NC of Children 2 Flashcards
ATI Standard Quiz
Nursing Care of Children 2
A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan?
Maintain the child on bed rest.
Monitor the child for increased temperature.
Administer oxygen to the child.
Monitor the child for bleeding.
Monitor the child for increased temperature.
The nurse should maintain bed rest for the child who has decreased ___
RBCs.
Leukopenia places the child at risk for
infection; therefore, the nurse should monitor the child for a fever.
W/ leukopneia, what should the nurse monitor
the nurse should monitor the child for a fever.
The nurse should administer oxygen to a child who has decreased what? And low what?
RBCs and low oxygen saturations.
The nurse should monitor a child who has a low ______ _____for bleeding.
platelet level
A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect?
1.010
1.035
1.020
1.005
1.035
What is the expected reference range for urine specific gravity for infants?
?? 1.010 to 1.030 CONFIRM
1.035 is a ________ specific gravity, which is an expected value for a child who is _______
concentrated
dehydrated;.
1.005 is ________ urine specific gravity, which could indicate what?
decreased
excessive fluid intake
A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make?
Increase the child’s protein intake.
Decrease the child’s calorie intake.
Increase the child’s fiber intake.
Decrease the child’s salt intake.
Increase the child’s protein intake.
The nurse should recommend an increase in _______ intake for the child who has cystic fibrosis.
protein
children w/ cystic fibrosis require up to _____ of the recommended daily allowances to meet their nutritional needs.
150%
The calorie intake for a child who has cystic fibrosis should be _______, rather than ______
increased
decreased.
Increasing fiber intake could result in
increase bulk and malabsorption
Why is increasing fiber intake not recommended for children w/ cystic fibrosis
increase bulk and malabsorption
Decreasing salt intake is____ _______ for the child who has cystic fibrosis.
not indicated
A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider?
Temperature of 37.5° C (99.5° F)
Apical pulse rate 140/min
BP 86/40 mm Hg
Respiratory rate of 32/min
BP 86/40 mm Hg
What is temperature expected reference range for a 6-month-old infant.
??
What is apical pulse level expected reference range for a 6-month-old infant.
??
What is BP ERR for a 6 month old infant?
??
A BP of 86/40 mm Hg in a 6 month old infant is indicative of what?
hypotension and bleedingand should be immediately reported to the provider.
What is ERR respiratory rate for a 6-month-old infant.
??
A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse’s priority?
Perform passive range of motion for unaffected joints.
Apply a pressure-reducing overlay to the child’s mattress.
Increase the child’s fluid intake.
Encourage the child to use an incentive spirometer.
Encourage the child to use an incentive spirometer.
Encouraging the child to use an incentive spirometer will assist the child in adequate oxygenation and is the priority nursing action.
For a child who is in skeletal traction, the nurse should perform _____ range of motion for unaffected joints
passive
For a child who is in skeletal traction, The nurse should apply a pressure-reducing overlay to the child’s mattress to
reduce the risk of skin breakdown related to immobility;
For a child who is in skeletal traction, The nurse should increase the child’s what?
fluid intake
For a child who is in skeletal traction, The nurse should apply what priority-setting framework.
ABC
A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is made. Which of the following responses should the nurse make?
“An abdominal ultrasound will confirm the pocket in the intestine.”
“Genotyping will be done to identify this condition.”
“A biopsy will be done on a small amount of tissue from the colon.”
“An upper GI series should identify the area involved.”
An abdominal ultrasound will confirm the pocket in the intestine.
intussusception
a condition in which part of the intestine folds into the section next to it.
Intussusception usually involves what part of the bowel?
the small bowel and rarely the large bowel.
Symptoms of intussusception include
abdominal pain, which may wax and wane, vomiting, bloating, and bloody stool. It may result in small bowel obstruction
Intussusception is the invasion of one part of the intestine into the other, creating a
pocket.
The presence of an intussusception is confirmed by
an abdominal x-ray, ultrasound, or CT scan.
Genotyping is performed to determine a child’s
gene composition and is used for hereditary disease identification.
A biopsy of a small amount of tissue from the colon is done to identify what?
a defect of nerve innervation in the colon
An upper gastrointestinal series focuses on an area that is
too high to see an intussusception
An upper gastrointestinal series fis used to diagnose what condition
pyloric stenosis.
A biopsy of a small amount of tissue from the colon is done to diagnosie what disease
Hirschprung’s disease.
Hirschprung’s disease.
a birth defect in which some nerve cells are missing in the large intestine, so a child’s intestine can’t move stool and becomes blocked
pyloric stenosis.
a thickening or swelling of the pylorus — the muscle between the stomach and the intestines — that causes severe and forceful vomiting in the first few months of life. It is also called infantile hypertrophic pyloric stenosis.
A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first?
Cover the child’s wounds with a clean, dry cloth.
Establish IV access for the child with a large-bore catheter.
Provide reassurance to the child’s parents.
Determine the child’s breathing pattern.
Determine the child’s breathing pattern.
for a 4-year-old child who has burns to the neck and face, The nurse should cover the child’s wounds w/ what?
a clean, dry cloth
for a 4-year-old child who has burns to the neck and face, The nurse should establish IV access for the child using a
large-bore catheter
for a 4-year-old child who has burns to the neck and face, The nurse should provide what to the childs parents
reassurance
for a 4-year-old child who has burns to the neck and face,
ABC
A nurse is caring for an infant following surgical repair of a cleft lip and palate. Which of the following actions should the nurse take?
Keep the infant’s mouth open by using a tongue blade for 4 hr following surgery.
Use a suction catheter to gently remove the infant’s oral secretions PRN.
Place the infant in prone position.
Clean the infant’s incision with chlorhexidine.
se a suction catheter to gently remove the infant’s oral secretions PRN.
After surgical repair of a cleft lip and palate, The nurse should avoid doing what and why?
placing objects in the infant’s mouth during the postoperative period
to avoid trauma to the incision.
After surgical repair of a cleft lip and palate, The nurse should use a suction catheter to
gently remove the infant’s oral secretions to prevent aspiration and maintain a patent airway.
After surgical repair of a cleft lip and palate, The nurse should position the infant in what position?
upright to facilitate drainage of secretions. Placing the infant in prone position could lead to aspiration.
After surgical repair of a cleft lip and palate, The nurse should clean the operative incision with what after each feeding?
sterile saline or sterile water after each feeding and as needed.
A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child’s parent asks the nurse to explain the purpose of the test. Which of the following responses should the nurse make?
“The test determines the level of antibiotics in your child’s blood.”
“The test tells us if your child ever had the measles.”
“The test verifies the amount of albumin in your child’s blood.”
“The test shows us if your child had a recent strep infection.”
“The test shows us if your child had a recent strep infection.”
antistreptolysin O (ASO) titer
a blood test to measure antibodies against streptolysin O, a substance produced by group A streptococcus bacteria.
Acute glomerulonephritis (AGN) comprises a specific set of kidney diseases in which
an immunologic mechanism triggers inflammation and proliferation of glomerular tissue that can result in damage to the basement membrane, mesangium, or capillary endothelium.
A therapeutic blood level indicates a medication, such as an antibiotic, is
effective.
Which type of titer will indicate the presence of measles.
A rubella titer
A serum albumin level is monitored in a child who has what type of syndrome
nephrotic syndrome.
An ASO titer indicates that the child has had a recent _____ infection.
strep
In determining a definitive diagnosis for acute glomerulonephritis, what be documented as it is usually the result of this type of infection.
ASO titer
A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider?
Platelets 150,000/mm3
Hgb 6 g/dL
WBC 6,000/mm3
Potassium 4.5 mEq/L
Hgb 6 g/dL
Platelets ERR for a toddler?
??
Hgb ERR for a toddler?
?? (Hgb <6g.dL is below ERR)
WBC ERR for a toddler?
??
Potassium ERR for a toddler?
??
A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect?
Hypotension
Stomatitis
Bloody diarrhea
Periorbital edema
Periorbital edema
What blood presure is an expected finding in a child who has acute glomerulonephritis.
elevated
Stomatitis is an expected finding in a child who has what condition
chronic renal failure.
Stomatitis
inflammation and redness of the oral mucosa that can lead to pain and difficulty talking, eating, and sleeping. Stomatitis can affect the inner cheeks, gums, inner lips, and tongue. The inflammation causes the formation of single or multiple painful mouth ulcers as well as white lesions
Bloody diarrhea is an expected finding in a child who has what condition?
hemolytic uremic syndrome.
hemolytic uremic syndrome.
a condition that affects the blood and blood vessels. It results in: the destruction of blood platelets (cells involved in clotting) a low red blood cell count (anemia) kidney failure due to damage to the tiny blood vessels of the kidneys.
Periorbital edema is an expected finding in a child who has what condition?
glomerulonephritis.
glomerulonephritis.
nflammation and damage to the filtering part of the kidneys (glomerulus). It can come on quickly or over a longer period of time. Toxins, metabolic wastes and excess fluid are not properly filtered into the urine. Instead, they build up in the body causing swelling and fatigue
A nurse is providing teaching to the parents of a school-age child who has type 1 diabetes mellitus about management of hypoglycemia. Which of the following responses by the parents indicates an understanding of the teaching?
“I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible.”
“I will give my child 2 units of regular insulin.”
“I will insist that my child lies down to rest for 30 minutes.”
“I will check my child’s urine for glucose twice daily.”
“I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible.”
Giving the child 10 to 15 g of simple carbohydrates, such as 240 mL (8 oz) of milk, will do what to glucose blood levels
elevate the blood glucose level and alleviate the hypoglycemia.
Administering additional insulin could have what effect?
worsen the child’s hypoglycemia and lead to neurologic effects such as seizures, shock, and coma.
Rest is important for overall health; however, rest will not alleviate symptoms related to what condition
Type 1 DM
Checking the child’s urine for glucose is not doing what?
managing a hypoglycemic episode.
Children who are hyperglycemic will have what in their urine.
glucose
A nurse is teaching about clinical manifestations of tracheomalacia to a parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching?
Absence of bowel sounds
Neck contortions
Barking cough
Projectile vomiting
Barking cough
Tracheomalacia
is the collapse of the airway when breathing. This means that when your child exhales, the trachea narrows or collapses so much that it may feel hard to breathe. This may lead to a vibrating noise or cough
Tracheoesophageal fistula is an
upper gastrointestinal disorder; therefore,
Because Tracheoesophageal fistula is an upper gastrointestinal disorder; what are the expected bowel sounds?
bowel sounds would not be absent in this condition.
Neck contortions are an expected finding in an infant who has what condition?
a hiatal hernia.
Infants who have tracheomalacia have a _______ trachea, which leads to collapse.
weakened
Clinical manifestations of tracheomalacia include
barking cough, stridor, wheezing cyanosis, and apnea.
Projectile vomiting is an expected finding in an infant who has what condition?
hypertrophic pyloric stenosis.
A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching?
“I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale.”
“If I get a reading in the green zone, I will tell my parents immediately so they can call the doctor.”
“I will slowly exhale through the mouthpiece over a 10 second interval.”
“I will record the highest reading of three attempts.”
I will record the highest reading of three attempts.
peak expiratory flow meter (PEFM) works by
measuring how fast air comes out of the lungs when you exhale forcefully after inhaling fully. This measure is called a “peak expiratory flow,” or “PEF.”
Keeping track of your PEF, is one way you can know if
your symptoms of asthma are in control or worsening
The nurse should instruct the adolescent to do what w/ a PFM
take a deep breath, place the lips around the mouthpiece, and then blow into the mouthpiece as hard and fast as possible.
Values in the green zone represent what percentage of the child’s personal best; therefore, this does not warrant calling the provider.
80 to 100%
Is Slowly exhaling over a 10 second interval - correct or incorrect method of using the PEFM.
incorrect
Once the client establishes a personal best, she should routinely check the PEFM by performing how many attempts?
three attempts and recording the highest reading of the three.
A nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis?
Lethargy
Spontaneous coughing
Drooling
Hoarseness
Drooling
A toddler who has epiglottitis is what rather than lethargic.
very restless and appears anxious
A toddler who has epiglottitis has an absence of of this and why?
spontaneous coughing due to inflammation of the epiglottis.
Epiglottitis is a disorder caused by
an inflammation of the epiglottis.
