Test 4 Practice Questions
252. A child with rheumatic fever will be arriving in the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Did the child have a sore throat or fever within the last 2 months?"
"Did the child have a sore throat or fever within the last 2 months?" Rationale: Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. Rheumatic fever characteristically manifests 2 to 6 weeks after an untreated or partially treated group A b-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child had a sore throat or an unexplained fever within the past 2 months
215. The comment made by a parent of a 1-month-old that would alert the nurse about the presence of a congenital heart defect is: a. "He is always hungry." b. "He tires out during feedings." c. "He is fussy for several hours every day." d. "He sleeps all the time."
"He tires out during feedings." Rationale: Fatigue during feeding or activity is common to most infants with congenital cardiac problems.
248. The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin (Lanoxin). Which statement made by the parent indicates the NEED FOR FURTHER INSTRUCTION? 1. "I will not mix the medications with the food." 2. "I will take my child's pulse before administering the medication." 3. If more than one dose is missed, I will call the health care provider." 4. "If my child vomits after medication administration, I will repeat the dose."
"If my child vomits after medication administration, I will repeat the dose." Rationale: Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after digoxin is administered, they are not to repeat the dose.
114 A woman who is 6 weeks pregnant tells the nurse that she is worried that the baby might have spina bifida because of a family history. The nurse's BEST response is: "There is no genetic basis for the defect." "Prenatal detection is not possible yet." "Chromosome studies done on amniotic fluid can diagnose the defect prenatally." "The concentration of alpha-fetoprotein in amniotic fluid can indicate the presence of the defect prenatally."
"The concentration of alpha-fetoprotein in amniotic fluid can indicate the presence of the defect prenatally." The origin of neural tube defects is unknown, but it appears to have a multifactorial inheritance pattern. Prenatal detection is possible through amniotic fluid or chorionic villi sampling. There is no chromosome study at this time. Fetal ultrasound and elevated concentrations of alpha-fetoprotein in amniotic fluid may indicate the presence of anencephaly or myelomeningocele.
191. A nurse is preparing a child, age 4, for cardiac catheterization. Which explanation of the procedure is appropriate? 1. "Don't worry. It won't hurt." 2. "The test usually takes an hour." 3. "You must sleep the whole time that the test is being done." 4. "The special medicine will feel warm when it's put in the tubing."
"The special medicine will feel warm when it's put in the tubing." RATIONALE: To prepare a 4-year-old child without increasing anxiety, the nurse should provide concrete information in small amounts about nonthreatening aspects of the procedure. Therefore, saying the special medicine will feel warm is most appropriate. Saying that it won't hurt may prevent the child from trusting the nurse in the future. Explaining the time needed for the procedure wouldn't provide sufficient information. Stating that the child will need to sleep isn't true and could provoke anxiety.
72. The mother of a child with type 1 diabetes mellitus asks why her child cannot avoid all those "shots" and take pills as an uncle does. The nurse's BEST reply is: "The pills work with an adult pancreas only." "The drugs affect fat and protein metabolism, not sugar." "Your child needs insulin replaced, and the oral hypoglycemics only add to an existing supply of insulin." "Perhaps when your child is older the pancreas will produce its own insulin, and then your child can take oral hypoglycemics."
"Your child needs insulin replaced, and the oral hypoglycemics only add to an existing supply of insulin." The oral medications have different modes of action, which supplement insulin production by the pancreas, decreasing insulin resistance or affecting liver production of glucose. They are not insulin substitutes. In type 1 diabetes, the b-cells have been destroyed. It is necessary to supply the insulin that they no longer produce. In type 1 diabetes, the b-cells are destroyed. Without a pancreas b-cell transplant, it is unlikely that insulin would be produced.
295. The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse should expect to note documentation of which most common assessment finding?
-Bluish discoloration of the skin The child with a right-to-left shunt will be considerably sicker than a child with a left-to-right shunt. Many of these children will present with symptoms in the first week of life. The most common assessment finding in these children is bluish discoloration of the skin, known as cyanosis. The child may also become dyspneic after feeding, crying, and other exertional activities. Many children with a left-to-right shunt may remain asymptomatic.
293. A nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. What is the initial action by the nurse?
-Place the infant in a knee-chest position. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return, so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to obtain this position and relieve chronic hypoxia
287. A 12-year-old is admitted to the hospital with a low-grade fever and joint pain. Which diagnostic test finding will assist to determine a diagnosis of rheumatic fever?
-Presence of Aschoff's bodies Rheumatic fever develops after a group A β-hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff's bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated antistreptolysin O titer; an elevated C-reactive protein level; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin's disease
288. The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply -Presence of Aschoff's bodies -Elevated antistreptolysin O titer -Elevated erythrocyte sedimentation rate
-Presence of Aschoff's bodies -Elevated antistreptolysin O titer -Elevated erythrocyte sedimentation rate
224. Hearing is expressed in decibels (dB), or units of loudness. Which of the following is, in decibels, the softest sound a normal ear can hear? a. 0 b. 10 c. 40 to 50 d. 100
0 Ratioanle: By definition, 0 dB is the softest sound the normal ear can hear.
251. The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a NEED FOR FURTHER INSTRUCTIONS? 1. "A balance of rest and exercise is important." 2. "I can apply lotion or powder to the incision if it is itchy." 3. "Activities in which my child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after surgery."
2. "I can apply lotion or powder to the incision if it is itchy." Rationale: Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site.
204. The school nurse recommends a heart healthy diet that limits fats to no more than ____% of the total dietary intake. a. 10 b. 15 c. 20 d. 30
30
189. A 9-year-old boy with diabetes mellitus tests his glucose level in the nurse's office before lunch. According to this sliding scale of insulin, he's due for 1 unit of regular insulin. What steps should a nurse follow after confirming the medication order, washing her hands, drawing up the appropriate dose, verifying the boy's identity, and putting on gloves? Put the following steps in chronological order. 1. Pinch the skin around the injection site 2. Release the skin and give the injection. 3. Clean site with an alcohol pad; loosen needle cover. 4. Select appropriate injection site with the child. 5. Cover the site with an alcohol pad. 6. Uncover needle; insert at 45- to 90- degree angle.
4. Select appropriate injection site with the child. 3. Clean site with an alcohol pad; loosen needle cover. 1. Pinch the skin around the injection site 6. Uncover needle; insert at 45- to 90- degree angle. 2. Release the skin and give the injection. 5. Cover the site with an alcohol pad. RATIONALE: To give a subcutaneous injection of insulin to a child, the nurse should first select an appropriate injection site, being sure to discuss the selection with the child to ensure that injection sites are rotated. She should then clean the injection site with an alcohol pad and loosen the needle cover. The next step is to pinch the skin around the site. She should then uncover the needle and insert the needle at a 45- to 90-degree angle, release the skin, and give the injection. When finished, the nurse should cover the injection site with an alcohol pad and avoid rubbing the site.
202. The nurse clarifies to the parents of a 4-year-old child recovering from rheumatic fever that the child will need to receive monthly injections of penicillin G for a minimum of _____ year(s). a. 1 b. 2 c. 5 d. 10
5 Children who recover from rheumatic fever should have a chemoprophylaxis protocol of penicillin G injections (about 200,000 units per dose) for a minimum of 5 years or up to the age of 18 to prevent further bouts of rheumatic fever.
285. A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation?
A hypercyanotic episode Children with tetralogy of Fallot or similar physiology may experience hypercyanotic episodes, or tet spells. These episodes are characterized by increased respiratory rate and depth and increased hypoxia. Immediate HCP notification is not required unless other appropriate nursing interventions are unsuccessful
234. The nurse should suspect a hearing impairment in an infant who demonstrates which of the following behaviors? a. Absence of the Moro reflex b. Absence of babbling by age 7 months c. Lack of eye contact when being spoken to d. Lack of gesturing to indicate wants after age 15 months
Absence of babbling by age 7 months Rationale: The absence of babbling or inflections in voice by age 7 months is an indication of hearing difficulties.
238. When a child with mild mental retardation reaches the end of adolescence, which of the following characteristics would be expected? a. Achieves a mental age of 5 to 6 years b. Achieves a mental age of 8 to 12 years c. Unable to progress in functional reading or arithmetic d. Acquires practical skills and useful reading and arithmetic to an eighth-grade level
Achieves a mental age of 8 to 12 years Rationale: By the end of adolescence, the child with mild mental retardation can acquire practical skills and useful reading and arithmetic to a third- to sixth-grade level. A mental age of 8 to 12 years is obtainable, and the child can be guided toward social conformity.
106 Which statement is most accurate in describing tetanus? Acute infectious disease caused by an exotoxin produced by an anaerobic gram-positive bacillus Inflammatory disease that causes extreme, localized muscle spasm Acute infection that causes meningeal inflammation resulting in symptoms of generalized muscle spasm Disease affecting the salivary gland with resultant stiffness of the jaw
Acute infectious disease caused by an exotoxin produced by an anaerobic gram-positive bacillus Tetanus is an acute, preventable disease caused by an exotoxin produced by an anaerobic spore-forming, gram-positive bacillus, Clostridium tetani. These symptoms are caused by the effect of the toxins becoming fixed on nerve cells. These symptoms are caused by the effect of the toxins becoming fixed on nerve cells. These symptoms are caused by the effect of the toxins becoming fixed on nerve cells.
34. The nurse is caring for an infant with an acyanotic heart defect. Why must the nurse continue to monitor this infant's mucous membranes, fingers, and toes? Because it explains the hemodynamics involved. Because cyanotic defects are easily identified. Because that is part of the standardized assessment. Acyanotic heart defects may have cyanosis if another cardiac problem arises or if the current one becomes worse.
Acyanotic heart defects may have cyanosis if another cardiac problem arises or if the current one becomes worse. A. The classification does not reflect the path of blood flow within the heart. B. Children with cyanosis may be easily identified, but that does not help with the diagnosis. C. Although these components are assessed regularly when an infant has a cardiac problem, the reason is that cyanosis can occur if the cardiac problem becomes worse in some cases. D. Children with traditionally named acyanotic defects may be slightly cyanotic, and children with traditionally classified cyanotic defects may appear pink, although they may eventually become cyanotic. It is most important to document specific assessment findings and let the classification be specified by the cardiologist.
128 John is a 6-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be which of the following? a. Directed at his parents because he is too young to understand b. Adapted to his level of development so that he can understand c. Done several days before the procedure so he will be prepared d. Provide details about the actual procedures so he will know what to expect
Adapted to his level of development so that he can understand Preoperative teaching should always be directed to the child's stage of development. The caregivers also benefit from these explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. This age-group will not understand in-depth descriptions. School-age children should be prepared close to the time of the cardiac catheterization.
10. Which of the following is an important nursing consideration when chest tubes will be removed from a child? Explain that it is not painful. Administer analgesics before procedure. Explain that only a Band-Aid will be needed. Expect bright red drainage for several hours after removal.
Administer analgesics before procedure. 2. Removal of chest tubes can be an uncomfortable, frightening experience. Analgesics should be used. 1. Children are forewarned that they will feel a sharp, momentary pain. 3. A petrolatum-covered gauze dressing is immediately applied over the wound and securely taped to the skin on all four sides to form an airtight seal. 4. No drainage is anticipated on the dressing.
261.Before giving a dose of digoxin (Lanoxin), the nurse checked an infant's apical heart rate and it was 114 bpm. What should the nurse do next? a. Administer the dose as ordered. b. Hold the medication until the next dose. c. Wait and recheck the apical heart rate in 30 minutes. d. Notify the physician about the infant's heart rate.
Administer the dose as ordered A The infant's heart rate is above the lower limit for which the medication is held. The dose can be given. B A dose of Lanoxin is withheld for a heart rate less than 100 bpm in an infant. C The infant's heart rate is acceptable for administering Lanoxin. It is unnecessary to recheck the heart rate at a later time. D The infant's heart rate is acceptable. The physician should be notified for a heart rate less than 100 bpm in an infant.
11. Therapeutic management of the child with rheumatic fever includes: Administration of penicillin. avoidance of salicylates (aspirin). strict bed rest for 4 to 6 weeks. administration of corticosteroids if chorea develops.
Administration of penicillin remains the drug of choice (oral or intramuscular injections), with macrolides or cephalosporins as a substitute in penicillin-sensitive children. Initial therapy includes a full 10-day course of penicillin or an alternative antibiotic. 2. Salicylates may be used to reduce the inflammatory process after diagnosis. 3. Bed rest is not indicated. Children can resume regular activities after the febrile stage is over. 4. The chorea is transient, and pharmacologic intervention is not indicated.
32. A 3-week-old neonate has been admitted to the hospital because inability to feed well and not growing as expected. What actions should the nurse implement when caring for this infant with suspected heart failure? (Select all that apply.) Allow extra time to feed the infant. Hold the infant securely in a supine position during feeding. Allow 45 minutes for each feeding to provide the ordered amount of formula. Watch for diaphoresis or tachypnea while feeding the infant. Encourage the mother to breastfeed, but allow 30 minutes for the total feeding. Watch for signs of hunger and irritability soon after the feeding is finished.
Allow extra time to feed the infant. Watch for diaphoresis or tachypnea while feeding the infant. Encourage the mother to breastfeed, but allow 30 minutes for the total feeding. Watch for signs of hunger and irritability soon after the feeding is finished. A. Allowing extra time to feed the infant should help the nurse provide a relaxed environment which this infant needs. Knowing that 30 minutes should be allocated for each feeding helps the nurse with time management. B. The infant should be held securely in an upright position may provide less stomach compression and improve respiratory effort during the feeding. C. Allow 30 minutes for each feeding to provide the ordered amount of formula. D. If diaphoresis or tachypnea is seen while the infant is feeding, then the infant may need a feeding tube to conserve energy. E. Encourage the mother to breastfeed but allow 30 minutes for the total feeding. F. Signs of hunger and irritability soon after the feeding is finished may indicate that the feeding did not fill up the infant so that comfort and fullness would be felt.
160. Substance known to disrupt normal hormone-related growth and development of children include all the following except: A. Aloin B. Dioxins C. Oral contraceptives D. Coumestans derived from alfalfa
Aloin Aloin is the one of the active compounds found in aloe vera gel, and has not been found to affect childhood growth and development. Dioxins are toxic byproducts of industrial processes. Oral contraceptives contain female sex hormones that can alter normal sexual development in children based on their time of exposure. Coumestans, while natural compounds found in some plants, are considered phytoestrogens, which have been shown to affect endocrine function.
254. A child had an aortic stenosis defect surgically repaired 6 months ago. Which antibiotic prophylaxis is indicated for an upcoming tonsillectomy? a. No antibiotic prophylaxis is necessary. b. Amoxicillin is taken orally 1 hour before the procedure. c. Oral penicillin is given for 7 to 10 days before the procedure. d. Parenteral antibiotics are administered for 5 to 7 days after the procedure.
Amoxicillin is taken orally 1 hour before the procedure A Antibiotic prophylaxis is indicated for the first 5 months after surgical repair. B The standard prophylactic agent is amoxicillin given orally 1 hour before the procedure. C Antibiotic prophylaxis is not given for this period of time. D The treatment for infective endocarditis involves parenteral antibiotics for 2 to 8 weeks.
46. A diagnosis of rheumatic fever is being ruled out for a child. Which lab test(s) is/are the most reliable? (Select all that apply.) Throat culture C-reactive protein (CRP) Antistreptolysin-O titer (ASO) titer Elevated white blood cell count (WBC) Erythrocyte sedimentation rate (ESR)
Antistreptolysin-O titer (ASO) titer The most reliable and best standardized lab for antistreptococcal antibodies is an Antistreptolysin-O (ASO) titer. A throat culture indicates a current streptococcal infection. C-reactive protein (CRP) laboratory test indicates inflammation. An elevated white blood cell (WBC) may indicate a possible infection but does not indicate a causative agent. An erythrocyte sedimentation rate (ESR) indicates inflammation.
23. A diagnosis of rheumatic fever is being ruled out for a child. Which lab test(s) is/are the most reliable? (Select all that apply.) Throat culture C-reactive protein (CRP) Antistreptolysin-O titer (ASO) titer Elevated white blood count (WBC) Erythrocyte sedimentation rate (ESR)
Antistreptolysin-O titer (ASO) titer The most reliable and best standardized lab for antistreptococcal antibodies is an Antistreptolysin-O (ASO) titer. A throat culture indicates a current streptococcal infection. C-reactive protein (CRP) lab test indicates inflammation. An elevated white blood count (WBC) may indicate a possible infection but does not indicate a causative agent. An erythrocyte sedimentation rate (ESR) indicates inflammation.
236. The school nurse is caring for a child with a penetrating eye injury. Emergency treatment includes which of the following? a. Apply a regular eye patch. b. Apply a Fox shield to affected eye and any type of patch to the other eye. c. Apply ice until the physician is seen. d. Irrigate eye copiously with a sterile saline solution.
Apply a Fox shield to affected eye and any type of patch to the other eye Rationale: The nurse's role in a penetrating eye injury is to prevent further injury to the eye. A Fox shield (if available) should be applied to the injured eye, and a regular eye patch to the other eye to prevent bilateral movement.
44. What should the nurse recognize as an early clinical sign of compensated shock in a child? Confusion Sleepiness Hypotension Apprehension
Apprehension Confusion indicates uncompensated shock. Sleepiness is not an indication of shock. Hypotension is a symptom of irreversible shock. Apprehension indicates compensated shock.
16. What should the nurse recognize as an early clinical sign of compensated shock in a child? Confusion Sleepiness Hypotension Apprehensiveness
Apprehensiveness Apprehensiveness is indicative of compensated shock. Confusion is indicative of uncompensated shock. Sleepiness is not an indication of shock. Hypotension is a symptom of irreversible shock.
241. When should children with cognitive impairment be referred for stimulation and educational programs? a. As young as possible b. As soon as they have the ability to communicate in some way c. At age 3 years, when schools are required to provide services d. At age 5 or 6 years, when schools are required to provide services
As young as possible Rationale: The child's education should begin as soon as possible. Considerable evidence exists that early intervention programs for children with disabilities are valuable for cognitively impaired children.
17. A cardiac assessment is required to determine if a child's physical symptoms are related to possible heart disease. The nurse is proceeding to auscultation techniques. When observing the nursing student perform this assessment, which action would indicate that additional training was required? Documentation of heart sounds in reference to anatomical location. Determination that there is no evidence of carotid bruits. Calculation of heart rate. Ascertaining whether there is evidence of splenic enlargement.
Ascertaining whether there is evidence of splenic enlargement. Evidence of splenic enlargement requires palpation as an assessment technique. All of the other options are in-line with auscultation techniques.
5. Nursing interventions for the child after a cardiac catheterization would include which of the following? Allow ambulation as tolerated. Monitor vital signs every 2 hours. Assess the affected extremity for temperature and color. Check pulses above the catheterization site for equality and symmetry.
Assess the affected extremity for temperature and color is carefully assessed for signs of complications. Pulses below the catheterization site are monitored for equality and symmetry. Temperature and color are also monitored. 1. The child is maintained on bed rest or in parent's lap for 4 to 6 hours after the procedure. 2. Initially, vital signs are taken every 15 minutes. 4. Pulses are checked distal to the catheterization site.
101 What is most descriptive of atopic dermatitis (eczema) in the infant? Worse in summer Worse in humid climates Associated with upper respiratory infections Associated with hereditary allergies
Associated with hereditary allergies Atopic dermatitis worsens in fall and winter. It improves in humid climates. It is associated with allergies. Most children with atopic dermatitis have a family history of eczema, asthma, food allergies, or allergic rhinitis. This suggests a genetic predisposition.
67. What nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious child? Suctioning child frequently Providing environmental stimulation Turning head side to side every hour Avoiding activities that cause pain or crying
Avoiding activities that cause pain or crying Suctioning is a distressing procedure. In addition the resultant decrease in carbon dioxide can increase ICP. Environmental stimulation should be minimized. The child's head should not be turned side to side. If the jugular vein is compressed, ICP can rise. Nursing interventions should focus on assessment and interventions to minimize pain. These activities can cause the intracranial pressure to increase.
227. Prevention of hearing impairment in children is a major goal for the nurse. This can be achieved through which of the following? a. Being involved in immunization clinics for children b. Assessing a newborn for hearing loss c. Answering parents' questions about hearing aids d. Participating in hearing screening in the community
Being involved in immunization clinics for children Rationale: Childhood immunizations can eliminate the possibility of acquired sensorineural hearing loss from rubella, mumps, or measles encephalitis.
193. A preschool child presents with a history of vomiting and diarrhea for 2 days. Which assessment finding indicates that the child is in the late stages of shock? 1. Tachycardia 2. Bradycardia 3. Irritability 4. Urine output 1 to 2 ml/kg/hour
Bradycardia RATIONALE: Bradycardia is a sign of late shock in a child. Cardiovascular dysfunction and impairment of cellular function lead to lowered perfusion pressures, increased precapillary arteriolar resistance, and venous capacitance. Decreased cardiac output occurs in late shock if the circulating volume isn't replaced. Sympathetic nervous innervation has limited compensation mechanisms if the volume isn't replaced. Tachycardia and irritability occur during the early phase of shock as compensatory mechanisms are implemented to increase cardiac output. Normal pediatric urine output is 1 to 2 ml/kg/hour; volumes less than this would indicate a decrease in renal perfusion and activation of the renin-angiotensin-aldosterone system to decrease water and sodium excretion.
277. What should the nurse include in discharge teaching as the highest priority for the child with a cardiac dysrhythmia? a. CPR instructions b. Repeating digoxin if the child vomits c. Resting if dizziness occurs d. Checking the child's pulse after digoxin administration
CPR instructions A This could potentially be life-saving for the child. The parents and significant others in the child's life should have CPR training. B The digoxin dose is not repeated if the child vomits. C Dizziness is a symptom the child should be taught to report to adults so that the physician can be notified. It is not the priority intervention. D The child's pulse should be counted before the medication is given. The dose is withheld if the pulse is below the parameters set by the physician.
245. Which of the following terms refers to opacity of the crystalline lens that prevents light rays from entering the eye and refracting on the retina? a. Myopia b. Amblyopia c. Cataract d. Glaucoma
Cataract Rationale: This is the definition of a cataract.
239. When assessing the eyes of a neonate, the nurse observes opacity of the lens. This represents which of the following? a. Blindness b. Glaucoma c. Cataracts d. Retinoblastoma
Cataracts Rationale: A cataract is opacity of the lens of the eye.
130 Patient irritability is a hallmark of Kawasaki disease and the most challenging problem. A quiet environment is necessary to promote rest. The diagnosis is often difficult to make, and the course of the disease can be unpredictable. Intravenous gamma globulin and salicylates are the therapy of choice, not antibiotics. The child often is reluctant to eat. Soft foods and fluids should be offered to prevent dehydration. The nurse is caring for a child with Kawasaki disease in the acute phase. Which of the following clinical manifestations would the nurse expect to observe? a. Osler nodes b. Cervical lymphadenopathy c. Strawberry tongue d. Chorea e. Erythematous palms f. Polyarthritis
Cervical lymphadenopathy strawberry tongue erythematous palms
39. The nurse is preparing to administer digoxin (Lanoxin) orally to a 9-month-old infant. The nurse checks the dose and prepares to draw up 4 mL of the drug. What are the most appropriate nursing actions? Mix the dose with several milliliters of juice to disguise the drug's taste. Check the dosage with another nurse after checking the orders then hold the dose. Check the heart rate, then administer the dose by placing it at the back and side of the mouth. Check the heart rate, then administer the dose by letting the infant suck it through a nipple.
Check the dosage with another nurse after checking the orders then hold the dose. A. The dosage is too high and should not be given. The physician must be immediately notified about the dosage error and so the infant can receive the dose needed as close to the administration schedule. B. Digoxin is often prescribed in micrograms. Rarely is more than 1 mL administered to an infant. Because it is a potentially dangerous drug, administration guidelines are very precise. Pediatric medication dosages should be checked with another licensed professional before administration. C. Checking the heart rate and administering the dose by placing it at the back and side of the mouth are correct procedure, but the dosage is too high. D. Checking the heart rate and administering the dose by letting the infant suck it through a nipple are correct procedure, but the dosage is too high.
226. Mark, a 9 year old with Down syndrome, is mainstreamed into a regular third grade for part of the school day. His mother asks the school nurse about programs, such as Cub Scouts, that he might join. The nurse's recommendation should be based on which of the following? a. Programs like Cub Scouts are inappropriate for children who are mentally retarded. b. Children with Down syndrome have the same need for socialization as other children. c. Children with Down syndrome socialize better with children who have similar disabilities. d. Parents of children with Down syndrome encourage programs, such as scouting, because they deny that their children have disabilities.
Children with Down syndrome have the same need for socialization as other children. Rationale: Children of all ages need peer relationships. Children with Down syndrome should have peer experiences similar to those of other children, such as group outings, Cub Scouts, and Special Olympics.
230. The most common cause of hearing impairment in children is which of the following? a. Auditory nerve damage b. Congenital ear defects c. Congenital rubella d. Chronic otitis media
Chronic otitis media Rationale: Chronic otitis media is the most common cause of hearing impairment in children. It is essential that appropriate measures be instituted to treat existing infections and prevent recurrences.
88. When teaching the adolescent about the management of acne, what intervention should the nurse include? Clean the face with an antibacterial soap twice each day. Clean the face gently with a mild soap once or twice each day. Avoid foods with a high fat content such as French fries and chocolate. Express comedones by gentle squeezing and then cleanse with alcohol.
Clean the face gently with a mild soap once or twice each day. Antibacterial soaps may be too drying when used in combination with topical medications. Cleansing the face with mild soap and water will remove surface dirt and oil. No relationship has been established between food intake and acne. This can break down the ductal walls of the lesions and cause the acne to worsen.
56. The postoperative care of a preschool child who has had a brain tumor removed should include which information? Colorless drainage is to be expected. Close supervision is needed while the child is regaining consciousness. Positioning is on the side in the Trendelenburg position. Analgesics are contraindicated because of altered consciousness.
Close supervision is needed while the child is regaining consciousness. Colorless drainage may be leakage of cerebral spinal fluid from the incision site. This needs to be reported as soon as possible. The child needs to be observed closely. Vital signs must be assessed carefully, and signs of increasing ICP need to be monitored. The child should not be positioned in the Trendelenburg position after surgery. Analgesics can be used for postoperative pain.
243. Which of the following is an implanted ear prosthesis for children with sensorineural hearing loss? a. Hearing aid b. Cochlear implant c. Auditory implant d. Amplification device
Cochlear implant Rationale: Cochlear implants are surgically implanted, and they provide a sensation of hearing for individuals who have severe or profound hearing loss of sensorineural origin.
240. When caring for a newborn with Down syndrome, the nurse should be aware that the most common congenital anomaly associated with Down syndrome is which of the following? a. Hypospadias b. Pyloric stenosis c. Congenital heart disease d. Congenital hip dysplasia
Congenital heart disease Rationale: Congenital heart malformations, primarily septal defects, are the most common congenital anomaly in Down syndrome.
247. On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? 1. Cracked lips 2. Normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin
Conjunctival hyperemia Rationale: Kawasaki disease, also known as mucocutaneous lymph node syndrome, is an acute systemic inflammatory illness. In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.
292. The nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever (RF) who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid (aspirin) is prescribed for the child. Which nursing action is most appropriate?
Consult with the health care provider to verify the prescription. Anti-inflammatory agents, including aspirin, may be prescribed for the child with RF. Aspirin should not be given to a child who has chickenpox or other viral infections. Therefore, the nurse should consult with the health care provider to verify the prescription. The nurse would not administer acetaminophen (Tylenol) without specific health care provider's prescriptions.
3. Which of the following is an important nursing responsibility when a dysrhythmia is suspected? Order an immediate electrocardiogram. Count radial rate every 1 minute for 5 minutes. Count apical rate for 1 full minute and compare with radial rate. Have someone else take the radial rate simultaneously with the apical rate.
Count apical rate for 1 full minute and compare with radial rate is the nurse's first action. If a dysrhythmia is occurring, the radial pulse may be lower than the apical rate. 1. Ordering an immediate electrocardiogram may be indicated after conferring with the practitioner. 2. Radial pulse needs to be compared with the apical. 4. It is the nurse's responsibility to check both rates, radial and apical.
15. What is an important nursing responsibility when a dysrhythmia is suspected? Order an immediate electrocardiogram. Count the radial pulse every 1 minute for five times. Count the apical pulse for 1 full minute, and compare the rate with the radial pulse rate. Have someone else take the radial pulse simultaneously with the apical pulse.
Count the apical pulse for 1 full minute, and compare the rate with the radial pulse rate. This is the nurse's first action. If a dysrhythmia is occurring, the radial pulse rate may be lower than the apical pulse rate. This may be indicated after conferring with the practitioner. The radial pulse rate needs to be compared with the apical pulse rate. It does not need to be counted for 1 minute five times. Only one nurse is needed to carry out this action.
157. An adolescent with Addison's disease may need an increased dosage of glucocorticoids to which of the following situations? A. completing spring semester of school B. Gaining 7 pounds C. Death of a family member D. Undergoing a root canal
D. Undergoing a root canal Physical stress, such as infection, surgery, dental work and pregnancy, can lead to adrenal crisis in those with Addison's disease. Psychological stress has less effect than physical stress. Adrenal insufficiency leads to weight loss.
1. The nurse is assessing a child with a cardiac problem. Extremities are cool with thready pulses, and urinary output is diminished. This is most suggestive of which of the following? Increased afterload Decreased contractility Increased stroke volume Decreased cardiac output
Decreased contractility is suspected if the extremities are cool with thready pulses and urinary output is diminished. Certain states (e.g., hypoxia, acidosis) are known to depress contractility. 1. Increased blood pressure is indicative of higher afterload. 3. Increased stroke volume and decreased cardiac output will not produce the symptoms described. 4. Increased stroke volume and decreased cardiac output will not produce the symptoms described.
253. A beneficial effect of administering digoxin (Lanoxin) is that it a. Decreases edema b. Decreases cardiac output c. Increases heart size d. Increases venous pressure
Decreases edema Rationale: A. Digoxin has a rapid onset and is useful increasing cardiac output, decreasing venous pressure, and as a result, decreasing edema. B. Cardiac output is increased by digoxin. C. Heart size is decreased by digoxin. D. Digoxin decreases venous pressure.
167. A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? a. Immobilize the neck before the client is moved onto a stretcher. b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. c. Place a cap over the client's head. d. Administer a sedative as ordered.
Determine whether the client is allergic to iodine, contrast dyes, or shellfish Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can't be expected to remain still during the CT scan.
153. A mother brings her child in the office for a follow-up appointment and voices concern that her child has started urinating more than normal and is constantly thirsty & hungry. As the RN, you suspect?* A. Hypoglycemia B. Phenylkentonuria C. Diabetes Mellitus D. Tret's syndrome
Diabetes mellitus The symptoms the mother is reports are the classic 3 P's of diabetes: polyuria, polydipsia, polyphagia
294. A nurse is caring for an infant with congenital heart disease. Which, if noted in the infant, should alert the nurse to the early development of heart failure (HF)?
Diaphoresis during feeding The early symptoms of HF include tachypnea, poor feeding, and diaphoresis during feeding. Tachycardia would occur during feeding. Paleness of the skin, pallor, may be noted in the infant with HF, but it is not an early symptom. A strong sucking reflex is unrelated to the development of HF. Fatigue would prevent the infant from eating a full meal. Smaller, more frequent meals (every 3 hours) would be indicated for HF babies.
20. If a child is being treated with ACE inhibitors as part of the therapeutic regimen for heart failure, which observation if noted would alert the nurse to a potential interaction? Diuretic therapy with Aldactone Child complains of being slightly dizzy at times Maintaining normal urine output Blood pressure monitoring at lower end of normal range
Diuretic therapy with Aldactone The use of ACE inhibitors in combination with Aldactone, which is a potassium sparing inhibitor can lead to potential hyperkalemia. As such this type of diuretic therapy should not be used. ACE inhibitors typically are not associated with dizziness but continued monitoring for this presentation should be included. Normal urine output is a favorable sign. ACE inhibitors can cause hypotension so continued monitoring would be needed at this point.
77. The nurse is teaching an adolescent, newly diagnosed with type I diabetes, ways to minimize discomfort with insulin injections. Which interventions are helpful in minimizing injection discomfort? (Select all that apply.) Do not reuse needles Inject insulin when it is cold Flex or tense the muscle during injection Remove all bubbles from the syringe before injection Do not move the direction of the needle-syringe during insertion or withdrawal
Do not reuse needles Remove all bubbles from the syringe before injection Do not move the direction of the needle-syringe during insertion or withdrawal The reuse of needles leads to more discomfort on injection from decreased sharpness of the needle and being an infection control problem. Removing bubbles from the syringe will minimize discomfort. Keeping the direction of the syringe constant during the insertion and withdrawal minimizes discomfort. Insulin should be injected at room temperature to minimize discomfort. Flexing or tensing muscles during injections causes more discomfort.
217. A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed nasal bridge, protruding tongue, and transverse palmar creases. These findings are most suggestive of which of the following? a. Microcephaly b. Down syndrome c. Cerebral palsy d. Fragile X syndrome
Down syndrome Rationale: These are characteristics associated with Down syndrome.
18. A physician suspects that a child may have congenital cardiac disease. Which noninvasive diagnostic procedure would help to confirm the possibility of heart disease? EKG Echocardiogram Chest x-ray Pulse oximetry
Echocardiogram An echocardiogram is the most common test used to identify either a cardiac anomaly or evidence of heart disease. EKG provides evidence of electrical system conduction. Pulse oximetry provides information relative to perfusion. And a chest x-ray focuses on lungs and airway exchange, it may not be sensitive and specific to determine cardiac pathology.
30. Which procedure uses high-frequency sound waves created by a transducer to produce an image of cardiac structures? Echocardiography Electrocardiography Cardiac catheterization Electrophysiology (EPS)
Echocardiography A. Echocardiography uses high-frequency sound waves. The child must lie completely still. With the improvements in technology, diagnosis can sometimes be made without cardiac catheterization. B. Electrocardiography is a tracing of the electrical path of the depolarization action of myocardial cells. C. Cardiac catheterization is an invasive procedure in which a catheter is threaded into the heart. D. EPS is an invasive procedure in which catheters with electrodes are used to record the impulses of the heart directly from the conduction system.
12. What procedure uses high-frequency sound waves obtained by a transducer to produce an image of cardiac structures? Echocardiography Electrocardiography Cardiac catheterization Electrophysiology
Echocardiography Echocardiography uses high-frequency sound waves. The child must lie completely still. With the improvements in technology, a diagnosis can sometimes be made without cardiac catheterization. Electrocardiography is an electrical tracing of the depolarization of myocardial cells. Cardiac catheterization is an invasive procedure where a catheter is threaded into the heart, a contrast medium is injected, and the heart and its vessels are visualized. Electrophysiology is an invasive procedure where catheters with electrodes record the impulses of the heart directly from the conduction system.
40. The nurse should instruct a child to remain completely still during which procedure in which high frequency sound waves are translated into images by a transducer? Echocardiography Electrocardiography Cardiac catheterization Electrophysiology
Echocardiography Echocardiography uses high-frequency sound waves. The child must lie completely still. With the improvements in technology, diagnosis can sometimes be made without cardiac catheterization. Electrocardiography is a tracing of the electrical path of the depolarization action of myocardial cells. Cardiac catheterization is an invasive procedure in which a catheter is threaded into the heart. Electrophysiology is an invasive procedure in which catheters with electrodes are used to record the impulses of the heart directly from the conduction system.
4. Which of the following procedures uses high-frequency sound waves obtained by a transducer to produce an image of cardiac structures? Echocardiography Electrophysiology Electrocardiography Cardiac catheterization
Echocardiography uses high-frequency sound waves. The child must lie completely still. With the improvements in technology, diagnosis can sometimes be made without cardiac catheterization. 2. Electrophysiology is an invasive procedure in which catheters with electrodes are used to record the impulses of the heart directly from the conduction system. 3. Electrocardiography is a tracing of the electrical path of the depolarization action of myocardial cells. 4. Cardiac catheterization is an invasive procedure in which a catheter is threaded into the heart.
286. A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this diagnosis is consistent with which laboratory result obtained for this child?
Elevated antistreptolysin O (ASO) titer In the presence of rheumatic fever, the child will exhibit an elevated ASO titer, an elevated ESR, leukocytosis, and a positive result on CRP determination
218. A nurse would suspect possible visual impairment in a child who displays which of the following? a. Excessive rubbing of the eyes b. Rapid lateral movement of the eyes c. Delay in speech development d. Lack of interest in casual conversation with peers
Excessive rubbing of the eyes Rationale: Excessive rubbing of the eyes is a clinical manifestation of visual impairment.
250. The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances
Exercise intolerance Rationale: A child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods
205. How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding techniques to adapt for the child's weakness and fatigue? Select all that apply. a. Feeding more frequently with smaller feedings b. Using a soft nipple with enlarged holes c. Holding and cuddling the child during feeding d. Substituting glucose water for formula e. Offering high-caloric formula
Feeding more frequently with smaller feedings using a soft nipple with enlarged holes holding and cuddling the child during feeding offering high-caloric formula Rationale: Infants with CHF fatigue easily. Feeding can be given more frequently in smaller amounts through a soft large-holed nipple. Formulas with a denser caloric content can be offered. The child may be encouraged to nurse if he or she is held.
296. The nurse is collecting data on a child with a diagnosis of rheumatic fever (RF). Which question should the nurse initially ask the mother of the child?
Has the child complained of a sore throat within the past few months? RF characteristically presents 2 to 6 weeks following an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child or any family members have had a sore throat or unexplained fever within the past 2 months.
21. An adolescent is being treated for new-onset hypertension with medication. First line therapy previously tried was with dietary management but the decision has now been made to start oral medications. Which complaint if provided by the patient would indicate a potential concern? Patient states that he is no longer losing weight after being on the medication for one week's time. Patient states he is maintaining his oral intake of 8 glasses of water a day. He is taking the medication in the evening rather than taking the medication in the morning as prescribed as he thinks that he feels better and has less side effects. He reports that he occasionally feels "lightheaded" when getting out of a chair during the course of the school day in some of his classes.
He reports that he occasionally feels "lightheaded" when getting out of a chair during the course of the school day in some of his classes. Safety aspects should be considered with use of anti-hypertensives and the possibility of orthostatic hypotension. As such the patient should be assessed for this event and prospective safety management should be instituted. Anti-hypertensive therapy is typically not associated with weight loss. Maintaining fluid hydration and the fact that the medication dosing is taken in the evening rather than the daytime to minimize size effects is showing individualization to patient's needs.
291. The nurse is developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse should include to monitor the child for signs of which condition?
Heart failure (HF) Kawasaki disease is a cause of acquired heart disease in children.
107 What is frequently associated with infant botulism? Contaminated soil Honey and corn syrup Commercial infant cereals Improperly sterilized bottles
Honey and corn syrup These substances are not usually associated with infants who have become affected. Unlike adult botulism, infant botulism is caused by ingesting spores of C. botulinum and the resultant release of toxin. The bacterium has been found in honey and corn syrup that was fed to affected infants. These substances are not usually associated with infants who have become affected. These substances are not usually associated with infants who have become affected.
156. A two-year-old has been admitted with a diagnosis of Kawasaki disease. Which of the following would be a priority on the plan of care for this child? A. vital signs every 6 hours B. Hourly intake and output records C. Skin care D. Passive range-of-motion exercises
Hourly intake and output records Those with Kawasaki disease are at high-risk for CHF in the initial stages. Vital signs would need to be recorded more often than every 6 hours. Skin care and ROM exercises are important, but not the priority at this time.
228. Spastic cerebral palsy is characterized by which of the following? a. Hypertonicity and poor control of posture, balance, and coordinated motion b. Athetosis and dystonic movements c. Wide-based gait and poor performance of rapid, repetitive movements d. Tremors and lack of active movement
Hypertonicity and poor control of posture, balance, and coordinated motion Rationale: Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic cerebral palsy
237. What is one of the major physical characteristics of the child with Down syndrome? a. Excessive height b. Spots on the palms c. Inflexibility of the joints d. Hypotonic musculature
Hypotonic musculature Rationale: Hypotonic musculature is one of the major characteristics.
150 A 5 year old has a temperature of 103.6 F and is brought into the emergency room by his mother. Which statement by the mother causes concern? A. "I've tried to encourage fluid intake every hour." B. "I administered Aspirin to help with the fever a few hours ago." C. "I re-took his temperature 30 minutes after I gave the medication and it was still high." D. "I gave him a sponge bath to help with the fever."
I administered aspirin to help with the fever a few hours ago A child should never have aspirin, especially for a fever due to Reyes Syndrome.
282. Which statement made by a parent indicates understanding of restrictions for a child after cardiac surgery? a. "My child needs to get extra rest for a few weeks." b. "My son is really looking forward to riding his bike next week." c. "I'm so glad we can attend religious services as a family this coming Sunday." d. "I am going to keep my child out of daycare for 6 weeks."
I am going to keep my child out of daycare for 6 weeks A The child should resume his regular bedtime and sleep schedule after discharge. B Activities during which the child could fall, such as riding a bicycle, are avoided for 4 to 6 weeks after discharge. C Large crowds of people should be avoided for 4 to 6 weeks after discharge, including public worship. D Settings where large groups of people are present should be avoided for 4 to 6 weeks after discharge, including day care.
283. Which statement suggests that a parent understands how to safely administer digoxin? a. "I measure the amount I am supposed to give with a teaspoon." b. "I put the medicine in the baby's bottle." c. "When she spits up right after I give the medicine, I give her another dose." d. "I give the medicine at 8 in the morning and evening every day."
I give the medicine at 8 in the morning and evening every day. A To ensure the dosage, the medication should be measured with a syringe. B The medication should not be mixed with formula or food. It is difficult to judge whether the child received the proper dose if the medication is placed in food or formula. C To prevent toxicity, the parent should not repeat the dose without contacting the child's physician. D For maximum effectiveness, the medication should be given at the same time every day.
235. The parents of a child with cerebral palsy ask the nurse if any drugs can decrease their child's spasticity. The nurse's response should be based on which of the following? a. Anticonvulsant medications are sometimes useful for controlling spasticity. b. Medications that would be useful in reducing spasticity are too toxic for use with children. c. Many different medications can be highly effective in controlling spasticity. d. Implantation of a pump to deliver medication into the intrathecal space to decrease spasticity has recently become available.
Implantation of a pump to deliver medication into the intrathecal space to decrease spasticity has recently become available. Rationale: Baclofen, given intrathecally, is best suited for children with severe spasticity that interferes with activities of daily living and ambulation
75. During the summer many children are more physically active. What changes in the management of the child with diabetes should be expected as a result of more exercise? Increased food intake Decreased food intake Increased risk of hyperglycemia Decreased risk of insulin shock
Increased food intake Food intake should be increased in the summer when the child is more active. Races and other competitions may require more food than other practice times. The child will require increased food on days of increased activity. The increased activity lowers blood glucose levels. Blood sugars must be monitored closely to avoid the administration of too much insulin during a time of reduced need.
35. The beneficial effect of performing surgery for patent ductus arteriosus (PDA) is to prevent which complication? Pulmonary infection Right-to-left shunt of blood Decreased workload on left side of heart Increased pulmonary vascular congestion
Increased pulmonary vascular congestion A. The increased pulmonary vascular congestion is the primary complication. B. The blood is shunted left to right. C. The increased pulmonary vascular congestion is the primary complication. D. A patent ductus arteriosus (PDA) allows blood to flow from the aorta (high pressure) to the pulmonary artery (low pressure). If the PDA stays open, increased pulmonary congestion can occur.
232. The nurse is discussing sexuality with the parents of an adolescent girl with moderate cognitive impairment. Which of the following should the nurse consider when dealing with this issue? a. Sterilization is recommended for any adolescent with cognitive impairment. b. Sexual drive and interest are limited in individuals with cognitive impairment. c. Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct. d. Sexual intercourse rarely occurs unless the individual with cognitive impairment is sexually abused.
Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct. Rationale: Adolescents with moderate cognitive impairment may be easily persuaded and lack judgment. A well-defined, concrete code of conduct with specific instructions for handling certain situations should be laid out for the adolescent.
47. When assessing for hypertension in an infant, the nurse will expect the infant to exhibit which signs? (Select all that apply.) Dizziness Changes in vision Irritability Head rubbing Waking up screaming in the night
Irritability Head rubbing Waking up screaming in the night Clinical manifestations of hypertension are: For adolescents and older children: · Frequent headaches · Dizziness · Changes in vision For infants or young children: · Irritability · Head banging or head rubbing · Waking up screaming in the night
38. As part of the treatment for congestive heart failure, a child is taking the diuretic furosemide (Lasix). As part of the discharge teaching plan, what should the nurse explain as the function of furosemide (Lasix)? It is a diuretic, which means that it eliminates extra fluid from the body. It is a beta blocker, which decreases the child's blood pressure. It is a form of digitalis that regulates the heart rate and rhythm. It is an ACE inhibitor, which regulates the amount of fluid that goes through the kidney.
It is a diuretic, which means that it eliminates extra fluid from the body. A. Furosemide (Lasix) is a diuretic used to eliminate excess water and salt to prevent reaccumulation of the fluid. B. A beta blocker reduces the heart rate or force. It is used to prevent, manage or treat angina, hypertension, or arrythmias. C. An ACE (angiotensin converting enzyme) inhibitor treats high blood pressure. D. Digitalis is a medication that regulates the heart rate so that each heartbeat is effective.
84. The nurse should include which information when teaching a patient about Cushing's syndrome? It is caused by excessive production of cortisol. The major clinical features are exophthalmia and pigment changes. Treatment involves replacement of cortisol. Diagnosis is suspected with findings of hypotension, hyperkalemia, and polyuria.
It is caused by excessive production of cortisol. Cushing's syndrome is a description of the clinical manifestations caused by too much circulating cortisol. Exophthalmia is a manifestation of hyperthyroidism, not Cushing's syndrome. The treatment is the reduction of circulating cortisol. If the cause is a pituitary tumor, surgery is indicated. Hypertension and hypokalemia are expected findings.
104 Which statement BEST describes pseudohypertrophic (Duchenne) muscular dystrophy? It is inherited as an autosomal dominant disorder. It is characterized by weakness of proximal muscles of both pelvic and shoulder girdles. It is characterized by muscle weakness usually beginning about 3 years old. Onset occurs in later childhood and adolescence.
It is characterized by muscle weakness usually beginning about 3 years old. It is inherited as an X-linked recessive trait. The first weakness is usually noted in walking. Then a progressive involvement of other muscle groups occurs. Usually children with Duchenne muscular dystrophy reach the early developmental milestones; the muscular weakness is usually observed in the third year of life. Onset usually develops in the third year of life.
36. A young child with tetralogy of Fallot may assume a posturing position as a compensatory mechanism. What position is automatically assumed by the child? Low Fowler's Prone Supine Knee-chest
Knee-chest A. Low Fowler's position would assist with respiratory issues, but would not assist with the need for cardiac compensation. B. Prone does not offer any advantage to the child. C. Supine does not offer any advantage to the child. D. The squatting or knee-chest position decreases the amount of blood returning to the heart and allows the child time to compensate.
145 Which of the following should the nurse consider when preparing a school-age child and the family for heart surgery? a. Unfamiliar equipment should not be shown. b. Let child hear the sounds of a cardiac monitor, including alarms. c. Explain that an endotracheal tube will not be needed if the surgery goes well. d. Discussion of postoperative discomfort and interventions is not necessary before the procedure.
Let child hear the sounds of a cardiac monitor, including alarms The child and family should be exposed to the sights and sounds of the intensive care unit (ICU). All positive, nonfrightening aspects of the environment are emphasized. The family and child should make the decision about a tour of the unit if it is an option. The child should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous lines, incision, endotracheal tube, expected discomfort, and management strategies.
172. A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? a. Strict adherence to a bowel retraining program b. Keeping the linen wrinkle-free under the client c. Preventing unnecessary pressure on the lower limbs d. Limiting bladder catheterization to once every 12 hours
Limiting bladder catheterization to once every 12 hours. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.
299. Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication?
Maintains adequate cardiac output
220. A young child who has an intelligence quotient (IQ) of 45 would be described as which of the following? a. Within the lower limits of the range of normal intelligence b. Mildly retarded but educable c. Moderately retarded but trainable d. Severely retarded and completely dependent on others for care
Moderately retarded but trainable Rationale: Moderately retarded IQs range between 35 and 55.
69. Why are infants particularly vulnerable to acceleration-deceleration head injuries? The anterior fontanel is not yet closed. The nervous tissue is not well developed. The scalp of the head has extensive vascularity. Musculoskeletal support of head is insufficient.
Musculoskeletal support of head is insufficient. These do not have an effect on this type of injury. These do not have an effect on this type of injury. These do not have an effect on this type of injury. The relatively large head size coupled with insufficient musculoskeletal support increases the risk to the infant.
246. Which of the following terms refers to the ability to see objects clearly at close range but not at a distance? a. Myopia b. Amblyopia c. Cataract d. Glaucoma
Myopia Rationale: Myopia, or nearsightedness, refers to the ability to see objects clearly at close range but not a distance.
151 A 7 year old has been having vomiting with diarrhea for 3 days. How do you expect the child to present clinically? A. Sunken eyeballs and bradycardia B. None of the options are correct. C. Bradycardia, dry mucous membranes, absence of tears D. Tachycardia, dry mucous membranes, weight loss
None of the options are correct THINK ANSWER D?! The child should be experiencing dehydration and would present clinically with: Tachycardia, dry mucous membranes, weight loss, sunken eyes and/or fontanles, decreased urinary output
137 The nurse notices that a child is increasingly apprehensive and has tachycardia after heart surgery. The chest tube drainage is now 8 ml/kg/hr. Which of the following should be the nurse's initial intervention? a. Apply warming blankets. b. Notify the practitioner of these findings. c. Give additional pain medication per protocol. d. Encourage child to cough, turn, and deep breathe.
Notify the practitioner of these findings The practitioner is notified immediately. Increases of chest tube drainage to more than 3 ml/kg/hr for more than 3 consecutive hours or 5 to 10 ml/kg in any 1 hour may indicate postoperative hemorrhage. Increased chest tube drainage with apprehensiveness and tachycardia may indicate cardiac tamponade—blood or fluid in the pericardial space constricting the heart—which is a life-threatening complication. Warming blankets are not indicated at this time. Additional pain medication can be given before the practitioner drains the fluid, but the notification is the first action. Encouraging the child to cough, turn, and deep breathe should be deferred until after evaluation by the practitioner.
174. A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? a. Caucasian race b. Female sex c. Obesity d. Bronchial asthma
Obesity Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age. The client's race, sex, and bronchial asthma aren't risk factors for CVA.
125 An infant is receiving digoxin (Lanoxin) for congestive heart failure. The baby's apical heart rate is assessed at 80 beats/minute. What intervention should the nurse implement? A. Call for a portable chest radiograph. B. Obtain a therapeutic drug level. C. Reassess the heart rate in 30 minutes. D. Administer digoxin immune Fab (Digibind) stat.
Obtain a therapeutic drug level Rationale: Sinus bradycardia (rate of less than 90 to 110 in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level has the highest priority (B). (A) is not indicated at this time. (C) provides helpful assessment data but does not address the cause of the problem and delays needed intervention. (D) is indicated for serious life-threatening overdose with digoxin.
165. A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: a. Getting too little exercise b. Taking excess medication c. Omitting doses of medication d. Increasing intake of fatty foods
Omitting doses of medication Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and fatty food intake are in. Overexertion and overeating possibly could trigger myasthenic crisis.
97. What is the most important step in the management of cellulitis? Burow's solution compresses Oral or parenteral antibiotics Topical application of an antibiotic Incision and drainage of severe lesions
Oral or parenteral antibiotics Warm water compresses may be indicated for limited cellulitis. Oral or parenteral antibiotics are indicated, depending on the extent of the cellulites. The antibiotic needs to be administered systemically. If done, there is a risk of spreading infection or making the lesion worse.
7. Nursing care of the infant and child with heart failure would include which of the following? Force fluids appropriate to age. Monitor respirations during active periods. Organize activities to allow for uninterrupted sleep. Give larger feedings less often to conserve energy.
Organize activities to allow for uninterrupted sleep. 3. The child needs to be well rested before feeding. The child's needs should be met as quickly as possible to minimize crying. The nurse must organize care to minimize the child's energy expenditure. 1. The child who has heart failure has an excess of fluid. 2. Monitoring vital signs is appropriate, but minimizing energy expenditure is a priority. 4. The child often cannot tolerate larger feedings.
31. What is included in nursing care of the infant or child with congestive heart failure? Forcing fluids appropriate for the patient's age Monitoring respirations during active periods Giving larger feedings less often to conserve energy Organizing activities to allow for uninterrupted sleep
Organizing activities to allow for uninterrupted sleep A. The child who has congestive heart failure has an excess of fluid. B. Monitoring of vital signs is appropriate, but minimizing energy expenditure is a priority. C. The child often cannot tolerate larger feedings. D. The child needs to be well rested before feeding. The child's needs should be met as quickly as possible to minimize crying. The nurse must organize care to facilitate a decrease in the child's energy expenditure which is known as clustering care.
92. Based on the nurse's knowledge of wounds and wound healing, what are factors that can delay or cause dysfunctional wound healing? (Select all that apply.) Overweight Hypoxemia Hypervolemia Prolonged infection Corticosteroid therapy
Overweight Hypervolemia Corticosteroid therapy Poor nutrition without proper protein and calorie intake affects healing more than being overweight itself. Hypovolemia, not hypervolemia, inhibits wound healing due to low circulating blood volume and oxygenation of tissues. Corticosteroid therapy or other immunocompromising therapy prevents macrophages from migrating to the site of injury, thus suppressing epithelialization. Hypoxemia makes tissues more susceptible to infection due to insufficient oxygenation. Prolonged infection affects the healing process and causes increased scarring. Prolonged infection affects the healing process and causes increased scarring.
262. Before preparing a teaching plan for the parents of an infant with ductus arteriosus, it is important that the nurse understands this condition. Which statement best describes patent ductus arteriosus? a. Patent ductus arteriosus involves a defect that results in a right-to-left shunting of blood in the heart. b. Patent ductus arteriosus involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close. c. Patent ductus arteriosus is a stenotic lesion that must be surgically closed at birth. d. Patent ductus arteriosus causes an abnormal opening between the four chambers of the heart.
Patent ductus arteriosus involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close A Patent ductus arteriosus allows blood to flow from the high-pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt. B Patent ductus arteriosus is failure of the fetal shunt between the aorta and the pulmonary artery to close. C Patent ductus arteriosus is not a stenotic lesion. Patent ductus arteriosus can be closed both medically and surgically. D Atrioventricular defect occurs when fetal development of the endocardial cushions is disturbed, resulting in abnormalities in the atrial and ventricular septa and the atrioventricular valves.
61. A 3-year-old child is status postshunt revision for hydrocephaly. Part of the discharge teaching plan for the parents is signs of shunt malformation. Which signs are of shunt malformation? (Select all that apply.) Personality change Bulging anterior fontanel Vomiting Dizziness Fever
Personality change Vomiting Fever Personality change can be a sign of shunt malformation related to increased intracranial pressure. Vomiting can be a sign of shunt malformation related to increased intracranial pressure. Fever can be a sign of shunt malformation and is a very serious complication. The anterior fontanel closes between 12 and 18 months old. Dizziness is difficult to assess in a 3-year-old and is not necessarily a sign of shunt malformation.
118 A 3-month-old infant has a hypercyanotic spell. The nurse's first action should be which of the following? a. Assess for neurologic defects. b. Prepare family for imminent death. c. Begin cardiopulmonary resuscitation. d. Place child in the knee-chest position.
Place child in the knee-chest position The first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. Preparing the family for imminent death or beginning cardiopulmonary resuscitation should be unnecessary. The child is assessed for airway, breathing, and circulation. Often, calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell.
255. A child with pulmonary atresia exhibits cyanosis with feeding. On reviewing this child's laboratory values, the nurse is not surprised to notice which abnormality? a. Polycythemia b. Infection c. Dehydration d. Anemia
Polycythemia A Polycythemia is a compensatory response to chronic hypoxia. The body attempts to improve tissue oxygenation by producing additional red blood cells and thereby increases the oxygen-carrying capacity of the blood. B Infection is not a clinical consequence of cyanosis. C Although dehydration can occur in cyanotic heart disease, it is not a compensatory mechanism for chronic hypoxia. It is not a clinical consequence of cyanosis. D Anemia may develop as a result of increased blood viscosity. Anemia is not a clinical consequence of cyanosis.
109 The pediatric clinic nurse completes an assessment on a 4-month-old infant brought in because the parents are concerned that something is "just not right" with their baby. The nurse should alert the health care provider to which assessment findings? (Select all that apply.) Inability to sit up without support. Poor head control and clenched fists. Inability to crawl. Failure to smile. Extreme irritability.
Poor head control and clenched fists. Failure to smile. Extreme irritability. The infant would be expected to sit up without support until 6 or 7 months old. Crawling would not be an expected finding in a 4-month-old infant. Early signs of cerebral palsy include: • Failure to meet any developmental milestones such as rolling over, raising head, sitting up, crawling • Persistent primitive reflexes such as Moro, asymmetrical tonic neck reflex • Poor head control (head lag) and clenched fists after 3 months old • Stiff or rigid arms or legs; scissoring legs • Pushing away or arching back; stiff posture • Floppy or limp body posture, especially while sleeping • Inability to sit up without support by 8 months • Using only one side of the body or only the arms to crawl • Feeding difficulties • Persistent gagging or choking when fed • After 6 months old, tongue pushing soft food out of the mouth • Extreme irritability or crying • Failure to smile by 3 months old • Lack of interest in surroundings 110 The major goals of therapy for children with cerebral palsy include: reversing degenerative processes that have occurred. curing underlying defect causing the disorder. preventing spread to individuals in close contact with the child. recognizing the disorder early and promoting optimal development. * recognizing the disorder early and promoting optimal development. It is very difficult to reverse degenerative processes. The underlying defect cannot be cured. Cerebral palsy is not contagious. Since cerebral palsy is currently a permanent disorder, the goal of therapy is to promote optimal development. This is done through early recognition and beginning of therapy.
297. A nurse is reviewing the health record of an infant with a diagnosis of congenital heart disease. The nurse notes documentation in the record that the infant has clubbing of the fingers. The nurse understands that this finding is caused by which problem?
Poor oxygenation
194. Which finding in a 3-year-old child with acute renal failure requires immediate follow-up? 1. Potassium level of 6.5 mEq/L 2. Blood pressure in right leg of 90/50 mm Hg 3. Abdominal cramps 4. No albumin in the urine
Potassium level of 6.5 mEq/L RATIONALE: A potassium level of 6.5 mEq/L requires immediate follow-up because it's considered critically high, making the child prone to cardiac arrhythmias. Whereas a blood pressure of 90/50 mm Hg should be recorded and monitored, it doesn't require immediate follow-up. Abdominal cramping may be caused by several conditions and can be observed over time.
168. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis? a. Anxiety b. Powerlessness c. Ineffective denial d. Risk for disuse syndrome
Powerlessness This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome, characterized by an active and functioning mind locked in a body that can't perform even simple daily tasks. Although Anxiety and Risk for disuse syndrome may be diagnoses associated with ALS, the client's comment specifically refers to an inability to act autonomously. A diagnosis of Ineffective denial would be indicated if the client didn't seem to perceive the personal relevance of symptoms or danger.
159. During teaching, the nurse should advise the family of a child newly-diagnosed with Graves' disease to: A. Encourage outdoor activities B. Limit bathing to prevent skin irritation C. Promote interaction with one friend instead of a group D. Set the thermostat higher than normal for comfort
Promote interaction with one friend instead of a group Children with Graves' disease (an autoimmune conditions that causes hyperthyriodism) tend to be more emotionally labile, and may have difficulty managing group dynamics. Sweating and feeling too warm are common complaints; showering should be encouraged. Bright light, such as sunshine, may be irritating because of disease-related ophthalmopathy.
9. Nurses counseling parents regarding the home care of the child with a cardiac defect before corrective surgery should stress which of the following? Be extremely concerned about cyanotic spells. Relax discipline and limit setting to prevent crying. Reduce caloric intake to decrease cardiac demands. Promote normality within the limits of the child's condition.
Promote normality within the limits of the child's condition. The child needs to have social interactions, discipline, and appropriate limit setting. Parents need to be encouraged to promote as normal a life as possible for their child. 1. Because cyanotic spells occur in children with some defects, the parents need to be taught how to manage these. 2. The child needs discipline and appropriate limits. 3. The child needs increased caloric intake.
120 A chest x-ray examination is ordered for a child with suspected cardiac problems. The child's parent asks the nurse, "What will the x-ray show about the heart?" The nurse's response should be based on knowledge that the x-ray film will do which of the following? a. Show bones of chest but not the heart b. Evaluate the vascular anatomy outside of the heart c. Show a graphic measure of electrical activity of the heart d. Provide information on heart size and pulmonary blood flow patterns
Provide information on heart size and pulmonary blood flow patterns Chest x-ray films provide information on the size of the heart and pulmonary blood flow patterns. The bones of the chest are visible on the chest x-ray film, but the heart and blood vessels are also seen. Magnetic resonance imaging is a noninvasive technique that allows for evaluation of vascular anatomy outside of the heart. A graphic measure of electrical activity of the heart is provided by electrocardiography.
221. Appropriate interventions to facilitate socialization of the cognitively impaired child include which of the following? a. Provide age-appropriate toys and play activities. b. Provide peer experiences, such as scouting, when older. c. Avoid exposure to strangers who may not understand cognitive development. d. Emphasize mastery of physical skills because they are delayed more often than verbal skills.
Provide peer experiences, such as scouting, when older. Rationale: The acquisition of social skills is a complex task. Children of all ages need peer relationships. Parents should enroll the child in preschool. When older, they should have peer experiences similar to those of other children such as group outings, Boy and Girl Scouts, and Special Olympics.
258. A nurse is conducting a class for nursing students about fetal circulation. Which statement is accurate about fetal circulation and should be included in the teaching session? a. Oxygen is carried to the fetus by the umbilical arteries. b. Blood from the inferior vena cava is shunted directly to the right ventricle through the foramen ovale. c. Pulmonary vascular resistance is high because the lungs are filled with fluid. d. Blood flows from the ductus arteriosus to the pulmonary artery.
Pulmonary vascular resistance is high because the lungs are filled with fluid A Oxygen and nutrients are carried to the fetus by the umbilical vein. B The inferior vena cava empties blood into the right atrium. The direction of blood flow and the pressure in the right atrium propel most of this blood through the foramen ovale into the left atrium. C Resistance in the pulmonary circulation is very high because the lungs are collapsed and filled with fluid. D Most of the blood in the pulmonary artery flows though the ductus arteriosus into the descending aorta.
219. A young boy has just been diagnosed with pseudohypertrophic (Duchenne) muscular dystrophy. The management plan should include which of the following? a. Recommend genetic counseling. b. Explain that the disease is easily treated. c. Suggest ways to limit use of muscles. d. Assist family in finding a nursing facility to provide his care.
Recommend genetic counseling. Rationale: Pseudohypertrophic (Duchenne) muscular dystrophy is inherited as an X-linked recessive gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring
124 After returning from cardiac catheterization, the nurse determines that the pulse distal to the catheter insertion site is weaker. The nurse should do which of the following? a. Elevate affected extremity. b. Notify practitioner of the observation. c. Record data on assessment flow record. d. Apply warm compresses to insertion site.
Record data on assessment flow record The pulse distal to the catheterization site may be weaker for the first few hours after catheterization, but should gradually increase in strength. Documentation of the finding provides a baseline. The extremity is maintained straight for 4 to 6 hours. This is an expected change. The pulse is monitored. If there are neurovascular changes in the extremity, the practitioner is notified. The site is kept dry. Warm compresses are not indicated.
33. A nurse caring for a child post cardiac catheterization assesses that the distal pulse of the catheter site is weaker and capillary refill less than three seconds. What is the most appropriate nursing action? Elevate the affected extremity. Notify the physician of the observation. Apply warm compresses to insertion site. Record the assessment finding.
Record the assessment finding. A. Elevation is not necessary; the extremity is kept straight. B. Because a weaker pulse is an expected finding and the capillary refill is within normal range, the nurse should document this and continue to monitor. C. The insertion site is kept dry. D. The pulse distal to the catheter insertion site may be weaker for the first few hours after catheterization and should gradually increase in strength. The capillary refill is normal.
166. A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client's plan of care? a. Disturbed sensory perception (visual) b. Self-care deficient: Dressing/grooming c. Impaired verbal communication d. Risk for injury
Risk for injury Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. Although the other options may be appropriate, they're secondary because they don't immediately affect the client's health or safety.
244. Which of the following should be the major consideration when selecting toys for a child who is mentally retarded? a. Safety b. Age appropriateness c. Ability to provide exercise d. Ability to teach useful skills
Safety Rationale: Safety is the primary concern in selecting recreational and exercise activities for all children. This is especially true for children who are mentally retarded.
223. Fragile X syndrome is which of the following? a. Chromosomal defect affecting only females b. Chromosomal defect that follows the pattern of X-linked recessive disorders c. Second most common genetic cause of mental retardation d. Most common cause of noninherited mental retardation
Second most common genetic cause of mental retardation Rationale: Fragile X syndrome is the second most common cause of mental retardation after Down syndrome.
222. Distortion of sound and problems in discrimination are characteristic of what type of hearing loss? a. Conductive b. Sensorineural c. Mixed conductive-sensorineural d. Central auditory imperceptive
Sensorineural Rationale: Sensorineural hearing loss, also known as perceptive or nerve deafness, involves damage to the inner ear structures or the auditory nerve. It results in distortion of sounds and problems in discrimination.
164. A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: a. Is clear and tests negative for glucose b. Is grossly bloody in appearance and has a pH of 6 c. Clumps together on the dressing and has a pH of 7 d. Separates into concentric rings and tests positive of glucose
Separates into concentric rings and tests positive of glucose Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.
170. A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position? a. Side-lying, with a pillow under the hip b. Prone, with a pillow under the abdomen c. Prone, in slight-Trendelenburg's position d. Side-lying, with the legs pulled up and head bent down onto chest.
Side-lying, with the legs pulled up and head bent down onto chest The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae.
190. A child is diagnosed with pituitary dwarfism. Which pituitary agent will the physician most likely order to treat this condition? 1. Corticotropin zinc hydroxide (Cortrophin-Zinc) 2. Somatrem (Protropin) 3. Desmopressin acetate (DDAVP) 4. Vasopressin (Pitressin)
Somatrem (Protropin) RATIONALE: Somatrem is used to treat linear growth failure stemming from hormonal deficiency. Corticotropin zinc hydroxide is used to treat adrenal insufficiency and a variety of other conditions; desmopressin acetate and vasopressin are used to treat diabetes insipidus.
116 What most accurately describes bowel function in children born with a myelomeningocele? Incontinence cannot be prevented. Enemas and laxatives are contraindicated. Some degree of fecal continence can usually be achieved. Colostomy is usually required by the time the child reaches adolescence.
Some degree of fecal continence can usually be achieved. Although a lengthy process, continence can be achieved with modification of diet, use of laxatives, and/or enemas. These are part of the strategy to achieve continence. There is no general contraindication. With diet modification and regular toilet habits to prevent constipation and impaction, some degree of fecal continence can be achieved. Colostomy usually is not required.
242. Which of the following facilitates lip reading by the hearing-impaired child? a. Speak at an even rate. b. Exaggerate pronunciation of words. c. Avoid using facial expressions. d. Repeat in exactly the same way if child does not understand.
Speak at an even rate. Rationale: The child should be helped to learn and understand how to read lips by speaking at an even rate.
51. A young child with tetralogy of Fallot may assume a posturing position as a compensatory mechanism. The position automatically assumed by the child is: low Fowler's. prone. supine. squatting.
Squatting. Low Fowler's would assist with respiratory issues but would not assist with the need for cardiac compensation. Prone does not offer any advantage to the child. Supine does not offer any advantage to the child. The squatting or knee-chest position decreases the amount of blood returning to the heart and allows the child time to compensate.
233. The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing aid is making an annoying whistling sound that the child cannot hear. Which of the following is the most appropriate nursing action? a. Ignore the sound. b. Ask him to reverse the hearing aids in his ears. c. Suggest he reinsert the hearing aid. d. Suggest he raise the volume of the hearing aid.
Suggest he reinsert the hearing aid. Rationale: The whistling sound is acoustic feedback. The nurse should have the child remove the hearing aid and reinsert it, making certain no hair is caught between the ear mold and the ear canal.
201. When the child with rheumatic fever begins involuntary, purposeless movements of her limbs, the nurse recognizes that this is an indication of: a. seizure activity. b. hypoxia. c. Sydenham's chorea. d. decreasing level of consciousness.
Sydenham's chorea As the effects of rheumatic fever affect the central nervous system, the child may develop Sydenham's chorea manifested by involuntary, purposeless movements of the limbs.
6. Which of the following is an early sign of heart failure that the nurse should recognize? Tachypnea Bradycardia Inability to sweat Increased urinary output
Tachypnea is one of the early signs that should be identified. Tachycardia at rest, dyspnea, retractions, and activity intolerance are other physical signs and symptoms. 2. Tachycardia, not bradycardia, is one of the symptoms suggestive of congestive heart failure. 3. The child may be diaphoretic. 4. Urinary output usually will be decreased.
171. A male client is having a tonic-clonic seizure. What should the nurse do first? a. Elevate the head of the bed. b. Restrain the client's arms and legs. c. Place a tongue blade in the client's mouth. d. Take measures to prevent injury.
Take measures to prevent injury Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth.
76. A 17-year-old boy with diabetes mellitus tells the school nurse that he has recently started drinking alcohol with his friends on weekends. The nurse should: Tell him not to do this. Ask him why he is drinking alcohol. Teach him about the effects of alcohol on diabetes and how to prevent problems associated with alcohol intake. Recommend counseling so he understands the serious consequences of alcohol consumption.
Teach him about the effects of alcohol on diabetes and how to prevent problems associated with alcohol intake. Recommend counseling so he understands the serious consequences of alcohol consumption. Admonishing him will not help the adolescent if he chooses to continue drinking. Asking him why will provide information to the nurse but will not address the information that the adolescent needs to have about managing his disease. The nurse is taking a proactive approach. The adolescent is provided with information to facilitate the management of his illness. A recommendation for counseling can be included in the teaching plan.
192. A physician orders an antibiotic for a child, age 6, who has an upper respiratory tract infection. To avoid tooth discoloration, the nurse expects the physician to avoid prescribing which drug? 1. Penicillin 2. Erythromycin 3. Tetracycline 4. Amoxicillin
Tetracycline RATIONALE: Tetracycline should be avoided in children younger than age 8 because it may cause enamel hypoplasia and permanent yellowish gray to brownish tooth discoloration. Penicillin, erythromycin, and amoxicillin don't discolor the teeth.
8. Which of the following heart defects causes hypoxemia and cyanosis because desaturated venous blood is entering the systemic circulation? Coarctation of the aorta Atrial septal defect Patent ductus arteriosus Tetralogy of Fallot
Tetralogy of Fallot is a cardiac defect that has a mixed blood circulation. 1. Coarctation of the aorta is an obstructive defect. There is no mixing of oxygenated and unoxygenated blood. 2. Atrial septal defect and patent ductus arteriosus have increased flow of blood to the pulmonary system. The pressure gradient allows for oxygenated blood to return to the lungs. 3. Atrial septal defect and patent ductus arteriosus have increased flow of blood to the pulmonary system. The pressure gradient allows for oxygenated blood to return to the lungs.
14. What should nurses stress when counseling parents regarding the home care of the child with a cardiac defect before corrective surgery? The importance of reducing caloric intake to decrease cardiac demands The importance of relaxing discipline and limit setting to prevent crying The need to be extremely concerned about cyanotic spells The desirability of promoting normalcy within the limits of the child's condition
The desirability of promoting normalcy within the limits of the child's condition The child needs to have social interactions, discipline, and appropriate limit setting. Parents need to be encouraged to promote as normal a life as possible for their child. The child needs increased caloric intake after cardiac surgery. The child needs discipline and appropriate limit setting, as would be done with any other child his or her age. Because cyanotic spells will occur in children with some defects, the parents need to be taught how to assess for and manage them appropriately, thereby decreasing their anxiety and concern.
188. A 5-year-old child returns to the pediatric unit following a cardiac catheterization using the right femoral vein. The child has a thick elastoplast dressing. Which assessment finding requires immediate intervention? 1. One leg is slightly cooler than the other leg. 2. The leg used for the catheter insertion is slightly paler than the other leg. 3. A small amount of bright red blood is seen on the dressing. 4. The pedal pulse of the right leg isn't detectable.
The pedal pulse of the right leg isn't detectable. RATIONALE: Using the femoral vein during catheterization can cause the affected blood vessels to spasm or cause a blood clot to develop, altering circulation in the leg. The inability to detect the pedal pulse in the affected leg is an ominous sign and requires immediate intervention. Small amounts of coolness or pallor are normal. These findings should improve. Although the nurse should continue to monitor a dressing with a small amount of blood on it, this finding isn't the priority in this situation.
143 When caring for the child with Kawasaki disease, the nurse should know which of the following? a. Aspirin is contraindicated. b. Principal area of involvement is the joints. c. Child's fever is usually responsive to antibiotics within 48 hours. d. Therapeutic management includes administration of gamma globulin and salicylates.
Therapeutic management includes administration of gamma globulin and salicylates High-dose intravenous gamma globulin and salicylate therapy is indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. Aspirin is part of the therapy. Mucous membranes, conjunctiva, changes in the extremities, and cardiac involvement are seen. The fever of Kawasaki disease is unresponsive to antibiotics. It is responsive to antiinflammatory doses of aspirin and antipyretics.
37. Which condition is classified as a mixed-blood cardiac defect? Pulmonic stenosis Atrial septal defect Patent ductus arteriosus Transposition of the great arteries
Transposition of the great arteries A. Pulmonic stenosis is classified as an obstructive defect. B. Atrial septal defect is classified as a defect with increased pulmonary blood flow. C. Patent ductus arteriosus is classified as a defect with increased pulmonary blood flow. D. Transposition of the great arteries allows the mixing of blood in the heart.
27. What is considered a mixed cardiac defect? Pulmonic stenosis Atrial septal defect Patent ductus arteriosus Transposition of the great arteries
Transposition of the great arteries Transposition of the great arteries allows the mixing of both oxygenated and unoxygenated blood in the heart. Pulmonic stenosis is classified as an obstructive defect. Atrial septal defect and patent ductus arteriosus are classified as defects with increased pulmonary blood flow.
52. Which is considered a mixed cardiac defect? Pulmonic stenosis Atrial septal defect Patent ductus arteriosus Transposition of the great arteries
Transposition of the great arteries. Pulmonic stenosis is classified as an obstructive defect. Atrial septal defect is classified as a defect with increased pulmonary blood flow. Patent ductus arteriosus is classified as a defect with increased pulmonary blood flow. Transposition of the great arteries allows the mixing of blood in the heart.
2. The primary therapy for secondary hypertension in children is: low-salt diet. weight reduction. increased exercise and fitness. treatment of underlying cause.
Treatment of underlying cause. 4. Secondary hypertension is a result of an underlying disease process or structural abnormality. It is usually necessary to treat the problem before the hypertension will be resolved.
86. The nurse is explaining that the destruction of pancreatic â-cells is the cause of which disorder? Type 1 diabetes Type 2 diabetes Impaired glucose tolerance Gestational diabetes
Type 1 diabetes Type 1 diabetes is characterized by destruction of the insulin-producing pancreatic â-cells. Type 2 diabetes is a result of insulin resistance. The insulin-producing pancreatic b-cells are destroyed in type 1 diabetes. The insulin-producing pancreatic b-cells are destroyed in type 1 diabetes.
173. A male client with Bell's palsy asks the nurse what has caused this problem. The nurse's response is based on an understanding that the cause is: a. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem b. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia c. Primarily genetic in origin, triggered by exposure to meningitis d. Primarily genetic in origin, triggered by exposure to neurotoxins
Unknown, but possibly includes ischemia, viral infection or an autoimmune problem Bell's palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown, but may include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these factors.
225. Many of the physical characteristics of Down syndrome present nursing problems. Care of the child should include which of the following? a. Delay feeding solid foods until the tongue thrust has stopped. b. Modify diet as necessary to minimize the diarrhea that often occurs. c. Provide calories appropriate to child's age. d. Use a cool-mist vaporizer to keep mucous membranes moist.
Use a cool-mist vaporizer to keep mucous membranes moist. Rationale: The constant stuffy nose forces the child to breathe by mouth, drying the mucous membranes and increasing the susceptibility to upper respiratory tract infections. A cool-mist vaporizer will keep the mucous membranes moist and liquefy secretions.
152 A child is ordered by the doctor for ketone and glucose urine testing. The patient is to collect it at home. How would you instruct the patient to collect the specimen? A. Cleanse the area with betadine. B. Encourage the patient to consume at least 24 oz of water prior to the specimen collection. C. Demonstrate a clean catch techinque. D. Use the second voided urine for most accurate results.
Use the second voided urine for most accurate results The patient should use the second voided urine to ensure that the results are accurate. First voided urines tend to be concentrated and could effect results.
298. A child is being discharged from the hospital following heart surgery. Prior to discharge, the nurse reviews the discharge instructions with the mother. Which statement by the mother indicates a need for further teaching?
Visitors are not allowed for 1 month. Visitors without signs of any infection are allowed to visit the child. The mother should be instructed, however, that the child needs to avoid large crowds of people for 1 week following discharge.
249. The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which MOST APPROPRIATE method to assess the urine output? 1. Weighing the diapers 2. Inserting a Foley catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula
Weighing the diapers Rationale: Although Foley catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant and places the infant at risk for infection.
158. As the nurse, taking care of the patient who has been hospitalized for 3 days with dehydration, what abnormal finding would you report to the MD? A. Weight change of 100 lbs to 92 lbs and urinary output of less than 1 ml/kg/hr B. 1-3 second skin turgor C. Weight change of 90 lbs to 93 lbs and dry mucous membranes D. Options A & C
Weight change of 100 lbs to 92 lbs and urinary output of less than 1 ml/kg/hr The only option is: Weight change of 100 lbs to 92 lbs and urinary output of less than 1 ml/kg/hr. All the other answers are normal findings that do not cause concern.
162. You are going over insulin administration education with a patient's mother. Which statement by her raises concern? A. "When she is sick I will hold her insulin." B."I always carry sugary items in case she has a hypoglycemic attack." C. "I will bring her in every 3 months for a glycosylate hemoglobin blood draw." D. "I ordered her a Medic-Alert bracelet yesterday."
When she is sick, I will hold her insulin. When a diabetic is sick, they should never hold their insulin. This is because when the body is stressed or has an infection they are at a very high risk for hyperglycemia so it is essential they monitor their blood glucose closely and administered insulin as needed. All the other options are .
289. The nurse is assessing a newborn with heart failure before administering the prescribed digoxin (Lanoxin). In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 2.4 ng/mL and an apical heart rate of 98 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take?
Withhold the medication and notify the health care provider. The apical pulse rate for a newborn is 120 to 140 beats/min. The therapeutic digoxin level ranges from 0.5 to 2.0 ng/dL. Because the apical rate is low and the digoxin blood level is elevated, indicating toxicity, the nurse would withhold the medication and notify the health care provider.
290. A nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats/minute. Based on this finding, which is the appropriate nursing action?
Withhold the medication. If the heart rate is less than 100 beats/minute in an infant, the nurse would withhold the dose and contact the health care provider.
169. A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? a. "You may have difficulty believing this, but the paralysis caused by this disease is temporary." b. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss." c. "It must be hard to accept the permanency of your paralysis." d. "You'll first regain use of your legs and then your arms."
You may have difficulty believing this, but the paralysis caused by this disease is temporary. The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.
28. The nurse should explain to the parents that their child is receiving furosemide (Lasix) for severe congestive heart failure because of its effects as a diuretic. a beta-blocker. a form of digitalis. an ACE inhibitor.
a diuretic. Furosemide is a loop diuretic used to eliminate excess water and salt to prevent the accumulation of fluid associated with congestive heart failure.
74. The nurse should recognize that, when a child develops diabetic ketoacidosis, it is: an expected outcome. a life-threatening situation. best treated at home. best treated at the practitioner's office/clinic.
a life-threatening situation. This is a medical emergency needing prompt assessment and intervention, usually in an intensive care environment. Diabetic ketoacidosis is the state of complete insulin deficiency. It is a medical emergency that must be diagnosed and treated. The child is usually admitted to an intensive care unit for assessment, insulin administration, and fluid and electrolyte replacement. This is a medical emergency needing prompt assessment and intervention, usually in an intensive care environment.
206. The assessment that would lead the nurse to suspect that a newborn infant has a ventricular septal defect is: a. a loud, harsh murmur with a systolic tremor. b. cyanosis when crying. c. blood pressure higher in the arms than in the legs. d. a machinery-like murmur.
a loud, harsh murmur with a systolic tremor. Rationale: A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal defect.
57. The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. The PRIORITY of nursing care is to: initiate isolation precautions as soon as the diagnosis is confirmed. initiate isolation precautions as soon as the causative agent is identified. administer antibiotic therapy as soon as it is ordered.
administer antibiotic therapy as soon as it is ordered. administer sedatives/analgesics on a preventive schedule to manage pain. Isolation should be instituted as soon as diagnosis is anticipated. Isolation should be instituted as soon as diagnosis is anticipated. This is the priority action. Antibiotics are begun as soon as possible to prevent death and avoid resultant disabilities. Antibiotics are the priority function; pain should be managed if it occurs.
112 An 8-year-old female child is diagnosed with moderate cerebral palsy (CP). She recently began participation in a regular classroom for part of the day. Her mother asks the school nurse about having her daughter join the after-school Girl Scout troop. The nurse's response should be based on knowledge that: most activities such as Girl Scouts cannot be adapted for children with CP. after-school activities usually result in extreme fatigue for children with CP. trying to participate in activities such as Girl Scouts leads to lowered self-esteem in children with CP. after-school activities often provide children with CP opportunities for socialization and recreation.
after-school activities often provide children with CP opportunities for socialization and recreation. Most activities can be adapted for children. The child, family, and activity director should assess the degree of activity to ensure that it meets with the child's capabilities. A supportive environment will add to the child's self-esteem. Recreational outlets and after-school activities should be considered for the child who is unable to participate in athletic programs.
275. What is the appropriate priority nursing action for the infant with a CHD who has an increased respiratory rate, is sweating, and is not feeding well? a. Recheck the infant's blood pressure. b. Alert the physician. c. Withhold oral feeding. d. Increase the oxygen rate.
alert the physician A Although this may be indicated, it is not the priority action. B These are signs of early congestive heart failure, and the physician should be notified. C Withholding the infant's feeding is an incomplete response to the problem. D Increasing oxygen may alleviate symptoms, but medications such as digoxin and furosemide are necessary to improve heart function and fluid retention. Notifying the physician is the priority nursing action.
269. When assessing a child for possible congenital heart defects (CHDs), where should the nurse measure blood pressure? a. The right arm b. The left arm c. All four extremities d. Both arms while the child is crying
all four extremities A Blood pressure measurements for upper and lower extremities are compared during an assessment for CHDs. B Discrepancies in blood pressure between the upper and lower extremities cannot be determined if blood pressure is not measured in all four extremities. C When a CHD is suspected, the blood pressure should be measured in all four extremities while the child is quiet. Discrepancies between upper and lower extremities may indicate cardiac disease. D Blood pressure measurements when the child is crying are likely to be elevated; thus the readings will be inaccurate. Also, all four extremities need to be measured.
200. The nurse is aware that the infant born with hypoplastic left heart syndrome must acquire his or her oxygenated blood through: a. the patent ductus arteriosus. b. a ventricular septal defect. c. the closure of the foramen ovale. d. an atrial septal defect.
an atrial septal defect Because the right side of the heart must take over pumping blood to both the lungs and systemic circulation, the ductus arteriosus must remain open to shunt the oxygenated blood from the lungs.
144 Which of the following defects results in obstruction to blood flow? a. Aortic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries
aortic stenosis Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. Tricuspid atresia results in decreased pulmonary blood flow. The atrial septal defect results in increased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow.
65. The temperature of an adolescent who is unconscious is 105° F. The PRIORITY nursing action is to: continue to monitor temperature. initiate a pain assessment. apply a hypothermia blanket. administer acetaminophen or ibuprofen.
apply a hypothermia blanket. The temperature needs to be monitored, but it also needs to be lowered. This should be ongoing; lowering the body temperature is the priority action. Brain damage can occur at temperatures this high. It is extremely important to institute temperature-lowering interventions, such as hypothermia blankets and tepid water baths. Antipyretics are not useful in cases of hyperthermia.
136 The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is which of the following? a. Notify the physician. b. Place child in Trendelenburg position. c. Apply a new bandage with more pressure. d. Apply direct pressure above catheterization site.
apply direct pressure above catheterization site When bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure on the vessel puncture. The physician can be notified and a new bandage with more pressure can be applied after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. Trendelenburg position would not be a helpful intervention. It would increase the drainage from the lower extremities.
96. When applying wet compresses or dressings to the skin, the nurse should: apply the dressing so the area is totally immobilized. apply the dressing when it is saturated and dripping. pour or syringe new solution over a dressing that has become dry. apply the desired solution on cotton gauze or soft cotton cloths such as clean handkerchiefs.
apply the desired solution on cotton gauze or soft cotton cloths such as clean handkerchiefs. The moist dressing should be laid flat on the area with an attempt to avoid restriction of movement. After immersion in the solution, the dressings are wrung out to avoid dripping. As the evaporation begins to dry them, the dressings are removed, rewet in the solution, and reapplied using aseptic technique. When the solution dries, concentrated residue is left in the dressing. The addition of fluid may result in a more concentrated soak being placed on the sensitive tissue. The desired solution should be applied to Kerlix gauze; soft cotton cloths; or strips from cloth diapers, sheets, handkerchiefs, or pillowcase material.
127 Decreasing the demands on the heart is a priority in care for the infant with congestive heart failure (CHF). In evaluating the infant's status, which of the following is indicative of achieving this goal? a. Irritability when awake b. Capillary refill of more than 5 seconds c. Appropriate weight gain for age d. Positioned in high Fowler position to maintain oxygen saturation at 90%
appropriate weight gain for age Appropriate weight gain for an infant is indicative of successful feeding and a reduction in caloric loss secondary to the CHF. Irritability is a symptom of CHF. The child also uses additional energy when irritable. Capillary refill should be brisk and within 2 to 3 seconds. The child needs to be positioned upright to maintain oxygen saturation at 90%. Positioning is helping to decrease respiratory effort, but the infant is still having difficulty with oxygenation.
276. What is the nurse's first action when planning to teach the parents of an infant with a CHD? a. Assess the parents' anxiety level and readiness to learn. b. Gather literature for the parents. c. Secure a quiet place for teaching. d. Discuss the plan with the nursing team.
assess the parents' anxiety level and readiness to learn A Any effort to organize the right environment, plan, or literature is of no use if the parents are not ready to learn or have high anxiety. Decreasing level of anxiety is often needed before new information can be processed. B A baseline assessment of prior knowledge should be taken into consideration before developing any teaching plan. C Locating a quiet place for meeting with parents is appropriate; however, an assessment should be done before any teaching is done. D Discussing a teaching plan with the nursing team is appropriate after an assessment of the parents' knowledge and readiness.
279.Which defect results in increased pulmonary blood flow? a. Pulmonic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries
atrial septal defect A Pulmonic stenosis is an obstruction to blood flowing from the ventricles. B Tricuspid atresia results in decreased pulmonary blood flow. C The atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. D Transposition of the great arteries results in mixed blood flow.
209. The nurse explains that which congenital cardiac defect(s) cause(s) increased pulmonary blood flow? Select all that apply. a. Atrial septal defects (ASDs) b. Tetralogy of Fallot c. Dextroposition of aorta d. Patent ductus arteriosus e. Ventricular septal defects (VSDs)
atrial septal defects (ASDs) patent ductus arteriosus ventricular septal defects (VSDs) Rationale: The congenital heart defects that cause increased pulmonary blood flow are ASDs, VSDs, and patent ductus arteriosus.
62. The MOST appropriate nursing interventions when caring for a child experiencing a seizure include: (Select all that apply.) restraining the child when a seizure occurs to prevent bodily harm. placing a padded tongue between the teeth if they become clenched. avoid suctioning the child during the seizure. describing and documenting the seizure activity observed. applying supplemental oxygen after inserting an artificial oral airway.
avoid suctioning the child during the seizure. describing and documenting the seizure activity observed. The priority nursing intervention is to observe the child and seizure, and document the activity observed. The child should not be restrained, because this may cause an injury. Nothing should be placed in the child's mouth, because this may cause an injury not only to the child but also to the nurse. To prevent aspiration, the child should be placed on the side if possible to facilitate drainage.
100. When giving instructions to a parent whose child has scabies, the school nurse should tell him or her to: treat all family members if symptoms develop. be prepared for symptoms to last 2 to 3 weeks. notify the practitioner so an antibiotic can be prescribed. carefully treat only those areas where there is a rash.
be prepared for symptoms to last 2 to 3 weeks. Only the affected child needs to be treated. The mite responsible for the scabies will most likely be killed with the administration of medications. It will take 2 to 3 weeks for the stratum corneum to heal. That is when the symptoms will abate. A scabicide is used. Permethrin and lindane are currently used for topical administration. Permethrin is applied to all skin surfaces.
195. The nurse explains that a ventricular septal defect will allow: a. blood to shunt left to right, causing increased pulmonary flow and no cyanosis. b. blood to shunt right to left, causing decreased pulmonary flow and cyanosis. c. no shunting because of high pressure in the left ventricle. d. increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume.
blood to shunt left to right, causing increased pulmonary flow and no cyanosis Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis.
229. The child with Down syndrome should be evaluated for which of the following before participating in some sports? a. Hyperflexibility b. Cutis marmorata c. Atlantoaxial instability d. Speckling of iris (Brushfield spots)
c. Atlantoaxial instability Rationale: Children with Down syndrome are at risk for atlantoaxial instability. Before participating in sports that put stress on the head and neck, a radiologic examination should be done.
257.A nurse is assigned to care for an infant with an unrepaired tetralogy of Fallot. What should the nurse do first when the baby is crying and becomes severely cyanotic? a. Place the infant in a knee-chest position. b. Administer oxygen. c. Administer morphine sulfate. d. Calm the infant.
calm the infant A Placing the infant in a knee-chest position will decrease venous return so that smaller amounts of highly saturated blood reach the heart. This should be done after calming the infant. B Administering oxygen is indicated after placing the infant in a knee-chest position. C Administering morphine sulfate calms the infant. It may be indicated some time after the infant has been calmed. D Calming the crying infant is the first response. An infant with unrepaired tetralogy of Fallot who is crying and agitated may eventually lose consciousness.
256. A common, serious complication of rheumatic fever is a. Seizures b. Cardiac dysrhythmias c. Pulmonary hypertension d. Cardiac valve damage
cardiac valve damage A Seizures are not common complications of rheumatic fever. B Cardiac dysrhythmias are not common complications of rheumatic fever. C Pulmonary hypertension is not a common complication of rheumatic fever. D Cardiac valve damage is the most significant complication of rheumatic fever.
139 The parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should include which of the following? a. Parents can meet all the child's needs. b. Child needs opportunities to play with peers. c. Constant parental supervision is needed to avoid overexertion. d. Child needs to understand that peers' activities are too strenuous.
child needs opportunities to play with peers The child needs opportunities for social development. Children are able to regulate and limit their activities based on their energy level. Parents must be encouraged to seek appropriate social activities for the child, especially before kindergarten. The child needs to have activities that foster independence.
197. The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, "Why do my child's fingertips look like that?" The nurse bases a response on the understanding that clubbing occurs as a result of: a. untreated congestive heart failure. b. a left-to-right shunting of blood. c. decreased cardiac output. d. chronic hypoxia.
chronic hypoxia Clubbing of the fingers develops in response to chronic hypoxia.
82. The MOST common cause of secondary hyperparathyroidism is: diabetes mellitus. chronic renal disease. congenital heart disease. growth hormone deficiency.
chronic renal disease. These conditions do not contribute to secondary hypoparathyroidism. Chronic renal disease is the most common cause of secondary hyperparathyroidism. These conditions do not contribute to secondary hypoparathyroidism.
212. An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). The nurse understands dyspnea occurs because blood is: a. circulated through the lungs again, causing pulmonary circulatory congestion. b. shunted past the pulmonary circulation, causing pulmonary hypoxia. c. shunted past cardiac arteries, causing myocardial hypoxia. d. circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the heart.
circulated through the lungs again, causing pulmonary circulatory congestion. Rationale: When PDA is present, oxygenated blood recycles through the lungs, overburdening the pulmonary circulation.
177. Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client? a. Speaking to the client at a slower rate b. Allowing plenty of time for the client to respond c. Completing the sentences that the client cannot finish d. Looking directly at the client during attempts at speech.
completing the sentences that the client cannot finish Clients with aphasia after brain attack (stroke) often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all the responses for the client.
231. The most common type of hearing loss, which results from interference of transmission of sound to the middle ear, is called: a. conductive. b. sensorineural. c. mixed conductive-sensorineural. d. central auditory imperceptive.
conductive Rationale: Conductive or middle-ear hearing loss is the most common type. It results from interference of transmission of sound to the middle ear, most often from recurrent otitis media.
119 A cardiac defect that allows blood to shunt from the (high pressure) left side of the heart to the (lower pressure) right side can result in: a. cyanosis. b. congestive heart failure. c. decreased pulmonary blood flow. d. bounding pulses in upper extremities.
congestive heart failure As blood is shunted into the right side of the heart, there is increased pulmonary blood flow and the child is at high risk for congestive heart failure. Cyanosis usually occurs in defects with decreased pulmonary blood flow. Bounding upper extremity pulses are a manifestation of coarctation of the aorta.
122 A nurse is preparing for the admission of a child with a diagnosis of acute-stage Kawasaki disease. On assessment of the child, the nurse expects to note which clinical manifestation of the acute stage of the disease? a) cracked lips b) a normal appearance c) conjunctival hyperemia d) desquamation of the skin
conjunctival hyperemia In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.
138 The nurse should recognize that congestive heart failure (CHF) is which of the following? a. Disease related to cardiac defects b. Consequence of an underlying cardiac defect c. Inherited disorder associated with a variety of defects d. Result of diminished workload imposed on an abnormal myocardium
consequence of an underlying cardiac defect CHF is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body's metabolic demands. CHF is not a disease but rather a result of the inability of the heart to pump efficiently. CHF is not inherited. CHF occurs most frequently secondary to congenital heart defects in which structural abnormalities result in increased volume load or increased pressures on the ventricles.
180. The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client: a. Gets angry with family if they interrupt a task b. Experiences bouts of depression and irritability c. Has difficulty with using modified feeding utensils d. Consistently uses adaptive equipment in dressing self
consistently uses adaptive equipment in dressing self Clients are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options A, B, and C are not adaptive behaviors.
271. The nurse is admitting a child who has been diagnosed with Kawasaki disease. What is the most serious complication for which the nurse should assess in Kawasaki disease? a. Cardiac valvular disease b. Cardiomyopathy c. Coronary aneurysm d. Rheumatic fever
coronary aneurysm A Cardiac valvular disease can occur in rheumatic fever. B Cardiomyopathies are diseases of the heart muscle, which can occur as a result of congenital heart disease, coronary artery disease, or other systemic disease. C Coronary artery aneurysms are seen in 20% to 25% of children with untreated Kawasaki disease. D Rheumatic fever is not a complication of Kawasaki disease.
141 The primary nursing intervention to prevent bacterial endocarditis is which of the following? a. Counsel parents of high-risk children. b. Institute measures to prevent dental procedures. c. Encourage restricted mobility in susceptible children. d. Observe children for complications, such as embolism and heart failure.
counsel parents of high-risk children The objective of nursing care is to counsel the parents of high-risk children about the need for both prophylactic antibiotics for dental procedures and maintaining excellent oral health. The child's dentist should be aware of the child's cardiac condition. Dental procedures should be done to maintain a high level of oral health. Restricted mobility in susceptible children is not indicated. Parents are taught to observe for unexplained fever, weight loss, or change in behavior.
272. The primary nursing intervention to prevent bacterial endocarditis is a. Institute measures to prevent dental procedures. b. Counsel parents of high-risk children about prophylactic antibiotics. c. Observe children for complications, such as embolism and heart failure. d. Encourage restricted mobility in susceptible children.
counsel parents of high-risk children about prophylactic antibiotics A Dental procedures should be done to maintain a high level of oral health. Prophylactic antibiotics are necessary. B The objective of nursing care is to counsel the parents of high risk children about both the need for prophylactic antibiotics for dental procedures and the necessity of maintaining excellent oral health. The child's dentist should be aware of the child's cardiac condition. C Observing children for complications should be done, but maintaining good oral health and prophylactic antibiotics is important. D Encouraging restricted mobility should be done, but maintaining good oral health and prophylactic antibiotics is important.
43. An important nursing responsibility when a dysrhythmia is suspected is to: order an immediate electrocardiogram. count the radial rate at 1-minute intervals 5 times in a row. count the apical rate for 1 full minute and compare it with the radial rate. have someone else take the radial rate while the nurse simultaneously checks the apical rate.
count the apical rate for 1 full minute and compare it with the radial rate. This may be indicated after conferring with the practitioner. The radial pulse needs to be compared with the apical. This is the nurse's first action. If an arrhythmia is occurring, the radial pulse may be lower than the apical rate. It is the responsibility of the nurse to check both rates.
19. The goals of therapeutic management for congestive heart failure is to increase afterload and perfusion to tissues. decrease preload and increase afterload. decrease preload, afterload and increase contractility. decrease contractility and increase preload and afterload.
decrease preload, afterload and increase contractility. Treatment goals for congestive heart failure are aimed at decreasing preload (volume), afterload (resistance) and increasing contractility (improving efficiency).
91. During the rehabilitative phase of care, pressure dressings are primarily applied to burned areas to: relieve pain. decrease the blood supply to the scar. limit motion during the healing process. encourage healing through scar formation.
decrease the blood supply to the scar. The goal of the pressure dressing is to improve the appearance of scars. Uniform pressure to the scar decreases blood supply. The use of pressure garments serves to decrease the blood supply to the hypertrophic tissue. This is done to prevent scarring and contractures. C. Motion is encouraged; it prevents contractures. The goal of the pressure dressing is to minimize the development of scar tissue.
42. Nurses counseling parents regarding the home care of the child with a cardiac defect before corrective surgery should stress the: importance of reducing caloric intake to decrease cardiac demands. importance of relaxing discipline and limit-setting to prevent crying. need to be extremely concerned about cyanotic spells. desirability of promoting normalcy within the limits of the child's condition.
desirability of promoting normalcy within the limits of the child's condition. Child needs increased caloric intake. Child needs discipline and appropriate limits. Because cyanotic spells occur in children with some defects, the parents need to be taught how to manage these. The child needs to have social interactions, discipline, and appropriate limit-setting. Parents need to be encouraged to promote as normal a life as possible for their child.
274. What is an expected assessment finding in a child with coarctation of the aorta? a. Orthostatic hypotension b. Systolic hypertension in the lower extremities c. Blood pressure higher on the left side of the body d. Disparity in blood pressure between the upper and lower extremities
disparity in blood pressure between the upper and lower extremities A Orthostatic hypotension is not present with coarctation of the aorta. B Systolic hypertension may be detected in the upper extremities. C The left arm may not accurately reflect systolic hypertension because the left subclavian artery can be involved in the coarctation. D The classic finding in children with coarctation of the aorta is a disparity in pulses and blood pressures between the upper and lower extremities.
53. The nurse should explain to the parents that their child is receiving Lasix for severe congestive heart failure because it is a/an: diuretic. alpha-blocker. form of digitalis. ACE inhibitor.
diuretic. Furosemide (Lasix) is a diuretic used to eliminate excess water and salt to prevent reaccumulation of the fluid. Lasix is a diuretic. Lasix is a diuretic. Lasix is a diuretic.
29. The nurse is preparing to give digoxin (Lanoxin) to a 9-month-old infant. The nurse checks the dose; 4 ml of the drug is to be drawn up. Based on the nurse's knowledge of this medication and safe pediatric dosages, the most appropriate action by the nurse is do not draw-up dose; suspect dosage error. mix dose with juice to disguise its taste. check heart rate; administer dose by placing it to the back and side of mouth. check heart rate; administer dose by letting infant suck it through a nipple.
do not draw-up dose; suspect dosage error. Digoxin is often prescribed in micrograms. Rarely is more than 1 ml administered to an infant. As a potentially dangerous drug, digoxin has precise administration guidelines. Some institutions require that digoxin dosages be checked with another professional before administration. The nurse has drawn up too much medication and should not give it to the child. Administration procedures as described are correct, but too much medication is prepared, so it should not be given to the child.
22. After a patient returns from cardiac catheterization, the nurse notes that the pulse distal to the catheter insertion site is weaker (+1). The most appropriate nursing intervention is to elevate the affected extremity. document the findings and continue to monitor. notify the health care provider of the finding. apply warm compresses to the insertion site.
document the findings and continue to monitor. The pulse distal to the catheter insertion site may be weaker for the first few hours after catheterization. It should gradually increase in strength. The extremity is kept straight and immobile, but elevation is not necessary. Because a weaker pulse is an expected finding, the nurse should document it and continue to monitor it. There is no need to notify the physician. The insertion site is kept dry. Warm compresses would increase the risk of bleeding from the insertion site.
71. When discussing a child's precocious puberty with the parents, the nurse should tell them that: the child is not yet fertile. heterosexual interest is usually advanced. dress and activities should be appropriate to chronologic age. appearance of secondary sexual characteristics does not proceed in the usual order.
dress and activities should be appropriate to chronologic age. Functioning sperm or ova may be produced, thereby making the child fertile at an early age. Heterosexual interest is usually appropriate to chronologic age. Because of the early sexual maturation of the child, both family and child require extensive teaching. Included in this is the information that the child should be engaged in activities according to chronologic age. The secondary sexual characteristics proceed in the usual order.
80. The MOST important nursing consideration related to congenital hypothyroidism is: early identification of the disorder. facilitation of parent-infant attachment. initiating referrals for cognitive impairment. helping parents deal with future prospects for the child.
early identification of the disorder. Early diagnosis is imperative. Because brain growth is complete by 2 to 3 years old, the deficiency must be detected, and replacement therapy begun as soon as possible. The parent-infant attachment is important for all infants. With appropriate intervention, the child may not have any developmental deficit. With appropriate intervention, the child may not have any developmental deficit.
68. The nurse is caring for a 2-year-old girl who is unconscious but stable following a car accident. Her parents are staying at the bedside most of the time. An appropriate nursing intervention is to: suggest that the parents go home until she is alert enough to know that they are present. use ointment on her lips but do not attempt to cleanse her teeth until swallowing returns. encourage the parents to hold, talk, and sing to her as they usually would. position her with proper body alignment and head of bed lowered 15 degrees.
encourage the parents to hold, talk, and sing to her as they usually would. This is not recommended. The daughter may be able to hear that they are present. Oral care is essential in the unconscious child. Mouth care should be done at least twice daily. The parents should be encouraged to interact with their daughter. Senses of hearing and tactile perception may be intact, and stimulation of these senses is important. The head of the bed should be elevated, not lowered.
79. The nurse is planning care for a child recently diagnosed with diabetes insipidus. The plan should include: encouraging the child to wear medical identification. discussing with the child and family ways to limit fluid intake. teaching the child and family how to do required urine testing. reassuring the child and family that this is usually not a chronic or life-threatening illness.
encouraging the child to wear medical identification. Because of the unstable nature of the child's fluid and electrolyte balance, this is an extremely important intervention. With diabetes insipidus the child should have unrestricted access to fluid. There is no required urine testing with diabetes insipidus. Diabetes insipidus is both lifelong and life threatening. The medication must be taken, and the effects monitored closely.
73. A school-age child recently diagnosed with type 1 diabetes mellitus asks the nurse if he can still play soccer, baseball, and swim. The nurse's response should be based on knowledge that: exercise is contraindicated. soccer and baseball are too strenuous, but swimming is acceptable. exercise is not restricted unless indicated by other health conditions. the level of activity depends on the type of insulin required.
exercise is not restricted unless indicated by other health conditions. Exercise is highly encouraged. The decrease in blood glucose can be accommodated by having snacks available. Sports are encouraged to help regulate the insulin, and food should be adjusted according to the amount of exercise. The child needs to be cautioned to monitor responses to the exercises. Exercise is encouraged for children with diabetes because it lowers blood glucose levels. Insulin and meal requirements require careful monitoring to ensure that the child has sufficient energy for exercise. The level of activity does not depend on the type of insulin used. Long- and short-acting insulin both may be used to compensate for the effects of training and sporting events.
85. An infant is born with ambiguous genitalia. Tests are being done to assist in gender assignment. The parents tell the nurse that family and friends are asking what caused the baby to be this way. The nurse's MOST appropriate action is to: explain the disorder so parents can explain it to others. help parents understand that no one knows how this occurs. suggest that parents avoid family and friends until the gender is assigned. encourage parents not to worry while the tests are being done.
explain the disorder so parents can explain it to others. This is the most therapeutic approach while the parents await the gender assignment of their child. The disorder is caused by decreased enzyme activity required for adrenal cortical production of cortisol. This is impractical and would isolate the family from their support system while awaiting test results. The parents will be concerned. Telling the parents not to worry without giving them specific alternative actions would not be effective.
93. A mother of a 12-year-old child informs the phone triage nurse that she has just removed a tick from her daughter's scalp and asks whether she needs to be concerned about Rocky Mountain spotted fever. The nurse's BEST response includes teaching about the clinical manifestations to look out for which include: (Select all that apply.) fatigue. fever. petechial rash. severe headache. severe diarrhea.
fatigue. fever. petechial rash. severe headache. Clinical manifestations of Rocky Mountain spotted fever are: Gradual onset—Fever, malaise, anorexia, myalgia Abrupt onset—Rapid temperature elevation, chills, vomiting, myalgia, severe headache Maculopapular or petechial rash primarily on extremities (ankles and wrists) but may spread to other areas, characteristically on palms and soles Abrupt onset of chills, fever, diffuse myalgia, headache, malaise Maculopapular rash becoming petechial 4 to 7 days later, spreading from trunk outward Headache, arthralgia, backache followed by fever; may last 9 to 14 days Maculopapular rash after 1 to 8 days of fever; begins in trunk and spreads to periphery; rarely involves face, palms, soles
155. A student with type I diabetes mellitus complains of feeling lightheaded. Her blood sugar is 60 mg/dL. Using the 15/15 rule, the nurse should: A. give 15 mL of juice, and repeat dose in 15 minutes B. give 15 grams of carbohydrates and retest blood sugar in 15 minutes C. Give 15 grams of carbohydrates and 15 g of protein D. Give 15 ounces of juice and retest blood sugar in 15 minutes
give 15 grams of carbohydrates and retest blood sugar in 15 minutes 15/15 rule states to give 15 g of carbohydrates (approx 60 calories; roughly 4 oz of juice or a tablespoon of honey or sugar). Protein by itself will treat hypoglycemia. Only 15 mL of juice does not contain enough calories to increase the blood sugar. Fifteen oz of juice nearly 4 times the recommended amount
179. The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? a. Giving the client thin liquids b. Thickening liquids to the consistency of oatmeal c. Placing food on the unaffected side of the mouth d. Allowing plenty of time for chewing and swallowing
giving the client thin liquids Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.
203. The nurse is aware that the characteristics of high-density lipoproteins (HDLs) are that they: a. have high amounts of triglycerides. b. have only small amounts of protein. c. have little cholesterol. d. aid in steroid production.
have little cholesterol. Rationale: HDLs have low amounts of triglycerides, large amounts of proteins, low amount of cholesterol, and are excreted via the liver. They have no role in the production of steroids.
45. The school nurse is called to the cafeteria because a child "has eaten something he is allergic to." The child is in severe respiratory distress. FIRST the nurse should: determine what the child has eaten. administer diphenhydramine (Benadryl). move the child to the nurse's office or hallway. have someone call for an ambulance/paramedic rescue squad.
have someone call for an ambulance/paramedic rescue squad. Because severe respiratory distress is occurring, treatment of the response is indicated first. The cause of the response can be determined later. Diphenhydramine will not be effective for this type of allergic reaction. The child should not be moved unless the child is in a place that puts the child at greater hazard. Because the child is in severe respiratory distress, the nurse should remain with the child while someone else calls for the rescue squad.
81. A neonate with a goiter has just been admitted to the newborn nursery. A PRIORITY nursing intervention is to: position the infant on the left side. explain transient paralysis to parents. have tracheostomy set at bedside. suction the infant at least every 5 to 10 minutes.
have tracheostomy set at bedside. This position is not indicated. Hyperextension of the child's neck may facilitate breathing. Transient paralysis does not exist. The presence of the goiter puts the infant at risk for respiratory failure. Preparations are made for emergency ventilation, including a tracheostomy set at the bedside. There is no indication for suctioning.
184. The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? a. Head midline b. Head turned to the side c. Neck in neutral position d. Head of bed elevated 30 to 45 degrees
head turned to the side The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.
214. A child develops carditis from rheumatic fever. The nurse knows that the areas of the heart affected by carditis are the: a. coronary arteries. b. heart muscle and the mitral valve. c. aortic and pulmonic valves. d. contractility of the ventricles.
heart muscle and the mitral valve. Rationale: The tissues that cover the heart and heart valves are affected. The heart muscle may be involved and the mitral valve is frequently involved.
149 A 15 year old, who is type 1 diabetic, reports that she almost "passes out" during gym class. What information would you assess from the teenager? A. None of the options are correct B. What type of form she needs to have filled out so she can be excused from gym class. C. How she takes her blood glucose after exercise. D. Her eating habits prior to gym class.
her eating habits prior to gym class It is very important to ask the teen when and what she eats before gym. Type 1 diabetics are encouraged to eat before physical activity to decrease the chances of hypoglycemia (which is what this teen is experiencing). She should take her blood glucose BEFORE exercise not AFTER. There is no need for her to be excused from gym class because exercise is essential for diabetics.
270. The nurse is admitting a child to the hospital for a cardiac workup. What is the first step in a cardiac assessment? a. Percussion b. Palpation c. Auscultation d. History and inspection
history and inspection A Percussion of the chest is usually deferred. B Palpation can be threatening to the child because it requires a significant amount of physical contact. For this reason it is not the initial step in a cardiac assessment. C Auscultation requires touching the child and is not the initial step in a cardiac assessment. D The assessment should begin with the least threatening interventions—the history and inspection. Assessment progression includes inspection, auscultation, and palpation because each step includes more touching.
196. The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. The nurse can determine the father understood the instructions when he states "If the baby turns blue, I will: a. hold him against my shoulder with his knees bent up toward his chest." b. lay him down on a firm surface with his head lower than the rest of his body." c. immediately put the baby upright in an infant seat." d. put the baby in supine position with his head elevated."
hold him against my shoulder with his knees bent up toward his chest In the event of a paroxysmal hypercyanotic or "tet" spell, the infant should be placed in a knee-chest position.
207. The nurse uses a diagram to illustrate what four structural heart anomalies that comprise tetralogy of Fallot? Select the four that apply. a. Hypertrophied right ventricle b. Patent ductus arteriosus c. Ventral septal defect d. Narrowing of pulmonary artery e. Dextroposition of aorta
hypertrophied right ventricle patent ductus arteriosus narrowing of pulmonary artery dextroposition of aorta Rationale: The four anomalies that comprise tetralogy of Fallot are hypertrophied right ventricle, patent ductus arteriosus, stenosis of pulmonary artery, and dextroposition of the aorta.
154. A patient with a history of diabetes is exhibiting sweating and slurred speech. What do you suspect is the cause? A. hyponaterima B. hypernaterima C. hyperglycemia D. hypoglycemia
hypoglycemia These are the classic symptoms of hypoglycemia.
123 A parent of a 7-year-old girl with a repaired ventricular septal defect (VSD) calls the cardiology clinic and reports that the child is just not herself. Her appetite is decreased, she has had intermittent fevers around 38o C (100.4o F), and now her muscles and joints ache. Based on this information you advise the mother to: a. immediately bring the child to clinic for evaluation. b. come to the clinic next week on a scheduled appointment. c. treat the symptoms with acetaminophen and fluids, since it is most likely a viral illness. d. recognize that the child is trying to manipulate the parent by complaining of vague symptoms.
immediately bring the child to clinic for evaluation These are the insidious symptoms of bacterial endocarditis. Since the child is in a high-risk group for this disorder (VSD repair), immediate evaluation and treatment are indicated to prevent cardiac damage. With appropriate antibiotic therapy, bacterial endocarditis is successfully treated in approximately 80% of the cases. The child's complaints should not be dismissed. The low-grade fever is not a symptom that the child can fabricate.
132 The infant with congestive heart failure (CHF) has a need for: a. decreased fat. b. increased fluids. c. decreased protein. d. increased calories.
increased calories Infants with CHF have a greater metabolic rate because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of average infants, yet their ability to take in calories is diminished by their fatigue. The diet should include increased protein and increased fat to facilitate the child's intake of sufficient calories. Fluids must be carefully monitored because of the CHF.
142 Ventricular septal defect has the following blood flow pattern: a. Mixed blood flow b. Increased pulmonary blood flow c. Decreased pulmonary blood flow d. Obstruction to blood flow from ventricles
increased pulmonary blood flow The opening in the septal wall allows for blood to flow from the higher pressure left ventricle into the lower pressure right ventricle. This left-to-right shunt creates increased pulmonary blood flow. The shunt is one way, from high pressure to lower pressure; oxygenated and unoxygenated blood do not mix. The outflow of blood from the ventricles is not affected by the septal defect.
25. Surgical repair for patent ductus arteriosus (PDA) is done to prevent the complication of pulmonary infection. right-to-left shunt of blood. decreased workload on left side of heart. increased pulmonary vascular congestion.
increased pulmonary vascular congestion. A PDA allows blood to flow from the aorta (high pressure) to the pulmonary artery (low pressure). If the PDA stays open, increased pulmonary vascular congestion can occur. The increased pulmonary vascular congestion is the primary complication; pulmonary infection may occur, but it is not the priority complication. A PDA involves a left-to-right shunt of blood. The decreased workload on the left side of the heart is not a priority complication of a PDA.
50. The doctor suggests that surgery be performed for patent ductus arteriosus (PDA) to prevent: pulmonary infection. right-to-left shunt of blood. decreased workload on left side of heart. increased pulmonary vascular congestion.
increased pulmonary vascular congestion. The increased pulmonary vascular congestion is the primary complication. The shunt of blood is left to right. The increased pulmonary vascular congestion is the primary complication. A PDA allows blood to flow from the aorta (high pressure) to the pulmonary artery (low pressure). If the PDA stays open, increased pulmonary congestion can occur.
211. When a father asks why his child with tetralogy of Fallot seems to favor a squatting position, the nurse would explain that squatting: a. increases the return of venous blood back to the heart. b. decreases arterial blood flow away from the heart. c. is a common resting position when a child is tachycardic. d. increases the workload of the heart.
increases the return of venous blood back to the heart. Rationale: The squatting position allows the child to breathe more easily because systemic venous return is increased
216. The nurse is caring for a child with a diagnosis of Kawasaki disease. The child's parent asks the nurse, "How does Kawasaki disease affect my child's heart and blood vessels?" The nurse's response is based on the understanding that: a. inflammation weakens blood vessels, leading to aneurysm. b. increased lipid levels lead to the development of atherosclerosis. c. untreated disease causes mitral valve stenosis. d. altered blood flow increases cardiac workload with resulting heart failure.
inflammation weakens blood vessels, leading to aneurysm. Rationale: Inflammation of vessels weakens the walls of the vessels and often results in aneurysm.
55. The nurse who is concerned about increased intracranial pressure in an infant should assess for: irritability. photophobia. pulsating anterior fontanel. vomiting and diarrhea.
irritability. Irritability is one of the changes that may indicate increased intracranial pressure. Photophobia does not indicate increased intracranial pressure in infants. Frequently pulsations are visible in the anterior fontanel. It is not an indication of increased intracranial pressure. Vomiting is one of the signs in children but, when present with diarrhea, indicates a gastrointestinal disturbance.
178. Nurse Maureen witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway in this victim by using which method? a. Flexed position b. Head tilt-chin lift c. Jaw thrust maneuver d. Modified head tilt-chin lift
jaw thrust maneuver If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tilt-chin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an inappropriate position for opening the airway.
281. Which postoperative intervention should be questioned for a child after a cardiac catheterization? a. Continue intravenous (IV) fluids until the infant is tolerating oral fluids. b. Check the dressing for bleeding. c. Assess peripheral circulation on the affected extremity. d. Keep the affected leg flexed and elevated.
keep the affected leg flexed and elevated A IV fluid administration continues until the child is taking and retaining adequate amounts of oral fluids. B The insertion site dressing should be observed frequently for bleeding. The nurse should also look under the child to check for pooled blood. C Peripheral perfusion is monitored after catheterization. Distal pulses should be palpable, although they may be weaker than in the contralateral extremity. D The child should be positioned with the affected leg straight for 4 to 6 hours after the procedure.
58. The nurse is planning care for a school-age child with bacterial meningitis. The plan should include: keeping environmental stimuli at a minimum. avoiding giving pain medications that could dull sensorium. measuring head circumference to assess developing complications. having child move head side to side at least every 2 hours.
keeping environmental stimuli at a minimum. Children with meningitis are sensitive to noise, bright lights, and other external stimuli. The nurse should keep the room as quiet as possible, with a minimum of external stimuli. After consultation with the practitioner, pain medications can be used if necessary. A school-age child will have closed sutures. Head circumference should not change. The child is placed in side-lying position with the head of the bed slightly elevated. The nurse should avoid measures such as lifting the child's head that would increase discomfort.
187. The nurse is working on a surgical floor. The nurse must logroll a male client following a: a. laminectomy. b. thoracotomy. c. hemorrhoidectomy. d. cystectomy.
laminectomy The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.
284. Which strategy is appropriate when feeding the infant with congestive heart failure? a. Continue the feeding until a sufficient amount of formula is taken. b. Limit feeding time to no more than 30 minutes. c. Always bottle feed every 4 hours. d. Feed larger volumes of concentrated formula less frequently.
limit feeding time to no more than 30 minutes A The infant with congestive heart failure may tire easily. If the infant does not consume an adequate amount of formula in 30 minutes, gavage feedings should be considered. B The infant with congestive heart failure may tire easily, so the feeding should not continue beyond 30 minutes. If inadequate amounts of formula are taken, gavage feedings should be considered. C Infants with congestive heart failure may be breastfed. Feedings every 3 hours is a frequently used interval. If the infant were fed less frequently than every 3 hours, more formula would need to be consumed and would tire the infant. D The infant is fed smaller volumes of concentrated formula every 3 hours.
210. The finding the nurse would expect when measuring blood pressure on all four extremities of a child with coarctation of the aorta is blood pressure that is: a. higher on the right side. b. higher on the left side. c. lower in the arms than in the legs. d. lower in the legs than in the arms
lower in the legs than in the arms Rationale: The characteristic symptoms of coarctation of the aorta are a marked difference in blood pressure and pulses between the upper and lower extremities. Pressure is increased proximal to the defect and decreased distal to the coarctation.
94. An occlusive dressing, Acu-derm, is applied to a large abrasion. This is advantageous because the dressing will: provide an antiseptic for the wound. deliver vitamin C to the wound. maintain a moist environment for healing. promote mechanical friction for healing.
maintain a moist environment for healing. The dressing does not have antiseptic capabilities. The dressing does not have vitamin C. Occlusive dressings such as Acu-derm provide a dressing that does not adhere to the wound site. It provides a moist wound surface and insulates the wound. It protects against friction.
117 An important nursing intervention when caring for a child with myelomeningocele in the postoperative stage is to: place child on his or her side to decrease pressure on the spinal cord. apply a heat lamp to facilitate drying and toughening of the sac. keep skin clean and dry to prevent irritation from diarrheal stools. measure head circumference and examine fontanels for signs that might indicate developing hydrocephalus.
measure head circumference and examine fontanels for signs that might indicate developing hydrocephalus. Before surgery the child is kept in a prone position to decrease tension on the sac and reduce risk of trauma. The sac must be kept moist. Sterile, moist, nonadherent dressings are placed over the sac. Most infants do not have diarrheal stools. Hydrocephalus is frequently associated with myelomeningocele. Assessment of the fontanels and daily measurements of head circumference will aid in early detection.
121 A mother states that she brought her child to the clinic because the 3-year-old girl was not keeping up with her siblings. During physical assessment, the nurse notes that the child has pale skin and conjunctiva and has muscle weakness. The hemoglobin on admission is 6.4 g/dl. After notifying the practitioner of the results, the nurse's priority intervention is to: a. reduce environmental stimulation to prevent seizures. b. have the laboratory repeat the analysis with a new specimen. c. minimize energy expenditure to decrease cardiac workload. d. administer intravenous fluids to the dehydration.
minimize energy expenditure to decrease cardiac workload The child has a critically low hemoglobin value. The expected range is 11.5 to 15.5 g/dl. When the oxygen-carrying capacity of the blood decreases slowly, the child is able to compensate by increasing cardiac output. With the increasing workload of the heart, additional stress can lead to cardiac failure. Reduction of environmental stimulation can help minimize energy expenditure, but seizures are not a risk. A repeat hemoglobin analysis is not necessary. The child does not have evidence of dehydration. If intravenous fluids are given, they can further dilute the circulating blood volume and increase the strain on the heart.
108 A 15-year-old is admitted to the intensive care unit (ICU) with a spinal cord injury. The MOST appropriate nursing interventions for this adolescent are: (Select all that apply.) monitoring neurologic status. administering corticosteroids. monitoring for respiratory complications. discussing long-term care issues with the family. monitoring and maintaining hemodynamic status.
monitoring neurologic status. administering corticosteroids. monitoring for respiratory complications. monitoring and maintaining hemodynamic status. Close monitoring of sensory and motor function is important to prevent further deterioration of neurologic status as a result of spinal cord edema. Corticosteroids are administered to minimize the inflammation associated with the injury. Close monitoring of respiratory status for possible need of ventilator support. Remember "A-B-C's," airway, breathing, and circulation. Monitoring and maintaining hemodynamic status may require immediate attention related to increased intracranial pressure resulting in hypotension and bradycardia. The discussion of long-term care issues with the family is not appropriate in the acute phase of spinal cord injury.
161. The nurse knows that diabetic teaching has been effective when parents of a newly diagnosed child state they will, during an illness, provide the child with: A. more insulin B. more calories C. less insulin D. less protein
more insulin Illness causes greater insulin resistance, so more is needed to achieve normal blood glucose levels. Increased calorie intake will be ineffective without more insulin to assist the body with metabolizing those calories. Restricting protein is not recommended, but during illness, fluids and light carbohydrates are usually tolerated best.
105 An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome). When explaining this disease process to the parents, the nurse should consider that: paralysis is progressive with little hope for recovery. muscle function will gradually return, and recovery is possible in most children. disease results from an apparently toxic reaction to certain medications. disease is inherited as an autosomal, sex-linked, recessive gene.
muscle function will gradually return, and recovery is possible in most children. The paralysis is progressive, but most children have full recovery. Supportive nursing care is essential. Most patients regain full muscle strength. The return of function is in reverse order of onset. It is an immune-mediated disease associated with viral and bacterial infections. It is an immune-mediated disease associated with viral and bacterial infections.
181. The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which of the following to test the client's peripheral response to pain? a. Sternal rub b. Nail bed pressure c. Pressure on the orbital rim d. Squeezing of the sternocleidomastoid muscle
nail bed pressure Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
64. The nurse is doing a neurologic assessment on a 2-month-old infant following a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes suggest: neurologic health. severe brain damage. decorticate posturing. decerebrate posturing.
neurologic health. The Moro, tonic neck, and withdrawing reflexes are usually present in infants under 3 to 4 months of age. Therefore, the presence of these reflexes indicates neurologic health. These are expected reflexes in a 2-month-old. Decorticate posturing indicates severe dysfunction of the cerebral cortex. Decerebrate posturing indicates dysfunction at the level of the midbrain.
78. The nurse is discharging a 10-year-old patient admitted to the hospital in diabetic ketoacidosis. The child has been newly diagnosed with type 1 diabetes mellitus (DM) on this admission. The nurse should teach the child and parents which signs of type 1? (Select all that apply.) weight gain nocturia irritability cool, clammy skin blurred vision
nocturia irritability blurred vision Clinical manifestations of type 1 diabetes mellitus include: Polyphagia, Polyuria, Polydipsia, Weight loss, Enuresis or nocturia, Irritability; "not himself" or "herself", Shortened attention span, Lowered frustration tolerance, Dry skin, Blurred vision, Poor wound healing, Fatigue, Flushed skin, Headache, Frequent infections, Hyperglycemia, Elevated blood glucose levels, Glucosuria, Diabetic ketosis, Ketones and glucose in urine, Dehydration in some cases, Diabetic ketoacidosis, Dehydration, Electrolyte imbalance, Acidosis, Deep, rapid breathing (Kussmaul respirations).
87. A toddler has a deep laceration contaminated with dirt and sand. Before suturing the nurse should irrigate the wound with: alcohol. normal saline. hydrogen peroxide. povidone-iodine.
normal saline These should not be used because they are toxic to the wound. Normal saline is the only acceptable fluid for irrigation listed. The nurse should cleanse the wound with a forced stream of normal saline or water. These should not be used because they are toxic to the wound. These should not be used because they are toxic to the wound.
54. The nurse is preparing to give digoxin to a 9-month-old infant. He or she checks the dose and draws up 4 ml of the drug. The MOST appropriate nursing action is to: not give the dose; suspect dosage error. mix the dose with juice to disguise its taste. check heart rate; administer the dose by placing it to the back and side of the mouth. check heart rate; administer the dose by letting the infant suck it through a nipple.
not give the dose; suspect dosage error. Digoxin is often prescribed in micrograms. Rarely is more than 1 ml administered to an infant. Because it is a potentially dangerous drug, administration guidelines are very precise. Some institutions require that digoxin dosages be checked with another professional before administration. The nurse has drawn up too much medication. These are correct procedures, but too much medication has been prepared. These are correct procedures, but too much medication has been prepared.
70. The nurse is caring for a toddler who has had surgery for a brain tumor. During an assessment, the nurse notes that the child is becoming irritable and pupils are unequal and sluggish. The MOST appropriate nursing action is to: notify the health care provider immediately. document level of consciousness. observe closely for signs of increased intracranial pressure (ICP). administer pain medication and assess for response.
notify the health care provider immediately. The worsening of symptoms may indicate that the ICP is increasing. The practitioner should be notified immediately. The health care provider should be notified first before documenting. The nurse is already noting signs of potentially increased ICP. Pain medication should not be given. Consultation with the practitioner should occur first.
13. Nursing care of the infant and child with congestive heart failure includes force fluids appropriate to age. monitor respirations during active periods. organize activities to allow for uninterrupted sleep. give larger feedings less often to conserve energy.
organize activities to allow for uninterrupted sleep. The child needs to be well rested before feeding. The child's needs should be met to minimize crying. The nurse must organize care to decrease energy expenditure. The child in congestive heart failure has an excess of fluid, so forcing fluids is contraindicated. Monitoring of vital signs is appropriate, but minimizing energy expenditure is a priority. The child often cannot tolerate larger feedings; small, frequent feedings should be given to the child in congestive heart failure.
41. Nursing care of the infant or child with congestive heart failure would include: forcing fluids appropriate to age. monitoring respirations during active periods. organizing activities to allow for uninterrupted sleep. giving larger feedings less often to conserve energy.
organizing activities to allow for uninterrupted sleep. The child who has congestive heart failure has an excess of fluid. Monitoring vital signs is appropriate, but minimizing energy expenditure is a priority. The child needs to be well rested before feeding. The child's needs should be met as quickly as possible to minimize crying. The nurse must organize care to facilitate a decrease in his or her energy expenditure. The child often cannot tolerate larger feedings.
265. Nursing care for the child in congestive heart failure includes a. Counting the number of saturated diapers b. Putting the infant in the Trendelenburg position c. Removing oxygen while the infant is crying d. Organizing care to provide rest periods
organizing care to provide rest periods A Diapers must be weighed for an accurate record of output. B The head of the bed should be raised to decrease the work of breathing. C Oxygen should be administered during stressful periods such as when the child is crying. D Nursing care should be planned to allow for periods of undisturbed rest.
198. A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever? a. Subcutaneous nodules and fever b. Painful, tender joints and carditis c. Erythema marginatum and arthralgia d. Chorea and elevated sedimentation rate
painful, tender joints and carditis The presence of two major Jones' criteria would indicate a high probability of rheumatic fever.
89. Enteral feedings are ordered for a young child with burns covering 40% of total body surface area. The nurse should know that: oral feedings are contraindicated. enteral feedings must be stopped during painful procedures. paralytic ileus precludes the use of enteral feedings. the feedings will be high carbohydrate, low protein.
paralytic ileus precludes the use of enteral feedings. Oral feedings are not contraindicated. They are encouraged; however, most children with burns are unable to consume sufficient calories by mouth. Enteral feedings can continue during procedures. Enteral feedings can begin when the paralytic ileus resolves. A high-protein, high-calorie diet is recommended.
266. The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur. This finding is associated with which congenital heart defect? a. Pulmonary stenosis b. Patent ductus arteriosus c. Ventricular septal defect d. Coarctation of the aorta
patent ductus arteriosus A A systolic ejection murmur that may be accompanied by a palpable thrill is a manifestation of pulmonary stenosis. B The classic murmur associated with patent ductus arteriosus is a machinery-like one that can be heard throughout both systole and diastole. C The characteristic murmur associated with ventricular septal defect is a loud, harsh, holosystolic murmur. D A systolic murmur that is accompanied by an ejection click may be heard on auscultation when coarctation of the aorta is present.
133 The mother of a child with tetralogy of Fallot asks the nurse why her child has clubbed fingers. The nurse bases the response on the understanding that clubbing is due to which of the following? a) Anemia. b) Peripheral hypoxia. c) Delayed physical growth. d) Destruction of bone marrow.
peripheral hypoxia Clubbing of the fingers is one common finding in the child with persistent hypoxia leading to tissue changes in the body because of the low oxygen content of the blood (hypoxemia). It apparently results from tissue fibrosis and hypertrophy from the hypoxemia and from an increase in capillaries in the area, which occur as the body attempts to improve blood supply. Clubbing of the fingers is associated with polycythemia, not anemia. Polycythemia results from the body's attempt to increase oxygen levels in the tissues. The child may be small for his or her chronological age, but clubbing does not result from slow physical growth. Destruction of the bone marrow is not related to this congenital heart malformation. Instead, bone marrow is actively producing erythrocytes to compensate for the chronic hypoxia.
102 Cerebral palsy may result from a variety of causes. It is now known that the most common cause of cerebral palsy is: birth asphyxia. neonatal diseases. cerebral trauma. prenatal brain abnormalities.
prenatal brain abnormalities. These issues were previously thought to be factors. These issues were previously thought to be factors. These issues were previously thought to be factors. Cerebral palsy results from existing brain abnormalities during the prenatal period.
135 The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes the risk of cerebrovascular accidents (strokes) occurring. Which of the following is an important objective to decrease this risk? a. Minimize seizures. b. Prevent dehydration. c. Promote cardiac output. d. Reduce energy expenditure.
prevent dehydration In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents.
259. A nurse is teaching an adolescent about primary hypertension. Which statement made by the adolescent indicates an understanding of primary hypertension? a. Primary hypertension should be treated with diuretics as soon as it is detected. b. Congenital heart defects are the most common cause of primary hypertension. c. Primary hypertension may be treated with weight reduction. d. Primary hypertension is not affected by exercise
primary hypertension may be treated with weight reduction A Primary hypertension is usually treated with weight reduction and exercise. If ineffective, pharmacologic intervention may be needed. B Primary hypertension is considered to be an inherited disorder. C Primary hypertension in children may be treated with weight reduction and exercise programs. D An exercise program in conjunction with weight reduction can be effective in managing primary hypertension in children.
49. Congenital heart defects have traditionally been divided into acyanotic or cyanotic defects. The nurse should recognize that in clinical practice this system is: helpful because it explains the hemodynamics involved. helpful because children with cyanotic defects are easily identified. problematic because cyanosis is rarely present in children. problematic because children with acyanotic heart defects may develop cyanosis.
problematic because children with acyanotic heart defects may develop cyanosis. The classification does not reflect the path of blood flow within the heart. Children with cyanosis may be easily identified, but that does not help with the diagnosis. Cyanosis is present when children have defects in which oxygenated blood and unoxygenated blood are mixed. This classification is problematic. Children with traditionally named acyanotic defects may be cyanotic, and children with traditionally classified cyanotic defects may appear pink.
24. Congenital heart defects have traditionally been divided into acyanotic or cyanotic defects. Based on the nurse's knowledge of congenital heart defects, this system in clinical practice is helpful, because it explains the hemodynamics involved. helpful, because children with cyanotic defects are easily identified. problematic, because cyanosis is rarely present in children. problematic, because children with acyanotic heart defects may develop cyanosis.
problematic, because children with acyanotic heart defects may develop cyanosis. This classification is problematic. Children with traditionally named acyanotic defects may become cyanotic, and children with traditionally classified cyanotic defects may be pink at times. The classification does not reflect the blood flow within the heart. Cardiac defects are best described by using the actual pathophysiologic process and mechanism. Children with cyanosis may be easily identified, but that does not help with the diagnosis. Cyanosis is present when children have defects where there is mixing of oxygenated blood with unoxygenated blood.
176. For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a. prevent respiratory alkalosis. b. lower arterial pH. c. promote carbon dioxide elimination. d. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg
promote carbon dioxide elimination The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.
163. A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of: a. Hypertension b. Heart failure c. Prosthetic valve replacement d. Chronic obstructive pulmonary disorder
prosthetic valve replacement The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if significant risk exists.
103 A child with spina bifida has developed a latex allergy from numerous bladder catheterizations and surgeries. A PRIORITY nursing intervention is to: recommend allergy testing. provide a latex-free environment. use only powder-free latex gloves. limit use of latex products as much as possible.
provide a latex-free environment. This may expose the child to the allergen; it is not recommended. This is the most important nursing intervention. From birth on, the limitation of exposure to latex is essential in an attempt to minimize sensitization. The gloves contain latex and will contribute to sensitization. Latex products should be avoided.
147 Which of the following structural defects constitute tetralogy of Fallot? a. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, ventricular septal defect, overriding aorta, left ventricular hypertrophy d. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy.
140 The physician suggests that surgery be performed for patent ductus arteriosus (PDA) to prevent which of the following complications? a. Hypoxemia b. Right-to-left shunt of blood c. Decreased workload on left side of heart d. Pulmonary vascular congestion
pulmonary vascular congestion In PDA, blood flows from the higher pressure aorta into the lower pressure pulmonary vein, resulting in increased pulmonary blood flow. This creates pulmonary vascular congestion. Hypoxemia usually results from defects with mixed blood flow and decreased pulmonary blood flow. The shunt is from left to right in a PDA. The closure would stop this. There is increased workload on the left side of the heart with a PDA.
63. The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. The MOST appropriate nursing assessment in this case is: reactivity of pupils. doll's head maneuver. oculovestibular response. funduscopic examination to identify papilledema.
reactivity of pupils. Pupil reactivity is an important indication of neurologic health. The pupils should be assessed for no reaction, unilateral reaction, and rate of reactivity. Doll's head maneuver should not be performed if there is a cervical spine injury. This is a painful test that should not be done on a child who is having variable levels of consciousness. Papilledema does not develop until 24 to 48 hours into the course of unconsciousness.
83. The nurse is caring for a child hospitalized with acute adrenocortical insufficiency. The acute phase seems to be over; then ascending flaccid paralysis occurs. The MOST appropriate nursing action is to: reassure the family that this condition is temporary. reassure the family that flaccid paralysis is not problematic. prepare the family for impending death. prepare the family for long-term consequences of paralysis.
reassure the family that this condition is temporary. During the recovery phase paralysis may develop. It is a temporary, quickly reversible clinical manifestation. Flaccid paralysis is problematic if not reversible. This is a reversible condition when associated with adrenocortical insufficiency.
110. The major goals of therapy for children with cerebral palsy include: reversing degenerative processes that have occurred. curing underlying defect causing the disorder. preventing spread to individuals in close contact with the child. recognizing the disorder early and promoting optimal development.
recognizing the disorder early and promoting optimal development. It is very difficult to reverse degenerative processes. The underlying defect cannot be cured. Cerebral palsy is not contagious. Since cerebral palsy is currently a permanent disorder, the goal of therapy is to promote optimal development. This is done through early recognition and beginning of therapy.
48. After a patient returns from cardiac catheterization, the nurse assesses that the pulse distal to the catheter insertion site is weaker. The nurse should: elevate the affected extremity. record the data on the nurse's notes. notify the physician of the observation. apply warm compresses to the insertion site.
record the data on the nurse's notes. Elevation is not necessary; the extremity is kept straight. The pulse distal to the catheter insertion site may be weaker for the first few hours after catheterization. It should gradually increase in strength. Because a weaker pulse is an expected finding, the nurse should document this and continue to monitor. The insertion site is kept dry.
134 The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. The nurse should do which of the following? a. Administer oxygen. b. Record data on nurses' notes. c. Report data to the practitioner. d. Place child in high Fowler position.
report data to the practitioner One of the earliest signs of CHF is tachycardia (sleeping heart rate >160 beats/min) as a direct result of sympathetic stimulation. The practitioner needs to be notified for evaluation of possible CHF. Although oxygen or a semiupright position may be indicated, the first action is to report the data to the practitioner.
131 Seventy-two hours after cardiac surgery, a young child has a temperature of 38.4o C (101.1° F). The nurse should do which of the following? a. Report findings to practitioner. b. Apply a hypothermia blanket. c. Keep child warm with blankets. d. Record temperature on assessment flow sheet.
report findings to practitioner In the first 24 to 48 hours after surgery, the body temperature may increase to 37.8° C (100° F) as part of the inflammatory response to tissue trauma. If the temperature is higher or fever continues after this period, it is most likely a sign of an infection, and immediate investigation is indicated. Hypothermia blanket is not indicated for this level of temperature. Blankets should be removed from the child to keep the temperature from increasing. The temperature should be recorded, but the practitioner must be notified for evaluation.
90. The nurse is caring for a 12-year-old boy who sustained major burns when he put charcoal lighter on a campfire. The nurse observes that he is "very brave" and appears to accept pain with little or no response. The most appropriate nursing action related to this is to: request a psychologic consultation. ask the child why he does not have pain. praise the child for his ability to withstand pain. encourage continued bravery as a coping strategy.
request a psychologic consultation. A psychologic consultation will assist the child to verbalize fears. This age group is concerned with physical appearance. The psychologists can help integrate the issues that the child is facing. It is likely that the child is having pain but not acknowledging it. If the child is feeling pain, the nurse should not praise him for hiding it. This may not be an effective coping strategy if the child is in severe pain.
66. The nurse is caring for a child with multiple injuries who is comatose. The nurse should recognize that pain: cannot occur if the child is comatose. may occur if the child regains consciousness. requires astute nursing assessment and management. is best assessed by family members who are familiar with the child.
requires astute nursing assessment and management. Pain can occur in the comatose child. The child can be in pain while comatose. Because the child cannot communicate pain through one of the standard pain rating scales, the nurse must be focused on physiologic and behavioral manifestations. The family can provide insight into different responses, but the nurse should be monitoring physiologic and behavioral manifestations.
185. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: a. take a hot bath. b. rest in an air-conditioned room c. increase the dose of muscle relaxants. d. avoid naps during the day
rest in an air-conditioned room Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.
183. The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? a. Loosening restrictive clothing b. Restraining the client's limbs c. Removing the pillow and raising padded side rails d. Positioning the client to side, if possible, with the head flexed forward
restraining the client's limbs Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.
99. The school nurse is seeing a child who brought poison ivy to school in his leaf collection. He says that only his hands touched it. The most appropriate nursing action is to: apply Burow's solution compresses. soak his hands in warm water. rinse his hands in cold, running water. scrub his hands thoroughly with antibacterial soap.
rinse his hands in cold, running water. This is effective for soothing the skin lesions, once the dermatitis has begun. Cold, running water is effective in removing the oil. This is the recommended first action. Once contact has been made, it is desirable to flush the skin with cold, running water within 15 minutes of exposure. This will neutralize the urushiol not yet bonded to the skin. The antibacterial soap removes protective skin oils and dilutes the urushiol, allowing it to spread.
60. The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. In the discussion the nurse should include that: parental protection is essential until the child reaches adulthood. cognitive impairment is to be expected with hydrocephalus. shunt malfunction or infection requires immediate treatment. most usual childhood activities must be restricted.
shunt malfunction or infection requires immediate treatment. Limits should be appropriate to the developmental age of the child. Except for contact sports, the child will have few restrictions. Cognitive impairment depends on the extent of damage before the shunt was placed. Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately if present. Limits should be appropriate to the developmental age of the child. Except for contact sports, the child will have few restrictions.
113 A neural tube defect that is not visible externally in the lumbosacral area would be called: meningocele. myelomeningocele. spina bifida cystica. spina bifida occulta.
spina bifida occulta. Meningocele contains meninges and spinal fluid but no neural tissue. Unless there are associated cutaneous findings, it is often not identified until later. Myelomeningocele is a neural tube defect that contains meninges, spinal fluid, and nerves. This is a cystic formation with an external saclike protrusion. Spina bifida occulta is completely enclosed. Often this defect will not be noticed.
208. What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing a paroxysmal hypercyanotic episode? Select all that apply. a. Spontaneous cyanosis b. Dyspnea c. Weakness d. Dry cough e. Syncope
spontaneous cyanosis dyspnea weakness syncope Rationale: Indicators of a paroxysmal hypercyanotic episode or a "tet" episode are spontaneous cyanosis, dyspnea, weakness, and syncope.
98. A nurse should explain that ringworm is: not contagious. a sign of uncleanliness. expected to recover spontaneously. spread by direct and indirect contact.
spread by direct and indirect contact. Ringworm is infectious. Because ringworm is easily transmitted, it is not a sign of uncleanliness. It can be transmitted by theater seats, gym mats, and animal-to-human transmission. The drug griseofulvin is indicated for a prolonged course, possibly several months. Ringworm is spread by both direct and indirect contact. Children should wear protective caps at night to avoid transfer of ringworm to bedding.
111 A 3-year-old male child has cerebral palsy and is currently hospitalized for orthopedic surgery. His mother says that he has difficulty swallowing and cannot hold a utensil to feed himself. He is slightly underweight for his height. The MOST appropriate nursing action related to feeding this child is to: bottle- or tube-feed him a specialized formula until he gains sufficient weight. stabilize his jaw with one hand (either from a front or side position) to facilitate swallowing. place him in a well-supported, semireclining position to make use of gravity flow. place him in a sitting position with his neck hyperextended to make use of gravity flow.
stabilize his jaw with one hand (either from a front or side position) to facilitate swallowing. Age 3 is too old for bottle-feeding. The neuromuscular compromise of the jaw interferes with the child's ability to eat. Because the jaw is compromised, more normal control can be achieved if the feeder provides stability. Manual jaw control assists with head control, ion of neck and trunk hyperextension, and jaw stabilization. The child should be sitting up for meals. For swallowing, the neck should not be hyperextended.
59. A young child is having a seizure that has lasted 35 minutes. There is a loss of consciousness. The nurse should recognize that this is: absence seizure. generalized seizure. status epilepticus. simple partial seizure.
status epilepticus. Absence seizures are brief losses of consciousness. Generalized seizures are the most common of seizures. They have a tonic phase of approximately 10 to 20 seconds. They involve both hemispheres of the brain. Status epilepticus is a generalized seizure that lasts more than 30 minutes. Simple partial seizures are characterized by varying sensations.
175. During a routine physical examination to assess a male client's deep tendon reflexes, the nurse should make sure to: a. use the pointed end of the reflex hammer when striking the Achilles tendon. b. support the joint where the tendon is being tested. c. tap the tendon slowly and softly d. hold the reflex hammer tightly.
support the joint where the tendon is being tested To prevent the attached muscle from contracting, the nurse should support the joint where the tendon is being tested. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn't provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc.
146 Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease? a.Susceptibility to respiratory infection b. Bleeding tendencies c. Frequent vomiting and diarrhea d. Seizure disorder
susceptibility to respiratory infection Children with congenital heart disease are more prone to respiratory infections.Bleeding tendencies, frequent vomiting, and diarrhea and seizure disorders are not associated with congenital heart disease
186. The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: a. Eating large, well-balanced meals b. Doing muscle-strengthening exercises c. Doing all chores early in the day while less fatigued d. Taking medications on time to maintain therapeutic blood levels
taking medications on time to maintain therapeutic blood levels Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications ly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.
115 A 6-year-old girl born with a myelomeningocele has a neurogenic bladder disorder. Her parents have been performing clean intermittent catheterization. The nurse's MOST appropriate action is to: teach the child to do self-catheterization. teach the child appropriate bladder control. continue having parents do catheterization. encourage the family to consider urinary diversion.
teach the child to do self-catheterization. At 6 years old this child should be able to perform the intermittent catheterization herself. This will give her more control and mastery over her disability. Bladder control cannot be taught to a child with a neurogenic bladder. This would be a good time to have the child begin caring for herself. A urinary diversion is not necessary.
267.The nurse caring for a child diagnosed with acute rheumatic fever should assess the child for a. Sore throat b. Elevated blood pressure c. Desquamation of the fingers and toes d. Tender, warm, inflamed joints
tender, wam, inflamed joints A The child may have had a sore throat previously associated with a group A beta-hemolytic streptococcal infection a few weeks earlier. A sore throat is not a manifestation of rheumatic fever. B Hypertension is not associated with rheumatic fever. C Desquamation of the fingers and toes is a manifestation of Kawasaki syndrome. D Arthritis, characterized by tender, warm, erythematous joints, is one of the major manifestations of acute rheumatic fever in the first 1 to 2 weeks of the illness.
280. Which information should be included in the nurse's discharge instructions for a child who underwent a cardiac catheterization earlier in the day? a. Pressure dressing is changed daily for the first week. b. The child may soak in the tub beginning tomorrow. c. Contact sports can be resumed in 2 days. d. The child can return to school on the third day after the procedure.
the child can return to school on the third day after the procedure A The day after the cardiac catheterization, the pressure dressing is removed and replaced with a Band-Aid. The catheter insertion site is assessed daily for healing. Any bleeding or sign of infection, such as drainage, must be reported to the cardiologist. B Bathing is limited to a shower, a sponge bath, or a brief tub bath (no soaking) for the first 1 to 3 days after the procedure. C Strenuous exercise such as contact sports, swimming, or climbing trees is avoided for up to 1 week after the procedure. D The child can return to school on the third day after the procedure. It is important to emphasize follow-up with the cardiologist.
129 Nursing care of the child with Kawasaki disease is challenging because of: a. the child's irritability. b. predictable disease course. c. complex antibiotic therapy. d. the child's ongoing requests for food.
the child's irritability
182. The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: a. The client has complete bilateral paralysis of the arms and legs. b. The client has weakness on the right side of the body, including the face and tongue. c. The client has lost the ability to move the right arm but is able to walk independently. d. The client has lost the ability to move the right arm but is able to walk independently.
the client has weakness on the right side of the body, including the face and tongue. Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.
26. A young child with tetralogy of Fallot may assume a posturing position as a compensatory mechanism. The position automatically assumed by the child is the low Fowler position. the prone position. the supine position. the squatting position.
the squatting position. The squatting or knee-chest position increases the return of blood flow to the heart for oxygenation in a child with a defect that consists of decreased pulmonary blood flow. The low Fowler, prone or supine position does not offer any physiologic advantage to the child related to cardiac compensation.
126 Clinical manifestations of Kawasaki disease in the acute phase include cervical lymphadenopathy, a strawberry tongue, and erythematous palms. Osler nodes are a clinical manifestation of endocarditis. Chorea and polyarthritis are seen in rheumatic fever. The regulation of red blood cell (RBC) production is thought to be controlled by: a. hemoglobin. b. tissue hypoxia. c. reticulocyte count. d. number of RBCs.
tissue hypoxia Hemoglobin does not directly control RBC production. If there is insufficient hemoglobin to adequately oxygenate the tissue, then erythropoietin may be released. When tissue hypoxia occurs, the kidneys release erythropoietin into the bloodstream. This stimulates the marrow to produce new RBCs. Reticulocytes are immature RBCs. The "retic" count can be used to monitor hematopoiesis. The number of RBCs does not directly control production. In congenital cardiac disorders with mixed blood flow or decreased pulmonary blood flow, RBC production continues secondary to tissue hypoxia.
263. For what reason might a newborn infant with a cardiac defect, such as coarctation of the aorta, that results in a right-to-left shunt receive prostaglandin E1? a. To decrease inflammation b. To control pain c. To decrease respirations d. To improve oxygenation
to improve oxygenation A Prostaglandin E1 is used to maintain a patent ductus arteriosus, thus increasing pulmonary blood flow. B Prostaglandin E1 is administered to infants with a right-to-left shunt to keep the ductus arteriosus patent, thus increasing pulmonary blood flow. C Prostaglandin E1 is given to infants with a right-to-left shunt to keep the ductus arteriosus patent to increase pulmonary blood flow. D Prostaglandin E1 is given to infants with a right-to-left shunt to keep the ductus arteriosus patent. This will improve oxygenation.
95. A child is being seen in the emergency department with multiple facial abrasions and lacerations. Lidocaine, adrenaline, and tetracaine (LAT) is applied topically to the wounds. The purpose of this is: to cleanse the wounds. to prevent infection. to provide anesthesia. to promote scab formation.
to provide anesthesia. LAT does not have a cleansing effect. LAT has no antibacterial effect. LAT provides anesthesia within 10 to 15 minutes of application. LAT has no effect on scab formation.
260. An adolescent being seen by the nurse practitioner for a sports physical is identified as having hypertension. On further testing, it is discovered the child has a cardiac abnormality. The initial treatment of secondary hypertension initially involves a. Weight control and diet b. Treating the underlying disease c. Administration of digoxin d. Administration of beta-adrenergic receptor blockers
treating the underlying disease A Weight control and diet is a non-pharmacologic treatment for primary hypertension. B Identification of the underlying disease should be the first step in treating secondary hypertension. C Digoxin is indicated in the treatment of congestive heart failure. D Beta-adrenergic receptor blockers are indicated in the treatment of primary hypertension.
264. In which situation is there a risk that a newborn infant will have a congenital heart defect (CHD)? a. Trisomy 21 detected on amniocentesis b. Family history of myocardial infarction c. Father has type 1 diabetes mellitus d. Older sibling born with Turner syndrome
trisomy 21 detected on amniocentesis A The incidence of congenital heart disease is approximately 50% in children with trisomy 21 (Down syndrome). B A family history of congenital heart disease, not acquired heart disease, increases the risk of giving birth to a child with CHD. C Infants born to mothers who are insulin dependent have an increased risk of CHD. D Infants identified as having certain genetic defects, such as Turner syndrome, have a higher incidence of CHD. A family history is not a risk factor.
148 Which of the following would the nurse perform to help alleviate a child's joint pain associated with rheumatic fever? a) maintaining the joints in an extended position b) applying gentle traction to the child's affected joints c) supporting proper alignment with rolled pillows d) using a bed cradle to avoid the weight of bed linens on the joints
using a bed cradle to avoid the weight of bed linens on the joints for a child with arthritis associated with rheumatic fever, the joints are usually so tender that even the weight of bed linens can cause pain. Use of the bed cradle is recommended to help remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not positioned inextension, to ensure that they remain functional.Applying gentle traction to the joints is not recommended because traction is usually used to relieve muscle spasms, not typically associated with rheumatic fever. Supporting the body in good alignment and changing the client's position are recommended, but these measures are not likely to relieve pain.
278. Which CHD results in increased pulmonary blood flow? a. Ventricular septal defect b. Coarctation of the aorta c. Tetralogy of Fallot d. Pulmonary stenosis
ventricular septal defect A Ventricular septal defect causes a left-to-right shunting of blood, thus increasing pulmonary blood flow. B Coarctation of the aorta is a stenotic lesion that causes increased resistance to blood flow from the proximal to distal aorta. C The defects associated with tetralogy of Fallot result in a right-to-left shunting of blood, thus decreasing pulmonary blood flow. D Pulmonary stenosis causes obstruction of blood flow from the right ventricle to the pulmonary artery. Pulmonary blood flow is decreased.
199. An infant with congestive heart failure is receiving digoxin (Lanoxin). The nurse recognizes a sign of digoxin toxicity, which is: a. restlessness. b. decreased respiratory rate. c. increased urinary output. d. vomiting.
vomiting Symptoms of digoxin toxicity include: nausea, vomiting, anorexia, irregularity in pulse rate and rhythm, and a sudden change in pulse.
273. What intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure? a. Weigh the infant every day on the same scale at the same time. b. Notify the physician when weight gain exceeds more than 20 g/day. c. Put the infant in a car seat to minimize movement. d. Administer digoxin (Lanoxin) as ordered by the physician.
weigh the infant every day on the same scale at the same time A Excess fluid volume may not be overtly visible. Weight changes may indicate fluid retention. Weighing the infant on the same scale at the same time each day ensures consistency. B An excessive weight gain for an infant is an increase of more than 50 g/day. C With fluid volume excess, skin will be edematous. The infant's position should be changed frequently to prevent undesirable pooling of fluid in certain areas. D Lanoxin is used in the treatment of congestive heart failure to improve cardiac function. Diuretics will help the body get rid of excess fluid.
213. An appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant would be: a. counting the apical rate for 30 seconds before administering the medication. b. withholding a dose if the apical heart rate is less than 100 beats/min. c. repeating a dose if the child vomits within 30 minutes of the previous dose. d. checking respiratory rate and blood pressure before each dose.
withholding a dose if the apical heart rate is less than 100 beats/min. Rationale: As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and the physician is notified.
268. The nurse discovers a heart murmur in an infant 1 hour after birth. She is aware that fetal shunts are closed in the neonate at what point? a. When the umbilical cord is cut b. Within several days of birth c. Within a month after birth d. By the end of the first year of life
within several days of birth A With the neonate's first breath, gas exchange is transferred from the placenta to the lungs. The separation of the fetus from the umbilical cord does not contribute to the establishment of neonatal circulation. B In the normal neonate, fetal shunts functionally close in response to pressure changes in the systemic and pulmonary circulations and to increased oxygen content. This process may take several days to complete. C The fetal shunts normally close within several days of birth. D Fetal shunts normally close soon after birth but may take several days.
