Peds 3 Saunders
A preschooler has just been diagnosed with impetigo. The child's mother tells the nurse, "But my children take baths every day." The nurse should make which therapeutic response to the mother?
"You are concerned about how your child got impetigo?" Rationale: By paraphrasing what the parent tells the nurse, the nurse is addressing the parent's thoughts. Option 1 demonstrates the therapeutic technique of paraphrasing. Options 2, 3, and 4 are blocks to communica- tion because they make the parent feel guilty for the child's illness. Priority Nursing Tip: A child with an integumentary disorder needs to be monitored for signs of a skin infection or a systemic infection.
A nurse is caring for a child with leukemia and notes that the platelet count is 20,000 cells/ mm3. Based on this finding, the nurse should include which of the following in the plan of care? Select all that apply.
1 Monitor stools for blood. 2 Clean oral cavity with soft swabs. 3 Provide appropriate play activities. Rationale: A platelet count of 20,000/mm places the child at risk for bleeding. Options 1, 2, and 3 are accurate interventions. Taking rectal tem- peratures and the use of suppositories is avoided because of the risk of rectal bleeding. Priority Nursing Tip: Bleeding precautions are instituted when the platelet count is low. Neutropenic precautions are instituted when the neutrophil count is low.
A nurse is reviewing the results of a sweat test performed on a child with cystic fibrosis (CF). The nurse would expect to note which finding?
A sweat chloride concentration greater than 60 mEq/L Rationale: Cystic fibrosis is a chronic multisystem disorder characterized by exocrine gland dysfunction. A consistent finding of abnormally high sodium and chloride concentrations in the sweat is a unique characteristic of CF. Normally the sweat chloride concentration is less than 40 mEq/L. A sweat chloride concentration greater than 60 mEq/L is diagnostic of CF. Priority Nursing Tip: Usually more than 75 mg of sweat is needed to per- form the sweat test. This amount is difficult to obtain from an infant; therefore an immunoreactive trypsinogen analysis and direct DNA analy- sis for mutant genes may be done to test for cystic fibrosis.
A child is admitted to the hospital with a sus- pected diagnosis of von Willebrand's disease. On assessment of the child, which symptom would most likely be noted?
Bleeding from the mucous membranes Rationale: The primary clinical manifestations of von Willebrand's disease are bruising and mucous membrane bleeding from the nose, mouth, and gastrointestinal tract. Prolonged bleeding after trauma and surgery, including tooth extraction, may be the first evidence of abnormal hemostasis in those with mild disease. In females, menorrhagia and profuse postpartum bleeding may occur. Bleeding associated with von Willebrand's disease may be severe and lead to anemia and shock, but unlike what is seen in clients with hemophilia, deep bleeding into joints and muscles is rare. Options 1, 2, and 3 are characteristic of those signs found in clients with hemophilia. Priority Nursing Tip: von Willebrand's disease is a disorder that causes platelets to adhere to damaged endothelium and is characterized by an increased tendency to bleed from mucous membranes.
A nurse is caring for an infant who is admitted to the hospital with a diagnosis of hemolytic disease. The nurse reviews the laboratory re- sults, expecting to note which of the following in this infant?
Decreased red blood cell count Rationale: The two primary pathophysiologic alterations associated with hemolytic disease are anemia and hyperbilirubinemia. The red blood cell count is decreased because red blood cell production cannot keep pace with red blood cell destruction. Hyperbilirubinemia results from the red blood cell destruction that accompanies this disorder as well as from the normally decreased ability of the neonate's liver to conjugate and excrete bilirubin efficiently from the body. Hypoglycemia is associated with hypertrophy of the pancreatic islet cells and increased levels of insu- lin. The white blood cell count is not related to this disorder. Priority Nursing Tip: Iron is found predominantly in hemoglobin and acts as a carrier of oxygen from the lungs to the tissues and indirectly aids in the return of carbon dioxide to the lungs.
A nurse is assessing the vital signs of a 3-year-old child hospitalized with a diagnosis of croup and notes that the respiratory rate is 28 breaths per minute. Based on this finding, which nursing action is appropriate?
Document the findings. Rationale: The normal respiratory rate for a 3-year-old child is approxi- mately 20 to 30 breaths per minute. Because the respiratory rate is normal, options 1, 2, and 4 are unnecessary actions. The nurse would document the findings.
A nurse is caring for an adolescent client with conjunctivitis. The nurse provides instructions to the client and tells the adolescent to:
Obtain a new set of contact lenses for use after the infection clears. Rationale: Conjunctivitis is inflammation of the conjunctiva. If the client has conjunctivitis, eye makeup should be replaced but can still be worn. Cool compresses decrease pain and irritation. Isolation for 24 hours after antibiotics are initiated is necessary. A new set of contact lenses should be obtained. Priority Nursing Tip: Chlamydial conjunctivitis is rare in older children. If diagnosed in a child who is not sexually active, the child should be assessed for possible sexual abuse.
A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine whether this child is experiencing a long-term effect of cleft palate, the nurse asks the parent which question?
"Is the child unresponsive when given directions?" Rationale: A child with cleft palate is at risk for developing frequent otitis media, which can result in hearing loss. Unresponsiveness may be an in- dication that the child is experiencing hearing loss. Options 2 and 4 are unrelated to cleft palate after repair. Option 1 is normal behavior for a pre- school child. Many preschoolers with vivid imaginations have imaginary friends.
A nurse has provided discharge instructions to the parent of a child who has undergone heart surgery. Which statement by the parent would indicate the need for further instruction?
"My child can return to school for full days 2 weeks after discharge." Rationale: The child may return to school the third week after hospital dis- charge, but he or she should go to school for half days for the first week. Outside play should be omitted for several weeks, with inside play allowed as tolerated. The child should avoid crowds of people for 2 weeks after discharge, including crowds at day care centers and churches. If any difficulty with breathing occurs, the parent should notify the physician. Priority Nursing Tip: Following cardiac surgery, the parents should be instructed the keep the child away from crowds for 2 weeks after discharge to decrease the risk of contracting an infection.
A nurse is preparing to suction a tracheotomy on an infant. The nurse prepares the equipment for the procedure and turns the suction to which setting?
90mmHg Rationale: The suctioning procedure for pediatric clients varies from that used for adults. Suctioning in infants and children requires the use of a smaller suction catheter and lower suction settings as compared with those used for adults. Suction settings for a neonate are 60 to 80 mm Hg; for an infant, they are 80 to 100 mm Hg; and, for larger children, they are 100 to 120 mm Hg. Priority Nursing Tip: The nurse should always hyperoxygenate the infant before performing respiratory suctioning.
A child is seen in the health care clinic, and ini- tial testing for human immunodeficiency virus (HIV) is performed because of the child's expo- sure to HIV infection. Which home care instruc- tion should the nurse provide to the parents of the child?
Avoid sharing toothbrushes. Rationale: Immunizations must be kept up to date. Blood spills are wiped up with a paper towel; the area is then washed with soap and water, rinsed with bleach and water, and allowed to air dry. Hands are washed with soap and water if they come in contact with blood. Parents are instructed that toothbrushes are not to be shared. Priority Nursing Tip: Human immunodeficiency virus (HIV) infects CD4þ T cells. A gradual decrease in the count occurs and this results in a progressive immunodeficiency. The risk for opportunistic infections is present.
A home care nurse is instructing a mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. The nurse tells the mother that the child needs to consume a:
High-calorie, high-protein diet Rationale: Children with CF are managed with a high-calorie, high- protein diet. Pancreatic enzyme replacement therapy and fat-soluble vitamin supplements are administered. Fat restriction is not necessary. Priority Nursing Tip: Cystic fibrosis is a progressive and incurable disor- der, and respiratory failure is a common cause of death; organ transplan- tations may be an option to increase survival rates.
A home care nurse visits a 3-year-old child with chickenpox. The child's mother tells the nurse that the child keeps scratching the skin at night and asks the nurse what to do. The nurse tells the mother to:
Place soft cotton gloves on the child's hands at night. Rationale: Gloves will keep the child from scratching the open lesions from chickenpox. Generous amounts of any topical cream can lead to medication toxicity. Warm milk will have no effect on itching. A warm room and blankets will increase the child's skin temperature and make itching worse. Priority Nursing Tip: The skin is the first line of defense against infection. Altered skin integrity can lead to a skin or systemic infection.
A nurse is preparing to teach the parents of a child with anemia about the dietary sources of iron that are easy for the body to absorb. Which food item should the nurse include in the teaching plan?
Poultry Rationale: Dietary sources of iron that are easy for the body to absorb in- clude meat, poultry, and fish. Vegetables, fruits, cereals, and breads are also dietary sources of iron, but they are harder for the body to absorb. Priority Nursing Tip: For anemia, instruct the parents and child about the food items that are high in iron such as meats, egg yolk, breads and cereals, and dark green leafy vegetables.
A newborn infant has been found to be human immunodeficiency virus (HIV) positive. When teaching the infant's mother, the nurse should instruct the mother to:
Provide meticulous skin care to the infant and change the infant's diaper after each voiding or stool. Rationale: Meticulous skin care helps protect the HIV-infected infant from secondary infections. Bulging fontanels, feeding the infant in an upright position, and using a special nipple are unrelated to the pathology associated with HIV. Priority Nursing Tip: Newborns born to HIV-positive clients may test positive because the mother's antibodies may persist in the newborn for 18 months after birth.
A nurse is caring for a child who has been diagnosed with rubeola (measles). The nurse notes that the physician has documented the presence of Koplik's spots. On the basis of this documentation, which of the following would the nurse expect to note during the assessment of the child?
Small, blue-white spots with a red base found on the buccal mucosa Rationale: In rubeola (measles), Koplik's spots appear approximately 2 days before the appearance of the rash. These are small, blue-white spots with a red base that are found on the buccal mucosa. The spots last approximately 3 days, after which time they slough off. Options 1, 2, and 3 are incorrect. Priority Nursing Tip: Rubeola (measles) is transmitted via airborne particles, direct contact with infectious droplets, or transplacental contact. The nurse must implement airborne precautions when caring for the hospitalized client with rubeola.
A 5-year-old child is admitted to the hospital for heart surgery to repair the tetralogy of Fallot. The nurse reviews the child's record and notes that the child has clubbed fingers. The nurse understands that the clubbing is most likely caused by:
Tissue hypoxia Rationale: Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of a chronic tissue hypoxia and poly- cythemia. Priority Nursing Tip: Hypercyanotic spells (acute episodes of cyanosis and hypoxia) are also called blue spells or tet spells and occur when the child's oxygen requirements exceed the blood supply, such as during feeding, crying, or defecating.
A nursing instructor asks a nursing student to describe live or attenuated vaccines. The student tells the instructor that these types of vaccines are:
Vaccines that have their virulence (potency) diminished so as to not produce a full-blown clinical illness Rationale: Live or attenuated vaccines have their virulence (potency) diminished so as to not produce a full-blown clinical illness. In response to vaccination, the body produces antibodies and causes immunity to be established. Option 1 identifies toxoids. Option 2 identifies killed or inac- tivated vaccines. Option 4 identifies human immune globulin. Priority Nursing Tip: An immunocompromised individual should not re- ceive a vaccine without first consulting with the health care provider.
A nurse is reviewing a plan of care prepared by a nursing student for an infant being admitted to the hospital with a diagnosis of congestive heart failure (CHF). The nurse intervenes if which incorrect intervention was included in the plan?
Waking the infant for feedings to ensure adequate nutrition Rationale: Measures that will decrease the workload on the heart include limiting the time that the infant is allowed to bottle- or breast-feed, elevat- ing the head of the bed, allowing for uninterrupted rest periods, and pro- viding oxygen during stressful periods. Priority Nursing Tip: An early sign of congestive heart failure in an infant is tachycardia, especially during rest or with slight exertion.
A nurse is assessing a child admitted to the hospital with a diagnosis of rheumatic fever. The nurse asks the child's mother which signif- icant question during the assessment?
"Has any family member had a sore throat within the past few weeks?" Rationale: Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infec- tion of the respiratory tract. Initially the nurse determines whether any family member has had a sore throat or unexplained fever within the past few weeks. Priority Nursing Tip: The parents of a child with a history of rheumatic fever should be informed if anyone in their child's school develops a strep- tococcal throat infection.
A nurse is performing an assessment on a 3-year-old child with chickenpox. The child's mother tells the nurse that the child keeps scratching at night, and the nurse teaches the mother about measures that will prevent an alteration in skin integrity. Which statement by the mother indicates that teaching was effective?
"I need to place white gloves on my child's hands at night." Rationale: Gloves will keep the child from causing an alteration in skin integrity from scratching. Generous amounts of any topical cream can lead to medication toxicity. A warm room will increase the child's skin temper- ature and make the itching worse. Warm milk will have no effect on itching. Priority Nursing Tip: Isolate high-risk children, such as children who have immunosuppressive disorders, from a child with a communicable disease.
A nurse is planning to teach a teenage client about sexuality. The nurse would begin the in- struction by:
Establishing a relationship and determining prior knowledge Rationale: The first step in effective communication is establishing a rela- tionship. By exploring the client's interest and prior knowledge, rapport is established, and learning needs are assessed. The other options may or may not be later steps, depending on the data obtained. Priority Nursing Tip: The nurse always needs to assess the client's readi- ness to learn before implementing a teaching plan.
The parents of a child with mumps express concern that their child will develop orchitis as a result of having mumps and ask the nurse about the signs of this complication. The nurse tells the parents that which of the following is a sign of this complication?
Fever Rationale: Unilateral orchitis occurs more frequently than bilateral orchi- tis. About 1 week after the appearance of parotitis, there is an abrupt onset of testicular pain, tenderness, fever, chills, headache, and vomiting. The affected testicle becomes red, swollen, and tender. Atrophy, resulting in sterility, occurs only in a small number of cases. Difficulty urinating is not a sign of this complication. Swollen glands and facial swelling normally occur in mumps. Priority Nursing Tip: Warmth and local support with snug, fitting underpants can be used to relieve orchitis.
After tonsillectomy, which of the following fluid or food items is appropriate to offer to the child?
Green Jell-O Rationale: After tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided because they may irritate the throat. Milk and milk products (pudding) are avoided because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding. Red liquids need to be avoided because they give the appearance of blood if the child vomits. Priority Nursing Tip: After tonsillectomy, position the client prone or side-lying to facilitate mouth drainage.
A nurse is preparing to care for an infant with pertussis. When planning care, the nurse ad- dresses which priority problem?
Ineffective Airway Clearance Rationale: The priority problem for the child with pertussis relates to ad- equate air exchange. Because of the copious, thick secretions that occur with pertussis and the small airways of an infant, air exchange is critical. Infection is an important consideration, but airway is the priority. A defi- cient fluid volume is more likely to occur in this infant because of the thick secretions and vomiting. Sleep patterns may be disturbed because of the coughing, but this is not the critical issue. Priority Nursing Tip: For the client with a respiratory problem, reduce en- vironmental factors that cause coughing spasms, such as dust, smoke, and sudden changes in temperature.
A nurse is caring for a hospitalized child with a diagnosis of rheumatic fever who has developed carditis. The mother asks the nurse to explain the meaning of carditis. The nurse plans to respond, knowing that which of the following most appropriately describes this complication of rheumatic fever?
Inflammation of all parts of the heart, primarily the mitral valve Rationale: Carditis is the inflammation of all parts of the heart, primarily the mitral valve, and it is a complication of rheumatic fever. Priority Nursing Tip: Initiate seizure precautions if a child with rheumatic fever is experiencing chorea.
A nurse is caring for a child with a patent ductus arteriosus. The nurse reviews the child's assessment data, knowing that which of the following is characteristic of this disorder?
It involves an artery that connects the aorta and the pulmonary artery during fetal life. Rationale: Patent ductus arteriosus is described as an artery that connects the aorta and the pulmonary artery during fetal life. It generally closes spontaneously within a few hours to several days after birth. It allows abnormal blood flow from the high-pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt. Priority Nursing Tip: In patent ductus arteriosus, a machinery-like murmur is present.
A nurse is caring for a child with a diagnosis of Kawasaki disease, and the mother of the child asks the nurse about the disorder. The nurse bases the response to the mother on which description of this disorder?
It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown etiology. Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology. Priority Nursing Tip: Cardiac involvement is the most serious complication of Kawasaki disease; aneurysms can develop.
A pediatric nurse specialist provides an educational session to the nursing students about childhood communicable diseases. A nursing student asks the nurse to describe the signs and symptoms associated with the most common complication of mumps. The pediatric nurse specialist responds, knowing that which of the following signs or symptoms is indicative of the most common complication of this communicable disease?
Nuchal rigidity Rationale: The most common complication of mumps is aseptic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication. Although mumps is one of the leading causes of unilateral nerve deafness, it does not occur frequently. A red swollen testicle may be indicative of orchitis. Although this complication appears to cause most concern among parents, it is not the most common complication. Priority Nursing Tip: Transmission of mumps is via direct contact or droplet spread from an infected person.
A nurse is caring for an infant with laryngomalacia (congenital laryngeal stridor). Which position would the nurse place the infant in to decrease the incidence of stridor?
Prone with the neck hyperextended Rationale: The prone position with the neck hyperextended improves the child's breathing. Priority Nursing Tip: A child experiencing respiratory difficulty is never left unattended.
A child with hemophilia is brought into the emergency department after being hit on the neck with a baseball. The nurse immediately assesses the child for:
Airway obstruction Rationale: Trauma to the neck may cause bleeding into the tissues of the neck, which may compromise the airway. Although hematuria is a symp- tom of hemophilia, it is not associated with neck injury. Headache and slurred speech are associated with head trauma. Factor VIII deficiency is not a symptom of hemophilia, but rather a common form of the disease. Priority Nursing Tip: Hemophilia is transmitted as an X-linked recessive disorder. (It may also occur as a result of a gene mutation.) Bleeding is the primary concern.
A 5-year-old child is hospitalized with Rocky Mountain spotted fever (RMSF). The nursing assessment reveals that the child was bitten by a tick 2 weeks ago. The child presents with complaints of headache, fever, and anorexia, and the nurse notes a rash on the palms of the hands and soles of the feet. The nurse reviews the physician's prescriptions and anticipates that which of the following medications will be prescribed?
Doxycycline (Vibramycin) Rationale: The nursing care of a child with RMSF includes the administra- tion of doxycycline. An alternative medication is chloramphenicol. Amphotericin B is used for fungal infections. Ganciclovir is used to treat cytomegalovirus. Amantadine is used to treat Parkinson's disease. Priority Nursing Tip: The agent that causes Rocky Mountain spotted fever is Rickettsia rickettsii; transmission is via the bite of an infected tick.
Intravenous immune globulin (IVIG) therapy is prescribed for a child with idiopathic throm- bocytopenic purpura (ITP). The nurse deter- mines that this medication is prescribed for the child to:
Increase the number of circulating platelets. Rationale: IVIG is usually effective to rapidly increase the platelet count. It is thought to act by interfering with the attachment of antibody-coded platelets to receptors on the macrophage cells of the reticuloendothelial system. Corticosteroids may be prescribed to enhance vascular stability and decrease the production of antiplatelet antibodies. Options 2, 3, and 4 are unrelated to the administration of this medication. Priority Nursing Tip: Manifestations of idiopathic thrombocytopenic purpura (ITP) are first noted in the skin and mucous membranes. Large ecchymotic areas or a petechial rash on the arms, legs, upper chest, and neck may be noted.
A child is admitted to the hospital with a diag- nosis of rheumatic fever. The nurse reviews the blood laboratory findings, knowing that which of the following will confirm the likelihood of this disorder?
Increased antistreptolysin-O (ASO) Rationale: Children suspected of having rheumatic fever are tested for streptococcal antibodies. The most reliable and best standardized test to confirm the diagnosis is the ASO titer. An elevated level indicates the pres- ence of rheumatic fever. The remaining options are unrelated to diagnos- ing rheumatic fever. Additionally, an increased leukocyte count indicates the presence of infection but is not specific in confirming a particular diagnosis. Priority Nursing Tip: Rheumatic fever manifests 2 to 6 weeks after a group A beta-hemolytic streptococcal infection of the upper respiratory tract.
A nurse is reviewing the physician's prescrip- tions for a child who was admitted to the hos- pital with vaso-occlusive pain crisis from sickle cell anemia. Which of the following physician prescriptions would the nurse question?
Meperidine hydrochloride (Demerol) for pain Rationale: Meperidine hydrochloride is contraindicated for ongoing pain management because of the increased risk of seizures associated with the use of the medication. The management of vaso-occlusive pain generally includes the use of strong opioid analgesics such as morphine sulfate or hydromorphone (Dilaudid). These medications are usually most effective when given as a continuous infusion or at regular intervals around the clock. Options 1, 2, and 3 are appropriate prescriptions for treating vaso-occlusive pain crisis. Priority Nursing Tip: The priority of care for a child with vaso-occlusive pain crisis from sickle cell anemia is to provide hydration and relieve pain.
The nurse prepares a teaching plan regarding the administration of eardrops for the parents of a 6-year-old child. The nurse tells the parents that, when administering the drops, they should:
Pull the ear up and back. Rationale: To administer eardrops in a child who is more than 3 years old, the ear is pulled upward and back. The ear is pulled down and back in children less than 3 years old. Gloves do not need to be worn by the par- ents, but handwashing before and after the procedure must be performed. The child needs to be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal with the help of gravity. Priority Nursing Tip: To administer ear medications to a child younger than age 3, pull the ear lobe down and back.
A mother of a child with mumps calls the health care clinic to tell the nurse that the child has been lethargic and vomiting. The nurse tells the mother:
To bring the child to the clinic to be seen by the physician Rationale: Mumps generally affects the salivary glands, but it can also af- fect multiple organs. The most common complication is septic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. The child should be seen by the physician. Priority Nursing Tip: Inform the parents of a child with mumps that bed- rest should be encouraged until the parotid swelling subsides.
A child is brought to the emergency depart- ment after being bitten in the arm by a neigh- borhood dog. The nurse performs a focused assessment, cleanses the wound as prescribed, and continues to perform a thorough assess- ment on the child. Which of the following is the priority question for the nurse to ask the mother of the child?
"Are the child's immunizations up-to-date?" Rationale: When a bite occurs, the injury site of the bite should be cleansed carefully and the child should be given tetanus prophylaxis if immuniza- tions are not up-to-date. Option 3 is the priority consideration. Options 1, 2, and 4 identify information that may have to be obtained, but are not the priority questions. Additionally the mother may not have the answers to these questions. Priority Nursing Tip: Always obtain an immunization history from the parent when the child is brought to the emergency department.
A clinic nurse provides home care instructions to a mother regarding the care of her child who is diagnosed with croup. Which statement by the mother indicates the need for further instructions?
"I will give cough syrup every night at bedtime." Rationale: The mother needs to be instructed that cough syrup and cold medicines should not be administered because they may dry and thicken secretions. Sips of warm fluid will relax the vocal cords and thin the mucus. A cool-mist humidifier rather than a steam vaporizer is recom- mended because of the danger of the child pulling the machine over and causing a burn. Acetaminophen (Tylenol) will reduce the fever. Priority Nursing Tip: Monitor the child with croup for signs of respiratory distress, including nasal flaring, sternal retraction, and inspiratory stridor.
A nurse provides instructions regarding home care to a parent of a 3-year-old child who has been hospitalized with hemophilia. Which statement by the parent indicates the need for further instructions?
"My child should not have any im- munizations." Rationale: Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The nurse must stress the importance of immunizations, dental hygiene, and routine well-child care. Options 1, 2, and 4 are appropriate. The parent should also be instructed regarding measures to implement if blunt trauma occurs (espe- cially trauma involving the joints) and how to apply prolonged pressure to superficial wounds until the bleeding has stopped. Priority Nursing Tip: Bleeding is a primary concern for the child with he- mophilia. Teach the parents about safety measures to implement to pre- vent injury such as wearing protective devices (helmets and knee and elbow pads) when participating in sports such as bicycling.
A child with rheumatic fever is admitted to the hospital. The nurse reviews the child's record and expects to note which clinical manifesta- tions documented in the record? Select all that apply.
1 Cardiac murmur 2 Cardiac enlargement 5 Small nontender lumps on bony prominences 6 Purposeless jerky movements of the extremities and face Rationale: Rheumatic fever is a systemic inflammatory disease that may develop as a delayed reaction to an inadequately treated infection of the upper respiratory tract by group A beta-hemolytic streptococci. Clinical manifestations of rheumatic fever are related to the inflammatory response. Major manifestations include arthritis manifested as tender, warm erythematous joints; carditis manifested as inflammation of the endocardium, including the valves, myocardium, and pericardium; cardiac murmur and cardiac enlargement; chorea, manifested as involuntary, purposeless jerky movements of the legs, arms, and face with speech impairment; erythema marginatum, manifested as red, painless skin lesions usually over the trunk; and subcutaneous nodules, manifested as small nontender lumps on joints and bony prominences. Priority Nursing Tip: Initiate seizure precautions if the child with rheumatic fever exhibits manifestations of chorea (involuntary, purposeless jerky movements of the legs, arms, and face with speech impairment).
The emergency department nurse prepares for which interventions in the care of a child with epiglottitis? Select all that apply.
1 Obtaining a chest x-ray 3 Monitoring pulse oximetr 4 Maintaining a patent airway 5 Providing humidified oxygen 6 Administering antipyretics and antibiotics Rationale: Epiglottitis is an acute inflammation and swelling of the epi- glottis and surrounding tissue. It is a life-threatening, rapidly progressive condition that may cause complete airway obstruction within a few hours of onset. The most reliable diagnostic sign is an edematous, cherry-red epiglottis. The primary concern is the development of complete airway obstruction. Therefore the child's throat is not examined or cultured because any stimulation with a tongue depressor or culture swab could trigger complete airway obstruction. Some interventions include maintaining a patent airway, providing humidified oxygen, monitoring pulse oximetry, obtaining a chest x-ray film, and administering antipyretics and antibiotics. The child may also require intubation and mechanical ventilation. Priority Nursing Tip: Epiglottitis is considered an emergency situation because it can progress rapidly to severe respiratory distress.
A child is admitted to the hospital with a suspected diagnosis of bacterial endocarditis. The child has been experiencing fever, malaise, anorexia, and a headache, and diagnostic studies are performed on the child. Which of the following studies will primarily confirm the diagnosis?
A blood culture Rationale: The diagnosis of bacterial endocarditis is primarily established on the basis of a positive blood culture of the organisms and the visual- ization of vegetation on echocardiographic studies. Other laboratory tests that may help to confirm the diagnosis are an elevated sedimentation rate and the C-reactive protein level. An ECG is not usually helpful for the diagnosis of bacterial endocarditis. Priority Nursing Tip: Instruct the parents of a child who had bacterial endocarditis of the need to inform the dentist and any other health care providers about the condition. Prophylactic antibiotics should be taken before dental procedures or any other invasive disorders to prevent the recurrence of endocarditis.
A child is admitted to the hospital with a sus- pected diagnosis of idiopathic thrombocyto- penic purpura (ITP), and diagnostic studies are performed. Which of the following diag- nostic results are indicative of this disorder?
A bone marrow examination showing an increased number of megakaryocytes Rationale: The laboratory manifestations of ITP include the presence of a low platelet count of usually less than 20,000 cells/mm3. Thrombocyto- penia is the only laboratory abnormality expected with ITP. If there has been significant blood loss, there is evidence of anemia in the blood cell count. If a bone marrow examination is performed, the results with ITP show a normal or increased number of megakaryocytes, which are the pre- cursors of platelets. Option 4 indicates the bone marrow result that would be found in a child with leukemia. Priority Nursing Tip: For the client with idiopathic thrombocytopenic purpura (ITP), platelet transfusions may be administered when platelet counts are less than 20,000 cells/mm3.
A nurse is performing an assessment of a child who is to receive a measles, mumps, and rubella (MMR) vaccine. The nurse notes that the child is allergic to eggs. Which of the following would the nurse anticipate being prescribed for this child?
Taking a careful history about the allergy and reporting this to the physician before administering the MMR vaccine Rationale: Live measles vaccine is produced by chick embryo cell culture, so the possibility of an anaphylactic hypersensitivity in children with egg allergies should be considered. The nurse should take a thorough history of the allergy to a previous MMR and report this to the physician. If this is the first MMR, the physician should be aware of the egg sensitivity before administering the vaccine. Priority Nursing Tip: Contraindications of the measles, mumps, and rubella (MMR) vaccine include severe allergic reaction to a previous dose or vaccine component (gelatin, neomycin, eggs), pregnancy, or known immunodeficiency.
A nurse provides discharge instructions to the mother of a child who was hospitalized for heart surgery. The nurse tells the mother that:
The physician is to be notified if the child develops a fever of more than 100.5 F. Rationale: After heart surgery, the child should not return to school until 3 weeks after hospital discharge, at which time the child should go to school for half days for the first few days. No creams, lotions, or powders should be placed on the incision until it is completely healed and without scabs. The mother is instructed to not allow the child to play outside for several weeks. The physician must be notified if the child develops a fever of more than 100.5 F. Priority Nursing Tip: Immunizations, dental visits, and invasive proce- dures must be avoided for 2 months in the child who had cardiac surgery.
