clients, visitors, and staff in the emergency department. This intervention must be implemented first.

Which order would the nurse question for a child just admitted with the diagnosis of bacterial meningitis? 1. Maintain isolation precautions until 24 hours after receiving intravenous antibiotics. 2. Intravenous fluids at 1 1⁄2 times regular maintenance. 3. Neurological checks every hour. 4. Administer acetaminophen (Tylenol) for temperatures higher than 38°C (100.4°F).

Correct: 2. Intravenous fluids at 1 1⁄2 times regular maintenance could cause fluid overload and lead to increased ICP. 1. Isolation precautions must be maintained for at least the first 24 hours of intravenous antibiotic therapy. 3. Neurological checks are usually made at least every hour. 4. Acetaminophen (Tylenol) is usually administered when the child has a fever, as increased temperature can lead to increased ICP. TEST-TAKING HINT: The test taker should consider the answers and eliminate those that may increase ICP. Intravenous fluids are often given at less than maintenance unless the child is hemodynamically unstable.

A child with cerebral palsy (CP) has been fitted for braces and is beginning physical therapy to assist with ambulation. The parents ask why he needs the braces when he was crawling without any assistive devices. Select the nurse's best response. 1. "The CP has progressed, and he now needs more assistance to ambulate." 2. "As your child grows, different muscle groups may need more assistance." 3. "Most children with CP need braces to help with ambulation." 4. "We have found that when children with CP use braces, they are less likely to fall."

Correct: 2. CP can manifest in different ways as the child grows. It does not progress, but its clinical manifestations may change. 1. CP is a nonprogressive disorder 3. Children with CP have different abilities and needs. CP can result in mild to severe motor deficits; therefore, one treatment regimen cannot be used or recommended for all children. 4. Although braces may assist some children with ambulation, they will not be useful in all cases. TEST-TAKING HINT: The test taker can eliminate answers 3 and 4 because generalizations cannot be made regarding CP. Each child has different abilities and disabilities

Which data would warrant immediate intervention from the pediatric nurse? 11. Proteinuria for the child diagnosed with nephrotic syndrome. 2. Petechiae for the child diagnosed with leukemia. 3. Drooling for a child diagnosed with acute epiglottitis. 4. Elevated temperature in a child diagnosed with otitis media.

Correct: 3 Drooling indicates the child is having trouble swallowing, and the epiglottis is at risk of completely occluding the airway. The nurse should notify the HCP and obtain an emergency tracheostomy tray from the bedside 1. The child diagnosed with nephrotic syndrome would be expected to have proteinuria. 2. The child diagnosed with leukemia would be expected to have petechiae 4. A child diagnosed with an ear infection would be expected to have an elevated temperature.

The home health nurse is planning the care of a 14-year-old client diagnosed with leukemia who is receiving chemotherapy. Which psychosocial problem is priority for this client? 1. Diversional activity deficit. 2. High risk for infection. 3. Social isolation. 4. Hopelessness.

Correct: 3 The client will be isolated from peers and schools because of the high risk of infection resulting from the immunosuppression secondary to chemotherapy and the disease process. Therefore, social isolation is the priority psychosocial problem for this client 1. Diversional activity deficit would be appropriate if the client did not have sufficient activities to keep him or her occupied 2. The client has leukemia and is receiving chemotherapy which leads to a risk of infection. This is a physiological problem not psychosocial 4. The nurse should not identify hopelessness because childhood leukemia has a good prognosis.

Which signs best indicate increased intracranial pressure (ICP) in an infant? Select all that apply. 1. Sunken anterior fontanel. 2. Complaints of blurred vision. 3. High-pitched cry. 4. Increased appetite. 5. Sleeping more than usual.

Correct: 3, 5. 1. The anterior fontanel is usually raised and bulging in infants with increased ICP. 2. The infant is not able to comprehend blurred vision or make any statements. 3. A high-pitched cry is often indicative of increased ICP in infants. 4. The infant with increased ICP usually has a poor appetite and does not feed well. 5. The infant may be sleeping more than usual because of increased ICP. TEST-TAKING HINT: The test taker needs to be familiar with hydrocephalus and how increased ICP is manifested in infants. Answer 2 can be eliminated because an infant cannot specifically verbalize.

To treat a common manifestation of Reye syndrome, which medication would the nurse expect to have readily available? 1. Furosemide (Lasix). 2. Insulin. 3. Glucose. 4. Morphine.

Correct: 3. A common manifestation is hypoglycemia, which is treated with the administration of intravenous glucose. 1. A common manifestation is increased ICP, which is treated with an osmotic diuretic. Furosemide (Lasix) is a loop diuretic. 2. A common manifestation is hypoglycemia. Insulin does not treat hypoglycemia, but decreases the blood sugar instead. 4. Morphine is a narcotic used for pain relief. It should be used with caution because it can lead to respiratory depression. TEST-TAKING HINT: The test taker needs to be aware that increased ICP is a very common manifestation of Reye syndrome and should therefore eliminate any answers that do not treat increased ICP. The test taker can also eliminate answers 2 and 4 because they do not treat hypoglycemia, which is another common manifestation of Reye syndrome.

The nurse knows further education is needed about Reye syndrome when a mother states: 1. "I will have my children immunized against varicella and influenza." 2. "I will make sure not to give my child any products containing aspirin." 3. "I will give aspirin to my child to treat a headache." 4. "Children with Reye syndrome are admitted to the hospital."

Correct: 3. The administration of aspirin or products containing aspirin has been associated with the development of Reye syndrome. A headache can be the first sign of a viral illness followed by other symptoms. It is best not to use aspirin or aspirin- containing products in children. 1. Having a child immunized helps prevent viral illnesses from occuring, thereby decreasing the likelihood of Reye syndrome. 2. The administration of aspirin or products containing aspirin has been associated with the development of Reye syndrome. 4. Children with Reye syndrome are always admitted to the hospital because there is a strong possibility for complications and rapid deterioration. TEST-TAKING HINT: The test taker should be aware that aspirin administration in children with viral infections has been linked to Reye syndrome.

Which plan would be appropriate in helping to control congestive heart failure (CHF) in an infant? 1. Promoting fluid restriction. 2. Feeding a low-salt formula. 3. Feeding in semi-Fowler position. 4. Encouraging breast milk.

Correct: 3. The infant has a great deal of difficulty feeding with CHF, so even getting the maintenance fluids is a challenge. The infant is fed in the more upright position so that fluid in the lungs can go to the base of the lungs, allowing better expansion. 1. The nurse would not need to restrict fluids, as the child likely would not be getting overloaded with oral fluids. 2. The infant likely will have sodium depletion because of the chronic diuretic use; the infant needs a normal source of sodium, so low-sodium formula would not be used. 4. Breast milk has slightly less sodium than does formula, and the child needs a normal source of sodium because of the diuretic. TEST-TAKING HINT: Infants are not able to concentrate urine well and may have sodium depletion, so they need a normal source of sodium.

During play, a toddler with a history of tetralogy of Fallot (TOF) might assume which position? 1. Sitting. 2. Supine. 3. Squatting. 4. Standing.

Correct: 3. The toddler will naturally assume this position to decrease preload by occluding venous flow from the lower extremities and increasing afterload. Increasing SVR in this position increases pulmonary blood flow. 1. The toddler will naturally assume a squatting position to decrease preload by occluding venous flow from the lower extremities and increasing afterload. Increasing SVR in this position increases pulmonary blood flow. 59. 2. The toddler will naturally assume a squatting position to decrease preload by occluding venous flow from the lower extremities and increasing afterload. Increasing SVR in this position increases pulmonary blood flow. 4. The toddler will naturally assume a squatting position to decrease preload by occluding venous flow from the lower extremities and increasing afterload. Increasing SVR in this position increases pulmonary blood flow. TEST-TAKING HINT: The child self-assumes this position during the "tet" spell which increases vascular return.

The nurse prepares baclofen for a child with cerebral palsy (CP) who just had her hamstrings surgically released. The child's parents ask what the medication is for. Select the nurse's best response. 1. "It is a medication that will help decrease the pain from her surgery." 2. "It is a medication that will prevent her from having seizures." 3. "It is a medication that will help control her spasms." 4. "It is a medication that will help with bladder control."

Correct: 3. Baclofen is given to help control the spasms associated with CP. 1. Baclofen is not given for postoperative pain control. 2. Baclofen is not given for seizures. 4. Baclofen is not given for bladder control. TEST-TAKING HINT: The test taker needs to be familiar with the medication baclofen.

The nurse is caring for a 2-month-old infant who is at risk for cerebral palsy (CP) due to extreme low birth weight and prematurity. His parents ask why a speech therapist is involved in his care. Select the nurse's best response. 1. "Your baby is likely to have speech problems because of his early birth. Involving the speech therapist now will ensure vocalization at a developmentally appropriate age." 2. "The speech therapist will help with tongue and jaw movements to assist with babbling." 3. "The speech therapist will help with tongue and jaw movements to assist with feeding." 4. "Many members of the health-care team are involved in your child's care so that we will know if there are any unmet needs."

Correct: 3. It is important to involve speech therapy to strengthen tongue and jaw movements to assist with feeding. The infant whois at risk for CP may have weakened and uncoordinated tongue and jaw movements. 1. The nurse cannot assume that the child will have speech difficulties. Speech therapy does not guarantee vocalization at a developmentally appropriate age. 2. Although speech therapy will assist with babbling at a later age, its primary purpose is to assist with feeding. 4. Members of a multidisciplinary team become involved in a child's care based on specific needs, not hospital routine. TEST-TAKING HINT: The test taker should immediately eliminate answer 4 because it does not consider the child's individual needs.

A child with a ventriculoperitoneal (VP) shunt complains of headache and blurry vision and now experiences irritability and sleeping more than usual. The parents ask the nurse what they should do. Select the nurse's best response. 1. "Give her some acetaminophen (Tylenol), and see if her symptoms improve. If they do not improve, bring her to the health-care provider's office." 2. "It is common for girls to have these symptoms, especially prior to beginning their menstrual cycle. Give her a few days, and see if she improves." 3. "You are probably worried that she is having a problem with her shunt. This is very unlikely because it has been working well for 9 years." 4. "You should immediately take her to the emergency department because these may be symptoms of a shunt malfunction."

Correct: 4 1. These are symptoms of a shunt malfunction and should be evaluated immediately. 2. Although these symptoms may be associated with the start of a girl's menstrual cycle, they are symptoms of a shunt malfunction and require immediate evaluation. 3. A shunt can malfunction at any point and should be evaluated when signs of increased ICP are evident. 4. These are symptoms of a shunt malfunction and should be evaluated immediately.

Which statement by a parent of an infant with congestive heart failure (CHF) who is being sent home on digoxin (Lanoxin) indicates the need for further education? 1. "I will give the medication at regular 12-hour intervals." 2. "If he vomits, I will not give a make-up dose." 3. "If I miss a dose, I will not give an extra dose." 4. "I will mix the digoxin in some formula to make it taste better."

Correct: 4 If the medication is mixed in his formula, and he refuses to drink the entire amount, the dose will be inadequate. 1. This is appropriate for digoxin administration. 2. This is appropriate for digoxin administration. 3. This is appropriate for digoxin administration. TEST-TAKING HINT: What if the child does not drink all the formula?

Which client should the pediatric nurse assess first after receiving the a.m. shift report? 1. The 6 month old child diagnosed with bacterial meningitis who is irritable and crying 2. The 9 month old child diagnosed with tetralogy of Fallot (TOF) who has edema of the face 3. The 11 month old child diagnosed with Reye syndrome who is lethargic and vomiting 4. The 13 month old child diagnosed with diarrhea who has sunken eyeballs and decreased urine output

Correct: 4 Sunken eyeballs and decreased urine output are signs of dehydration, which is a life-threatening complication of diarrhea; therefore, this child should be assessed first. 1. irritability and crying are expected signs and symptoms for a child diagnosed with bacterial meningitis; therefore this child does not need to be assessed first. 2. The cild diagnosed with tetralogy of Fallot (TOF) would be expected to have signs of congestive heart failure, so this child would not be assessed first. 3. The child diagnosed with Reye syndrome would present with lethargy and vomiting, so this child would be assessed first.

During a well-child checkup for an infant with tetralogy of Fallot (TOF), the child develops severe respiratory distress and becomes cyanotic. The nurse's first action should be to: 1. Lay the child flat to promote hemostasis. 2. Lay the child flat with legs elevated to increase blood flow to the heart. 3. Sit the child on the parent's lap, with legs dangling, to promote venous pooling. 4. Hold the child in knee-chest position to decrease venous blood return.

Correct: 4 The increase in the SVR would increase afterload and increase blood return to the pulmonary artery. 1. Laying the child flat would increase preload, increasing blood to the heart, therefore making respiratory distress worse. 2. Laying the child flat with legs elevated would increase preload, increasing blood to the heart, therefore making respiratory distress worse. 3. Sitting the child on the parent's lap with legs dangling might possibly help, but it would not be as effective as the knee-chest position in occluding the venous return. TEST-TAKING HINT: The test taker should choose the response that decreases the preload in this patient.

The nurse is caring for clients on the pediatric medical unit. Which client should the nurse assess FIRST? 1. The child diagnosed with type 1 diabetes who has a blood glucose level of 180 mg/dL 2. The child diagnosed with pneumonia who is coughing and has a temperature of 100*F 3. The child diagnosed with gastroenteritis who has a potassium (K+) level of 3.9 mEq/L 4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%

Correct: 4. A pulse oximeter reading of lower than 93% is significant and indicates hypoxia, which is life-threatening; therefore this child should be assessed first 1. A 180 mg/dL glucose level for a child diagnosed with type 1 diabetes is not life-threatening, and the nurse would not assess this child first. 2. The nurse would expect the child diagnosed with pneumonia to have these signs and symptoms; therefore, the nurse would not assess this child first. 3. This is a normal potassium level; therefore the nurse would not assess this child first. CLINICAL JUDGMENT GUIDE: When deciding which client to assess first, the test taker should determine whether the signs and symptoms the client is exhibiting are normal or expected for the client's situation. After eliminating the expected options, the test taker should determine which situation is more life-threatening.

Which position initially is most beneficial for an infant who has just returned from having a ventriculoperitoneal (VP) shunt placed? 1. Semi-Fowler in an infant seat. 2. Flat in the crib. 3. Trendelenburg. 4. In the crib with the head elevated to 90 degrees.

Correct: Flat in the crib is the position usually used initially, with the angle gradually increasing as the child tolerates. A semi-Fowler position in an infant seat may allow the ventricles to drain too rapidly in the immediate postoperative period. The Trendelenburg position is not used immediately after ventriculoperitoneal shunt placement because it would increase ICP. The head elevated to 90 degrees will allow the ventricle of the brain to drain too quickly.