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The nurse is preparing to perform ostomy care on a pediatric client. The nurse has explained the procedure to the child and caregiver. Place the remaining steps of the procedure in the order the nurse will complete them. Use all options. 1. Clean the stoma and skin as needed, allowing it to dry thoroughly. 2. Obtain and set up equipment. 3. Apply the new pouch. 4. Mark the new pouch backing, and cut the new backing to size. 5. Measure the stoma. 6. Assess the stoma and surrounding skin. 7. Remove the old pouch.
2, 7, 6, 1, 5, 4, 3 2. Obtain and set up equipment. 7. Remove the old pouch. 6. Assess the stoma and surrounding skin. 1. Clean the stoma and skin as needed, allowing it to dry thoroughly. 5. Measure the stoma. 4. Mark the new pouch backing, and cut the new backing to size. 3. Apply the new pouch. The nurse would first gather the needed equipment to complete the procedure (washcloths, clean pouch and clamp, skin barrier powder, paste, and/or sealant, pen, scissors, and measuring pattern). The nurse would then wash hands and apply gloves. The stoma should now be assessed, then cleaned and allowed to thoroughly air dry. The nurse would then measure the stoma, mark the new backing, and cut the new backing. Last, the new pouch would be applied, gloves removed, hands washed, and any questions answered.
The nurse is caring for a 12-year-old girl with nephrotic syndrome. The girl confides that she feels like a "freak" compared to her peers because of her weight, edema, and moon face. Which response by the nurse would be most appropriate? A)"Let's put you in touch with some other girls who are also having the same body changes." B)"Luckily, this is just a temporary, unfortunate part of your condition; you need to accept it." C)"Your real friends do not care about your appearance and just want you to get well." D)"You are beautiful in your own way; what matters is what is on the inside."
A. "Let's put you in touch with some other girls who are also having the same body changes." Feedback: It is important to introduce the girl to other youngsters with chronic renal conditions so she does not feel so isolated. Adolescents need interaction with peers. Telling the girl that this is a temporary condition, her real friends don't care about her appearance, and she is beautiful in her own way dismisses the girl's concerns and does not offer solutions. Nephrotic syndrome is a chronic condition, so telling her the condition is temporary also is inaccurate.
A nurse is caring for a 14-year-old girl scheduled for a barium swallow/upper gastrointestinal (GI) series. Before providing instructions, what would be the priority? A)Screening the girl for pregnancy B)Reminding her to drink plenty of fluids after the procedure C)Ordering a bowel preparation D)Reminding the girl about potential light-colored stools
A. Screening the girl for pregnancy. Females of reproductive age must be screened for pregnancy prior to the test because radiography is used. A bowel preparation is not necessary for a barium swallow/upper GI series. The reminders about fluids and light-colored stools are appropriate but are not the first priority.
The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. Which foods would be permitted in the diet of the child with celiac syndrome? Select all that apply. A. bananas B. rye bread C. wheat bread D. applesauce E. skim milk
A. bananas D. applesauce E. skim milk The child is usually started on a gluten-free, low-fat diet. Skim milk and bananas are usually well tolerated. Lean meats, puréed vegetables, and fruits are gradually added to the diet. Wheat, rye, and oats (unless specifically gluten free) are not included in the diet.
The nurse is caring for a school-age child with tinea captitis. The child has open lesions from the disease and has lost hair in the areas affected. Which nursing diagnoses would be a part of this patient's care plan? Select all that apply. A) Impaired skin integrity B) Risk for infection C) Disturbed body image D) Bathing, self-care deficit E) Altered nutrition
Ans: A, B, C Feedback:Tinea is a fungal disease of the skin occurring on any part of the body, in this case the head (scalp, eyebrows, or eyelashes). Since this child has open lesions and hair loss from affected areas, there is impairment of skin integrity (which makes the areas at risk for infection. Body image is disturbed since the hair loss is visible. There is no indication of bathing deficit or altered nutrition.
What information would the nurse include in the preoperative plan of care for an infant with myelomeningocele? A) Positioning supine with a pillow under the buttocks B) Covering the sac with saline-soaked nonadhesive gauze C) Wrapping the infant snugly in a blanket D) Applying a diaper to prevent fecal soiling of the sac
Ans: B Feedback: For the infant with a myelomeningocele, saline-soaked nonadhesive gauze or antibiotic-soaked gauze is used to keep the sac moist. The infant is positioned prone, with a folded towel under the abdomen, so that the urine and feces flow away from the sac. A warmer or isolette is used to keep the infant warm. Blankets are avoided because they could place excess pressure on the sac. Diapering may be contraindicated to avoid placing pressure on the sac.
A nurse is preparing a presentation for a parent group about musculoskeletal injuries. When describing a child's risk for this type of injury, the nurse integrates knowledge that bone growth occurs primarily in which area? A) Growth plate B) Epiphysis C) Physis D) Metaphysis
Ans: B Feedback: Growth of the bones occurs primarily in the epiphyseal region. This area is vulnerable and structurally weak. Traumatic force applied to the epiphysis during injury may result in fracture in that area of the bone. The growth plate refers to the combination of the epiphysis, the end of a long bone, and the physis, a cartilaginous area between the epiphysis and the metaphysis.
A nurse is inspecting the skin of a child with atopic dermatitis. What would the nurse expect to observe? A) Erythematous papulovesicular rash B) Dry, red, scaly rash with lichenification C) Pustular vesicles with honey-colored exudates D) Hypopigmented oval scaly lesions
Ans: B Feedback:Atopic dermatitis or eczema is characterized by a dry, red, scaly rash with lichenification and hypertrophy. An erythematous papulovesicular rash is associated with contact dermatitis. Pustules and vesicles with honey-colored exudates suggest nonbullous impetigo. Hypopigmented oval scaly lesions are associated with tinea versicolor.
The nurse is caring for an infant with candidal diaper rash. Which topical agent would the nurse expect the physician to order? A) Corticosteroids B) Antifungals C) Antibiotics D) Retinoids
Ans: B Feedback:Candidal diaper rash would require a fungicide. The nurse would expect to administer topical antifungals as ordered. Corticosteroids are not typically recommended for young infants and are used for atopic dermatitis and certain types of contact dermatitis. Antibiotics would be ineffective against fungal infections. Retinoids are indicated for moderate to severe acne.
A nurse is preparing a program for a group of parents about injury prevention. What would the nurse include as an important contributing factor for cervical spine injury in a child? A) Exposure to teratogens while in utero B) Immaturity of the central nervous system C) Increased mobility of the spine D) Incomplete myelinization
Ans: C Feedback: Compared to the adult, a child's spine is very mobile, especially in the cervical spine region, resulting in a higher risk for cervical spine injury. Exposure to teratogens in utero may lead to altered growth and development of the brain or spinal cord. Immaturity of the central nervous system places the infant at risk for insults that may result in delayed motor skill attainment or cerebral palsy. Incomplete myelinization reflects the lack of motor control.
The nurse is caring for a female infant with torticollis and is providing instructions to the parents about how to help their daughter. Which statement by the parents indicates a need for further teaching? A) "We must encourage our daughter to turn her head both ways." B) "Flatness on one side of the head is a common side effect." C) "We must apply firm pressure and stretching every other day." D) "We will do a daily stretching regimen with multiple sessions."
Ans: C Feedback: The nurse needs to remind the parents that the stretching exercises should be done several times a day. The stretching is applied with gentle, not firm, pressure and should be done every day for multiple sessions. The statements about turning the head both ways, flatness on one side as common, and daily stretching with multiple sessions are correct.
A 3-year-old child has sustained severe burns and is ordered to receive 100% oxygen. What would the nurse use to administer the oxygen? A) Nasal cannula B) Venturi mask C) Nonrebreather mask D) Oxygen hood
Ans: C Feedback:All children with severe burns should receive 100% oxygen via a nonrebreather mask or bag-valve-mask ventilation. A nasal cannula provides only low oxygen concentrations (22% to 44%); a Venturi mask provides only 24% to 50% oxygen concentrations. An oxygen hood is used for infants only.
A 4-year-old is brought to the emergency department with a burn. What would alert the nurse to the possibility of child abuse? A) Burn assessment correlates with mother's report of contact with a portable heater. B) Parents state that the injury occurred approximately 15 to 20 minutes ago. C) Clear delineations are noted between burned and nonburned skin areas. D) The burn area appears asymmetric and nonuniform.
Ans: C Feedback:Suggested signs of a burn resulting from possible child abuse include a uniform appearance of the burn with clear delineations of burned and nonburned areas. Abuse would also be suspected if the report of the injury was inconsistent with burn injury or there was a delay in seeking treatment. An asymmetric nonuniform burn often correlates with a splatter-type burn resulting from the child pulling a source of hot fluid onto himself or herself.
When developing the plan of care for a child with burns requiring fluid replacement therapy, what information would the nurse expect to include? A) Administration of colloid initially followed by a crystalloid B) Determination of fluid replacement based on the type of burn C) Administration of most of the volume during the first 8 hours D) Monitoring of hourly urine output to achieve less than 1 mL/kg/hour
Ans: C Feedback:With fluid replacement therapy, most of the volume is administered during the first 8 hours. Crystalloids (such as Ringer lactate) are administered for the first 24 hours, and then colloids are used once capillary permeability is less of a concern. Fluid replacement is determined by the amount of body surface area burned. Hourly urine output is expected to be at least 1 mL/kg/hour.
The nurse is assessing a child with acute poststreptococcal glomerulonephritis. What would the nurse expect to assess? Select all that apply. A)Irritability B)Abdominal pain C)Hypertension D)Crackles E)Polyphagia
B, C, D Feedback: Assessment findings associated with acute poststreptococcal glomerulonephritis include fatigue, lethargy, abdominal pain, hypertension, crackles, and anorexia.
A child is diagnosed with hemolytic-uremic syndrome (HUS). Review of the child's laboratory test results would reveal which finding? A)Decreased blood urea nitrogen (BUN) and creatinine B)Decreased platelets and leukocytosis C)Hypernatremia and hypokalemia D)Respiratory acidosis and proteinuria
B. Decreased platelets and leukocytosis Feedback: The child with HUS typically exhibits severe thrombocytopenia (decreased platelets) and leukocytosis. BUN and creatinine are elevated. Hyponatremia, hyperkalemia, metabolic acidosis, and proteinuria also may be noted.
The nurse is caring for a client with hemolytic-uremic syndrome (HUS). The client is demonstrating oliguria. What does the nurse expect to find when reviewing the client's records? A)A pattern of below-normal blood pressure B)Higher fluid output than fluid intake C)Elevated BUN and creatinine levels D)Increased glomerular filtration rate (GFR)
C Feedback: Oliguria is the result of acute renal failure associated with HUS. The BUN and creatinine level are indications of kidney function and are elevated with acute renal failure. Hypertension is associated with HUS. Output is decreased with renal failure, as is GFR.
The nurse is reviewing the laboratory test results of a child with nephrotic syndrome. What would the nurse least likely expect to find? A)Hyperlipidemia B)Hypoalbuminemia C)Decreased blood urea nitrogen (BUN) D)Hypoproteinemia
C. Decreased blood urea nitrogen (BUN) Feedback: With nephrotic syndrome, proteinuria, hyperlipidemia, decreased serum protein levels (hypoproteinemia), and decreased serum albumin levels (hypoalbuminemia) are present. BUN typically becomes elevated.
The mother of a child with end-stage renal disease asks the nurse why her son is getting an injection of erythropoietin. When responding to the mother, the nurse explains this as the rationale. A)To treat low calcium levels B)To stimulate growth in stature C)To stimulate red blood cell growth D)To correct acidosis
C. To stimulate red blood cell growth Feedback: Erythropoietin is given to stimulate red blood cell growth. Vitamin D and calcium are used to correct hypocalcemia. Growth hormone is used to stimulate growth in stature. Bicitra or sodium bicarbonate tablets are used to correct acidosis.
The nurse is caring for a teenager diagnosed with acute pancreatitis. Which order would the nurse question? A. NPO B. nasogastric tube placed to suction C. serum amylase levels D. PO pain management
D. PO pain management Maintain NPO status and nasogastric tube suction and patency. Administer intravenous fluids to keep the child hydrated and correct any alterations in fluid and electrolyte balance. Pain management is crucial in children with pancreatitis; due to NPO status, medications are typically prescribed intravenously. Serial monitoring of serum amylase levels will determine when oral feeding may be restarted.
The nurse is reviewing the medical record of a child with a cleft lip and palate. When reviewing the child's history, which of the following would the nurse identify as a risk factor for this condition? a) Mother age 42 with pregnancy b) Maternal use of acetaminophen in third trimester c) Preterm birth d) History of hypoxia at birth
a. Mother age 42 with pregnancy Explanation: Advanced maternal age is a risk factor for cleft lip and palate. Drugs such as anticonvulsants, steroids, and other medications during early pregnancy are considered risk factors. Acetaminophen is not associated with an increased risk for cleft lip and palate. Preterm birth is not a risk factor for the development of cleft lip and palate. Hypoxia or anoxia is a risk factor for the development of necrotizing enterocolitis.
The nurse is caring for a child admitted with pyloric stenosis. Which of the following clinical manifestations would likely have been noted in the child with this diagnosis? a) Severe abdominal pain b) Explosive diarrhea c) Frequent urination d) Projectile vomiting
a. Projectile vomiting Explanation: During the first weeks of life, the infant with pyloric stenosis often eats well and gains weight and then starts vomiting occasionally after meals. Within a few days the vomiting increases in frequency and force, becoming projectile. The child may have constipation, and peristaltic waves may be seen in the abdomen, but the child does not appear in severe pain. Urine output is decrease and urination is infrequent.
Which of the following occurs in the gastrointestinal system of the child with Hirschsprung disease? a) There is an invagination or telescoping of one portion of the bowel into a distal portion. b) There is a relaxed sphincter in the lower portion of the esophagus. c) There is a partial or complete mechanical obstruction in the intestine. d) There is a severe narrowing of the lumen of the pylorus.
c. There is a partial or complete mechanical obstruction in the intestine. Explanation: Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin.
A child with Duchenne muscular dystrophy is to receive prednisone as part of his treatment plan. After teaching the child's parents about this drug, which statement by the parents indicates the need for additional teaching? A) "We should give this drug before he eats anything." B) "We need to watch carefully for possible infection." C) "The drug should not be stopped suddenly." D) "He might gain some weight with this drug."
Ans: A Feedback: Corticosteroids such as prednisone can cause gastric upset, so the medication should be given with food to reduce this risk. The drug may mask the signs of infection, so the parents need to monitor the child closely for any changes. Treatment with this drug should not be stopped abruptly due to the risk for acute adrenal insufficiency. Common side effects of this drug include weight gain, osteoporosis, and mood changes.
The nurse is assessing the neuromusculoskeletal system of a newborn. What is an abnormal assessment finding? A) Sluggish deep tendon reflexes B) Full range of motion in extremities C) Absence of hypotonia D) Lack of purposeful muscular control
Ans: A Feedback: Deep tendon reflexes are present at birth and are initially brisk in the newborn and progress to average over the first few months. Sluggish deep tendon reflexes indicate an abnormality. The newborn is capable of spontaneous movement but lacks purposeful control. Full range of motion is present at birth. Healthy infants and children demonstrate normal muscle tone; hypertonia or hypotonia is an abnormal finding.
A group of students are preparing for a class exam on skin disorders. As part of their preparation, they are reviewing information about acne vulgaris and its association with increased sebum production. The students demonstrate understanding of the information when they identify which areas as having the highest sebaceous gland activity? Select all that apply. A) Face B) Upper chest C) Neck D) Back E) Shoulders
Ans: A, B, D Feedback:The face, upper chest, and back are the areas of highest sebaceous activity and thus the most common areas for acne lesions to occur. The neck and shoulders are not typical areas involved with acne.
The nurse is conducting a physical examination of a child with suspected developmental dysplasia of the hip. Which finding would help confirm this diagnosis? A) Abduction occurs to 75 degrees and adduction to within 30 degrees (with stable pelvis). B) A distinct "clunk" is heard with Barlow and Ortolani maneuvers. C) A high-pitched "click" is heard with hip flexion or extension. D) The thigh and gluteal folds are symmetric
Ans: B Feedback: A distinct "clunk" while performing Barlow and Ortolani maneuvers is caused as the femoral head dislocates or reduces back in to the acetabulum. A higher-pitched "click" may occur with flexion or extension of the hip. This is a benign, adventitious sound that should not be confused with a true "clunk" when assessing for developmental dysplasia of the hip. Abduction to 75 degrees, adduction within 30 degrees, and symmetric thigh and gluteal folds are normal findings.
A nurse is caring for a 14-year-old girl following myelography. What is the priority nursing action? A) Monitoring for a decrease in spasticity B) Observing for signs of meningeal irritation C) Assessing motor function D) Observing for mental confusion or hallucinations
Ans: B Feedback: Following myelography, the nurse should carefully observe for signs of meningeal irritation because of what is involved in this procedure. Monitoring for a decrease in muscle spasticity, assessing motor function, and observing for mental confusion or hallucinations is appropriate following an intrathecal test dose of baclofen.
The nurse is providing parental teaching about home care for an 8-year-old boy with widespread sunburn on his back and shoulders. Which response indicates a need for further teaching? A) "Cool compresses may help cool the burn." B) "He should manually peel off any flaking skin." C) "Nonsteroidal anti-inflammatory drugs like ibuprofen are helpful." D) "He should avoid hot showers or baths for a couple of days."
Ans: B Feedback: If skin flaking occurs, the child should be discouraged from manually "peeling" the flaked skin as it can cause further injury. Using cool compresses, taking nonsteroidal anti-inflammatory drugs, and avoiding hot showers or baths are appropriate measures.
The nurse is caring for an infant with osteogenesis imperfecta and is providing instruction on how to reduce the risk of injury. Which response from the mother indicates a need for further teaching? A) "I need to avoid pushing or pulling on an arm or leg." B) "I must carefully lift the baby from under the armpits." C) "I should not bend an arm or leg into an awkward position." D) "We must avoid lifting the legs by the ankles to change diapers."
Ans: B Feedback: The nurse needs to emphasize that the mother must not lift a baby or young child with osteogenesis imperfecta from under the armpits as it may cause harm. Avoiding pushing or pulling, not bending an arm or leg into an awkward position, and avoiding lifting the legs by the ankles are appropriate responses
The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention would the nurse implement to best promote maximum chest expansion? A) Deep-breathing exercises B) Upright positioning C) Coughing D) Chest percussion
Ans: B Feedback: The nurse should emphasize that the child's position should be arranged to promote maximum chest expansion. This is usually in the upright position. Deep-breathing exercises are for strengthening/maintaining respiratory muscles. Coughing helps clear the airways. Chest percussion helps loosen secretions in lungs
The nurse is caring for a 15-year-old boy who has sustained burn injuries. The nurse observes the burn developing a purplish color with discharge and a foul odor. The nurse suspects which infection? A) Burn wound cellulitis B) Invasive burn cellulitis C) Burn impetigo D) Staphylococcal scalded skin syndrome
Ans: B Feedback:Invasive burn cellulitis results in the burn developing a dark brown, black, or purplish color with a discharge and foul odor. In burn wound cellulitis, the area around the burn becomes increasingly red, swollen, and painful early in the course of burn management. Burn impetigo is characterized by multifocal, small, superficial abscesses. Staphylococcal scalded skin syndrome is not a burn infection; however, it is managed similarly to burns.
A nurse is performing a primary survey on a child who has sustained partial thickness burns over his upper body areas. What action should the nurse take first? A) Inspect the child's skin color. B) Assess for a patent airway. C) Observe for symmetric breathing. D) Palpate the child's pulse.
Ans: B Feedback:When performing a primary survey, the nurse first assesses the child's airway for patency and then intervenes accordingly to ensure that the airway is patent. Next the nurse would evaluate the child's skin color, respiratory effort, and symmetry of breathing and breath sounds. Then the nurse would determine the pulse strength, perfusion status, and heart rate.
A nurse is preparing a presentation for a local parent group about burn prevention and care in children. What would the nurse be least likely to include in the presentation when describing how to care for a superficial burn? A) Using cool water over the burned area until the pain lessens B) Applying ice directly to the burned skin area C) Covering the burn with a clean, nonadhesive bandage D) Giving the child acetaminophen for pain relief
Ans: B Feedback:With a superficial burn, ice should not be applied to the skin. Using cool water over the burn area; covering with a clean, nonadhesive bandage; and using acetaminophen for pain relief are appropriate to include in the presentation.
A nurse is preparing a class for parents of infants about managing diaper dermatitis. What advice would the nurse include in the presentation? Select all that apply. A) Applying topical nystatin to the diaper area B) Using a blow dryer on warm to dry the diaper area C) Refraining from using rubber pants over diapers D) Using scented diaper wipes to clean the area E) Washing the diaper area with an antibacterial soap
Ans: B, C Feedback:For diaper dermatitis, topical products such as ointments or creams containing vitamins A, D, and E; zinc oxide; or petrolatum help to provide a barrier. Nystatin is an antifungal agent used for diaper candidiasis. Using a blow dryer on warm to dry the area, avoiding the use of rubber pants, and using unscented diaper wipes or ones free of preservatives are appropriate. The area should be washed with a soft cloth, without harsh soaps.
A nurse is providing instructions to the parents of a 3-month-old with developmental dysplasia of the hip who is being treated with a Pavlik harness. Which statements by the parents demonstrate understanding of the instructions? Select all that apply. A) "We need to adjust the straps so that they are snug but not too tight." B) "We should change her diaper without taking her out of the harness." C) "We need to check the area behind her knees for redness and irritation." D) "We need to send the harness to the dry cleaners to have it cleaned." E) "We need to call the doctor if she is not able to actively kick her legs."
Ans: B, C, E Feedback: Instructions related to use of a Pavlik harness include changing the child's diaper while in the harness; checking the areas behind the knees and diaper area for redness, irritation, or breakdown; and calling the doctor if the child is unable to actively kick her legs. The straps are not to be adjusted without checking with the physician or nurse practitioner first. The harness can be washed with mild detergent by hand and air dried. A hair dryer can be used to dry the harness but only if the air fluffing setting is used.
The nurse is assessing an 11-year-old girl with scoliosis. What would the nurse expect to find? Select all answers that apply. A) Complaints of severe back pain B) Asymmetric shoulder elevation C) Even curve at the waistline D) Pronounced one-sided hump on bending over E) Diminished motor function F) Hyperactive reflexes
Ans: B, D Feedback: Assessment findings associated with scoliosis include asymmetric shoulder elevation, uneven curve at the waistline, rib hump on one side, and a pronounced hump on one side when bending over. Typically, only mild back discomfort is found and balance, motor strength, sensation, and reflexes are normal
A nursing instructor is preparing for a class discussion on spinal muscular atrophy (SMA). When describing type 2 SMA, which information would the instructor include? Select all answers that apply. A) Onset before 6 months of age B) Weakness most severe in shoulders and hips C) Difficulty with swallowing D) Slowly progressing condition E) Genetic disease with autosomal recessive inheritance
Ans: B, D, E Feedback: Any type of spinal muscular atrophy is a genetic motor neuron disease due to autosomal recessive inheritance. Type 2 SMA usually occurs between 6 and 18 months of age, with weakness that is most severe in the shoulders, hips, thighs, and upper back. It is slower in progression than type 1. Survival into adulthood is common if respiratory status is maintained appropriately. Type 1 SMA occurs before birth to 6 months of age and the child usually has difficulty swallowing, sucking, and breathing.
An 18-month-old was brought to the emergency department by her mother, who states, "I think she broke her arm." The child is sent for a radiograph to confirm the fracture. Additional assessment of the child leads the nurse to suspect possible child abuse. Which type of fracture would the radiograph most likely reveal? A) Plastic deformity B) Buckle fracture C) Spiral fracture D) Greenstick fracture
Ans: C Feedback: A spiral fracture is very rare in children. A spiral femoral or humeral fracture, particularly in a child younger than 2 years of age, should always be thoroughly investigated to rule out the possibility of child abuse. Plastic, buckle, and greenstick fractures are common in children and do not usually suggest child abuse.
The nurse is caring for a 13-year-old boy in traction prior to surgery for slipped capital femoral epiphysis. He has been in an acute care setting for 2 weeks and will require an additional 10 days in the hospital. He is complaining that he feels isolated and is resisting further treatment. Which response by the nurse would be most appropriate? A) "I know it is boring, but you must remain immobile for 2 more weeks." B) "If there are no complications, you only have 2 more weeks here." C) "Let's come up with things to do like books, movies, games, and friends to visit." D) "If you resist your treatment, your condition will only get worse."
Ans: C Feedback: After 2 weeks in traction, a teenager can become easily bored and isolated from usual peer interaction. The most helpful intervention would be to engage the help of the child to develop a list of books, games, movies, and other activities that he would enjoy. The nurse should also encourage visitation and phone calls from friends. Telling the adolescent that he needs to remain immobile or telling him that he has only 2 more weeks do not address the adolescent's issue. Telling the adolescent that his condition will worsen if he resists is threatening and inappropriate.
A child with spastic cerebral palsy is to receive botulin toxin. The nurse prepares the child for administration of this drug by which route? A) Oral B) Subcutaneous injection C) Intramuscular injection D) Intravenous infusion
Ans: C Feedback: Botulin toxin is administered by injection into the muscle. It may cause dry mouth. It is not administered orally, by subcutaneous injection, or by intravenous infusion
A nurse is caring for a 5-year-old in Buck traction. When conducting a skin examination for signs of pressure ulcers, the nurse pays particular attention to which area? A) Sacral area B) Hip area C) Occiput D) Upper arm
Ans: C Feedback: Common sites of pressure ulcers in hospitalized children include the occiput and toes, while children who require wheelchairs for mobility demonstrate pressure ulcers in the sacral or hip areas more frequently. The upper arm is not a common site for pressure ulcers.
A child with cerebral palsy has undergone surgery for placement of a baclofen pump. Which instruction would the nurse include when teaching the parents about caring for their child? A) Waiting 48 hours before allowing the child to take a tub bath B) Not allowing the child to sleep on his side for about 4 weeks C) Calling the physician if the child's temperature is over 100.5°F D) Discouraging the child from stretching or bending forward for 4 weeks
Ans: D Feedback: After insertion of a baclofen pump, the parents should discourage any twisting at the waist, reaching high overhead, stretching, or bending forward or backward for 4 weeks. The child would avoid tub baths for about 2 weeks and avoid sleeping on his stomach for 4 weeks. The parents should notify the physician or nurse practitioner if the child's temperature is greater than 101.5°F
A 6-year-old boy has been admitted to the hospital with burns. The nurse notes carbonaceous sputum. What action would be the priority? A) Determining the burn depth B) Eliciting a description of the burn C) Estimating burn extent D) Ensuring a patent airway
Ans: D Feedback: Carbonaceous sputum is a sign of potential airway injury due to smoke inhalation. Therefore, the nurse should ensure a patent airway while obtaining a brief history and simultaneously evaluating the child and providing emergency care. If the burn does not pose an immediate, life-threatening risk, the nurse would obtain an in-depth history and elicit a description of the burn. Determining the burn depth and extent are part of the secondary survey.
A nurse is caring for a 14-year-old girl who received an electrical burn. The nurse would anticipate preparing the girl for which diagnostic tests as ordered? A) Pulse oximetry B) Fiberoptic bronchoscopy C) Xenon ventilation-perfusion scanning D) Electrocardiographic monitoring
Ans: D Feedback: Electrocardiographic monitoring is important for the child who has suffered an electrical burn to identify possible cardiac arrhythmias, which can be noted for up to 72 hours after a burn injury. Fiberoptic bronchoscopy and xenon ventilation-perfusion scanning may be ordered to evaluate an inhalation injury, not an electrical burn. Pulse oximetry is used to evaluate pulmonary function and would not be indicated in the case of an electrical burn.
The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury? A) Recommend the bed's side rails be raised throughout the day and night. B) Suggest a caregiver be present continuously to prevent falls from bed. C) Encourage a loose restraint to be used when he is in bed. D) Recommend raising the bed's side rails when a caregiver is not present.
Ans: D Feedback: The nurse should recommend that side rails on the bed be elevated when a caregiver is not present. The use of restraints should be avoided if at all possible. Suggesting that a caregiver be present at all times places undue stress on the family. Close observation is more appropriate. Recommending side rails be elevated at all times may be upsetting to the child and make him feel like a "baby."
As part of a clinical conference with a group of nursing students, the instructor is describing the burn classification. The instructor determines that the teaching has been successful when the group identifies what as characteristic of full thickness burns? A) Skin that is reddened, dry, and slightly swollen B) Skin appearing wet with significant pain C) Skin with blistering and swelling D) Skin that is leathery and dry with some numbness
Ans: D Feedback:Full thickness burns may be very painful, numb, or pain-free in some areas. They appear red, edematous, leathery, dry, or waxy and may display peeling or charred skin. Superficial burns are painful, red, dry, and possibly edematous. Partial thickness and deep partial thickness burns are very painful and edematous and have a wet appearance or blisters.
A child is diagnosed with atopic dermatitis. Which laboratory test would the nurse expect the child to undergo to provide additional evidence for this condition? A) Erythrocyte sedimentation rate B) Potassium hydroxide prep C) Wound culture D) Serum immunoglobulin E (IgE) level
Ans: D Feedback:IgE levels are often used to evaluate for atopic dermatitis. IgE levels are elevated in this condition. Erythrocyte sedimentation rate may be used but this test is nonspecific and only indicates infection or inflammation. Potassium hydroxide prep is used to identify fungal infections. Wound culture would be done to identify a specific organism if an infection occurs with atopic dermatitis.
The nurse is assessing a 5-year-old child's genitourinary system. Which findings would the nurse document as normal? Select all that apply. A)Labial fusion B)Round abdomen C)Positive bowel sounds D)Dullness over the spleen E)Undescended testicles
B, C, D Feedback: Normal findings include a round abdomen, positive bowel sounds, dullness over the spleen, and descended testicles. Labial fusion, a distended abdomen, and undescended testicles are abnormal findings.
The nurse is caring for a child with gastrointestinal concerns. What statement by the parent would indicate a need for the nurse to further assess the child for constipation? A. "My child only has a bowel movement about four times a week." B. "My child has such large bowl movements that it clogs the toilet." C. "My child does not have liquid stool or leak liquid stools that I am aware of." D. "My child eats vegetables and fresh fruit, but does not like beans."
B. "My child has such large bowl movements that it clogs the toilet." Constipation may manifest by bowel movements that are large enough to clog the toilet, fewer bowel movements than normal, and bowel movements that are hard and pellet-like. Constipation is not likely if the child eats fruits and vegetables, even when beans are not incorporated into the child's diet. Passage of liquid stools can be a sign of constipation.
After teaching the parents of a child with a hydrocele about this condition, which statement indicates that the teaching was successful? A)"If this gets worse and we don't treat it, our son could become infertile." B)"This condition should gradually go away on its own." C)"The surgeon is going to operate on him immediately." D)"It's going to be difficult putting ice packs on his scrotum."
B. "This condition should gradually go away on its own." Feedback: Hydrocele requires watchful waiting because it will usually resolve spontaneously on its own. Hydrocele is not associated with the development of infertility; a varicocele, if left untreated, can lead to infertility. Immediate surgery is warranted for testicular torsion. Ice packs to the scrotum are helpful in relieving pain associated with epididymitis.
A 9-month-old girl is brought to the emergency room with what appears to be bouts of intense abdominal pain 15 minutes apart in which she draws up her legs and cries, often accompanied by vomiting. In between the bouts, the child recovers and appears to be without symptoms. Blood is found in the stool. What condition should the nurse suspect in this case? A. Short-bowel/short-gut syndrome B. Intussusception C. Volvulus with malrotation D. Necrotizing enterocolitis
B. Intussusception Intussusception, the invagination of one portion of the intestine into another, usually occurs in the second half of the first year of life. Children with this disorder suddenly draw up their legs and cry as if they are in severe pain; they may vomit. After the peristaltic wave that caused the discomfort passes, they are symptom-free and play happily. In approximately 15 minutes, however, the same phenomenon of intense abdominal pain strikes again. After approximately 12 hours, blood appears in the stool and possibly in vomitus, described as a "currant jelly" appearance. Volvulus with malrotation and necrotizing enterocolitis typically occur in the first 6 months of life and do not match the symptoms described above. Short-bowel/short-gut syndrome typically occurs when a large portion of the intestine has been removed due to a previous disease or trauma.
A child is scheduled for a urea breath test. The nurse understands that this test is being performed for which reason? A. evaluate gastric pH B. detect Helicobacter pylori C. determine esophageal contractility D. confirm pancreatitis
B. detect Helicobacter pylori Urea breath test is used to detect the presence of H. pylori in the exhaled breath. This test does not evaluate gastric pH. Serum amylase and lipase levels are used to confirm pancreatitis. Esophageal manometry is used to evaluate esophageal contractile activity and effectiveness.
A 6-year-old child has undergone a renal transplant and is receiving cyclosporine. The nurse instructs the parents to be especially alert for which complication? A)Weight loss B)Hypotension C)Signs of infection D)Hair loss
C. Signs of infection Feedback: The parents should be especially alert for signs of infection as cyclosporine is an immunosuppressant drug. Weight gain instead of weight loss, hypertension instead of hypotension, and increased facial hair instead of hair loss are some other potential side effects.
The nurse is assessing a 10-day-old infant for dehydration. Which finding indicates severe dehydration? A. Blood pressure of 80/42 mm Hg B. Pale and slightly dry mucosa C. Tenting of skin D. Soft and flat fontanels (fontanelles)
C. Tenting of skin Tenting of skin is an indicator of severe dehydration. Soft and flat fontanels (fontanelles) indicate mild dehydration. Pale and slightly dry mucosa indicates mild or moderate dehydration. Blood pressure of 80/42 mm Hg is a normal finding for an infant.
The nurse is providing postsurgical care for an infant who has undergone a hypospadias repair. Which action by the nurse would be most important to help keep the area clean while maintaining proper position of the drainage tubing? A)Keeping the drainage tube taped in an upright position B)Administering antibiotics as ordered C)Administering analgesics as prescribed D)Using a double-diapering technique
D. Using a double-diapering technique Feedback: Double diapering is a method used to protect a child's urethra and stent or catheter after surgery and additionally helps to keep the area clean and free from infection. Keeping the drainage tube taped in an upright position, administering antibiotics, and administering analgesics are also important, but double diapering keeps the area clean and helps prevent infection.
A nurse caring for Paulo, an infant born with a cleft palate, notices that the parents rarely interact with their child. The nurse overhears the mother telling her husband that she "feels like crying" every time she looks at their son. Which of the following would be the best response from the nurse? a) "I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?" b) "Keep in mind that your son's condition is not life-threatening and can be corrected eventually." c) "Many infants are born with this condition. Your son's palate is not nearly as bad as some cases." d) "Your son needs you right now. You should put your negative feelings about his condition aside for his sake."
a. "I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?" Explanation: The nurse should support the family's adjustment to a child's condition by demonstrating an accepting, caring attitude toward the child and family and providing the parents with opportunities and support for normal infant-parent interactions.
A nurse manages the interdisciplinary care for a client with pancreatitis. What are recommended interventions for this condition? Select all that apply. a) Administering analgesics for pain b) Administering corticosteroids c) Providing glycemia control d) Positioning the client in a fetal position e) Keeping the child NPO to rest the pancreas f) Using a high-fat diet when lipase occurs
a. Administering analgesics for pain c. Providing glycemia control d. Positioning the client in a fetal position e. Keeping the child NPO to rest the pancreas The main interventions for pancreatitis are supportive, including administration of antibiotics; stress ulcer prophylaxis; pain relief by analgesic administration; managing fluids; glycemia control; using a low-fat diet when lipase occurs; positioning the child in the fetal position to minimize tension of the peritoneum; and keeping the child NPO to rest the pancreas.
A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting several feet from his mouth. He is always hungry again just after vomiting. At the physician's office, the nurse holds the child and gives him a bottle of water. While he drinks, she notes an olive-size lump in his right abdomen. Which of the following conditions should the nurse suspect in this child? a) Pyloric stenosis b) Gastroesophageal reflux c) Peptic ulcer disease d) Appendicitis
a. Pyloric stenosis Explanation: With pyloric stenosis, at 4 to 6 weeks of age, infants typically begin to vomit almost immediately after each feeding. The vomiting grows increasingly forceful until it is projectile, possibly projecting as much as 3 to 4 feet. Infants are usually hungry immediately after vomiting because they are not nauseated. A definitive diagnosis can be made by watching the infant drink. If a pyloric stenosis is present, the sphincter feels round and firm, approximately the size of an olive in the right abdomen. Peptic ulcer disease in neonates usually presents with hematemesis (blood in vomitus) or melena (blood in the stool). Gastroesophageal reflux involves a small (1-2 tsp) volume and is not forceful. Appendicitis typically begins with anorexia for 12 to 24 hours; children do not eat and do not act like their usual selves. Nausea and vomiting may then occur, followed by diffuse abdominal pain.
The nurse is teaching the mother of an infant with a temporary ileostomy about stoma care. Which of the following is the most important instruction to emphasize to the mother to avoid an emergency situation? a) "Gather all of your supplies before you begin." b) "Call the doctor immediately if the stoma is not pink/red and moist." c) "You may need adhesive remover to ease pouch removal." d) "You must be meticulous in caring for the surrounding skin."
b. "Call the doctor immediately if the stoma is not pink/red and moist." Explanation: A healthy stoma is pink and moist. If the stoma is dry or pale, the mother must notify the doctor immediately because it could indicate compromised circulation. Gathering supplies is important but would not be involved in avoiding an emergency situation. All of the other instructions are valid, but emphasizing the color of the healthy stoma is most important to avoid an emergency situation. Adhesive remover may be needed to ease pouch removal, but this action would not necessarily avoid an emergency situation. Meticulous skin care is important, but this action would not necessarily avoid an emergency situation.
A 6-month-old boy is diagnosed with pyloric stenosis. When you take a health history from his mother, which symptom would you expect to hear her describe? a) Chronic diarrhea b) Vomiting about 2 hours after feeding c) Refusal to eat d) Vomiting immediately after feeding
b. Vomiting immediately after feeding Explanation: A narrowing of the pyloric valve leads to projectile vomiting soon after eating.
You care for a 12-year-old girl with Crohn's disease. A primary assessment you would want to make when caring for her would be to note if a) her joints are not swollen. b) she has a temperature. c) she has a headache. d) lung sounds are clear.
b. she has a temperature. Explanation: Because Crohn's disease leads to patches of inflammation in the bowel, the temperature increases if more patches become involved.
The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of congenital aganglionic megacolon? a) In this disorder the sphincter that leads into the stomach is relaxed. b) There are recurrent paroxysmal bouts of abdominal pain. c) A partial or complete intestinal obstruction occurs. d) A thickened, elongated muscle causes an obstruction at the end of the stomach.
c. A partial or complete intestinal obstruction occurs. Explanation: Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus which leads to an obstruction at the distal end of the stomach. Colic consists of recurrent paroxysmal bouts of abdominal pain. Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus is relaxed and allows gastric contents to be regurgitated back into the esophagus.
The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of pyloric stenosis? a) There are recurrent paroxysmal bouts of abdominal pain. b) In this disorder the sphincter that leads into the stomach is relaxed. c) A thickened, elongated muscle causes an obstruction at the end of the stomach. d) A partial or complete intestinal obstruction occurs.
c. A thickened, elongated muscle causes an obstruction at the end of the stomach. Explanation: Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, with a severe narrowing of its lumen. The pylorus is thickened to as much as twice its size, is elongated, and has a consistency resembling cartilage. As a result of this obstruction at the distal end of the stomach, the stomach becomes dilated. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Colic consists of recurrent paroxysmal bouts of abdominal pain. Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus is relaxed and allows gastric contents to be regurgitated back into the esophagus.
The nurse has performed client teaching to a 15-year-old boy with Crohn disease, and his parents regarding the cobblestone lesions in his small intestine. Which comment by the family indicates learning occurred? a) "I may end up with a colectomy because the disease is continuous from the beginning to the end of my intestines." b) "It's unusual for someone my age to get Crohn disease." c) "I have a lot of diarrhea every day because of how my small intestine is damaged." d) "I have to be careful because I am prone to not absorbing nutrients."
d. "I have to be careful because I am prone to not absorbing nutrients." Crohn disease typically effects the small intestine more than the large intestine and it's onset is between the ages of 10 to 20 years. The cobblestone lesions in the small intestine prevents absorption of nutrients that normally occurs. The diarrhea is not directly related to the cobblestone lesions, and ulcerative colitis is characterized by the disease effecting the intestine(s) in a continuous pattern.
The nurse examining an infant forms the following diagnosis: "Risk for impaired skin integrity related to effects of diarrhea." This diagnosis would be most appropriate for which of the following disease states (select all that apply): a) Congenital diaphragmatic hernia b) Meckel diverticulum c) Ulcerative colitis d) Inflammatory bowel disease e) Crohn disease f) Pyloric stenosis
d. Inflammatory bowel disease e. Crohn disease c. Ulcerative colitis Explanation: Inflammatory bowel disease (IBD) is a group of diseases characterized by inflammation of the GI tract and diarrhea. Crohn disease (CD) and ulcerative colitis (UC) are the most common forms of IBD and account for more than 80% of all cases.