PEDS Nursing-Exam III
A patient diagnosed with systemic lupus erythematosus (SLE) is scheduled for plasmapheresis. The nurse plans to teach the patient that plasmapheresis will
remove antibody-antigen complexes from circulation.
Which of the following is most likely associated with a cerebrovascular accident (CVA) resulting from congenital heart disease? a. Polycythemia b. Cardiomyopathy c. Endocarditis d. Low blood pressure
Answer: A The child with congenital heart disease develops polycythemia resulting from an inadequate mechanism to compensate for decreased oxygen saturation.
After teaching a patient on immunosuppressant therapy after a kidney transplant about the posttransplant drug regimen, the nurse determines that additional teaching is needed when the patient says, ____________
"After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor."
The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is which of the following? a. Notify the physician. b. Place child in Trendelenburg position. c. Apply a new bandage with more pressure. d. Apply direct pressure above catheterization site.
ANS: D When bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure on the vessel puncture. The physician can be notified and a new bandage with more pressure can be applied after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. Trendelenburg position would not be a helpful intervention. It would increase the drainage from the lower extremities.
A 16 month old child diagnosed with Kawasaki Disease (KD) is very irritable,refuses to eat, and exhibits peeling skin on the hands and feet. Which of the following would the nurse interpret as the priority? a) applying lotions to the hands and feet b) offering foods the toddler likes c) placing the toddler in a quiet environment d) encouraging the parents to get some rest
Answer: C One of the characteristics of children with KD is irritability. They are often inconsolable.Placing the child in a quiet environment may help quiet the child and reduce the workload of the heart. The child's irritability takes priority over peeling of the skin.
A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing around when a blood specimen is obtained. The child's color becomes blue and respiratory rate increases to 44 bpm. Which of the following actions would the nurse do first? a) obtain an order for sedation for the child b) assess for an irregular heart rate and rhythm c) explain to the child that it will only hurt for a short time d) place the child in knee-to-chest position
Answer: D. the child is experiencing a "tet spell" or hypoxic episode. Therefore the nurse should place the child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of fallot. As a result, the blood then entering the systemic circulation has higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may need sedative. Once the child is in this position, the nurse may assess for an irregular heart rate and rhythm. Explaining tho the child that it will only hurt for a short time does nothing to alleviate hypoxia.
A patient is being evaluated for possible atopic dermatitis. The nurse will review the patient's laboratory values for the level of
IgE
A patient is admitted to the hospital with acute rejection of a kidney transplant. The nurse will anticipate ________________
administration of immunosuppressant medications.
The nurse will monitor a patient who is undergoing plasmapheresis for
numbness and tingling.
Nursing care of the child with Kawasaki disease is challenging because of: a. the child's irritability. b. predictable disease course. c. complex antibiotic therapy. d. the child's ongoing requests for food.
ANS: A Patient irritability is a hallmark of Kawasaki disease and the most challenging problem. A quiet environment is necessary to promote rest. The diagnosis is often difficult to make, and the course of the disease can be unpredictable. Intravenous gamma globulin and salicylates are the therapy of choice, not antibiotics. The child often is reluctant to eat. Soft foods and fluids should be offered to prevent dehydration.
Which of the following defects results in obstruction to blood flow? a. Aortic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries
ANS: A 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. Tricuspid atresia results in decreased pulmonary blood flow. The atrial septal defect results in increased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow.
Seventy-two hours after cardiac surgery, a young child has a temperature of 38.4o C (101.1° F). The nurse should do which of the following? a. Report findings to practitioner. b. Apply a hypothermia blanket. c. Keep child warm with blankets. d. Record temperature on assessment flow sheet.
ANS: A In the first 24 to 48 hours after surgery, the body temperature may increase to 37.8° C (100° F) as part of the inflammatory response to tissue trauma. If the temperature is higher or fever continues after this period, it is most likely a sign of an infection, and immediate investigation is indicated. Hypothermia blanket is not indicated for this level of temperature. Blankets should be removed from the child to keep the temperature from increasing. The temperature should be recorded, but the practitioner must be notified for evaluation.
Which of the following structural defects constitute tetralogy of Fallot? a. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, ventricular septal defect, overriding aorta, left ventricular hypertrophy d. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
ANS: A Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy.
The primary nursing intervention to prevent bacterial endocarditis is which of the following? a. Counsel parents of high-risk children. b. Institute measures to prevent dental procedures. c. Encourage restricted mobility in susceptible children. d. Observe children for complications, such as embolism and heart failure.
ANS: A The objective of nursing care is to counsel the parents of high-risk children about the need for both prophylactic antibiotics for dental procedures and maintaining excellent oral health. The child's dentist should be aware of the child's cardiac condition. Dental procedures should be done to maintain a high level of oral health. Restricted mobility in susceptible children is not indicated. Parents are taught to observe for unexplained fever, weight loss, or change in behavior.
A parent of a 7-year-old girl with a repaired ventricular septal defect (VSD) calls the cardiology clinic and reports that the child is just not herself. Her appetite is decreased, she has had intermittent fevers around 38o C (100.4o F), and now her muscles and joints ache. Based on this information you advise the mother to: a. immediately bring the child to clinic for evaluation. b. come to the clinic next week on a scheduled appointment. c. treat the symptoms with acetaminophen and fluids, since it is most likely a viral illness. d. recognize that the child is trying to manipulate the parent by complaining of vague symptoms.
ANS: A These are the insidious symptoms of bacterial endocarditis. Since the child is in a high-risk group for this disorder (VSD repair), immediate evaluation and treatment are indicated to prevent cardiac damage. With appropriate antibiotic therapy, bacterial endocarditis is successfully treated in approximately 80% of the cases. The child's complaints should not be dismissed. The low-grade fever is not a symptom that the child can fabricate.
A cardiac defect that allows blood to shunt from the (high pressure) left side of the heart to the (lower pressure) right side can result in: a. cyanosis. b. congestive heart failure. c. decreased pulmonary blood flow. d. bounding pulses in upper extremities.
ANS: B As blood is shunted into the right side of the heart, there is increased pulmonary blood flow and the child is at high risk for congestive heart failure. Cyanosis usually occurs in defects with decreased pulmonary blood flow. Bounding upper extremity pulses are a manifestation of coarctation of the aorta.
The nurse should recognize that congestive heart failure (CHF) is which of the following? a. Disease related to cardiac defects b. Consequence of an underlying cardiac defect c. Inherited disorder associated with a variety of defects d. Result of diminished workload imposed on an abnormal myocardium
ANS: B CHF is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body's metabolic demands. CHF is not a disease but rather a result of the inability of the heart to pump efficiently. CHF is not inherited. CHF occurs most frequently secondary to congenital heart defects in which structural abnormalities result in increased volume load or increased pressures on the ventricles.
The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes the risk of cerebrovascular accidents (strokes) occurring. Which of the following is an important objective to decrease this risk? a. Minimize seizures. b. Prevent dehydration. c. Promote cardiac output. d. Reduce energy expenditure.
ANS: B In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents.
John is a 6-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be which of the following? a. Directed at his parents because he is too young to understand b. Adapted to his level of development so that he can understand c. Done several days before the procedure so he will be prepared d. Provide details about the actual procedures so he will know what to expect
ANS: B Preoperative teaching should always be directed to the child's stage of development. The caregivers also benefit from these explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. This age-group will not understand in-depth descriptions. School-age children should be prepared close to the time of the cardiac catheterization.
Which of the following should the nurse consider when preparing a school-age child and the family for heart surgery? a. Unfamiliar equipment should not be shown. b. Let child hear the sounds of a cardiac monitor, including alarms. c. Explain that an endotracheal tube will not be needed if the surgery goes well. d. Discussion of postoperative discomfort and interventions is not necessary before the procedure.
ANS: B The child and family should be exposed to the sights and sounds of the intensive care unit (ICU). All positive, nonfrightening aspects of the environment are emphasized. The family and child should make the decision about a tour of the unit if it is an option. The child should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous lines, incision, endotracheal tube, expected discomfort, and management strategies.
The parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should include which of the following? a. Parents can meet all the child's needs. b. Child needs opportunities to play with peers. c. Constant parental supervision is needed to avoid overexertion. d. Child needs to understand that peers' activities are too strenuous.
ANS: B The child needs opportunities for social development. Children are able to regulate and limit their activities based on their energy level. Parents must be encouraged to seek appropriate social activities for the child, especially before kindergarten. The child needs to have activities that foster independence.
Ventricular septal defect has the following blood flow pattern: a. Mixed blood flow b. Increased pulmonary blood flow c. Decreased pulmonary blood flow d. Obstruction to blood flow from ventricles
ANS: B The opening in the septal wall allows for blood to flow from the higher pressure left ventricle into the lower pressure right ventricle. This left-to-right shunt creates increased pulmonary blood flow. The shunt is one way, from high pressure to lower pressure; oxygenated and unoxygenated blood do not mix. The outflow of blood from the ventricles is not affected by the septal defect.
The nurse notices that a child is increasingly apprehensive and has tachycardia after heart surgery. The chest tube drainage is now 8 ml/kg/hr. Which of the following should be the nurse's initial intervention? a. Apply warming blankets. b. Notify the practitioner of these findings. c. Give additional pain medication per protocol. d. Encourage child to cough, turn, and deep breathe.
ANS: B The practitioner is notified immediately. Increases of chest tube drainage to more than 3 ml/kg/hr for more than 3 consecutive hours or 5 to 10 ml/kg in any 1 hour may indicate postoperative hemorrhage. Increased chest tube drainage with apprehensiveness and tachycardia may indicate cardiac tamponade—blood or fluid in the pericardial space constricting the heart—which is a life-threatening complication. Warming blankets are not indicated at this time. Additional pain medication can be given before the practitioner drains the fluid, but the notification is the first action. Encouraging the child to cough, turn, and deep breathe should be deferred until after evaluation by the practitioner.
SELECT ALL THAT APPLY. The nurse is caring for a child with Kawasaki disease in the acute phase. Which of the following clinical manifestations would the nurse expect to observe? a. Osler nodes b. Cervical lymphadenopathy c. Strawberry tongue d. Chorea e. Erythematous palms f. Polyarthritis
ANS: B, C, E Clinical manifestations of Kawasaki disease in the acute phase include cervical lymphadenopathy, a strawberry tongue, and erythematous palms. Osler nodes are a clinical manifestation of endocarditis. Chorea and polyarthritis are seen in rheumatic fever.
Decreasing the demands on the heart is a priority in care for the infant with congestive heart failure (CHF). In evaluating the infant's status, which of the following is indicative of achieving this goal? a. Irritability when awake b. Capillary refill of more than 5 seconds c. Appropriate weight gain for age d. Positioned in high Fowler position to maintain oxygen saturation at 90%
ANS: C Appropriate weight gain for an infant is indicative of successful feeding and a reduction in caloric loss secondary to the CHF. Irritability is a symptom of CHF. The child also uses additional energy when irritable. Capillary refill should be brisk and within 2 to 3 seconds. The child needs to be positioned upright to maintain oxygen saturation at 90%. Positioning is helping to decrease respiratory effort, but the infant is still having difficulty with oxygenation.
The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. The nurse should do which of the following? a. Administer oxygen. b. Record data on nurses' notes. c. Report data to the practitioner. d. Place child in high Fowler position.
ANS: C One of the earliest signs of CHF is tachycardia (sleeping heart rate >160 beats/min) as a direct result of sympathetic stimulation. The practitioner needs to be notified for evaluation of possible CHF. Although oxygen or a semiupright position may be indicated, the first action is to report the data to the practitioner.
After returning from cardiac catheterization, the nurse determines that the pulse distal to the catheter insertion site is weaker. The nurse should do which of the following? a. Elevate affected extremity. b. Notify practitioner of the observation. c. Record data on assessment flow record. d. Apply warm compresses to insertion site.
ANS: C The pulse distal to the catheterization site may be weaker for the first few hours after catheterization, but should gradually increase in strength. Documentation of the finding provides a baseline. The extremity is maintained straight for 4 to 6 hours. This is an expected change. The pulse is monitored. If there are neurovascular changes in the extremity, the practitioner is notified. The site is kept dry. Warm compresses are not indicated.
When caring for the child with Kawasaki disease, the nurse should know which of the following? a. Aspirin is contraindicated. b. Principal area of involvement is the joints. c. Child's fever is usually responsive to antibiotics within 48 hours. d. Therapeutic management includes administration of gamma globulin and salicylates.
ANS: D High-dose intravenous gamma globulin and salicylate therapy is indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. Aspirin is part of the therapy. Mucous membranes, conjunctiva, changes in the extremities, and cardiac involvement are seen. The fever of Kawasaki disease is unresponsive to antibiotics. It is responsive to antiinflammatory doses of aspirin and antipyretics.
A chest x-ray examination is ordered for a child with suspected cardiac problems. The child's parent asks the nurse, "What will the x-ray show about the heart?" The nurse's response should be based on knowledge that the x-ray film will do which of the following? a. Show bones of chest but not the heart b. Evaluate the vascular anatomy outside of the heart c. Show a graphic measure of electrical activity of the heart d. Provide information on heart size and pulmonary blood flow patterns
ANS: D Chest x-ray films provide information on the size of the heart and pulmonary blood flow patterns. The bones of the chest are visible on the chest x-ray film, but the heart and blood vessels are also seen. Magnetic resonance imaging is a noninvasive technique that allows for evaluation of vascular anatomy outside of the heart. A graphic measure of electrical activity of the heart is provided by electrocardiography.
The physician suggests that surgery be performed for patent ductus arteriosus (PDA) to prevent which of the following complications? a. Hypoxemia b. Right-to-left shunt of blood c. Decreased workload on left side of heart d. Pulmonary vascular congestion
ANS: D In PDA, blood flows from the higher pressure aorta into the lower pressure pulmonary vein, resulting in increased pulmonary blood flow. This creates pulmonary vascular congestion. Hypoxemia usually results from defects with mixed blood flow and decreased pulmonary blood flow. The shunt is from left to right in a PDA. The closure would stop this. There is increased workload on the left side of the heart with a PDA.
The infant with congestive heart failure (CHF) has a need for: a. decreased fat. b. increased fluids. c. decreased protein. d. increased calories.
ANS: D Infants with CHF have a greater metabolic rate because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of average infants, yet their ability to take in calories is diminished by their fatigue. The diet should include increased protein and increased fat to facilitate the child's intake of sufficient calories. Fluids must be carefully monitored because of the CHF.
A 3-month-old infant has a hypercyanotic spell. The nurse's first action should be which of the following? a. Assess for neurologic defects. b. Prepare family for imminent death. c. Begin cardiopulmonary resuscitation. d. Place child in the knee-chest position.
ANS: D The first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. Preparing the family for imminent death or beginning cardiopulmonary resuscitation should be unnecessary. The child is assessed for airway, breathing, and circulation. Often, calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell.
The mother of a child with tetralogy of Fallot asks the nurse why her child has clubbed fingers. The nurse bases the response on the understanding that clubbing is due to which of the following? a) Anemia. b) Peripheral hypoxia. c) Delayed physical growth. d) Destruction of bone marrow.
Answer: B Clubbing of the fingers is one common finding in the child with persistent hypoxia leading to tissue changes in the body because of the low oxygen content of the blood (hypoxemia). It apparently results from tissue fibrosis and hypertrophy from the hypoxemia and from an increase in capillaries in the area, which occur as the body attempts to improve blood supply. Clubbing of the fingers is associated with polycythemia, not anemia. Polycythemia results from the body's attempt to increase oxygen levels in the tissues. The child may be small for his or her chronological age, but clubbing does not result from slow physical growth. Destruction of the bone marrow is not related to this congenital heart malformation. Instead, bone marrow is actively producing erythrocytes to compensate for the chronic hypoxia.
A nurse is preparing for the admission of a child with a diagnosis of acute-stage Kawasaki disease. On assessment of the child, the nurse expects to note which clinical manifestation of the acute stage of the disease? a) cracked lips b) a normal appearance c) conjunctival hyperemia d) desquamation of the skin
Answer: C 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.
