Peds ch23 TestBank

ANS: A, B, C, D As shock progresses, perfusion in the microcirculation becomes marginal despite compensatory adjustments, and the signs are more obvious. Signs include tachypnea, oliguria, confusion, and pale extremities, as well as decreased skin turgor and poor capillary filling. Hypotension and a thready pulse are clinical manifestations of irreversible shock.

1. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.) a. Tachypnea b. Oliguria c. Confusion d. Pale extremities e. Hypotension f. Thready pulse

ANS: C The infant's kidneys are functionally immature at birth and are inefficient in excreting waste products of metabolism. Infants have a relatively high body surface area (BSA) compared with adults. This allows a higher loss of fluid to the environment. A higher metabolic rate is present as a result of the higher BSA in relation to active metabolic tissue. The higher metabolic rate increases heat production, which results in greater insensible water loss. Infants have a greater exchange of extracellular fluid, leaving them with a reduced fluid reserve in conditions of dehydration.

1. What factor predisposes an infant to fluid imbalances? a. Decreased surface area b. Lower metabolic rate c. Immature kidney functioning d. Decreased daily exchange of extracellular fluid

ANS: A The immediate threat to life in children with thermal injuries is airway compromise and profound shock. Anemia is not of immediate concern. During the healing phase, local infection or sepsis is the primary complication.

12. What is the most immediate threat to life in children with thermal injuries? a. Shock b. Anemia c. Local infection d. Systemic sepsis

ANS: A, B, C The nurse should recognize that conditions such as oliguric renal failure, increased intracranial pressure, and mechanical ventilation can cause an increase or a decrease in fluid requirements. Conditions such as hypotension, tetralogy of Fallot, and diabetes mellitus (type 1) do not cause an alteration in fluid requirements.

2. In what condition should the nurse be alert for altered fluid requirements in children? (Select all that apply.) a. Oliguric renal failure b. Increased intracranial pressure c. Mechanical ventilation d. Compensated hypotension e. Tetralogy of Fallot f. Type 1 diabetes mellitus

ANS: C For the first 10 kg of body weight, a child requires 100 mL/kg. For each additional kilogram of body weight, an extra 50 mL is needed. 10 kg ´ 100 mL/kg/day = 1000 mL 4 kg ´ 50 mL/kg/day = 200 mL 1000 mL + 200 mL = 1200 ml/day 800 to 1000 mL is too little; 1400 mL is too much.

2. What is the required number of milliliters of fluid needed per day for a 14 kg child? a. 800 b. 1000 c. 1200 d. 1400

ANS: C These clinical manifestations indicate water depletion or dehydration. Edema and weight gain occur with water excess or overhydration. Sodium or potassium excess would not cause these symptoms.

3. An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation? a. Water excess b. Sodium excess c. Water depletion d. Potassium excess

ANS: B, C, D Clinical manifestations of hypotonic dehydration include slightly moist mucous membranes, absent tears, and a very rapid pulse. A thick, doughy feel to the skin and hyperirritability are signs of hypertonic dehydration.

3. What clinical manifestations should be observed in a 2-year-old child with hypotonic dehydration? (Select all that apply.) a. Thick, doughy feel to the skin b. Slightly moist mucous membranes c. Absent tears d. Very rapid pulse e. Hyperirritability

ANS: B, D, E Signs and symptoms of hypokalemia are hypotension, muscle weakness, and cardiac arrhythmias. Twitching and hyperreflexia are signs of hyperkalemia.

4. The nurse is caring for a child with hypokalemia. The nurse evaluates the child for which signs and symptoms of hypokalemia? (Select all that apply.) a. Twitching b. Hypotension c. Hyperreflexia d. Muscle weakness e. Cardiac arrhythmias

ANS: A The excess water in the circulatory system results in hemodilution. The laboratory results show a falsely decreased hematocrit. Laboratory analysis of blood that is hemodiluted reveals decreased serum osmolality and blood urea nitrogen. The urine specific gravity is variable relative to the child's ability to correct the fluid imbalance.

4. What laboratory finding should the nurse expect in a child with an excess of water? a. Decreased hematocrit b. High serum osmolality c. High urine specific gravity d. Increased blood urea nitrogen

ANS: C Compensatory mechanisms attempt to maintain fluid volume. Initially, interstitial fluid moves into the intravascular compartment to maintain blood volume. Aldosterone is released to promote sodium retention and conserve water in the kidneys. Hemoconcentration results from the fluid volume loss. With less circulating volume, tachycardia results. Vasoconstriction of peripheral arterioles occurs to help maintain blood pressure

5. Physiologically, the child compensates for fluid volume losses by which mechanism? a. Inhibition of aldosterone secretion b. Hemoconcentration to reduce cardiac workload c. Fluid shift from interstitial space to intravascular space d. Vasodilation of peripheral arterioles to increase perfusion

ANS: B, C, E Signs and symptoms of hypercalcemia are anorexia, constipation, and muscle hypotonicity. Tetany and laryngospasm are signs of hypocalcemia.

5. The nurse is caring for a child with hypercalcemia. The nurse evaluates the child for which signs and symptoms of hypercalcemia? (Select all that apply.) a. Tetany b. Anorexia c. Constipation d. Laryngospasm e. Muscle hypotonicity

ANS: B, C, E Signs and symptoms of hypernatremia are nausea; oliguria; and dry, sticky mucus. Apathy and lethargy are signs of hyponatremia.

6. The nurse is caring for a child with hypernatremia. The nurse evaluates the child for which signs and symptoms of hypernatremia? (Select all that apply.) a. Apathy b. Lethargy at rest c. Oliguria d. Intense thirst e. Dry, sticky mucus

ANS: B In general, the number of days in life (up to 6-10 days) should be equal to the number of wet diapers per day. Having parents estimate output would be inaccurate. It is difficult to estimate how much fluid is in a diaper. The urine collection device would irritate the child's skin. It would be difficult for a toddler who is not toilet trained to sit on a potty chair 30 minutes after eating.

6. What is an approximate method of estimating output for a child who is not toilet trained? a. Have parents estimate output. b. Document number of wet diapers. c. Place a urine collection device on the child. d. Have the child sit on a potty chair 30 minutes after eating.

ANS: C Children who are vomiting should be given ORS at frequent intervals and in small amounts. Intravenous fluids are not indicated for mild dehydration. Carbonated beverages are high in carbohydrates and are not recommended for the treatment of diarrhea and vomiting. The child is not kept NPO because this would cause additional fluid losses.

7. A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solutions (ORS). The child's mother calls the clinic nurse because he is also occasionally vomiting. The nurse should recommend which intervention? a. Bring the child to the hospital for intravenous fluids. b. Alternate giving ORS and carbonated drinks. c. Continue to give ORS frequently in small amounts. d. Keep child NPO (nothing by mouth) for 8 hr and resume ORS if vomiting has subsided.

ANS: B Blood loss is the most frequent cause of hypovolemic shock in children. Sepsis causes septic shock, which is overwhelming sepsis and circulating bacterial toxins. Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Heart failure contributes to hypervolemia, not hypovolemia.

8. What is the most frequent cause of hypovolemic shock in children? a. Sepsis b. Blood loss c. Anaphylaxis d. Heart failure

ANS: C The initial nursing action for a patient in shock is to establish ventilatory support. Oxygen is provided, and the nurse carefully observes for signs of respiratory failure, which indicates a need for intubation. Cardiac monitoring would be indicated to assess the child's status further, but ventilatory support comes first. Oxygen saturation monitoring should be begun. Arterial blood gases would be indicated if alternative methods of monitoring oxygen therapy were not available. The Trendelenburg position is not indicated and is detrimental to the child. The head-down position increases intracranial pressure and decreases diaphragmatic excursion and lung volume.

9. The nurse suspects shock in a child 1 day after surgery. What should be the initial nursing action? a. Place the child on a cardiac monitor. b. Obtain arterial blood gases. c. Provide supplemental oxygen. d. Put the child in the Trendelenburg position.