Wongs Essentials of Pediatric Nursing 9 Part 2 of 2 By Maryln – Test Bank

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Wongs Essentials of Pediatric Nursing 9 Part 2 of 2 By Maryln – Test Bank

Chapter 14: Health Problems of Toddlers and Preschoolers

 

MULTIPLE CHOICE

 

  1. Which is described as the time interval between infection or exposure to disease and appearance of initial symptoms?
a. Incubation period
b. Prodromal period
c. Desquamation period
d. Period of communicability

 

 

ANS:  A

The incubation period is the interval between infection or exposure and appearance of symptoms. The prodromal period is the interval between the time when early manifestations of disease appear and the overt clinical syndrome is evident. Desquamation refers to the shedding of skin. The period of communicability is the time or times during which an infectious agent may be transferred directly or indirectly from an infected person to another person.

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   424

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Airborne isolation is required for a child who is hospitalized with:
a. mumps.
b. chickenpox.
c. exanthema subitum (roseola).
d. erythema infectiosum (fifth disease).

 

 

ANS:  B

Chickenpox is communicable through direct contact, droplet spread, and contaminated objects. Mumps is transmitted from direct contact with saliva of infected person and is most communicable before onset of swelling. The transmission and source of the viral infection exanthema subitum (roseola) is unknown. Erythema infectiosum (fifth disease) is communicable before onset of symptoms.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   424

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Safe and Effective Care Environment

 

  1. Acyclovir (Zovirax) is given to children with chickenpox to:
a. minimize scarring.
b. decrease the number of lesions.
c. prevent aplastic anemia.
d. prevent spread of the disease.

 

 

ANS:  B

Acyclovir decreases the number of lesions; shortens duration of fever; and decreases itching, lethargy, and anorexia. Treating pruritus and discouraging itching minimizes scarring. Aplastic anemia is not a complication of chickenpox. Strict isolation until vesicles are dried prevents spread of disease.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   429-430

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. The single parent of a 3-year-old child who has just been diagnosed with chickenpox tells the nurse that she cannot afford to stay home with the child and miss work. The parent asks the nurse if some medication will shorten the course of the illness. Which is the most appropriate nursing intervention?
a. Reassure the parent that it is not necessary to stay home with the child.
b. Explain that no medication will shorten the course of the illness.
c. Explain the advantages of the medication acyclovir (Zovirax) to treat chickenpox.
d. Explain the advantages of the medication VCZ immune globulin (VariZIG) to treat chickenpox.

 

 

ANS:  C

Acyclovir is effective in treating the number of lesions; shortening the duration of fever; and decreasing itching, lethargy, and anorexia. It is important the parent stay with the child to monitor fever. Acyclovir lessens the severity of chickenpox. VariZIG is given only to high-risk children.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   429-430

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which may be given to high-risk children after exposure to chickenpox to prevent varicella?
a. Acyclovir (Zovirax)
b. Varicella globulin
c. Diphenhydramine hydrochloride (Benadryl)
d. VCZ immune globulin (VariZIG)

 

 

ANS:  D

VariZIG is given to high-risk children to prevent the development of chickenpox. Acyclovir decreases the severity, not the development, of chickenpox. Varicella globulin is not effective because it is not the immune globulin. Diphenhydramine may help pruritus but not the actual chickenpox.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   429

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Vitamin A supplementation may be recommended for the young child who has which disease?
a. Mumps
b. Rubella
c. Measles (rubeola)
d. Erythema infectiosum

 

 

ANS:  C

Evidence shows vitamin A decreases morbidity and mortality in measles. Mumps is treated with analgesics for pain and antipyretics for fever. Rubella is treated similarly to mumps. Erythema infectiosum is treated similarly to mumps and rubella.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   431

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is teaching parents about caring for their child with chickenpox. The nurse should let the parents know that the child is considered to be no longer contagious when which occurs?
a. When fever is absent
b. When lesions are crusted
c. 24 hours after lesions erupt
d. 8 days after onset of illness

 

 

ANS:  B

When the lesions are crusted, the chickenpox is no longer contagious. This may be a week after onset of disease. Chickenpox is still contagious when child has fever. Children are contagious after lesions erupt. If lesions are crusted at 8 days, the child is no longer contagious.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   424

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is assessing a child and notes Koplik spots. In which of these communicable diseases are Koplik spots present?
a. Rubella
b. Measles (rubeola)
c. Chickenpox (varicella)
d. Exanthema subitum (roseola)

 

 

ANS:  B

Koplik spots are small irregular red spots with a minute, bluish white center found on the buccal mucosa 2 days before systemic rash. Rubella occurs with rash on the face, which rapidly spreads downward. Varicella appears with highly pruritic macules, followed by papules and vesicles. Roseola is seen with rose-pink macules on the trunk, spreading to face and extremities.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   426

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which is a common childhood communicable disease that may cause severe defects in the fetus when it occurs in its congenital form?
a. Erythema infectiosum
b. Roseola
c. Rubeola
d. Rubella

 

 

ANS:  D

Rubella causes teratogenic effects on the fetus. There is a low risk of fetal death to those in contact with children affected with fifth disease. Roseola and rubeola are not dangerous to the fetus.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   428

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which is the causative agent of scarlet fever?
a. Enteroviruses
b. Corynebacterium organisms
c. Scarlet fever virus
d. Group A b-hemolytic streptococci (GABHS)

 

 

ANS:  D

GABHS infection causes scarlet fever. Enteroviruses do not cause the same complications. Corynebacterium organisms cause diphtheria. Scarlet fever is not caused by a virus.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   428

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A parent reports to the nurse that her child has inflamed conjunctivae of both eyes with purulent drainage and crusting of the eyelids, especially on awakening. These manifestations suggest:
a. viral conjunctivitis.
b. allergic conjunctivitis.
c. bacterial conjunctivitis.
d. conjunctivitis caused by foreign body.

 

 

ANS:  C

Bacterial conjunctivitis has these symptoms. Viral or allergic conjunctivitis has watery drainage. Foreign body causes tearing and pain, and usually only one eye is affected.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   432

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which is an important nursing consideration when caring for a child with herpetic gingivostomatitis (HGS)?
a. Apply topical anesthetics before eating.
b. Drink from a cup, not a straw.
c. Wait to brush teeth until lesions are sufficiently healed.
d. Explain to parents how this is sexually transmitted.

 

 

ANS:  A

Treatment for HGS is aimed at relief of pain. Drinking bland fluids through a straw helps avoid painful lesions. Mouth care is encouraged with a soft toothbrush. HGS is usually caused by herpes simplex virus type 1, which is not associated with sexual transmission.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   433

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A parent has asked the nurse about how her child can be tested for pinworms. The nurse responds by stating that which is the most common test for diagnosing pinworms in a child?
a. Lower gastrointestinal (GI) series
b. Three stool specimens, at intervals of 4 days
c. Observation for presence of worms after child defecates
d. Laboratory examination of a fecal smear

 

 

ANS:  D

Laboratory examination of substances containing the worm, its larvae, or ova can identify the organism. Most are identified by examining fecal smears from the stools of persons suspected of harboring the parasite. Fresh specimens are best for revealing parasites or larvae. Lower GI series is not helpful for diagnosing enterobiasis. Stool specimens are not necessary to diagnose pinworms. Worms will not be visible after child defecates.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   433

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. The nurse suspects that a child has ingested some type of poison. Which clinical manifestation would be most suggestive that the poison was a corrosive product?
a. Tinnitus
b. Disorientation
c. Stupor, lethargy, coma
d. Edema of lips, tongue, pharynx

 

 

ANS:  D

Edema of lips, tongue, and pharynx indicates a corrosive ingestion. Tinnitus is indicative of aspirin ingestion. Corrosives do not act on the central nervous system (CNS).

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   437

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The nurse taking the call should know that the primary danger is which result?
a. Hepatic dysfunction
b. Dehydration secondary to vomiting
c. Esophageal stricture and shock
d. Bronchitis and chemical pneumonia

 

 

ANS:  D

Lighter fluid is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose, not hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger. Esophageal stricture is a late or chronic issue of hydrocarbon ingestion.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   438

TOP:   Integrated Process: Nursing Process: Diagnosis

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which is a clinical manifestation of acetaminophen poisoning?
a. Hyperpyrexia
b. Hepatic involvement
c. Severe burning pain in stomach
d. Drooling and inability to clear secretions

 

 

ANS:  B

Hepatic involvement is the third stage of acetaminophen poisoning. Hyperpyrexia is a severe elevation in body temperature and is not related to acetaminophen poisoning. Acetaminophen does not cause burning pain in stomach or pose an airway threat.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   438

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Acute salicylate (ASA, aspirin) poisoning results in:
a. chemical pneumonitis.
b. hepatic damage.
c. retractions and grunting.
d. disorientation and loss of consciousness.

 

 

ANS:  D

ASA poisoning causes disorientation and loss of consciousness. Chemical pneumonitis is caused by hydrocarbon ingestion. Hepatic damage is caused by acetaminophen overdose. ASA does not cause airway obstruction.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   438

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A young child has just arrived at the emergency department after ingestion of aspirin at home. The practitioner has ordered activated charcoal. The nurse administers charcoal in which way?
a. Administer through a nasogastric tube because the child will not drink it because of the taste.
b. Serve in a clear plastic cup so the child can see how much has been drunk.
c. Give half of the solution, and then give the other half in 1 hour.
d. Serve in an opaque container with a straw.

 

 

ANS:  D

Although the activated charcoal can be mixed with a flavorful beverage, it will be black and resemble mud. When it is served in an opaque container, the child does not have any preconceived ideas about its being distasteful. The nasogastric tube should be used only in children without a gag reflex. The ability to see the charcoal solution may affect the child’s desire to drink it. The child should be encouraged to drink the solution all at once.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   440

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which is the most frequent source of acute childhood lead poisoning?
a. Folk remedies
b. Unglazed pottery
c. Lead-based paint
d. Cigarette butts and ashes

 

 

ANS:  C

Lead-based paint in houses built before 1978 is the most frequent source of lead poisoning. Some folk remedies and unglazed pottery may contain lead, but they are not the most frequent source. Cigarette butts and ashes do not contain lead.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   441-442

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Chelation therapy for lead poisoning is initiated when a child’s blood level is _____ g/dl.
a. 10 to 14
b. 15 to 19
c. 20 to 44
d. >45

 

 

ANS:  D

Chelation therapy is initiated if the child’s blood level is greater than 45 g/dl. At 10 to 14 g/dl, the family should have lead-poisoning education and follow-up level. At 15 to 19 g/dl, the family should have lead-poisoning education and follow-up level but if it persists, initiate environmental investigation. At 20 to 44 g/dl environmental investigation and lead hazard control are necessary.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   444

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which describes a child who is abused by the parent(s)?
a. Unintentionally contributes to the abusing situation
b. Belongs to a low socioeconomic population
c. Is healthier than the nonabused siblings
d. Abuses siblings in the same way as child is abused by the parent(s)

 

 

ANS:  A

Child’s temperament, position in the family, additional physical needs, activity level, or degree of sensitivity to parental needs unintentionally contribute to the abusing situation. Abuse occurs among all socioeconomic levels. Children who are ill or have additional physical needs are more likely to be abused. The abused child may not abuse siblings.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   447

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Psychosocial Integrity

 

  1. Which is a common characteristic of those who sexually abuse children?
a. Pressure victim into secrecy
b. Are usually unemployed and unmarried
c. Are unknown to victims and victims’ families
d. Have many victims that are each abused once only

 

 

ANS:  A

Sex offenders may pressure the victim into secrecy regarding the activity as a “secret between us” that other people may take away if they find out. The offender may be anyone, including family members and persons from any level of society. Sex offenders are usually trusted acquaintances of the victims and victims’ families. Many victims are abused many times over a long period.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   447

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Psychosocial Integrity

 

  1. A 3-month-old infant dies shortly after arrival to the emergency department. The infant has subdural and retinal hemorrhages but no external signs of trauma. The nurse should suspect:
a. unintentional injury.
b. shaken-baby syndrome.
c. sudden infant death syndrome (SIDS).
d. congenital neurologic problem.

 

 

ANS:  B

Shaken-baby syndrome causes internal bleeding but may have no external signs. Unintentional injury would not cause these injuries. SIDS and congenital neurologic problems would not appear this way.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   446

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Psychosocial Integrity

 

  1. Which is probably the most important criterion on which to base the decision to report suspected child abuse?
a. Inappropriate parental concern for the degree of injury
b. Absence of parents for questioning about child’s injuries
c. Inappropriate response of child
d. Incompatibility between the history and injury observed

 

 

ANS:  D

Conflicting stories about the “accident” are the most indicative red flags of abuse. Inappropriate response of caregiver or child may be present, but is subjective. Parents should be questioned at some point during the investigation.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   449

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Psychosocial Integrity

 

  1. A nurse is admitting a child to the hospital with a diagnosis of giardiasis. Which medication should the nurse expect to be prescribed?
a. Metronidazole (Flagyl)
b. Amoxicillin clavulanate (Augmentin)
c. Clarithromycin (Biaxin)
d. Prednisone (Orapred)

 

 

ANS:  A

The drugs of choice for treatment of giardiasis are metronidazole (Flagyl), tinidazole (Tindamax), and nitazoxanide (Alinia). These are classified as antifungals. Amoxicillin and clarithromycin are antibiotics that treat bacterial infections. Prednisone is a steroid and is used as an anti-inflammatory medication.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   435

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is beginning chelation therapy on a child for lead poisoning. Which intervention should the nurse implement during the time the child is receiving chelation therapy?
a. Calorie counts
b. Strict intake and output
c. Telemetry monitoring
d. Contact isolation

 

 

ANS:  B

Because calcium disodium edetate (EDTA) and lead are toxic to the kidneys, a nurse should keep strict records of intake and output to monitor renal functioning. Adequate hydration is essential during therapy because the chelates are excreted via the kidneys. Calorie counts, telemetry, or contact isolation would not be nursing interventions appropriate for a child undergoing chelation therapy.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   444

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A child has been admitted to the emergency department with an acetaminophen (Tylenol) poisoning. An antidote is being prescribed by the health care provider. Which antidote should the nurse prepare to administer?
a. Naloxone (Narcan)
b. N-acetylcysteine (Mucomyst)
c. Flumazenil (Romazicon)
d. Digoxin immune Fab (Digibind)

 

 

ANS:  B

Antidotes available to treat toxin ingestion include N-acetylcysteine for acetaminophen poisoning, naloxone for opioid overdose, flumazenil (Romazicon) for benzodiazepines (diazepam [Valium], midazolam [Versed]) overdose, and digoxin immune Fab (Digibind) for digoxin toxicity.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   440

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A clinic nurse is assessing a child with erythema infectiosum (fifth disease). Which figure depicts the rash the nurse should expect to assess?
a. c.
b. d.

 

 

ANS:  A

Erythema infectiosum rash appears in three stages: erythema on face, chiefly on cheeks (“slapped face” appearance); disappears by 1-4 days. Chicken pox rash begins as macule, rapidly progresses to papule and then vesicle (surrounded by erythematous base; becomes umbilicated and cloudy; breaks easily and forms crusts); all three stages (papule, vesicle, crust) present in varying degrees at one time. Roseola rash is discrete rose-pink macules or maculopapules appearing first on trunk and then spreading to neck, face, and extremities; nonpruritic; fades on pressure; lasts 1-2 days. Rubeola rash—appears 3-4 days after onset of prodromal stage; begins as erythematous maculopapular eruption on face and gradually spreads downward; more severe in earlier sites (appears confluent) and less intense in later sites (appears discrete); after 3-4 days, assumes brownish appearance, and fine desquamation occurs over area of extensive involvement.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   425

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

MULTIPLE RESPONSE

 

  1. A nurse is teaching parents methods to reduce lead levels in their home. Which should the nurse include in the teaching? (Select all that apply.)
a. Plant bushes around the outside of the house.
b. Ensure your child eats frequent meals.
c. Use hot water from the tap when boiling vegetables.
d. Food can be stored in ceramic in the refrigerator.
e. Ensure that your child’s diet contains sufficient iron and calcium.

 

 

ANS:  A, B, E

Methods to reduce lead levels in homes include: planting bushes around the outside of the house, if soil is contaminated with lead, so children cannot play there; ensuring that children eat regular meals because more lead is absorbed on an empty stomach; and ensuring that children’s diets contain sufficient iron and calcium. Cold water should only be used for drinking, cooking, and reconstituting powder infant formula. Hot water dissolves lead more quickly than cold water and thus contains higher levels of lead. Do not use pottery or ceramic ware that was inadequately fired or is meant for decorative use for food storage or service.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   445

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

ESSAY

 

  1. Place in order the correct sequence for emergency treatment of poisoning in a child. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d).
  2. Locate the poison.
  3. Assess the child.
  4. Prevent absorption of poison.
  5. Terminate exposure to the toxic substance.

 

ANS:

b, d, a, c

The initial step in treating poisonings is to assess the child, treat immediate life-threatening conditions, and initiate cardiopulmonary resuscitation (CPR) if indicated. Terminating the exposure to the toxic substance is the second step. Locating the poison for identification is the third step. Preventing absorption of poison is the fourth step.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   437

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

Chapter 24: The Child with Gastrointestinal Dysfunction

 

MULTIPLE CHOICE

 

  1. Which condition in a child should alert a nurse for increased fluid requirements?
a. Fever
b. Mechanical ventilation
c. Congestive heart failure
d. Increased intracranial pressure (ICP)

 

 

ANS:  A

Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid overload in children. Increased ICP does not lead to increased fluid requirements in children.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   763

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. A nurse is conducting an in-service on gastrointestinal disorders. The nurse includes that melena, the passage of black, tarry stools, suggests bleeding from which area?
a. Perianal or rectal area
b. Hemorrhoids or anal fissures
c. Upper gastrointestinal (GI) tract
d. Lower GI tract

 

 

ANS:  C

Melena is denatured blood from the upper GI tract or bleeding from the right colon. Blood from the perianal or rectal area, hemorrhoids, or lower GI tract would be bright red.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   792

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Which type of dehydration is defined as “dehydration that occurs in conditions in which electrolyte and water deficits are present in approximately balanced proportion”?
a. Isotonic dehydration
b. Hypotonic dehydration
c. Hypertonic dehydration
d. All types of dehydration in infants and small children

 

 

ANS:  A

Isotonic dehydration is the correct term for this definition and is the most frequent form of dehydration in children. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. Hypertonic dehydration results from water loss in excess of electrolyte loss and is usually caused by a proportionately larger loss of water or a larger intake of electrolytes. This definition is specific to isotonic dehydration.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   767

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. A nurse is admitting an infant with dehydration caused from water loss in excess of electrolyte loss. Which type of dehydration is this infant experiencing?
a. Isotonic
b. Isosmotic
c. Hypotonic
d. Hypertonic

 

 

ANS:  D

Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion and is another term for isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   767

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. An infant is brought to the emergency department with dehydration. Which physical assessment finding does the nurse expect?
a. Weight gain
b. Bradycardia
c. Poor skin turgor
d. Brisk capillary refill

 

 

ANS:  C

Clinical manifestations of dehydration include poor skin turgor, weight loss, lethargy, and tachycardia. The infant would have prolonged capillary refill, not brisk.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   767

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. Parents call the clinic and report that their toddler has had acute diarrhea for 24 hours. The nurse should further ask the parents if the toddler has which associated factor that is causing the acute diarrhea?
a. Celiac disease
b. Antibiotic therapy
c. Immunodeficiency
d. Protein malnutrition

 

 

ANS:  B

Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy. Celiac disease is a problem with gluten intolerance and may cause chronic diarrhea if not identified and managed appropriately. Immunodeficiency would occur with chronic diarrhea. Protein malnutrition or kwashiorkor causes chronic diarrhea from lowered resistance to infection.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   772

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. Which pathogen is the viral pathogen that frequently causes acute diarrhea in young children?
a. Giardia organisms
b. Shigella organisms
c. Rotavirus
d. Salmonella organisms

 

 

ANS:  C

Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia (parasite) and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial pathogen that is uncommon in the United States.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   772

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. Which is a parasite that causes acute diarrhea?
a. Shigella organisms
b. Salmonella organisms
c. Giardia lamblia
d. Escherichia coli

 

 

ANS:  C

  1. lamblia is a parasite that represents 10% of non-dysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   775

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. A child is admitted with bacterial gastroenteritis. Which lab results of a stool specimen confirm this diagnosis?
a. Eosinophils
b. Occult blood
c. pH less than 6
d. Neutrophils and red blood cells

 

 

ANS:  D

Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance and parasitic infections are suspected in the presence of eosinophils. Occult blood may indicate pathogens such as Shigella, Campylobacter, or hemorrhagic Escherichia coli strains. A pH of less than 6 may indicate carbohydrate malabsorption or secondary lactase insufficiency.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   775

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Which therapeutic management should the nurse prepare to initiate first for a child with acute diarrhea and moderate dehydration?
a. Clear liquids
b. Adsorbents, such as kaolin and pectin
c. Oral rehydration solution (ORS)
d. Antidiarrheal medications such as paregoric

 

 

ANS:  C

ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended. Antidiarrheals are not recommended because they do not get rid of pathogens.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   775

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. A school-age child with diarrhea has been rehydrated. The nurse is discussing the child’s diet with the family. Which statement by the parent would indicate a correct understanding of the teaching?
a. “I will keep my child on a clear liquid diet for the next 24 hours.”
b. “I should encourage my child to drink carbonated drinks but avoid food for the next 24 hours.”
c. “I will offer my child bananas, rice, applesauce, and toast for the next 48 hours.”
d. “I should have my child eat a normal diet with easily digested foods for the next 48 hours.”

 

 

ANS:  D

Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness. Clear liquids and carbonated drinks have high carbohydrate content and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. The BRAT diet has little nutritional value and is high in carbohydrates.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   775-776

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

 

  1. A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child should begin with:
a. intravenous (IV) fluids.
b. ORS.
c. clear liquids, 1 to 2 ounces at a time.
d. administration of antidiarrheal medication.

 

 

ANS:  A

In children with severe dehydration, IV fluids are initiated. ORS is acceptable therapy if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth. These fluids have a high carbohydrate content, low electrolyte content, and high osmolality. Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   776

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. A mother calls the clinic nurse about her 4-year-old son who has acute diarrhea. She has been giving him the antidiarrheal drug loperamide (Imodium A-D). The nurse’s response should be based on knowledge that this drug is:
a. not indicated.
b. indicated because it slows intestinal motility.
c. indicated because it decreases diarrhea.
d. indicated because it decreases fluid and electrolyte losses.

 

 

ANS:  A

Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea. These medications have adverse effects and toxicity, such as worsening of the diarrhea because of slowing of motility and ileus, or a decrease in diarrhea with continuing fluid losses and dehydration. Antidiarrheal medications are not recommended in infants and small children.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   777

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

  1. Constipation has recently become a problem for a school-age girl. She is healthy except for seasonal allergies that are being treated with antihistamines. The nurse should suspect that the constipation is most likely caused by:
a. diet.
b. allergies.
c. antihistamines.
d. emotional factors.

 

 

ANS:  C

Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids, antiepileptics, and iron. Because this is the only known change in her habits, the addition of antihistamines is most likely the cause of the diarrhea. With a change in bowel habits, the role of any recently prescribed medications should be assessed.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   778

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

  1. Which is a high-fiber food that the nurse should recommend for a child with chronic constipation?
a. Popcorn
b. Pancakes
c. Muffins
d. Ripe bananas

 

 

ANS:  A

Popcorn is a high-fiber food. Pancakes and muffins do not have significant fiber unless made with fruit or bran. Raw fruits, especially those with skins and seeds, other than ripe bananas, have high fiber.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   779-780

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

 

  1. Which therapeutic management treatment is implemented for children with Hirschsprung disease?
a. Daily enemas
b. Low-fiber diet
c. Permanent colostomy
d. Surgical removal of affected section of bowel

 

 

ANS:  D

Most children with Hirschsprung disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery. The colostomy that is created in Hirschsprung disease is usually temporary.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   781

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease. The enema solution should be:
a. tap water.
b. normal saline.
c. oil retention.
d. phosphate preparation.

 

 

ANS:  B

Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid overload. Oil-retention enemas will not achieve the “until clear” result. Phosphate enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the phosphate enema can result in diarrhea, which can lead to metabolic acidosis.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   781

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child psychologically is:
a. not necessary because of child’s age.
b. not necessary because colostomy is temporary.
c. necessary because it will be an adjustment.
d. necessary because the child must deal with a negative body image.

 

 

ANS:  C

The child’s age dictates the type and extent of psychological preparation. When a colostomy is performed, the child who is at least preschool age is told about the procedure and what to expect in concrete terms, with the use of visual aids. It is necessary to prepare a 3-year-old child for procedures. The preschooler is not yet concerned with body image.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   781

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Psychosocial Integrity: Coping and Adaptation

 

  1. The nurse is explaining to a parent how to care for a school-age child with vomiting associated with a viral illness. Which action should the nurse include?
a. Avoid carbohydrate-containing liquids.
b. Give nothing by mouth for 24 hours.
c. Brush teeth or rinse mouth after vomiting.
d. Give plain water until vomiting ceases for at least 24 hours.

 

 

ANS:  C

It is important to emphasize the need for the child to brush the teeth or rinse the mouth after vomiting to dilute the hydrochloric acid that comes in contact with the teeth. Ad libitum administration of glucose-electrolyte solution to an alert child will help restore water and electrolytes satisfactorily. It is important to include carbohydrate to spare body protein and avoid ketosis.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   782

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. A 4-month-old infant has gastroesophageal reflux (GER) but is thriving without other complications. Which should the nurse suggest to minimize reflux?
a. Place in Trendelenburg position after eating.
b. Thicken formula with rice cereal.
c. Give continuous nasogastric tube feedings.
d. Give larger, less frequent feedings.

 

 

ANS:  B

Small, frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula has been recommended. Milk-thickening agents have been shown to decrease the number of episodes of vomiting and to increase the caloric density of the formula. This may benefit infants who are underweight as a result of GER disease. Placing the child in a Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   783

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. A histamine-receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is ordered for an infant with GER. The purpose of this is to:
a. prevent reflux.
b. prevent hematemesis.
c. reduce gastric acid production.
d. increase gastric acid production.

 

 

ANS:  C

The mechanism of action of histamine-receptor antagonists is to reduce the amount of acid present in gastric contents and perhaps prevent esophagitis. Preventing reflux or hematemesis and increasing gastric acid production are not the modes of action of histamine-receptor antagonists.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   783

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

  1. Which clinical manifestation would be the most suggestive of acute appendicitis?
a. Rebound tenderness
b. Bright red or dark red rectal bleeding
c. Abdominal pain that is relieved by eating
d. Abdominal pain that is most intense at McBurney point

 

 

ANS:  D

Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain localizes to the right lower quadrant at McBurney point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Bright red or dark red rectal bleeding and abdominal pain that is relieved by eating are not signs of acute appendicitis.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   785

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. When caring for a child with probable appendicitis, the nurse should be alert to recognize that which condition or symptom is a sign of perforation?
a. Bradycardia
b. Anorexia
c. Sudden relief from pain
d. Decreased abdominal distention

 

 

ANS:  C

Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical manifestation of appendicitis. Abdominal distention usually increases.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   786

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. Which is appropriate to relieve the abdominal discomfort?
a. Place in Trendelenburg position.
b. Allow to assume position of comfort.
c. Apply moist heat to the abdomen.
d. Administer a saline enema to cleanse bowel.

 

 

ANS:  B

The child should be allowed to take a position of comfort, usually with the legs flexed. The Trendelenburg position will not help with the discomfort. In any instance in which appendicitis is a possibility, there is a danger in administering a laxative or enemas or applying heat to the area. Such measures stimulate bowel motility and increase the risk of perforation.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   787

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. A nurse is conducting an in-service on childhood gastrointestinal disorders. Which statement is most descriptive of Meckel diverticulum?
a. It is more common in females than in males.
b. It is acquired during childhood.
c. Intestinal bleeding may be mild or profuse.
d. Medical interventions are usually sufficient to treat the problem.

 

 

ANS:  C

Bloody stools are often a presenting sign of Meckel diverticulum. It is associated with mild to profuse intestinal bleeding. It is twice as common in males as in females, and complications are more frequent in males. Meckel diverticulum is the most common congenital malformation of the GI tract and is present in 1% to 4% of the general population. The standard therapy is surgical removal of the diverticulum.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   788

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. A nurse is admitting a child with Crohn disease. Parents ask the nurse, “How is this disease different from ulcerative colitis?” Which statement should the nurse make when answering this question?
a. “With Crohn’s the inflammatory process involves the whole GI tract.”
b. “There is no difference between the two diseases.”
c. “The inflammation with Crohn’s is limited to the colon and rectum.”
d. “Ulcerative colitis is characterized by skip lesions.”

 

 

ANS:  A

The chronic inflammatory process of Crohn disease involves any part of the GI tract from the mouth to the anus but most often affects the terminal ileum. Crohn disease involves all layers of the bowel wall in a discontinuous fashion, meaning that between areas of intact mucosa, there are areas of affected mucosa (skip lesions). The inflammation found with ulcerative colitis is limited to the colon and rectum, with the distal colon and rectum the most severely affected. Inflammation affects the mucosa and submucosa and involves continuous segments along the length of the bowel with varying degrees of ulceration, bleeding, and edema.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   789

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. Which is used to treat moderate to severe inflammatory bowel disease?
a. Antacids
b. Antibiotics
c. Corticosteroids
d. Antidiarrheal medications

 

 

ANS:  C

Corticosteroids, such as prednisone and prednisolone, are used in short bursts to suppress the inflammatory response in inflammatory bowel disease. Antacids and antidiarrheal medications are not drugs of choice in the treatment of inflammatory bowel disease. Antibiotics may be used as an adjunctive therapy to treat complications.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   790

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

  1. Bismuth subsalicylate, clarithromycin, and metronidazole are prescribed for a child with a peptic ulcer to:
a. eradicate Helicobacter pylori.
b. coat gastric mucosa.
c. treat epigastric pain.
d. reduce gastric acid production.

 

 

ANS:  A

The drug therapy combination of bismuth subsalicylate, clarithromycin, and metronidazole is effective in the treatment of H. pylori and is prescribed to eradicate it.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   793

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

  1. Which statement best characterizes hepatitis A?
a. Incubation period is 6 weeks to 6 months.
b. Principal mode of transmission is through the parenteral route.
c. Onset is usually rapid and acute.
d. There is a persistent carrier state.

 

 

ANS:  C

Hepatitis A is the most common form of acute hepatitis in most parts of the world. It is characterized by a rapid and acute onset. The incubation period is approximately 3 weeks for hepatitis A and the principal mode of transmission for it is the fecal-oral route. Hepatitis A does not have a carrier state.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   795

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Which vaccine is now recommended for the immunization of all newborns?
a. Hepatitis A vaccine
b. Hepatitis B vaccine
c. Hepatitis C vaccine
d. Hepatitis A, B, and C vaccines

 

 

ANS:  B

Universal vaccination for hepatitis B is now recommended for all newborns. A vaccine is available for hepatitis A, but it is not yet universally recommended. No vaccine is currently available for hepatitis C. Only hepatitis B vaccine is recommended for newborns.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   797

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The best chance of survival for a child with cirrhosis is:
a. liver transplantation.
b. treatment with corticosteroids.
c. treatment with immune globulin.
d. provision of nutritional support.

 

 

ANS:  A

The only successful treatment for end-stage liver disease and liver failure may be liver transplantation, which has improved the prognosis for many children with cirrhosis. Liver transplantation has revolutionized the approach to cirrhosis. Liver failure and cirrhosis are indications for transplantation. Liver transplantation reflects the failure of other medical and surgical measures to prevent or treat cirrhosis.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   798

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. A nurse is admitting an infant with biliary atresia. Which is the earliest clinical manifestation of biliary atresia the nurse should expect to assess?
a. Jaundice
b. Vomiting
c. Hepatomegaly
d. Absence of stooling

 

 

ANS:  A

Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in the sclera, may be present at birth, but is usually not apparent until age 2 to 3 weeks. Vomiting is not associated with biliary atresia. Hepatomegaly and abdominal distention are common but occur later. Stools are large and lighter in color than expected because of the lack of bile.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   798-799

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. Initial therapeutic approach to the mother should be:
a. restating what the physician has told her about plastic surgery.
b. encouraging her to express her feelings.
c. emphasizing the normalcy of her baby and the baby’s need for mothering.
d. recognizing that negative feelings toward the child continue throughout childhood.

 

 

ANS:  B

For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must place emphasize not only the infant’s physical needs but also the parents’ emotional needs. The mother needs to be able to express her feelings before she can accept her child. Although the nurse will restate what the physician has told the mother about plastic surgery, it is not part of the initial therapeutic approach. As the mother expresses her feelings, the nurse’s actions should convey to the parents that the infant is a precious human being. The nurse emphasizes the child’s normalcy and helps the mother recognize the child’s uniqueness. Maternal-infant attachment was not negatively affected at age 1 year.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   800

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Psychosocial Integrity

 

  1. Caring for the newborn with a cleft lip and palate before surgical repair includes:
a. gastrostomy feedings.
b. keeping infant in near-horizontal position during feedings.
c. allowing little or no sucking.
d. providing satisfaction of sucking needs.

 

 

ANS:  D

Using special or modified nipples for feeding techniques helps meet the infant’s sucking needs. Gastrostomy feedings are usually not indicated. Feeding is best accomplished with the infant’s head in an upright position. The child requires both nutritive and nonnutritive sucking.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   801

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing interventions should include:
a. giving medication to suppress lactation.
b. encouraging and helping mother to breastfeed.
c. teaching mother to feed breast milk by gavage.
d. recommending use of a breast pump to maintain lactation until infant can suck.

 

 

ANS:  B

The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infant’s oral cavity so that the tongue action facilitates milk expression. Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation. Because breastfeeding can usually be accomplished, gavage feedings are not indicated. The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   801

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infant’s postoperative care include:
a. arm restraints, postural drainage, mouth irrigations.
b. cleansing the suture line, supine and side-lying positions, arm restraints.
c. mouth irrigations, prone position, cleansing suture line.
d. supine and side-lying positions, postural drainage, arm restraints.

 

 

ANS:  B

The suture line should be cleansed gently after feeding. The child should be positioned on the back, on the side, or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. There is no reason to perform mouth irrigations, and the child should not be placed in the prone position where injury to the suture site can occur.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   802

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. During the first few days after surgery for cleft lip, which intervention should the nurse do?
a. Leave infant in crib at all times to prevent suture strain.
b. Keep infant heavily sedated to prevent suture strain.
c. Remove restraints periodically to cuddle infant.
d. Alternate position from prone to side-lying to supine.

 

 

ANS:  C

Remove restraints periodically, while supervising the infant, to allow him or her to exercise arms and to provide cuddling and tactile stimulation. The infant should not be left in the crib, but should be removed for appropriate holding and stimulation. Analgesia and sedation are administered for pain. Heavy sedation is not indicated. The child should not be placed in the prone position.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   802

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for a neonate with a suspected tracheoesophageal fistula. Nursing care should include:
a. elevating the head but give nothing by mouth.
b. elevating the head for feedings.
c. feeding glucose water only.
d. avoiding suctioning unless infant is cyanotic.

 

 

ANS:  A

When a newborn is suspected of having a tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. Feedings should not be given to infants suspected of having tracheoesophageal fistulas. The oral pharynx should be kept clear of secretion by oral suctioning. This is to prevent the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   803-804

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Which type of hernia has an impaired blood supply to the herniated organ?
a. Hiatal hernia
b. Incarcerated hernia
c. Omphalocele
d. Strangulated hernia

 

 

ANS:  D

A strangulated hernia is one in which the blood supply to the herniated organ is impaired. Hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus. Incarcerated hernia is a hernia that cannot be reduced easily. Omphalocele is the protrusion of intra-abdominal viscera into the base of the umbilical cord. The sac is covered with peritoneum, not skin.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   805

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Pyloric stenosis can best be described as:
a. dilation of the pylorus.
b. hypertrophy of the pyloric muscle.
c. hypotonicity of the pyloric muscle.
d. reduction of tone in the pyloric muscle.

 

 

ANS:  B

Hypertrophic pyloric stenosis occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel. Dilation of the pylorus, hypotonicity of the pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   805

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Which observation made of the exposed abdomen is most indicative of pyloric stenosis?
a. Abdominal rigidity
b. Substernal retraction
c. Palpable olive-like mass
d. Marked distention of lower abdomen

 

 

ANS:  C

The diagnosis of pyloric stenosis is often made after the history and physical examination. The olive-like mass is easily palpated when the stomach is empty, the infant is quiet, and the abdominal muscles are relaxed. Abdominal rigidity and substernal retraction are usually not present. The upper abdomen, not lower abdomen, is distended.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   806

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?
a. Abdominal rigidity and pain on palpation
b. Rounded abdomen and hypoactive bowel sounds
c. Visible peristalsis and weight loss
d. Distention of lower abdomen and constipation

 

 

ANS:  C

Visible gastric peristaltic waves that move from left to right across the epigastrium and weight loss are observed in pyloric stenosis. Abdominal rigidity and pain on palpation or a rounded abdomen and hypoactive bowel sounds are usually not present. The upper abdomen, not lower abdomen, is distended.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   808

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. An infant with pyloric stenosis experiences excessive vomiting that can result in:
a. hyperchloremia.
b. hypernatremia.
c. metabolic acidosis.
d. metabolic alkalosis.

 

 

ANS:  D

Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Chloride ions and sodium are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   808

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Invagination of one segment of bowel within another is called:
a. atresia.
b. stenosis.
c. herniation.
d. intussusception.

 

 

ANS:  D

Intussusception occurs when a proximal section of the bowel telescopes into a more distal segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction. Invagination of one segment of bowel within another is the definition of intussusception, not atresia, stenosis, or herniation.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   809

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. Which nursing action is the most appropriate?
a. Notify practitioner.
b. Measure abdominal girth.
c. Auscultate for bowel sounds.
d. Take vital signs, including blood pressure.

 

 

ANS:  A

Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic-therapeutic care plan. The first action would be to report the normal stool to the practitioner.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   809

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Which is an important nursing consideration in the care of a child with celiac disease?
a. Refer to a nutritionist for detailed dietary instructions and education.
b. Help child and family understand that diet restrictions are usually only temporary.
c. Teach proper hand washing and standard precautions to prevent disease transmission.
d. Suggest ways to cope more effectively with stress to minimize symptoms.

 

 

ANS:  A

The main consideration is helping the child adhere to dietary management. Considerable time is spent explaining to the child and parents about the disease process, the specific role of gluten in aggravating the condition, and foods that must be restricted. Referral to a nutritionist would help in this process. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible or stress related.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   814

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

 

  1. An infant with short bowel syndrome will be discharged home on total parenteral nutrition (TPN) and gastrostomy feedings. Nursing care should include:
a. preparing family for impending death.
b. teaching family signs of central venous catheter infection.
c. teaching family how to calculate caloric needs.
d. securing TPN and gastrostomy tubing under diaper to lessen risk of dislodgment.

 

 

ANS:  B

During TPN therapy, care must be taken to minimize the risk of complications related to the central venous access device, such as catheter infections, occlusions, or accidental removal. This is an important part of family teaching. The prognosis for patients with short bowel syndrome depends in part on the length of residual small intestine. It has improved with advances in TPN. Although parents need to be taught about nutritional needs, the caloric needs and prescribed TPN and rate are the responsibility of the health care team. The tubes should not be placed under the diaper due to risk of infection.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   815

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

  1. A nurse is receiving report on a newborn admitted yesterday after a gastroschisis repair. In the report, the nurse is told the newborn has a physician’s prescription for an NG tube to low intermittent suction. The reporting nurse confirms that the NG tube is to low intermittent suction and draining light green stomach contents. Upon initial assessment, the nurse notes that the newborn has pulled the NG tube out. Which is the priority action the nurse should take?
a. Replace the NG tube and continue the low intermittent suction.
b. Leave the NG tube out and notify the physician at the end of the shift.
c. Leave the NG tube out and monitor for bowel sounds.
d. Replace the NG tube, but leave to gravity drainage instead of low wall suction.

 

 

ANS:  A

A newborn with a gastroschisis performed the day before will require bowel decompression with an NG tube to low wall intermittent suction. The nurse’s priority action is to replace the NG tube and continue with the low wall intermittent suctioning. The NG tube cannot be left out this soon after surgery. The physician’s prescription was to have the NG tube to low wall intermittent suction so the tube cannot be placed to gravity drainage.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   807

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Parents of a child undergoing an endoscopy to rule out peptic ulcer disease (PUD) from H. pylori ask the nurse, “If H. pylori is found will my child need another endoscopy to know that it is gone?” Which is the nurse’s best response?
a. “Yes, the only way to know the H. pylori has been eradicated is with another endoscopy.”
b. “We can collect a stool sample and confirm that the H. pylori has been eradicated.”
c. “A blood test can be done to determine that the H. pylori is no longer present.”
d. “Your child will always test positive for H. pylori because after treatment it goes into remission, but can’t be completely eradicated.”

 

 

ANS:  B

An upper endoscopy is the procedure initially performed to diagnose PUD. A biopsy can determine the presence of H. pylori. Polyclonal and monoclonal stool antigen tests are an accurate, noninvasive method to confirm H. pylori has been eradicated after treatment. A blood test can identify the presence of the antigen to this organism, but because H. pylori was already present it would not be as accurate as a stool sample to determine whether it has been eradicated. H. pylori can be treated and, once the treatment is complete, the stool sample can determine that it was eradicated.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   793

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. A child has recurrent abdominal pain (RAP) and a dairy-free diet has been prescribed for 2 weeks. Which explanation is the reason for prescribing a dairy-free diet?
a. To rule out lactose intolerance
b. To rule out celiac disease
c. To rule out sensitivity to high sugar content
d. To rule out peptic ulcer disease

 

 

ANS:  A

Treatment for RAP involves providing reassurance and reducing or eliminating symptoms. Dietary modifications may include removal of dairy products to rule out lactose intolerance. Fructose is eliminated to rule out sensitivity to high sugar content and gluten is removed to rule out celiac disease. A dairy-free diet would not rule out peptic ulcer disease.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   784

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

MULTIPLE RESPONSE

 

  1. A child who has just had definitive repair of a high rectal malformation is to be discharged. Which should the nurse address in the discharge preparation of this family? (Select all that apply.)
a. Perineal and wound care
b. Necessity of firm stools to keep suture line clean
c. Bowel training beginning as soon as child returns home
d. Reporting any changes in stooling patterns to practitioner
e. Use of diet modification to prevent constipation

 

 

ANS:  A, D, E

Wound care instruction is necessary in a child who is being discharged after surgery. The parents are taught to notify the practitioner if any signs of an anal stricture or other complications develop. Constipation is avoided, since a firm stool will place strain on the suture line. Fiber and stool softeners are often given to keep stools soft and avoid tension on the suture line. The child needs to recover from the surgical procedure. Then bowel training may begin, depending on the child’s developmental and physiologic readiness.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   812

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Which is true concerning hepatitis B? (Select all that apply.)
a. Hepatitis B cannot exist in carrier state.
b. Hepatitis B can be prevented by HBV vaccine.
c. Hepatitis B can be transferred to an infant of a breastfeeding mother.
d. Onset of hepatitis B is insidious.
e. Principal mode of transmission for hepatitis B is fecal-oral route.
f. Immunity to hepatitis B occurs after one attack.

 

 

ANS:  B, C, D, F

The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is protective against hepatitis B. Hepatitis B can be transferred to an infant of a breastfeeding mother, especially if the mother’s nipples are cracked. The onset of hepatitis B is insidious. Immunity develops after one exposure to hepatitis B. Hepatitis B has a carrier state. The fecal-oral route is the principal mode of transmission for hepatitis A. Hepatitis B is transmitted through the parenteral route.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   795

TOP:   Integrated Process: Nursing Process: Diagnosis

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. A nurse is planning preoperative care for a newborn with tracheoesophageal fistula (TEF). Which interventions should the nurse plan to implement? (Select all that apply.)
a. Positioning with head elevated on a 30-degree plane
b. Feedings through a gastrostomy tube
c. Nasogastric tube to continuous low wall suction
d. Suctioning with a Replogle tube passed orally to the end of the pouch
e. Gastrostomy tube to gravity drainage

 

 

ANS:  A, D, E

The most desirable position for a newborn who has TEF is supine (or sometimes prone) with the head elevated on an inclined plane of at least 30 degrees. This positioning minimizes the reflux of gastric secretions at the distal esophagus into the trachea and bronchi, especially when intraabdominal pressure is elevated. It is imperative to immediately remove any secretions that can be aspirated. Until surgery, the blind pouch is kept empty by intermittent or continuous suction through an indwelling double-lumen or Replogle catheter passed orally or nasally to the end of the pouch. In some cases, a percutaneous gastrostomy tube is inserted and left open so that any air entering the stomach through the fistula can escape, thus minimizing the danger of gastric contents being regurgitated into the trachea. The gastrostomy tube is emptied by gravity drainage. Feedings through the gastrostomy tube and irrigations with fluid are contraindicated before surgery in an infant with a distal TEF. A nasogastric tube to low intermittent suctioning could not be accomplished because the esophagus ends in a blind pouch in TEF.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   804

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is preparing to care for an infant returning from pyloromyotomy surgery. Which prescribed orders should the nurse anticipate implementing? (Select all that apply.)
a. NPO for 24 hours
b. Administration of analgesics for pain
c. Ice bag to the incisional area
d. IV fluids continued until tolerating PO
e. Clear liquids as the first feeding

 

 

ANS:  B, D, E

Feedings are usually instituted soon after a pyloromyotomy surgery, beginning with clear liquids advancing to formula or breast milk as tolerated. IV fluids are administered until the infant is taking and retaining adequate amounts by mouth. Appropriate analgesics should be given around the clock because pain is continuous. Ice should not be applied to the incisional area as it vasoconstricts and would reduce circulation to the incisional area and impair healing.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   809

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. A nurse is conducting dietary teaching on high-fiber foods for parents of a child with constipation. Which foods should the nurse include as being high in fiber? (Select all that apply.)
a. White rice
b. Avocados
c. Whole grain breads
d. Bran pancakes
e. Raw carrots

 

 

ANS:  C, D, E

High-fiber foods include whole grain breads, bran pancakes, and raw carrots. Unrefined (brown) rice is high in fiber but not white rice. Raw fruits, especially those with skins or seeds, other than ripe banana or avocado are high in fiber.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   780

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

SHORT ANSWER

 

  1. A child has an NG tube to continuous low intermittent suction. The physician’s prescription is to replace the previous 4-hour NG output with a normal saline piggyback over a 2-hour period. The NG output for the previous 4 hours totaled 50 ml. What milliliter/hour rate should the nurse administer to replace normal saline piggyback? (Record your answer in a whole number.)

 

ANS:

25

The previous total 4-hour output was 50 ml. To run the 50 ml over a 2-hour period, the nurse would divide 50 by 2 = 25. The normal saline replacement fluid would be run at 25 ml per hour.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   775

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

Chapter 32: The Child with Neuromuscular or Muscular Dysfunction

 

MULTIPLE CHOICE

 

  1. The nurse is planning a staff in-service on childhood spastic cerebral palsy. Spastic cerebral palsy is characterized by:
a. hypertonicity and poor control of posture, balance, and coordinated motion.
b. athetosis and dystonic movements.
c. wide-based gait and poor performance of rapid, repetitive movements.
d. tremors and lack of active movement.

 

 

ANS:  A

Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic cerebral palsy. Athetosis and dystonic movements are part of the classification of dyskinetic (athetoid) cerebral palsy. Wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic cerebral palsy. Tremors and lack of active movement may indicate other neurologic disorders.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   1092

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. The parents of a child with cerebral palsy ask the nurse whether any drugs can decrease their child’s spasticity. The nurse’s response should be based on which statement?
a. Anticonvulsant medications are sometimes useful for controlling spasticity.
b. Medications that would be useful in reducing spasticity are too toxic for use with children.
c. Many different medications can be highly effective in controlling spasticity.
d. Implantation of a pump to deliver medication into the intrathecal space to decrease spasticity has recently become available.

 

 

ANS:  D

Baclofen, given intrathecally, is best suited for children with severe spasticity that interferes with activities of daily living and ambulation. Anticonvulsant medications are used when seizures occur in children with cerebral palsy. The intrathecal route decreases the side effects of the drugs that reduce spasticity. Few medications are currently available for the control of spasticity.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   1094

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

 

  1. The nurse is preparing to admit a newborn with myelomeningocele to the neonatal intensive care nursery. Which describes this newborn’s defect?
a. Fissure in the spinal column that leaves the meninges and the spinal cord exposed
b. Herniation of the brain and meninges through a defect in the skull
c. Hernial protrusion of a saclike cyst of meninges with spinal fluid but no neural elements
d. Visible defect with an external saclike protrusion containing meninges, spinal fluid, and nerves

 

 

ANS:  D

A myelomeningocele is a visible defect with an external saclike protrusion, containing meninges, spinal fluid, and nerves. Rachischisis is a fissure in the spinal column that leaves the meninges and the spinal cord exposed. Encephalocele is a herniation of brain and meninges through a defect in the skull, producing a fluid-filled sac. Meningocele is a hernial protrusion of a saclike cyst of meninges with spinal fluid, but no neural elements.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   1098

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. The nurse is conducting a staff in-service on common problems associated with myelomeningocele. Which common problem is associated with this defect?
a. Hydrocephalus
b. Craniosynostosis
c. Biliary atresia
d. Esophageal atresia

 

 

ANS:  A

Hydrocephalus is a frequently associated anomaly in 80% to 90% of children. Craniosynostosis is the premature closing of the cranial sutures and is not associated with myelomeningocele. Biliary and esophageal atresia is not associated with myelomeningocele.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   1100

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. The nurse is teaching a group of nursing students about newborns born with the congenital defect of myelomeningocele. Which common problem is associated with this defect?
a. Neurogenic bladder
b. Mental retardation
c. Respiratory compromise
d. Cranioschisis

 

 

ANS:  A

Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder dysfunction among children. Risk of mental retardation is minimized through early intervention and management of hydrocephalus. Respiratory compromise is not a common problem in myelomeningocele. Cranioschisis is a skull defect through which various tissues protrude. It is not associated with myelomeningocele.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   1101

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. The nurse is reviewing prenatal vitamin supplements with an expectant client. Which supplement should be included in the teaching?
a. Vitamin A throughout pregnancy
b. Multivitamin preparations as soon as pregnancy is suspected
c. Folic acid for all women of childbearing age
d. Folic acid during the first and second trimesters of pregnancy

 

 

ANS:  C

The widespread use of folic acid among women of childbearing age has decreased the incidence of spina bifida significantly. Vitamin A is not related to the prevention of spina bifida. Folic acid supplementation is recommended for the preconception period and during the pregnancy. Only 42% of women actually follow these guidelines.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   1102

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

 

  1. How much folic acid is recommended for women of childbearing age?
a. 1.0 mg
b. 0.4 mg
c. 1.5 mg
d. 2.0 mg

 

 

ANS:  B

It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age will prevent 50% to 70% of cases of neural tube defects; 1.0 mg is too low a dose; 1.5 to 2.0 mg are not the recommended dosages of folic acid.

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   1102

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

 

  1. The nurse is caring for a neonate born with a myelomeningocele. Surgery to repair the defect is scheduled the next day. The most appropriate way to position and feed this neonate is which position?
a. Prone and tube-fed
b. Prone, head turned to side, and nipple-fed
c. Supine in an infant carrier and nipple-fed
d. Supine, with defect supported with rolled blankets, and nipple-fed

 

 

ANS:  B

In the prone position, feeding is a problem. The infant’s head is turned to one side for feeding. If the child is able to nipple-feed, tube feeding is not needed. Before surgery, the infant is kept in the prone position to minimize tension on the sac and risk of trauma.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   1103

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

 

  1. The nurse is talking to a parent with a child who has a latex allergy. Which statement by the parent would indicate a correct understanding of the teaching?
a. “My child will have an allergic reaction if he comes in contact with yeast products.”
b. “My child may have an upset stomach if he eats a food made with wheat or barley.”
c. “My child will probably develop an allergy to peanuts.”
d. “My child should not eat bananas or kiwis.”

 

 

ANS:  D

There are cross-reactions between latex allergies and a number of foods such as bananas, avocados, kiwi, and chestnuts. Children with a latex allergy will not develop allergies to other food products such as yeast, wheat, barley, or peanuts.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   1104

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which action?
a. Avoid using any latex product.
b. Use only nonallergenic latex products.
c. Administer medication for long-term desensitization.
d. Teach family about long-term management of asthma.

 

 

ANS:  A

Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment. There are no nonallergenic latex products. At this time, desensitization is not an option. The child does not have asthma. The parents must be taught about allergy and the risk of anaphylaxis.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   1104

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is admitting a child with Werdnig-Hoffmann disease (spinal muscular atrophy type 1). Which signs and symptoms are associated with this disease?
a. Spinal muscular atrophy
b. Neural atrophy of muscles
c. Progressive weakness and wasting of skeletal muscle
d. Pseudohypertrophy of certain muscle groups

 

 

ANS:  C

Werdnig-Hoffmann disease (spinal muscular atrophy type 1) is the most common paralytic form of floppy infant syndrome (congenital hypotonia). It is characterized by progressive weakness and wasting of skeletal muscle caused by degeneration of anterior horn cells. Kugelberg-Welander disease is a juvenile spinal muscular atrophy with a later onset. Charcot-Marie-Tooth disease is a form of progressive neural atrophy of muscles supplied by the peroneal nerves. Progressive weakness is found of the distal muscles of the arms and feet. Duchenne muscular dystrophy is characterized by muscles, especially in the calves, thighs, and upper arms, which become enlarged from fatty infiltration and feel unusually firm or woody on palpation. The term pseudohypertrophy is derived from this muscular enlargement.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   1105

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. Which clinical manifestations in an infant would be suggestive of spinal muscular atrophy (Werdnig-Hoffmann disease)?
a. Hyperactive deep tendon reflexes
b. Hypertonicity
c. Lying in the frog position
d. Motor deficits on one side of body

 

 

ANS:  C

The infant lies in the frog position with the legs externally rotated, abducted, and flexed at knees. The deep tendon reflexes are absent. The child has hypotonia and inactivity as the most prominent features. The motor deficits are bilateral.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   1105

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. A 4-year-old child has just been diagnosed with pseudohypertrophic (Duchenne) muscular dystrophy. The management plan should include which action?
a. Recommend genetic counseling.
b. Explain that the disease is easily treated.
c. Suggest ways to limit use of muscles.
d. Assist family in finding a nursing facility to provide his care.

 

 

ANS:  A

Pseudohypertrophic (Duchenne) muscular dystrophy is inherited as an X-linked recessive gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring. No effective treatment exists at this time for childhood muscular dystrophy. Maintaining optimal function of all muscles for as long as possible is the primary goal. It has been found that children who remain as active as possible are able to avoid wheelchair confinement for a longer time. Assisting the family in finding a nursing facility to provide his care is inappropriate at the time of diagnosis. When the child becomes increasingly incapacitated, the family may consider home-based care, a skilled nursing facility, or respite care to provide the necessary care.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   1109

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Therapeutic management of a child with tetanus includes the administration of:
a. nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation.
b. muscle stimulants to counteract muscle weakness.
c. bronchodilators to prevent respiratory complications.
d. tetanus immunoglobulin therapy.

 

 

ANS:  D

Tetanus immunoglobulin therapy, to neutralize toxins, is the most specific therapy for tetanus. Tetanus toxin acts at the myoneural junction to produce muscular stiffness and lowers the threshold for reflex excitability. NSAIDs are not routinely used. Sedatives or muscle relaxants are used to help reduce titanic spasm and prevent seizures. Respiratory status is carefully evaluated for any signs of distress because muscle relaxants, opioids, and sedatives that may be prescribed may cause respiratory depression. Bronchodilators would not be used unless specifically indicated.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   1112

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

 

  1. The nurse is conducting reflex testing on infants at a well-child clinic. Which reflex finding should be reported as abnormal and considered as a possible sign of cerebral palsy?
a. Tonic neck reflex at 5 months of age
b. Absent Moro reflex at 8 months of age
c. Moro reflex at 3 months of age
d. Extensor reflex at 7 months of age

 

 

ANS:  D

Establishing a diagnosis of cerebral palsy (CP) may be confirmed with the persistence of primitive reflexes: (1) either the asymmetric tonic neck reflex or persistent Moro reflex (beyond 4 months of age) and (2) the crossed extensor reflex. The tonic neck reflex normally disappears between 4 and 6 months of age. The crossed extensor reflex, which normally disappears by 4 months, is elicited by applying a noxious stimulus to the sole of one foot with the knee extended. Normally, the contralateral foot responds with extensor, abduction, and then adduction movements. The possibility of CP is suggested if these reflexes occur after 4 months.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   1091

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for an infant with myelomeningocele scheduled for surgical closure in the morning. Which interventions should the nurse plan for the care of the myelomeningocele sac?
a. Open to air
b. Covered with a sterile moist nonadherent dressing
c. Reinforcement of the original dressing if drainage noted
d. A diaper secured over the dressing

 

 

ANS:  B

Before surgical closure, the myelomeningocele is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. The moistening solution is usually sterile normal saline. Dressings are changed frequently (every 2 to 4 hours), and the sac is closely inspected for leaks, abrasions, irritation, and any signs of infection. The sac must be carefully cleansed if it becomes soiled or contaminated. The original dressing would not be reinforced but changed as needed. A diaper is not placed over the dressing because stool contamination can occur.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   1102

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is admitting a school-age child with suspected Guillain-Barré syndrome (GBS). Which is a priority in the care for this child?
a. Monitoring intake and output
b. Assessing respiratory efforts
c. Placing on a telemetry monitor
d. Obtaining laboratory studies

 

 

ANS:  B

Treatment of GBS is primarily supportive. In the acute phase, patients are hospitalized because respiratory and pharyngeal involvement may require assisted ventilation, sometimes with a temporary tracheotomy. Treatment modalities include aggressive ventilatory support in the event of respiratory compromise, intravenous (IV) administration of immunoglobulin (IVIG), and sometimes steroids; plasmapheresis and immunosuppressive drugs may also be used. Intake and output, telemetry monitoring and obtaining laboratory studies may be part of the plan of care but are not the priority.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   1110

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for an intubated infant with botulism in the pediatric intensive care unit. Which health care provider prescriptions should the nurse clarify with the health care provider before implementing?
a. Administer 250 mg botulism immune globulin intravenously (BIG-IV) one time.
b. Provide total parenteral nutrition (TPN) at 25 ml/hr intravenously.
c. Titrate oxygen to keep pulse oximetry saturations greater than 92.
d. Administer gentamicin sulfate (Garamycin) 10 mg per intravenous piggyback every 12 hours.

 

 

ANS:  D

The nurse should clarify the administration of an aminoglycoside antibiotic. Antibiotic therapy is not part of the management of infant botulism because the botulinum toxin is an intracellular molecule, and antibiotics would not be effective; aminoglycosides in particular should not be administered because they may potentiate the blocking effects of the neurotoxin. Treatment consists of immediate administration of botulism immune globulin intravenously (BIG-IV) without delaying for laboratory diagnosis. Early administration of BIG-IV neutralizes the toxin and stops the progression of the disease. The human-derived botulism antitoxin (BIG-IV) has been evaluated and is now available nationwide for use only in infant botulism. Approximately 50% of affected infants require intubation and mechanical ventilation; therefore, respiratory support is crucial, as is nutritional support because these infants are unable to feed.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   1113-1114

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

 

  1. A home care nurse is caring for an adolescent with a T1 spinal cord injury. The adolescent suddenly becomes flushed, hypertensive, and diaphoretic. Which intervention should the nurse perform first?
a. Place the adolescent in a flat right side-lying position.
b. Place a cool washcloth on the adolescent’s forehead and continue to monitor the blood pressure.
c. Implement a standing prescription to empty the bladder with a sterile in and out Foley catheter.
d. Take a full set of vital signs and notify the health care provider.

 

 

ANS:  C

The adolescent is experiencing an autonomic dysreflexia episode. The paralytic nature of autonomic function is replaced by autonomic dysreflexia, especially when the lesions are above the mid-thoracic level. This autonomic phenomenon is caused by visceral distention or irritation, particularly of the bowel or bladder. Sensory impulses are triggered and travel to the cord lesion, where they are blocked, which causes activation of sympathetic reflex action with disturbed central inhibitory control. Excessive sympathetic activity is manifested by a flushing face, sweating forehead, pupillary constriction, marked hypertension, headache, and bradycardia. The precipitating stimulus may be merely a full bladder or rectum or other internal or external sensory input. It can be a catastrophic event unless the irritation is relieved. Placing a cool washcloth on the adolescent’s forehead, continuing to monitor blood pressure and vital signs, and notifying the healthcare provider would not reverse the sympathetic reflex situation.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   1115

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

MULTIPLE RESPONSE

 

  1. A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Nursing care for this child includes which action(s)? (Select all that apply.)
a. Monitoring and maintaining systemic blood pressure
b. Administering corticosteroids
c. Minimizing environmental stimuli
d. Discussing long-term care issues with the family
e. Monitoring for respiratory complications

 

 

ANS:  A, B, E

Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury. Corticosteroids are administered to minimize the inflammation present with the injury. It is not necessary to minimize environmental stimuli for this type of injury. Discussing long-term care issues with the family is inappropriate. The family is focusing on the recovery of their child. It will not be known until the rehabilitation period how much function the child may recover.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   1115-1116

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. Which assessment findings should the nurse note in a school-age child with Duchenne muscular dystrophy (DMD)? (Select all that apply.)
a. Lordosis
b. Gower sign
c. Kyphosis
d. Scoliosis
e. Waddling gait

 

 

ANS:  A, B, E

Difficulties in running, riding a bicycle, and climbing stairs are usually the first symptoms noted in Duchenne muscular dystrophy. Typically, affected boys have a waddling gait and lordosis, fall frequently, and develop a characteristic manner of rising from a squatting or sitting position on the floor (Gower sign). Lordosis occurs as a result of weakened pelvic muscles, and the waddling gait is a result of weakness in the gluteus medius and maximus muscles. Kyphosis and scoliosis are not assessment findings with DMD.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   1107

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is conducting discharge teaching to parents of a preschool child with myelomeningocele, repaired at birth, being discharged from the hospital after a urinary tract infection (UTI). Which should the nurse include in the discharge instructions related to management of the child’s genitourinary function? (Select all that apply.)
a. Continue to perform the clean intermittent catheterizations (CIC) at home.
b. Administer the oxybutynin chloride (Ditropan) as prescribed.
c. Reduce fluid intake in the afternoon and evening hours.
d. Monitor for signs of a recurrent urinary tract infection.
e. Administer furosemide (Lasix) as prescribed.

 

 

ANS:  A, B, D

Discharge teaching to prevent renal complications in a child with myelomeningocele include: (1) regular urologic care with prompt and vigorous treatment of infections; (2) a method of regular emptying of the bladder, such as clean intermittent catheterization (CIC) taught to and performed by parents and self-catheterization taught to children; (3) medications to improve bladder storage and continence, such as oxybutynin chloride (Ditropan) and tolterodine (Detrol). Fluids should not be limited and Lasix is not used to improve renal function for children with myelomeningocele.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   1101

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Which should the nurse expect to find in the cerebral spinal fluid (CSF) results of a child with Guillain-Barré syndrome (GBS)? (Select all that apply.)
a. Decreased protein concentration
b. Normal glucose
c. Fewer than 10 white blood cells (WBCs/mm3)
d. Elevated red blood cell (RBC) count

 

 

ANS:  B, C

Diagnosis of GBS is based on clinical manifestations, CSF analysis, and EMG findings. CSF analysis reveals an abnormally elevated protein concentration, normal glucose, and fewer than 10 WBCs/mm3. CSF fluid should not contain RBCs.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   1110

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. The nurse in the neonatal intensive care unit is caring for an infant with myelomeningocele scheduled for surgical repair in the morning. Which early signs of infection should the nurse monitor on this infant? (Select all that apply.)
a. Temperature instability
b. Irritability
c. Lethargy
d. Bradycardia
e. Hypertension

 

 

ANS:  A, B, C

The nurse should observe an infant with unrepaired myelomeningocele for early signs of infection, such as temperature instability (axillary), irritability, and lethargy. Bradycardia and hypertension are not early signs of infection in infants.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   1102

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

SHORT ANSWER

 

  1. A toddler is admitted to the hospital with a possible diagnosis of tetanus. The health care provider has prescribed lorazepam (Ativan) intravenously 0.05 mg/kg/dose every 6 hours prn as a muscle relaxant. The child weighs 22 lb. How many milligrams of Ativan should the nurse administer per dose? (Record your answer using one decimal place.)

 

ANS:

0.5

Find the child’s weight in kilograms by dividing 22 by 2.2 = 22/2.2 = 10 kg. Multiply the 0.05 mg dose by 10 = 0.05 mg ´ 10 kg = 0.5 mg per dose.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   1112

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

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