Exam 3 Pangbata

The nurse in an outpatient clinic is conducting a follow-up assessment on a child who had a severe streptococcal infection 1 week ago. The client is doing better, and the nurse is providing teaching to the parents about continuing to monitor the client for possible complications of the infection. Which information is most important for the nurse to discuss with the parents?

"Return immediately if acute flank or mid-abdominal pain occurs." Explanation: Acute glomerulonephritis is a major complication of streptococcal infections in children. The onset is often marked by a sudden occurrence of acute flank or mid-abdominal pain. The child may show signs of fluid retention, such as weight gain and edema. Hypertension also commonly occurs.

The nurse is planning interventions for a school-aged child hospitalized with acute poststreptococcal glomerulonephritis in need of diversional activity. Which activity should the nurse expect to include? watching a movie with a younger brother playing video games with a 4-year-old playing a card game with someone the same age putting together a puzzle with mother

playing a card game with someone the same age Explanation: Generally, school-age children enjoy activities with their peers first, then family members, and lastly younger children. School-age children like to be busy but also to accomplish something. This helps to meet their task of industry versus inferiority, feeling good about what they are able to accomplish. School-age children typically desire to carry a task to completion to achieve a sense of personal accomplishment.

What should the nurse include as a reason to seek prompt health care in the discharge teaching for the parents of a child following a sickle cell crisis? headaches and nausea skin rash and itching fatigue and lassitude sore throat and fever

sore throat and fever Children with sickle cell disease are prone to develop infections as a result of necrosis of areas within the body and a generalized less-than-optimal health status. If the child with sickle cell anemia develops signs of infection, such as sore throat and fever, prompt evaluation is necessary because an infection can precipitate a crisis.

What is the primary reason that the nurse inserts an indwelling urinary (Foley) catheter in a child with severe burns? to monitor for a urinary tract infection to measure urine output accurately to assess urine specific gravity to prevent urinary retention

to measure urine output accurately

A nurse is assessing the growth and development of a 10-year-old. What is the expected behavior of this child? has a strong sense of justice and fair play is selfish and insensitive to the welfare of others enjoys physical demonstrations of affection is uncooperative in play and school

has a strong sense of justice and fair play School-age children are concerned about justice and fair play. They become upset when they think someone is not playing fair. Physical affection makes them embarrassed and uncomfortable. They are concerned about others and are cooperative in play and school.

A nurse is taking a health history of a 10-year-child and discovers that the child has difficulties in urinary control during the day. The parents are confused about the condition and ask the nurse for help. What is the most appropriate response by the nurse? "Lack of urinary control during the day is indicative of a urinary tract infection." "You need to provide suitable undergarments to prevent embarrassment." "Your child must be forgetting to go to the bathroom during the day." "There may be a significant stressor in your child's life that's causing this."

"There may be a significant stressor in your child's life that's causing this." Diurnal enuresis is urinary incontinence that occurs during the day. It is most often caused by stress, urinary infections, or a defect of the urinary tract.

A school-age child is admitted to the hospital in vasoocclusive sickle cell crisis. Place the prescriptions in the order of priority (first to last) that the nurse should implement them. All options must be used. 1 Start an intravenous infusion. 2 Administer morphine for the pain. 3 Draw blood for electrolyte levels and pH balance. 4 Start oxygen via nasal cannula.

1 Start an intravenous infusion. 2 Start oxygen via nasal cannula. 3 Administer morphine for the pain. 4 Draw blood for electrolyte levels and pH balance.

According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage? Industry versus inferiority Initiative versus guilt Identity versus role confusion Trust versus mistrust

Industry versus inferiority

9. A school-age child who has received burns over 60% of his body is to receive 2,000 mL of I.V. fl uid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump? ____________________ mL/hour

9. 250 mL/hour 2,000 mL ÷ 8 hours = 250 mL/hour

The nurse is teaching the mother of a newly diagnosed diabetic child about the principles of the diabetic diet. Which statement by the mother indicates effective teaching? "Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks." "By spreading the calories throughout the day in small, frequent meals, the risk of hyperglycemia is eliminated." "Most children find it difficult to eat all the calories required by their diets in three main meals." "Snacks are used to offset the desire for sweets and to keep the meals smaller so my child can eat better."

"Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks."

42. A 12-year-old with leukemia is receiving cyclophosphamide (Cytoxan). The nurse should assess for the adverse effect of: ■ 1. Photosensitivity. ■ 2. Ataxia. ■ 3. Cystitis. ■ 4. Cardiac arrhythmias

42. 3. Cystitis is a potential adverse effect of cyclophosphamide. The client should be monitored for pain on urination. Photosensitivity, ataxia, and cardiac arrhythmias are not adverse effects associated with cyclophosphamide.

What is the most appropriate method to use when drawing blood from a child with hemophilia? Apply heat to the extremity before venipunctures. Use finger punctures for lab draws. Schedule all labs to be drawn at one time. Prepare to administer platelets.

Schedule all labs to be drawn at one time. Explanation: Coordinating labs to minimize sticks reduces trauma and the risk of bleeding.

A school-age child is being discharged with a diagnosis of rheumatic fever. Which instructions should be included in the teaching plan for the family?

The child should stay on penicillin and return for a follow-up appointment.

1. A 17-year-old female with severe nodular acne is considering treatment with isotretinoin (Accutane). Prior to beginning the medication, the nurse explains that the client will be required to: ■ 1. Enroll in a risk management plan. ■ 2. Have proof of a mental health evaluation. ■ 3. Begin an effective form of birth control. ■ 4. Temporarily give up sports

1. 1. Because of the risk of birth defects with isotretinoin, the FDA has created a web-based risk management plan known as iPLEDGE. The program requires that all clients meet qualifi cation criteria and monthly program requirements to obtain the medication. Currently, only providers enrolled in the iPLEDGE program can prescribe this medication and only clients who enroll in iPLEDGE can receive the drug. Providers are advised to closely monitor clients for signs of depression, but a mental health evaluation is not universally required. Women of child bearing age must use two forms of effective birth control for two months before, during, and 1 month after taking the drug. Isotretinoin may cause muscle aches and extreme exercise should be avoided, but general participation in sports should be considered on an individual basis

13. When caring for a child with moderate burns from the waist down, which of the following should the nurse do when positioning the child? ■ 1. Place the child in a position of comfort. ■ 2. Allow the child to lie on the abdomen. ■ 3. Ensure the application of leg splints. ■ 4. Have the child fl ex the hips and knees

13. 3. A child with moderate burns is at high risk for contractures. A position of comfort would encourage contracture formation. Therefore, splints need to be applied to maintain proper positioning and joint function, thereby preventing contractures and loss of function. Allowing the child to lie on the abdomen or with hips and knees fl exed often encourages contracture formation

17. A student with type 1 diabetes tells the nurse she is feeling light-headed. The student's blood sugar is 60 mg/dL. Using the 15-15 rule, the nurse should: ■ 1. Give 15 mL of juice and give another 15 mL in 15 minutes. ■ 2. Give 15 g of carbohydrate and retest the blood sugar in 15 minutes. ■ 3. Give 15 g of carbohydrate and 15 g of protein. ■ 4. Give 15 oz of juice and retest in 15 minutes

17. 2. The 15-15 rule is a general guideline for treating hypoglycemia where the client consumes 15 g of carbohydrate and repeats testing the blood sugar in 15 minutes. Fifteen grams of carbohydrate equals 60 calories and is roughly equal to ½ cup of juice or soda, 6 to 8 lifesavers, or a tablespoon of honey or sugar. The general recommendation is if the blood sugar is still low, the client may repeat the sequence. Fifteen milliliters of juice would only provide 15 calories. This would not be suffi cient carbohydrates to treat the hypoglycemia. Protein does not treat insulin-related hypoglycemia; however a protein-starch snack may be offered after the blood glucose improves. Fifteen ounces of juice would be almost 4 times the recommended 4 oz of juice.

2. When teaching an adolescent with facial acne about skin care, the nurse should instruct the adolescent to: ■ 1. Wash the face twice a day with mild soap and water. ■ 2. Remove whiteheads and comedones after washing his face with antibacterial soap. ■ 3. Apply vitamin E ointment twice daily to the affected skin. ■ 4. Apply tretinoin (Retin-A) daily in the morning and expose the face to the sun

2. 1. Washing the face once or twice a day with a mild soap removes fatty acids from the skin. Acne is an infl ammation of the sebaceous glands that produce sebum. Washing the face with mild soap and water keeps the sebaceous glands from becoming plugged. Excessive washing or squeezing the eruptions can cause rupture of these glands, spreading the sebum and causing further infl ammation. Applying vitamin E to the lesions does not reduce the infl ammation and, due to the greasiness of the preparation, may plug the ducts. Retin-A should be applied at night. Exposure to the sun can result in sunburn and an increased risk of skin cancer and should be avoided. Sunscreen with a sun protection factor of at least 15 must be applied before the client can be exposed to the sun

20. The nurse is evaluating a child's skills in self-administering insulin. The nurse should ■ 1. Have the child use both hands on the syringe. ■ 2. Ask the child to place the needle at a 45 degree angle. ■ 3. Tell the child to use a site lower on her thigh. ■ 4. Remind the child to rotate sites

20. 4. The child is using correct injection technique, and the nurse can remind the child to rotate sites. The nurse should also reinforce that the child has used correct technique and praise the child for doing so. If the child can manipulate the plunger of the syringe with one hand, this is appropriate. Insulin is administered at a 90 degree angle as shown. The child should identify appropriate sites on the thighs as one handbreadth below the hip and above the knee; the child is using appropriate sites.

29. The nurse explains to the parents of a 1-yearold child admitted to the hospital in sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following? ■ 1. Autoimmune reaction complicated by hypoxia. ■ 2. Lack of oxygen in the red blood cells. ■ 3. Obstruction to circulation. ■ 4. Elevated serum bilirubin concentration.

29. 3. Characteristic sickle cells tend to cause "log jams" in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of the red blood cells. The erythrocytes are sickle-shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease

31. A 10-year old child is admitted to the hospital with complications related to chickenpox. The nurse should do which of the following to prevent the transmission of the infection to other children on the unit? Select all that apply. ■ 1. Place the child on contact isolation. ■ 2. Wear a gown, mask, and gloves before entering the room. ■ 3. Place the child in a room with a 10-year-old who has had chickenpox. ■ 4. Place the child in a negative air-fl ow room. ■ 5. Maintain isolation until lesions have disappeared

31. 2, 4. Gowns, mask, and gloves are needed before the nurse or anyone can enter the room of a client who has chickenpox because the varicella virus is spread by air, droplets, and contact. It is very contagious so a negative-air fl ow room is recommended. Contact isolation only includes a gown and gloves. Because varicella is spread by air and contact, a private room is needed. The child should remain in isolation until all lesions have crusted.

The nurse is assessing a child with suspected juvenile hypothyroidism. Which signs or symptoms should the nurse expect this child to manifest? dry skin and constipation rapid pulse and heat intolerance short attention span and weight loss weight loss and flushed skin

dry skin and constipation Clinical manifestations of juvenile hypothyroidism include dry skin, constipation, sparse hair, and sleepiness. Short attention span, weight loss, moist flushed skin, rapid pulse, and heat intolerance suggest hyperthyroidism.

A preschool-age child with sickle cell anemia is admitted to the health care facility in vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's highest priority when caring for this child? Maintaining protective isolation Administering antipyretics as ordered Applying cool compresses to affected joints Providing fluids

Providing fluids Explanation: During a vaso-occlusive crisis, sickle-shaped red blood cells (RBCs) clump together and obstruct blood vessels, causing ischemia and tissue damage. Therefore, the highest priority is providing I.V. and oral fluids, which promotes hemodilution and aids the free flow of RBCs through blood vessels. The client must be kept away from known infection sources but doesn't require protective isolation. Warm compresses may be applied to painful joints to promote comfort; cool compresses would cause vasoconstriction, which exacerbates sickling. Antipyretics may be administered to reduce fever but don't play a crucial role in resolving the crisis.

3. The parents of a 3-year-old suspect that the child has recently ingested a large amount of acetaminophen. The child does not appear in immediate distress. The nurse should anticipate doing which of these interventions in order of priority, from fi rst to last? 1. Draw acetaminophen serum levels. 2. Attempt to determine the exact time and amount of drug ingested 3. Administer acetylcysteine (Acetadote IV) 4. Administer activated charcoal

2. Attempt to determine the exact time and amount of drug ingested 4. Administer activated charcoal. 1. Draw acetaminophen serum levels. 3. Administer acetylcysteine (Acetadote IV)

A school nurse is examining a student at an elementary school. Which findings would lead the nurse to suspect impetigo? Vesicular lesions that ooze, forming crusts on the face and extremities Small, red lesions on the trunk and in the skin folds Red spots with a blue base found on the buccal membranes A discrete pink-red maculopapular rash that starts on the head and progresses down the body

Vesicular lesions that ooze, forming crusts on the face and extremities

A school-aged child is admitted to the hospital with newly diagnosed insulin-dependent diabetes mellitus. On admission at 1000, his blood glucose is 180 mg/dL (10 mmol/L). He receives 10 units of regular insulin subcutaneously at 1030. The nurse should plan to: carefully regulate an IV solution of normal saline and NPH insulin at 1230. begin IV administration of 5% dextrose in water at 1100. encourage the child to drink at least 500 mL of a sugar-free clear liquid by 1130. assess the child beginning at 1230 for shakiness, feelings of anxiety, or decreased level of consciousness.

assess the child beginning at 1230 for shakiness, feelings of anxiety, or decreased level of consciousness.

12. After teaching the mother of a child with severe burns about the importance of specifi c nutritional support in burn management, which of the following, if chosen by the mother from the child's diet menu, indicates the need for further instruction? ■ 1. Bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks. ■ 2. Cheeseburger, cottage cheese and pineapple salad, chocolate milk, and a brownie. ■ 3. Chicken nuggets, orange and grapefruit sections, and a vanilla milkshake. ■ 4. Beef, bean, and cheese burrito; a banana; fruit-fl avored yogurt; and skim milk.

12. 1. Hypoproteinemia is common after severe burns. The child's diet should be high in protein to compensate for protein loss and to promote tissue healing. The child will also require a diet that is high in calories and rich in iron. The menu of bacon, lettuce, and tomato sandwich; milk; and celery sticks is lacking in suffi cient protein and calories

18. An overweight adolescent has been diagnosed with type 2 diabetes. To increase the client's self-effi cacy to manage their disease, the nurse should: ■ 1. Provide the client with a written daily food and exercise plan. ■ 2. Discuss eliminating junk food in the home with the parents. ■ 3. Arrange for the school nurse to weigh the child weekly. ■ 4. Utilize a peer with type 2 diabetes to role model lifestyle changes

18. 4. Self-effi cacy, or the belief that one can act in a way to produce a desired outcome, can be promoted through the observation of role models. Peers are particularly effective role models because clients can more readily identify with them and believe they are capable of similar behaviors. Providing a written plan alone does not promote self-effi cacy. Having parents eliminate junk food and having the school nurse weigh the adolescent can be part of the plan, but these actions do not empower the client

21. An 8-year-old with newly diagnosed diabetes is in the hospital for regulation of diet and medications. The child is using an exchange method for the diet. The nurse should instruct the client that the American Diabetes Association's (ADA's) exchange method for dietary regulation includes: ■ 1. Choosing food from each exchange list. ■ 2. Using a scale to weigh all food. ■ 3. Selecting from lists that group food according to protein, fat, and carbohydrate content. ■ 4. Carbohydrate counting for each meal and snack

21. 4. Carbohydrate counting identifi es the number of grams of carbohydrate to be eaten at each meal and snack. The ADA's exchange diet allows the substitution of one food for another on the same diet list. The exchange list does not require that all food is weighed. Choices are made from lists referred to as carbohydrate, meat or meat substitute, and fat. The client's prescription identifi es how many items from each food group are to be consumed at each meal and snack. The exchange assumes that foods with similar nutrient content affect blood glucose levels in a similar manner

26. The mother asks the nurse about using a car seat for her toddler who is in a hip spica cast. The nurse should tell the mother: ■ 1. "You can use a seat belt because of the spica cast." ■ 2. "You will need a specially designed car seat for your toddler." ■ 3. "You can still use the car seat you already have." ■ 4. "You'll need to get a special release from the police so that a car seat won't be needed."

26. 2. The toddler in a hip spica cast needs a specially designed car seat. The one that the mother already has will not be appropriate because of the need for the car seat to accommodate the cast and abductor bar. Legally, all children younger than 4 years of age are required to be restrained in a car seat

35. Which of the following foods should the nurse encourage the mother to offer to her child with iron defi ciency anemia? ■ 1. Rice cereal, whole milk, and yellow vegetables. ■ 2. Potato, peas, and chicken. ■ 3. Macaroni, cheese, and ham. ■ 4. Pudding, green vegetables, and rice.

35. 2. Potatoes, peas, chicken, green vegetables, and rice cereal contain signifi cant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron. Macaroni, cheese, and ham are not high in iron. While pudding (made with fortifi ed milk) and green vegetables contain some iron, the better diet has protein and iron from the chicken and potato.

43. The parents of a child tell the nurse that they feel guilty because their child almost drowned. Which of the following remarks by the nurse would be most appropriate? ■ 1. "I can understand why you feel guilty, but these things happen." ■ 2. "Tell me a little bit more about your feelings of guilt." ■ 3. "You should not have taken your eyes off of your child." ■ 4. "You really shouldn't feel guilty; you're lucky because your child will be all right.

43. 2. Guilt is a common parental response. The parents need to be allowed to express their feelings openly in a nonthreatening, nonjudgmental atmosphere. Telling the parents that these things happen does not allow them to verbalize their feelings. Telling the parents that they should not have taken their eyes off the child blames them, possibly further contributing to their guilt. Telling the parents that they shouldn't feel guilty denies the parents' feelings of guilt and is inappropriate. Telling the parents that they are lucky that the child will be okay does not remove the feelings of guilt

49. The nurse and parents are planning for the discharge of a child with leukemia who is receiving dactinomycin (actinomycin D) and vincristine (Oncovin). The nurse should teach the parents to: ■ 1. Encourage increased fl uid intake. ■ 2. Keep the child out of the sun. ■ 3. Monitor the child's heart rate. ■ 4. Observe the child for drowsiness

49. 1. Dactinomycin and vincristine both cause nausea and vomiting. Oral fl uids are encouraged, and antiemetics are given to prevent dehydration. Avoiding sun exposure is not necessary because photosensitivity is not associated with these drugs. Heart rate changes and drowsiness also are not associated with either of these two drugs.

5. While assessing a preschooler brought by her parents to the emergency department after ingestion of kerosene, the nurse should be alert for which of the following? ■ 1. Uremia. ■ 2. Hepatitis. ■ 3. Carditis. ■ 4. Pneumonitis.

5. 4. Chemical pneumonitis is the most common complication of ingestion of hydrocarbons, such as in kerosene. The pneumonitis is caused by irritation from the hydrocarbons aspirated into the lungs. Uremia is the result of renal insufficiency, which causes nitrogenous waste products to build up in the blood rather than being excreted. Hepatitis is caused by a viral infection. Carditis in a preschooler may be the result of rheumatic fever

51. A 12-year-old with leukemia will be taking vincristine. The nurse should encourage the child to eat what kind of diet? ■ 1. High-residue. ■ 2. Low-residue. ■ 3. Low-fat. ■ 4. High-calorie

51. 1. Vincristine may cause constipation, so the client should be encouraged to eat a high-residue (fi ber) diet. The other diets do not help with constipation that can occur while receiving vincristine.

51. Which of the following actions initiated by the parents of an 8-month-old indicates they need further teaching about preventing childhood accidents? ■ 1. Placing a fi re screen in front of the fi replace. ■ 2. Placing a car seat in a front-seat, front-facing position. ■ 3. Inspecting toys for loose parts. ■ 4. Placing toxic substances out of reach or in a locked cabinet

51. 2. The recommended safety-seat arrangement for infants up to 20 lb and less than 1 year old is rear-facing with shoulder restraints. The middle of the back seat is considered the safest area of the car. Burns are a major cause of childhood accidents, and using fi re screens in front of fi replaces can help prevent children from getting too close to a fi re in a fi replace. Toys that contain loose parts or plastic eyes that can be swallowed or aspirated by small children should be avoided. Parents should inspect all toys for these parts before giving one to a child. Poisonings are most commonly caused by improper storage of a toxic substance. Keeping toxic substances in a child-proof container in a locked cabinet and continually observing the child's activities can prevent most poisonings

55. An infant has been transferred from the ICU to the pediatric fl oor after undergoing surgery to correct a heart defect. Which tasks can the nurse delegate to the licensed practical nurse (LPN)? Select all that apply. ■ 1. Administering oral medications. ■ 2. Administering I.V. morphine. ■ 3. Obtaining vital signs. ■ 4. Recording the input and output. ■ 5. Administering blood products. ■ 6. Morning hygiene. ■ 7. Circulation checks. ■ 8. Discharge teaching

55. 1, 3, 4, 6. The RN's scope of practice includes assessment, planning, implementing, and evaluation. Only aspects of care implementation may be delegated to the LPN and the exact skills which may be delegated vary by state and institution. In general, LPNs have been trained to perform the tasks of administering oral medications, performing hygiene, and recording the intake and output. LPNs may also take vital signs to gather data, but the nurse must interpret the data. Administering I.V. morphine requires assessment of the client's respiratory status before, during, and after the procedure. While institutions may allow for LPNs to monitor vital signs during a transfusion, a nurse would be in the best position to assess for a transfusion reaction. Circulation checks are assessments the nurses should complete. Discharge teaching requires an evaluation of learning and thus should be done by the nurse.

7. In an initial screening for lead poisoning a 2-year-old child is found to have a lead level of 12 mcg/dL. The nurse should: ■ 1. Arrange a follow-up appointment in 6 months. ■ 2. Obtain a consultation for chelation therapy. ■ 3. Educate parents on ways to reduce lead in the environment. ■ 4. Assure the parents this is a normal lead level

7. 3. Healthy People 2010 has set a goal of eliminating blood lead levels of greater than 10 mcg/dL in children age 1 to 5 years of age. The CDC recommends that the treatment for children with lead levels between 10 and 14 mcg/dL should include family lead education, follow-up testing, and a social service consultation if needed. Waiting 6 months for a follow-up screening is too long because the effects of lead are irreversible. Oral chelation therapy is not begun until levels approach 45 mcg/dL. There is no such thing as a "normal" lead level because there is no benefi cial action in the body

A mother tells a nurse that her child has been exposed to roseola. After teaching the mother about the illness, which finding, if stated by the mother as the most characteristic sign of roseola, indicates successful teaching? high fever followed by a drop and then a rash normal temperature followed by a low-grade fever fever and sore throat cold-like signs and symptoms and a rash

high fever followed by a drop and then a rash

A nurse is planning care for a 12-year-old with rheumatic fever. The nurse should teach the parents to: allow the child to participate in activities that will not tire him. provide for adequate periods of rest between activities. observe the child closely. encourage someone in the family to be with the child 24 hours a day.

provide for adequate periods of rest between activities. The nurse should teach the parents to provide for sufficient periods of rest to decrease the client's cardiac workload.

A 5-year-old child with burns on the trunk and arms has no appetite. The nurse and parent develop a plan of care to stimulate the child's appetite. Which suggestion made by the parent would indicate the need for additional teaching? offering the child finger foods that the child likes serving smaller and more frequent meals withholding dessert and treats unless meals are eaten deciding that the parent will feed the child

withholding dessert and treats unless meals are eaten Withholding certain foods until the child complies is punitive and rarely successful. Allowing the parent to feed the child, serving smaller and more frequent meals, and offering finger foods are all acceptable interventions for a 5-year-old child. This is true whether the child is well or ill.

11. A 5-year-old child with burns on the trunk and arms has no appetite. The nurse and mother develop a plan of care to stimulate the child's appetite. Which of the following suggestions made by the mother would indicate that she needs additional teaching? ■ 1. Deciding that she will feed the child herself. ■ 2. Withholding dessert and treats unless meals are eaten. ■ 3. Offering the child fi nger foods that the child likes. ■ 4. Serving smaller and more frequent meals

11. 2. Withholding certain foods until the child complies is punitive and rarely successful. Allowing the mother to feed the child, serving smaller and more frequent meals, and offering fi nger foods are all acceptable interventions for a 5-year-old child. This is true whether the child is well or ill

19. After 6 months of treatment with diet and exercise, a 12-year-old with type 2 diabetes still has a fasting blood glucose level of 140 mg/dL. The primary care provider has decided to begin metformin (Glucophage). The adolescent asks how the medication works. The nurse should tell the client that the medicine decreases the glucose production and: ■ 1. Replaces natural insulin. ■ 2. Helps the body make more insulin. ■ 3. Increases insulin sensitivity. ■ 4. Decreases carbohydrate adsorption

19. 3. Metformin is currently approved by the FDA to treat type 2 diabetes in children. The medication decreases glucogenesis in the liver and increases insulin sensitivity in the peripheral tissues. Only insulin can actually replace insulin. This treatment is reserved for clients with type 1 diabetes or those with type 2 who do not respond to diet, exercise, and an oral diabetic agent. Other oral medications used to treat diabetes augments insulin production or decreases carbohydrate absorption, but those medications are primarily used in adults.

2. After the acute stage following an ingestion of drain cleaner by a child, the nurse should be alert for the development of which of the following as a likely complication? ■ 1. Tracheal stenosis. ■ 2. Tracheal varices. ■ 3. Esophageal strictures. ■ 4. Esophageal diverticula

2. 3. As the burn from the lye ingestion heals, scar tissue develops and can lead to esophageal strictures, a common complication of lye ingestion. Tracheal stenosis would occur if the child had vomited and aspirated. Tracheal varices do not commonly occur after the ingestion of lye or other substances. Although very rare, esophageal diverticula may occur. Diverticula are commonly found in the colon of adults

22. A 14-year-old is using glargine (Lantus) and lispro (Humolog) to manage type I diabetes. The order for sliding scale lispro reads: Lispro subcutaneous give units according to sliding scale: Blood glucose: 70 - 150 mg/dL = 0 units 151-200 mg/dL = 1 unit 201-250 mg/dL = 2 units 251-300 mg/dL = 3 units 301-350 mg/dL = 4 units Call for Blood glucose > 350 In addition give 1 unit for every 15 grams of carbohydrate. The morning blood glucose is 202 mg/dL and the client is going to eat 2 carbohydrate exchanges. The nurse has the client administer how many units of lispro? ______________________units

22. 4 units. Each carbohydrate food exchange has 15 grams of carbohydrate. Two units are needed to cover the current blood glucose and 2 units are needed to cover the anticipated carbohydrate intake.

3. A 9-month-old infant with eczema has lesions that are secondarily infected. Which of the following is most appropriate to help the parents best meet the needs of the child? ■ 1. Preventing siblings from being in close contact. ■ 2. Sending the child to day care as usual. ■ 3. Playing video games for several hours each evening. ■ 4. Playing with the child every day

3. 4. The parents can best meet the needs of their 9-month-old infant by playing with the child every day. All infants need time with their parents to develop trust and thus attain optimal development. The parents of a child with a chronic problem may need more guidance to meet the child's needs because of the focus on medical problems. The child's lesions are secondarily infected and therefore should not be contagious. Siblings do not need to stay away. Even with lesions that are infected, the child can still attend day care, but the child needs attention from the parents as well. Playing video games for several hours is not appropriate for a 9-month-old infant

30. The mother asks the nurse why her child's hemoglobin was normal at birth but now the child has S hemoglobin. Which of the following responses by the nurse is appropriate? ■ 1. "The placenta bars passage of the hemoglobin S from the mother to the fetus." ■ 2. "The red bone marrow does not begin to produce hemoglobin S until several months after birth." ■ 3. "Antibodies transmitted from you to the fetus provide the newborn with temporary immunity." ■ 4. "The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth."

30. 4. Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of a newborn's hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin S begins to replace the fetal hemoglobin. The gene for sickle cell disease is transmitted at the time of conception, not passed through the placenta. Some hemoglobin S is produced by the fetus near term. The fetus produces all its own hemoglobin from the earliest production in the fi rst trimester. Passive immunity conferred by maternal antibodies is not related to sickle cell disease, but this transmission of antibodies is important to protect the infant from various infections during early infancy.

32. The mother of an 8-year-old with diabetes tells the nurse that she does not want the school to know about her daughter's condition. The nurse should reply: ■ 1. "I think that would be a good idea." ■ 2. "What is it that concerns you about having the school know about your daughter's condition?" ■ 3. "It would be fine not to tell your daughter's friends, but the teacher must know." ■ 4. "In order to keep your daughter safe, it is necessary for all adults in the school to know her condition."

32. 2. The nurse's fi rst response should be to obtain more information about the mother's concerns. It is true that the child may have a diabetic reaction anywhere at school, and it is advisable that her teacher, classmates, and other adults know about her diabetes in order to help her; however, it is ultimately the client and her parents who will make the decision about informing the school. The nurse can facilitate a dialogue that will help the mother reach this decision. Dictating to the mother does not explain any rationale for the necessity of the information

4. When developing the plan of care for a toddler who has taken an acetaminophen overdose, which of the following should the nurse expect to include as part of the initial treatment? ■ 1. Frequent blood level determinations. ■ 2. Gastric lavage. ■ 3. Tracheostomy. ■ 4. Electrocardiogram

4. 2. Initial management of a child who has ingested a large amount of acetaminophen would include inducing vomiting or performing gastric lavage with or without activated charcoal to aid in the removal of the substance. Frequent blood level determinations may be obtained during the follow-up phase, but they are not done as part of the initial treatment. Tracheostomy is not typically part of the initial treatment for acetaminophen overdose. However, it may be necessary later if respiratory distress develops. Acetaminophen primarily affects the liver, not the heart. Therefore, an electrocardiogram would not be considered part of the initial treatment plan

26. The nurse talks to an adolescent about how she can tell her friends about her new diagnosis of diabetes. Which of the following behaviors by the adolescent indicates that the adolescent has responded positively to the discussion? ■ 1. She asks the nurse for material on diabetes for a school paper. ■ 2. She introduces the nurse to her friends as "the one who taught me all about my diabetes." ■ 3. She says, "I'll try to tell my friends, but they'll probably quit hanging out with me." ■ 4. She asks her friends what they think about someone who has a lifelong illness.

26. 2. The ability to talk about her diabetes indicates that the adolescent feels good enough about herself to share her problem with her peers. Asking for reference material does not specifi cally indicate that the client's self-esteem has improved or that she has accepted her diagnosis. Saying that her friends will probably desert her if she tells them about the illness indicates that the adolescent still needs to work on her self-esteem and her feelings about the disease. Asking her friends what they think of someone with a lifelong illness would not indicate that the nurse's interventions targeted toward improving self-esteem have been successful. Rather, this statement demonstrates the adolescent's uncertainty about herself

28. An adolescent with insulin-dependent diabetes is being taught the importance of rotating the sites of insulin injections. The nurse should judge that the teaching was successful when the adolescent identifi es which of the following as a result of using the same site? ■ 1. Destruction of the fat tissue and poor absorption. ■ 2. Destruction of nerves and painful neuritis. ■ 3. Destruction of the tissue and too-rapid insulin uptake. ■ 4. Development of resistance to insulin and need for increased amounts

28. 1. Repeated use of the same injection site can result in atrophy of the fat in the subcutaneous tissue and lead to poor insulin absorption. The neuritis that develops from diabetes is related to microvascular changes that occur. Subcutaneous tissue is not destroyed and insulin is not rapidly absorbed. Resistance to insulin is caused by an immune response to the insulin protein.

39. Because of the risks associated with administration of factor VIII concentrate, the nurse should teach the child's family to recognize and report which of the following? ■ 1. Yellowing of the skin. ■ 2. Constipation. ■ 3. Abdominal distention. ■ 4. Puffi ness around the eyes

39. 1. Because factor VIII concentrate is derived from large pools of human plasma, the risk of hepatitis is always present. Clinical manifestations of hepatitis include yellowing of the skin, mucous membranes, and sclera. Use of factor VIII concentrate is not associated with constipation, abdominal distention, or puffi ness around the eyes

44. Laboratory fi ndings indicate that a child with leukemia is also anemic. The nurse interprets this fi nding as most likely resulting from which of the following? ■ 1. Inadequate dietary folic acid intake. ■ 2. Decreased red blood cell production. ■ 3. Increased destruction of red blood cells by lymphocytes. ■ 4. Progressive replacement of bone marrow with scar tissue

44. 2. The anemia seen in children with leukemia is caused by the bone marrow's overproduction of immature white blood cells at the expense of producing red blood cells and platelets. In this client, anemia is not caused by an inadequate intake of iron but, rather, by insuffi cient red blood cells. The anemia is not caused by destruction of red blood cells by lymphocytes or by the replacement of bone marrow with scar tissue

46. Which of the following beverages should the nurse plan to give a child with leukemia to relieve nausea? ■ 1. Orange juice. ■ 2. Weak tea. ■ 3. Plain water. ■ 4. A carbonated beverage

46. 4. Carbonated beverages ordinarily are the best tolerated when a child feels nauseated. Many children fi nd cola drinks especially easy to tolerate, but noncola beverages are also recommended. Orange juice usually is not tolerated well because of its high acid content. Tea may also be too acidic and many children do not like tea. Water does not relieve nausea

50. After doing well for a period of time, a child with leukemia develops an overwhelming infection. The child's death is imminent. Which of the following statements offers the nurse the best guide in making plans to assist the parents in dealing with their child's imminent death? ■ 1. Knowing that the prognosis is poor helps prepare relatives for the death of children. ■ 2. Relatives are especially grieved when a child does well at fi rst but then declines rapidly. ■ 3. Trust in health care personnel is most often destroyed by a death that is considered untimely. ■ 4. It is more diffi cult for relatives to accept the death of an older child than that of a toddler

50. 2. It has been found that parents are more grieved when optimism is followed by defeat. The nurse should recognize this when planning various ways to help the parents of a dying child. It is not necessarily true that knowing about a poor prognosis for years helps prepare parents for a child's death. Death is still a shock when it occurs. Trust in health care personnel is not necessarily destroyed when a death is untimely if the family views the personnel as having done all that was possible. It is not more diffi cult for parents to accept the death of an older child than that of a younger child

54. A transfusion of packed red blood cells has been ordered for a 1-year-old with a sickle cell anemia. The infant has a 25 gauge I.V. infusing dextrose with sodium and potassium. Using the Situation, Background, Assessment, Recommendation (SBAR) method of communication, the nurse contacts the physician and recommends: ■ 1. Starting a second I.V. with a 22 gauge catheter to infuse normal saline with the blood. ■ 2. Using the existing I.V., but changing the fl uids to normal saline for the transfusion. ■ 3. Replacing the I.V. with a 22 gauge catheter to infuse the ordered fl uids. ■ 4. Starting a second I.V. with a 25 gauge catheter to infuse normal saline with the transfusion.

54. 2. The best evidence indicates that a catheter as small as 27 gauge may safely be used for transfusion in children, but blood must be infused with normal saline, not dextrose. A 1-year-old should be able to maintain their blood glucose for the 2 hour duration of the infusion without the need for a second I.V.

6. When developing the teaching plan for the mother of a 2-year-old child diagnosed with scabies, which of the following points should the nurse expect to include? ■ 1. The fl oors of the house should be cleaned with a damp mop. ■ 2. The child should be held frequently. ■ 3. Itching should cease in a few days. ■ 4. The entire family should be treated

6. 4. Scabies is caused by the scabies mite, Sarcoptes scabiei. The mite burrows into the stratum corneum of the epidermis, where the female deposits eggs and fecal material. These burrows are linear. Scabies is highly contagious. The length of time from infestation to physical symptoms is 30 to 60 days, so everyone in close contact with the child will need to be treated. The bed linens and the child's clothing should be washed in hot water and dried on the hot setting. It is not necessary to damp mop the fl oors to prevent the spread of scabies. The child should be held minimally until treatment is completed. Family members should wash their hands after contact with the child. Itching lasts for 2 to 3 weeks until the stratum corneum is replaced.

7. A 10-year-old has just spilled hot liquid on his arm, and a 4-inch area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do? ■ 1. Keep the child warm. ■ 2. Cover the burned area with an antibiotic cream. ■ 3. Apply cool water to the burned area. ■ 4. Call 911 to transport the child to the hospital.

7. 3. To prevent further injury to the skin, the mother should apply cool water to the burn site. Doing so causes vasoconstriction, retards further damage to tissues, and decreases fl uid loss. Keeping the child warm promotes vasodilation, increases fl uid loss, and decreases blood pressure and, thus, circulation to the area. Applying ointment to the burn is contraindicated because it does not allow healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or chilling. If only the arm is burned, a call to 911 for emergency care is not necessary, but the mother should seek health care services immediately

7. The nurse is discharging an 8-month-old who weighs 15 lb from the hospital. The parents have put the child in the back seat of the car with the car seat facing the front. The nurse should: ■ 1. Ask the parents to wait while obtaining the correct car seat. ■ 2. Complete the discharge with the child sitting facing the front seat. ■ 3. Give the parents a manual on proper car seat placement. ■ 4. Explain the need for the rear-facing position and request assistance from a car seat technician

7. 4. Proper car seat placement for a child younger than 1 year or weighing less than 20 lb is facing the rear of the car. Without specialized training, nurses may not understand how to correctly use all brands of car seats. Families who need help installing car seats should be referred to persons who have had specialized training. The car seat is not in question and does not need to be replaced. Keeping the infant in an incorrect position while completing the discharge reinforces the incorrect placement. The parents are unlikely to read a manual, especially since the child is 8 months old and it is very likely that they have been using this position since birth. Additionally, the manual may not be specifi c for their brand of car seat.

8. When teaching the mother of a toddler diagnosed with lead poisoning, which of the following should the nurse include as the most serious complication if the condition goes untreated? ■ 1. Cirrhosis of the liver. ■ 2. Stunted growth rate. ■ 3. Neurologic defi cits. ■ 4. Heart failure.

8. 3. The most serious and irreversible consequence of lead poisoning is mental retardation due to neurologic changes. It can be expected if lead poisoning is long-standing and goes untreated. Lead poisoning also affects the hematologic and renal systems. Cirrhosis is the end stage of several chronic liver diseases, such as biliary atresia and hepatitis. Lead poisoning is not associated with stunted growth. Chronic illnesses, such as cystic fi brosis, cause slowing of the growth velocity. Heart failure is associated with congenital heart disease and rheumatic fever.

24. A nurse is teaching an 8-year-old with diabetes and her parents about managing diabetes during illness. The nurse determines the parents understand the instruction when they indicate that, when the child is ill, they will provide: ■ 1. More calories. ■ 2. More insulin. ■ 3. Less insulin. ■ 4. Less protein and fat

24. 2. The child needs more insulin during an illness, because the cells becomes more insulin resistant during illness and need more insulin to achieve a normal blood glucose level. During an acute illness, simple carbohydrates and fl uids are usually tolerated best

52. A 10-year-old with leukemia is taking immunosuppressive drugs. To maintain health the nurse should instruct the child and parents to: ■ 1. Continue with immunizations. ■ 2. Not receive any live attenuated vaccines. ■ 3. Receive vitamin and mineral supplements. ■ 4. Stay away from peers

52. 2. Children who are immunosuppressed should not receive any live attenuated vaccines. Clients who are immunosuppressed and are given live attenuated vaccines such as measles, mumps, rubella and oral polio vaccine can develop severe forms of the diseases for which they are being immunized, which can result in death. Inactivated vaccines may be given if necessary, but the client is not able to adequately produce needed antibodies and it is recommended that immunizations be delayed for 3 months after the immunosuppressive drugs have be discontinued. Vitamin and mineral supplements are not normally given in conjunction with immunosuppressive drugs. When the client is immunosuppressed, the client should avoid only persons who have an infection. CN: Health promotion and

53. A nurse is teaching the family of an 8-yearold boy with acute lymphocytic leukemia about appropriate activities. Which of the following activities should the nurse recommend? ■ 1. Home schooling. ■ 2. Restriction from participating in athletic activities. ■ 3. Avoiding trips to the shopping mall. ■ 4. Being treated as "normal" as much as possible.

53. 4. Any child with a chronic illness should be treated as normally as possible. Unless the child has severe bone marrow depression, he should be allowed to go to school with others and can go to the mall. If the child is in remission, athletic activities are allowed.

A nurse is caring for a child with intussusception. What is an expected outcome for a goal to relieve acute pain from abdominal cramping? The child exhibits no manifestations of discomfort. The child has a normal bowel movement. The child has not vomited in 3 hours. The child is very still.

The child exhibits no manifestations of discomfort. Explanation: An expected client outcome for a goal to reduce acute pain related to cramping is that the client exhibits no manifestations of discomfort, such as crying or drawing the legs to the abdomen. Being very still may indicate either a pain state or a state of relaxation, and the nurse would need to assess the client further. Having normal bowel movements and not vomiting are desired outcomes, but the goal here is to relieve the pain.

A child who was hospitalized for sickle cell crisis is being discharged. Which parent outcome demonstrates effective teaching regarding prevention of future crises? The parent verbalizes appropriate dietary restrictions. The parent participates in an aerobic exercise program. The parent verbalizes the need to stay away from persons with known infections. The parent verbalizes the need to restrict fluid intake.

The parent verbalizes the need to stay away from persons with known infections. Explanation: Preventing infections through proper hand washing and staying away from persons with known infections is an important measure in preventing sickle cell crises. Dietary restrictions aren't significant in preventing these crises. The client should maintain adequate hydration, not restrict fluid intake, and should avoid strenuous activity such as aerobics.

1. A toddler is brought to the emergency room after ingesting an undetermined amount of drain cleaner. The nurse should expect to assist with which of the following fi rst? ■ 1. Administering an emetic. ■ 2. Performing a tracheostomy. ■ 3. Performing gastric lavage. ■ 4. Inserting an indwelling urinary (Foley) catheter

1. 2. Drain cleaner almost always contains lye, which can burn the mouth, pharynx, and esophagus on ingestion. The nurse would be prepared to assist with a tracheostomy, which may be necessary because of swelling around the area of the larynx. An emetic is contraindicated because, as the substance burns on ingestion, so too would it burn when vomiting. Additionally, the mucosa becomes necrotic and vomiting could lead to perforations. Gastric lavage is contraindicated because the mucosa is burned from the ingestion of the caustic lye, causing necrosis. Gastric lavage also could lead to perforation of the necrotic mucosa. Insertion of an indwelling urinary (Foley) catheter would be indicated after the measures to remove the caustic substance have been started.

10. Which of the following would be most appropriate to institute when a school-age child with burns becomes angry and combative when it is time to change the dressings and apply mafenide acetate (Sulfamylon)? ■ 1. Ensure parental support during the dressing changes. ■ 2. Allow the child to assist in removing the dressings and applying the cream. ■ 3. Give the child permission to cry during the procedure. ■ 4. Allow the child to schedule the time for dressing changes

10. 2. Expressions of anger and combativeness are often the result of loss of control and a feeling of powerlessness. Some control over the situation is regained by allowing the child to participate in care. Although having parental support during the dressing changes may be helpful, this action does nothing to allow the child control. Giving the child permission to cry may help with verbalizing feelings, but doing so does nothing to provide the child with control over the situation. Although allowing the child to determine the time for dressing changes may provide a sense of control over the situation, doing so is inappropriate because the dressing changes need to be performed as ordered to ensure effectiveness and healing

28. The nurse is teaching the parents of a child with sickle cell disease. To instruct them on how to prevent sickle cell crisis, she should include which instruction? ■ 1. Restrict the child's fl uid intake to less than 1 quart per day. ■ 2. Drink at least 2 quarts of fl uids per day. ■ 3. Stay away from other teenagers. ■ 4. Avoid physical activity

2. Increasing fl uid intake and being well hydrated will help prevent cell stasis in the small vessels. Restricting fl uids causes stasis of red blood cells and promotes obstruction and increases the chance of sickling with hypoxia and pain to the part that is involved. Clients with sickle cell disease should stay away from others who have infections. When the spleen of a client who has sickle cell disease has become fi brotic and nonfunctional, the client is more susceptible to infections. Clients with sickle cell disease should not avoid physical activity as long as the client stays well hydrated

23. An 8-year-old with diabetes is placed on neutral protamine Hagedorn (NPH) and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. The snack will: ■ 1. Help her regain lost weight. ■ 2. Provide carbohydrates for immediate use. ■ 3. Prevent late night hypoglycemia. ■ 4. Help her stay on her diet

23. 3. NPH insulin peaks in 6 to 8 hours, which would occur during sleep. A bedtime snack is needed to prevent late night hypoglycemia. The snack is not given to help regain weight. Milk contains fat and protein which cause delayed absorption into the blood stream and maintains the blood glucose level at night when the NPH insulin will peak. The snack is not used to provide carbohydrates for immediate use because NPH insulin, unlike regular insulin, does not peak immediately. The snack has nothing to do with a diet

25. A nurse is assessing an 8-year-old with diabetes who is experiencing hyperglycemia. Which symptom (s) indicate (s) that the hyperglycemia requires immediate intervention? Select all that apply. ■ 1. Weakness. ■ 2. Thirst. ■ 3. Shakiness. ■ 4. Hunger. ■ 5. Headache. ■ 6. Irritability. ■ 7. Dizziness

25. 1, 2, 7. Weakness, thirst, and dizziness are symptoms related to dehydration caused by excretion of large amounts of glucose and water in the urine. The nurse should notify the physician. Shakiness, hunger, headache, and irritability are related to hypoglycemia and result from the brain and other cells being starved for nutrients

27. When developing the teaching plan for the mother and a child with insulin-dependent diabetes about sick-day management, which of the following instructions should the nurse include? ■ 1. Adhere to the same schedule and type and amount of insulin. ■ 2. Immediately call the physician for information about what to do. ■ 3. Adjust insulin based on more frequent testing of blood glucose levels. ■ 4. Take the child to the emergency department for immediate care

27. 3. Sick-day management requires more frequent monitoring of the child's blood glucose to evaluate for changes associated with a decreased intake and absorption of food, commonly associated with illness. Based on the child's glucose levels, insulin adjustments may be needed. In this case, regular insulin is used. Adhering to the same schedule, type, and amount of insulin is inappropriate because the child's ability to take in food and absorb nutrients can change rapidly. Typically, the child and parents are provided with specifi c instructions about sick-day management rules. Commonly the physician will prescribe adjustments to insulin (e.g., on a sliding scale) based on the child's blood glucose levels. Therefore, calling the physician to report that the child is ill and ask what to do is inappropriate. However, the parents do need to notify the physician should any problems arise with management of the child's blood glucose levels. The child who can tolerate oral feedings of simple sugars can be kept at home as long as the parents monitor the child's blood glucose levels frequently for changes.

31. Which of the following is the priority nursing diagnosis during a toddler's vasoocclusive sickle cell crisis? ■ 1. Ineffective coping related to presence of a lifethreatening disease. ■ 2. Decreased cardiac output related to abnormal hemoglobin formation. ■ 3. Pain related to tissue anoxia. ■ 4. Excess fl uid volume related to infection

31. 3. For the child in sickle cell crisis, Pain is the priority nursing diagnosis because the sickled cells clump and obstruct the blood vessels, leading to occlusion and subsequent tissue ischemia. Although Ineffective coping may be important, it is not the priority. Decreased cardiac output is not a problem with this type of vasoocclusive crisis. Typically, a sickle cell crisis can be precipitated by a fl uid volume defi cit or dehydration.

32. Which of the following actions indicates that the parents of a 12-month-old with iron defi ciency anemia understand how to administer iron supplements? Select all that apply. ■ 1. They administer iron supplements in combination with fruit juice. ■ 2. They administer iron supplements with meals. ■ 3. They report dark stools. ■ 4. They brush the child's teeth after administering the iron supplements. ■ 5. They decrease dietary intake of foods fortifi ed with iron

32. 1, 4. Parent teaching concerning a child with iron defi ciency anemia should include directions about giving iron combined with fruit juice, in divided doses, between meals, and with a dropper for a 12-month-old or through a straw for older toddlers. Iron stains teeth; so brushing the teeth and administering liquid iron through a dropper or straw are necessary to prevent staining the teeth. Iron should not be given with milk, antacids, or tea and should be administered on an empty stomach. Iron will cause the stool to become black or green, which is normal and does not need to be reported. However, light-colored stools indicate the iron is not being absorbed and should be reported

33. A mother asks the nurse if her child's iron defi ciency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following? ■ 1. Little is known about iron defi ciency anemia and its relationship to infection in children. ■ 2. Children with iron defi ciency anemia are more susceptible to infection than are other children. ■ 3. Children with iron defi ciency anemia are less susceptible to infection than are other children. ■ 4. Children with iron defi ciency anemia are equally as susceptible to infection as are other children

33. 2. Children with iron defi ciency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.

34. Which statements by the mother of a toddler should lead the nurse to suspect that the child is at risk for iron defi ciency anemia? Select all that apply. ■ 1. "He drinks over three cups of milk per day." ■ 2. "I can't keep enough apple juice in the house; he must drink over 10 oz per day." ■ 3. "He refuses to eat more than two different kinds of vegetables." ■ 4. "He doesn't like meat, but he will eat small amounts of it." ■ 5. "He sleeps 12 hours every night and takes a 2-hour nap."

34. 1, 2. Toddlers should have between two and three cups of milk per day and 8 oz of juice per day. If they have more than that, then they are probably not eating enough other foods, including iron-rich foods that have the needed nutrients. Food preferences vary among children. It is acceptable for the child to refuse foods as long as the diet is balanced and contains adequate calories. The child is obtaining a normal amount of sleep.

36. What is the most appropriate method to use when drawing blood from a child with hemophilia? ■ 1. Use fi nger punctures for lab draws. ■ 2. Be prepared to administer platelets for prolonged bleeding. ■ 3. Apply heat to the extremity before venipunctures. ■ 4. Schedule all labs to be drawn at one time.

36. 4. Coordinating labs to minimize sticks reduces trauma and the risk of bleeding. Finger sticks in general are more painful and associated with more bleeding than venipunctures. In hemophilia, platelets are typically normal. Heat would increase vasodilatation and increase bleeding

37. A diagnosis of hemophilia A is confi rmed in an infant. Which of the following instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl? ■ 1. Administer one-half of a children's aspirin for a temperature higher than 101° F (38.3° C). ■ 2. Sew thick padding into the elbows and knees of the child's clothing. ■ 3. Check the color of the child's urine every day. ■ 4. Expect the eruption of the primary teeth to produce moderate to severe bleeding.

37. 2. As the hemophilic infant begins to acquire motor skills, the risk of bleeding increases because of falls and bumps. Such injuries can be minimized by padding vulnerable joints. Aspirin is contraindicated because of its antiplatelet properties, which increase the infant's risk for bleeding. Because genitourinary bleeding is not a typical problem in children with hemophilia, urine testing is not indicated. Although some bleeding may occur with tooth eruption, it does not normally cause moderate to severe bleeding episodes in children with hemophilia.

38. A child with hemophilia presents with a burning sensation in the knee and reluctance to move the body part. The nurse collaborates with the care team to provide factor replacement and: ■ 1. Administer an aspirin-containing compound. ■ 2. Institute Rest, Ice, Compression, and Elevation (RICE). ■ 3. Begin physical therapy with active range of motion. ■ 4. Initiate skin traction

38. 2. The child is displaying symptoms of bleeding in the joint and factor replacement is indicated. The RICE method is used additionally as a supportive measure to help control the bleeding. Aspirin containing compounds contribute to bleeding and should never be used to control pain. Physical therapy is instituted after the acute bleeding to prevent further damage. Orthopedic traction is considered in some rare cases during the rehabilitation phase, but not the acute phase

4. After the nurse teaches the mother of a child with atopic dermatitis how to bathe her child, which of the following statements by the mother indicates effective teaching? ■ 1. "I let my child play in the tub for 30 minutes every night." ■ 2. "My child loves the bubble bath I put in the tub." ■ 3. "When my child gets out of the tub I just pat the skin dry." ■ 4. "I make sure my child has a bath every night."

4. 3. Atopic dermatitis is a chronic pruritic dermatitis that usually begins in infancy. Many of the children diagnosed with it have a family history of eczema, allergies, or asthma. Atopic dermatitis is best treated with hydrating the skin, controlling the pruritus, and preventing secondary infection. Patting the skin dry removes less natural skin moisturizer and thus maintains skin hydration. Water has a drying effect on the skin. Playing in the tub for 30 minutes each night would deplete the skin of its natural moisturizers, thereby leading to increased pruritus and dry skin. Bubble baths are to be avoided in children with atopic dermatitis because they may act as an irritant, possibly exacerbating the condition. Also, bubble baths deplete the skin of its natural moisturizers. The issue is not whether the child bathes every night. Rather, the goal is to decrease dryness and itching

27. A 14-year-old girl with sickle cell disease has her fourth hospitalization for sickle cell crisis. Her family is planning a ski vacation in the mountains. What should the nurse tell the parents? ■ 1. Encourage them to go on the trip. ■ 2. Go on the trip, but fi nd a sitter for the 14-yearold. ■ 3. Suggest the trip be postponed until next year. ■ 4. Explain that the high altitude may cause a crisis.

4. High altitude causes deoxygenation, which might precipitate a crisis. In clients with sickle cell anemia, cells sickle when the client experiences any situation where increased demand for oxygen is needed, such as in an infection or dehydration, or when low oxygen concentration is experienced, such as in high altitudes or deep sea diving. Crises can commonly be prevented by maintaining hydration. It would be unsafe to encourage the family, or to say nothing about taking the client to high altitude areas, but giving the parents adequate information will allow them to make an appropriate decision. Postponing the trip or leaving the child at home does not address the immediate concern for the child's health.

40. The mother tells the nurse she will be afraid to allow her child with hemophilia to participate in sports because of the danger of injury and bleeding. After explaining that physical fi tness is important for children with hemophilia, which of the following activities should the nurse suggest as ideal? ■ 1. Snow skiing. ■ 2. Swimming. ■ 3. Basketball. ■ 4. Gymnastics

40. 2. Swimming is an ideal activity for a child with hemophilia because it is a noncontact sport. Many noncontact sports and physical activities that do not place excessive strain on joints are also appropriate. Such activities strengthen the muscles surrounding joints and help control bleeding in these areas. Noncontact sports also enhance general mental and physical well-being. Falls and subsequent injury to the child may occur with snow skiing. Basketball is a contact sport and therefore increases the child's risk for injury. Gymnastics is a very strenuous sport. Gymnasts frequently have muscle and joint injuries that result in bleeding episodes.

41. A 15-year-old has been admitted to the hospital with the diagnosis of acute lymphocytic leukemia. Which of the following signs and symptoms require the most immediate nursing intervention? ■ 1. Fatigue and anorexia. ■ 2. Fever and petechiae. ■ 3. Swollen neck lymph glands and lethargy. ■ 4. Enlarged liver and spleen.

41. 2. Fever and petechiae associated with acute lymphocytic leukemia indicate a suppression of normal white blood cells and thrombocytes by the bone marrow and put the client at risk for other infections and bleeding. The nurse should initiate infection control and safety precautions to reduce these risks. Fatigue is a common symptom of leukemia due to red blood cell suppression. Although the client should be told about the need for rest and meal planning, such teaching is not the priority intervention. Swollen glands and lethargy may be uncomfortable but they do not require immediate intervention. An enlarged liver and spleen do require safety precautions that prevent injury to the abdomen; however, these precautions are not the priority.

41. The nurse is admitting a toddler with the diagnosis of near-drowning in a neighbor's heated swimming pool to the emergency department. The nurse should assess the child for: ■ 1. Hypothermia. ■ 2. Hypoxia. ■ 3. Fluid aspiration. ■ 4. Cutaneous capillary paralysis

41. 2. Hypoxia is the primary problem because it results in brain cell damage. Irreversible brain damage occurs after 4 to 6 minutes of submersion. Hypothermia occurs rapidly in infants and children because of their large body surface area. Hypothermia is more of a problem when the child is in cold water. Although fl uid aspiration occurs in most drownings and results in atelectasis and pulmonary edema, further aggravating hypoxia, hypoxia is the primary problem. Cutaneous capillary paralysis is not a problem.

41. When teaching a mother about measures to prevent lead poisoning in her children, which of the following preventive measures should the nurse include as the most effective? ■ 1. Condemning of old housing developments. ■ 2. Educating the public on common sources of lead. ■ 3. Educating the public on the importance of good nutrition. ■ 4. Keeping pregnant women out of old homes that are being remodeled

41. 2. Public education about the sources of lead that could cause poisoning has been found to be the most effective measure to prevent lead poisoning. This includes recent efforts to alert the public to lead in certain types of window blinds. Condemning old housing developments has been ineffective because lead paint still exists in many other dwellings. Providing education about good nutrition, although important, is not an effective preventive measure. Pregnant women and children should not remain in an older home that is being remodeled because they may breathe in lead in the dust, but this is not the most effective preventive measure.

42. The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should fi rst: ■ 1. Administer oxygen. ■ 2. Institute rewarming. ■ 3. Prepare for intubation. ■ 4. Start an intravenous infusion

42. 1. Near-drowning victims typically suffer hypoxia and mixed acidosis. The priority is to restore oxygenation and prevent further hypoxia. Here, the client has blunted sensorium, but is not unconscious; therefore, delivery of supplemental oxygen with a mask is appropriate. Warming protocols and fl uid resuscitation will most likely be needed to help correct acidosis, but these interventions are secondary to oxygen administration. Intubation is required if the child is comatose, shows signs of airway compromise, or does not respond adequately to more conservative therapies.

43. After teaching the parents of a child newly diagnosed with leukemia about the disease, which of the following descriptions given by the mother best indicates that she understands the nature of leukemia? ■ 1. "The disease is an infection resulting in increased white blood cell production." ■ 2. "The disease is a type of cancer characterized by an increase in immature white blood cells." ■ 3. "The disease is an infl ammation associated with enlargement of the lymph nodes." ■ 4. "The disease is an allergic disorder involving increased circulating antibodies in the blood."

43. 2. Leukemia is a neoplastic, or cancerous, disorder of blood-forming tissues that is characterized by a proliferation of immature white blood cells. Leukemia is not an infection, infl ammation, or allergic disorder

45. Which of the following statements should the nurse use to describe to the parents why their child with leukemia is at risk for infections? ■ 1. "Play activities are too strenuous." ■ 2. "Vitamin C intake is reduced over a period of time." ■ 3. "The number of red blood cells is inadequate for carrying oxygen." ■ 4. "Immature white blood cells are incapable of handling an infectious process."

45. 4. In leukemia, the number of normal white blood cells that are capable of fi ghting an infection is decreased. Although there is an increased number of immature white blood cells, they are unable to combat infection. Therefore, a child with leukemia is subject to infection. The major morbidity and mortality factor associated with leukemia is infection resulting from the presence of granulocytopenia. While increased activity may cause fatigue, it does not put the child at risk for infection. Vitamin C intake should not decrease if the child has adequate dietary intake. Decreased red blood cells are not directly caused by infection

47. Which of the following medication orders to help relieve discomfort in a child with leukemia should the nurse question? ■ 1. Acetaminophen (Tylenol). ■ 2. Acetaminophen with codeine (Tylenol with Codeine). ■ 3. Ibuprofen (Motrin). ■ 4. Propoxyphene hydrochloride (Darvon)

47. 3. Ibuprofen prolongs bleeding time and is contraindicated in clients with leukemia. Non-narcotic drugs other than ibuprofen or aspirin, such as acetaminophen (Tylenol), may be prescribed to control pain. Narcotic analgesics, such as acetaminophen with codeine or propoxyphene hydrochloride, may be required when pain is severe

48. After teaching a child with leukemia scheduled for a bone marrow aspiration about the procedure, the nurse determines that the teaching has been successful when the child identifi es which of the following as the site for the aspiration? ■ 1. Right lateral side of the right wrist. ■ 2. Middle of the chest. ■ 3. Distal end of the thigh. ■ 4. Back of the hipbone

48. 4. Although bone marrow specimens may be obtained from various sites, the most commonly used site in children is the posterior iliac crest, the back of the hipbone. This area is close to the body's surface but removed from vital organs. The area is large, so specimens can easily be obtained. For infants, the proximal tibia and the posterior iliac crest are used. The middle of the chest or sternum is the usual site for bone marrow aspiration in an adult. The wrist, chest, and thigh are not sites from which to obtain bone marrow specimens.

5. A 5-year-old child brought to the clinic with several superfi cial sores on the front of the left leg is diagnosed with impetigo. Which of the following instructions should the nurse give the parent? ■ 1. Wash the child's legs gently three times per day with a mild soap. ■ 2. Cover the sores with loose gauze. ■ 3. Allow the child to go back to school after 24 hours of treatment. ■ 4. Have the child return to the clinic the next week for a follow-up examination

5. 3. Impetigo involving several superfi cial lesions is usually treated topically, including washing the affected areas, removing crusts, and applying antibiotic ointment several times a day. The child can return to day care or school after being treated for 24 hours. The lesions do not need to be covered, they can remain open to the air. There is no need for follow-up unless the lesions have not resolved or have become more severe

6. Which of the following statements by the mother of an 18-month-old child should indicate to the nurse that the child needs laboratory testing for lead levels? ■ 1. "My child does not always wash after playing outside." ■ 2. "My child drinks 2 cups of milk every day." ■ 3. "My child has more temper tantrums than other kids." ■ 4. "My child is smaller than other kids of the same age.

6. 1. Eating with dirty hands, especially after playing outside, can lead to lead poisoning because lead is often present in soil surrounding homes. Also, children who eat lead-containing paint chips commonly develop lead poisoning. Drinking 2 cups of milk per day is less than that which is recommended for this age group, so more nutritional information would need to be obtained. Temper tantrums are characteristic of 18-month-old children as they try to assert themselves. Determining whether the child is smaller than other children the same age requires measuring height and weight and plotting them on growth charts. In addition, inadequate growth could be a result of numerous causes, such as genetics, chronic illness, or chronic drug use (e.g., prednisone)

8. The nurse is assessing a 9-year-old child who has third-degree burns as shown below. Using the "Rule of Nines" adapted for children, the nurse estimates that the extent of burns for this child is: ■ 1. 9%. ■ 2. 14%. ■ 3. 18%. ■ 4. 24%

8. 2. The child has burns of the entire leg. Because of the smaller size of children's legs, the estimate of 14% is used instead of 18%, which is used with adults. The arms of children are estimated at 9%, and the anterior and posterior trunk at 18% each. The head of the child is estimated at 18%, rather than the 9% used for adults

9. Which of the following is the nurse's best response to a mother who asks about the outcome for her child with lead poisoning? ■ 1. "Many children suffer brain damage from lead poisoning." ■ 2. "Many of its effects require the child to receive special schooling." ■ 3. "Most children with lead poisoning experience problems with the law." ■ 4. "Most effects of lead poisoning are reversible if diagnosed early.

9. 4. Most of the pathologic effects of lead poisoning are reversible as long as the problem is diagnosed early. The most serious effects are those on the central nervous system (e.g., brain damage, mental retardation, behavior changes), not problems with the law. However, because of screening programs, many children with lead poisoning are diagnosed and treated early. As a result, little if any brain damage occurs that would require children to receive special schooling.