Y- Issues Related to Pediatric Health - Chapter 3

60. Which statement is true of shaken baby syndrome? 1. There may be absence of external signs of injury. 2. Shaken babies usually do not have retinal hemorrhage. 3. Shaken babies usually do not have signs of a subdural hematoma. 4. Shaken babies have signs of external head injury.

1. There may be absence of external signs of injury in shaken baby syndrome because the injury can cause retinal hemorrhage and subdural hematoma

11. Expected nursing assessments of a newborn with suspected cystic fibrosis would include: 1. Observe frequency and nature of stools. 2. Provide chest physical therapy. 3. Observe for weight gain. 4. Assess parent's compliance with fluid restrictions.

11. 1. Cystic fibrosis is inherited as an autosomal-recessive trait, causing exocrine gland dysfunction. About 7% to 10% of newborns with cystic fibrosis present with meconium ileus, so assessing stool frequency and con sistency is important.

48. What would be the nurse's best advice to a mother who says her 3-year-old son ingested his father's Visine eye solution? 1. "Initiate vomiting immediately." 2. "Call the Poison Control Center." 3. "Call the pediatrician right away." 4. "Dilute with milk 1:1 volume of suspected ingestion."

2. Calling Poison Control is the first step for ingestion of any known or un known substance. Visine (topical sym pathomimetic) can cause serious or fatal consequences if even a little is ingested.

49. What would be the best response if a mother tells the nurse that the only way she can get her 2-year-old daughter to take medicine is to call it candy? 1. Tell her that is fine as long as the child takes all of the medicine. 2. Discuss the importance of not calling medicine candy to prevent accidental drug ingestion. 3. Discuss with the mother that the child does not have to take the medicine if she does not want it. 4. Tell the mother her child will have to go to "time out" if she does not take her medicine.

2. Medications should never be called candy so as to prevent accidental inges tion of medication by children thinking it is candy.

34. A child with a newly applied left leg cast initially feels fine, then starts to cry and tells his mother his leg hurts. Which assessment would be the nurse's first priority? 1. Cast integrity. 2. Neurovascular integrity. 3. Musculoskeletal integrity. 4. Soft-tissue integrity.

2. Neurovascular integrity should be as sessed first and frequently because neurovascular compromise may cause serious consequences. Neurovascular integrity should be assessed for pain: increased Pain out of proportion with injury, Pallor of extremity, Paresthesia, Pulselessness at distal part of extrem ity, and Paralysis post cast application (5 Ps). Cast integrity would be assessed, but neurovascular integrity is the highest priority.

36. Which assessment is most important after any injury in a child? 1. History of loss of consciousness and length of time unconscious. 2. Serial assessments of level of consciousness. 3. Initial neurological assessment. 4. Initial vital signs and oxygen saturation level.

2. Serial assessments of level of con sciousness are the most important observations of a child after any injury. That information tells you if the child's condition is changing.

37. Which would be the most appropriate nursing intervention when caring for a child newly admitted with a mild head concussion and no cervical spine injury? 1. Keep head of bed flat, side rails up, and safety measures in place. 2. Elevate head of bed, side rails up, and safety measures in place. 3. Observe for drainage from any orifice and notify physician immediately. 4. Continually stimulate the child to keep awake to check neurological status.

2. The head of the bed should be elevated to decrease intracranial pressure. Side rails should be up to help ensure the child stays in bed, and age-appropriate safety measures should be instituted.

42. Which intervention would be most appropriate for a 3-year-old boy who had just ingested dish detergent? 1. Discuss childproofing measures in the home in a nonthreatening manner. 2. Inquire about the circumstances of the ingestion. 3. Discuss having ipecac and the Poison Control phone number in the home. 4. Tell the mother you will be giving the boy medicine to make him throw up.

2. The most therapeutic approach is to inquire about the circumstances of the ingestion in a nonjudgmental manner.

43. Which would be the most appropriate intervention for a 4 year-old boy brought to the emergency department after ingesting a small watch battery? 1. No treatment would be needed; assess and monitor airway, breathing, circulation, and abdominal pain. 2. Ask the mother the time of the ingestion; if it was more than 2 hours ago, it will probably pass in his bowel movement. 3. Assess and monitor airway, breathing, circulation, and abdominal pain; anticipate admission and prepare for surgical intervention. 4. Discuss childproofing measures needed in the home with a 4-year-old child; provide anticipatory guidance concerning other possible poisonous ingestions.

3. Batteries are considered corrosives; the child will be admitted, and surgery may be necessary for removal.

33. Which would be the most appropriate discharge instructions for a child with a right wrist sprain 3 hours ago? 1. "You should rest, elevate the wrist above the heart, apply heat wrapped in a towel, and use the sling when walking." 2. "You can use the wrist, but stop if it hurts; elevate the wrist when not in use, and use the sling when walking." 3. "You should rest, apply ice wrapped in a towel, elevate the wrist above the heart, and use the sling when walking." 4. "You do not have to take any special precautions; do not use any movements that cause pain, and apply alternate heat and ice, each wrapped in a towel.

3. For the first 24 hours, rest, ice, compression, and elevation are recommended for acute injury. This is best remembered by the acronym RICE (rest, ice, compression, and elevation).

50. Which nursing plan would be most successful if the nurse has to administer activated charcoal to a 5-year-old boy? 1. Have his parents tell him he has to drink it while providing a movie to distract him. 2. Tell him it is candy, it tastes good, do not let him look at it, and tell him he will get a toy after he takes it all down. 3. Mix it with a sweetening flavoring, provide a straw, give in an opaque cup with a cover. 4. Have his mother take some first to show the boy it does not taste too bad, and then administer it to him quickly.

3. Mixing charcoal with a sweetening agent may help the child ingest it. Children usually like sweeter drinks. Hiding the black color in an opaque container with a lid may also make it more palatable.

55. Which assessment of a 2-year-old with burns on his feet would cause suspicion of child abuse? 1. Splash marks on his right lower leg. 2. Burns noted on right arm. 3. Symmetrical burns on both feet. 4. Burns mainly noted on right foot.

3. Physical abuse has certain characteris tics. Symmetrical burns on both feet indicate abuse.

31. When discharging a newborn, which injury prevention instruction would be of highest priority to tell the parents? 1. "Place safety locks on all medicine cabinets and household cleaning supplies." 2. "Transport the infant in the front seat when driving alone so you can see the baby." 3. "Never leave the baby unattended on a raised, unguarded area." 4. "Place safety guards in front of any heating appliance, stove, fireplace, or radiator."

3. The highest priority in newborn injury prevention is to never leave the baby unattended on a raised, unguarded sur face. Involuntary reflexes may cause the infant to move and fall.

32. A 10-month-old female is carried into the emergency department by her parents after she fell down 15 stairs in her walker. Which would be your highest priority nursing intervention? 1. Assess airway while simultaneously maintaining cervical spine precautions. 2. Assess airway, breathing, and circulation simultaneously. 3. Prepare for diagnostic radiological testing to check for any injuries. 4. Obtain venous access and draw blood for testing.

32. 1. Priority nursing intervention with pediatric trauma patients is airway assessment while maintaining cervical spine precautions. If the airway is com promised, immediate corrective action should be taken prior to assessment of breathing.

35. An adolescent male comes in for his yearly physical. Which would be the most appropriate injury prevention/safety teaching for him? 1. Inquire which are his favorite sports and discuss his knowledge and application of appropriate safety principles. 2. Tell him to be careful performing sports activities because every sport has the potential for injury. 3. Tell him not to let his friends encourage him to drink or smoke or take any drugs. 4. Ask his mother what sports he plays and if he wears a helmet with contact sports.

35. 1. Adolescence is a time of need for independence and learning to make appropriate decisions. Safety is always a concern, and tying a safety discussion to the teen's interest in sports will help keep him safe. The nurse needs to inquire and build on the teen's interests and knowledge.

38. Which would be the most appropriate teaching to the parents of a female child in the emergency department who is awake, alert, and has no respiratory distress after a near-drowning experience? 1. "She will most likely be discharged, and you should watch for any cough or trouble breathing." 2. "She will need to have a preventive tube for breathing and ventilation to ensure her lungs are clear." 3. "She will be fine but sometimes antibiotics are started as a preventive." 4. "She will most likely be admitted for at least 24 hours and observed for respiratory distress or any swelling of the brain."

4. Any child who has had a near-drowning experience should be admitted for observation. Even if a child does not appear to have any injury from the event, complications can occur within 24 hours after the event. Respiratory compromise and cerebral edema can be delayed complications.

44. Which nursing intervention would be of highest priority for a 2-year-old suspected of ingestion of his grandmother's digoxin? 1. Provide supplemental oxygen. 2. Establish intravenous access. 3. Draw blood for a STAT digoxin level. 4. Provide continuous cardiac monitoring.

4. Bradycardia and cardiac dysrhythmias are common signs of digoxin toxicity in children. Continuous cardiac monitor ing is the highest priority to detect dys rhythmias before they became lethal.

47. Which would be the best response to a 10-year-old girl who asks if she can take acetaminophen daily if she gets aches and pains? 1. Tell her it is better not to take medication if she gets aches and pains; she should check with her mother before taking any medication. 2. Teach her that nonprescription drugs like acetaminophen can be a poisoning hazard if too many are taken; it is best for her to check with her mother. 3. Encourage her to keep a log of when she takes acetaminophen to try to establish what is causing her aches and pains. 4. Sometimes it is okay to take acetaminophen daily, but it depends on why she has aches and pains.

4. If she needs pain medication daily, a cause needs to be determined.

41. Which response about safety measures is the most appropriate advice to the 2-year old girl's mother who had her older home remodeled to reduce the lead level? 1. "Wash and dry the child's hands and face before eating." 2. "Remodeling the home to remove the lead is all you need to do." 3. "It is best to use hot water to prepare the child's food to decrease the lead." 4. "Diet does not matter in reducing lead levels in the child."

41. 1. Washing and drying hands and face, especially before eating, decrease lead ingestion.

45. Which would be the priority nursing intervention for a child with carbon monoxide poisoning? 1. Provide supplemental 100% oxygen. 2. Provide continuous oxygen saturation monitoring. 3. Establish intravenous access. 4. Draw blood for a STAT carbon monoxide level.

45. 1. 100% oxygen via non-rebreather mask is given as quickly as possible if carbon monoxide poisoning is suspected be cause the signs and symptoms of car bon monoxide poisoning are related to tissue hypoxia.

46. Which of the following would be appropriate anticipatory guidance for a well-care visit of a 17-year-old? 1. Discuss alcohol use and potential for alcohol poisoning. 2. Discuss secondary sex characteristics that will develop. 3. Teach about anger management and safe sex. 4. Teach about peer pressure and desire for independence.

46. 1. Age- and developmentally appropriate anticipatory guidance teachings for a 17-year-old are to discuss alcohol use and potential for alcohol poisoning.