Test 2 - Chapter 21: The Child with Respiratory Dysfunction

21. The nurse is caring for a child with carbon monoxide poisoning associated with smoke inhalation. Which is essential in this child's care? a. Monitor pulse oximetry. b. Monitor arterial blood gases. c. Administer oxygen if respiratory distress develops. d. Administer oxygen if child's lips become bright, cherry red.

ANS: B Arterial blood gases are the best way to monitor carbon monoxide poisoning. Pulse oximetry is contraindicated in the case of carbon monoxide poisoning because the PaO2 may be normal. The child should receive 100% oxygen as quickly as possible, not only if respiratory distress or other symptoms develop.

26. B-Adrenergic agonists and methylxanthines are often prescribed for a child with an asthma attack. Which describes their action? a. Liquefy secretions b. Dilate the bronchioles c. Reduce inflammation of the lungs d. Reduce infection

ANS: B B-Adrenergic agonists and methylxanthines work to dilate the bronchioles in acute exacerbations. These medications do not liquefy secretions or reduce infection. Corticosteroids and mast cell stabilizers reduce inflammation in the lungs.

22. A nurse is admitting an infant with asthma. What usually triggers asthma in infants? a. Medications b. A viral infection c. Exposure to cold air d. Allergy to dust or dust mites

ANS: B Viral illnesses cause inflammation that causes increased airway reactivity in asthma. Medications such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and antibiotics may aggravate asthma, but not frequently in infants. Exposure to cold air may exacerbate already existing asthma. Allergy is associated with asthma, but 20% to 40% of children with asthma have no evidence of allergic disease. Page 664 Evidence shows that viral respiratory infections, including RSV infection, may also have a significant role in the development and expression of asthma.

2. The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which intervention should be included in the child's care? (Select all that apply.) a. Place in a mist tent. b. Administer antibiotics. c. Administer cough syrup. d. Encourage the child to drink 8 ounces of formula every 4 hours. e. Cluster care to encourage adequate rest. f. Place on noninvasive oxygen monitoring.

ANS: D, E, F Hydration is important in children with RSV bronchiolitis to loosen secretions and prevent shock. Clustering of care promotes periods of rest. The use of noninvasive oxygen monitoring is recommended. Mist tents are no longer used. Antibiotics do not treat illnesses with viral causes. Cough syrup suppresses clearing of respiratory secretions and is not indicated for young children.

ANS: A, C, D, F a. Breast milk provides essential nutrients and antibodies that can help the infant's immune system fight the infection. c. Monitoring for signs of respiratory distress or pauses in breathing is crucial for early intervention. d. This helps clear nasal congestion, aiding in breathing and feeding. f. RSV is highly contagious, and limiting exposure to other children can prevent further spread of the virus.

5. A 2-month-old formerly healthy infant born at term is seen in the urgent care clinic with intercostal retractions, respiratory rate of 62, heart rate of 128, refusal to breastfeed, abundant nasal secretions, and a pulse oximeter reading of 88% in room air. The diagnosis of respiratory syncytial virus (RSV) is made, and a bronchodilator is administered. The infant's oxygen saturation (SaO2) remains 95% in room air, and the respiratory rate is 54, with intercostal retractions; heart rate is 120 bpm. After 2 hours of observation and an intravenous (IV) bolus of fluids, the infant is being discharged home. The nurse provides which of the following home care instructions for this infant? Select all that apply. a. Continue breastfeeding infant. b. Discontinue breastfeeding and administer Pedialyte for 24 hours. c. Observe infant for labored breathing or apnea (cessation of breathing). d. Instill normal saline drops in both nares and suction thoroughly before feeding and before placing to sleep. e. Place infant to sleep on his side with the head of bed slightly elevated to facilitate breathing. f. Keep the infant out of daycare or nursery.

31. A child is being admitted to the hospital to be tested for cystic fibrosis (CF). Which tests should the nurse expect? a. Sweat chloride test, stool for fat, chest radiograph films b. Stool test for fat, gastric contents for hydrochloride, chest radiograph films c. Sweat chloride test, bronchoscopy, duodenal fluid analysis d. Sweat chloride test, stool for trypsin, biopsy of intestinal mucosa

ANS: A A sweat test result of greater than 60 mEq/L is diagnostic of CF, a high level of fecal fat is a gastrointestinal (GI) manifestation of CF, and a chest radiograph showing patchy atelectasis and obstructive emphysema indicates CF. Gastric contents contain hydrochloride normally; it is not diagnostic. Bronchoscopy and duodenal fluid are not diagnostic. Stool test for trypsin and intestinal biopsy are not helpful in diagnosing CF.

11. An 18-month-old child is seen in the clinic with AOM. Trimethoprim-sulfamethoxazole (Bactrim) is prescribed. Which statement made by the parent indicates a correct understanding of the instructions? a. "I should administer all the prescribed medication." b. "I should continue medication until the symptoms subside." c. "I will immediately stop giving medication if I notice a change in hearing." d. "I will stop giving medication if fever is still present in 24 hours."

ANS: A Antibiotics should be given for their full course to prevent recurrence of infection with resistant bacteria. Symptoms may subside before the full course is given. Hearing loss is a complication of AOM. Antibiotics should continue to be given. Medication may take 24 to 48 hours to make symptoms subside. It should be continued.

24. A child is admitted to the hospital with asthma. Which assessment findings support this diagnosis? a. Nonproductive cough, wheezing b. Fever, general malaise c. Productive cough, rales d. Stridor, substernal retractions

ANS: A Asthma presents with a nonproductive cough and wheezing. Pneumonia appears with an acute onset, fever, and general malaise. A productive cough and rales would be indicative of pneumonia. Stridor and substernal retractions are indicative of croup. Page 665 Diagnostic Evaluation The classic manifestations of asthma are dyspnea, wheezing, and coughing. Page 665 Box 21-16 Clinical Manifestations of Asthma Cough Hacking, paroxysmal, irritative, and nonproductive Becomes rattling and productive of frothy, clear, gelatinous sputum Respiratory-Related Signs Shortness of breath Prolonged expiratory phase Audible wheeze May have a malar flush and red ears Lips deep, dark red color May progress to cyanosis of nail beds or circumoral cyanosis Restlessness Apprehension Prominent sweating as the attack progresses Older children sitting upright with shoulders in a hunched-over position, hands on the bed or chair, and arms braced (tripod) Speaking with short, panting, broken phrases Chest Hyperresonance on percussion Coarse, loud breath sounds Wheezes throughout the lung fields Prolonged expiration Crackles Generalized inspiratory and expiratory wheezing; increasingly high pitched With Repeated Episodes Barrel chest Elevated shoulders Use of accessory muscles of respiration Facial appearance—flattened malar bones, dark circles beneath the eyes, narrow nose, prominent upper teeth

16. A school-age child had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. The cough has become productive in the past 24 hours. This is most suggestive of which diagnosis? a. Bronchitis b. Bronchiolitis c. Viral-induced asthma d. Acute spasmodic laryngitis

ANS: A Bronchitis is characterized by these symptoms and occurs in children older than 6 years. Bronchiolitis is rare in children older than 2 years. Asthma is a chronic inflammation of the airways that may be exacerbated by a virus. Acute spasmodic laryngitis occurs in children between 3 months and 3 years of age. Page 651 Bronchitis Bronchitis (sometimes referred to as tracheobronchitis) is inflammation of the large airways (trachea and bronchi), which is frequently associated with URIs. Viral agents are the primary cause of the disease, although M. pneumoniae is a common cause in children older than 6 years of age. A dry, hacking, nonproductive cough that worsens at night and becomes productive in 2 or 3 days characterizes this condition. Bronchitis is a mild, self-limiting disease that requires only symptomatic treatment, including analgesics, antipyretics, and humidity. Cough suppressants may be useful to allow rest but can interfere with clearance of secretions. Most patients recover uneventfully in 5 to 10 days. It can be associated with other underlying conditions (such as CF and bronchiectasis) and can become chronic in nature (cough >3 months). Adolescents with chronic bronchitis (>3 months) should be screened for tobacco or marijuana use.

33. A child with cystic fibrosis (CF) receives aerosolized bronchodilator medication. When should this medication be administered? a. Before chest physiotherapy (CPT) b. After CPT c. Before receiving 100% oxygen d. After receiving 100% oxygen

ANS: A Bronchodilators should be given before CPT to open bronchi and make expectoration easier. Aerosolized bronchodilator medications are not helpful when used after CPT. Oxygen administration is necessary only in acute episodes with caution because of chronic carbon dioxide retention.

29. Parents of a child with cystic fibrosis ask the nurse about genetic implications of the disorder. Which statement, made by the nurse, expresses accurately the genetic implications? a. If it is present in a child, both parents are carriers of this defective gene. b. It is inherited as an autosomal dominant trait. c. It is a genetic defect found primarily in non-Caucasian population groups. d. There is a 50% chance that siblings of an affected child also will be affected.

ANS: A CF is an autosomal recessive gene inherited from both parents and is inherited as an autosomal recessive, not autosomal dominant, trait. CF is found primarily in Caucasian populations. An autosomal recessive inheritance pattern means that there is a 25% chance a sibling will be infected but a 50% chance a sibling will be a carrier.

36. In providing nourishment for a child with cystic fibrosis (CF), which factor should the nurse keep in mind? a. Diet should be high in carbohydrates and protein b. Diet should be high in easily digested carbohydrates and fats c. Most fruits and vegetables are not well tolerated. d. Fats and proteins must be greatly curtailed.

ANS: A Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired intestinal absorption. Enzyme supplementation helps digest foods; other modifications are not necessary. A well-balanced diet containing fruits and vegetables is important. Fats and proteins are a necessary part of a well-balanced diet.

5. When caring for a child after a tonsillectomy, what intervention should the nurse do? a. Watch for continuous swallowing. b. Encourage gargling to reduce discomfort. c. Apply warm compresses to the throat. d. Position the child on the back for sleeping.

ANS: A Continuous swallowing, especially while sleeping, is an early sign of bleeding. The child swallows the blood that is trickling from the operative site. Gargling is discouraged because it could irritate the operative site. Ice compresses are recommended to reduce inflammation. The child should be positioned on the side or abdomen to facilitate drainage of secretions.

3. Which explains why cool-mist vaporizers rather than steam vaporizers are recommended in home treatment of childhood respiratory tract infections? a. They are safer. b. They are less expensive. c. Respiratory secretions are dried. d. A more comfortable environment is produced.

ANS: A Cool-mist vaporizers are safer than steam vaporizers, and little evidence exists to show any advantages to steam. The cost of cool-mist and steam vaporizers is comparable. Steam loosens secretions, not dries them. Both may promote a more comfortable environment, but cool-mist vaporizers present decreased risk for burns and growth of organisms.

2. A nurse is charting that a hospitalized child has labored breathing. Which describes labored breathing? a. Dyspnea b. Tachypnea c. Hypopnea d. Orthopnea

ANS: A Dyspnea is labored breathing. Tachypnea is rapid breathing. Hypopnea is breathing that is too shallow. Orthopnea is difficulty breathing except in an upright position.

12. An infant's parents ask the nurse about preventing OM. Which should be recommended? a. Avoid tobacco smoke. b. Use nasal decongestant. c. Avoid children with OM. d. Bottle-feed or breastfeed in a supine position.

ANS: A Eliminating tobacco smoke from the child's environment is essential for preventing OM and other common childhood illnesses. Nasal decongestants are not useful in preventing OM. Children with uncomplicated OM are not contagious unless they show other upper respiratory tract infection (URI) symptoms. Children should be fed in an upright position to prevent OM. Page 647 Nursing Care Management Reducing the chances of OM is possible with measures such as sitting or holding an infant upright for feedings, maintaining routine childhood immunizations, and exclusively breastfeeding until at least 6 months old. Propping bottles is discouraged to avoid pooling of milk while the child is in the supine position and to encourage human contact during feeding. Eliminating tobacco smoke and known allergens is also recommended. Early detection of middle ear effusion is essential to prevent complications. Infants and preschool children should be screened for effusion, and all schoolchildren, especially those with learning disabilities, should be tested for hearing deficits related to a middle ear effusion.

Which of the following interventions would be an appropriate nursing intervention when caring for a child with pneumonia? a. Encourage rest. b. Instruct the child to avoid lying on the affected side. c. Administer analgesics. d. Place the child in the Trendelenburg position.

ANS: A Encouraging rest by clustering care and promoting a quiet environment is the best intervention for a child with pneumonia. Lying on the affected side may promote comfort by splinting the chest and reducing pleural rubbing. Analgesics are not indicated. Children should be placed in a semierect position or position of comfort.

23. A nurse is conducting an in-service on asthma. Which statement is the most descriptive of bronchial asthma? a. There is heightened airway reactivity. b. There is decreased resistance in the airway. c. The single cause of asthma is an allergic hypersensitivity. d. It is inherited.

ANS: A In bronchial asthma, spasm of the smooth muscle of the bronchi and bronchioles causes constriction, producing impaired respiratory function. In bronchial asthma, there is increased resistance in the airway. There are multiple causes of asthma, including allergens, irritants, exercise, cold air, infections, medications, medical conditions, and endocrine factors. Atopy or development of an immunoglobulin E (IgE)-mediated response is inherited but is not the only cause of asthma. Page 665 Pathophysiology There is general agreement that inflammation contributes to heightened airway reactivity in asthma. Page 664 FIG 21-7 Airway obstruction caused by asthma. A, A normal lung. B, Bronchial asthma: Thick mucus, mucosal edema, and smooth muscle spasm causing obstruction of small airways; breathing becomes labored, and expiration is difficult.

43. A school-age child has been admitted with an acute asthma episode. The child is receiving oxygen by nasal prongs at 2 liters. How often should the nurse plan to monitor the child's pulse oximetry status? a. Continuous b. Every 30 minutes c. Every hour d. Every 2 hours

ANS: A The child on supplemental oxygen requires intermittent or continuous oxygenation monitoring, depending on severity of respiratory compromise and initial oxygenation status. The child in status asthmaticus should be placed on continuous cardiorespiratory (including blood pressure) and pulse oximetry monitoring.

30. A nurse is teaching nursing students about clinical manifestations of cystic fibrosis (CF). Which is/are the earliest recognizable clinical manifestation(s) of CF? a. Meconium ileus b. History of poor intestinal absorption c. Foul-smelling, frothy, greasy stools d. Recurrent pneumonia and lung infections

ANS: A The earliest clinical manifestation of CF is a meconium ileus, which is found in about 10% of children with CF. Clinical manifestations include abdominal distention, vomiting, failure to pass stools, and rapid development of dehydration. History of malabsorption is a later sign that manifests as failure to thrive. Foul-smelling stools are a later manifestation of CF. Recurrent respiratory tract infections are a later sign of CF. Page 674 Pathophysiology The earliest postnatal manifestation of CF is often meconium ileus in the newborn, in which the small intestine is blocked with thick, puttylike, tenacious, mucilaginous meconium.

3. A 3-month-old infant is seen in the clinic with the following symptoms: irritability, crying, refusal to nurse for more than 2 to 3 minutes, rhinitis, and a rectal temperature of 101.8° F (38.8° C). The labor, delivery, and postpartum history for this term infant is unremarkable. The nurse anticipates a diagnosis of: a. Acute otitis media (AOM) b. Otitis media with effusion (OME) c. Otitis externa d. Respiratory syncytial virus (RSV)

ANS: A These symptoms align with a typical presentation of acute otitis media, which commonly includes irritability, crying due to ear pain, feeding difficulties or refusal, and fever. It's essential to have a healthcare provider evaluate the infant to confirm the diagnosis and initiate appropriate treatment if AOM is suspected.

4. Decongestant nose drops are recommended for a 10-month-old infant with an upper respiratory tract infection. Instructions for nose drops should include which action? a. Avoid using for more than 3 days. b. Keep drops to use again for nasal congestion. c. Administer drops until nasal congestion subsides. d. Administer drops after feedings and at bedtime.

ANS: A Vasoconstrictive nose drops such as phenylephrine (Neo-Synephrine) should not be used for more than 3 days to avoid rebound congestion. Drops should be discarded after one illness because they may become contaminated with bacteria. Vasoconstrictive nose drops can have a rebound effect after 3 days of use. Drops administered before feedings are more helpful. Page 639 Nursing Alert To avoid rebound nasal congestion, vasoconstrictive nose drops or sprays should not be administered for more than 3 days.

2. A 5-year-old is recovering from a tonsillectomy and adenoidectomy and is being discharged home with his mother. Home care instructions should include which of the following? Select all that apply. a. Observe the child for continuous swallowing. b. Encourage the child to take sips of cool, clear liquids. c. Administer codeine elixir as necessary for throat pain. d. Observe the child for restlessness or difficulty breathing. e. Encourage the child to cough every 4 to 5 hours to prevent pneumonia. f. Administer an analgesic such as acetaminophen for pain.

ANS: A, B, D, F a. Continuous swallowing, especially while sleeping, is an early sign of bleeding. The child swallows the blood that is trickling from the operative site. b. Hydration is important for recovery and can soothe the throat. d. Monitoring for signs of respiratory distress or other complications is crucial post-surgery. f. Providing pain relief as recommended by the healthcare provider helps manage discomfort.

3. The nurse is caring for a 5-year-old child who is scheduled for a tonsillectomy in 2 hours. Which action should the nurse include in the child's postoperative care plan? (Select all that apply.) a. Notify the surgeon if the child swallows frequently. b. Apply a heat collar to the child for pain relief. c. Place the child on the abdomen until fully wake. d. Allow the child to have diluted juice after the procedure. e. Encourage the child to cough frequently.

ANS: A, C, D Frequent swallowing is a sign of bleeding in children after a tonsillectomy. The child should be placed on the abdomen or the side to facilitate drainage. The child can drink diluted juice, cool water, or popsicles after the procedure. An ice collar should be used after surgery. Frequent coughing and nose blowing should be avoided.

1. An infant has developed staphylococcal pneumonia. Nursing care of the child with pneumonia includes which interventions? (Select all that apply.) a. Cluster care to conserve energy b. Round-the-clock administration of antitussive agents c. Strict intake and output to avoid congestive heart failure d. Administration of antibiotics

ANS: A, D Antibiotics are indicated for a bacterial pneumonia. Often the child will have decreased pulmonary reserve, and the clustering of care is essential. Antitussive agents are used sparingly. It is desirable for the child to cough up some of the secretions. Fluids are essential to kept secretions as liquefied as possible.

1. The nurse is teaching nursing students about normal physiologic changes in the respiratory system of toddlers. Which best describes why toddlers have fewer respiratory tract infections as they grow older? a. The amount of lymphoid tissue decreases. b. Repeated exposure to organisms causes increased immunity. c. Viral organisms are less prevalent in the population. d. Secondary infections rarely occur after viral illnesses.

ANS: B Children have increased immunity after exposure to a virus. The amount of lymphoid tissue increases as children grow older. Viral organisms are not less prevalent, but older children have the ability to resist invading organisms. Secondary infections after viral illnesses include Mycoplasma pneumoniae and group A B-hemolytic streptococcal infections. Page 636 Age Healthy full-term infants younger than 3 months old are presumed to have a lower infection rate because of the protective function of maternal antibodies; however, infants may be susceptible to specific respiratory tract infections, namely pertussis, during this period. The infection rate increases from 3 to 6 months old, which is the period between the disappearance of maternal antibodies and the infant's own antibody production. The viral infection rate remains high during the toddler and preschool years. By 5 years old, viral respiratory tract infections are less frequent, but the incidence of Mycoplasma pneumoniae and GABHS infections increases. The amount of lymphoid tissue increases throughout middle childhood, and repeated exposure to organisms confers increasing immunity as children grow older. Some viral or bacterial agents produce a mild illness in older children but severe lower respiratory tract illness or croup in infants. For example, pertussis causes a relatively harmless tracheobronchitis in childhood but is a serious disease in infancy.

14. Which type of croup is always considered a medical emergency? a. Laryngitis b. Epiglottitis c. Spasmodic croup d. Laryngotracheobronchitis (LTB)

ANS: B Epiglottitis is always a medical emergency needing antibiotics and airway support for treatment. Laryngitis is a common viral illness in older children and adolescents, with hoarseness and URI symptoms. Spasmodic croup is treated with humidity. LTB may progress to a medical emergency in some children. Page 648 Acute Epiglottitis Acute epiglottitis, or acute supraglottitis, is a medical emergency. It is a serious obstructive inflammatory process that occurs predominantly in children 2 to 5 years old but can occur from infancy to adulthood.

13. The nurse is assessing a child with acute epiglottitis. Examining the child's throat by using a tongue depressor might precipitate which symptom or condition? a. Inspiratory stridor b. Complete obstruction c. Sore throat d. Respiratory tract infection

ANS: B If a child has acute epiglottitis, examination of the throat may cause complete obstruction and should be performed only when immediate intubation can take place. Stridor is aggravated when a child with epiglottitis is supine. Sore throat and pain on swallowing are early signs of epiglottitis. Epiglottitis is caused by H. influenzae in the respiratory tract. Page 649 Therapeutic Management The child who is suspected of having epiglottitis should be examined in a setting where emergency airway equipment is readily available. Examination of the throat with a tongue depressor is contraindicated until experienced personnel and equipment are available to proceed with immediate intubation or tracheostomy in the event that the examination precipitates further or complete obstruction. PowerPoint slide 25 on comment section Nursing considerations: have emergency airway equipment available - do not use a tongue depressor - can precipitate full obstruction

37. Cardiopulmonary resuscitation (CPR) is begun on a toddler. Which pulse is usually palpated because it is the most central and accessible? a. Radial b. Carotid c. Femoral d. Brachial

ANS: B In a toddler, the carotid pulse is palpated. The radial pulse is not considered a central pulse. The femoral pulse is not the most central and accessible. Brachial pulse is felt in infants younger than 1 year.

13. The mother of a 20-month-old boy tells the nurse that he has a barking cough at night. His temperature is 37 C (98.6 F). The nurse suspects mild croup and should recommend which intervention? a. Admit to the hospital and observe for impending epiglottitis. b. Provide fluids that the child likes and use comfort measures. c. Control fever with acetaminophen and call if cough gets worse tonight. d. Try over-the-counter cough medicine and come to the clinic tomorrow if no improvement.

ANS: B In mild croup, therapeutic interventions include adequate hydration (as long as the child can easily drink) and comfort measures to minimize distress. The child is not exhibiting signs of epiglottitis. A temperature of 37 C is within normal limits. Although a return to the clinic may be indicated, the mother is instructed to return if the child develops noisy respirations or drooling.

20. The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. What is the priority nursing intervention? a. Forcing fluids b. Monitoring pulse oximetry c. Instituting seizure precautions d. Encouraging a high-protein diet

ANS: B Monitoring cardiopulmonary status is an important evaluation tool in the care of the child with ARDS. Maintenance of vascular volume and hydration is important and should be done parenterally. Seizures are not a side effect of ARDS. Adequate nutrition is necessary, but a high-protein diet is not helpful.

34. A child with cystic fibrosis (CF) is receiving recombinant human deoxyribonuclease (DNase). Which is an adverse effect of this medication? a. Mucus thickens b. Voice alters c. Tachycardia d. Jitteriness

ANS: B One of the only adverse effects of DNase is voice alterations and laryngitis. DNase decreases viscosity of mucus, is given in an aerosolized form, and is safe for children younger than 12 years. B2 Agonists can cause tachycardia and jitteriness.

15. The nurse encourages the mother of a toddler with acute laryngotracheobronchitis (LTB) to stay at the bedside as much as possible. The nurse's rationale for this action is described primarily in which statement? a. Mothers of hospitalized toddlers often experience guilt. b. The mother's presence will reduce anxiety and ease the child's respiratory efforts. c. Separation from the mother is a major developmental threat at this age. d. The mother can provide constant observations of the child's respiratory efforts.

ANS: B The family's presence will decrease the child's distress. It is true that mothers of hospitalized toddlers often experience guilt but this is not the best answer. The main reason to keep parents at the child's bedside is to ease anxiety and therefore respiratory effort. The child should have constant monitoring by cardiorespiratory monitor and noninvasive oxygen saturation monitoring, but the parent should not play this role in the hospital.

4. A nurse is caring for a school-age child with left unilateral pneumonia and pleural effusion. A chest tube has been inserted to promote continuous closed chest drainage. Which interventions should the nurse implement when caring for this child? (Select all that apply.) a. Positioning child on the right side b. Assessing the chest tube and drainage device for correct settings c. Administering prescribed doses of analgesia d. Clamping the chest tube when child ambulates e. Monitoring for need of supplemental oxygen

ANS: B, C, E Nursing care of the child with a chest tube requires close attention to respiratory status; the chest tube and drainage device used are monitored for proper function (i.e., drainage is not impeded, vacuum setting is correct, tubing is free of kinks, dressing covering chest tube insertion site is intact, water seal is maintained, and chest tube remains in place). Movement in bed and ambulation with a chest tube are encouraged according to the child's respiratory status, but children require frequent doses of analgesia. Supplemental oxygen may be required in the acute phase of the illness and may be administered by nasal cannula, face mask, flow-by, or face tent. The child should be positioned on the left side, not the right. Lying on the affected side if the pneumonia is unilateral ("good lung up") splints the chest on that side and reduces the pleural rubbing that often causes discomfort. The chest tube should never be clamped; this can cause a pneumothorax. The chest tube should be maintained to the underwater seal at all times.

7. When is it generally recommended that a child with acute streptococcal pharyngitis may return to school? a. When sore throat is better. b. If no complications develop. c. After taking antibiotics for 24 hours. d. After taking antibiotics for 3 days

ANS: C After children have taken antibiotics for 24 hours, they are no longer contagious to other children. Sore throat may persist longer than 24 hours after beginning antibiotic therapy, but the child is no longer considered contagious. Complications may take days to weeks to develop. Page 642 - 643 Nursing Care Management Children are considered infectious to others at the onset of symptoms and up to 24 hours after initiation of antibiotic therapy, but they should not return to school or daycare until they have been taking antibiotics for a full 24-hour period. Nurses should remind the children to discard their toothbrushes and replace them with new ones after they have been taking antibiotics for 24 hours. Orthodontic appliances should be washed and disinfected thoroughly because they may harbor the organisms. Parents are cautioned to prevent other household members, especially if immunocompromised, from having close contact with the sick child and avoid sharing towels, drinking or eating items. If the child continues to have a high fever that does not respond to antipyretics, has an extremely sore throat, refuses liquids, and appears toxic 24 to 48 hours after starting antibiotics, further evaluation by the practitioner is recommended.

42. A nurse is teaching an adolescent how to use the peak expiratory flowmeter. The adolescent has understood the teaching if which statement is made? a. "I will record the average of the readings." b. "I should be sitting comfortably when I perform the readings." c. "I will record the readings at the same time every day." d. "I will repeat the routine two times."

ANS: C Instructions for use of a peak flowmeter include standing up straight before performing the reading, recording the highest of the three readings (not the average), measuring the peak expiratory flow rate (PEFR) close to the same time each day, and repeating the entire routine three times, waiting 30 seconds between each routine.

45. Home care is being considered for a young child who is ventilator-dependent. Which factor is most important in deciding whether home care is appropriate? a. Level of parents' education b. Presence of two parents in the home c. Preparation and training of family d. Family's ability to assume all health care costs

ANS: C One of the essential elements is the family's training and preparation. The family must be able to demonstrate all aspects of care for the child. In many areas, it cannot be guaranteed that nursing care will be available on a continual basis, and the family will have to care for the child. The amount of formal education reached by the parents is not the important issue. The determinant is the family's ability to care adequately for the child in the home. At least two family members should learn and demonstrate all aspects of the child's care in the hospital, but it does not have to be two parents. Few families can assume all health care costs. Creative financial planning, including negotiating arrangements with the insurance company and/or public programs, may be required.

8. A child is diagnosed with influenza. Management includes which recommendation? a. Clear liquid diet for hydration b. Aspirin to control fever c. Oseltamivie (Tamiflu) d. Antibiotics to prevent bacterial infection

ANS: C Oseltamivie (Tamiflu) may reduce symptoms related to influenza A if administered within 24 to 48 hours of onset. A clear liquid diet is not necessary for influenza, but maintaining hydration is important. Aspirin is not recommended in children because of increased risk of Reye syndrome. Acetaminophen or ibuprofen is a better choice. Preventive antibiotics are not indicated for influenza unless there is evidence of a secondary bacterial infection. Page 644 Therapeutic Management Uncomplicated influenza in children usually requires only symptomatic treatment, including acetaminophen or ibuprofen for fever and sufficient fluids to maintain hydration. There are four influenza antiviral drugs approved by the US Food and Drug Administration for use in the United States, but only oseltamivir (Tamiflu) and zanamivir (Relenza) are recommended because of widespread resistance to amantadine (Symmetrel) and rimantadine (Flumadine). PowerPoint Slide 17 Influenza •Clinical manifestations -Dry cough, myalgia, exhaustion, fever, chills, hyperesthesia •Therapeutic management -Antipyretics and analgesics -Hydration -Rest -Tx associated PNA with ABX -Antivirals to treat s/sx •Oseltamivir & Zanamivir •Prevention -Flu vaccine •Nursing considerations -Same as URI

15. An infant with bronchiolitis is hospitalized. The causative organism is respiratory syncytial virus (RSV). The nurse knows that a child infected with this virus requires what type of isolation? a. Reverse isolation b. Airborne isolation c. Contact Precautions d. Standard Precautions

ANS: C RSV is transmitted through droplets. In addition to Standard Precautions and hand washing, Contact Precautions are required. Caregivers must use gloves and gowns when entering the room. Care is taken not to touch their own eyes or mucous membranes with a contaminated gloved hand. Children are placed in a private room or in a room with other children with RSV infections. Reverse isolation focuses on keeping bacteria away from the infant. With RSV, other children need to be protected from exposure to the virus. The virus is not airborne.

41. A nurse is caring for a child in acute respiratory failure. Which blood gas analysis indicates the child is still in respiratory acidosis? a. pH 7.50, CO2 48 b. pH 7.30, CO2 30 c. pH 7.32, CO2 50 d. pH 7.48, CO2 33

ANS: C Respiratory failure is a process that involves pulmonary dysfunction generally resulting in impaired alveolar gas exchange, which can lead to hypoxemia or hypercapnia. Acidosis indicates the pH is less than 7.35 and the CO2 is greater than 45. If the pH is less than 7.35 but the CO2 is low, it is metabolic acidosis. Alkalosis is when the pH is greater than 7.45. If the pH is high and the CO2 is high, it is metabolic alkalosis. When the pH is high and the CO2 is low, it is respiratory alkalosis.

27. Parents of two school-age children with asthma ask the nurse, "What sports can our children participate in?" The nurse should recommend which sport? a. Soccer b. Running c. Swimming d. Basketball

ANS: C Swimming is well tolerated in children with asthma because they are breathing air fully saturated with moisture and because of the type of breathing required in swimming. Exercise-induced bronchospasm is more common in sports that involve endurance, such as soccer. Prophylaxis with medications may be necessary. Page 668 Exercise Exercise-induced bronchospasm (EIB) is an acute, reversible, usually self-terminating airway obstruction that develops during or after vigorous activity, reaches its peak 5 to 10 minutes after stopping the activity, and usually stops in another 20 to 30 minutes. Patients with EIB have cough, shortness of breath, chest pain or tightness, wheezing, and endurance problems during exercise, but an exercise challenge test in a laboratory is necessary to make the diagnosis. The problem is rare in activities that require short bursts of energy (e.g., baseball, sprints, gymnastics, skiing) and more common in those that involve endurance exercise (e.g., soccer, basketball, distance running). Swimming is well tolerated by children with EIB because they are breathing air fully saturated with moisture and because of the type of breathing required in swimming. Children with asthma are often excluded from exercise by parents, teachers, and practitioners, as well as by the children themselves because they are reluctant to provoke an attack. However, this practice can seriously hamper peer interaction and physical health. Exercise is advantageous for children with asthma, and most children can participate in activities at school and in sports with minimal difficulty, provided their asthma is under control. Evaluate participation on an individual basis. Appropriate prophylactic treatment with β-adrenergic agents or cromolyn sodium before exercise usually permits full participation in strenuous exertion

The nurse caring for a child with a common cold (nasopharyngitis). The primary goal of nursing care is directed toward: a. Preventing injury b. Promoting nutrition c. Relieving symptoms d. Administering antibiotics

ANS: C The focus is on managing and alleviating the discomfort caused by the cold, such as congestion, cough, and fever. Antibiotics aren't usually prescribed for a common cold because it's caused by a virus, not bacteria. Therefore, the aim is to provide comfort and alleviate symptoms rather than administering antibiotics

25. It is now recommended that children with asthma who are taking long-term inhaled steroids should be assessed frequently because which disease or assessment findings may develop? a. Cough b. Osteoporosis c. Slowed growth d. Cushing syndrome

ANS: C The growth of children on long-term inhaled steroids should be assessed frequently to assess for systemic effects of these drugs. Cough is prevented by inhaled steroids. No evidence exists that inhaled steroids cause osteoporosis. Cushing syndrome is caused by long-term systemic steroids.

4. A 5-year-old is seen in the urgent care clinic with the following history and symptoms: sudden onset of severe sore throat after going to bed, drooling and difficulty swallowing, axillary temperature of 102.2° F (39.0° C), clear breath sounds, and absence of cough. The child appears anxious and is flushed. Based on these symptoms and history, the nurse anticipates a diagnosis of: a. Group A beta-hemolytic streptococcus (GABHS) pharyngitis b. Acute tracheitis c. Acute epiglottitis d. Acute laryngotracheobronchitis (LTB)

ANS: C These symptoms—especially the difficulty in swallowing, drooling, and anxious appearance—align closely with the classic presentation of acute epiglottitis, which is considered a medical emergency. It's important to seek immediate medical attention in such cases to prevent airway compromise.

1. A 12-year-old child is in the urgent care clinic with a complaint of fever, headache, and sore throat. A diagnosis of group A beta-hemolytic streptococcus (GABHS) pharyngitis is established with a rapid-strep test, and oral penicillin is prescribed. The nurse knows which of the following statements about GABHS is correct? a. Children with a GABHS infection are less likely to contract the illness again after the antibiotic regimen is completed. b. A follow-up throat culture is recommended following the completion of antibiotic therapy. c. Children with a GABHS infection are at increased risk for the development of rheumatic fever (RF) and glomerulonephritis. d. Children with a GABHS infection are at increased risk for the development of rheumatoid arthritis in adulthood.

ANS: C This bacterium, if left untreated, can lead to complications like rheumatic fever and glomerulonephritis. Rheumatic fever can affect the heart, joints, skin, and nervous system, while glomerulonephritis impacts the kidneys. Antibiotic treatment is crucial to prevent these complications. Follow-up throat cultures might not always be necessary if symptoms resolve and treatment is completed successfully, but the risk of complications emphasizes the importance of proper treatment.

The mother of a neonate hospitalized with an upper respiratory infection asks why her baby won't take her bottle. The nurse's best answer would be: a. She's probably not hungry b. It's okay because we are giving her intravenous fluids, therefore she is not hungry c. Newborns breathe through their noses. Congestion may be interfering with her breathing and eating at the same time d. She might need a different type of formula. We will call the physician to get a new order

ANS: C This explanation helps the mother understand that the baby's difficulty in feeding might be due to congestion affecting her ability to breathe while eating. It addresses a common issue in newborns with upper respiratory infections, helping the mother comprehend the potential reason behind the feeding difficulty.

32. Cystic fibrosis (CF) is suspected in a toddler. Which test is essential in establishing this diagnosis? a. Bronchoscopy b. Serum calcium c. Urine creatinine d. Sweat chloride test

ANS: D A sweat chloride test result greater than 60 mEq/L is diagnostic of CF. Bronchoscopy, although helpful for identifying bacterial infection in children with CF, is not diagnostic. Serum calcium is normal in children with CF. Urine creatinine is not diagnostic of CF. Page 675 Diagnostic Evaluation The consistent finding of abnormally high sodium and chloride concentrations in the sweat is a unique characteristic of CF. Parents may report that their infant tastes "salty" when they kiss him or her. The quantitative sweat chloride test (pilocarpine iontophoresis) remains the best diagnostic tool for CF and involves stimulating the production of sweat with a special device (involves stimulation with 3-mA electric current), collecting the sweat on filter paper, and measuring the sweat electrolytes. The quantitative analysis requires a sufficient volume of sweat (>75 mg). Two separate samples are collected to ensure the reliability of the test for any individual. Normally, sweat chloride content is less than 40 mEq/L, with a mean of 18 mEq/L. A chloride concentration greater than 60 mEq/L in a child 6 months old or older is diagnostic of CF, a concentration between 40 and 59 mmol/L is indeterminate and a repeat test should be performed in 1 to 2 months

7. Parents bring their 15-month-old infant to the emergency department at 3:00 AM because the toddler has a temperature of 39 C (102.2 F), is crying inconsolably, and is tugging at the ears. A diagnosis of otitis media (OM) is made. In addition to antibiotic therapy, the nurse practitioner should instruct the parents to use what medication? a. Decongestants to ease stuffy nose b. Antihistamines to help the child sleep c. Aspirin for pain and fever management d. Benzocaine ear drops for topical pain relief

ANS: D Analgesic ear drops can provide topical relief for the intense pain of OM. Decongestants and antihistamines are not recommended in the treatment of OM. Aspirin is contraindicated in young children because of the association with Reye syndrome.

35. Pancreatic enzymes are administered to the child with cystic fibrosis (CF). What nursing considerations should be included? a. Do not administer pancreatic enzymes if the child is receiving antibiotics. b. Decrease dose of pancreatic enzymes if the child is having frequent, bulky stools. c. Administer pancreatic enzymes between meals if at all possible. d. Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.

ANS: D Enzymes may be administered in a small amount of cereal or fruit at the beginning of a meal or swallowed whole. Pancreatic enzymes are not a contraindication for antibiotics. The dosage of enzymes should be increased if the child is having frequent, bulky stools. Enzymes should be given just before meals and snacks.

4. It is important that a child with acute streptococcal pharyngitis be treated with antibiotics to prevent which condition? a. Otitis media b. Diabetes insipidus (DI) c. Nephrotic syndrome d. Acute rheumatic fever

ANS: D Group A hemolytic streptococcal infection is a brief illness with varying symptoms. It is essential that pharyngitis caused by this organism be treated with appropriate antibiotics to avoid the sequelae of acute rheumatic fever and acute glomerulonephritis. The cause of otitis media is either viral or other bacterial organisms. DI is a disorder of the posterior pituitary. Infections such as meningitis or encephalitis, not streptococcal pharyngitis, can cause DI. Glomerulonephritis, not nephrotic syndrome, can result from acute streptococcal pharyngitis.

6. The parent of an infant with nasopharyngitis should be instructed to notify the health professional if the infant displays which clinical manifestation? a. Fussiness b. Coughing c. A fever over 99° F d. Signs of an earache

ANS: D If an infant with nasopharyngitis shows signs of an earache, it may mean a secondary bacterial infection is present and the infant should be referred to a practitioner for evaluation. Irritability is common in an infant with a viral illness. Cough can be a sign of nasopharyngitis. Fever is common in viral illnesses. Page 641 Parents should know the signs of respiratory complications and should notify a health professional if complications occur or the child does not improve within 2 or 3 days. Box 21-4 Early Evidence of Respiratory Complications Parents are instructed to notify the health professional if any of the following are noted: • Refusal to eat • Evidence of earache • Respirations faster than 50 to 60 breaths/min • Fever over 38.3° C (101° F) • Listlessness • Confusion • Increasing irritability with or without fever • Persistent cough for 2 days or more • Wheezing • Restlessness and poor sleep patterns

9. How is chronic otitis media with effusion (OME) differentiated from acute otitis media (AOM)? a. A fever as high as 40° C (104° F) b. Severe pain in the ear c. Nausea and vomiting d. A feeling of fullness in the ear

ANS: D OME is characterized by feeling of fullness in the ear or other nonspecific complaints. Fever is a sign of AOM. OME does not cause severe pain. This may be a sign of AOM. Nausea and vomiting are associated with otitis media. Page 645 Box 21-5 Standard Terminology for Otitis Media Otitis media (OM): An inflammation of the middle ear without reference to etiology or pathogenesis Acute otitis media (AOM): An inflammation of the middle ear space with a rapid onset of the signs and symptoms of acute infection—namely, fever and otalgia (ear pain) Otitis media with effusion (OME): Fluid in the middle ear space without symptoms of acute infection

10. Parents have understood teaching about prevention of childhood otitis media if they make which statement? a. "We will only prop the bottle during the daytime feedings." b. "Breastfeeding will be discontinued after 4 months of age." c. "We will place the child flat right after feedings." d. "We will be sure to keep immunizations up to date."

ANS: D Parents have understood the teaching about preventing childhood otitis media if they respond they will keep childhood immunizations up to date. The child should be maintained upright during feedings and after. Otitis media can be prevented by exclusively breastfeeding until at least 6 months of age. Propping bottles is discouraged to avoid pooling of milk while the child is in the supine position. Page 647 Nursing Care Management Reducing the chances of OM is possible with measures such as sitting or holding an infant upright for feedings, maintaining routine childhood immunizations, and exclusively breastfeeding until at least 6 months old. Propping bottles is discouraged to avoid pooling of milk while the child is in the supine position and to encourage human contact during feeding. Eliminating tobacco smoke and known allergens is also recommended. Early detection of middle ear effusion is essential to prevent complications. Infants and preschool children should be screened for effusion, and all schoolchildren, especially those with learning disabilities, should be tested for hearing deficits related to a middle ear effusion.

5. Which is an appropriate nursing intervention when caring for an infant with an upper respiratory tract infection and elevated temperature? a. Give tepid water baths to reduce fever. b. Encourage food intake to maintain caloric needs. c. Have child wear heavy clothing to prevent chilling. d. Give small amounts of favorite fluids frequently to prevent dehydration.

ANS: D Preventing dehydration by small frequent feedings is an important intervention in the febrile child. Tepid water baths may induce shivering, which raises temperature. Food should not be forced; it may result in the child vomiting. The febrile child should be dressed in light, loose clothing. Page 640 Reduce Body Temperature Children with respiratory illnesses will perform activities as appropriate to their energy level. One of the cardinal signs that the child is feeling better is the increase in activity; this may, however, be temporary if a high fever returns after a few hours of increased activity. Cool liquids are encouraged to reduce the temperature and minimize the chances of dehydration Promote Hydration Dehydration is a potential complication when children have respiratory tract infections and are febrile or anorexic, especially when vomiting or diarrhea is present. Infants are especially prone to fluid and electrolyte deficits when they have a respiratory illness because a rapid respiratory rate that accompanies such illnesses precludes adequate oral fluid intake. In addition, the presence of fever increases the total body fluid turnover in infants. [...] Adequate fluid intake is encouraged by offering small amounts of favorite fluids (clear liquids if vomiting) at frequent intervals. Oral rehydration solutions, such as Infalyte or Pedialyte, should be considered for infants, and water or a low-carbohydrate (≤5 g per 8 oz) flavored drink should be considered for older children. Fluids with caffeine (tea, coffee) are avoided, because these may act as diuretics and promote fluid loss. Sports drinks, sodas, apple juice, and energy drinks are not recommended for oral rehydration.

28. Which drug is usually given first in the emergency treatment of an acute, severe asthma episode in a young child? a. Ephedrine b. Theophylline c. Aminophylline d. Short-acting B2 agonists

ANS: D Short-acting B2 agonists are the first treatment in an acute asthma exacerbation. Ephedrine is not helpful in acute asthma exacerbations. Theophylline is unnecessary for treating asthma exacerbations. Aminophylline is not helpful for acute asthma exacerbation.

19. The mother of a toddler yells to the nurse, "Help! He is choking to death on his food." The nurse determines that lifesaving measures are necessary based on which symptom? a. Gagging b. Coughing c. Pulse over 100 beats/min d. Inability to speak

ANS: D The inability to speak is indicative of a foreign-body airway obstruction of the larynx. Abdominal thrusts are needed for treatment of the choking child. Gagging indicates irritation at the back of the throat, not obstruction. Coughing does not indicate a complete airway obstruction. Tachycardia may be present for many reasons.

11. A 4-year-old girl is brought to the emergency department. She has a froglike croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should intervene in which manner? a. Make her lie down and rest quietly. b. Examine her oral pharynx and report to the physician. c. Auscultate her lungs and prepare for placement in a mist tent. d. Notify the physician immediately and be prepared to assist with a tracheostomy or intubation.

ANS: D This child is exhibiting signs of respiratory distress and possible epiglottitis. Epiglottitis is always a medical emergency requiring antibiotics and airway support for treatment. Sitting up is the position that facilitates breathing in respiratory disease. The oral pharynx should not be visualized. If the epiglottis is inflamed, there is the potential for complete obstruction if it is irritated further. Although lung auscultation provides useful assessment information, a mist tent would not be beneficial for this child. Immediate medical evaluation and intervention are indicated.

The nurse would select which of the following as an appropriate nursing diagnosis for the family of a toddler being treated for acute laryngotracheobronchitis? a. Anticipatory grieving related to loss of airway b. Impaired growth and development related to acute onset of illness c. Impaired social interactions related to confinement in hospital d. Fear/anxiety related to dyspnea and noisy breathing

ANS: D This diagnosis addresses the emotional response the family might experience due to witnessing their toddler's struggle with breathing difficulties, which often accompanies acute laryngotracheobronchitis. It acknowledges their fear and anxiety related to the symptoms and the distressing nature of the condition.