Peds Exam 5: Ch 13, 22-24

The pediatric nurse explains to a student that which actions are most important in preventing and controlling infections? (Select all that apply.) A. Administering antibiotics B. Educating the public C. Monitoring for outbreaks D. Providing immunizations E. Scheduling physical exams

ANS: B, C, D Prevention and control of infections, especially communicable diseases, centers around surveillance, public education, and immunization.

A child has been hospitalized with rubeola. Which actions by the nursing staff are most important? (Select all that apply.) A. Administer ordered antibiotics on time. B. Assess the child for Koplik's spots. C. Ensure the room is dark for photophobia. D. Monitor the child for febrile seizures. E. Report the disease to health authorities.

ANS: B, C, E Appropriate nursing care for the child with rubeola includes assessing the child's mouth for Koplik's spots, providing comfort for photophobia by darkening the room, and reporting the disease to authorities. Rubeola is a viral disease not treated with antibiotics. Fever is moderate and seizures are not usually seen.

20. A patient is experiencing an anaphylactic reaction. Which action by the nurse takes priority? A. Determine what the patient is allergic to. B. Listen to the patient's lung sounds. C. Maintain the patient's airway. D. Provide oxygen at 4 L nasal cannula.

ANS: C Anaphylaxis is a medical emergency. Airway comes first. The patient may need oxygen, but if the airway is not patent, the oxygen will not help. Listening to the lungs and determining the allergen come later.

31. A child is being sent home from the doctor's office with a prescription for azithromycin (Zithromax) for presumed cat-scratch disease. Which instruction to the parents is most important? A. "Be sure to treat your cat for fleas." B. "Don't take this unless the scratch gets infected." C. "Make sure he takes all of this antibiotic." D. "You should not have cats around small children."

ANS: C As with any antibiotic, taking all the prescribed medication is a priority instruction. For some reason, cats with fleas have higher rates of the bacteria that causes the disease, so flea control is important. The other two instructions are not appropriate.

22. A parent calls a pediatric information line to ask about treating sinus congestion in a child. Which suggestion is not appropriate for the nurse to make to the parent? A. Warm facial compress B. Cool-mist steamer C. Sine-Off sinus medication D. Gentle nasal suctioning

ANS: C Common comfort measures for sinus or respiratory problems include a cool-mist steamer, decongestants, and gentle nasal suctioning. A warm facial compress would be more helpful. Sine-Off over-the-counter sinus medication contains salicylates, or aspirin compounds, which are not given to children due to the risk of Reye's syndrome.

19. A patient is experiencing an anaphylactic reaction. Which IV solution does the nurse anticipate will be ordered for this patient? A. 0.45% normal saline B. 5% dextrose in water C. 0.9% normal saline D. 3% saline

ANS: C The fluid of choice in any emergency is an isotonic crystalloid; 0.9% normal saline is isotonic, 0.45% normal saline and 5% dextrose in water are both hypotonic, and 3% saline is hypertonic.

34. A parent is refusing to have a child vaccinated, preferring to have the child contract the illness and develop "natural immunity." Which response by the nurse is best? A. "I'm sure you know what is best for your baby." B. "I'll have to report you to social work." C. "That practice is dangerous and illegal." D. "These diseases have many serious consequences."

ANS: D Parents do have the right to refuse vaccinations, but the nurse has the responsibility of ensuring the parents have adequate information about the diseases and vaccinations. Informing the parent about possible consequences of contracting a disease is an important part of this job. The nurse should not just acquiesce and say the parent knows best without educating him or her. The other two options are threatening, and it is not illegal for a parent to opt out of vaccinations.

13. The nurse is providing care to a school-age client diagnosed with idiopathic thrombocytopenic purpura (ITP). Which nursing diagnosis is the priority for this client? 1. Risk for Injury 2. Ineffective Breathing Pattern 3. Nausea 4. Fluid-Volume Deficit.

Answer: 1 Rationale 1: ITP is the most common bleeding disorder in children, so risk for injury (bleeding) is the priority nursing diagnosis. The disease process does not usually cause ineffective breathing patterns, nausea, or fluid-volume deficits.

3. A child is diagnosed with sickle cell disease. The parents are unsure how their child contracted the disease. Which explanation by the nurse is the most appropriate? 1. "Both the mother and the father have the sickle cell trait." 2. "The mother has the trait, but the father doesn't." 3. "The father has the trait, but the mother doesn't." 4. "The mother has sickle cell disease, but the father doesn't have the disease or the trait."

Answer: 1 Rationale 1: Sickle cell disease is an autosomal recessive disorder; both parents must have the trait in order for a child to have the disease.

A school-age client is admitted to the pediatric intensive care unit (PICU) in critical condition after a motor vehicle accident. Which intervention should be implemented at this time? 1. Maintain consistent caregivers. 2. Turn the lights off at night. 3. Keep alarm levels low. 4. Consult the hospital play therapist.

Answer: 1 Rationale 1: The intensive care environment is fast-paced, overwhelming, and frightening. Maintaining consistent caregivers is invaluable in developing a familiar and trusting relationship with the child. Turning off the lights in an intensive care environment is not feasible. Keeping alarm levels low could increase risk of injury if an alarm is not heard by staff. Consulting the play therapist is not appropriate at this time.

The nurse is providing care to an adolescent client who is dying. Which assessment findings indicate the client is experiencing a decrease in peripheral circulation? (Select all that apply.) 1. Cool skin 2. Mottled appearance 3. Cheyne-Stokes respirations 4. Increased agitation 5. Increased urine output

Answer: 1,2 Rationale 1: A client who is experiencing decreased peripheral circulation will have cool, mottled skin. While Cheyne-Stokes respirations may indicate death is approaching, this is not indicative of a decrease in peripheral circulation. Increased agitation indicates decreased perfusion to the brain. A client will not experience increased urine output near the end life.

17. The nurse is providing an educational session for parents with children diagnosed with iron deficiency anemia. Which statements will the nurse include educate about the normal functions of red blood cells? (Select all that apply.) 1. "Red blood cells transport oxygen from the lungs to the tissue." 2. "Red blood cells carbon dioxide to the lungs." 3. "Red blood cells protect the body against bacterial invaders." 4. "Red blood cells form hemostatic plugs to stop bleeding." 5. "Red blood cells are responsible for psychosocial development."

Answer: 1,2 Rationale 1: The normal function of red blood cells includes transporting oxygen from the lungs to the tissue and transporting carbon dioxide to the lungs. White blood cells protect the body against bacterial invaders. Platelets form hemostatic plugs to stop bleeding. Red blood cells are not directly responsible for psychosocial development.

18. The nurse is providing care to a school-age client with neutropenia. Which clinical manifestations does the nurse anticipate when assessing this client? (Select all that apply.) 1. Fever 2. Fatigue 3. Tachycardia 4. Hypertension 5. Tachypnea

Answer: 1,2,3,5 Rationale 1: A school-age client who is diagnosed with neutropenia, or a decrease in white blood cells, will likely exhibit fever, fatigue, tachycardia, and tachypnea (as a result of congestive heart failure). The nurse would not anticipate that the client will exhibit hypertension as a result of the diagnosis.

The pediatric nurse educator is conducting an in-service for novice nurses who will begin working on the pediatric oncology unit. The educator wants to include the common clinical manifestations of cancer. Which manifestation will the educator include in the presentation? (Select all that apply.) 1. Cachexia 2. Anemia 3. Gene abnormalities 4. Palpable mass 5. Chromosomal abnormalities

Answer: 1,2,4 Rationale 1: Common clinical manifestations of childhood cancer include cachexia, anemia, and a palpable mass. Gene abnormalities and chromosomal abnormalities are common etiologies to childhood cancer, not clinical manifestations.

A child is diagnosed with rhabdomyosarcoma. Which nursing intervention is most appropriate for this child? 1. Position the child with the head elevated. 2. Monitor for hematuria. 3. Demonstrate the use of a conformer. 4. Administer oxygen.

Answer: 2 Rationale 1: The most common area of the body affected by rhabdomyosarcoma is the bladder. The nursing intervention that is most appropriate is to monitor the child's urine for hematuria. Positioning the child with the head elevated and administering oxygen is appropriate for a child diagnosed with lymphoma. Demonstrating the use of a conformer is appropriate for a child diagnosed with retinoblastoma.

Which intervention is considered supportive care for a family whose infant has died from sudden infant death syndrome (SIDS)? 1. Interviewing parents to determine the cause of the SIDS incident 2. Allowing parents to hold, touch, and rock the infant 3. Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints 4. Advising parents that an autopsy is not necessary

Answer: 2 Rationale 1: The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say good-bye to their baby. The other options are nontherapeutic. The death of an infant without a known medical condition is an indication for an autopsy.

A child is on a ventilator in the pediatric intensive care unit (PICU). Which nursing intervention would best meet the psychosocial needs of this child? 1. Allow the parents to remain at the bedside. 2. Touch and talk to the child often. 3. Provide the child with a blanket from home. 4. Provide consistent caregivers.

Answer: 2 Rationale 1: Touch and verbal exchanges will aid in psychosocial support. The other responses provide a sense of security.

Which client in the pediatric intensive care unit (PICU) would most benefit from palliative care? 1. A child with end-stage leukemia. 2. A child with a broken arm after a motor vehicle accident. 3. A child with burn injuries to the legs. 4. A child with recurrent asthma.

Answer: 3 Rationale 1: A child with burn injuries to the legs will benefit most from palliative care to help control pain, anxiety, sleep disturbances, etc. The child with end-stage leukemia will benefit from hospice care. The child with a broken arm or recurrent asthma will not need palliative care.

10. A school-age child with hemophilia falls on the playground and goes to the nurse's office with superficial bleeding above the knee. Which action by the nurse is the most appropriate? 1. Apply a warm, moist pack to the area. 2. Perform some passive range of motion to the affected leg. 3. Apply pressure to the area for at least 15 minutes. 4. Keep the affected extremity in a dependent position.

Answer: 3 Rationale 1: If a hemophiliac child experiences a bleeding episode, superficial bleeding should be controlled by applying pressure to the area for at least 15 minutes. Ice should be applied, not heat. The extremity should be immobilized and elevated, so passive range of motion and keeping the extremity in a dependent position would not be appropriate interventions at this time.

A school-age child with congenital heart block codes in the emergency department (ED). The parents witness this and stare at the resuscitation scene unfolding before them. Which nursing intervention is most appropriate in this situation? 1. Ask the parents to leave until the child has stabilized. 2. Ask the parents to call the family to come into watch the resuscitation. 3. Ask the parents to sit near the child's face and hold her hand. 4. Ask the parents to stand at the foot of the cart to watch.

Answer: 3 Rationale 1: Parents should be helped to support their child through emergency procedures, if they are able. Parents should never be asked to take part in emergency efforts unless absolutely necessary. Merely watching the resuscitation serves no purpose for the child. If the parents interfere with resuscitation efforts or they are unable to tolerate the situation, they can be asked to leave later.

16. The nurse is caring for a child who is in a sickle cell crisis and has severe pain. Which nursing intervention is the most appropriate for this child? 1. Giving comfort measures, such as back rubs 2. Suggesting diversional activities, such as coloring 3. Administering pain medication 4. Preparing the child for painful procedures

Answer: 3 Rationale 1: Severe pain requires administration of pain medication for pain relief. Comfort measures and diversional activities are not effective against severe pain in children. Comfort measures should be given to every child and can be used after pain medication is given. A child in severe pain is not capable of participating in or enjoying diversional activities. Preparing the child for painful procedures is not appropriate when the child is already in pain.

A school bus carrying children in grades K-12 crashed into a ravine. The critically injured children were transported by ambulance and admitted to the pediatric intensive-care unit (PICU). The nurse is concerned about calming the frightened children. Which nursing intervention is most appropriate to achieve the goal of calming the frightened children? 1. Tell the children that the physicians are competent. 2. Assure the children that the nurses are caring. 3. Explain that the PICU equipment is state of the art. 4. Call the children's parents to come into the PICU

Answer: 4 Rationale 1: A sense of physical and psychological security is best achieved by the presence of parents. Children at all developmental levels look first to their parents or whoever acts as their parents for safety and security. Healthcare providers, no matter how competent or caring, cannot substitute for parents. Children often neither recognize nor care about state-of-the-art equipment.

The nurse is monitoring the urine specific gravity and pH on a child receiving chemotherapy. Which urinalysis result is the goal for this child? 1. Spec gravity 1.030; pH 6 2. Spec gravity 1.030; pH 7.5 3. Spec gravity 1.005; pH 6 4. Spec gravity 1.005; pH 7.5

Answer: 4 Rationale 1: Because the breakdown of malignant cells releases intracellular components into the blood and electrolyte imbalance causes metabolic acidosis, the urine specific gravity should remain at less than 1.010 and the pH at 7 to 7.5. A specific gravity higher than 1.010 can mean fluid intake is not high enough, and a pH of less than 7 means acidosis.

37. A nurse is caring for a patient taking lamivudine (Epivir). Which laboratory test is most important for the nurse to assess? A. CD4+ count B. Hemoglobin C. Platelet count D. White blood cell count

ANS: A Lamivudine is used in children with HIV infection or AIDS. It is a nucleotide reverse transcriptase inhibitor. The CD4+ is the critical laboratory value to monitor in these children.

11. A nurse is caring for an HIV-positive child diagnosed with Pneumocystis jiroveci pneumonia who is receiving trimethoprim-sulfamethoxazole. Which finding indicates a possible complication of using this drug? A. Hemorrhagic blisters B. Polyuria C. Severe headache D. Seizures

ANS: A P. jiroveci is usually treated with trimethoprim-sulfamethoxazole (TMP-SMZ), a sulfa drug. A potential complication of this drug is Stevens-Johnson syndrome, characterized by a rash that turns into hemorrhagic blistering, fever, cough, sore throat, nausea, and vomiting. Polyuria, headache, and seizures are not typical findings in this condition.

16. A parent of a child suspected of having systemic lupus erythematosus (SLE) asks why so many blood tests are being done. Which response by the nurse is the most appropriate? A. "Many of these blood tests look for possible organ damage from SLE." B. "SLE is a complicated disorder and is very hard to diagnose." C. "This is a very typical pattern of diagnostic blood tests we usually do." D. "We are also checking for other possible autoimmune diseases."

ANS: A The diagnostic workup for SLE is indeed complex, but many of the tests are done to determine if organ damage has already occurred and to obtain a baseline to which future tests can be compared. The other options are vague and do not really answer the parent's questions.

28. A nurse is assessing a 7-year-old who has white patches inside his mouth. Which question by the nurse would be most helpful to ask? A. "Do you have asthma?" B. "Do you drink milk?" C. "How much soda do you drink?" D. "When you do brush your teeth?"

ANS: A This child's complaint sounds like oral thrush. Often seen in infants, it can also be caused by inhaler use in children with asthma. The other questions are not related.

The pediatric clinic nurse assesses a child who reports swallowing problems and skin changes on the hands in response to cold exposure. Which other manifestations will the nurses assess for in this child? (Select all that apply.) A. Calcinosis B. Fungal nail infections C. Oral thrush D. Sclerodactyly E. Telangiectasias

ANS: A, D, E This child has two manifestations referred to as CREST syndrome (Raynaud's phenomenon and esophageal dysmotility). The other three signs are calcinosis (formation of calcium deposits under the skin), sclerodactyly (stiff skin over the hands), and telangiectasias (tiny broken capillaries on skin). Fungal nail infections and oral thrush are not related.

The family practice nurse counsels parents to avoid giving their child salicylates for fever or mild pain. Which over-the-counter medications does the nurse warn about that contain this product? (Select all that apply.) A. Alka-Seltzer B. Bufferin C. Dristan D. Kaopectate E. Robitussin

ANS: A, B, C, D Many over-the-counter medications contain salicylates. Common medications include Alka-Seltzer, Bufferin, Dristan, and Kaopectate. Robitussin is not on this list.

25. A child has been diagnosed with a localized herpes simplex virus (HSV) type 1 infection. The nurse is educating the parents on topical acyclovir (Zovirax) ointment. Which statement by the nurse is most appropriate to include during the medication teaching session? A. "Acyclovir can shorten the outbreak." B. "If this doesn't work we can give it IV." C. "This medication will cure the infection." D. "Zovirax must be used for the child's life."

ANS: A Acyclovir and penciclovir (Danavir) can be used to shorten the duration and lessen the pain of HSV infection. It is not curative. IV medication is used for disseminated infection or in children with severe immunocompromise. The medication is used during outbreaks.

13. An adolescent patient is taking combination retroviral therapy for HIV infection. He is not responding as expected. Which action by the nurse is most appropriate? A. Asking why he does not take the medications B. Assessing the patient for noncompliance C. Consulting a pediatric social worker D. Starting a simpler drug regimen for the HIV

ANS: A Adolescents are notorious for wanting to fit in with their peers, even at the cost of their health, and are frequently noncompliant with medication regimens. This is compounded by the very complex nature of multi-drug therapy for HIV. The nurse needs to assess for noncompliance first. Asking "why" questions often puts people on the defensive and may not lead to a truthful response. Consulting a social worker may be needed, but not as the first step. Unfortunately, simple drug regimens for HIV do not exist.

12. An HIV-positive mother wants to return to work because she is feeling well after starting therapy for her disease. She has a 10-month-old infant. What does the nurse advise her when selecting a day care or care provider for her child, who also is HIV-positive? A. "Assess their ability to use standard precautions and properly dispose of diapers." B. "Do not disclose the nature of your baby's disease to the day-care providers." C. "Find out their policy on allowing children who are sick to come to day care." D. "Find out if they consistently wear gloves for all diaper changes they perform."

ANS: A An important concept when caring for babies who are HIV-positive is that diaper changes must include using standard precautions and proper disposal of soiled diapers in biohazard bags and hazardous waste containers. To protect public safety, any day care or care provider the mother chooses must be educated on these procedures. Wearing gloves is not enough. The mother should disclose the baby's illness to protect the day-care workers. Keeping ill children away from her baby is important, too, and most day-care centers have specific guidelines about when sick children can attend. The mother should know these policies and advise the staff to keep her child away from other ill children. But the priority is proper disposal of waste.

A nurse is caring for an HIV-positive school-age child who is moderately malnourished. Which interventions are appropriate to include in this child's plan of care? (Select all that apply.) A. Assess the oral cavity once a shift. B. Determine the child's food preferences. C. Encourage adequate fluid intake. D. Provide oral hygiene after each meal. E. Teach the parents about tube feedings.

ANS: A, B, C, D There are several good strategies for improving nutrition. Assess the oral cavity for mouth sores that make it difficult and painful to eat. Frequent oral care helps reduce the possibility of these lesions occurring. Adequate fluids will help maintain intact oral mucosa. Of course, giving a child favorite foods will increase the likelihood of the child eating. The risks associated with tube feedings are high and not appropriate for a child with mild to moderate malnutrition.

1. A nursing faculty member is explaining the pediatric immune system to students. Which statement is correct? A. Children are born with intact immune systems. B. Children's immune systems develop over 1 year. C. Immunity isn't functional until about 6 months. D. Mothers' immunity is babies' primary line of defense.

ANS: A Children are born with an intact immune system. There immune system, however, is immature. Infants do retain some immunity from their mothers from birth until about 6 months. The other statements are incorrect.

26. A parent brings her child to the pediatric clinic and reports that the child has a rash on one side of his body that reminds her of chickenpox, but is more painful. Which medication does the nurse anticipate teaching the parent about? A. Acyclovir (Zovirax) B. Azathioprine (Imuran) C. Diphenhydramine (Benadryl) D. Intravenous immune globulin (IVIG)

ANS: A This rash sounds like herpes zoster (shingles), which is treated with acyclovir. Imuran is used in autoimmune disorders. Benadryl is used for itching. IVIG is also used in immune disorders.

30. A child is seen in the emergency department after being bitten by a squirrel while playing outside. Which discharge instruction to the parents is most important? A. "Give acetaminophen (Tylenol) for pain." B. "Have the child rest tonight." C. "Keep the wound clean and dry." D. "Return here in 3 days."

ANS: D This child is at risk of rabies. Because of the disease's potentially fatal course, it is imperative that the child complete the rabies vaccination series. Rabies vaccination is given on the day of exposure, and then again on days 3, 7, and 14. The other instructions are not specific for this disease.

29. A child is hospitalized with a serious bacterial infection. Which assessment finding indicates that the goals for a priority nursing diagnosis have been met? A. Intact skin integrity B. Normal temperature C. Stable weight D. Urine output of 1 mL/kg/hour

ANS: D This urine output is normal, demonstrating that the goals for the diagnosis of risk for fluid volume deficit have been met. The other outcomes are demonstrative of met goals, but do not take priority over a possible fluid volume deficit.

38. The day after attending a large birthday party for a classmate, a child breaks out in a rash characteristic of chickenpox. When counseling the parents, which information is most appropriate? A. "Inform all the parents of children at the party that your child has chickenpox." B. "This disease is spread through respiratory droplets, so don't get too close." C. "We can give your child a dose of varicella zoster immune globulin right away." D. "Your child is only contagious for 3 days after the rash first appears."

ANS: A Children with chickenpox are contagious from 1-2 days prior to the rash erupting until the time when all the lesions have crusted over, usually about 7 days. The parents of this child should inform the other parents about their children's exposure to the disease. The disease is spread via airborne and contact routes. Immune globulin can be used within 72 hours after an exposure in immunosuppressed children.

33. The pediatric nurse explains to a nursing student about the most important role the nurse has in preventing disease. What does this role include? A. Ensuring that immunizations are up to date in all children B. Facilitating research on new forms of immunizations C. Giving reminders about immunizations to parents in clinic D. Scheduling and conducting immunization clinics

ANS: A Immunizations are the cornerstone of communicable disease prevention. The most important role the nurse has related to this topic is to ensure that all children in contact with him or her have vaccinations that are up to date. The other activities can be important components of disease prevention, but are not as important.

15. A faculty member is discussing systemic lupus erythematosus (SLE) with a group of nursing students. Which pathophysiological process does the nurse describe as the major problem in this disorder? A. Autoimmune process creates antigen-antibody complexes that damage tissues B. Genetic defect linked strictly to male offspring leading to organ damage C. Limited autoimmune process destroys tissues in specific target organs D. Rapidly progressive disease triggered by hormonal changes such as pregnancy

ANS: A SLE is an autoimmune disorder in which antigen-antibody complexes are formed and deposited widely throughout the body, damaging many organs and tissues. It is tied to a genetic disposition but is not solely genetic in origin; it affects females more than males. The destruction is widespread, not limited to a few target organs. The disease is characterized by exacerbations and remissions.

24. The pediatric nurse is discharging a child diagnosed with cytomegalovirus infection (CMV). Which teaching is most appropriate for this child? A. Ensure adequate rest. B. Keep the child isolated. C. Offer favorite foods. D. Provide plenty of fluids.

ANS: A The most common problem for children during the convalescent phase after acute CMV infection is fatigue. The nurse teaches the parents to ensure the child gets plenty of rest. Adequate nutrition and hydration are always important and are not specific for this condition. The child does not need to be isolated.

39. A child has been hospitalized with rubella. Which action by the charge nurse is most appropriate? A. Do not allow pregnant nursing staff in the room. B. Inform the parents that fresh produce is not allowed. C. Place the child on contact isolation precautions. D. Use standard precautions when caring for the child.

ANS: A The most serious consequence of rubella infection occurs prenatally; exposure in utero can lead to cognitive impairment, deafness, eye disorders, cardiac defects, and stillbirth. Pregnant staff should not enter this room. Disallowing produce is not related to this disorder. Contact precautions are not warranted; this disease is spread through the airborne route. Standard precautions are used for all patients.

27. The clinic nurse is assessing a teenage girl who reports fever, chills, sore throat, and extreme fatigue during the last 2 weeks. Which focused assessment should the nurse perform? A. Assess lymph nodes. B. Collect buccal swabs. C. Obtain a urinalysis. D. Palpate the abdomen.

ANS: A This girl's age and symptoms are highly suggestive of infectious mononucleosis. The nurse should assess for swollen and tender occipital and cervical lymph nodes. The nurse should not palpate the abdomen because the spleen, if enlarged, can rupture under pressure. Buccal swabs and urinalysis are not related.

2. A child is receiving vaccinations at a well-baby clinic. The nurse explains to the mother that the vaccinations provide which type of immunity? A. Active B. Innate C. Man-made D. Passive

ANS: A Vaccinations provide one type of active immunity. Passive immunity is brought about through immunoglobulins, either passed via the mother or given to the child through another means. Innate protection is provided by physical barriers, such as the skin or mucous membranes. Man-made immunity is not a classification of immunity.

The pediatric nurse is aware of the Core Strategies to reduce the spread of MRSA. Which actions do these strategies include? (Select all that apply.) A. Assess hand-hygiene practices. B. Implement contact precautions. C. Rapid reporting of MRSA laboratory results D. Recognize previously colonized patients. E. Screen all patients for MRSA.

ANS: A, B, C, D There are several core strategies to prevent the spread of MRSA, including assessing hand-hygiene practices, implementing contact precautions, rapid reporting of MRSA laboratory results, recognizing previously colonized patients, and educating health-care providers. Screening all patients is not one of the core strategies.

An 8-year-old child is in the clinic and is diagnosed with ringworm. Which medications does the nurse anticipate teaching the child and parents about? (Select all that apply.) A. Griseofulvin (Fulvicin) B. Infliximab (Remicade) C. Ketaconazole (Selenium) D. Naproxen (Naprosyn) E. Salicylates (Aspirin)

ANS: A, C A child diagnosed with ringworm will require teaching regarding antifungal medications. Griseofulvin (Fulvicin) and ketaconazole (Selenium) are appropriate medications to include in the teaching session. The other medications are not used to treat ringworm.

The student studying pediatric infectious diseases recognizes that the epidemiological triangle consists of which concepts? (Select all that apply.) A. Agent B. Communicable period C. Environment D. Host E. Virulence

ANS: A, C, E The epidemiological triangle consists of the agent, the environment, and the host. Communicable period is the time during which the child can transmit the disease to others. Virulence refers to the severity of the health problems caused by the agent.

The nurse is caring for a 15-year-old suspected of having HIV infection. Which laboratory tests does the nurse anticipate will be ordered for this patient? (Select all that apply.) A. ELISA antibody test B. IgA quantification test C. Saliva antibody test D. Urine HIV antigen test E. Western blot test

ANS: A, E The two major diagnostic tests for HIV infection are the ELISA, and if positive, the confirmatory Western blot test. Urine and oral fluid testing is available but is not as accurate. IgA testing is not related.

21. A nurse is working with a student on the pediatric unit caring for patients in contact isolation for infectious diarrhea. Which action by the student warrants intervention by the nurse? A. Changes gloves, performs hand hygiene after touching a contaminated site B. Performs hand hygiene with alcohol-based rubs after caring for patients C. Uses an alcohol-based hand sanitizer prior to putting on gloves D. Washes her hands with soap and hot water when they are visibly soiled

ANS: B After caring for patients with potential or actual infectious diarrhea, hand hygiene is performed using soap and hot water. The other actions are correct.

5. A 4-month old baby was recently hospitalized with septicemia and now has a severe diaper rash. Which primary immunodeficiency disorder does the nurse suspect? A. Antibody deficiency: B-cell disorder B. Combined deficiency: T- and B-cell disorder C. Complement defect disorder D. Phagocyte defect disorder

ANS: B Combined deficiency: T- and B-cell disorder usually manifests before 6 months of age and includes severe infections such as meningitis and septicemia, diaper dermatitis, and opportunistic infections. Antibody deficiencies are usually seen after 6 months of age. Complement defect disorder is often accompanied by autoimmune diseases. Phagocyte defect disorders include impetigo, mouth ulcers, suppurative adenitis, osteomyelitis, and poor wound healing.

32. A child has been diagnosed with influenza and is prescribed oseltamivir (Tamiflu). Which instruction by the nurse is most important? A. "Do not use aspirin with this drug." B. "Encourage plenty of liquids." C. "Rinse the inhaler after each use." D. "This will cure the flu in 5 days."

ANS: B Common side effects of Tamiflu include nausea, vomiting, GI distress, and diarrhea. The child should drink plenty of fluids to avoid dehydration. Aspirin is not used in children at all due to the risk of Reye's syndrome. Tamiflu is not given via inhaler. The medication is not curative.

23. An immunocompromised child has been admitted to the hospital with Fifth's disease. Which action by the nurse is most appropriate? A. Place the child in contact precautions. B. Place the child in droplet precautions. C. Place the child in protective isolation. D. Place the child on standard precautions.

ANS: B Fifth's disease is spread through respiratory droplets, so droplet precautions are appropriate. Of course standard precautions should be used with all patients, but this is not enough in this situation. Contact and protective precautions are not needed for this disease.

17. A teenage girl is diagnosed with systemic lupus erythematosus (SLE). Which health promotion guidance is important for the nurse to provide? A. "Acetaminophen (Tylenol) is best for daily pain." B. "Consider adding vitamin D to your daily routine." C. "Plan to choose a career that is sedentary." D. "You should consider elective sterilization."

ANS: B Sun exposure is a frequent cause of SLE exacerbations, so patients with SLE must use sunscreen and avoid prolonged time in the sun. This decreases vitamin D synthesis, which is required to metabolize and utilize calcium, leading to increased risk of osteoporosis. A side effect of steroid use is also osteoporosis, so patients with SLE (women especially) need to guard against this occurrence by adding supplemental vitamin D. NSAIDs are best for the pain and inflammation that accompany SLE. The patient does not have to be sedentary; a balance of rest and activity is needed. Pregnancy is not absolutely contraindicated in the patient with SLE; however, it must be considered cautiously in consultation with the health-care provider.

A nurse is educating a community group of parents about prevention of West Nile virus. Which information does the nurse include in the teaching session? (Select all that apply.) A. All children should be sprayed with DEET before going outside. B. Eliminate standing water around your house, such as in birdbaths. C. Holistic mosquito repellent, such as lavender, is very effective. D. Long sleeves and long pants help prevent mosquito bites. E. The peak season for this virus is late summer to early autumn.

ANS: B, D, E West Nile is most prevalent in late summer and early fall. Standing water is a breeding ground for mosquitoes and should be eliminated. Long sleeves and pant legs help keep mosquito bites from occurring on the arms and legs. Mosquito repellants containing DEET are most effective in preventing mosquito bites. Holistic methods are not as effective. Children under the age of 2 years should not have DEET sprayed onto their skin; rather, it should be applied to their clothing.

6. A 10-month-old-child is in the pediatric clinic for his eighth ear infection. Which assessment is most important for the nurse to perform on this child? A. Ask the parent about possible allergy testing. B. Assess the child's mouth for oral thrush. C. Graph height and weight on the growth chart. D. Inquire about the health of the entire family.

ANS: C Children with primary immunodeficiencies can often be identified using Modell's 10 Warning Signs, which include failure to gain weight or grow properly. The nurse should assess the child's height and weight and graph it on the growth chart, comparing it to normal values for the child's age. Persistent oral or skin thrush is another sign if it persists past 1 year of age. Assessing for parental views on allergy testing is not related. Because these deficiencies are congenital, asking about the health of the entire family is too vague; it would be important to ask specifically about a history of primary immunodeficiencies, however.

18. A parent calls a pediatric information line worried about muscular dystrophy because her daughter has new onset of muscle weakness. Which question by the nurse would elicit the most useful information? A. "Does anyone else in your house have this?" B. "Does this seem to come and go sporadically?" C. "Does your child have a rash on her face?" D. "Does your daughter complain of stiffness?"

ANS: C Dermatomyositis is an autoimmune disorder characterized by proximal muscle weakness, a red-purple facial rash, possibly a rash similar to that seen in systemic lupus erythematosus, tender and stiff muscles, voice changes, and dysphagia. The muscle weakness combined with the facial rash would provide the nurse a basis to suspect this disorder. This is not contagious nor is it inherited, so asking about others' symptoms would not be helpful. It is not characterized by exacerbations and remissions, and although stiffness is a common manifestation, that could be indicative of many other conditions.

40. The pediatric charge nurse receives this report on an incoming admission: a 3-year-old boy with ear and jaw pain, bilateral parotid gland swelling, and mild dehydration. Which action by the charge nurse is most appropriate? A. Do not assign pregnant nursing staff. B. Inform parents that sterility is common. C. Place the child on droplet precautions. D. Place the child on airborne precautions.

ANS: C Hospitalized children who have mumps require droplet precautions. There is no danger to a fetus. Sterility is possible in male children due to orchitis, but it is rare.

10. A nurse volunteers for a disaster relief program and has traveled to an area devastated by a natural disaster. All basic services have been disrupted. When counseling an HIV-positive mother, what is the priority for her 8-month-old infant? A. Availability of family members to help B. Local supplies of immunizations C. Safety of the drinking water supply D. Types of shelter space available

ANS: C If the mother must mix dry powered formula to feed her baby, it is imperative that the water used be sanitary to avoid further compromising the infant and causing infection. The other information is important, but feeding is an immediate need.

14. An HIV-positive child has low titers after a measles vaccination. She has now been exposed to the disease. Which action by the nurse is most appropriate? A. Administer prophylactic antibiotics. B. Place the child in protective isolation. C. Prepare to administer immunoglobulin. D. Repeat the vaccination as soon as possible.

ANS: C When the immune-compromised child does not show an appropriate response to a vaccination, she should be treated with immunoglobulin if exposed. Repeating the vaccination will not help if the child's immune system cannot mount a response. Antibiotics are not used to treat measles. Protective isolation is not warranted.

8. A nurse is caring for a 5-year-old child diagnosed with Wiskott-Aldrich syndrome. When reviewing today's laboratory results, which finding does the nurse correlate with this condition? A. Hemoglobin: 7.3 mg/dL B. PaO2: 64 mm Hg C. Platelet count: 6,000 D. White blood cell count: 33,000/mm3

ANS: C Wiskott-Aldrich syndrome is characterized by thrombocytopenia, so the low platelet count of 6,000 correlates with this condition. The low hemoglobin could be found if the child has significant bleeding, but is not a specific finding. The low PaO2 is also not directly related, and neither is the high white blood cell count.

A child diagnosed with cancer is prescribed chemotherapy. The latest lab value indicates the white-blood-cell count is very low. Which medication order does the nurse anticipate? 1. Filgrastim (Neupogen) 2. Ondansetron (Zofran) 3. Oprelvekin (Neumega) 4. Epoetin alfa (human recombinant erythropoietin)

Answer: 1 Rationale 1: Filgrastim (Neupogen) increases production of neutrophils by the bone marrow. Ondansetron (Zofran) is an antiemetic, oprelvekin (Neumega) increases platelets, and epoetin alfa (human recombinant erythropoietin) stimulates red-blood-cell (RBC) production.

36. A patient was hospitalized 2 years ago with a resistant bacterial infection. The patient is admitted for an unrelated problem and placed on contact isolation. The parents question the need for this action. Which response by the nurse is best? A. "It is possible that your child could still contaminate the nursing staff." B. "It's our policy to isolate anyone who has had this infection in the past." C. "This seems distressing for you; would you like me to call the charge nurse?" D. "Your child may be colonized with the bacteria so we isolate until we know."

ANS: D A person who had a bout with a resistant bacteria may be colonized. Many facilities require placing such patients in isolation until this has been ruled out. This is the most factual and informative answer. Contaminating the nursing staff is not really the problem; the nursing staff spreading the organism to susceptible patients is. The nurse should provide information and not just call someone else to explain. Telling the parents that this practice is policy may be true, but does not give them any information.

4. A nurse is providing anticipatory guidance to new parents. Which instruction by the nurse will assist the parents in maintaining physical barriers to prevent infection in their newborn? A. Breastfeeding provides some antibodies. B. Ensure your baby is getting enough nutrition. C. Keep your baby away from people who are sick. D. Wash your baby with gentle soap and dry well.

ANS: D All options are sound advice for helping to keep a newborn well. However, the only option specific to physical barriers available to protect against infection (skin, mucous membranes) is to wash the baby's skin with gentle soap and dry it well, helping to keep it intact.

3. A nursing student is learning about the immune system. Which statement about immunoglobulins is correct? A. Adult levels of IgG are reached by the age of 6 months. B. Children are born with adult levels of IgA. C. IgE leads the body's attack against bacteria and viruses. D. IgM is the first type of antibody made in response to infection.

ANS: D IgM is the first antibody made in response to an infection. Adult levels of IgG are reached by 1 year of age. Children attain an adult level of IgA by 5 years of age. IgE is important in the response against fungus spores, animal dander, and pollen.

7. A child with a primary immunodeficiency disorder had postimmunization titers drawn. The titers came back low. Which explanation does the nurse give the parents? A. "The immunizations had no effect on the child." B. "This result indicates a hyperactive response." C. "Vaccinations are not needed in your child." D. "Your child's immune system did not respond."

ANS: D The most correct answer is that the low titers indicate that the child's immune system did not respond adequately to the vaccinations. It cannot be determined if they had no effect at all on the child. Although vaccinations did not produce the desired response, that does not mean they are not needed; they just did not work as planned. This child had a hypoactive, not hyperactive, response.

35. A nurse has given an infant a vaccination. Which information is important to document specifically for this vaccination? A. Date of next regularly scheduled immunization B. Drug, dose, site of administration, infant's reaction C. Parental education provided before administration D. Vaccine information sheet given before administration

ANS: D The nurse is legally required to provide the appropriate vaccine information sheet to the parent/guardian prior to administering a vaccination. The other information is important to document too, but is not specific for vaccinations

9. A nurse is caring for an infant with an HIV-positive mother. Which statement made by the nursing during teaching is the most appropriate? A. "As long as your CD4+ count is fine, you can nurse." B. "Breastfeeding is OK if you both take zidovudine (AZT)." C. "The HIV virus is not passed through breast milk." D. "You should bottle feed your baby consistently."

ANS: D Vertical (mother-to-infant) transmission can occur via breast milk, so the mother should be taught to bottle feed her baby. The other statements are inaccurate.

5. The nurse is providing care for an adolescent client who is experiencing pain related to a sickle cell crisis. Which medication does the nurse prepare to administer to this client? 1. Morphine sulfate 2. Meperidine 3. Acetaminophen 4. Ibuprofen

Answer: 1 Rationale 1: The pain during a sickling crisis is severe, and morphine is needed for pain control around the clock or by patient-controlled analgesia (PCA). Meperidine is not used for pain control for clients with sickle cell pain crisis because it could cause seizures. Acetaminophen or ibuprofen is used for mild pain and would not be effective for the severe pain experienced by a child in sickle cell pain crisis.

A toddler-age client is in end-stage renal failure. Which nursing intervention will assist this child most? 1. Maintain the child's normal routines. 2. Explain body changes that will take place. 3. Encourage friends to visit. 4. Allow the child to talk about the illness.

Answer: 1 Rationale 1: A toddler has no real concept of death, but does sense changes in routine and parent behavior. Maintaining normal routines is the best intervention to assist this child. A toddler will not understand the body changes; this approach would be more appropriate for a school-age child. Encouraging friends to visit and allowing the child to talk about the illness are more appropriate for older children.

9. A child recently diagnosed with aplastic anemia is being prepared for discharge. When planning support for the family, which service should the nurse plan to include in the discharge plan? 1. Referrals to support groups and social services 2. Short-term support 3. Genetic counseling 4. Nutrition counseling

Answer: 1 Rationale 1: Families require support in dealing with a child who has a life-threatening disease. They should be referred to support groups for counseling, if indicated, and to social services. The support will be long term in nature. Aplastic anemia is not a genetically transmitted disease. Nutrition counseling is not a priority and may or may not be needed with aplastic anemia.

Parents of a child in the pediatric intensive care unit (PICU) have been experiencing shock and disbelief regarding their situation. Which statement by the parents indicates they are moving forward into the next stage of coping? 1. "Why not me instead of my child?" 2. "It is hard for me to have others take care of my child." 3. "I feel like life is suspended in time." 4. "I am glad I can help with his care."

Answer: 1 Rationale 1: The parents initially enter the stage of shock and disbelief. Asking "Why not me instead of my child?" shows they are moving into the next stage, which is anger and disbelief. Having feelings about others caring for their child is the third stage of deprivation and loss. The feeling of being suspended in time is the fourth stage, which is anticipatory guidance.

A child is diagnosed with a Wilms tumor. Which nursing action is most appropriate prior to surgery? 1. Careful bathing and handling 2. Monitoring of behavioral status 3. Maintenance of strict isolation 4. Administration of packed red-blood cells

Answer: 1 Rationale 1: The tumor should never be palpated; careful bathing and handling are an important nursing consideration. Palpating the tumor can cause a piece of the tumor to dislodge. The child's behavior will not be affected with a Wilms tumor. The tumor does not cause excessive lowering of WBCs or RBCs, so strict isolation or administration of packed red-blood cells is not usually a nursing intervention.

A child is diagnosed with thrombocytopenia secondary to chemotherapy treatments. Which action by the nurse is not appropriate? 1. Administer intramuscular injections (IM). 2. Perform oral hygiene. 3. Monitor intake and output. 4. Use palpation as a component of assessment.

Answer: 1 Rationale 1: When the child is thrombocytopenic (decreased platelets) from chemotherapy, the nurse should not administer IM injections because of the risk of bleeding. Oral hygiene care should be done with a soft toothbrush and intake and output monitored for any abnormalities. Gentle palpation should still be included in physical assessments.

A novice nurse in the newborn intensive care unit (NICU) has just performed post-mortem care on a premature infant who passed away. The novice nurse asks to be excused near the end of the shift. Which interventions can be implemented to support this nurse? (Select all that apply.) 1. Schedule additional education on bereavement care 2. Ask a seasoned nurse to talk with the novice nurse 3. Tell the nurse it is ok to grieve with the family 4. Recommend that the nurse transfer to another unit 5. Assign the nurse to stable clients only

Answer: 1,2,3 Rationale 1: Appropriate interventions for this nurse include scheduling additional education on bereavement care, asking a seasoned nurse to talk about the situation with the novice nurse, and telling the nurse it is ok to grieve with the family. Recommending a transfer and assigning the nurse to only stable clients are not appropriate interventions to support the novice nurse.

The pediatric nurse is providing care to a school-age child receiving chemotherapy to treat cancer. Which interventions are appropriate to include in the plan of care in order to monitor for oncologic emergencies? (Select all that apply.) 1. Monitor complete blood count (CBC). 2. Document intake and output. 3. Observe for behavioral changes. 4. Refer for psychosocial support. 5. Implement neutropenic precautions.

Answer: 1,2,3 Rationale 1: Oncologic emergencies can be organized into three groups: metabolic, hematologic, and those involving space-occupying lesions. Appropriate interventions for the nurse to include in the plan of care to monitor for these emergencies include monitoring the CBC to prevent sepsis and hemorrhage; monitoring intake and output by encouraging hydration to prevent hypercalcemia and observing for signs of water intoxication; and observing for behavioral changes as space-occupying lesions may cause seizures or increased intracranial pressure. Referring for psychosocial support and implementing neutropenia precautions may be appropriate, but these interventions do not address oncologic emergencies.

A young school-age child is in the pediatric intensive-care unit (PICU) with a fractured femur and head trauma. The child was not wearing a helmet while riding his new bicycle on the highway and collided with a car. Which nursing diagnoses may be appropriate for this family? (Select all that apply.) 1. Guilt Related to Lack of Child Supervision and Safety Precautions 2. Family Coping: Compromised, Related to the Critical Injury of the Child 3. Parental Role Conflict Related to Child's Injuries and PICU Policies 4. Knowledge Deficit Related to Home Care of Fractured Femur 5. Anger Related to Feelings of Helplessness

Answer: 1,2,3,5 Rationale 1: All of these nursing diagnoses except Knowledge Deficit are possible in this situation. Although planning for discharge begins with admission, it is too early to begin teaching the parents about home care. The astute and experienced PICU nurse is prepared to recognize current problems and intervene appropriately.

6. The nurse is teaching parents how to prevent a sickle cell crisis in the child with sickle cell disease. Which precipitating factors to a sickle cell crisis will the nurse include in the explanation? (Select all that apply.) 1. Fever 2. Dehydration 3. Regular exercise 4. Altitude 5. Increased fluid intake

Answer: 1,2,4 Rationale 1: Fever, dehydration, and altitude are precipitating factors contributing to a sickle cell crisis. Regular exercise and increased fluid intake are recommended activities for a child with sickle cell disease and will not contribute to a sickle cell crisis.

A seasoned nurse is precepting a novice nurse on a pediatric oncology unit. The seasoned nurse would like to review the ongoing physiologic and psychosocial care of the children who survive cancer. Which topics will the seasoned nurse include in the discussion with the novice nurse? (Select all that apply.) 1. Developing other cancers 2. Recommending regular office visits 3. Encouraging school-age clients to manage their own care 4. Needing weekly laboratory tests 5. Providing educational and psychosocial support

Answer: 1,2,5 Rationale 1: Appropriate topics include discussing the increased risk for these children to develop other cancers; recommending regular office visits for monitoring purposes; and providing educational and psychosocial support. It would be appropriate to encourage the adolescent and young adult clients to manage their own care, not a school-age child. While these clients need regular laboratory examinations, weekly laboratory tests are not appropriate.

12. The nurse is caring for a child with disseminated intravascular coagulation (DIC). Which nursing intervention is a priority for this child? 1. Frequent ambulation 2. Maintenance of skin integrity 3. Monitoring of fluid restriction 4. Preparation for x-ray procedures

Answer: 2 Rationale 1: Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should be placed on bed rest. Fluids need to be monitored but will not be restricted, and DIC is not diagnosed with x-ray examination but by serum lab studies.

The emergency-room nurse receives a preschool-age child who was hit by a car. Which nursing interventions are a priority for this child? (Select all that apply.) 1. Performing a rapid head-to-toe assessment 2. Recording the parents' insurance information 3. Assessing airway, breathing, and circulation 4. Asking the parents about organ donation 5. Asking the parents if anyone witnessed the accident

Answer: 1,3 Rationale 1: Assessing airway, breathing, and circulation and performing a rapid head-to-toe assessment are the priority nursing interventions. Asking the parents about organ donation is insensitive until the extent of the child's injuries is known. Recording insurance information is necessary but should never come before lifesaving assessment and intervention. Detailed information about the accident is helpful in determining the child's point of impact with the car and mechanism of injury, but this is not the initial priority.

15. A child who has undergone a hematopoietic stem cell transplantation (HSCT) is ready for discharge. Which items will the nurse include in the discharge teaching for this child and family? (Select all that apply.) 1. Recognize the signs of graft-versus-host disease. 2. Return the child to school within six weeks. 3. Practice good handwashing. 4. Avoid obtaining influenza vaccinations. 5. Avoid live plants and fresh vegetables.

Answer: 1,3,5 Rationale 1: A child who is preparing for discharge after a HSCT will require specific interventions to decrease the risk of contracting communicable illnesses. Appropriate teaching points include: recognizing the signs of graft-versus-host disease; practicing good handwashing; and avoiding live plants and fresh vegetables. The child will require home schooling for 6 to 12 months. The child and family members should be encouraged to obtain yearly influenza vaccinations.

A child is admitted to the neonatal intensive care unit (NICU). The parents are concerned because they cannot stay for long hours to visit. Which statement made by the nurse is most appropriate? 1. "One of you might take a leave of absence to be here more." 2. "Parents often feel this way; would you be interested in talking with others who have experienced having a child in the NICU?" 3. "Perhaps the grandparents can make the visits for you." 4. "Why can't you visit after work every day?"

Answer: 2 Rationale 1: "Parents often feel this way; would you be interested in talking with others who have experienced having a child in the NICU?" is therapeutic; it focuses on feelings and offers support to the parents. The other options do not focus on how the parents feel and attempt to solve the issue rather than allow for the parents to deal with their feelings and form solutions.

A 24-hour urine collection for vanillylmandelic acid (VMA) has been ordered on a child suspected of having neuroblastoma. When is the most appropriate time for the nurse to begin the collection? 1. At 0700 2. After the next time the child voids 3. At bedtime 4. When the order is noted

Answer: 2 Rationale 1: A 24-hour urine collection is started after the child voids. That specimen is not saved, but all subsequent specimens in that 24-hour period should be collected. It would not be an accurate collection of 24 hours of urine if the collection began at 0700, bedtime, or when the order is noted.

An adolescent client has a stiff neck, a headache, a fever of 103 degrees Fahrenheit, and purpuric lesions noted on the legs. Although the adolescent's physical needs take priority at the present time, the nurse can expect which to be the most significant psychological stressor forthis adolescent? 1. Separation from parents and home. 2. Separation from friends and permanent changes in appearance 3. Fear of painful procedures and bodily mutilation 4. Fear of getting behind in schoolwork

Answer: 2 Rationale 1: Adolescents are developing their identity and rely most on their friends. They are concerned about their appearance and how they look compared to their peers. Separation from parents and home is the main psychological stressor for infants and toddlers. Preschoolers fear pain and bodily mutilation. School-age children are developing a sense of industry and fear getting behind in schoolwork.

A child with a brain tumor is admitted to the pediatric intensive care unit (PICU)after brain surgery to remove the tumor. Which postoperative order would the nurse question? 1. Antibiotics 2. Sodium levels every 24 hours 3. Anticonvulsants 4. Hourly intake and output

Answer: 2 Rationale 1: Antibiotics, anticonvulsants, and hourly intake and output are appropriate orders. Serum sodium levels should be done every 4-6 hours, not every 24 hours.

7. The nurse is administering packed red blood cells to a child with sickle cell disease (SCD). The nurse is monitoring for a transfusion reaction and knows it is most likely to occur during which time frame? 1. Six hours after the transfusion is given 2. Within the first 20 minutes of administration of the transfusion 3. At the end of the administration of the transfusion 4. Never; children with SCD do not have reactions.

Answer: 2 Rationale 1: Blood reactions can occur as soon as the blood transfusion begins or within the first 20 minutes. The nurse should remain with the child for the first 20 minutes of the transfusion.

11. A child diagnosed with hemophilia plans on participating in a bicycling club. Which recommendation by the nurse is the most appropriate? 1. Consider a swim club instead of the bicycling club. 2. Wear kneepads, elbow pads, and a helmet while bicycling. 3. Participate only in the social activities of the club. 4. Not join the club.

Answer: 2 Rationale 1: Children with hemophilia should be encouraged to participate in noncontact sports activities. Bicycling is an excellent option and is recommended along with swimming. The child should always use kneepads, elbow pads, and a helmet when participating in a physical sport. Participating only in the social aspects of the club would not encourage physical activity. Discouraging a child from joining a club would not foster growth and development.

A preschool-age child is brought to the clinic by the mother, who says the child has been lethargic and anorexic lately and complains of bone pain. On exam, the nurse notes petechiae, joint pain, and an enlarged liver. Which diagnosis does the nurse anticipate for this child? 1. Hodgkin disease 2. Leukemia 3. Rhabdomyosarcoma 4. Ewing sarcoma

Answer: 2 Rationale 1: Hodgkin disease, rhabdomyosarcoma, and Ewing sarcoma are all childhood cancers, but they do not have the clinical manifestations listed. Leukemia is one of the most common childhood cancers, and has those clinical symptoms.

A preschool child is seen in the clinic, and the nurse anticipates a diagnosis of leukemia. Which reaction does the nurse anticipate this child will exhibit upon diagnosis? 1. Acceptance, especially if able to discuss the disease with children their own age 2. Thoughts that they caused their illness and are being punished 3. Understanding of what cancer is and how it is treated 4. Unawareness of the illness and its severity

Answer: 2 Rationale 1: Preschool-age children may think they caused their illness. Adolescents find contact with others who have gone through their experience helpful. School-age children can understand a diagnosis of cancer. Infants and toddlers are unaware of the severity of the disease.

2. Which action by the parents demonstrates an understanding of the nurse's teaching with regard to prevention of iron-deficient anemia? 1. Feeding their infant with a formula that is not iron fortified 2. Starting iron-fortified infant cereal at 4 to 6 months of age 3. Introducing cow's milk at 6 months of age 4. Limiting vitamin C consumption after 1 year of age

Answer: 2 Rationale 1: Starting iron-fortified infant cereal at 4 to 6 months of age is recommended for prevention of iron deficiency in children. Infants who are not breast-fed should get iron-fortified formula. Cow's milk should not be introduced until 12 months of age. Vitamin C should be started at 6 to 9 months of age and continued, because foods rich in vitamin C improve iron absorption.

Which nursing interventions would be best for the nursing diagnosis of Powerlessness Related to Relinquishing Control to the Healthcare Team? (Select all that apply.) 1. Provide a primary nursing care model. 2. Prepare the child in advance for procedures. 3. Provide optimal pain relief. 4. Explain procedures in developmentally appropriate terms. 5. Incorporate home rituals when possible.

Answer: 2,4,5 Rationale 1: Preparation in advance—and in terms that are developmentally appropriate—and incorporating home rituals provide some degree of control, and might reduce the feeling of powerlessness. Providing a primary nursing care model will help decrease anxiety, and providing pain relief will decrease pain.

An adolescent is receiving methotrexate chemotherapy after undergoing limb-salvage surgery for osteogenic sarcoma. Which statement by the adolescent indicates understanding of the purpose of leucovorin therapy after the methotrexate? 1. "I'm glad I only need one dose of the leucovorin." 2. "I don't have any pain so I won't need to take the leucovorin this time." 3. "I know I will be taking the leucovorin every 6 hours for about the next 3 days." 4. "I don't have any nausea so I won't need the leucovorin."

Answer: 3 Rationale 1: Leucovorin (citrovorum factor) is a form of folic acid that helps to protect normal cells from the destructive action of methotrexate. It is started within 24 hours of methotrexate administration and is given along with hydration therapy. Usual administration is every 6 hours for 72 hours or until serum methotrexate is at the desired level.

A child diagnosed with a Wilms tumor is prescribed chemotherapy. Which laboratory test will the nurse monitor prior to administering the chemotherapy to determine the child's infection-fighting capability? 1. Hemoglobin 2. Red-blood-cell count 3. Absolute neutrophil count (ANC) 4. Platelets

Answer: 3 Rationale 1: The absolute neutrophil count uses both the segmented (mature) and bands (immature) neutrophils as a measure of the body's infection-fighting capability. Red-blood-cell count, hemoglobin, and platelets cannot determine infection-fighting capabilities.

The antiemetic drug ondansetron (Zofran) is administered to a child receiving chemotherapy. When should the nurse administer this medication? 1. Only if the child experiences nausea 2. After the chemotherapy has been administered 3. Before chemotherapy administration as a prophylactic measure 4. Never; this antiemetic is not effective for controlling nausea and vomiting associated with chemotherapy.

Answer: 3 Rationale 1: The antiemetic ondansetron (Zofran) should be administered before chemotherapy as a prophylactic measure. Giving it after the child has nausea or at the end of chemotherapy treatment does not help with preventing nausea. It is the drug of choice for controlling nausea caused by chemotherapy agents.

The child is admitted to the hospital after being diagnosed with retinoblastoma. Which assessment finding does the nurse anticipate for this child? 1. A red reflex 2. Yellow sclera 3. A white pupil 4. Blue-tinged sclera

Answer: 3 Rationale 1: The first sign of retinoblastoma is a white pupil. The red reflex is absent. Yellow sclera is a sign of jaundice, not retinoblastoma. Blue-tinged sclera is a sign of osteogenesis imperfecta, not retinoblastoma.

A child who is diagnosed with leukemia has a sibling who is expressing feelings of anger and guilt. How would the nurse characterize this reaction by the sibling? 1. Abnormal; the sibling should be referred to a psychologist. 2. Normal; the illness doesn't affect the sibling. 3. Unexpected; the cancer is easily treated. 4. Normal; the sibling is affected too, and anger and guilt are expected feelings.

Answer: 4 Rationale 1: A diagnosis of cancer affects the whole family, and initial feelings experienced by the sibling may be anger and guilt. Seldom will the sibling be unaffected; however, the response is not abnormal.

Siblings of a client in pediatric intensive care unit (PICU) are preparing to visit their brother, who was hit by a car while riding his bike. Which intervention by the nurse will assist the siblings in preparing for the visit? 1. Spend time developing a relationship with the siblings. 2. Have the parents go with the siblings when they visit. 3. Encourage the siblings to talk to a social worker before seeing their brother. 4. Explain what the siblings will hear and see when they visit.

Answer: 4 Rationale 1: Explaining what the siblings will hear and see when they visit will best prepare them for the visit with their brother. The other responses are good ways to help alleviate stress but won't help prepare the siblings for the visit.

1. The nurse is evaluating the activity tolerance of a 9-month-old with iron deficiency anemia. Which finding indicates that the infant is not tolerating activity? 1. Heart rate of 138 2. Increased alertness 3. Respiratory rate less than 40 with activity 4. Muscle weakness

Answer: 4 Rationale 1: Iron deficiency anemia can result in less oxygen reaching the cells and tissues, causing activity intolerance. An indication that a 9-month-old child is not tolerating activity and that iron deficiency anemia is worsening would be the presence of muscle weakness during activity. A heart rate of 138, increased alertness, and a respiratory rate of less than 40 with activity are all signs that iron deficiency anemia is resolving and activity tolerance is improving.

8. A child who has beta-thalassemia is receiving numerous blood transfusions. The child is also receiving deferoxamine (Desferal) therapy. The parents ask how the deferoxamine will help their child. Which rationale does the nurse use when responding to the parents? 1. It prevents blood transfusion reactions. 2. It stimulates red blood cell production. 3. It provides vitamin supplementation. 4. It prevents iron overload.

Answer: 4 Rationale 1: Iron overload can be a side effect of a hypertransfusion therapy. Deferoxamine (Desferal) is an iron-chelating drug, which binds excess iron so it can be excreted by the kidneys. It does not prevent blood-transfusion reactions, stimulate red blood cell production, or provide vitamin supplementation.

14. A child with meningococcemia is being admitted to the pediatric intensive-care unit. Which room assignment is the most appropriate for this child? 1. Semiprivate room 2. Private room, but not in isolation 3. Private room, in protective isolation 4. Private room, in respiratory isolation

Answer: 4 Rationale 1: Meningococcemia follows an infection with Neisseria meningitidis. N. meningitidis is transmitted through airborne droplets; thus, the child should be placed in a private room in respiratory isolation. A private room with protective isolation (child is essentially kept in a "bubble") would not be appropriate.

4. The charge nurse on a pediatric unit is making a room assignment for a school-age child diagnosed with sickle cell disease, who is in splenic sequestration crisis. Which room assignment is most appropriate for this client? 1. Semiprivate room 2. Reverse-isolation room 3. Contact-isolation room 4. Private room

Answer: 4 Rationale 1: Splenic sequestration can be life-threatening, and there is profound anemia. The child does not need an isolation room but should not be placed in a room with any child who may have an infectious illness. The private room is appropriate for this child.

An adolescent with cystic fibrosis is intubated with an endotracheal tube. Which nursing diagnosis is most appropriate for this adolescent? 1. Potential for Imbalanced Nutrition, More Than Body Requirements Related to Inactivity 2. Anxiety Related to Leaving Chores Undone at Home 3. Potential for Fear of Future Pain Related to Medical Procedures 4. Powerlessness (Moderate) Related to Inability to Speak to or Communicate with Friends

Answer: 4 Rationale 1: The adolescent values communication with peers and may feel frustrated that he cannot speak to them while intubated. The adolescent is present-oriented and is unlikely to worry about household chores or future unknown procedures. The adolescent with cystic fibrosis is likely to be underweight and is unlikely to take in more calories than needed while intubated.

The parents of a toddler-age child who sustained severe head trauma from falling out a second-story window are arguing in the pediatric intensive-care unit (PICU) and blaming each other for the child's accident. Which nursing diagnosis is most appropriate for this family? 1. Parental Role Conflict Related to Protecting the Child 2. Hopelessness Related to the Child's Deteriorating Condition 3. Anxiety Related to the Critical-Care-Unit Environment 4. Family Coping: Compromised, Related to the Child's Critical Injury

Answer: 4 Rationale 1: The parents are displaying ineffective coping behaviors as a family. Parental role conflict does not refer to the parents' argument in the PICU, but means a parent is conflicted or confused about some aspect of the parental role. Each parent may be experiencing hopelessness, frustration, and anxiety, but they are not coping well as a family unit.

The nurse must prepare parents to see their adolescent daughter in the pediatric intensive-care unit (PICU). The child arrived by life flight after experiencing multiple traumas in a car accident involving a suspected drunk driver. At this time, which statement by the nurse to the family is the most appropriate? 1. "Don't worry; everything will be okay. We will take excellent care of your child." 2. "You should press charges against the drunk driver." 3. "Your child's leg was crushed and may have to be amputated." 4. "Your child's condition is very critical; her face is swollen, and she may not look like herself."

Answer: 4 Rationale 1: The priority is to prepare the parents for the child's changed appearance. The nurse must not offer false reassurance nor project future stressful events. Truthful statements about the child's condition can be introduced after the parents have seen the child and grasped the situation. The nurse supports the family but remains nonjudgmental about accident details.