pediatric exam 4

A child is brought to the emergency department after being accidentally struck in the lower back region with a baseball bat. When gathering assessment data, the nurse discovers that the child has hemophilia. The nurse should immediately assess for which data? 1.Slurred speech 2.Presence of hematuria 3.Complaints of headache 4.Change in respiratory rate

2 Rationale:Because the kidneys are located in the flank region of the body, trauma to the back area can cause hematuria, particularly in a child with hemophilia. The nurse would be most concerned about the child's airway and respiratory rate if the child had sustained an injury to the neck region. Slurred speech and headache are associated with head trauma.

Laboratory studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia? 1.Elevated hemoglobin level 2.Decreased reticulocyte count 3.Elevated red blood cell count 4.Red blood cells that are microcytic and hypochromic

4 Rationale:In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. The results of a complete blood cell count in children with iron deficiency anemia show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

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 Rationale: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 1½ to 2 times the daily requirement to prevent dehydration.

Oral iron supplements are prescribed for a 6-year-old child with iron deficiency anemia. Which beverage is the best option to recommend with iron administration? 1.Milk 2.Water 3.Apple juice 4.Orange juice

4 Rationale:Vitamin C (ascorbic acid) increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or juice high in vitamin C. From the options presented, the correct option is the only one that identifies the food highest in vitamin C.

A school-age child with Down syndrome is brought to the ambulatory care center by the mother. The child has bruising all over the body. To work most effectively with this child, the nurse first addresses which complication associated with Down syndrome? 1.Children with Down syndrome are more likely to develop acute leukemia than the average child. 2.Children with Down syndrome fall down easily as a result of hyperflexibility and muscle weakness. 3.Children with Down syndrome are at risk for physical abuse because of their low intellectual functioning. 4.Children with Down syndrome scratch themselves a lot because of dry, cracked, and frequently fissuring skin.

1 Rationale:Children with Down syndrome have an increased risk for developing leukemia compared with the average child. The other statements also could be true, but the nurse should first gather baseline data to determine the cause of the bruising before making other assumptions.

The mother of a 4-year-old child tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms' tumor, should avoid which during the physical assessment? 1.Palpating the abdomen for a mass 2.Assessing the urine for the presence of hematuria 3.Monitoring the temperature for the presence of fever 4.Monitoring the blood pressure for the presence of hypertension

1 Rationale:Wilms' tumor is the most common intraabdominal and kidney tumor of childhood. If Wilms' tumor is suspected, the tumor mass should not be palpated by the nurse. Excessive manipulation can cause seeding of the tumor and spread of the cancerous cells. Hematuria, fever, and hypertension are clinical manifestations associated with Wilms' tumor.

The nurse is caring for a 3-year-old boy with a diagnosis of acute lymphocytic leukemia. The child is crying and complaining that his knees hurt. Which nursing intervention is most appropriate? 1.Administer acetaminophen to the child. 2.Involve the child in a diversional activity. 3.Ask the child if he would like a "baby aspirin." 4.Apply heat to the child's knees and elevate the knees on a pillow.

1 Rationale:Acetaminophen is acceptable and does not have anticoagulant properties. Diversional activities would not relieve the pain. Aspirin is not administered to the child with acute lymphocytic leukemia (ALL) because of its anticoagulant properties, and administering aspirin could lead to bleeding in the joints. Heat also would increase the pain by increasing circulation to the area.

The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child? 1.Platelet count 2.Hematocrit level 3.Hemoglobin level 4.Partial thromboplastin time

4 Rationale:Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Abnormal laboratory results in hemophilia indicate a prolonged partial thromboplastin time. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia

The mother of a 4-year-old child tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment of subjective data, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms' tumor, should avoid which during the physical assessment? 1.Palpating the abdomen for a mass 2.Assessing the urine for the presence of hematuria 3.Monitoring the temperature for the presence of fever 4.Monitoring the blood pressure for the presence of hypertension

1 Rationale:Wilms' tumor is the most common intraabdominal and kidney tumor of childhood. If Wilms' tumor is suspected, the tumor mass should not be palpated by the nurse. Excessive manipulation can cause seeding of the tumor and spread of the cancerous cells. Hematuria, fever, and hypertension are clinical manifestations associated with Wilms' tumor.

The nurse is reviewing the laboratory and diagnostic test results of a 5-year-old child scheduled to be seen in the clinic. The nurse notes that the health care provider documented that diagnostic studies revealed the presence of Reed-Sternberg cells. The nurse prepares to assist the health care provider to discuss which initial procedure with the parents? 1.Chemotherapy 2.Surgical biopsy 3.High-dose radiation 4.Intravenous antibiotics

1 Rationale:Hodgkin's disease is a neoplasm of lymphatic tissue. The presence of giant, multinucleated cells (Reed-Sternberg cells) is the hallmark of this disease. Initially the nurse should prepare the child for diagnostic procedures and a surgical biopsy. Once Hodgkin's disease is confirmed, induction chemotherapy is then begun as soon as the child is stable and staging of the disease has been completed. High-dose radiation may be used if the disease is detected in a single site or in full-grown adolescents but usually is not the initial treatment in small children. Hodgkin's disease is cancer, not a bacterial infection.

The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 × 109/L). On the basis of this laboratory result, which intervention should the nurse include in the plan of care? 1.Initiate bleeding precautions. 2.Monitor closely for signs of infection. 3.Monitor the temperature every 4 hours. 4.Initiate protective isolation precautions.

1 Rationale:Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). If a child is severely thrombocytopenic and has a platelet count less than 20,000 mm3 (20.0 × 109/L), bleeding precautions need to be initiated because of the increased risk of bleeding or hemorrhage. Precautions include limiting activity that could result in head injury, using soft toothbrushes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories, enemas, and rectal temperatures are avoided. Options 2, 3, and 4 are related to the prevention of infection rather than bleeding.

The nurse instructs the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement, if made by the parent, indicates a need for further instructions? 1."I will take a rectal temperature daily." 2."I will inspect the skin daily for redness." 3."I will inspect the mouth daily for lesions." 4."I will perform proper hand washing techniques."

1 Rationale:Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. The risk of injury to fragile mucous membranes and resultant bleeding is so high in the child with leukemia that tympanic or axillary temperatures should be taken. In addition, rectal abscesses can occur easily to damaged rectal tissue. No rectal temperatures should be taken. In addition, oral temperature taking should be avoided, especially if the child has oral ulcers. All other options are appropriate measures to prevent infection.

The nurse has reviewed the health care provider's prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. What should the nurse expect to do next to assist in confirming the diagnosis? 1.Collect a 24-hour urine sample. 2.Perform a neurological assessment. 3.Assist with a bone marrow aspiration. 4.Send to the radiology department for a chest x-ray.

1 Rationale:Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically, the tumor infringes on adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated vanillylmandelic acid levels. A bone marrow aspiration will assist in determining marrow involvement. A neurological examination and a chest x-ray may be performed but will not confirm the diagnosis.

Oral iron is prescribed for a child with iron deficiency anemia. The nurse provides instructions to the mother regarding the administration of the iron. The nurse should instruct the mother to administer the medication in which way? 1.Between meals 2.Just before a meal 3.Just after the meal 4.With a fruit low in vitamin C

1 Rationale:The mother should be instructed to administer oral iron supplements between meals. The iron should be given with a citrus fruit or juice high in vitamin C because vitamin C increases the absorption of iron by the body.

The home care nurse is providing safety instructions to the mother of a child with hemophilia. Which instruction should the nurse include to promote a safe environment for the child? 1.Eliminate any toys with sharp edges from the child's play area. 2.Allow the child to use play equipment only when a parent is present. 3.Allow the child to play indoors only, and avoid any outdoor play or playgrounds. 4.Place a helmet and elbow pads on the child every day as soon as the child awakens.

1 Rationale:The nurse should instruct the mother to remove toys with sharp edges that may cause injury from the child's play area. It is not necessary to restrict play if safety measures have been implemented. It is not necessary that the child be restricted from outdoor play activity, but the activities that the child participates in should be monitored. Requiring that the child wear a helmet and elbow pads immediately on awakening and throughout the day is not necessary; however, these items should be worn during activities that could cause injury.

Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents should include which intervention? 1.Restrict oral fluids. 2.Use good hand washing technique. 3.Give immunizations appropriate for age. 4.Institute strict isolation with no visitors allowed.

2 Rationale:A child with myelosuppression is at risk for infection. Good hand washing technique is necessary to prevent the spread of infection. Restricting oral fluids would not be an intervention to reduce the risk of infection and could actually be harmful to the child. Live virus vaccines are not given when the child is myelosuppressed, so assessment of the child's immune status should be done before administration of immunizations appropriate for age. Strict isolation without visitors is not warranted, although visitors should wear a mask and gloves while in the child's room.

A 13-year-old child is diagnosed with Ewing's sarcoma of the femur. After a course of radiation and chemotherapy, it was decided that leg amputation is necessary. After the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which nursing statement is most appropriate to assist in alleviating the child's fear? 1."The pain medication that I give you will take these feelings away." 2."This aching and cramping is normal and temporary and will subside." 3."This pain is not real pain, and relaxation exercises will help it go away." 4."This normally occurs after the surgery, and we will teach you ways to deal with it."

2 Rationale:After amputation, phantom limb pain is a temporary condition that some children experience. This sensation of burning, aching, or cramping in the missing limb is distressing to the child. The child needs to be reassured that the condition is normal and only temporary. All other options are not appropriate responses to the child, as they are incorrect or inappropriate statements.

A child's fasting blood glucose levels range between 100 and 120 mg/dL (5.7 and 6.9 mmol/L) daily. The before-dinner blood glucose levels are between 120 and 130 mg/dL (6.9 and 7.4 mmol/L), with no reported episodes of hypoglycemia. Mixed insulin is administered before breakfast and before dinner. The nurse should make which interpretation about these findings? 1.Exercise should be increased to reduce blood glucose levels. 2.Insulin doses are appropriate for food ingested and activity level. 3.Dietary needs are being met for adequate growth and development. 4.Dietary intake should be increased to avoid hypoglycemic reactions.

2 Rationale:Blood glucose levels are a measure of the balance among diet, medication, and exercise. Options 1 and 4 imply that the data analyzed are abnormal. The question presents no data for determining growth and development status, such as height, weight, age, or behavior. Supporting normal growth and development is an important goal in managing diabetes in children, but that is not what is being evaluated here.

The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which intervention should the nurse perform immediately? 1.Reinforce the dressing. 2.Notify the health care provider (HCP). 3.Document the findings and continue to monitor. 4.Circle the area of drainage and continue to monitor.

2 Rationale:Colorless drainage on the dressing in a child after craniotomy indicates the presence of cerebrospinal fluid and should be reported to the HCP immediately. Options 1, 3, and 4 are not the immediate nursing intervention because they do not address the need for immediate intervention to prevent complications.

An 11-year-old child is admitted to the hospital in vaso-occlusive sickle cell crisis. The nurse plans for which priority treatments in the care of the child? 1.Splenectomy, correction of acidosis 2.Adequate hydration, pain management 3.Frequent ambulation, oxygen administration 4.Passive range-of-motion exercises, adequate hydration

2 Rationale:During vaso-occlusive sickle cell crisis, the care focuses on adequate hydration and pain management. Adequate hydration with intravenous normal saline and oral fluids maintains blood flow and decreases the severity of the vaso-occlusive crisis. Analgesics for pain management are necessary during a vaso-occlusive crisis. Splenectomy would not be done with a vaso-occlusive crisis. Acidosis is not present. Oxygen can be administered to increase tissue perfusion but is not the priority treatment for a vaso-occlusive crisis. Passive range of motion is not recommended; bed rest is prescribed initially.

A 9-year-old child with leukemia is in remission and has returned to school. The school nurse calls the mother of the child and tells the mother that a classmate has just been diagnosed with chickenpox. The mother immediately calls the clinic nurse because the leukemic child has never had chickenpox. Which is an appropriate response by the clinic nurse to the mother? 1."There is no need to be concerned." 2."Bring the child into the clinic for a vaccine." 3."Keep the child out of school for a 2-week period." 4."Monitor the child for an elevated temperature, and call the clinic if this happens."

2 Rationale:Immunocompromised children are unable to fight varicella adequately. Chickenpox can be deadly to the immunocompromised child. If an immunocompromised child who has not had chickenpox is exposed to someone with varicella, the child should receive varicella-zoster immune globulin within 96 hours of exposure. All other options are incorrect because they do nothing to minimize the chances of developing the disease.

The nurse is instructing the parents of a child with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the parents? 1.Administer the iron at mealtimes. 2.Administer the iron through a straw. 3.Mix the iron with cereal to administer. 4.Add the iron to formula for easy administration.

2 Rationale:In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth because the iron stains the teeth. The parents should be instructed to brush or wipe the child's teeth or have the child brush the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not added to formula or mixed with cereal or other food items.

A child with sickle cell anemia who is in vaso-occlusive crisis is admitted to the hospital. Which health care provider prescription would assist in reversing the vaso-occlusive crisis? 1.Monitor pulse oximetry. 2.Begin intravenous fluids. 3.Administer oxygen by face mask. 4.Monitor vital signs and respiratory status.

2 Rationale:Increased fluid volume reduces the viscosity of the blood, preventing further vascular occlusion and further sickling caused by dehydration. Pulse oximetry and vital sign monitoring may be components of care, but they are actions that relate to monitoring the client versus treating. The intravenous fluids, however, will treat the condition. Vaso-occlusive crisis treatment includes analgesic and fluid administration. Oxygen may help relieve symptoms of respiratory distress, but analgesics and fluids treat the condition.

A 4-year-old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which laboratory result confirms the diagnosis? 1.Lumbar puncture showing no blast cells 2.Bone marrow biopsy showing blast cells 3.Platelet count of 350,000 mm3 (350 × 109/L) 4.White blood cell count 4,500 mm3 (4.5 × 109/L)

2 Rationale:Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. The confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate and biopsy, which is considered positive if blast cells are present. An altered platelet count occurs as a result of the disease, but also may occur as a result of chemotherapy and does not confirm the diagnosis. The white blood cell count may be normal, high, or low in leukemia. A lumbar puncture may be done to look for blast cells in the spinal fluid that indicate central nervous system disease.

The nurse provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information? 1."The femur is the most common site of this sarcoma." 2."The child does not experience pain at the primary tumor site." 3."Limping, if a weight-bearing limb is affected, is a clinical manifestation." 4."The symptoms of the disease in the early stage are almost always attributed to normal growing pains."

2 Rationale:Osteosarcoma is the most common bone cancer in children. Cancer usually is found in the metaphysis of long bones, especially in the lower extremities, with most tumors occurring in the femur. Osteosarcoma is manifested clinically by progressive, insidious, and intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor. Options 1, 3, and 4 are accurate regarding osteosarcoma.

The pediatric nurse specialist provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information? 1."The femur is the most common site of this sarcoma." 2."The child does not experience pain at the primary tumor site." 3."Limping, if a weight-bearing limb is affected, is a clinical manifestation." 4."The symptoms of the disease in the early stage are almost always attributed to normal growing pains."

2 Rationale:Osteosarcoma is the most common bone cancer in children. Cancer usually is found in the metaphysis of long bones, especially in the lower extremities, with most tumors occurring in the femur. Osteosarcoma is manifested clinically by progressive, insidious, and intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor. The statements in the remaining options are accurate regarding osteosarcoma.

A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1 mg/dL (60.5 mcmol/L). The nurse reviews this result and makes which interpretation? 1.It is positive. 2.It is negative. 3.It is inconclusive. 4.It requires rescreening at age 6 weeks.

2 Rationale:Phenylketonuria is a genetic (autosomal recessive) disorder that results in central nervous system damage from toxic levels of phenylalanine (an essential amino acid) in the blood. It is characterized by blood phenylalanine levels greater than 20 mg/dL (12.1 mcmol/L); (normal level is 0 to 2 mg/dL (0 to 121 mcmol/L). A result of 1 mg/dL is a negative test result.

The pediatric nursing instructor asks a nursing student to prioritize care for a child diagnosed with sickle cell disease. Which student response correctly identifies the priority of care? 1.Fatigue 2.Hypoxia 3.Delayed growth 4.Avascular necrosis

2 Rationale:Sickle cell disease is 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. Hypoxia causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow and leading to a vaso-occlusive crisis. All the clinical manifestations of sickle cell anemia result from the sickled cells being unable to flow easily through the microvasculature, and their clumping obstructs blood flow. With reoxygenation most of the sickled red blood cells resume their normal shape. Fatigue is a result of hypoxia; hypoxia should be addressed first. Avascular necrosis of the hips and shoulders and delayed growth are general manifestations of sickle cell disease.

The nurse is providing home care instructions to the mother of a child receiving radiation therapy. Which statement by the mother indicates a need for further teaching? 1."I should dress my child in loose-fitting clothing." 2."I won't need to limit the amount of sun that my child gets." 3."My child may experience fatigue and need more rest periods." 4."I need to try to provide food and fluids to prevent dehydration."

2 Rationale:Sun protection is essential during radiation treatments. The child should not be exposed to sun during these treatments because of the risk of an alteration of skin integrity. The statements in the remaining options reflect appropriate measures for the child during radiation therapy.

A child with a diagnosis of sickle cell anemia and vaso-occlusive crisis is complaining of severe pain, selecting number 8 on the 1 to 10 pain scale. Which medication would the nurse expect to be prescribed for pain control? 1.Ibuprofen 2.Meperidine 3.Acetaminophen 4.Morphine sulfate

4 Rationale:Morphine sulfate is the medication of choice for severe pain for the child with sickle cell anemia. Opioids such as morphine sulfate provide systemic relief. Ibuprofen decreases inflammation locally. Meperidine has neurological adverse effects and can cause seizures and should be avoided. Acetaminophen would not provide adequate pain relief.

The nurse is caring for a 9-year-old child with leukemia who is hospitalized for the administration of chemotherapy. The nurse would monitor the child specifically for central nervous system involvement by checking which item? 1.Pupillary reaction 2.Level of consciousness 3.The presence of petechiae in the sclera 4.Color, motion, and sensation of the extremities

2 Rationale:The central nervous system (CNS) status is monitored in the child with leukemia because of the risk of infiltration of blast cells into the CNS. The nurse should check the child's level of consciousness (LOC) and should also monitor for signs of irritability, vomiting, and lethargy. Changes in pupillary reaction are specific to conditions related to increased intracranial pressure. The presence of petechiae in the sclera is an objective sign that may be noted in leukemia but is not specifically related to the CNS. Color, motion, and sensation of the extremities relate to a neurovascular assessment and are not specifically related to CNS status.

The nurse assists a health care provider in performing a lumbar puncture on a 3-year-old child with leukemia in whom central nervous system disease is suspected. In which position will the nurse place the child during this procedure? 1.Lithotomy position 2.Modified Sims' position 3.Lateral recumbent position with the knees flexed and chin resting on the chest 4.Prone with knees flexed to the abdomen and head bent with chin resting on the chest

3 Rationale:A lateral recumbent position with the knees flexed to the abdomen and the head bent with the chin resting on the chest is assumed for a lumbar puncture. This position separates the spinal processes and facilitates needle insertion into the subarachnoid space. The positions in the remaining options are incorrect.

The pediatric nurse assists the health care provider in performing a lumbar puncture on a 3-year-old child with leukemia and suspected central nervous system metastasis. The nurse should place the child in which position for this procedure? 1.Lithotomy position 2.Modified Sims' position 3.Lateral recumbent, knees flexed to the abdomen and the head bent, chin down 4.Prone, with the knees flexed to the abdomen and the head bent, the chin resting on the chest

3 Rationale:A lateral recumbent position, with the knees flexed to the abdomen and the head bent with the chin resting on the chest, is assumed for a lumbar puncture. This position separates the spinal processes and facilitates needle insertion into the subarachnoid space. The remaining options are incorrect positions

The nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which finding should the nurse expect to note in this child? 1.Cyanosis 2.Bronze skin 3.Tachycardia 4.Hyperactivity

3 Rationale:Clinical manifestations of iron deficiency anemia will vary with the degree of anemia but usually include extreme pallor with a porcelain-like skin, tachycardia, lethargy, and irritability.

The nurse is providing home care instructions to the parents of a 10-year-old child with hemophilia. Which sport activity should the nurse suggest for this child? 1.Soccer 2.Basketball 3.Swimming 4.Field hockey

3 Rationale:Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Children with hemophilia need to avoid contact sports and to take precautions such as wearing elbow and knee pads and helmets with other sports. The safe activity for them is swimming.

A 10-year-old child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription? 1.Injection of factor X 2.Intravenous infusion of iron 3.Intravenous infusion of factor VIII 4.Intramuscular injection of iron using the Z-track method

3 Rationale:Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The primary treatment is replacement of the missing clotting factor; additional medications, such as agents to relieve pain, may be prescribed depending on the source of bleeding from the disorder. A child with hemophilia A is at risk for joint bleeding after a fall. Factor VIII would be prescribed intravenously to replace the missing clotting factor and minimize the bleeding. Factor X and iron are not used to treat children with hemophilia A.

The nurse is caring for a child with a diagnosis of hemophilia, and hemarthrosis is suspected because the child is complaining of pain in the joints. Which measure should the nurse expect to be prescribed for the child? 1.Range-of-motion exercises to the affected joint 2.Application of a heating pad to the affected joint 3.Application of a bivalved cast for joint immobilization 4.Nonsteroidal antiinflammatory drugs for the pain

3 Rationale:In an acute period, immobilization of the joint would be prescribed. Range-of-motion exercise during the acute period can increase the bleeding and would be avoided at this time. Heat will increase blood flow to the area, so it would promote increased bleeding to the area. Nonsteroidal antiinflammatory drugs (NSAIDs) can prolong bleeding time and would not be prescribed for the child.

The pediatric nurse clinician is discussing the pathophysiology related to childhood leukemia with a class of nursing students. Which statement made by a nursing student indicates a need for further teaching of the pathophysiology of this disease? 1.The platelet count is decreased. 2.Red blood cell production is affected. 3.Reed-Sternberg cells are found on biopsy. 4.Normal bone marrow is replaced by blast cells.

3 Rationale:In leukemia, normal bone marrow is replaced by malignant blast cells. As the blast cells take over the bone marrow, eventually red blood cell and platelet production is affected, and the child becomes anemic and thrombocytopenic. The Reed-Sternberg cell is found in Hodgkin's disease.

The nurse is talking to the parents of a child newly diagnosed with diabetes mellitus. Which statement by the parents indicates an understanding of preventing and managing hyperglycemia? 1."I will give 8 oz of diet cola at the first sign of weakness." 2."I will administer glucagon immediately if shakiness is felt." 3."I will check for ketones when my child is suffering from an illness." 4."I will report to the emergency department if the blood glucose level is over 150 mg/dL (8.6 mmol/L)."

3 Rationale:It is recommended that urine be tested for ketones every 3 hours during an illness or whenever the blood glucose level is over 240 mg/dL (13.7 mmol/L) when illness is not present. The child or parents should carry a source of glucose so it is readily available in the event of a hypoglycemic, not hyperglycemic, reaction. A diet carbonated beverage does not meet the need of providing a glucose source during a hypoglycemic episode. If the blood glucose level is greater than 150 mg/dL (8.6 mmol/L), it is unnecessary to report to the emergency department as a first-line treatment. Glucagon is used for an unconscious client who is experiencing a hypoglycemic, not hyperglycemic, reaction and who is unable to swallow.

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden, and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother? 1."I have a vase in the utility room, and I will get it for you." 2."I will get the vase and wash it well before you put the flowers in it." 3."The flowers from your garden are beautiful, but should not be placed in the child's room at this time." 4."When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible."

3 Rationale:Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). For a hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas aeruginosa, to which the child is susceptible. In addition, fresh fruits and vegetables harbor molds and should be avoided until the white blood cell count increases.

In caring for a child diagnosed with Hodgkin's disease. Which oncologic emergency should the nurse be most concerned about? 1.Hyperleukocytosis 2.Spinal cord compression 3.Superior vena cava syndrome 4.Disseminated intavascular coagulation

3 Rationale:Pediatric oncologic emergencies include tumor lysis syndrome, hyperleukocytosis, superior vena cava syndrome, spinal cord compression, and disseminated intravascular coagulation. Because Hodgkin's disease causes a space-occupying lesion in the chest, superior vena cava syndrome is the most likely emergency that will occur with this type of malignancy. This complication could lead to airway compromise and respiratory failure. The other complications are possible, due to issues with immune response, treatment response, and obstruction, but are less likely to occur due to lesion location in Hodgkin's disease

A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemotherapy is planned to begin immediately. The mother of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. What is the nurse's best response? 1."It's very costly, and chemotherapy works just as well." 2."I'm not sure. I'll discuss it with the health care provider." 3."Sometimes age has to do with the decision for radiation therapy." 4."The health care provider would prefer that you discuss treatment options with the oncologist."

3 Rationale:Radiation therapy is usually delayed until a child is 8 years old, whenever possible, to prevent retardation of bone growth and soft tissue development. Options 1, 2, and 4 are inappropriate responses to the mother and place the mother's question on hold.

The nurse is collecting data on a 9-year-old child suspected of having a brain tumor. Which question should the nurse ask to elicit data related to the classic symptoms of a brain tumor? 1."Do you have trouble seeing?" 2."Do you feel tired all the time?" 3."Do you throw up in the morning?" 4."Do you have headaches late in the day?"

3 Rationale:The classic symptoms of children with brain tumors are headache and morning vomiting related to the child getting out of bed. Headaches worsen on arising but improve during the day. Fatigue may occur but is a vague symptom. Visual changes may occur, including nystagmus, diplopia, and strabismus, but these signs are not the hallmark symptoms with a brain tumor.

A 6-year-old child with diabetes mellitus and the child's mother come to the health care clinic for a routine examination. The nurse evaluates the data collected during this visit to determine if the child has been euglycemic since the last visit. Which information is the most significant indicator of euglycemia? 1.Daily glucose monitor log 2.Dietary history for the previous week 3.Glycosylated hemoglobin (hemoglobin A1c) 4.Fasting blood glucose performed on the day of the clinic visit

3 Rationale:The glycosylated hemoglobin assay measures the glucose molecules that attach to the hemoglobin A molecules and remain there for the life of the red blood cell, approximately 120 days. This is not reversible and cannot be altered by human intervention. Daily glucose logs are useful if they are kept regularly and accurately. However, they reflect only the blood glucose at the time the test was done. A fasting blood glucose test performed on the day of the clinic visit is time limited in its scope, as is the dietary history.

The nurse is monitoring for bleeding in a child following surgery for removal of a brain tumor. The nurse checks the head dressing and notes the presence of dried blood on the back of the dressing. The child is alert and oriented, and the vital signs and neurological signs are stable. Which nursing action is most appropriate initially? 1.Prepare to change the dressing. 2.Recheck the dressing in 1 hour. 3.Check the operative record to determine whether a drain is in place. 4.Document the findings and notify the health care provider immediately.

3 Rationale:The initial nursing action is to determine whether a drain is in place because the drainage seen on the dressing could be attributed to this. The nurse would not change the dressing without a health care provider's prescription. Rechecking the dressing is an appropriate action, but it is not the initial action. The findings would be documented; however, there is no reason to notify the health care provider immediately. The initial action would be to further assess the cause of the drainage.

The nurse provides instructions regarding home care to the parents of a 3-year-old child hospitalized with hemophilia. Which statement, if made by the parent, indicates a need for further instructions? 1."We will supervise our child closely." 2."We will pad corners of the furniture." 3."We will avoid having our child receive immunizations." 4."We will remove household items that can easily fall over."

3 Rationale:The nurse needs to stress the importance of immunizations, dental hygiene, and routine well-child care. The remaining options are appropriate. The parents also are instructed in the measures to implement in the event of blunt trauma, especially trauma involving the joints, and taught to apply prolonged pressure to superficial wounds until the bleeding has stopped.

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? 1.Hold the next dose of insulin. 2.Come to the clinic immediately. 3.Encourage the child to drink liquids. 4.Administer an additional dose of regular insulin

3 Rationale:When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses should not be adjusted or changed.

An adolescent with type 1 diabetes mellitus has been chosen for the school's cheerleading squad. The adolescent visits the school nurse to obtain information regarding adjustments needed in the treatment plan for diabetes. What should the school nurse instruct the student to do? 1.Eat half the amount of food normally eaten. 2.Take two times the amount of prescribed insulin on practice and game days. 3.Eat six graham crackers or drink a cup of orange juice prior to practice or game time. 4.Take the prescribed insulin 1 hour prior to practice or game time rather than in the morning.

3 Rationale:An extra snack of 15 to 30 g of carbohydrate eaten before activities, such as cheerleader practice, will prevent hypoglycemia. Six graham crackers or a cup of orange juice will provide 15 to 30 g of carbohydrate. The adolescent should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be decreased.

A pediatric nurse educator provides a teaching session to the nursing staff regarding phenylketonuria. Which statement should the nurse educator include in the session? 1."Treatment includes dietary restriction of tyramine." 2."Phenylketonuria is an autosomal dominant disorder." 3."Phenylketonuria primarily affects the gastrointestinal system." 4."All 50 states require routine screening of all newborn infants for phenylketonuria."

4 Rationale:All 50 states require routine screening in newborn infants. Phenylketonuria is an autosomal recessive disorder. Treatment includes dietary restriction of phenylalanine intake. Phenylketonuria is a genetic disorder that results in central nervous system damage from toxic levels of phenylalanine in the blood.

The nurse is reviewing the record of a 10-year-old child suspected of having Hodgkin's disease. Which characteristic manifestation should the nurse anticipate to be documented in the assessment notes? 1.Fever 2.Malaise 3.Painful lymph nodes in the supraclavicular area 4.Painless and movable lymph nodes in the cervical area

4 Rationale:Clinical manifestations specifically associated with Hodgkin's disease include painless, firm, and movable adenopathy in the cervical and supraclavicular areas. Hepatosplenomegaly is also noted. Although anorexia, weight loss, fever, and malaise are associated with Hodgkin's disease, these manifestations are vague and can be seen in many disorders.

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion? 1.Potassium infusion 2.NPH insulin infusion 3.5% dextrose infusion 4.Normal saline infusion

4 Rationale:Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Rehydration is the initial step in resolving diabetic ketoacidosis. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose level decreases to an acceptable level. Intravenously administered potassium may be required, depending on the potassium level, but would not be part of the initial treatment.

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? 1.Sweating and tremors 2.Hunger and hypertension 3.Cold, clammy skin and irritability 4.Fruity breath odor and decreasing level of consciousness

4 Rationale:Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic ketoacidosis. Hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. Cold clammy skin, irritability, sweating, and tremors all are signs of hypoglycemia.

The nurse is caring for a child diagnosed with Down syndrome. Which explanation of this syndrome should the nurse provide the parents? 1.Subaverage intellectual functioning with a congenial nature 2.Above-average intellectual functioning with deficits in adaptive behavior 3.Average intellectual functioning and the absence of deficits in adaptive behavior 4.Moderate to severe intellectual disability and linkage to an extra chromosome 21, group G

4 Rationale:Down syndrome is a form of mental retardation and is a congenital condition that results in moderate to severe intellectual disability. Most cases are attributable to an extra chromosome (group G)—hence the name trisomy 21. The characteristics in the remaining options are incorrect characteristics of this syndrome.

The pediatric nurse educator provides a teaching session to the nursing staff regarding hemophilia. Which statement regarding this disorder should the nurse plan to include in the discussion? 1.Males inherit hemophilia from their fathers. 2.Hemophilia is a Y-linked hereditary disorder. 3.Females inherit hemophilia from their mothers. 4.Hemophilia A results from deficiency of factor VIII.

4 Rationale:Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Hemophilia A results from a deficiency of factor VIII. Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome. Hemophilia B (Christmas disease) is a deficiency of factor IX.

A diagnosis of Hodgkin's disease is suspected in a 12-year-old child. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm the diagnosis of Hodgkin's disease? 1.Elevated vanillylmandelic acid urinary levels 2.The presence of blast cells in the bone marrow 3.The presence of Epstein-Barr virus in the blood 4.The presence of Reed-Sternberg cells in the lymph nodes

4 Rationale:Hodgkin's disease (a type of lymphoma) is a malignancy of the lymph nodes. The presence of giant, multinucleated cells (Reed-Sternberg cells) is the classic characteristic of this disease. Elevated levels of vanillylmandelic acid in the urine may be found in children with neuroblastoma. The presence of blast cells in the bone marrow indicates leukemia. Epstein-Barr virus is associated with infectious mononucleosis

A school-age child with type 1 diabetes mellitus has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do? 1.Eat twice the amount normally eaten at lunchtime. 2.Take half the amount of prescribed insulin on practice days. 3.Take the prescribed insulin at noontime rather than in the morning. 4.Eat a small box of raisins or drink a cup of orange juice before soccer practice.

4 Rationale:Hypoglycemia is a blood glucose level less than 70 mg/dL (4 mmol/L) and results from too much insulin, not enough food, or excessive activity. An extra snack of 15 to 30 g of carbohydrates eaten before activities such as soccer practice would prevent hypoglycemia. A small box of raisins or a cup of orange juice provides 15 to 30 g of carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be doubled.

The nurse is asked to prepare for the admission of a child to the pediatric unit with a diagnosis of Wilms' tumor. The nurse is creating a plan of care for the child and should include which intervention in the plan? 1.Monitor the temperature for hypothermia. 2.Monitor the blood pressure for hypotension. 3.Palpate the abdomen for an increase in the size of the tumor. 4.Inspect the urine for the presence of hematuria at each voiding.

4 Rationale:If Wilms' tumor is suspected, the tumor mass should not be palpated. Excessive manipulation can cause seeding of the tumor and cause spread of the cancerous cells. Fever (not hypothermia), hematuria, and hypertension (not hypotension) are clinical manifestations associated with Wilms' tumor.

A child is scheduled for allogeneic bone marrow transplantation (BMT). The parent of the child asks the nurse about the procedure. The nurse should provide which description about the BMT? 1.Aspiration of bone marrow from the child 2.Obtaining bone marrow from the child's twin 3.Obtaining bovine (cow) bone marrow and administering it to the child 4.Obtaining bone marrow from a donor who matches the child's tissue type

4 Rationale:In allogeneic BMT, a donor who matches the child's tissue type is found. That bone marrow is then given to the child. In autologous BMT, the child undergoes general anesthesia for aspiration of his or her bone marrow, which is then processed in the laboratory and frozen until that marrow needs to be infused back into the child. Syngeneic BMT is done when the child has an identical twin. Administering bovine bone marrow to the child is not used in BMT

A diagnostic workup is being performed on a 1-year-old child with suspected neuroblastoma. The nurse reviews the results of the diagnostic tests and understands that which finding is most specifically related to this type of tumor? 1.Positive Babinski's sign 2.Presence of blast cells in the bone marrow 3.Projectile vomiting, usually in the morning 4.Elevated vanillylmandelic acid urinary levels

4 Rationale:Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically, the tumor compresses adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated vanillylmandelic acid levels. The presence of blast cells in the bone marrow occurs in leukemia. Projectile vomiting occurring most often in the morning and a positive Babinski's sign are clinical manifestations of a brain tumor.

A child in whom sickle cell anemia is suspected is seen in a clinic, and laboratory studies are performed. The nurse checks the laboratory results, knowing that which value would be increased in this disease? 1.Platelet count 2.Hematocrit level 3.Hemoglobin level 4.Reticulocyte count

4 Rationale:Sickle cell anemia is 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. A diagnosis is established on the basis of a complete blood count, examination for sickled red blood cells in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin level and hematocrit, a decreased platelet count, an increased reticulocyte count, and the presence of nucleated red blood cells. Reticulocyte counts are increased in children with sickle cell disease because the life span of their sickled red blood cells is shortened.

The home care nurse is visiting a child newly diagnosed with diabetes mellitus. The nurse is instructing the child and parents regarding actions to take if hypoglycemic reactions occur. The nurse should tell the child to take which action? 1.Administer glucagon immediately if shakiness is felt. 2.Drink 8 ounces (235 ml) of diet cola at the first sign of weakness. 3.Report to a hospital emergency department if the blood glucose is 60 mg/dL (3.4 mmol/L). 4.Carry hard candies whenever leaving home in case a hypoglycemic reaction occurs.

4 Rationale:The child should be instructed to carry a source of glucose for ready use in the event of a hypoglycemic reaction. Hard candies such as Life Savers will provide a source of glucose. Glucagon is not administered if shakiness is felt but is used in an unconscious client or a person unable to swallow who is experiencing a hypoglycemic reaction. A diet beverage is sugar free and will not be helpful. If the blood glucose level is 60 mg/dL (3.4 mmol/L), a source of glucose may be needed, but it is not necessary to report to the emergency department.

A home care nurse is teaching an adolescent with type 1 diabetes mellitus about insulin administration and rotation sites. Which statement, if made by the adolescent, would indicate effective teaching? 1."I should use only my stomach and my thighs for injections." 2."I need to use a different major site for each insulin injection." 3."I should use the same major site for 1 month before rotating to another site." 4."I need to give 4 to 6 injections in one area, about an inch apart, and then move to another area."

4 Rationale:The most efficient rotation plan involves giving about four to six injections in one area, each injection about 1 inch (2.5 cm) apart, or the diameter of the insulin vial from the previous injection, and then moving to another area of the major site the next day. All other options are incorrect.

The nurse provides instructions to the mother of a child with sickle cell disease. Which statement by the mother indicates a need for further teaching? 1."I need to be sure that my child has adequate rest periods." 2."I will take my child's temperature and watch for a fever." 3."I need to encourage my child to drink large amounts of fluids." 4."I know my child must spend as much time as possible in the sun."

4 Rationale:The nurse should instruct the mother to encourage fluid intake 1.5 to 2 times the daily requirements. Adequate rest periods should be provided, and the child should not be exposed to cold or heat stress. The mother should be taught how to take the child's body temperature and how to use a thermometer properly. Sources of infection should be avoided, as should prolonged exposure to the sun.

The nurse on the pediatric unit is caring for a child with hemophilia who has been in a motor vehicle crash. Which assessment finding, if noted in the child, indicates the need for follow-up? 1.The child maintains affected joints in an immobilized position and denies pain at this time. 2.The child's urine is noted to be clear and light yellow and is negative for red blood cells. 3.The child maintains bruised joints in an elevated position; the bruises noted are beginning to turn yellow. 4.The child is drowsy and difficult to arouse; previously the child was able to respond to questions effectively.

4 Rationale:When caring for a child with hemophilia who has sustained injuries, the nurse should monitor for signs of internal bleeding. One sign of internal bleeding is change in level of consciousness, which could indicate intracranial hemorrhage. Additional signs of bleeding include pain, tenderness, and bruising of the affected area and hematuria. Denial of pain of affected joints, clear and light yellow urine that is negative for red blood cells, and bruises that are beginning to turn yellow are not signs of internal or external bleeding.