MCN 374 EXAM 2: Ch 16, 21, 22, 23, 29

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

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

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

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

A child comes to the clinic for an assessment 20 days postbone marrow transplant. Which system should receive the highest priority during the nursing assessment? 1. Integumentary 2. Gastrointestinal 3. Respiratory 4. Cardiovascular

1. Integumentary he skin is most commonly affected in graft-versus-host disease after a transplant. A pruritic, macular papular rash and a blistering, burning sensation can occur. The other systems are important to assess, but are not the highest priority.

The family has just been informed by the healthcare provider that their newborn is diagnosed with a congenital heart defect, Tetralogy of Fallot (TOF). The family tells the nurse that the healthcare provider told them that TOF is comprised of several defects, and they ask the nurse what the defects are. What will the nurse tell the family? Select all that apply. 1. Pulmonary stenosis 2. Coarctation of the aorta 3. Right ventricular hypertrophy 4. Ventral septal defect 5. Overriding aorta

1. Pulmonary stenosis 3. Right ventricular hypertrophy 4. Ventral septal defect 5. Overriding aorta Four defects are involved with TOF include: pulmonary stenosis, right ventricular hypertrophy, ventral septal defect, and overriding aorta.

A nurse is planning care for a child with human immunodeficiency virus (HIV). Which nursing diagnosis is the highest priority for this child? 1. Risk for Infection 2. Risk for Fluid-Volume Deficit 3. Ineffective Thermoregulation 4. Ineffective Tissue Perfusion, Peripheral

1. Risk for Infection A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Fluid-Volume Deficit, Ineffective Thermoregulation, and Ineffective Tissue Perfusion, Peripheral would not be priority problems with this disease process.

Parents of a child who experienced a moderately severe allergic reaction after eating peanuts ask the nurse what they can do to help if it happens again. Which response by the nurse is the most appropriate? 1. If it happens again, I will teach you what to do. 2. You should have an antihistamine like Benadryl with you at all times. 3. We can start a desensitization process to take the allergy away. 4. I will teach you how to use an EpiPen.

4. I will teach you how to use an EpiPen. An EpiPen is the appropriate treatment if this reaction occurs again. Benadryl is fine, but most likely is not strong enough in light of the serious reaction the child had. Desensitization is not the appropriate instruction at this time. Telling the parents that they will be taught if it happens again is brushing off the seriousness of the situation.

The nurse is providing care to a preschool-age client who is diagnosed with acquired immune deficiency syndrome (AIDS). In planning the clients care, which vaccine is inappropriate for the client to receive? 1. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) 2. Haemophilus influenzae type B (HIB conjugate vaccine) 3. Varicella vaccine 4. Hepatitis B vaccine (Hep B)

3. Varicella vaccine A child with an immune disorder should not be immunized with a live varicella vaccine because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines and should be given on schedule.

An adolescent client must wear a brace for the correction of scoliosis. Which nursing diagnosis is most appropriate for this client? 1. Risk for Impaired Skin Integrity 2. Risk for Altered Growth and Development 3. Risk for Impaired Mobility 4. Risk for Impaired Gas Exchange

1. Risk for Impaired Skin Integrity The skin should be monitored for breakdown in any area the brace may rub. The other diagnoses would not be a priority and should be corrected by the wearing of the brace.

The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. To administer this injection safely, the nurse chooses which needle, size and length, injection type, and injection site? 1. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh. 2. 22-gauge, 1/2-inch needle; IM (intramuscular); ventrogluteal. 3. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid. 4. 25-gauge, 3/4-inch needle; SQ (subcutaneous); anterolateral thigh.

1. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh. The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, 5/8- to 3/4-inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh

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

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

A child with human immunodeficiency virus (HIV) also has oral candidiasis. Which type of mouth care solution will the nurse teach the child to use? 1. Normal saline 2. Listerine 3. Scope 4. Viscous lidocaine

1. Normal saline The mouth care should be with a nonalcohol base. Normal saline can keep the childs lips and mouth moist. Listerine and Scope are commercial mouth rinses that can have an alcohol base and cause drying of the membranes. Viscous lidocaine causes numbing and could depress the gag reflex in a younger child

The nurse has admitted a child with tricuspid atresia. The nurse would expect which initial lab result? 1. A high hemoglobin 2. A low hematocrit 3. A high white blood cell count 4. A low platelet count

1. A high hemoglobin The childs bone marrow responds to chronic hypoxemia by producing more red blood cells to increase the amount of hemoglobin available to carry oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid atresia. Therefore, the hematocrit would not be low, the white blood cell count would not be high (unless an infection were present), and the platelets would be normal.

The school nurse is providing care to a school-age client who experienced a sprain of the right ankle on the playground. Which intervention is appropriate for the nurse to implement for this client? 1. Apply ice to the extremity 2. Apply a warm, moist pack to the extremity 3. Perform passive range of motion to the extremity 4. Lower the extremity to below the level of the heart

1. Apply ice to the extremity For the first 24 hours of a sprain, rest, ice, compression, and elevation should be used. Therefore, the nurse should apply ice to the extremity.

The nurse is admitting an infant diagnosed with supraventricular tachycardia. Which intervention is the priority for this infant? 1. Apply ice to the face. 2. Perform Valsalvas maneuver. 3. Administer a beta blocker. 4. Prepare for cardioversion.

1. Apply ice to the face. Supraventricular tachycardia episodes are initially treated with vagal maneuvers to slow the heart rate when the infant is stable. In stable infants, the application of ice or iced saline solution to the face can reduce the heart rate. The infant is not capable of performing Valsalvas maneuver. Calcium channel blockers, not beta blockers, are the drugs of choice. Cardioversion is used in an urgent situation, but is not typically the initial treatment.

The nurse in the newborn nursery is performing the admission assessment on a neonate. Which assessment finding indicates the neonate may have congenital hip dysplasia? 1. Asymmetry of the gluteal and thigh fat folds 2. Trendelenburg sign 3. Telescoping of the affected limb 4. Lordosis

1. Asymmetry of the gluteal and thigh fat folds A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat folds. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia. Lordosis does not occur with hip dysplasia

A child is diagnosed with sickle cell disease. The parents are unsure how their child contracted the disease. Which explanation by the nurse is the most appropriate? 1. Both the mother and the father have the sickle cell trait. 2. The mother has the trait, but the father doesnt. 3. The father has the trait, but the mother doesnt. 4. The mother has sickle cell disease, but the father doesnt have the disease or the trait.

1. Both the mother and the father have the sickle cell trait. Sickle cell disease is an autosomal recessive disorder; both parents must have the trait in order for a child to have the disease.

The mother of a child with a heart defect is questioning the nurse about the childs diuretic. When teaching the mother about the medication, what should the emphasis from the nurse? 1. Close monitoring of output 2. The digitalization process 3. The possibility that pulses in the child might be weak 4. The childs increased appetite

1. Close monitoring of output It is important to monitor the output of the child on a diuretic to determine effectiveness of the drug. Digitalization pulses are not associated with diuretics. The child will usually have a decreased appetite.

The family and school-age child are at the healthcare clinic for immunizations. The nurse takes the time to talk with the child and family about reducing the transmission of infection. What practices should the nurse suggest for the family? Select all that apply. 1. Do not share dishes, utensils, and cups. 2. Sanitize toys every week with Lysol. 3. Use alcohol-based hand sanitizer with the child after eating and toileting. 4. Cough or sneeze into cloth tissue 5. Dispose of diapers in a closed container.

1. Do not share dishes, utensils, and cups. 5. Dispose of diapers in a closed container. Teach families to reduce transmission of infection among family members with the following practices: use disposable tissues and dispose immediately after using, wash hands thoroughly with soap/water after all contact with diapers/tissues/mucous, sneeze/cough into elbow, wash hands with soap/water after eating and toileting, do not share dishes/utensils/cups, wash hands thoroughly before preparing food and again several times during the preparation process, use soapy warm water to wash dishes/cutting boards, wipe counters/surfaces that are used for diaper changes or that the child touches with disinfectant, make sure diaper changing area is well away from food prep areas, dispose of diapers in closed containers. This is a practice that the nurse should suggest for the family.

The nurse is performing the initial assessment of a child newly diagnosed Kawasaki disease. Which symptoms would the nurse expect to assess with this child? 1. Dry, swollen, fissured lips 2. Non-palpable lymph nodes 3. Conjunctivitis with exudates 4. Cyanosis of the hands and feet

1. Dry, swollen, fissured lips Dry, swollen, fissured lips are symptoms of Kawasaki disease. Lymph nodes can be palpable, conjunctivitis is present but without exudates, and hands and feet are typically erythematous.

361. The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply. 1. Easy bruising occurs. 2. Gum bleeding occurs. 3. It is a hereditary bleeding disorder. 4. Treatment and care are similar to that for hemophilia. 5. It is characterized by extremely high creatinine levels. 6. The disorder causes platelets to adhere to damaged endothelium.

1. Easy bruising occurs. 2. Gum bleeding occurs. 3. It is a hereditary bleeding disorder. 4. Treatment and care are similar to that for hemophilia. 6. The disorder causes platelets to adhere to damaged endothelium. von Willebrand's disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in a protein termed von Willebrand factor. The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assess- ment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. An elevated creatinine level is not associated with this disorder.

A child is admitted with a diagnosis of early localized Lyme disease. Which clinical manifestations would the nurse expect to find on the initial assessment of this client? Select all that apply. 1. Erythema 515 cm in diameter 2. Hyperactivity 3. Cranial nerve palsies 4. Fever 5. Headache

1. Erythema 515 cm in diameter 4. Fever 5. Headache Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

The parents of a child with Duchenne muscular dystrophy are in the clinic after diagnosis and ask the nurse if the family should have genetic testing completed. Who should the nurse suggest to have genetic testing? Select all that apply. 1. Female cousins 2. Aunts 3. Sisters 4. Brothers 5. Uncles and male cousins

1. Female cousins 2. Aunts 3. Sisters This is an X-linked disorder so all females in the family should be tested.

The nurse admits a child with a ventricular septal defect (VSD) to the unit. Which nursing diagnosis for this child is the most appropriate? 1. Impaired Gas Exchange Related to Pulmonary Congestion Secondary to the Increased Pulmonary Blood Flow 2. Deficient Fluid Volume Related to Hyperthermia Secondary to the Congenital Heart Defect 3. Acute Pain Related to the Effects of a Congenital Heart Defect 4. Hypothermia Related to Decreased Metabolic State

1. Impaired Gas Exchange Related to Pulmonary Congestion Secondary to the Increased Pulmonary Blood Flow Because of the increased pulmonary congestion, Impaired Gas Exchange would be an appropriate nursing diagnosis. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.

450. A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition? 1. Limited range of motion in the affected hip 2. An apparent lengthened femur on the affected side 3. Asymmetrical adduction of the affected hip when the infant is placed supine with the knees and hips flexed 4. Symmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table

1. Limited range of motion in the affected hip In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Asymmetrical and restricted abduction of the affected hip, when the child is placed supine with the knees and hips flexed, would be an assessment finding in developmental dysplasia of the hip in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity.

The nurse is caring for an adolescent client diagnosed with rheumatoid arthritis. Which nonpharmacological measure to reduce joint pain is most appropriate for the nurse to recommend to this client? 1. Moist heat 2. Elevation of extremity 3. Massage 4. Immobilization

1. Moist heat Moist heat can promote relief of pain and decrease joint stiffness. Elevation of extremity would not have an effect on reducing pain in rheumatoid arthritis. Massage of extremities should be avoided because of a potential risk for emboli. Immobilization can lead to contractures, and range of motion to the involved joint should be maintained.

The nurse is providing care to a school-age client admitted to the emergency department following a motor vehicle crash. The client is exhibiting symptoms of hypovolemic shock. Which nursing interventions are appropriate for this client? Select all that apply. 1. Monitor hemoglobin and hematocrit. 2. Monitor liver enzymes. 3. Administer oxygen, as needed. 4. Administer a dextrose solution. 5. Monitor blood glucose.

1. Monitor hemoglobin and hematocrit. 3. Administer oxygen, as needed. 5. Monitor blood glucose. Nursing care for a client experiencing hypovolemic shock is aimed at monitoring the childs condition and response to clinical therapy. It is appropriate for the nurse to monitor hemoglobin, hematocrit, and blood glucose. The nurse will also administer oxygen. The nurse will administer large volumes of crystalloid fluids (normal saline or lactated Ringers), not dextrose. It is not necessary to monitor liver enzymes for this client.

An infant with tetralogy of Fallot is having a hypercyanotic episode (tet spell). Which nursing interventions are appropriate for the nurse to implement for this infant? Select all that apply. 1. Place the child in knee-chest position. 2. Draw blood for a serum hemoglobin. 3. Administer oxygen. 4. Administer morphine and propranolol intravenously as ordered. 5. Administer Benadryl as ordered.

1. Place the child in knee-chest position. 3. Administer oxygen. 4. Administer morphine and propranolol intravenously as ordered. When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities), and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed. Benadryl is not appropriate for this child.

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

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

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

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

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

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

360. The nurse is reviewing a health care provider's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply. 1. Restrict fluid intake. 2. Position for comfort. 3. Avoid strain on painful joints. 4. Apply nasal oxygen at 2 L/minute. 5. Provide a high-calorie, high-protein diet. 6. Give meperidine, 25 mg intravenously, every 4 hours for pain.

1. Restrict fluid intake. 6. Give meperidine, 25 mg intravenously, every 4 hours for pain. Sickle cell anemia is one of a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. Oral and intravenous fluids are an important part of treatment. Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would question the prescription for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan.

An adolescent client who is diagnosed with Duchenne muscular dystrophy is seen in the clinic for a routine health visit. Which nursing diagnosis is the priority for this client? 1. Risk for Impaired Mobility Related to Hypertrophy of Muscles 2. Risk for Infection Related to Altered Immune System 3. Risk for Impaired Skin Integrity Related to Paresthesia 4. Risk for Altered Comfort Related to Effects of the Illness

1. Risk for Impaired Mobility Related to Hypertrophy of Muscles Nursing care for muscular dystrophy (MD) focuses on promoting independence and mobility for this progressive, incapacitating disease. Risk for Infection, Risk for Impaired Skin Integrity, and Risk for Altered Comfort are not as high a priority as Risk for Impaired Mobility.

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

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

A preschool-age child has just had a moderate reaction to latex. When teaching the parents about latex allergy, the nurse should inform the parents of what common household items that contain latex? Select all that apply. 1. Rubber bands 2. Sneakers 3. Toothbrushes 4. Big Wheel tricycle 5. Water toys

1. Rubber bands 2. Sneakers 3. Toothbrushes 5. Water toys Rubber bands, sneakers, toothbrushes, and water toys are household items that might contain latex. A Big Wheel tricycle is plastic and does not contain latex.

A child is admitted with infective endocarditis. Which nursing intervention is most appropriate for this child? 1. Start an intravenous line. 2. Place the child in contact isolation. 3. Place the child on seizure precautions. 4. Assist with a lumbar puncture.

1. Start an intravenous line. Infective endocarditis is treated with intravenous antibiotics for two to eight weeks. It is not contagious, so the child is not placed in contact isolation. Seizures are not a risk of infective endocarditis. A lumbar puncture is not a diagnostic test done for infective endocarditis.

The nurse is providing care to a toddler client who is diagnosed with osteogenesis imperfect. Which nursing intervention is appropriate for this client? 1. Support of the trunk and extremities when moving 2. Traction care 3. Cast care 4. Postop spinal surgery care

1. Support of the trunk and extremities when moving With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones are fragile, the entire body must be supported when the child is moved. Traction, casts, and spinal surgery are not routinely done for osteogenesis.

An HIV-positive mother states she is relieved after the birth of her child to hear that the child is HIV-negative. Which response by the nurse is the most appropriate? 1. Symptoms could still appear over the next 2 years. 2. You took good care of yourself, so your child did not get HIV. 3. We will assess for signs of pneumonia to be sure. 4. The test will be repeated in 1 week to verify the negative status.

1. Symptoms could still appear over the next 2 years. Symptoms of HIV could still manifest within the first 2 years. An infant is retested 12 months after the initial negative result. The HIV-positive mother can infect the newborn regardless of how well she takes care of herself once she is HIV-positive. There is no reason to assess for signs of pneumonia if the newborn is HIV-negative.

A school health nurse is screening school-age students for scoliosis. Which assessment findings indicate the need for further evaluation for scoliosis? Select all that apply. 1. Uneven shoulders and hips 2. A one-sided rib hump 3. Prominent scapula 4. Lordosis 5. Pain

1. Uneven shoulders and hips 2. A one-sided rib hump 3. Prominent scapula The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. Lordosis and pain are not present with scoliosis.

416. The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? 1. Weighing the diapers 2. Inserting a urinary catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula

1. Weighing the diapers Heart failure is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The most appropriate method for assessing urine output in an infant receiving diuretic therapy is to weigh the diapers. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the amount of output. Although urinary catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant and places the infant at risk for infection.

The nurse has completed discharge teaching for the family of a child diagnosed with Legg-Calve-Perthes disease. Which statement by the family indicates the need for further education? 1. Were glad this will only take about six weeks to correct. 2. We understand swimming is a good sport for Legg-Calve-Perthes. 3. We know to watch for areas on the skin the brace may rub. 4. We understand that abduction of the affected leg is important.

1. Were glad this will only take about six weeks to correct. The treatment generally takes approximately two years. Swimming is a good activity to increase mobility. A brace may be worn, so skin irritation should be monitored. The leg should be kept in the abducted position.

The nurse completes parent education related to treatment for a pediatric client with congenital clubfoot. Which statement by the parents indicates the need for further education? 1. Were happy this is the only cast our baby will need. 2. Well watch for any swelling of the feet while the casts are on. 3. Well keep the casts dry. 4. Were getting a special car seat to accommodate the casts.

1. Were happy this is the only cast our baby will need. Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every one to two weeks. Parents should be watching for swelling while the casts are on, keeping the casts dry, and using a car seat to accommodate the casts.

418. The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction? 1. "A balance of rest and exercise is important." 2. "I can apply lotion or powder to the incision if it is itchy." 3. "Activities in which my child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after surgery."

2. "I can apply lotion or powder to the incision if it is itchy." The mother should be instructed that lotions and powders should not be applied to the incision site after cardiac surgery. Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site. Options 1, 3, and 4 are accurate instructions regarding home care after cardiac surgery.

445. A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction? 1. "The cast may feel warm as the cast dries." 2. "I can use lotion or powder around the cast edges to relieve itching." 3. "A small amount of white shoe polish can touch up a soiled white cast." 4. "If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast."

2. "I can use lotion or powder around the cast edges to relieve itching." Teaching about cast care is essential to prevent complications from the cast. The parents need to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation. Options 1, 3, and 4 are appropriate statements.

A nurse is administering an intramuscular vaccination to an infant diagnosed with WiskottAldrich syndrome (WAS). Which reaction is the infant more at risk for due to the diagnosis of WAS? 1. Pain at injection site 2. Bleeding at injection site 3. Redness and swelling at injection site 4. Mild rash at injection site

2. Bleeding at injection site WiskottAldrich syndrome is characterized by thrombocytopenia, with bleeding tendencies appearing during the neonatal period. The syndrome would not put the child at higher risk for pain, redness, swelling, or rash at the injection site.

The nurse is caring for a pediatric client in Bryant skin traction. Which nursing intervention is most appropriate for this client? 1. Remove the adhesive traction straps daily to prevent skin breakdown. 2. Check the traction frequently to ensure that proper alignment is maintained. 3. Place the child in a prone position to maintain good alignment. 4. Move the child as infrequently as possible to maintain traction.

2. Check the traction frequently to ensure that proper alignment is maintained. The traction apparatus should be checked frequently to ensure that proper alignment is maintained. The adhesive straps should not be removed. The child should be placed in a supine position, and frequent repositioning is necessary to prevent complications of immobility.

The nurse is teaching a prenatal class about infant care. Under which circumstances should the nurse emphasize that parents should call their healthcare provider immediately? Select all that apply. 1. Child 4 months old, received a DTaP immunization yesterday, and has a temperature of 38.0 degrees C (100.4 degrees F) 2. Child under 3 months old and has a temperature over 40.1 degrees C (104.2 degrees F) 3. Child difficult to awaken and has a pulsing fontanel 4. Child has purple spots on the skin and is lethargic. 5. Child has a stiff neck and has been irritable for three days.

2. Child under 3 months old and has a temperature over 40.1 degrees C (104.2 degrees F) 3. Child difficult to awaken and has a pulsing fontanel 4. Child has purple spots on the skin and is lethargic. 5. Child has a stiff neck and has been irritable for three days. Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

The child and family come to the clinic requesting information about causes of cardiac defects. The father has high incidence of cardiac defects in his family, and the child is frequently cyanotic around the lips. What causes should the nurse tell the family about? Select all that apply. 1. Decreased maternal age 2. Chromosomal abnormalities 3. Fetal exposure to maternal drugs 4. Maternal viral infections 5. Maternal metabolic disorders

2. Chromosomal abnormalities 3. Fetal exposure to maternal drugs 4. Maternal viral infections 5. Maternal metabolic disorders Cardiac defects may result from fetal exposure to maternal drugs, increased maternal age, chromosomal abnormalities, maternal viral infections, maternal metabolic disorders, and multifactorial genetic factors.

A child recently had a heart transplant and the nurse teaches the parents the importance of administering cyclosporine A. Which statement by the parents indicates an appropriate understanding of the teaching session? 1. Cyclosporin A reduces serum-cholesterol level. 2. Cyclosporin A prevents rejection. 3. Cyclosporin A treats hypertension. 4. Cyclosporin A treats infections.

2. Cyclosporin A prevents rejection. Cyclosporin A is given to prevent rejection. Lovastatin is given to reduce serum-cholesterol level, calcium channel blockers may be used to treat hypertension, and an antibiotic may be given to treat an infection.

An infant returns from surgery for correction of bilateral congenital clubfeet. The infant has bilateral long-leg casts. The toes on both feet are edematous, but there is color, sensitivity, and movement to them. Which action by the nurse is the most appropriate? 1. Call the healthcare provider to report the edema. 2. Elevate the legs on pillows. 3. Apply a warm, moist pack to the feet. 4. Encourage movement of toes.

2. Elevate the legs on pillows. The legs should be elevated on a pillow for 24 hours to promote healing and help with venous return. Some amount of swelling can be expected, so it would not be appropriate to notify the healthcare provider, especially if the color, sensitivity, and movement remain normal to the toes. Ice should be applied, not heat. An infant would not be able to follow directions to move toes, and in this case it would not be as effective as elevating the legs on pillows

A mother brings her 4-month-old infant in for a routine checkup and vaccinations. The mother reports that the infant was exposed to a brother who has the flu. Which action by the nurse is most appropriate based on these assessment findings? 1. Withhold the vaccinations. 2. Give the vaccinations as scheduled. 3. Withhold the DTaP vaccination but give the others as scheduled. 4. Give the infant the flu vaccination but withhold the others.

2. Give the vaccinations as scheduled. Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old

The nurse is preparing to discharge an infant with a congenital heart defect. The infant will be cared for at home by the parents until surgery. Which items will the nurse include in the discharge teaching for this infant and family? Select all that apply. 1. Allow the infant to feed for 60 minutes. 2. Hold the infant at a 45 degree angle. 3. Encourage frequent hand hygiene. 4. Notify the health care provider for fever. 5. Pump the breasts and feed with a bottle if weight gain is an issue.

2. Hold the infant at a 45 degree angle. 3. Encourage frequent hand hygiene. 4. Notify the health care provider for fever. 5. Pump the breasts and feed with a bottle if weight gain is an issue. Children are often managed at home until surgery. The parents should hold the infant at a 45 degree angle to decrease tachypnea. The parents should also encourage frequent hand hygiene to decrease the risk of infection. It is important to notify the health care provider for a fever, as the infant will be at risk for dehydration and digoxin toxicity. If the mother is breastfeeding and the infant is losing weight, the mother should be encouraged to pump the milk and feed the infant from a bottle, but each feeding should be limited to 30 minutes. Tube feedings may be needed for this infant to conserve calories expenditure.

16) The nurse is caring for the newborn with bilateral clubfoot. What nursing diagnoses would the nurse address? Select all that apply. 1. Activity intolerance 2. Impaired physical mobility 3. Risk for impaired skin integrity 4. Ineffective breathing pattern 5. Impaired parenting

2. Impaired physical mobility 3. Risk for impaired skin integrity 5. Impaired parenting Nursing diagnoses that may apply to the newborn with bilateral clubfoot are impaired physical mobility, risk for impaired skin integrity, impaired parenting, and ineffective health maintenance.

452. The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply. 1. Use the fingertips to lift the cast while it is drying. 2. Keep small toys and sharp objects away from the cast. 3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. 4. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. 5. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. 6. Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity.

2. Keep small toys and sharp objects away from the cast. 5. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. 6. Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity. While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the under- lying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified.

The nurse is providing care to an adolescent child who is at risk for developing adult-onset cardiovascular disease. Which teaching points will decrease the adolescents risk? Select all that apply. 1. Encourage a decrease in smoking. 2. Limit fat intake to 20% to 35% of intake. 3. Encourage participation in vigorous exercise for at least 30 minutes. 4. Maintain a normal weight. 5. Include high-fat dairy products in the daily diet.

2. Limit fat intake to 20% to 35% of intake. 3. Encourage participation in vigorous exercise for at least 30 minutes. 4. Maintain a normal weight. Teaching points that will decrease the adolescents risk of developing adult-onset cardiovascular disease include: limiting fat intake to 20% to 35% of total daily intake; encouraging the participation in vigorous exercise at least 30 minutes each day; and maintaining a normal weight. The adolescent and family members should be encouraged to stop smoking, not just to decrease smoking. The family should be educated to include low-fat dairy products in the daily diet.

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

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

A nurse is assessing a child after an open reduction of a fractured femur. Which assessment findings would indicate that the child is experiencing compartment syndrome? Standard Text: Select all that apply. 1. Pink, warm extremity 2. Pain not relieved by pain medication 3. Dorsalis pedis pulse present 4. Prolonged capillary-refill time with paresthesia 5. Skin appears tense.

2. Pain not relieved by pain medication 4. Prolonged capillary-refill time with paresthesia 5. Skin appears tense.

The nurse is providing care to a school-age client with a documented immunodeficiency who is admitted to the general pediatric unit for intravenous medication administration. Which interventions are appropriate for this client? Select all that apply. 1. Institute droplet precautions. 2. Place in a positive-pressure room. 3. Avoid live vaccines. 4. Perform frequent handwashing. 5. Recommend fresh fruits brought in by the family.

2. Place in a positive-pressure room. 3. Avoid live vaccines. 4. Perform frequent handwashing. Pediatric clients with documented immunodeficiency require specific interventions to decrease their risk for developing infections while in the hospital environment. Appropriate interventions for this client include a positive-pressure room, avoiding live vaccines, and meticulous handwashing from staff and visitors. This client would require standard precautions, not droplet precautions. Because of the risk of infection with fresh fruit, the family would not be allowed to bring this to the client during their hospital stay.

The nurse is caring for the adolescent with systemic lupus erythematosus (SLE). What nursing diagnoses would the nurse address? Select all that apply. 1. Activity intolerance 2. Risk for impaired skin integrity 3. Body image disturbed 4. Ineffective breathing pattern 5. Risk for infection

2. Risk for impaired skin integrity 3. Body image disturbed 5. Risk for infection Nursing diagnoses that may apply to the adolescent with SLE are: risk for impaired skin integrity, risk for activity intolerance, disturbed body image, risk for infection, acute pain, and ineffective family therapeutic regimen management.

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

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

A nurse working in a pediatric clinic is responsible for monitoring and maintaining the vaccinations on site. Which actions are appropriate for this nurse to implement? Select all that apply. 1. Fluctuate refrigerator and freezer temperatures each day. 2. Store vaccines in the center of the unit. 3. Check and record the temperature of the unit twice each day. 4. Have a plan for power outages. 5. Place bottles of water in each unit to help keep temperatures consistent.

2. Store vaccines in the center of the unit. 3. Check and record the temperature of the unit twice each day. 4. Have a plan for power outages 5. Place bottles of water in each unit to help keep temperatures consistent. Appropriate interventions for the nurse to implement in order to maintain the potency of vaccines include storing the vaccines in the center of the unit, checking and recording the temperature of the storage unit twice a day, having a plan for power outages, and placing bottles of water in each unit to help keep temperatures consistent. The temperature of the refrigerator and freezer should be consistent and not fluctuate.

2. Store vaccines in the center of the unit. 3. Check and record the temperature of the unit twice each day. 4. Have a plan for power outages. 5. Place bottles of water in each unit to help keep temperatures consistent. Appropriate interventions for the nurse to implement in order to maintain the potency of vaccines include storing the vaccines in the center of the unit, checking and recording the temperature of the storage unit twice a day, having a plan for power outages, and placing bottles of water in each unit to help keep temperatures consistent. The temperature of the refrigerator and freezer should be consistent and not fluctuate.

466. The clinic nurse is assessing a child who is sched- uled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. 1. The child has symptoms of a cold. 2. The child had a previous anaphylactic reaction to the vaccine. 3. The mother reports that the child is having intermittent episodes of diarrhea. 4. The mother reports that the child has not had an appetite and has been fussy. 5. The child has a disorder that caused a severely deficient immune system. 6. The mother reports that the child has recently been exposed to an infectious disease.

2. The child had a previous anaphylactic reaction to the vaccine. 5. The child has a disorder that caused a severely deficient immune system. The general contraindications for receiving live virus vaccines include a previous anaphylactic reaction to a vaccine or a component of a vaccine. In addition, live virus vaccines generally are not administered to individuals with a severely deficient immune system, individuals with a severe sensitivity to gelatin, or pregnant women. A vaccine is administered with caution to an individual with a moderate or severe acute illness, with or without fever. Options 1, 3, 4, and 6 are not contraindications to receiving a vaccine.

The nurse is teaching the parents of a group of cardiac patients. Which teaching guideline will the nurse include for any child who has undergone cardiac surgery? 1. The child should be restricted from most play activities. 2. The child should be evaluated to determine if prophylactic antibiotics for dental, oral, or upper-respiratory-tract procedures are necessary. 3. The child should not receive routine immunizations. 4. The child can be expected to have a fever for several weeks following the surgery.

2. The child should be evaluated to determine if prophylactic antibiotics for dental, oral, or upper-respiratory-tract procedures are necessary. Parents should be taught that the child may need prophylactic antibiotics for some dental procedures, according to the American Heart Association, to prevent endocarditis. The child should live a normal and active life following repair of a cardiac defect. Immunizations should be provided according to the schedule, and any unexplained fever should be reported.

A parent brings her school-age child to the clinic because the child has a temperature of 100.2F. The child remains active without other symptoms. Which statement by the nurse to the parents is most appropriate? 1. Take the childs temperature every 2 hours and call the clinic if it reaches 102F or above. 2. Unless the fever bothers the child, it is best to let the natural body defenses respond to the infection. 3. Keep the child warm, because shivering often occurs with fever. 4. Alternate acetaminophen and ibuprofen to help keep the fever down and keep the child comfortable.

2. Unless the fever bothers the child, it is best to let the natural body defenses respond to the infection. Fever is the bodys response to an infection, and is not a disease. Allowing the bodys natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, etc. Taking the childs temperature more than every 46 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.

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

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

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

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

446. The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse should make which response? 1. "Avoid all exercise during painful periods." 2. "Range-of-motion exercises must be performed every day." 3. "Have the child perform simple isometric exercises during this time." 4. "Administer additional pain medication before performing range-of-motion exercises."

3. "Have the child perform simple isometric exercises during this time. Juvenile idiopathic arthritis is an autoimmune inflammatory disease affecting the joints and other tissues, such as articular cartilage. During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain. Although resting the extremity is appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important. These exercises do not involve joint movement.

451. Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder? 1. "Treatment needs to be started as soon as possible." 2. "I realize my infant will require follow-up care until fully grown." 3. "I need to bring my infant back to the clinic in 1 month for a new cast." 4. "I need to come to the clinic every week with my infant for the casting."

3. "I need to bring my infant back to the clinic in 1 month for a new cast." Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

448. The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? 1. "I will encourage my child to perform prescribed exercises." 2. "I will have my child wear soft fabric clothing under the brace." 3. "I should apply lotion under the brace to prevent skin breakdown." 4. "I should avoid the use of powder because it will cake under the brace."

3. "I should apply lotion under the brace to prevent skin breakdown." A brace may be prescribed to treat scoliosis. Braces are not curative, but may slow the progression of the curvature to allow skeletal growth and maturity. The use of lotions or powders under a brace should be avoided because they can become sticky and cake under the brace, causing irritation. Options 1, 2, and 4 are appropriate interventions in the care of a child with a brace.

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

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

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

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

The nurse is teaching family members how to care for their infant in a Pavlik harness to treat congenital developmental dysplasia of the hip. Which statement will the nurse include in the teaching session? 1. Apply lotion or powder to minimize skin irritation. 2. Put clothing over the harness for maximum effectiveness of the device. 3. Check at least two or three times a day for red areas under the straps. 4. Place a diaper over the harness, preferably using a thin, superabsorbent, disposable diaper.

3. Check at least two or three times a day for red areas under the straps. The brace should be checked two or three times for red areas under the straps. Lotion or powder can contribute to skin breakdown. A light layer of clothing should be under the brace, not over. The diaper should also be under the brace.

The nurse is providing discharge teaching to a school-age client who was recently diagnosed with a latex allergy. Which product will the nurse educate the client and family to avoid? 1. Plastic bottles 2. Footballs 3. Chewing gum 4. Paper bags

3. Chewing gum When a child is diagnosed with a latex allergy, it is essential for the nurse to educate both the child and the family regarding sources of latex within the home and the community. The child and family should be educated to avoid chewing gum as it contains latex. The other items do not contain latex and do not pose a risk for this child in the community.

414. On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? 1. Cracked lips 2. Normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin

3. Conjunctival hyperemia Kawasaki disease, also known as mucocutaneous lymph node syndrome, is an acute systemic inflammatory illness. In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.

417. The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances

3. Exercise intolerance Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. Achild with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.

The nurse is caring for the 5-year-old just diagnosed with von Willebrand disease after a tooth extraction with increased bleeding. The family asks the nurse how the signs and symptoms of von Willebrand disease are manifested. What will the nurse tell the family? Select all that apply. 1. Decreased partial thromboplastin time 2. Factor VI deficiency 3. Frequent nosebleeds 4. Bleeding from mucous membranes 5. Frequent bruising

3. Frequent nosebleeds 4. Bleeding from mucous membranes 5. Frequent bruising Characteristic manifestations are prolonged and excessive mucocutaneous bleeding, in children this is exhibited through gingival bleeding, epistaxis, menorrhagia, bruising, and minor wounds or lacerations.

A toddler client with a fever is prescribed amoxicillin clavulanate 250 mg/5 cc three times daily by mouth 10 days for otitis media. Which teaching point will guard against antibiotic resistance to the disease process? 1. Administer a loading dose for the first dose. 2. Measure the prescribed dose in a household teaspoon. 3. Give the antibiotic for the full 10 days. 4. Stop the antibiotic if the child is afebrile.

3. Give the antibiotic for the full 10 days. Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon may contain less than 5 cc, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. The absence of a fever is not an indication that all bacteria are killed or not reproducing.

Which athletic activity can the nurse recommend for a school-age client with pulmonary-artery hypertension? 1. Cross-country running 2. Soccer 3. Golf 4. Basketball

3. Golf A child with pulmonary-artery hypertension should have exercise tailored to avoid dyspnea. Golf would require less exertion than soccer, basketball, or cross-country running.

The hospital has just provided its nurses with information about biologic threats and terrorism. After completing the course, a group of nurses is discussing its responsibility in relation to bioterrorism. Which statement by the nurse indicates a correct understanding of the concepts presented? 1. It is important to separate clients according to age and illness to prevent the spread of disease. 2. It is important to dispose blood-contaminated needles in the lead-lined container. 3. I will notify the Centers for Disease Control (CDC) if a large number of persons with the same life-threatening infection present to the emergency room. 4. I will initiate isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA).

3. I will notify the Centers for Disease Control (CDC) if a large number of persons with the same life-threatening infection present to the emergency room. The CDC must be contacted to investigate the source of serious infections and to determine if a bioterrorist threat exists. Separating clients according to age and illness to prevent the spread of disease will do nothing to stop terrorism. Proper disposal of blood-contaminated needles in the sharps container and initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) are appropriate nursing actions but do not relate to bioterrorism

449. The nurse is assisting a health care provider (HCP) examining a 3-week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the HCP to assess? 1. Babinski's sign 2. The Moro reflex 3. Ortolani's maneuver 4. The palmar-plantar grasp

3. Ortolani's maneuver In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Ortolani's maneuver is a test to assess for hip instability and can be done only before 4 weeks of age. The examiner abducts the thigh and applies gentle pressure forward over the greater trochanter. A "clicking" sensation indicates a dislocated femoral head moving into the acetabulum. Babinski's sign is abnormal in anyone older than 2 years of age and indicates central nervous system abnormality. The Moro reflex is normally present at birth but is absent by 6 months; if still present at 6 months, there is an indication of neurological abnormality. The palmar-plantar grasp is pre- sent at birth and lessens within 8 months.

A nurse notes blue sclerae during a newborn assessment. Which item will the newborn require further assessment for based on this finding? 1. Marfan syndrome 2. Achondroplasia 3. Osteogenesis imperfecta 4. Muscular dystrophy

3. Osteogenesis imperfecta Clinical manifestations of osteogenesis imperfecta include blue sclerae. This is not present in Marfan syndrome, achondroplasia, or muscular dystrophy

The student nurse is learning a lesson about communicable diseases and how they are spread. On a quiz the next day the nurse uses the information learned in this lesson and demonstrates learning. For a communicable disease to occur what factors must be in place? Select all that apply. 1. Antibodies 2. Toxoid 3. Pathogen 4. Transmission 5. Host

3. Pathogen 4. Transmission 5. Host For a communicable disease to occur, three factors need to be in place: an infectious agent or pathogen, means of transmission, and a host. This is not a factor needed for communicable disease to occur.

The nurse is discussing ways to treat fever in the home environment to a group of parents in the community. Which statement is appropriate for the nurse to include in the presentation? 1. Ibuprofen is the only effective means to reduce fever. 2. If the child requires more than one dose of acetaminophen antibiotics are needed. 3. Purchase a new bottle of acetaminophen for your newborn because it will have recommended medication concentration. 4. It is not necessary to follow the recommendations on the bottle of ibuprofen as this will not prevent an overdose for your child.

3. Purchase a new bottle of acetaminophen for your newborn because it will have recommended medication concentration. The recommendation to purchase a new bottle of acetaminophen due to recommended medication concentrations is an appropriate statement for the nurse to include in the teaching session. The other statements are inaccurate or inappropriate for the nurse to include in the teaching session

A child is prescribed Didanosine (Videx), a nucleoside reverse transcriptase inhibitor, for human immunodeficiency virus (HIV). Which lab value will the nurse monitor closely for this child? 1. Potassium 2. Sodium 3. Red blood cell count 4. Glucose

3. Red blood cell count Didanosine (Videx) causes bone-marrow suppression with resulting anemia. Red blood cell counts are monitored at least monthly for changes. Potassium and sodium are electrolytes, and glucose is a laboratory test for checking diabetes. Didanosine (Videx) does not affect these values.

The school nurse is trying to prevent the spread of a flu virus through the school. Which infection-control strategies can be employed to prevent the spread of the flu virus? Select all that apply. 1. Teaching parents safe food preparation and storage 2. Withholding immunizations for children with compromised immune systems 3. Sanitizing toys, telephones, and door knobs to kill pathogens 4. Separating children with infections from children who are well 5. Teaching children to wash their hands after using the bathroom

3. Sanitizing toys, telephones, and door knobs to kill pathogens 4. Separating children with infections from children who are well 5. Teaching children to wash their hands after using the bathroom To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

A nurse begins an infusion of intravenous immune globulin (IVIG) to a child who has combined immunodeficiency disease. Which assessment finding indicates that the nurse should stop the infusion? 1. A mild headache 2. Clear yellow urine 3. Severe shaking, chills, and fever 4. Complaints of being thirsty

3. Severe shaking, chills, and fever Hypersensitivity reaction can be seen with IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction. A mild headache is an adverse side effect of IVIG but not a severe reaction. Thirst is not an indication of a reaction. Voiding clear yellow urine is a normal finding.

The nurse is providing care to an adolescent client diagnosed with systemic lupus erythematosus (SLE). Which action by the client indicates acceptance of body changes associated with SLE? 1. She refuses to attend school. 2. She doesnt want to attend any social functions. 3. She discusses the body changes with a peer. 4. She discusses the body changes with healthcare personnel only.

3. She discusses the body changes with a peer. Peer interaction is important to the teen. Being able to discuss the changes to her body with a peer indicates acceptance of the change in body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to body-image changes. Refusing to go to school or not going to social functions indicates nonacceptance of the changes to body image.

A school-age child diagnosed with rheumatoid arthritis asks the nurse to recommend an exercise activity. Which activity is most appropriate for this child? 1. Softball 2. Football 3. Swimming 4. Basketball

3. Swimming Swimming helps to exercise all of the extremities without putting undue stress on joints. Softball, football, and basketball could exacerbate joint discomfort.

412. The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? 1. Pallor 2. Cough 3. Tachycardia 4. Slow and shallow breathing

3. Tachycardia HF is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in HF as a result of mucosal swelling and irritation, but is not an early sign. Pallor may be noted in an infant with HF, but is not an early sign.

A child has been admitted to the hospital unit in congestive heart failure (CHF). Which symptom would the nurse anticipate upon assessment of the child? 1. Weight loss 2. Bradycardia 3. Tachycardia 4. Increased blood pressure

3. Tachycardia Tachycardia is a sign of congestive heart failure because the heart attempts to improve cardiac output by beating faster. Bradycardia is a serious sign and can indicate impending cardiac arrest. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.

A nurse is providing information to a group of new mothers. Which statement best explains why newborns and young infants are more susceptible to infection? 1. They have high levels of maternal antibodies to diseases to which the mother has been exposed. 2. They have passive transplacental immunity from maternal immunoglobulin G. 3. They have immune systems that are not fully mature at birth. 4. They have been exposed to microorganisms during the birth process.

3. They have immune systems that are not fully mature at birth. Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection. Newborns and young infants high levels of maternal antibodies, passive transplacental immunity, and exposure to microorganisms during the birth process are all true but are incorrect answers because they do not explain the susceptibility of newborns and young infants to infection.

419. Achild with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Did the child have a sore throat or fever within the last 2 months?"

4. "Did the child have a sore throat or fever within the last 2 months?" Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. Rheumatic fever characteristically manifests 2 to 6 weeks after an untreated or partially treated group A β-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to rheumatic fever.

415. The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? 1. "I will not mix the medication with food." 2. "I will take my child's pulse before administering the medication." 3. "If more than 1 dose is missed, I will call the health care provider." 4. "If my child vomits after medication administration, I will repeat the dose."

4. "If my child vomits after medication administration, I will repeat the dose." Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. In addition, the parents should be instructed that if a dose is missed and is not identified until 4 hours later, the dose should not be administered.

The nurse is checking peripheral perfusion to a childs extremity following a cardiac catheterization. Which assessment finding indicates adequate peripheral circulation to the affected extremity? 1. A capillary refill of greater than three seconds 2. A palpable dorsalis pedis pulse but a weak posterior tibial pulse 3. A decrease in sensation with a weakened dorsalis pedis pulse 4. A capillary refill of less than three seconds with palpable warmth

4. A capillary refill of less than three seconds with palpable warmth The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color. If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation may not be adequate.

A toddler is started on digoxin (Lanoxin) for cardiac failure. Which is the initial symptom the nurse would assess if the child develops digoxin (Lanoxin) toxicity? 1. Lowered blood pressure 2. Tinnitus 3. Ataxia 4. A change in heart rhythm

4. A change in heart rhythm An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm. Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in the ears), or ataxia (unsteady gait).

464. A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a his- tory of a severe allergy to which substance? 1. Eggs 2. Pen icillin 3. Sulfonamides 4. A previous dose of hepatitis B vaccine or component

4. A previous dose of hepatitis B vaccine or component A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to a previous dose of hepatitis B vaccine or to a component (aluminum hydroxide or yeast protein) of the vaccine. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.

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

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

413. The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? 1. Immunoglobulin 2. Red blood cell count 3. White blood cell count 4. Anti-streptolysin O titer

4. Anti-streptolysin O titer Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. A diagnosis of rheumatic fever is confirmed by the presence of 2 major manifestations or 1 major and 2 minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive anti-streptolysin O titer, Streptozyme assay, or anti-DNase B assay. Options 1, 2, and 3 would not help to confirm the diagnosis of rheumatic fever.

A school-age client is admitted to the hospital with osteomyelitis. Which statement regarding the treatment of osteomyelitis is most appropriate for the nurse to share with the parents? 1. Cultures should be done immediately after the first dose of antibiotic infuses. 2. Antibiotics are ineffective against this virus. 3. Methicillin is the antibiotic of choice. 4. Antibiotic therapy should continue for 36 weeks.

4. Antibiotic therapy should continue for 36 weeks. Medical management of osteomyelitis begins with intravenous administration of a broad-spectrum antibiotic. Antibiotic therapy should continue for 36 weeks. Cultures are always done before an antibiotic is started. Methicillin is not the drug of choice.

463. An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent? 1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. 3. Apply a hot pack to the injection site. 4. Apply a cold pack to the injection site.

4. Apply a cold pack to the injection site On occasion, tenderness, redness, or swelling may occur at the site of the DTaP injection. This can be relieved with cold packs for the first 24 hours, followed by warm or cold compresses if the inflammation persists. Bringing the infant back to the clinic is unnecessary. Option 1 may be an appropriate intervention, but is not specific to the subject of the question, a localized reaction at the injection site. Hot packs are not applied and can be harmful by causing burning of the skin.

The nurse finds that an infant has stronger pulses in the upper extremities than in the lower extremities, and higher blood pressure readings in the arms than in the legs. Which assessment will the nurse perform next on this infant? 1. Pedal pulses 2. Pulse oximetry level 3. Hemoglobin and hematocrit values 4. Blood pressure of the four extremities

4. Blood pressure of the four extremities Coarctation of the aorta can present with stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs because of obstruction of circulation to the lower extremities. Blood pressure values of the four limbs should be the next assessment data collected. Pedal pulses, pulse oximetry, and labs themselves will not provide the data needed.

444. A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention? 1. Ensure that all ropes are outside the pulleys. 2. Ensure that the weights are resting lightly on the floor. 3. Restrict diversional and play activities until the child is out of traction. 4. Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied.

4. Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied. When a child is in traction, the nurse would check the HCP's prescription to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as prescribed, ensure that the weights hang freely, check the ropes for fraying and ensure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms of immobilization. The nurse would provide therapeutic and diversional play activities for the child.

465. A parent brings her 4-month-old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant? 1. Varicella, hepatitis B vaccine (HepB) 2. Diphtheria, tetanus, acellular pertussis (DTaP); measles, mumps, rubella (MMR); inactivated poliovirus vaccine (IPV) 3. MMR, Haemophilus influenzae type b (Hib), DTaP 4. DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus vaccine (RV)

4. DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus vaccine (RV) DTaP, Hib, IPV, PCV, and RV are administered at 4 months of age. DTaP is administered at 2, 4, and 6 months ofage;at15to18monthsofage;andat4to6yearsofage.Hib is administered at 2, 4, and 6 months of age and at 12 to 15 months of age. IPV is administered at 2, 4, and 6 months of age and at 4 to 6 years of age. PCV is administered at 2, 4, and 6 months of age and at 12 to 15 months of age. The first dose of MMR vaccine is administered at 12 to 15 months of age; the second dose is administered at 4 to 6 years of age (if the second dose was not given by 4 to 6 years of age, it should be given at the next visit). The first dose of HepB is administered at birth, the second dose is administered at 1 month of age, and the third dose is administered at 6 months of age. Varicella-zoster vaccine is administered at 12 to 15 months of age and again at 4 to 6 years of age.

447. A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action? 1. Administer an antiemetic. 2. Increase the intravenous fluids. 3. Place the child in a Sims'position. 4. Notify the health care provider (HCP)

4. Notify the health care provider (HCP) Scoliosis is a three-dimensional spinal deformity that usually involves lateral curvature, spinal rotation resulting in rib asymmetry, and hypokyphosis of the thorax. A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child's abdominal contents, resulting from lengthening of the child's body. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or children who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Options 1, 2, and 3 are incorrect.

A mother refuses to have her child be immunized with measles, mumps, and rubella (MMR) vaccine because she believes that letting her infant get these diseases will help him fight off other diseases later in life. Which response by the nurse is most appropriate? 1. Honor her request because she is the parent. 2. Explain that antibodies can fight many diseases. 3. Tell her that not immunizing her infant may protect pregnant women. 4. Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases.

4. Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases. Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Honoring her request is not correct because the nurse has a professional duty to explain that the mothers belief about immunizations is erroneous and may result in harm to her infant. Explaining that antibodies can fight many diseases is not correct because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease. Telling her that not immunizing her infant may protect pregnant women is not correct because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.

A parent reports that her school-age child, who has had all recommended immunizations, had a mild fever one week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. Which disease process does the nurse suspect based on the parents description? 1. Chicken pox (varicella) 2. German measles (rubella) 3. Roseola (exanthem subitum) 4. Fifth disease (erythema infectiosum)

4. Fifth disease (erythema infectiosum) Fifth disease manifests first with a flulike illness, followed by a red slapped-cheek sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. The rash of varicella progresses from papules to vesicles to pustules. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.

356. The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction? 1. Stress 2. Trauma 3. Infection 4. Fluid overload

4. Fluid overload Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency; these include vaso-occlusive crisis, splenic sequestration, hyperhemolytic crisis, and aplastic crisis. Sickle cell crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 11⁄2 to 2 times the daily requirement to prevent dehydration.

The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis (DTaP) and second inactivated polio vaccine (IPV) immunization injections for an infant who is 4 months old. The nurse may also give which of immunizations during the same well-child-care appointment? 1. Var (varicella) 2. TIV (influenza) 3. MMR (measles, mumps, rubella) 4. Haemophilus influenza type B (HIB)

4. Haemophilus influenza type B (HIB) Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 1215 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 1215 months and 46 years of age (two doses). Varicella (Var) is given at 1218 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 48 weeks apart.

A child returns from spinal-fusion surgery. Which item is the priority assessment for this child? 1. Increased intracranial pressure 2. Seizure activity 3. Impaired pupillary response during neurological checks 4. Impaired color, sensitivity, and movement to lower extremities

4. Impaired color, sensitivity, and movement to lower extremities When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities. The other signs are neurological impairment and are not high risk with spinal surgery.

Reducing the number of preventable childhood illnesses is a major national goal in Healthy People 2020. What will the school nurse teach families regarding immunizations in order to reach this goal? 1. A minor illness with a low-grade fever is a contraindication to receiving an immunization according to Healthy People 2020. 2. Vaccines should be given one at a time for optimum active immunity in the prevention of illness and disease. 3. Premature infants and low-birth-weight infants should receive half doses of vaccines for protection from communicable diseases. 4. It is important to maintain vaccination coverage for recommended vaccines in early childhood and to maintain them through kindergarten.

4. It is important to maintain vaccination coverage for recommended vaccines in early childhood and to maintain them through kindergarten. The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.

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

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

443. A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take? 1. Administer an analgesic. 2. Release the skin traction. 3. Apply ice to the extremity. 4. Notify the health care provider (HCP).

4. Notify the health care provider (HCP). An absent pulse to an extremity of the affected limb after a bone fracture could mean that the child is developing or experiencing compartment syndrome. This is an emergency situation, and the HCP should be notified immediately. Administering analgesics would not improve circulation. The skin traction should not be released without an HCP's prescription. Applying ice to an extremity with absent perfusion is incorrect. Ice may be prescribed when perfusion is adequate to decrease swelling.

The hospital admitting nurse is taking a history of a childs illness from the parents. The nurse concludes that the parents treated their 6-year-old child appropriately for a fever related to otitis media. Which action by the parents brought the nurse to this conclusion? 1. Used aspirin every four hours to reduce the fever 2. Alternated acetaminophen with ibuprofen every two hours 3. Put the child in a tub of cold water to reduce the fever 4. Offered generous amounts of fluids frequently

4. Offered generous amounts of fluids frequently The bodys need for fluids increases during a febrile illness. Aspirin has been associated with Reyes syndrome and should not be given to children with a febrile illness. Alternating acetaminophen with ibuprofen every two hours may result in an overdose. Pediatric medication doses are more accurately calculated using the childs weight, not age. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.

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

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

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

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

379. The nurse has just administered ibuprofen to a child with a temperature of 102 °F (38.8 °C). The nurse should also take which action? 1. Withhold oral fluids for 8 hours. 2. Sponge the child with cold water. 3. Plan to administer salicylate in 4 hours. 4. Remove excess clothing and blankets from the child.

4. Remove excess clothing and blankets from the child. After administering ibuprofen, excess clothing and blankets should be removed. The child can be sponged with tepid water but not cold water, because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin is not administered to a child with fever because of the risk of Reye's syndrome. Fluids should be encouraged to prevent dehydration, so oral fluids should not be withheld.

420. A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? 1. During sleep 2. When changing the infant's diapers 3. When the mother is holding the infant 4. When drawing blood for electrolyte level testing

4. When drawing blood for electrolyte level testing Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options 1, 2, and 3 are not likely to produce crying in the infant.

A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect resulting in congestive heart failure. Which clinical signs would most likely be present? A. Tachypnea B. Weight gain C. Decreased systolic pressure D. Irregular WBC lab values

A. Tachypnea or B. Weight gain Pulmonary blood volume overload associated with congenital heart defects is a common cause of CHF.

A parent of a child with cyanotic heart defects expresses concerns regarding potential developmental problems due to lack of oxygen to the brain. Which is the most appropriate response by the nurse? A. "Regular developmental screening is needed to prior to starting school." B. "Speech therapy might be needed." C. "Physical therapy might be needed." D. "Expressive therapy might be needed."

A. "Regular developmental screening is needed to prior to starting school." Regular developmental screenings are needed to identify the specific neurodevelopmental problems that a child could have prior to school entry. Children with complex CHD may need an individualized education plan when disabilities affect learning.

Which should the nurse expect to note as a frequent complication for a child with increased pulmonary blood flow congenital heart disease? A. Susceptibility to respiratory infections B. Bleeding tendencies C. Frequent vomiting and diarrhea D. Seizure disorder

A. Susceptibility to respiratory infections Children with congenital heart disease are more prone to respiratory infections due to increased volume in the lungs which can provide a moist environment for bacterial growth

A parent asks the nurse why limiting the amount of time the infant feeds is important in the care of the infant with congestive heart failure. Which response by the nurse is the most appropriate? A. "Resting is essential in the care of the newborn with congestive heart failure." B. "Extending feeding time consumes calories required for the infant to gain weight." C. "Calories are not a major concern in congestive heart failure." D. "Limiting fluids is necessary in congestive heart failure."

B. "Extending feeding time consumes calories required for the infant to gain weight." An infant with congestive heart failure requires more calories than a healthy infant does. Prolonged feedings use more calories and increase the workload of the heart.

A child with Kawasaki disease has been ordered to receive aspirin therapy. The parents are distraught as their pediatrician told them to never give aspirin to their child. What is the nurse's best response? A. "You are correct, the doctor must have made a mistake." B. "Low dose aspirin therapy is given to prevent clot formation until the platelet count returns to normal." C. "Aspirin therapy is necessary to prevent a heart attack." D. "Aspirin therapy replaces immunoglobulin therapy."

B. "Low dose aspirin therapy is given to prevent clot formation until the platelet count returns to normal." Lower dose aspirin (2-5 mg/kg/day) is administered once the child is afebrile for 2-3 days to reduce/prevent clot formation until platelets return to normal levels.

A child with tetralogy of Fallot squats in a knee chest position. The purpose of this knee chest position is to: A. Promote blood flow to the extremities with increased cardiac output. B. Decrease systemic venous return and increase blood flow to the lungs. C. Decrease systemic vascular resistance to improve cardiac function. D. To prevent bradycardia from occurring.

B. Decrease systemic venous return and increase blood flow to the lungs. The knee chest position relieves dyspnea with a decrease in cardiac output due to decreased blood return from the lower extremities and increased systemic vascular resistance and an increase in pulmonary blood flow.

A preschooler has been diagnosed with Kawasaki disease. The parents ask if cleaning their carpets caused this disease. The nurse's best response would be: A. "Yes, it is caused by wet carpets after they have been cleaned." B. "It is an inherited disorder so one of you parents must have had the disease as a child." C. "The underlying cause is largely unknown but it is thought to be triggered by an infection." D. "No, that is not possible. It is caused solely by genetic factors."

C. "The underlying cause is largely unknown but it is thought to be triggered by an infection." The etiology of Kawasaki disease is unknown but is thought to be caused by or related to an infectious agent that has not yet been identified. The disorder appears to result in an exaggerated immune response to an infection in a genetically susceptible child.

Which would be an appropriate nursing diagnosis for a child hospitalized with congestive heart failure? A. Readiness for Enhanced Nutrition B. Fluid Volume Deficit C. Cardiac Output, decreased D. Activity Intolerance

C. Cardiac Output, decreased or D. Activity Intolerance Cardiac output is decreased related to the cardiac anomaly that is resulting in increased pulmonary blood flow.

When planning teaching interventions for a child who has just undergone a cardiac catheterization and is being discharged home, it is a priority to teach parents to monitor for: (Select all that apply.) A. Developmental delays B. Nutritional needs C. Signs of infection D. Bleeding

C. Signs of infection D. Bleeding Notify the healthcare provider if bleeding or a bruise increasing in size at the catheterization site. Foot on side of catheterization is cooler than other foot. Loss of feeling in foot on side of catheterization. Fever. pg 525 Families Want to Know box

A 2-year-old child with tetralogy of Fallot becomes upset during a routine blood draw. The child turns blue and the respiratory rate increases to 45 breaths per minute. Which of the following interventions should the nurse do first? A. Notify the provider and request sedation. B. Assess for irregular heart rhythm and rate. C. Reassure the child that the pain will be mild. D. Position the child with the knees to the chest.

D. Position the child with the knees to the chest. Hypoxic or hypercyanotic episodes are treated aggressively. Place child in knee chest position. Reduce any irritating or painful stimuli and try to calm the child.

MCN 374 EXAM 2: Ch 16, 21, 22, 23, 29

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