Practice Sylvestri Questions for Exam #2
The nurse caring for a child diagnosed with rubeola (measles) notes that the pediatrician has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected? a) Pinpoint petechiae noted on both legs b) Whitish vesicles located across the chest c) Petechiae spots that are reddish and pinpoint on the soft palate d) Small, blue-white spots with a red base found on the buccal mucosa
Answer: d) 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 spots last approximately 3 days, after which time they slough off.
The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis? a) Prove less frequent, larger feedings b) Burp the infant less frequently during feedings c) Thin the feedings by adding water to the formula d) Thicken the feedings by adding rice cereal to the formula
Answer: d) Thicken the feedings by adding rice cereal to the formula Rationale: Gastroesophageal reflux is backflow of gastric contents into the esophagus as a result of relaxation or incompetence of the lower esophageal or cardiac sphincter. Small, more frequent feedings with frequent burping often are prescribed in the treatment of gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis.
The clinic nurse reviews the record of an infant and notes that the primary health care provider (PCHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessments findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant? a) Diarrhea b) Projectile vomiting c) Regurgitation of feedings d) Foul-smelling ribbon-like stools
Answer: d) Foul-smelling ribbon-like stools Rationale: Hirschsprung's disease is a congenital anomaly also known as congenital aganglionosis or aganglionic megacolon. It occurs as the result of an absence of ganglion cells in the rectum and other areas of the affected intestine. Chronic constipation beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foul-smelling is a clinical manifestation of this disorder.
An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time? a) Prone position b) On the stomach c) Left lateral position d) Right lateral position
Answer: c) Left lateral position Rationale: A cleft lip is a congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic development. After cleft lip repair, the nurse avoids positioning an infant on the side of the repair or in the prone position.
The nurse is caring for a child diagnosed with erythemia infectiosum (fifth disease). Which clinical manifestation should the nurse expect to note in the child? a) An intense fiery red edematous rash on the cheeks b) Pinkish-rose maculopapular rash on the face, neck, and scalp c) Reddish and pinpoint petechiae spots found on the soft palate d) Small bluish-white spots with a red base found on the buccal mucosa
Answer: a) An intense fiery red edematous rash on the cheeks Rationale: Fifth disease is characterized by the presence of an intense fiery red edematous rash on the cheeks, which gives an appearance that the child has been slapped.
The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin? a) Fine grayish red lines b) Purple-colored lesions c) Thick, honey-colored crusts d) Clusters of fluid-filled vesicles
Answer: a) Fine grayish red lines Rationale: Scabies is a parasitic skin disorder caused by an infestation of Sarcoptes scabiei (itch mite). Scabies appears as burrow or fine, grayish red, thread-like lines.
A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the child's parents indicates a need for further instruction? a) "The cast may feel warm as the cast dries." b) "I can use lotion or powder around the cast edges to relieve itching." c) "A small amount of white shoe polish can touch up a soiled white cast." d) "If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast."
Answer: b) "I can use lotion or powder around the cast edges to relieve itching." Rationale: The parents need to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation.
The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. a) The child has symptoms of a cold b) The child had a previous anaphylactic reaction to the vaccine c) The mother reports that the child is having intermittent episodes of diarrhea d) The mother reports that the child has not has an appetite and has been fussy e) The child has a disorder that caused a severely deficient immune system f) The mother reports that the child has recently been exposed to an infectious disease
Answer: b) & e) Rationale: The general contraindications for receiving live virus vaccines include a previous anaphylactic shock reaction to a vaccine or a component of a vaccine. In addition, live virus vaccines generally are not administered to individuals with a severely deficient immune system, individuals with a severe sensitivity to gelatin, or pregnant women.
A 10-year-old child with Asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? a) Warm, dry skin b) Decreased wheezing c) Pulse rate of 90 beats per minute d) Respirations of 18 breaths per minute
Answer: b) Decreased wheezing Rationale: Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air.
The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's symptoms? a) Watery diarrhea b) Projectile vomiting c) Increased urine output d) Vomiting large amounts of bile
Answer: b) Projectile vomiting Rationale: In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes a narrowing of the pyloric canal between the stomach and the duodenum. Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, hungry and crying, constipation, and signs of dehydration, including a decrease in urine output.
The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation made by the nurse indicates the presence of this condition? a) The child has difficulty hearing b) The child consistently tilts the head to see c) The child does not respond when spoken to d) The child consistently turns the head to hear
Answer: b) The child consistently tilts the head to see Rationale: Strabismus is a condition in which the eyes are not aligned because of lack of the extraocular muscles. The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see.
The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. a) Scarring is less severe in a child than in an adult b) A delay in growth may occur after a burn injury c) An immature immune system presents an increased risk for infection for infants and young children d) Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area. e) The lower proportion of body fluid to body mass in a child increases the risk of cardiovascular problems f) Infants and young children are at increased risk for protein and calorie deficiency, because they have smaller muscle mass and less body fat than adults.
Answer: b) c) & f) Rationale: Pediatric considerations in the care of a burn victim include the following: Scarring is more severe in a child than in an adult. A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. The higher proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. Burns involving more than 10% of total body surface area require some form of fluid resuscitation. Infants and young children are at increased risk for protein and calorie deficiencies because they have smaller muscle mass and less body fat than adults.
The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply. a) Use the fingertips to lift the cast while it is drying b) Keep small toys and sharp objects away from the cast c) Use a padded ruler or another padded object to scratch the skin under the cast if it itches. d) Place a heating pad on the lower end of the cast and over the fingertips if the fingers feel cold e) Elevate the extremity on pillows for the first 24-48 hours after casting to prevent swelling f) Contact the primary health care provider (PHCP) if the child complains of numbness or tingling the extremity.
Answer: b), e) & f) Rationale: While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling, and the PHCP is notified immediately if any signs neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the PHCP should be notified.
The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question should the nurse ask the child's parents during the assessment? a) "Has your child had difficulty urinating?" b) "Has your child been exposed to anyone with chickenpox?" c) "Has any family member had a sore throat within the past few weeks?" d) "Has any family member had a gastrointestinal disorder in the past few weeks?"
Answer: c) "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 infection of the respiratory tract.
The nurse is providing instruction to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? a) "I will encourage my child to perform prescribed exercises." b) "I will have my child wear soft fabric clothing under the brace." c) "I should apply lotion under the brace to prevent skin breakdown." d) "I should avoid the use of powder because it will cake under the brace."
Answer: c) "I should apply lotion under the brace to prevent skin breakdown." Rationale: A brace may be prescribed to treat scoliosis. Braces are not curative but may slow the progression of the curative to allow skeletal growth and maturity. The use of lotions or powders under a brace should be avoided because they can become sticky and cake under the brace, causing irritation.
The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching? a) "I need to wash my hands frequently." b) "I need to clean the eye as prescribed." c) "It is okay to share towels and washcloths." d) "I need to give the eye drops as prescribed."
Answer: c) "It is okay to share towels and washcloths." Rationale: Conjunctivitis is an inflammation of the conjunctive. Bacterial conjunctivitis is highly contagious, and the nurse should teach infection control measures. These include good hand washing and not sharing towels and washcloths.
The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction? a) "It is extremely contagious." b) "It is most common in humid weather." c) "Lesions most often are located on the arms and chest." d) "It might show up in an area of broken skin, such as an insect bite."
Answer: c) "Lesions most often are located on the arms and chest." Rationale: Impetigo is a contagious bacterial infection of the skin caused by beta-hemolytic streptococci or staphylococci, or both. Impetigo may begin in an area of broken skin, such as an insect bite or atopic dermatitis. Lesions usually are located around the mouth and nose but may be present on the hands and extremities.
The nurse is monitoring a child with burns during treatment. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation? a) Skin turgor b) Level of edema at burn site c) Adequacy of capillary filling d) Amount of fluid tolerated in 24 hours
Answer: c) Adequacy of capillary refilling Rationale: Parameters such as vital signs (especially heart rate), urinary output volume, adequacy of capillary filling, and state of sensorium determine adequacy of fluid resuscitation.
The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction? a) "We need to encourage our child to drink fluids." b) "Coughing spells may be triggered by dust or smoke." c) "Vomiting may occur when our child has coughing episodes." d) "We need to maintain droplet precautions and a quiet environment for at least 2 weeks."
Answer: d) "We need to maintain droplet precautions and a quiet environment for at least 2 weeks." Rationale: Pertussis is transmitted by direct contact or respiratory droplets from coughing.
An Infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent? a) Monitor the infant for a fever b) Bring the infant back to the clinic c) Apply a hot pack to the injection site d) Apply a cold pack to the injection site
Answer: d) Apply a cold pack to the injection site Rationale: On occasion, tenderness, redness, or swelling may occur at the site of the DTaP injection. This can be relieved with cold packs for the first 24 hours, followed by warm or cold compresses if the inflammation persists.
The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? a) Watery diarrhea b) Ribbon-like stools c) Profuse projectile vomiting d) Bright red blood and mucus in the stools
Answer: d) Bright red blood and mucus in the stools Rationale: Intussusception is a telescoping of 1 portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. A child with intussusception typically has severe abdominal pain that is crampy an intermittent, causing the child to draw in the knees to the chest. Vomiting may be present, but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly-like stools.
A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention? a) Ensure that all ropes are outside the pulleys b) Ensure that the weights are resting lightly on the floor c) Restrict diversional and play activities until the child is out of traction d) Check the primary health care provider's (PCHP's) prescriptions for the amount of weight to be applied
Answer: d) Check the primary health care provider's (PHCP's) prescriptions for the amount of weight to be applied Rationale: When a child is in traction, the nurse would check the PHCP's prescription to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as prescribed, ensure that the weights hang freely, check the ropes for fraying and ensure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms pf complications of immobilization. The nurse would provide therapeutic and diversional play activities for the child.
The nurse is preparing to care for 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? a) A radio b) A sports video c) Large picture books d) Crayons and a coloring book
Answer: d) Crayons and a coloring book Rationale: In the preschooler, play is simple and imaginative and includes activities such as crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh.
A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take? a) Administer an analgesic b) Release the skin traction c) Apply ice to the extremity d) Notify the primary health care provider (PHCP)
Answer: d) Notify the primary health care provider (PHCP) Rationale: An absent pulse to an extremity of the affected limb after a bone fracture could mean that the child is developing or experiencing compartment syndrome. This is an emergency situation, and the PHCP needs to be notified immediately.
A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distension. On the basis of these findings, the nurse should take which action? a) Administer an antiemetic b) Increase the intravenous fluids c) Place the child in a Sims' position d) Notify the primary health care provider (PHCP)
Answer: d) Notify the primary health care provider (PHCP) Rationale: Scoliosis is a three-dimensional spinal deformity that usually involves lateral curvature, spinal rotation resulting in rib asymmetry, and hypokyphosis of the thorax. A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child's abdominal contents, resulting from lengthening of the child's body. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or children who have undergone spinal fusion warrants attention because of the possibility of super mesenteric artery syndrome.
The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a "positive" head check for lice? a) Maculopapular lesions behind the ears b) Lesions in the scalp that extend to the hairline or neck c) White flaky particles throughout the entire scalp region d) White sacs attached to the hair shafts in the occipital area
Answer: d) White sacs attached to the hair shafts in the occipital area Rationale: Pediculosis capitis is an infestation of the hair and scalp with lice. The nits are visible and attached firmly to the hair shaft near the scalp. The occiput is an area in which nits can be seen.
