Test 3 EAQ's
Which response is appropriate for the parent of a child with sickle cell disease that is concerned her child is becoming addicted to opioid?
"Very few children who are prescribed opioids for severe pain become behaviorally addicted to the drugs."
The nurse is caring for a patient 36 hours after coronary artery bypass grafting (CABG), with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the patient to bed?
Respiratory rate 28/min
What clinical manifestation should the nurse expect to find in a child with infective endocarditis?
Splinter hemorrhages under the nails
Which is an early sign of congestive heart failure?
Tachyapnea
Which is the primary therapy for secondary hypertension in children?
Treatment of the cause
Which score is appropriate for a Glasgow Coma Scale (GCS) documented as a moderate head injury?
11
Which complication of sickle cell disease is similar to pneumonia?
Acute chest syndrome
Which chance is appropriate for a woman with sickle cell anemia (SCA) and her husband without the condition to have a child with sickle cell anemia?
0% chance that their children will have SCA
Which drug is an inotrope that may be used to maintain organ perfusion in a patient who had heart failure after a myocardial infarction (MI)?
Dobutamine
Which finding is appropriate when assessing a microscopic study of red blood cell (RBC) morphology as a sign of sickle cell anemia (SCA)?
Drepanocytes
Which clinical manifestations suggest increased intracranial pressure in an infant? Select all that apply.
Drowsiness Poor feeding Tense, bulging fontanel Irritability and restlessness
How is a complex partial seizure different from an absence seizure? Select all that apply.
Duration is usually 60 seconds. Frequently is associated with postictal impairment. Commonly is associated with mental disorientation.
In what procedure are high-frequency sound waves directed through a transducer to produce an image of cardiac structures?
Echocardiography
Which supportive measure is appropriate for the child with hemophilia after an arm injury until factor replacement therapy can be instituted?
Elevating the area above the level of the heart
Which neurologic diagnostic procedure is appropriate to identify shifts in midline structures from their normal positions resulting from intracranial lesions?
Endocephalography
The nurse is caring for a child with a bedside cardiac monitor for electrocardiogram (ECG). Which intervention by the nurse is appropriate?
Ensure that the white electrode is on the right of the chest.
Which postoperative care does the nurse include for a child immediately after surgery?
Ensure the child is warm immediately after surgery
Which process produces red blood cells?
Erythropoiesis
Which nursing instruction is appropriate for the 4-year-old child that is prescribed liquid iron for iron-deficiency anemia? Select all that apply
Give the iron using a straw. Brush the child's teeth after administration of iron
Which nursing information is appropriate when teaching the family about caring for a child with sickle cell anemia? Select all that apply.
Identify early signs of dehydration. Administer prophylactic penicillin. Encourage the child to drink a lot of fluids. Check the child for proper hand-washing technique.
Which nursing consideration when to seek medication attention is appropriate for the parents of a child with simple febrile seizures?
If the seizure lasts more than 5 minutes
Which clinical manifestation indicates aversive seizure in a child with partial seizure?
Loss of consciousness
The nurse is caring for a child with heart failure. What teaching does the nurse give to the parents of the child about reducing the workload on the child's heart while hospitalized?
Medication may be used to sedate the child.
Which medication is contraindicated in patients with sickle cell disease (SCD)?
Meperidine
A child has undergone a cardiac catheterization procedure. Which nursing intervention should the nurse employ during the immediate postcatheterization phase?
Monitor both oral and intravenous fluid intake.
Which nursing interventions are most important when the nurse is managing the care for a child with Kawasaki disease? Select all that apply.
Monitor temperature carefully. Check the patency of the intravenous line.
Which assessment finding is appropriate with a comminuted fracture?
Multiple associated linear fractures
Which drug is appropriate to administer to reverse the effects of morphine in a patient?
Naloxone
Which test is appropriate for the child with stiffness, tingling, and aches in the knee joints and has a tendency toward prolonged bleeding?
Partial thromboplastin time
Which nursing information is appropriate for the parents of a 3-year-old child that has just undergone shunt revision for hydrocephaly about signs of shunt malformation? Select all that apply.
Personality change Vomiting Fever
The nurse is caring for a patient in phase 1 cardiac rehabilitation. Which suggestion does the nurse make?
Placing a chair in the shower for independent hygiene
Which laboratory finding is appropriate when distinguishing bacterial meningitis from viral meningitis?
Positive Gram stain
Which complication is appropriate for the 8-year-old boy who has sustained a basilar skull fracture and is becoming increasingly drowsy and now has a fever?
Posttraumatic meningitis
The patient presents to the emergency room with severe chest pain. After administration of two sublingual nitroglycerin tablets, the patient is now reporting pain of 2 on a scale of 1-10. What action by the nurse is priority?
Prepare to administer a third nitroglycerin tablet
Which finding is appropriate when assessing for nuchal rigidity? Select all that apply.
Presence of Kernig sign Inability to place the chin on chest
Which laboratory finding indicates hemolysis?
Presence of nucleated red blood cells
Which focus is appropriate when teaching the parents of a child whose laboratory results show an absolute neutrophil count of less than 500/mm3?
Preventing infection
Congenital heart defects have traditionally been divided into acyanotic and cyanotic defects. What does the nurse know about this system in clinical practice?
Problematic because children with acyanotic heart defects may experience cyanosis
Which nursing recommendations are appropriate when teaching the parents of a preterm infant ways to prevent possible nutritional deficiency anemia? Select all that apply.
Provide breast milk as much as possible. Give citrus fruit or juice with iron supplements. Administer iron supplements in two divided doses between meals. Limit quantities of milk and introduce solid food rich in iron, fluoride, zinc, and vitamin C.
Which intervention should the nurse take when obtaining a blood pressure measurement for a child with systemic hypertension?
Quiet the child when the blood pressure is recorded.
The nurse asks the parent of an infant with pulmonary congestion to help the infant sit up. What is the nurse trying to achieve?
Relief from dyspnea at rest
Which similarity is appropriate for both the diagnostic procedures of the subdural tap and the ventricular puncture?
Remove cerebrospinal fluid to relieve pressure
Which treatment is appropriate for hemophilia?
Replacement of missing clotting factor
Which concept regarding pain is appropriate for a comatose child with multiple injuries?
Requires astute nursing assessment and management
Which is the most important laboratory test result that must be evaluated before administering digoxin to a child with congestive heart failure?
Serum potassium level
A patient with coronary artery disease (CAD) is prescribed carvedilol. What side effect does the nurse monitor for during the assessment?
Shortness of breath
Which clinical manifestation is appropriate for increased intracranial pressure in infants?
Shrill, high-pitched cry
Which nursing information is appropriate when discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus?
Shunt malfunction or infection requires immediate treatment
Which findings are appropriate when describing a postoperative child's level of consciousness (LOC) as "lethargic"? Select all that apply.
Sluggish speech Limited spontaneous movement Drowsy and falls asleep quickly
Which condition is appropriate for the child that tends to walk on the toes with flexion at the knees and hips, and also walks stiffly, taking slow and deliberate steps?
Spastic paraplegic gait
Which type of seizure is indicated when a child has a seizure lasting 35 minutes and loss of consciousness?
Status epilepticus
A patient who is undergoing robotic surgery for coronary artery disease (CAD) asks the nurse about disadvantages of the surgery. Which fact about robotic surgery would the nurse provide?
Surgery time is longer
What medications should the nurse assess the patient for prior to administering nitroglycerin for chest pain? Select all that apply.
Tadalafil Sildenafil
Which immediate nursing intervention is appropriate for the patient who has sustained a head injury and exhibits rhinorrea?
Test the discharge for presence of glucose.
Which HIV test is appropriate when diagnosing a 2-month-old child born to an HIV-infected mother?
The HIV polymerase chain reaction test for detection of proviral DNA
Which statement correctly describes the purpose of the intra-aortic balloon pump (IABP) as treatment for cardiogenic shock?
The IABP improves coronary blood flow during diastole and reduces afterload during systole.
A patient with angina reports chest discomfort. Which principle related to angina pain is important for the nurse to remember?
The administration of nitroglycerin (NTG) will improve oxygen supply
What is a priority patient outcome for a child with congestive heart failure?
The child will not have distended neck veins
Which methods are appropriate when planning to perform a caloric test on a patient? Select all that apply.
Using 10 mL of ice water for irrigation Elevating head of bed to 30 degrees Irrigating the auditory canal for 20 seconds
Which treatment is appropriate to include in the care plan for a patient who has developed diabetes insipidus (DI) following a head trauma?
Vasopressin
Which clinical manifestations enable the nurse to recognize a child's head injury as a minor injury? Select all that apply.
Vomiting Listlessness Somnolence
Which specific signs are appropriate in the diagnosis of bacterial meningitis in neonates? Select all that apply.
Weak cry Poor tone Full, tense, bulging fontanel
Which statement is appropriate when explaining the significance of white blood cells to a 10-year-old patient?
White blood cells help keep germs from causing infections.
Which method is appropriate when injecting parenteral iron preparations?
Injection into a large muscle with the use of the Z-track method
Which is a sign of increased intracranial pressure in infants?
Irritability
Which reason is appropriate for replacing intravenous (IV) phenytoin with fosphenytoin in a patient with seizures? Select all that apply.
Is suitable with saline solutions Is suitable with glucose solutions Can be administered at a higher push rate Can be given by the intramuscular route.
Which nursing information is appropriate for the patient having a positron emission tomography (PET) scan following the removal of a tumor in the skull when discussing the importance of this scan? Select all that apply.
It measures the blood flow to the brain. It detects biochemical changes in tissue. It detects the metabolic activity in the brain
Which nursing intervention is appropriate for a school-age child with bacterial meningitis?
Keeping environmental stimuli to a minimum during hospital stay
Which method is an appropriate way to stop an occasional episode of epistaxis?
Having the child sit up and lean forward
The nurse is concerned that a patient who had a myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? Select all that apply.
Cool, diaphoretic skin Crackles in the lung fields Anxiety and restlessness
What clinical manifestation does the nurse expect to find during the assessment of an infant with coarctation of the aorta?
Cooler lower extremities
When a dysrhythmia is suspected, which is the nurse's first action?
Counting the apical rate for 1 full minute and comparing it with the radial rate
Which nursing response is appropriate for the parent of a 2-month-old formula-fed baby that has been advised by a friend to give fresh cow's milk to the baby instead of formula milk because it has high nutritional value?
Cow's milk should be avoided before 12 months of age, because it may cause iron-deficiency anemia.
The patient in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure?
Crackles in the lung fields
Which organism causes aseptic meningitis?
Cytomegalovirus
Which patient activity best reflects the goal of phase 3 cardiac rehabilitation?
Developing a plan to walk briskly for physical conditioning
Which nursing action is appropriate during a blood transfusion, when a child reports mild precordial pain?
Transfuse the blood slower.
Which medication administration is avoided when caring for a child with epilepsy who is being treated with phenytoin?
IV phenytoin with glucose
Which nursing advice is appropriate for the parents of an 8-week-old baby with sickle cell disease that does not want penicillin prophylaxis? Select all that apply.
"Children with sickle cell disease should take penicillin prophylaxis by 2 months of age." "If a baby is put on penicillin, medical advice is needed if the temperature exceeds 38.3°C."
How is complex partial seizure similar to absence seizure?
Clonic movements may occur occasionally.
Which nursing response is appropriate for the parents of a child admitted to the pediatric intensive care unit for a submersion injury that feel guilty over the injury?
"Tell me more about your feelings."
What does the nurse teach the parents who are concerned and fearful of their child's bluish color?
"The child has cyanosis associated with a lack of oxygen."
Which nursing response is appropriate when asked what deferoxamine is from the parents of a child with β-thalassemia that is receiving numerous blood transfusions and deferoxamine therapy?
"The medication helps prevent iron overload."
Which nursing response is appropriate for the parents of a child with sickle cell anemia that are concerned about subsequent children having the disease?
"There is a 25% chance of a sibling having sickle cell anemia."
Which is the most common type of head injury in children?
Acceleration-deceleration injuries
What medication is administered prior to nitrates to reduce headache discomfort?
Acetaminophen
An LPN/LVN is scheduled to work on the inpatient "step-down" cardiac unit. Which patient does the charge nurse assign to the LPN/LVN?
66-year-old who has a prescription for a nitroglycerin patch and is scheduled for discharge to a group home later today
Which is the most suitable body temperature for cardiopulmonary bypass?
96
What should be the temperature of warm cardioplegia?
98
Which condition is appropriate when explaining to parents that there is a left shift on the complete blood count for their child?
A bacterial infection
The nurse explains to the parents of a child receiving furosemide that it is which type of medication?
A diuretic
Surgical repair for patent ductus arteriosus (PDA) is performed to prevent which complication?
A worsening of pulmonary vascular congestion
How should the nurse administer a digitalizing dosage to a child prescribed digoxin?
Administer divided doses intravenously over 24 hours
Which nursing intervention is appropriate when preventing antithymocyte globulin (ATG) from accumulating in the extravascular space of an aplastic anemia patient causing extravasation?
Administer medication to prevent tissue damage.
A patient has been admitted to the emergency department with chest pain and tightness and shortness of breath. After an initial assessment, the nurse suspects the patient has acute coronary syndrome (ACS). What will the nurse expect the health care provider to do immediately based on the recommendations provided by the American Heart Association (AHA)?
Administer morphine sulphate to the patient
Which nursing intervention is appropriate for a child who develops a severe vasoocclusive crisis?
Administration of analgesic to relieve pain
Which ethnic group has the highest incidence of sickle cell disease?
African Americans
A nurse is caring for a fragile infant with a serious congenital heart disease. What does the nurse teach the mother about feeding the infant?
Allow 30 minutes to complete a feeding
A nurse is caring for an infant with heart failure. What is the best intervention for decreasing the cardiac demand of the infant?
Allow the infant to have uninterrupted periods of sleep
Which drug is appropriate for abortive treatment of migraine in a 15-year-old adolescent?
Almotriptan
Which nursing explanation is appropriate for the parent of a child receiving an iron preparation whose stools are a tarry black color?
An expected change caused by the iron preparation
Which hematologic disorder is common in infancy and childhood?
Anemia
Which nursing intervention is appropriate to prevent increased intracranial pressure in an unconscious child?
Avoiding activities that result in pain or crying
Which combination therapy treatment method has improved the prognosis for children with HIV infection?
Antiretroviral
Which heart defect causes narrowing of the aortic valve?
Aortic stenosis
Which similarity is appropriate for both supratentorial features of an epidural hematoma and a subdural hematoma?
Associated with increased intracranial pressure
In which procedure for cardiac diagnosis are radiopaque catheters placed in a peripheral blood vessel and advanced into the heart?
Cardiac catheterization
What symptom of cardiac tamponade may occur in a patient after coronary artery bypass graft (CABG) surgery?
Cessation of previously heavy mediastinal drainage
A nurse is preparing to administer digoxin to an infant. Which is the most appropriate action when the nurse is administering digoxin?
Checking the apical heart rate and holding the medication if the pulse is below 90 to 110 beats/min
Which procedure is appropriate when identifying the means of eliminating excess iron in a child with thalassemia major?
Chelation therapy
A patient has just returned from coronary artery bypass graft (CABG) surgery. For which finding does the nurse contact the surgeon?
Chest tube drainage 175 mL last hour
Which clinical manifestations are appropriate with the diagnosis of hemophilia? Select all that apply.
Excessive bruising Hemorrhage from any trauma Prolonged bleeding from or in the body
After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign?
Facial drooping
Which blood coagulation factor abnormality can be determined using only the prothrombin time (PT) rather than using both the PT and the partial thromboplastin time (PTT)?
Factor VII
Which posturing finding is appropriate with severe dysfunction of the cerebral cortex or lesions to cortiocospinal tracts above the brainstem?
Flexion
Which manifestations of the clonic phase differ from those of the tonic phase in a child who has generalized tonic-clonic seizures?
Foaming at mouth
Which medications are diuretics used in the management of heart failure? Select all that apply.
Furosemide Chlorothiazide Spironolactone
Which drug is appropriate for the infant with Lennox-Gastaut Syndrome (LGS) that is not responding to front-line therapy?
Gabapentin
Which clinical features are appropriate in children with sickle cell anemia? Select all that apply.
Gallstones Hematuria Osteomyelitis Hepatomegaly
Which nursing instruction is appropriate for the child diagnosed with iron-deficiency anemia and is being treated with iron supplements that cause vomiting after ingestion? Select all that apply.
Give iron supplements with meals. Decrease dose and then increase to ordered dose as tolerated.
Which routine vaccines are appropriated for reducing the incidence of bacterial meningitis during infancy? Select all that apply.
H. influenza vaccine Pneumococcal vaccine
Which condition is appropriate for the child that complains of a sudden severe headache after 30 minutes of a blood transfusion?
Hemolytic reaction to the blood transfusion
Which funduscopic findings are appropriate for the patient diagnosed with papilledema? Select all that apply.
Hemorrhage Optic disc swelling Tortuosity of vessels
The nurse is caring for a patient with coronary artery disease (CAD) who has been prescribed metoprolol XR. What action does the nurse perform when caring for the patient?
Hold the medication if the heart rate is less than 50-60 beats/min
Which nursing action is appropriate for the child with sickle cell anemia who experiences severe chest pain, fever, a cough, and dyspnea?
Notifying the practitioner because the child may be experiencing chest syndrome
Which findings are appropriate when taking the medical history of a child suffering from anemia? Select all that apply.
Nutrition Correct2 Eating habits Correct3 Bowel habits Correct4 Family history History of chronic infection
Which level of consciousness is appropriate for the young child who is arousable with stimulation after a head injury?
Obtundation
A patient who has had a myocardial infarction is speaking angrily and finding fault with nurses, family members, and hospital employees. What is the best nursing intervention for this patient?
Offer the patient the ability to make decisions related to care.
Which clinical manifestations are appropriate for an HIV infection in children? Select all that apply.
Oral candidiasis Chronic diarrhea Lymphadenopathy Developmental delay
What does the nurse stress when counseling parents regarding the home care of the child with a cardiac defect before corrective surgery?
The desirability of promoting normalcy within the limits of the child's condition
Which assessment finding takes precedence when a patient returns from percutaneous transluminal coronary angioplasty?
The groin dressing has a 10-cm round bloodstain
Which reason is appropriate when explaining to parents why infants are particularly vulnerable to acceleration-deceleration head injuries?
The musculoskeletal support of the head is insufficient
After receiving change-of-shift report in the coronary care unit, which patient does the nurse assess first?
The patient with acute coronary syndrome who has a 3-pound weight gain and dyspnea
Which factor is appropriate to consider when administering iron?
To administer with ascorbic acid
Which purpose is appropriate when performing a lumbar puncture (LP)?
To analyze cerebrospinal fluid
Which reason is appropriate for immediately placing a child having a seizure episode into a side-lying position on a flat bed?
To prevent aspiration and choking
Which is an appropriate reason why a patient with an alarming rise in intracranial pressure would be induced into a coma using barbiturates? Select all that apply.
To reduce the intracranial pressure of the brain To protect the brain from the effects of low brain perfusion
Which type of seizure is occurring when the child's arms are flexed, eyes are rolled upwards, and legs, head, and neck are extended with increased salivation and loss of swallowing reflex, followed by violent jerking movements as the trunk and extremities undergo rhythmic contraction and relaxation?
Tonic-clonic seizure
A nurse is assessing an infant with a suspected cardiac anomaly. Which manifestation indicates the infant has chronic tissue hypoxemia?
clubbing
