PEDS EXAM 4 Chapter 34

Which nursing action facilitates care being provided to a child in an emergency situation? a. Encourage the family to remain in the waiting room. b. Include parents as partners in providing care for the child. c. Always reassure the child and family. d. Give explanations using professional terminology.

ANS: B Include parents as partners in the child's treatments. Parents may need direct guidance in concrete terms to help distract the child. Allowing the parents to remain with the child may help calm the child. Telling the truth is the most important thing. False reassurance does not facilitate a trusting relationship. Professional terminology may not be understood. Speak to the child and family in language that they will understand.

What is the goal of the initial intervention for a child in cardiopulmonary arrest? a. Establishing a patent airway b. Determining a pulse rate c. Removing clothing d. Reassuring the parents

ANS: A The first intervention for a child in cardiopulmonary arrest, as for an adult, is to establish a patent airway. Assessment of pulse follows establishment of a patent airway. Clothing may be removed from the upper body for chest compressions after a patent airway is established. Reassuring the parents is important, but the primary survey and associated interventions come first.

A nurse is working triage in the emergency department. A school-age child is brought in for treatment, carried by her mother. What assessment takes priority? a. Assess airway patency. b. Obtain a health history. c. Obtain a full set of vital signs. d. Evaluate for pain.

ANS: A The primary assessment consists of assessing the child's airway, breathing, circulation, level of consciousness, and exposure (ABCDEs). Airway always comes first. History, vital signs, and pain assessment are all part of the secondary survey

What condition does the nurse recognize as an early sign of distributive shock? a. Hypotension b. Skin warm and flushed c. Oliguria d. Cold, clammy skin

ANS: B An early sign of distributive shock is extremities that are warm to the touch. The child with distributive shock may have hypothermia or hyperthermia. Hypotension is a late sign of all types of shock. Oliguria is a manifestation of hypovolemic shock. Cold, clammy skin is a late sign of septic shock, which is a type of distributive shock.

Which observations made by an emergency department nurse raises the suspicion that a 3-year-old child has been maltreated? a. The parents are extremely calm in the emergency department. b. The injury is unusual for a child of that age. c. The child does not remember how he got hurt. d. The child was doing something unsafe when the injury occurred.

ANS: B An injury that is rarely found in children or is inconsistent with the age and condition of the child should raise suspicion of child maltreatment. The nurse should observe the parents' reaction to the child but must keep in mind that people behave very differently depending on culture, ethnicity, experience, and psychological makeup. The child may not remember what happened as a result of the injury itself, for example, sustaining a concussion. Also, a 3-year-old child may not be a reliable historian. The fact that the child was not supervised might be an area for health teaching. The nurse needs to gather more information to determine whether the parents have been negligent in the care of their child.

A nurse is caring for a child diagnosed with septic shock. He develops a dysrhythmia and hemodynamic instability. Endotracheal intubation is necessary. The physician feels that cardiac arrest may soon develop. What drug do you anticipate the physician will order? a. Atropine sulfate b. Epinephrine c. Sodium bicarbonate d. Inotropic agents

ANS: B Epinephrine is the drug of choice for the management of cardiac arrest, dysrhythmias, and hemodynamic instability. Atropine sulfate is used to treat symptomatic bradycardia. Sodium bicarbonate is given to treat severe acidosis associated with cardiac arrest. Inotropic agents are indicated for hypotension or poor peripheral circulation in a child.

A preschool child in the emergency department has a respiratory rate of 10 breaths per minute. How should the nurse interpret this finding? a. The child is relaxed. b. Respiratory failure is likely. c. This child is in respiratory distress. d. The child's condition is improving.

ANS: B Very slow breathing in an ill child is an ominous sign, indicating respiratory failure. Although the respiratory rate slows when an individual is relaxed, a rate of 10 breaths per minute in an ill preschool child is not a normal finding and is cause for concern. A rapid respiratory rate indicates respiratory distress. Other signs of respiratory distress may include retractions, grunting, and nasal flaring. A respiratory rate of 10 breaths per minute is not a normal finding for a preschool child nor does it demonstrate improvement.

A child is brought to the emergency department. When he is called to triage, which vital sign should be measured first? a. Temperature b. Heart rate c. Respiratory rate d. Blood pressure

ANS: C When taking children's vital signs, the nurse observes the respiratory rate first. Temperature and blood pressure should be measured after respiratory and heart rate because it can be upsetting for children. Heart rate is measured after respiratory rate.

The nurse observes abdominal breathing in a 2-year-old child. What does this finding indicate? a. Imminent respiratory failure b. Hypoxia c. Normal respiration d. Airway obstruction

ANS: C Young children normally exhibit abdominal breathing. When measuring respiratory rate, the nurse should observe the rise and fall of the abdomen. A very slow respiration rate is an indicator of respiratory failure. Nasal flaring with inspiration and grunting on expiration occurs when hypoxia is present. The child with an airway obstruction will use accessory muscles to breathe.

The father of a child in the emergency department is yelling at the physician and nurses. Which action is contraindicated in this situation? a. Provide a nondefensive response. b. Encourage the father to talk about his feelings. c. Speak in simple, short sentences. d. Tell the father he must wait in the waiting room.

ANS: D Because a parent who is upset may be aggravated by observers, he should be directed to a quiet area. When dealing with parents who are upset, it is important not to be defensive or attempt to justify anyone's actions. Encouraging the father to talk about his feelings may assist him to acknowledge his emotions and may defuse his angry reaction. People who are upset need to be spoken to with simple words (no longer than five letters) and short sentences (no more than five words).

The nurse is teaching a first-time mother with a 14-month-old boy about child safety. Which is the most effective overall safety information to provide guidance for the mother? a) "Never let him out of your sight when outdoors." b) "Don't smoke in the house or car." c) "Put chemicals in a locked cabinet." d) "Place a gate at the top of each stairway."

a) "Never let him out of your sight when outdoors." Because they are curious and mobile, toddlers require direct observation and cannot be trusted to be left alone, especially when outdoors. The priority guidance is to never let the child be out of sight. Gating stairways, locking up chemicals, and not smoking around the child are excellent, but specific, safety interventions.

A child is brought to the emergency department with a suspected poisoning. What treatment would the nurse least likely expect to be used? a) Activated charcoal b) Gastric lavage c) Syrup of ipecac d) Whole bowel irrigation

c) Syrup of ipecac Ipecac is rarely used in the health care setting to induce vomiting and is no longer recommended for use in the home setting. Gastric lavage, administration of activated charcoal (binds with the chemical substance in the bowel), or whole bowel irrigation with polyethylene glycol electrolyte solutions may be used.

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b) Toddlers Toddlers and older adolescents have the highest actual rate of death from drowning.

Which is the most critical element of pediatric emergency care? a. Airway management b. Prevention of neurologic impairment c. Maintaining adequate circulation d. Supporting the child's family

ANS: A Airway management is the most critical element in pediatric emergency care. The other elements are important, but airway is always the priority.

A 2-year-old child is in the playroom. The nurse observes him picking up a small toy and putting it in his mouth. The child begins to choke. He is unable to speak. Which intervention is appropriate? a. Heimlich maneuver b. Abdominal thrusts c. Five back blows d. Five chest thrusts

ANS: A To clear a foreign body from the airway, the American Heart Association recommends the Heimlich maneuver for a conscious child older than 1 year of age. Abdominal thrusts are indicated when the child is unconscious. Back blows are indicated for an infant with an obstructed airway. Chest thrusts follow back blows for the infant with an obstructed airway.

An emergency department nurse is making a general appearance assessment on a preschool child just admitted to the emergency department. Which general assessment findings indicate the child "looks bad"? (Select all that apply.) a. Color pale b. Capillary refill less than 2 seconds c. Unwilling to separate from parents d. Cold extremities e. Lethargic

ANS: A, D, E Signs of a child "looking bad" on a general appearance assessment include pale skin, cold extremities, and lethargy. A capillary refill of less than 2 seconds is a "good sign" as well as a child who is unwilling to separate from parents (separation anxiety, expected).

A child has been brought to the emergency department with carbon monoxide poisoning. After the child is stabilized, what action by the nurse is best? a. Have all family members tested for carbon monoxide poisoning. b. Help family determine source of the carbon monoxide. c. Prepare to administer syrup of ipecac. d. Notify social services about the child's condition.

ANS: B After the child has been stabilized, the nurse should help the family brainstorm about the source of the carbon monoxide poisoning, which must be eliminated before the child goes home. The nurse may need to offer assistance to find companies that can help in this search or notify the local fire department for assistance. There is no indication that other family members need to be tested, but those who show signs of carbon monoxide poisoning should be. Syrup of ipecac is no longer used after an oral ingestion. Social services may or may not need to be notified.

Which initial assessment made by the triage nurse suggests that a child requires immediate intervention? a. The child has thick yellow rhinorrhea. b. The child has a frequent nonproductive cough. c. The child's oxygen saturation is 95% by pulse oximeter. d. The child is grunting.

ANS: D One of the initial observations for triage is respiratory rate and effort. Grunting is a sign of hypoxemia and represents the body's attempt to improve oxygenation by generating positive end-expiratory pressure. Rhinorrhea, coughing, and a normal SaO2do not need immediate intervention.

What is the leading cause of unintentional death in children younger than 19 years of age in the United States? a. Drowning b. Airway obstruction c. Pedestrian injury d. Motor vehicle injuries

ANS: D The Centers for Disease Control and Prevention (CDC) has consistently found that motor vehicle injuries are the leading cause of unintentional death in children younger than 19 years of age in the United States. Drowning, airway obstruction, and pedestrian injury do cause death but not at the rate of motor vehicle crashes.

A 4-year-old girl has been admitted to the emergency department after accidently ingesting a cleaning product. Which treatment is most likely appropriate in the immediate treatment of the girl's poisoning? a) Gastric lavage b) Administration of activated charcoal c) Inducing vomiting d) Intravenous rehydration

b) Administration of activated charcoal Activated charcoal is the most common treatment for many poisonings and is more effective and safe than induced vomiting or gastric lavage. Rehydration is likely necessary, but this does not actively treat the girl's poisoning.

The nurse is examining a 10-month-old girl who has fallen from the back porch. Which assessment will directly follow evaluation of the "ABCs?" a) Palpating the abdomen for soreness b) Palpating the anterior fontanel c) Auscultating for bowel sounds d) Observing skin color and perfusion

b) Palpating the anterior fontanel Once the ABCs have been evaluated, the nurse will move on to "D" and assess for disability by palpating the anterior fontanel for signs of increased intracranial pressure. Observing skin color and perfusion is part of evaluating circulation. Palpating the abdomen for soreness and auscultating for bowel sounds would be part of the full-body examination that follows assessing for disability.

A group of students are reviewing information about respiratory arrest in children. The students demonstrate understanding of this information when they identify what common causes of respiratory arrest involving the upper airway? Select all that apply. a) Pneumothorax b) Asthma c) Croup d) Pertussis e) Epiglottitis

c) Croup e) Epiglottitis Common causes of respiratory arrest involving the upper airway include croup and epiglottitis. Asthma, pertussis, and pneumothorax are common causes involving the lower airway.

A school-aged child develops heat exhaustion at a soccer game. What action by the nurse in attendance is best? a. Call 911 immediately. b. Move the child to a cooler environment. c. Provide oxygen by face mask. d. Prepare to begin CPR.

ANS: B For simple heat exhaustion, treatment consists of moving the child to a cooler environment, apply cool, moist cloths to the skin; remove clothing or change to dry clothing; elevate legs; offer oral rehydration fluids if no altered mental status or vomiting. There is no need to call 911, provide oxygen, or prepare to begin CPR at this point.

A 5-year-old child is in cardiopulmonary arrest, and the nursing staff is performing CPR. One of the nurses is doing compressions at the rate of 90 per minute. What action by the charge nurse is best? a. Take over compressions. b. Tell the nurse to speed up. c. Tell the nurse to slow down. d. Have the nurse compress more deeply.

ANS: B The rate of compressions for a child is at least 100/minute. The charge nurse tells the compressing nurse to speed up. If the compressor is fatigued, someone should take over, but that is not indicated in the question. The depth of compressions is not the issue.

A child is brought to the emergency department after ingesting an acidic substance. What action by the nurse is best? a. Induce vomiting in the child. b. Give syrup of ipecac. c. Ensure a patent airway. d. Attach the child to a cardiac monitor.

ANS: C Ensuring a patent airway is always the priority. Since the child ingested an acid that causes corrosive damage, inducing vomiting (which is what syrup of ipecac does) is not advised. The child may need a cardiac monitor, but airway is the priority

When a poison has been ingested by a child, what should the parents do first? a) Call the local poison control center. b) Induce vomiting. c) Get the child to an emergency facility. d) Administer an emetic.

a) Call the local poison control center. Not all poisons should be vomited. Strong acids, for example, could cause as much destruction of tissue being vomited as being swallowed. The poison control center will provide the most accurate information on the next steps for the client.

A 14-year-old girl arrives at the hospital in a comatose state. Her father, who found her comatose in her room, tells you that she has an opiate addiction. Which of the following would confirm that the coma was caused by opiate intoxication? a) One pupil dilated and the other normal b) Both pupils are dilated c) Both pupils are pinpoints d) One pupil dilated and the other deviated downward

c) Both pupils are pinpoints Observe the child's eyes for signs of dilated pupils from increased ICP. If both pupils are dilated, irreversible brainstem damage is suggested, although such a finding may also be present with poisoning with an atropine-like drug. Pinpoint pupils suggest barbiturate or opiate intoxication. One pupil dilated or the eye deviated downward or laterally more than the other suggests third cranial nerve compression or a tentorial tear (laceration of the membrane between the cerebellum and cerebrum) with herniation of the temporal lobe into the torn membrane.

The nurse is caring for a 2-year-old who has been rushed to the clinic immediately after swallowing an unknown number of acetaminophen tablets. Which of the following is the priority intervention? a) Administer N-acetylcysteine. b) Start IV fluid replacement. c) Perform a gastric lavage. d) Initiate chelation therapy.

c) Perform a gastric lavage. If the child ingested the pills within the last 60 minutes, a gastric lavage and administration of activated charcoal would be the preferred treatment. If the acetaminophen is in the bloodstream, N-acetylcysteine may be administered. Chelation therapy is meant for metal poisoning. IV fluid replacement is used to treat hypovolemic shock.

The parents bring their 3-year-old son to the emergency department after he ingested some of his mother's medicine. Which assessment would be of critical importance for this child? a) Evaluating the effectiveness of the child's breathing b) Noting the child's pulse rate and quality c) Auscultating all lung fields for signs of edema d) Assessing mental status and skin moisture and color

d) Assessing mental status and skin moisture and color In cases of poisoning, clinical manifestations vary widely depending on the medication or chemical ingested. Therefore, it is important to pay particular attention to the child's mental status, skin moisture and color, and bowel sounds. Evaluating the effectiveness of the child's breathing and noting the child's pulse rate and quality are basic to any rapid cardiopulmonary assessment. Auscultating all lung fields for signs of pulmonary edema would be critically important for a child who is a near-drowning victim.

A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in teaching parents about how to protect a toddler from accidental poisoning? a) Closely monitor the toddler's activity. b) Label poisonous solutions. c) Do not leave the toddler alone. d) Keep cleaning solutions locked up.

d) Keep cleaning solutions locked up. The parents should keep cleaning solutions locked up to protect the toddler from accidental poisoning. Accidental poisonings usually occur among toddlers and commonly involve substances located in bathrooms or kitchens. Labeling poisonous substances may not help as toddlers are unable to read. Not leaving the child alone and closely monitoring the child are important, but not feasible all the time.

The nurse is conducting a physical examination of a toddler with suspected lead poisoning. Lab results indicate blood lead level 52 mcg/dL. Which action would the nurse expect to happen next? a) Repeat testing within 1 week with education to decrease lead exposure. b) Prepare to admit child to begin chelation therapy. c) Confirm with repeat testing in 1 month and referral to local health department. d) Repeat testing within 2 days and prepare to begin chelation therapy as ordered.

d) Repeat testing within 2 days and prepare to begin chelation therapy as ordered. The recommendation for blood lead levels of 45 to 69 mcg/dL is to confirm the level with a repeat laboratory test within 2 days and educate the parents to decreased lead exposure. She should also expect to begin chelation therapy as ordered and refer the case to the local health department for investigation of home lead reduction with referrals for support services. Repeat testing in 1 week with parent education is appropriate for lead levels between 20 and 44 mcg/dL. Repeat testing in 1 month and education would be appropriate for levels between 15 and 19 mcg/dL. Preparing to admit the child to begin chelation therapy immediately would be appropriate for lead levels greater than 70 mcg/dL

What may cause hypovolemic shock in children? (Select all that apply.) a. Hyperthermia b. Burns c. Vomiting or diarrhea d. Hemorrhage e. Skin abscesses

ANS: A, B, C, D Hypovolemic shock is due to decreased circulating volume and can be caused by fluid loss due to hyperthermia, burns, vomiting or diarrhea, and hemorrhage. An abscess will not cause hypovolemia.

What should be the emergency department nurse's next action when a 6-year-old child has a systolic blood pressure of 58 mm Hg? a. Alert the physician about the systolic blood pressure. b. Comfort the child and assess respiratory rate. c. Assess the child's responsiveness to the environment. d. Alert the physician that the child may need intravenous fluids.

ANS: A Hypotension is a late sign of shock in children. The lower limit for systolic blood pressure for a child more than 1 year old is 70 mm Hg plus two times the child's age in years. A systolic blood pressure of 58 mm Hg calls for immediate action. The nurse should be direct in relaying the child's condition to the physician. Comforting the child and assessing respiratory rate are not priorities. Assessing the child's responsiveness is included in a neurologic assessment. It does not address the systolic blood pressure of 58 mm Hg. Although this child most likely requires intravenous fluids, the physician must be apprised of the systolic blood pressure so that appropriate intervention can be initiated.

The nurse teaching safety to teens knows that which of these is the leading cause of death among adolescents? a) Diseases b) Unintentional injuries c) Drowning d) Poisoning

b) Unintentional injuries Unintentional injuries are the leading causes of death in adolescents (U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 2008). Injuries kill more adolescents than all diseases combined, with 46% of injury-related deaths due to motor vehicle accidents (U.S. Department of Health and Human Services, 2007). Unintentional injury accounts for about 48% of adolescent injury deaths, violence and homicide for 15.2%, and suicide for 11.8% of adolescent injury deaths (U.S. Department of Health and Human Services, 2007). Males are more likely than females to die of any type of injury.