PEDS exam 2
The school nurse has just finished an educational program for the children at a local elementary school. Which statement by a student would indicate a need for further education?
"I love to eat dry cereal for breakfast." Protein is important at breakfast, a glass of milk or milk on your cereal is a good source. Most dry cereals don't provide enough protein and may consist of high amounts of sugar that could make the child sleepy. Low-fat chocolate milk is more nutritious than prepackaged juice boxes, which have high sugar concentrations. Freeze fruits before putting them in the lunch box. This will keep the lunch items cool and the fruit fresh tasting.
The nurse is caring for a child with celiac disease. The parents and the child have attended a class with a group of other clients with the disorder. Which statements by the child or the parents indicates the need for further teaching? Select all that apply.
"Celiac disease is the same as gluten intolerance that everyone is talking about these days." "I love pasta, so as long as I only eat it occasionally I should be fine." "I must be careful to eat only 100% whole grain foods." Celiac disease is an immunologic disorder in which gluten, a product most commonly found in grains, causes damage to the small intestine. It is total gluten intolerance, which is different than what most people refer to as gluten intolerance in the general population. The child with celiac disease must follow a strict gluten free diet at all times. The disease does have familial tendencies. There is no cure for the disease but it can be managed with strict diet control.
The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with rheumatic fever. The nurses in the group make the following statements. Which statement is most accurate regarding the diagnosis of rheumatic fever?
"Children who have this diagnosis may have had strep throat." Rheumatic fever is precipitated by a streptococcal infection, such as strep throat, tonsillitis, scarlet fever, or pharyngitis, which may be undiagnosed or untreated. Rheumatic fever is a chronic disease of childhood, affecting the connective tissue of the heart, joints, lungs, and brain. There is no immunization to prevent rheumatic fever. The onset of rheumatic fever is often slow and subtle.
The nurse is discussing fever with the parents of a child who is in the emergency department with a temperature of 101 degrees Fahrenheit. Which statement by a parent indicates an understanding about fevers and their management in the ill child?
"Fevers can be beneficial because they can slow down the growth of the bacteria or virus that may be causing the infection." Fevers can be protective and can help the body fight the infection. Fevers slow down bacterial or viral growth. Mismanaging fevers include inappropriate dosing of antipyretics, awakening a child at night to administer antipyretics, and using cold water or sponging the child with alcohol to reduce the temperature.
A mother voices concern to the nurse that her child should not be using alcohol-based hand gels to help prevent the spread of infection. How should the nurse respond?
"Hand gels are actually very effective in preventing the spread of infection." Hand hygiene includes both hand washing with soap and water and the use of alcohol-based products (gels, rinses, foams) that do not require water. If there is no visible soiling of the hands, approved alcohol-based products are preferred because of their superior microbicidal activity, reduced drying of the skin, and convenience.
The nurse is caring for a 2-year-old boy with an umbilical hernia and is teaching the mother about this condition. Which response from the mother indicates a need for further teaching?
"I can tape a quarter over the hernia to reduce it." The use of home remedies to reduce an umbilical hernia should be discouraged because of the risk of bowel strangulation. The mother needs to be aware that strangulation can occur, but it is rare with an umbilical hernia. Pain, tenderness, or redness indicates incarceration, which although rare with umbilical hernias, can occur.She needs to understand the signs of strangulation and understand that some children have self-esteem issues related to the large protrusion of the unrepaired umbilical hernia. Physical needs of the child have priority over any types of potential psychosocial issues. Self-esteem issues may arise due to a large protrusion of an unrepaired umbilical hernia.
The nurse is caring for families at a health clinic. Which statement by a client would indicate to the nurse the health clinic could be more effective at providing health supervision to this communiuty?
"My husband takes off work to go to the clinic with our child so he can relay the visit details to me in our language." To be effective, the child's medical home must be easy to access, focused on the family, be culturally congruent and be community focuses. The clinic not having interpreters and printed information in the parents' native language demonstrates a lack of cultural congruency. Additional barriers are encountered when a parent must take time off from work in order to be at the appointment. Easy access is demonstrated by a location near the bus stop and the waiting room is child friendly. Offering a list of resources within the community and via city transportation further enhances the effectiveness of the clinic.
The parents of a 3-year-old child report he was exposed to pertussis 2 days ago. They are concerned and ask the nurse how long it will take until he becomes ill if he indeed contracted the infection. What response by the nurse is indicated?
"The signs of disease will be noted in 1 to 3 weeks." Pertussis is an acute respiratory disorder characterized by paroxysmal cough (whooping cough) and copious secretions. The disease is caused by Bordetella pertussis. The incubation period is 6 to 21 days, usually 7 to 10 days.
The nurse is preparing a client for surgery and the client asks, "What does it mean when they say they are going to reduce my abdominal hernia?" Which response by the nurse is most appropriate
"This means the hernia contents will be manipulated back into your peritoneal cavity during surgery." A hernia in the abdominal region is considered reducible when its contents are easily manipulated back through the inguinal ring into the peritoneal cavity. The nurse would reinforce this education, already provided by the primary health care provider when the surgery was explained, to the client. It is not necessary to cancel surgery when the nurse can provide education to the client. Reducing does not mean the intestines are twisted and edematous. Nor does it mean half of the contents will be removed.
A nurse is teaching the parents of a child diagnosed with rheumatic fever about prescribed drug therapy. Which statement would indicate to the nurse that additional teaching is needed?
"We can stop the penicillin when her symptoms disappear." For a child with rheumatic fever, drug therapy must be given for the full 10 to 14 days to ensure complete eradication of the infection. The drug must not be stopped when the signs and symptoms disappear. To prevent recurrent attacks, prophylactic antibiotic therapy is prescribed for at least 5 years or until the child is 18 years old. Additional prophylactic therapy should be instituted when dental or tonsillar surgery is planned.
The nurse is providing teaching to the parents of a child with varicella. Which statement indicates that the parents have understood the instructions?
"We need to make sure that he washes his hands frequently." The child with varicella needs to wash his hands frequently with antibacterial soap to reduce bacterial colonization. A cool bath with soothing colloidal oatmeal may help the skin discomfort. Alcohol would be too drying to the skin. Acetaminophen, not aspirin, should be used to reduce fever. The lesions should eventually crust over. Soft crusts with drainage may suggest an infection.
The nurse is caring for an infant with Down syndrome who has been diagnosed with atrioventricular canal defect. The parents ask the nurse, "Why do you not put oxygen on our baby more often when his lips and fingernails are blue?" What is the best response by the the nurse?
"While it seems that oxygen would help, it actually worsens this condition. Treating the cause of the disease will help." For children with congenital defects with increased pulmonary blood flow, oxygen supplementation is not helpful. Oxygen acts as a pulmonary vasodilator. If pulmonary dilation occurs, pulmonary blood flow is even greater, causing tachypnea, increasing lung fluid retention, and eventually causing a much greater problem with oxygenation; therefore, preventing the development of pulmonary disease via early surgical correction is essential. Although oxygen must be ordered by the physician and it isn't the best treatment, the nurse stating, "While it seems that oxygen would help, it actually makes the condition worse. Treating the cause of the disease will help" best answers the question while also showing empathy.
The nurse is caring for a child who receives dialysis via an AV fistula. Which finding indicates an immediate need to notify the physician?
Absence of a thrill The nurse should always auscultate the site for presence of a bruit and palpate for presence of a thrill. The nurse should immediately notify the physician if there is an absence of a thrill. Dialysate without fibrin or cloudiness is normal and is used with peritoneal dialysis, not hemodialysis.
The nurse is conducting a physical examination of an infant with a suspected cardiovascular disorder. Which assessment finding is suggestive of sudden ventricular distention?
Accentuated third heart sound An accentuated third heart sound is suggestive of sudden ventricular distention. Decreased blood pressure, cool, clammy, and pale extremities, and a heart murmur are all associated with cardiovascular disorders; however, these findings do not specifically indicate sudden ventricular distention.
Which nursing diagnosis would best apply to a child with rheumatic fever?
Activity intolerance related to inability of heart to sustain extra workload Acute rheumatic fever affects the joints, central nervous system, skin and soft tissue. It causes chronic, progressive damage to the heart and valves. Children with rheumatic fever need to reduce activity to relieve stress on the heart and joints during the course of the illness. Rheumatic fever does not produce cardiomegaly nor does it interfer with respirations or the ability to oxygenate the body. Children with rheumatic fever may develop chorea. These movements are involuntary and are not related to hyperexcitability.
The rash in roseola is pruritic. Which measure would you teach the parent to provide comfort?
Apply cool compresses to the skin to stop local itching. Rashes can be uncomfortable and irritating. Parents need to be educated on ways to relieve discomfort and to protect and maintain skin integrity. Cool compresses or cool baths will help to relieve the itching associated with the rash. Antipuretics may be necessary also to help with itching. To protect the skin the child should be instructed not to scratch the skin to alleviate itching. The child's fingernails should be kept short. Keeping the child dressed warmly will not bring out the rash any sooner. Being warm will, however, cause an increased temperature and intensify the itching. Aspirin should not be used in children as an antipyretic. There is an increased risk of developing Reye's syndrome.
The nurse is caring for a child whose family recently immigrated from a developing country. While completing the admission history, the parents report all the child's immunizations are up to date. Which nursing action is most appropriate?
Ask parents which immunizations have been given. When caring for a child recently immigrated from a developing country, the nurse should be aware that WHO recommended vaccinations and U.S. recommended vaccinations may be different. The most appropriate action is for the nurse to determine which vaccinations have been given to decide if additional immunizations may be needed.
The nurse is triaging a child diagnosed with poliomyelitis. After ensuring appropriate precautions are in place, what will the nurse do next?
Auscultate the child's lungs. Because poliomyelitis can cause motor paralysis of the respiratory muscles, assessing respiratory status is priority. Once the nurse has ensured respiratory function is intact, the nurse can place the child on bedrest, administer an antipyretic, and begin physical therapy.
Parents of a preschooler with cerebral palsy ask the nurse what the surgeon plans to implant in their child's body to control spasticity. What is the nurse's answer?
Baclofen pump A baclofen pump can be placed surgically to deliver continuous medication intrathecally. Baclofen can also be taken orally. Botulinum toxin is injected by a practioner into specified muscle groups to reduce spasticity. A central venous catheter places medication directly into rapidly moving blood and would not be used. A vagal nerve stimulator is used to control seizures.
What information would be included in the care plan of an infant in heart failure?
Begin formulas with increased calories. Infants with heart failure need increased calories for growth. The infants are typically given smaller, more frequent feedings to decrease the amount given and to help conserve energy for feeding. They often times are given a higher-calorie formula. The infant should be placed in an upright position or in a car seat to increase oxygenation. The infant should not have any pressure on the diaphragm while in this position. Vomiting is a sign of digoxin toxicity and this should be considered before administering.
The nurse is assessing a child with aortic stenosis. Which findings would the nurse most likely assess? Select all that apply.
Chest pain with activity Dizziness with prolonged standing Thrill palpated at base of heart Assessment findings associated with aortic stenosis include angina or chest pain with activity, dizziness with prolonged standing, and a thrill palpated at the base of the heart. A moderately loud systolic murmur at the base of the heart and blood pressure that is significantly higher in the arms than in the legs, possibly 20 mm Hg or higher, suggests coarctation of the aorta.
The nurse is planning to teach the parents of a child with newly diagnosed muscular dystrophy about the disease. Which definition should she use to best describe this condition?
Degeneration of muscle fibers Degeneration of muscle fibers with progressive weakness and wasting best describes muscular dystrophy. Demyelination of myelin sheaths is a description of multiple sclerosis. Lesions within the brain cortex and the upper motor neurons suggest a neurologic, not a muscular, disease.
The mother of a 10-year-old child diagnosed with rubella asks what can be done to help her child feel better during her illness. What information can be provided?
Encourage rest and relaxation. Rubella infection is usually mild and self-limited. The care given is normally supportive. Rest is encouraged. Medications administered are normally limited to anti-pyretics and analgesics. Antibiotic and antiviral therapies are not normally included in the plan of treatment. Range of motion is not needed as mobility of the client is not limited.
A nurse is developing a teaching plan for the parents of an 8-year-old experiencing nocturnal enuresis. The nurse determines that additional teaching is needed when the parents identify what as an appropriate measure?
Encouraging fluid intake after dinner In many children, limiting fluids after dinner can be helpful for nocturnal enuresis. Bladder-stretching exercises also can be helpful. If these measures are ineffective, desmopressin may be prescribed. Stress factors may be contributing to the child's problem. Therefore, measures to address stress and promote coping would be appropriate.
The nurse is preparing to administer acetaminophen to a 4-year-old child to provide comfort. Which precaution is specific to antipyretics?
Ensure proper dose and interval It is very important to ensure that the proper dose is given at the proper interval because an overdose can be toxic to the child. Concerns with allergies and taking the entire, prescribed dose are precautions when administering antibiotics and all medications. Drowsiness is not a side effect of antipyretics.
The nurse in a pediatric cardiovascular clinic is talking with the father of a 5-year-old child who underwent cardiac surgery for a heart defect at the age of 3. The father reports that the child has been having increased shortness of breath, tires easily after playing, and has been gaining weight. The nurse is aware that the child is most likely demonstrating symptoms of which acquired cardiovascular disorder?
Heart failure Infective endocarditis would present with intermittent, unexplained low-grade fever, fatigue, anorexia, weight loss, or flu-like symptoms. Characteristics of cardiomyopathy include respiratory distress, fatigue, poor growth (dilated), chest pain, dizziness, and syncope. Abdominal pain, joint pain, fever, irritability are signs of Kawasaki disease.
A 6-year-old child is being treated for a parasitic infection. When reviewing results from the child's white blood cell count, which finding would be anticipated?
Increased eosinophils levels Eosinophils are the first line of defense against parasitic infections and allergic reactions and will be elevated. Monocytes are a second line of defense and will be elevated in response to leukemias, lymphomas, and chronic inflammation. Basophils respond to allergic disorders and hypersensitivity reactions. Neutrophils are the first line of defense upon invasion of bacteria, fungus, cell debris, and other foreign substances.
The nurse is caring for child who present to the emergency department with reports of a fever for 5 days. The nurse notes a diffuse maculopapular rash, reddened cracked lips, erythema of hands, and bilateral conjunctivitis and suspects Kawasaki disease. Which nursing action is priority?
Initiate intravenous access. A child with signs of Kawasaki disease is at risk for dehydration due to a prolonged fever and oral pain. The priority for the nurse is to establish intravenous access to begin IV fluids. Placing the child on a soft diet will be done after ensuring IV access. Pain is not a priority, and children with Kawasaki disease are given aspirin because of the anti-inflammatory properties of aspirin, instead of acetaminophen. Because the child already has the required four signs of Kawasaki disease, assessing cervical lymph nodes is minimally helpful and could be performed later.
A 6-year-old girl is diagnosed with pulmonary stenosis. The mother asks the nurse what the likely treatment for this condition will involve. What should the nurse tell the mother?
Insertion of a catheter with an uninflated balloon tip into the affected valve, followed by inflation of the balloon to break up adhesions Balloon angioplasty by way of cardiac catheterization is the procedure of choice for pulmonary stenosis. With this procedure, a catheter with an uninflated balloon at its tip is inserted and passed through the heart into the stenosed valve. As the balloon is inflated, it breaks valve adhesions and relieves the stenosis. The other answers refer to interventions related to patent ductus arteriosus, not pulmonary stenosis.
The nurse is obtaining a health history and assessment for a child being admitted who is suspected of having measles. What signs and symptoms does the nurse expect to find during the assessment? Select all that apply.
Maculopapular rash that began on the face and has spread to the rest of the body Fever Upper respiratory infection symptoms Maculopapular rash that began on the face and has spread to the rest of the body, fever, and upper respiratory infection symptoms are characteristic of both rubella (German measles) and rubeola (measles). Clear, fluid-filled vesicles are characteristic of chicken pox (varicella zoster. Erythematous flushing is common with erythema infectiosum (fifth disease).
A 16-year-old is seen in the emergency department with symptoms including a high fever, chills, headache, nausea and vomiting, and painful joints. During the nursing history the teenager reports recently returning from a trip to a rain forest in South America. What infectious disease does the nurse suspect the client has contracted?
Malaria Malaria comes from a bite of Anopheles species of mosquito and is mostly found in Africa, Asia and South America. Anaplasmosis comes from a tick and occurs mostly in the upper Midwest and northeast United States. West Nile disease comes from a mosquito and is found throughout United States, with higher rates found in Great Plains and mountain regions. Rabies is a viral infection that comes from close contact with the saliva of a rabid animal.
A 15-year-old boy visits his primary care physician's office with fever, headache, and malaise, along with complaints of pain on chewing and pain in the jawline just in front of the ear lobe. The boy asks his mother to leave the exam room for a minute and then tells the nurse that he is also experiencing testicular pain and swelling. The nurse recognizes that this client most likely has which condition?
Mumps Initial symptoms of mumps include fever, headache, anorexia, and malaise. Within 24 hours, pain on chewing and an "earache" occurs. When the child points to the site of the earache, however, he points to the jawline just in front of the ear lobe, the site of the parotid gland. By the next day, the gland appears swollen and feels tender; the ear becomes displaced upward and backward. Boys may also develop testicular pain and swelling (orchitis). None of the other conditions listed matches the symptoms indicated.
When developing a teaching plan for the parents of a child diagnosed with tricuspid atresia, the nurse would integrate knowledge of what factor as the major mechanism involved?
Obstruction of blood flow to the lungs Tricuspid atresia is a congenital heart defect in which the valve between the right atrium and right ventricle fails to develop, resulting in no opening to allow blood to flow from the right atrium to the right ventricle and subsequently through the pulmonary artery into the lungs. It is classified as a disorder of decreased pulmonary blood flow due to obstruction of blood flow to the lungs. Defects with connections involving the left and right sides, such as atrial or ventricular septal defects, will shunt blood from the higher-pressure left side to the lower-pressure right side and subsequently more blood will go to the lungs. A narrowed major vessel leads to an obstructive defect, interfering with the ability of the blood to flow freely through the vessel. Mixed defects such as transposition of the great vessels involve the mixing of well-oxygenated with poorly oxygenated blood, leading to a systemic blood flow that contains a lower oxygen content.
A 10-year-old child has an unknown infection and will need to provide a urine specimen for culture and sensitivity. To assure that the sensitivity results are accurate, which step is most important?
Obtain specimen before antibiotics are given In order to ensure a successful culture, the nurse must determine if the child is taking antibiotics. Throat cultures require specimens taken from the pharyngeal or tonsilar area. Stool cultures may require three specimens, each on a different day. The nurse would use aseptic technique when getting a blood specimen as well as the urine, but antibiotics cannot be received by the child prior to the test being done.
A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see?
Peeling hands and feet; fever Kawasaki disease is an acute sytemic vasculitis. Symptoms begin with very high fevers. One of the signs of Kawasaki disease is the peeling hands and feet and in perineal region. The child is usually tachycardic and laboratory values would indicate increased platelets and decreased hemoglobin. Another classic sign of Kawasaki is the strawberry tongue. The other symptoms are not necessarily characteristic of Kawasaki disease. The child should be evaluated if there are impalpable pulses because this could indicate a heart defect or some other serious illness.
A child is diagnosed with scarlet fever. History reveals that the child has no known drug allergies. When preparing the child's plan of care, the nurse would anticipate administering which agent as the drug of choice?
Penicillin V Penicillin V is the antibiotic of choice. In those sensitive to penicillin, erythromycin may be used. Trimethoprim-sulfamethoxazole and clarithromycin are not used.
When the health care provider looks in a child's mouth during a sick-visit examinaiton, the parent exclaims: "The tongue is bright red! It was not like that yesterday." The health care provider would most likely prescribe which medication based on the probable diagnosis?
Penicillin to prevent acute glomerulonephritis A "strawberry tongue" is a classic sign of scarlet fever. Penicillin is prescribed to treat the beta-hemolytic group A strococcal infection and to prevent the complication of developing acute glomerulonephritis and rheumatic fever. Erythromycin can be used to treat the disease if the child is allergic to penicillin. Antibiotics are not give prophylactally to siblings. The disease is spread via droplets, so keeping the siblings away from the infected child and handwashing are the best preventative measures. Acetaminophen can be administered for fever control. It works systemically and has very little, if any, affect locally. Antibiotics are the mainstay of treatment. Steroids are used infrequently.
An infant with tetralogy of Fallot becomes cyanotic. Which nursing intervention would be the firstpriority?
Place the infant in the knee-chest position. Placing the infant in the knee-chest position is the first priority when caring for an infant with tetralogy of Fallot. Starting IV fluids and preparing the child for surgery would not be necessary since it is known that the infant has a cyanotic birth defect. Raising the head of the bed would not be a priority since the infant needs to be placed in the knee-chest position.
What would be the most important measure to implement for an infant who develops heart failure?
Placing the infant in a semi-Fowler's position Placing an infant with heart failure in a semi-Fowler's position reduces the pressure of the abdominal contents against the chest and allows for better lung expansion. Keeping the infant supine would cause more pressure on the heart and lungs and increase the work of the heart and breathing. Infants with heart disease need calories to grow. They are given formula or breast milk which is fortified with extra nutirents. Thus the infant can have an intake of the same amount of fluid but receive extra nutrients.
The nurse is caring for a 16-year-old child with a diagnosis of acquired immunodeficiency syndrome (AIDS). What treatment goal has the highest priority for this child?
Preventing spread of infection Major goals for the child include maintaining the highest level of wellness possible by preventing infection and the spread of the infection. Because the adolescent has the belief that nothing can hurt him or her, and because of the increasing rate of sexual activity in this age group often involving multiple partners, the highest priority is teaching and preventing the spread of the infection. Other goals include maintaining skin integrity, minimizing pain, improving nutrition, alleviating social isolation, and diminishing a feeling of hopelessness. The primary goal for the family is improving coping skills and helping the teen cope with the illness.
A nurse is reading a journal article about congenital heart conditions that are associated with decreased pulmonary blood flow. The nurse demonstrates understanding of the information when the nurse identifies which anomalies as being associated with Tetralogy of Fallot? Select all that apply.
Pulmonary stenosis Overriding aorta Right ventricular hypertrophy Tetralogy of Fallot is a congenital heart defect composed of four heart defects: pulmonary stenosis (a narrowing of the pulmonary valve and outflow tract, creating an obstruction of blood flow from the right ventricle to the pulmonary artery), ventricular septal defect, overriding aorta (enlargement of the aortic valve to the extent that it appears to arise from the right and left ventricles rather than the anatomically correct left ventricle), and right ventricular hypertrophy (the muscle walls of the right ventricle increase in size due to continued overuse as the right ventricle attempts to overcome a high-pressure gradient).
The nurse at an outpatient facility is obtaining a blood specimen from a 9-year-old girl. Which technique would most likely be used?
Puncturing a vein on the dorsal side of the hand The usual sites for obtaining blood specimens are veins on the dorsal side of the hand or the antecubital fossa. Administration of sucrose prior to beginning helps control pain for young infants. Accessing an indwelling venous access device may be appropriate if the child is in an acute care setting. An automatic lancet device is used for capillary puncture of an infant's heel.
The nursing staff at the clinic are discussing the best way to encourage cooperation from young pediatric clients during screenings. Which suggestion would be appropriate?
Purchase stickers or make coloring pages to be given to the children after the screening is completed. Young children respond well to a reward system. Allowing them to have a sticker or a coloring page after the screening is finished will encourage cooperation. They should not be permitted to play with equipment that is dangerous (syringes/medication) or should be sterile when used on them. Playing with medication is contraindicated also because it gives the illusion that medication is a toy. Allowing a child the choice of completing the reward before the screening will hinder cooperation...the child should only complete the reward after screening.
A nurse practitioner suspects that a child has scarlet fever based on which assessment finding?
Red, strawberry tongue The characteristic assessment finding that distinguishes scarlet fever from other disorders is the appearance of the red, strawberry tongue. Sore throat, an enanthematous and exanthematous rash, and white exudate on the tonsils are also seen with scarlet fever, but it is the strawberry tongue that helps to confirm the diagnosis.
What information should be included in the teaching plan for a child with varicella?
Remind the child not to scratch the lesions. Varicella lesions appear first on the scalp. They spead to the face, the trunk and then to the extremities. There may be various stage of the lesions present at any one time. The lesions are intensely pruritic. The teaching plan for varicella should include that the child not scratch the lesions. Opening the lesions gives access for secondary infection to occur and causes acarring. Acetaminophen should be administered for fever, not aspirin, due to the link with Reye syndrome. The best treatment for skin discomfort is a cool bath with soothing colloidal oatmeal every 3 to 4 hours for the first few days. Warm baths cause more itching and dry the skin.
Which nursing diagnosis will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot?
Risk for ineffective cardiopulmonary tissue perfusion Nursing priority following cardiac surgery will focus on assessing for ineffective cardiopulmonary tissue perfusion. Monitoring for excess fluid volume, infection, and anxiety will be monitored after ensuring cardiopulmonary tissue perfusion is adequate.
A 6-year-old child is brought to the clinic by his parents. The parents state, "He had a sore throat for a couple of days and now his temperature is over 102°F (38.9°C). He has this rash on his face and chest that looks like sunburn but feels really rough." What would the nurse suspect?
Scarlet fever Scarlet fever typically is associated with a sore throat, fever greater than 101° F (38.9° C), and the characteristic rash on the face, trunk, and extremities that looks like sunburn but feels like sandpaper. CAMRSA is typically manifested by skin and tissue infections. Diphtheria is characterized by a sore throat and difficulty swallowing but fever is usually below 102°F . Airway obstruction is apparent. Pertussis is characterized by cough and cold symptoms that progress to paroxysmal coughing spells along with copious secretions.
What is a true statement regarding varicella zoster virus infection?
Secondary bacterial infections of the skin can occur. Varicella zoster virus infection carries with it the complication of a secondary bacterial infection of the skin. The lesions are intensely puritic making the child want to scratch the lesions opening them to a variety of organisms to invade. The incubation period is 10 to 21 days. It is transmitted by direct contact with the vesicles and by airborne route. It tends to be more severe in adolescents and adults.
The nurse is caring for a 10-year-old boy with end-stage renal disease (ESRD) with metabolic acidosis. What would the nurse expect to administer if ordered?
Sodium bicarbonate tablets Bicitra or sodium bicarbonate tablets are used for the correction of acidosis. Ferrous sulfate is used for the treatment of anemia. Vitamin D and calcium are used for the correction of hypocalcemia and hyperphosphatemia. Erythropoietin stimulates red blood cell growth.
A child is suspected of having tricuspid atresia. Which findings are consistent with this disorder? Select all that apply.
Tachypnea Weak infant sucking Bilateral crackles in lung fields Tricuspid atresia is a congenital heart defect in which the valve between the right atrium and right ventricle fails to develop. As a result, there is no opening to allow blood to flow from the right atrium to the right ventricle and subsequently through the pulmonary artery into the lungs. Related findings include tachypnea, respiratory crackles or wheezes, and diminished sucking reflex. Peripheral cyanosis in the immediate hours after birth is a normal finding for many infants and is not specific to this disorder.
A caregiver brings her 7-year-old son to the pediatrician's office, concerned about the child's bedwetting after being completely toilet trained even at night for over 2 years. The caregiver further reports that the child has wet the bed every night since returning home from a 1-week fishing trip. The child refuses to talk about the bedwetting. The nurse notes the child is shy, skittish, and will not make eye contact. Further evaluation needs to be done to rule out what possible explanation for the bedwetting?
The child has been sexually abused, maybe on the fishing trip. Enuresis may have a physiologic or psychological cause and may indicate a need for further exploration and treatment. Enuresis in the older child may be an expression of resentment toward family caregivers or of a desire to regress to an earlier level of development to receive more care and attention. Emotional stress can be a precipitating factor. The health care team also needs to consider the possibility that enuresis can be a symptom of sexual abuse. Bruising, bleeding, or lacerations on the external genitalia, especially in the child who is extremely shy and frightened, may be a sign of child abuse and should be further explored.
A 9-month-old child has been admitted to rule out sepsis. Which finding offers the most support to the presence of this disorder?
The child has had 8 ounces of formula in the past 24 hours. Sepsis is a systemic overresponse to infection resulting from bacteria and viruses, which are the most common fungi, viruses, rickettsia, or parasites. It can lead to septic shock, which results in hypotension, low blood flow, and multisystem organ failure. Signs of sepsis include a lack of appetite, letheragy, hypotonia, and temperature elevations.
A school nurse finds a 10-year-old's blood pressure is over the 95th percentile. The nurse advises the parent to seek medical attention for the child. What outcome would the nurse expect?
The child will need the blood pressure checked two more times. The child will need the blood pressure checked two more times. It is routine to check the blood pressure on three separate occasions to get the most accurate analysis of the blood pressure. The child usually does not need surgery or need to go to the emergency room. This is not a normal result in a blood pressure finding.
A newborn is diagnosed with hypospadias and the parents want the newborn to be circumcised. What would be the best response by the nurse?
The foreskin is needed for repair. Hypospadias occurs when the meatal opening is on the ventral surface of the penis rather than at the end of the penis. The newborn with this condition is not circucised at birth because the excess skin may be needed to reconstruct the meatus during surgical repair. Once the hypospadias is repaired, a circumcision can be performed as part of the procedure. Hypospadias repair is usually done after the newborn is 1 year or older. Meatal stenosis has to do with the urethral opening diameter, not the placement. Circumcision or hypospadias repair does not affect the functioning of the renal system so neither would predispose the newborn to renal failure.
A 6-month-old infant develops roseola. When obtaining information from the parent, what would the nurse expect the parent to report?
The infant's temperature fell when the rash appeared. Roseola is characterized by high temperatures (101°F to 106°F; 38.3°C to 41.1°C) for 3 to 5 days. The fever resolves abruptly. The rash appears 12 to 24 hours later. The rash is pinkish red, and the spots are flat or raised and blanch when touched. There are no papules or pustules associated with roseola. The infant may be lethargic while experiencing high fever but energy returns to normal once the fever is gone and the rash occurs.
The nurse is caring for a 7-year-old child in droplet precautions due to the diagnosis of pertussis. While visiting the child, which actions by the parents require the nurse to intervene? Select all that apply.
The parents state, "We should postpone immunizing our 5-year-old since there has been contact with the infection." The parents state, "We have been limiting our child's fluids to help decrease the amount of coughing." All close contacts who are younger than 7 years of age and who are unimmunized or underimmunized should have pertussis immunization initiated or the series completed according to the recommended dosing schedule. Fluids should be increased in order to help thin secretions and prevent dehydration during the infection. The parents are correct in removing their PPE at the door and washing their hands when leaving the room, and wearing a mask. All antibiotics should be finished in order to treat the infection adequately and prevent immunity to antibiotics.
The nurse has just taken the blood pressure of a 13-year-old, and the percentile rank is 88%. Why would the nurse categorize the child as prehypertensive?
The teenager's blood pressure was 122/83. A blood pressure greater than 120/80 is categorized as prehypertensive regardless of the percentile. Preterm birth is a risk factor for hypertension and does not indicate prehypertension itself. A high-fat diet and lack of exercise are risks for cardiovascular disease. Both require the nurse's attention to promote health but are not factors in categorizing the adolescent as prehypertensive.
A parent is asking for more information about their infant's patent ductus arteriosus (PDA). What would be included in the education?
This is caused by an opening that usually closes by 1 week of age. A PDA is caused by an opening that usually closes by 1 week of age called the ductus arteriosus. The defect is usually fixed by a single surgery or during a cardiac catheterization procedure. IV fluids are not a routine intervention for the PDA. Most of the time a PDA occurs in premature infants.
The nurse is caring for multiple clients on the pediatric unit. Which child will the nurse see first?
a child with erythema infectiosum experiencing fatigue and confusion A child with erythema infectiosum experiencing fatigue and confusion is showing signs of decreased oxygenation, possibly related to aplasia of erythrocytes caused by the virus. A child with signs and symptoms of decreased oxygenation should be seen first. Nausea and malaise are symptoms of chicken pox. A child with herpes simplex will most likely report pain an pruritis. Signs and symptoms of measles include photophobia and coryza
A client has just been admitted to the unit with a history of recent strep infection, hematuria, and proteinuria. Based on these findings, the nurse would suspect which condition?
acute glomerulonephritis Recent strep infection, hematuria, and proteinuria are indicative of acute glomerulonephritis. These symptoms do not suggest any of the other options.
After assessing a child, the nurse suspects coarctation of the aorta based on a finding of:
femoral pulse weaker than brachial pulse. A femoral pulse that is weak or absent in comparison to the brachial pulse is associated with coarctation of the aorta. Bounding pulse is characteristic of patent ductus arteriosus or aortic regurgitation. A narrow or thread pulse is associated with heart failure or severe aortic stenosis. Hepatomegaly is a sign of right-sided heart failure.
A young client arrives at the clinic with a rash on the trunk and flexor surfaces of the extremities. The parent informs the nurse that the rash started a day before on the exterior surfaces of the extremities; 2 days before, the child had a really bad rash on the face. The health care provider diagnoses the child with erythema infectiosum. The nurse tells the parent that this is also known as:
fifth disease. Erythema infectiosum is also known as "fifth disease." It starts with a fever, headache, and malaise. One week later, a rash appears on the face. A day later, the rash appears on the extensor surfaces of the extremities. One more day later, the rash appears on the trunk and flexor surfaces of the extremities. Pityriasis rosea is a skin rash that begins with a large spot on the chest, abdomen or back that is followed by paatern of small lesions. It is self limiting and can be treated with steroid creams. Roseacea is a chronic inflmmatory skin condition that causes redness to the face. An enterovirus infection can many times cause the same symptoms as the common cold or it can include the respiratory system. It is contagious.
Which is a priority for the nurse caring for a client with bladder exstrophy?
preventing skin breakdown Prevention of skin breakdown is the priority to prevent infection and the surface from drying out. Encouraging fluids and voiding are not the priority for this client. Prone position is not recommended; the correct position is supine so urine drains freely.
The nurse is caring for a child admitted to the hospital for sepsis. Which assessment finding is the most concerning?
urine output of 10 ml over 3 hours Children with sepsis will show alteration in temperature, heart rate, respiratory rate, and white blood cell count. Septic shock with organ dysfunction is more serious as can be manifested by decreased urine output.
