practice exam 1 questions Flashcards
Decreasing the demands on the heart is a priority in care for the infant with heart failure (HF). In evaluating the infant’s status, which finding is indicative of achieving this goal?
Irritability when awake
Capillary refill of more than 5 seconds
Appropriate weight gain for age
Positioned in high Fowler position to maintain oxygen saturation at 90%
Appropriate weight gain for age
Appropriate weight gain for an infant is indicative of successful feeding and a reduction in caloric loss secondary to the HF. Irritability is a symptom of HF. The child also uses additional energy when irritable. Capillary refill should be brisk and within 2 to 3 seconds. The child needs to be positioned upright to maintain oxygen saturation at 90%. Positioning is helping to decrease respiratory effort, but the infant is still having difficulty with oxygenation.
Rectal temperatures are indicated in which situation?
In the newborn period
Whenever accuracy is essential
Rectal temperatures are never indicated
When rapid temperature changes are occurring
Whenever accuracy is essential
Rectal temperatures are recommended when definitive measurements are necessary in infants older than age 1 month. Rectal temperatures are not done in the newborn period to avoid trauma to the rectal mucosa. Rectal temperature is an intrusive procedure that should be avoided whenever possible.
A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is the priority intervention?
Administering preoperative antibiotic
Verifying that the child and procedure are correct
Ensuring that the toddler has been NPO since midnight
Informing the parents where they can wait during the procedure
Verifying that the child and procedure are correct
The most important intervention is to ensure that the correct child is going to the operating room for the identified procedure. It is the nurse’s responsibility to verify identification of the child and what procedure is to be done. If an antibiotic is ordered, administering it is important, but correct identification is a priority. Clear liquids can be given up to 2 hours before surgery. If the child was NPO (taking nothing by mouth) since midnight, intravenous fluids should be administered. Parents should be encouraged to accompany the child to the preoperative area. Many institutions allow parents to be present during induction.
The nurse is preparing a staff education program about pediatric asthma. What concepts should the nurse include when discussing the asthma severity classification system? (Select all that apply.)
Children with mild persistent asthma have nighttime signs or symptoms less than two times a month.
Children with moderate persistent asthma use a short-acting -agonist more than two times per week.
Children with severe persistent asthma have a peak expiratory flow (PEF) of 60% to 80% of predicted value.
Children with mild persistent asthma have signs or symptoms more than two times per week.
Children with moderate persistent asthma have some limitations with normal activity.
Children with severe persistent asthma have frequent nighttime signs or symptoms.
Children with mild persistent asthma have signs or symptoms more than two times per week.
Children with moderate persistent asthma have some limitations with normal activity.
Children with severe persistent asthma have frequent nighttime signs or symptoms.
Children with mild persistent asthma have signs or symptoms more than two times per week and nighttime signs or symptoms three or four times per month. Children with moderate persistent asthma have some limitations with normal activity and need to use a short-acting -agonist for sign or symptom control daily. Children with severe persistent asthma have frequent nighttime signs or symptoms and have a PEF of less than 60%.
The clinic nurse is administering influenza vaccinations. Which children should not receive the live attenuated influenza vaccine (LAIV)? (Select all that apply.)
A child with asthma
A child with diabetes
A child with hemophilia A
A child with cancer receiving chemotherapy
A child with gastroesophageal reflux disease
A child with asthma
A child with diabetes
A child with cancer receiving chemotherapy
The nurse’s approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle?
The child may think the equipment is alive.
Explaining the equipment will only increase the child’s fear.
One brief explanation will be enough to reduce the child’s fear.
The child is too young to understand what the equipment does
The child may think the equipment is alive
Young children attribute human characteristics to inanimate objects. They often fear that the objects may jump, bite, cut, or pinch all by themselves without human direction. Equipment should be kept out of sight until needed. Simple, concrete explanations about what the equipment does and how it will feel will help alleviate the child’s fear. Preschoolers need repeated explanations as reassurance..
The nurse is caring for a child in respiratory distress. What is an early but less obvious sign of respiratory failure?
Stupor
Headache
Bradycardia
Somnolence
Headache
When checking the intravenous (IV) site on a child, the nurse should take which action?
Look at the site.
Ask the child if the site “hurts.”
Look at the site while palpating the area.
Take all the tape off, assess the site, and redress.
Look at the site while palpating the area.
To appropriately check the intravenous (IV) site, the nurse should look at the site and palpate the area. The other options would not be adequate assessments of the site.
A cancer patient is experiencing neuropathic cancer pain. Which prescription should the nurse expect to be ordered to control anxiety?
Lorazepam (Ativan)
Gabapentin (Neurontin)
Hydromorphone (Dilaudid)
Morphine sulfate (MS Contin)
Gabapentin (Neurontin)
Anticonvulsants (gabapentin, carbamazepine) have demonstrated effectiveness in neuropathic cancer pain. Ativan is an antianxiety agent, and Dilaudid and MS Contin are opioid analgesics.
The nurse is caring for a child receiving a continuous intravenous (IV) low-dose infusion of morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to do which first?
Administer naloxone (Narcan). Discontinue the IV infusion. Discontinue morphine until the child is fully awake. Stimulate the child by calling his or her name, shaking gently, and asking the child to breathe deeply.
Administer naloxone (Narcan).
The management of opioid-induced respiratory depression includes lowering the rate of infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be aroused, then IV naloxone should be administered. The child will be in pain because of the reversal of the morphine. The morphine should be discontinued, but naloxone is indicated if the child is unresponsive.
A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care?
Use an 18-gauge needle if possible.
Show the child the equipment to be used before the procedure.
If not successful after four attempts, have another nurse try.
Restrain the child completely.
Show the child the equipment to be used before the procedure.
To provide atraumatic care the child should be able to see the equipment to be used before the procedure begins. Use the smallest gauge needle that permits free flow of blood. A two-try-only policy is desirable, in which two operators each have only two attempts. If insertion is not successful after four punctures, alternative venous access should be considered. Restrain the child only as needed to perform the procedure safely; use therapeutic hugging.
A 2-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which rate?
60 beats/min
90 beats/min
100 beats/min
120 beats/min
90 beats/min
If a 1-minute apical pulse is less than 90 beats/min for an infant or young child, the digoxin is withheld. Sixty beats/min is the cut-off for holding the digoxin dose in an adult. One hundred to 120 beats/min is an acceptable pulse rate for the administration of digoxin.
For children who do not have a matched sibling bone marrow donor, the therapeutic management of aplastic anemia includes what intervention?
Antibiotics
Antiretroviral drugs
Iron supplementation
Immunosuppressive therapy
Immunosuppressive therapy
It is thought that aplastic anemia may be an autoimmune disease. Immunosuppressive therapy, including antilymphocyte globulin, antithymocyte globulin, cyclosporine, granulocyte colony-stimulating factor, and methylprednisone, has greatly improved the prognosis for patients with aplastic anemia. Antibiotics are not indicated as the management. They may be indicated for infections. Antiretroviral drugs and iron supplementation are not part of the therapy.
At which age should a nurse keep teaching time short (5 minutes)?
Infant
Toddler
Preschool
School age
Toddler
Toddlers have limited time concept, and teaching time should be kept short (5–10 minutes).
The nurse is using the CRIES pain assessment tool on a preterm infant in the neonatal intensive care unit. Which are the components of this tool? (Select all that apply.)
Color Moro reflex Oxygen saturation Posture of arms and legs Sleeplessness Facial expression
Oxygen saturation
Sleeplessness
Facial expression
Need for increased oxygen, crying, increased vital signs, expression, and sleeplessness are components of the CRIES pain assessment tool used with neonates. Color, Moro reflex, and posture of arms and legs are not components of the CRIES scale.
A 10-year-old child requires daily medications for a chronic illness. Her mother tells the nurse that the child continually forgets to take the medicine unless reminded. What nursing action is most appropriate to promote adherence to the medication regimen?
Establish a contract with her, including rewards.
Suggest time-outs when she forgets her medicine.
Discuss with her mother the damaging effects of her rescuing the child.
Ask the child to bring her medicine containers to each appointment so they can be counted.
Establish a contract with her, including rewards.
Many factors can contribute to the child’s not taking the medication. The nurse should resolve those issues such as unpleasant side effects, difficulty taking medicine, and time constraints before school. If these factors do not contribute to the issue, then behavioral contracting is usually an effective method to shape behaviors in children. Time-outs provide negative reinforcement. If part of a contract, negative consequences can work, but they need to be structured. Discussing with her mother the damaging effects of her rescuing the child is not the most appropriate action to encourage compliance. For a school-age child, parents should refrain from nagging and rescuing the child. This child is old enough to partially assume responsibility for her own care. If the child brings her medicine containers to each appointment so they can be counted, this will help determine if the medications are being taken, but it will not provide information about whether the child is taking them by herself.
What is the earliest recognizable clinical manifestation(s) of cystic fibrosis (CF)?
Meconium ileus
History of poor intestinal absorption
Foul-smelling, frothy, greasy stools
Recurrent pneumonia and lung infections
Meconium ileus
The earliest clinical manifestation of CF is a meconium ileus, which is found in about 10% of children with CF. Clinical manifestations include abdominal distention, vomiting, failure to pass stools, and rapid development of dehydration. History of malabsorption is a later sign that manifests as failure to thrive. Foul-smelling stools and recurrent respiratory infections are later manifestations of CF.
What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?
Rinne test
Weber test
Pure tone audiometry
Eliciting the startle reflex
Pure tone audiometry
Pure tone audiometry uses an audiometer that produces sounds at different volumes and pitches in the child’s ears. The child is asked to respond in some way when the tone is heard in the earphone. The Rinne and Weber tests measure bone conduction of sound. Eliciting the startle reflex may be useful in infants.
The nurse is preparing to assess a 10-month-old infant. He is sitting on his father’s lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate?
Initiate a game of peek-a-boo.
Ask the infant’s father to place the infant on the examination table.
Talk softly to the infant while taking him from his father.
Undress the infant while he is still sitting on his father’s lap.
Initiate a game of peek-a-boo.
Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done with the child on the father’s lap. The nurse should have the father undress the child as needed during the examination.
The school nurse is evaluating the number of school-age children classified as obese. The nurse recognizes that the percentile of body mass index that classifies a child as obese is greater than which?
50th percentile
75th percentile
80th percentile
95th percentile
95th percentile
The nurse is planning care for a child with chickenpox (varicella). Which prescribed supportive measures should the nurse plan to implement? (Select all that apply.)
Administration of acyclovir (Zovirax)
Administration of azithromycin (Zithromax)
Administration of Vitamin A supplementation
Administration of acetaminophen (Tylenol) for fever
Administration of diphenhydramine (Benadryl) for itching
Administration of acyclovir (Zovirax)
Administration of acetaminophen (Tylenol) for fever
Administration of diphenhydramine (Benadryl) for itching
Chickenpox is a virus, and acyclovir is ordered to lessen the symptoms. Benadryl and Tylenol are prescribed as supportive treatments. Vitamin A supplementation is used for treating rubeola. Zithromax is an antibiotic prescribed for bacterial infections such as pertussis.
A school-age child with cystic fibrosis takes four enzyme capsules with meals. The child is having four or five bowel movements per day. The nurse’s action in regard to the pancreatic enzymes is based on the knowledge that the dosage is what?
Adequate
Adequate but should be taken between meals
Needs to be increased to increase the number of bowel movements per day
Needs to be increased to decrease the number of bowel movements per day
Needs to be increased to decrease the number of bowel movements per day
The amount of enzyme is adjusted to achieve normal growth and a decrease in the number of stools to one or two per day.
Which muscle is contraindicated for the administration of immunizations in infants and young children?
Deltoid
Dorsogluteal
Ventrogluteal
Anterolateral thigh
Dorsogluteal
The dorsogluteal site is avoided in children because of the location of nerves and veins. The deltoid is recommended for 12 months and older. The ventrogluteal and anterolateral thigh sites can safely be used for the administration of vaccines to infants.
The nurse is testing an infant’s visual acuity. By which age should the infant be able to fix on and follow a target?
1 month
1 to 2 months
3 to 4 months
6 months
3 to 4 months
Visual fixation and ability to follow a target should be present by ages 3 to 4 months. One to 2 months is too young for this developmental milestone. If an infant is not able to fix and follow by 6 months, further ophthalmologic evaluation is needed
When assessing a preschooler’s chest, what should the nurse expect?
Respiratory movements to be chiefly thoracic
Anteroposterior diameter to be equal to the transverse diameter
Retraction of the muscles between the ribs on respiratory movement
Movement of the chest wall to be symmetric bilaterally and coordinated with breathing
Movement of the chest wall to be symmetric bilaterally and coordinated with breathing
Movement of the chest wall should be symmetric bilaterally and coordinated with breathing. In children younger than 6 or 7 years, respiratory movement is principally abdominal or diaphragmatic. The anteroposterior diameter is equal to the transverse diameter during infancy. As the child grows, the chest increases in the transverse direction, so that the anteroposterior diameter is less than the lateral diameter. Retractions of the muscles between the ribs on respiratory movement are indicative of respiratory distress.
Pertussis vaccination should begin at which age?
Birth
2 months
6 months
12 months
2 months
A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most appropriate nursing action at this time??
Allow her to wear her underpants.
Discuss with her mother why this is important to the child.
Ask her mother to explain to her why she cannot wear them.
Explain in a kind, matter-of-fact manner that this is hospital policy.
Allow her to wear her underpants.
It is appropriate for the child to leave her underpants on. If necessary, the underpants can be removed after she has received the initial medications for anesthesia. This allows her some measure of control in this procedure. The mother should not be required to make the child more upset. The child is too young to understand what hospital policy means.
A child is in uncompensated metabolic acidosis. What should the nurse expect the arterial blood gas to be?
HCO3, 24; pH, 7.35
HCO3, 28; pH, 7.50
HCO3, 20; pH, 7.30
HCO3, 26; pH, 7.40
HCO3, 20; pH, 7.30
The parents of a preterm infant in a neonatal intensive care unit are concerned about their infant experiencing pain from so many procedures. The nurse’s response should be based on which characteristic about preterm infants’ pain?
They may react to painful stimuli but are unable to remember the pain experience.
They perceive and react to pain in much the same manner as children and adults.
They do not have the cortical and subcortical centers that are needed for pain perception.
They lack neurochemical systems associated with pain transmission and modulation.
They perceive and react to pain in much the same manner as children and adults.
Numerous research studies have indicated that preterm and newborn infants perceive and react to pain in the same manner as children and adults. Preterm infants can have significant reactions to painful stimuli. Pain can cause oxygen desaturation and global stress response. These physiologic effects must be avoided by use of appropriate analgesia. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response.
Pancreatic enzymes are administered to the child with cystic fibrosis. What nursing consideration should be included in the plan of care?
Give pancreatic enzymes between meals if at all possible.
Do not administer pancreatic enzymes if the child is receiving antibiotics.
Decrease the dose of pancreatic enzymes if the child is having frequent, bulky stools.
Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.
Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.
Enzymes may be administered in a small amount of cereal or fruit at the beginning of a meal or swallowed whole. Enzymes should be given just before meals and snacks. Pancreatic enzymes are not a contraindication for antibiotics. The dose of enzymes should be increased if child is having frequent, bulky stools.
A child with hemophilia A will have which abnormal laboratory result?
PT (ProTime)
Platelet count
Fibrinogen level
PTT (partial thromboplastin time)
PTT (partial thromboplastin time)
The basic defect of hemophilia A is a deficiency of factor VIII. The partial thromboplastin time measures abnormalities in the intrinsic pathway (abnormalities in factors I, II, V, VIII, IX, X, XII, HMK, and KAL). The prothrombin time measures abnormalities of the extrinsic pathway (abnormalities in factors I, II, V, VII, and X). Fibrinogen level is not dependent on the intrinsic pathway. Platelets are not affected with hemophilia A.
Which coanalgesics should the nurse expect to be prescribed for pruritus? (Select all that apply.)
Naloxone (Narcan) Inapsine (Droperidol) Hydroxyzine (Atarax) Promethazine (Phenergan) Diphenhydramine (Benadryl)
Naloxone (Narcan)
Hydroxyzine (Atarax)
Diphenhydramine (Benadryl)
The coanalgesics prescribed for pruritus include naloxone, hydroxyzine, and diphenhydramine. Inapsine and promethazine are administered as antiemetics.
A mother states that she brought her child to the clinic because the 3-year-old girl was not keeping up with her siblings. During physical assessment, the nurse notes that the child has pale skin and conjunctiva and has muscle weakness. The hemoglobin on admission is 6.4 g/dl. After notifying the practitioner of the results, what nursing priority intervention should occur next?
Reduce environmental stimulation to prevent seizures.
Have the laboratory repeat the analysis with a new specimen.
Minimize energy expenditure to decrease cardiac workload.
Administer intravenous fluids to correct the dehydration.
Minimize energy expenditure to decrease cardiac workload.
The child has a critically low hemoglobin value. The expected range is 11.5 to 15.5 g/dl. When the oxygen-carrying capacity of the blood decreases slowly, the child is able to compensate by increasing cardiac output. With the increasing workload of the heart, additional stress can lead to cardiac failure. Reduction of environmental stimulation can help minimize energy expenditure, but seizures are not a risk. A repeat hemoglobin analysis is not necessary. The child does not have evidence of dehydration. If intravenous fluids are given, they can further dilute the circulating blood volume and increase the strain on the heart.
What pain medication is contraindicated in children with sickle cell disease (SCD)?
Meperidine (Demerol)
Hydrocodone (Vicodin)
Morphine sulfate
Ketorolac (Toradol)
Meperidine (Demerol)
Meperidine (pethidine [Demerol]) is not recommended. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Patients with SCD are particularly at risk for normeperidine-induced seizures.
An infant with respiratory syncytial virus (RSV) is being admitted to the hospital. The nurse should plan to place the infant on which precaution?
Enteric
Airborne
Droplet
Contact
Contact
The nurse is teaching a parent of an infant to limit the amount of formula to encourage the intake of iron-rich food. What amount should the nurse teach to the parent?
500 ml
750 ml
1000 ml
1250 ml
1000 ml
The nurse is preparing to give digoxin (Lanoxin) to a 9-month-old infant. The nurse checks the dose and draws up 4 ml of the drug. The most appropriate nursing action is which?
Mix the dose with juice to disguise its taste.
Do not give the dose; suspect a dosage error.
Check the heart rate; administer digoxin if the rate is greater than 100 beats/min.
Check the heart rate; administer digoxin if the rate is greater than 80 beats/min.
Do not give the dose; suspect a dosage error.
Infants rarely receive more than 1 ml (50 mcg, or 0.05 mg) of digoxin in one dose; a higher dose is an immediate warning of a dosage error. To ensure safety, compare the calculation with that of another staff member before giving digoxin.
A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry represents best documentation of his breakfast meal?
Tolerated breakfast well
Finished all of breakfast ordered
One pancake, eggs, and 240 ml OJ
No documentation is needed for this age child.
One pancake, eggs, and 240 ml OJ
Specific information is necessary for hospitalized children. It is essential to be able to identify caloric intake and eating patterns for assessment and intervention purposes. That he tolerated breakfast well only provides information that the child did not become ill with the meal. Even if he finished all his breakfast, an evaluation cannot be completed unless the quantity of food ordered is known. Nutritional information is essential, especially for children with chronic illnesses.
A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his “regular diet” trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What nursing action is the most appropriate?
Request these favorite foods for him.
Identify healthier food choices that he likes.
Explain that he needs fruits and vegetables.
Reward him with ice cream at the end of every meal that he eats.
Request these favorite foods for him.
Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate nutrition, the nurse should request favorite foods for the child. The foods he likes provide nutrition and can be supplemented with additional fruits and vegetables. Ice cream and other desserts should not be used as rewards or punishment.
An 18-month-old child has been diagnosed with pediculosis capitis (head lice). Which prescription should the nurse question if ordered for the child?
Malathion (Ovide)
Permethrin 1% (Nix)
Benzyl alcohol 5% lotion
Pyrethrin with piperonyl butoxide (RID)
Malathion (Ovide)
The nurse is administering the first hepatitis A vaccine to an 18-month-old child. When should the child return to the clinic for the second dose of hepatitis A vaccination?
After 2 months
After 3 months
After 4 months
After 6 months
After 6 months
A child is in uncompensated respiratory alkalosis. What should the nurse expect the arterial blood gas to be?
CO2, 30; pH, 7.50
CO2, 55; pH, 7.30
CO2, 35; pH, 7.28
CO2, 54; pH, 7.35
CO2, 30; pH, 7.50
A 3-month-old infant has a hypercyanotic spell. What should be the nurse’s first action?
Assess for neurologic defects.
Prepare the family for imminent death.
Begin cardiopulmonary resuscitation.
Place the child in the knee–chest position.
Place the child in the knee–chest position.
The first action is to place the infant in the knee–chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. Preparing the family for imminent death or beginning cardiopulmonary resuscitation should be unnecessary. The child is assessed for airway, breathing, and circulation. Often, calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell.
With the National Center for Health Statistics criteria, which body mass index (BMI)–for-age percentiles should indicate the patient is at risk for being overweight?
10th percentile
75th percentile
85th percentile
95th percentile
85th percentile
Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children who are greater than or equal to the 95th percentile are considered overweight. Children whose BMI is between the 10th and 75th percentiles are within normal limits
Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests?
Apply a urine collection bag to the perineal area.
Tape a small medicine cup inside of the diaper.
Aspirate urine from cotton balls inside the diaper with a syringe without a needle.
Use a syringe without a needle to aspirate urine from a superabsorbent disposable diaper.
Aspirate urine from cotton balls inside the diaper with a syringe without a needle.
To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. Diapers with superabsorbent gels absorb the urine; if these are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine and aspirate the urine with a syringe. For frequent urine sampling, the collection bag would be too irritating to the child’s skin. It is not feasible to tape a small medicine cup to the inside of the diaper; the urine will spill from the cup.
A cardiac defect that allows blood to shunt from the (high pressure) left side of the heart to the (lower pressure) right side can result in which condition?
Cyanosis
Heart failure
Decreased pulmonary blood flow
Bounding pulses in upper extremities
Heart failure
As blood is shunted into the right side of the heart, there is increased pulmonary blood flow and the child is at high risk for heart failure. Cyanosis usually occurs in defects with decreased pulmonary blood flow. Bounding upper extremity pulses are a manifestation of coarctation of the aorta.
A 5-year-old child is admitted to the hospital in a sickle cell crisis. The child has been alert and oriented but in severe pain. The nurse notes that the child is complaining of a headache and is having unilateral hemiplegia. What action should the nurse implement?
Notify the health care provider.
Place the child on bed rest.
Administer a dose of hydrocodone (Vicodin).
Start O2 per the hospital’s protocol
Notify the health care provider.
Any number of neurologic symptoms can indicate a minor cerebral insult, such as headache, aphasia, weakness, convulsions, visual disturbances, or unilateral hemiplegia. Loss of vision is usually the result of progressive retinopathy and retinal detachment. The nurse should notify the health care provider.
Which nonpharmacologic intervention appears to be effective in decreasing neonatal procedural pain?
Tactile stimulation
Commercial warm packs
Doing procedure during infant sleep
Oral sucrose and nonnutritive sucking
Oral sucrose and nonnutritive sucking
Nonnutritive sucking attenuates behavioral, physiologic, and hormonal responses to pain. The addition of sucrose has been demonstrated to have calming and pain-relieving effects for neonates. Tactile stimulation has a variable effect on response to procedural pain. No evidence supports commercial warm packs as a pain control measure. With resulting increased blood flow to the area, pain may be greater. The infant should not be disturbed during the sleep cycle. It makes it more difficult for the infant to begin organization of sleep and awake cycles.
What statement best describes iron deficiency anemia in infants?
It is caused by depression of the hematopoietic system.
Diagnosis is easily made because of the infant’s emaciated appearance.
It results from a decreased intake of milk and the premature addition of solid foods.
Clinical manifestations are related to a reduction in the amount of oxygen available to tissues.
Clinical manifestations are related to a reduction in the amount of oxygen available to tissues.
In iron-deficiency anemia, the child’s clinical appearance is a result of the anemia, not the underlying cause. Usually the hematopoietic system is not depressed. The bone marrow produces red blood cells that are smaller and contain less hemoglobin than normal red blood cells. Children who have iron deficiency from drinking excessive quantities of milk are usually pale and overweight. They are receiving sufficient calories but are deficient in essential nutrients. The clinical manifestations result from decreased intake of iron-fortified solid foods and an excessive intake of milk.
The nurse is assessing breath sounds on a child. Which are expected auscultated breath sounds? (Select all that apply.)
Wheezes Crackles Vesicular Bronchial Bronchovesicular
Vesicular
Bronchial
Bronchovesicular
Normal breath sounds are classified as vesicular, bronchovesicular, or bronchial. Wheezes or crackles are abnormal or adventitious sounds.
The nurse has just collected blood by venipuncture in the antecubital fossa. What should the nurse do next?
Keep the child’s arm extended while applying a Band-Aid to the site.
Keep the child’s arm extended and apply pressure to the site for a few minutes.
Apply a Band-Aid to the site and keep the arm flexed for 10 minutes.
Apply a gauze pad or cotton ball to the site and keep the arm flexed for several minutes.
Keep the child’s arm extended and apply pressure to the site for a few minutes.
Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation. Pressure should be applied before a bandage or gauze pad is applied.
What are signs and symptoms of anemia? (Select all that apply.)
Pallor Fatigue Dilute urine Bradycardia Muscle weakness
Pallor
Fatigue
Muscle weakness
The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. What nursing action should be included in the care of the child?
Force fluids.
Monitor pulse oximetry.
Institute seizure precautions.
Encourage a high-protein diet.
Monitor pulse oximetry.
Careful monitoring of oxygenation and cardiopulmonary status is an important evaluation tool in the care of the child with ARDS. Maintenance of vascular volume and hydration is important and should be done parenterally. Seizures are not a side effect of ARDS. Adequate nutrition is necessary, but a high-protein diet is not helpful.
The clinical manifestations of sickle cell anemia (SCA) are primarily the result of which physiologic alteration?
Decreased blood viscosity
Deficiency in coagulation
Increased red blood cell (RBC) destruction
Greater affinity for oxygen
Increased red blood cell (RBC) destruction
The clinical features of SCA are primarily the result of increased RBC destruction and obstruction caused by the sickle-shaped RBCs. When the sickle cells change shape, they increase the viscosity in the area where they are involved in the microcirculation. SCA does not have a coagulation deficit. Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low oxygen tension.
What rationale explains why prolonged use of oxygen should be discouraged in a child with anemia?
Prolonged use of oxygen can decrease erythropoiesis.
Prolonged use of oxygen can interfere with iron production.
Prolonged use of oxygen interferes with a child’s appetite.
Prolonged use of oxygen can affect the synthesis of hemoglobin.
Prolonged use of oxygen can decrease erythropoiesis.
Oxygen administration is of limited value, because each gram of hemoglobin is able to carry a limited amount of the gas. In addition, prolonged use of supplemental oxygen can decrease erythropoiesis. Prolonged use of oxygen does not interfere with iron production, a child’s appetite, or affect the synthesis of hemoglobin.
Which is the most consistent and commonly used data for assessment of pain in infants?
Self-report
Behavioral
Physiologic
Parental report
Behavioral
Behavioral assessment is useful for measuring pain in young children and preverbal children who do not have the language skills to communicate that they are in pain. Infants are not able to self-report. Physiologic measures are not able to distinguish between physical responses to pain and other forms of stress. Parental report without a structured tool may not accurately reflect the degree of discomfort.
The nurse is interviewing the mother of an infant. The mother reports, “I had a difficult delivery, and my baby was born prematurely.” This information should be recorded under which heading?
History
Present illness
Chief complaint
Review of systems
History
The history refers to information that relates to previous aspects of the child’s health, not to the current problem. The difficult delivery and prematurity are important parts of the infant’s history. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of the present illness. The chief complaint is the specific reason for the child’s visit to the clinic, office, or hospital. It should not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth but might include sequelae such as pulmonary dysfunction.
Which parameter correlates best with measurements of total muscle mass?
Height
Weight
Skinfold thickness
Upper arm circumference
Upper arm circumference
Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the body’s major protein reserve and is considered an index of the body’s protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skinfold thickness is a measurement of the body’s fat content.
The nurse is assessing a child with croup in the emergency department. The child has a sore throat and is drooling. Examining the child’s throat using a tongue depressor might precipitate what condition?
Sore throat
Inspiratory stridor
Complete obstruction
Respiratory tract infection
Complete obstruction
If a child has acute epiglottitis, examination of the throat may cause complete obstruction and should be performed only when immediate intubation can take place. Sore throat and pain on swallowing are early signs of epiglottitis. Stridor is aggravated when a child with epiglottitis is supine. Epiglottitis is caused by Haemophilus influenzae in the respiratory tract.
The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes the risk of cerebrovascular accidents (strokes) occurring. What strategy is an important objective to decrease this risk?
Minimize seizures.
Prevent dehydration.
Promote cardiac output.
Reduce energy expenditure.
Prevent dehydration
In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents.
In a child with sickle cell anemia (SCA), adequate hydration is essential to minimize sickling and delay the vasoocclusion and hypoxia–ischemia cycle. What information should the nurse share with parents in a teaching plan?
Encourage drinking.
Keep accurate records of output.
Check for moist mucous membranes.
Monitor the concentration of the child’s urine.
Check for moist mucous membranes.
Children with SCA have impaired kidney function and cannot concentrate urine. Parents are taught signs of dehydration and ways to minimize loss of fluid to the environment. Encouraging drinking is not specific enough for parents. The nurse should give the parents and child a target fluid amount for each 24-hour period. Accurate monitoring of output may not reflect the child’s fluid needs. Without the ability to concentrate urine, the child needs additional intake to compensate. Dilute urine and specific gravity are not valid signs of hydration status in children with SCA.
What statement best identifies the cause of heart failure (HF)?
Disease related to cardiac defects
Consequence of an underlying cardiac defect
Inherited disorder associated with a variety of defects
Result of diminished workload imposed on an abnormal myocardium
Consequence of an underlying cardiac defect
HF is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body’s metabolic demands. HF is not a disease but rather a result of the inability of the heart to pump efficiently. HF is not inherited. HF occurs most frequently secondary to congenital heart defects in which structural abnormalities result in increased volume load or increased pressures on the ventricles.
A school-age child has asthma. The nurse should teach the child that if a peak expiratory flow rate is in the yellow zone, this means that the asthma control is what?
80% of a personal best, and the routine treatment plan can be followed.
50% to 79% of a personal best and needs an increase in the usual therapy.
50 % of a personal best and needs immediate emergency bronchodilators.
Less than 50% of a personal best and needs immediate hospitalization
50% to 79% of a personal best and needs an increase in the usual therapy.
The interpretation of a peak expiratory flow rate that is yellow (50%–79% of personal best) signals caution. Asthma is not well controlled. An acute exacerbation may be present. Maintenance therapy may need to be increased. Call the practitioner if the child stays in this zone.
A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse recognizes that in addition to a private room, the child is placed on what precautions?
Droplet
Contact
Airborne
Standard
Contact
MRSA is an increasingly significant source of hospital-acquired infections. This organism meets the criteria of being epidemiologically important and can be transmitted by direct contact. Gowns and gloves should be worn when exposed to potentially contagious materials, and meticulous hand washing is required. S. aureus is not an organism that is spread through airborne or droplet mechanisms. Additional precautions, beyond Standard Precautions, are needed to prevent spread of this organism.
The nurse is preparing to administer a measles, mumps, rubella, and varicella (MMRV) vaccine. Which is a contraindication associated with administering this vaccine?
The child has recently been exposed to an infectious disease.
The child has symptoms of a cold but no fever.
The child is having intermittent episodes of diarrhea.
The child has a disorder that causes a deficient immune system
The child has a disorder that causes a deficient immune system.
The MMRV (measles, mumps, rubella, and varicella) vaccine is an attenuated live virus vaccine. Children with deficient immune systems should not receive the MMRV vaccine because of a lack of evidence of its safety in this population. Exposure to an infectious disease, symptoms of a cold, or intermittent episodes of diarrhea are not contraindications to receiving a live vaccine.
The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?
Use the small cuff.
Use the large cuff.
Use either cuff using the palpation method.
Wait to take the blood pressure until a proper cuff can be located.
Use the large cuff.
If blood pressure measurement is indicated and the appropriate size cuff is not available, the next larger size is used. The nurse recognizes that this may be a falsely low blood pressure. Using the small cuff will give an incorrectly high reading. The palpation method will not improve the inaccuracy inherent in the cuff.
A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the child’s heart rate is 20 beats/min less than it was preoperatively. What should be the nurse’s next action?
Follow the orders and check in 2 hours.
Ask the parents if this is the child’s usual heart rate.
Recheck the pulse and blood pressure in 15 minutes.
Notify the surgeon that the child is probably going into shock.
Recheck the pulse and blood pressure in 15 minutes.
In a 5-year-old child, this is a significant change in vital signs. The nurse should assess the child to see if his condition mirrors a drop in heart rate. The assessment and vital signs should be redone in 15 minutes to determine whether the child’s condition is stable. When a disparity in vital signs or other assessment data is observed, the nurse should reassess sooner. Most parents will not know their child’s heart rate. It is important to determine how the child is recovering from surgery. The nurse should collect additional information before notifying the surgeon. This includes blood pressure, respiratory rate, and pain status.
A burn patient is experiencing anxiety over dressing changes. Which prescription should the nurse expect to be ordered to control anxiety?
Lorazepam (Ativan)
Oxycodone (OxyContin)
Fentanyl (Sublimaze)
Morphine Sulfate (Morphine)
Lorazepam (Ativan)
A benzodiazepine such as lorazepam is prescribed as an antianxiety agent. Oxycodone, fentanyl, and morphine sulfate are opioid analgesics.
The Asian parent of a child being seen in the clinic avoids eye contact with the nurse. What is the best explanation for this considering cultural differences?
The parent feels inferior to the nurse.
The parent is showing respect for the nurse.
The parent is embarrassed to seek health care.
The parent feels responsible for her child’s illness.
The parent is showing respect for the nurse.
In some ethnic groups, eye contact is avoided. In the Vietnamese culture, an individual may not look directly into the nurse’s eyes as a sign of respect. The nurse providing culturally competent care would recognize that the other answers listed are not why the parent avoids eye contact with the nurse.
The nurse is planning to administer immunizations to a 6-month-old infant. Which interventions should the nurse implement to minimize local reactions from the vaccines? (Select all that apply.)
Select a needle length of 1 inch.
Administer in the deltoid muscle.
Inject the vaccine into the vastus lateralis.
Draw the vaccine up from a vial with a filter needle.
Change the needle on the syringe after drawing up the vaccine and before injecting.
Select a needle length of 1 inch.
Inject the vaccine into the vastus lateralis.
To minimize local reactions from vaccines, the nurse should select a needle of adequate length (25 mm [1 inch] in infants) to deposit the antigen deep in the muscle mass and inject it into the vastus lateralis muscle. The deltoid may be used in children 18 months of age or older but not in a 6-month-old infant. A filter needle is not needed to draw the vaccine from a vial. Changing the needle on the syringe after drawing up the vaccine before injecting it has not been shown to decrease local reactions.
During examination of a toddler’s extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is which?
Abnormal and requires further investigation
Abnormal unless it occurs in conjunction with knock-knee
Normal if the condition is unilateral or asymmetric
Normal because the lower back and leg muscles are not yet well developed
Normal because the lower back and leg muscles are not yet well developed
Lateral bowing of the tibia (bowlegged) is an expected finding in toddlers when they begin to walk. It usually persists until all of their lower back and leg muscles are well developed. Further evaluation is needed if it persists beyond ages 2 to 3 years, especially in African American children.
The clinic nurse is evaluating causes for iron deficiency due to impaired iron absorption. What should the nurse recognize as causes for iron deficiency due to impaired iron absorption? (Select all that apply.)
Gastric acidity Chronic diarrhea Lactose intolerance Absence of phosphates Inflammatory bowel disease
Chronic diarrhea
Lactose intolerance
Inflammatory bowel disease
Causes for iron deficiency due to impaired iron absorption include chronic diarrhea, lactose intolerance, and inflammatory bowel disease. Gastric alkalinity, not acidity, and the presence, not absence, of phosphates can be causes of impaired iron absorption.
Which heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?
S1 and S2
S3 and S4
Murmur
Physiologic splitting
Murmur
Murmurs are the sounds that are produced in the heart chambers or major arteries from the back-and-forth flow of blood. S1 and S2 are normal heart sounds. S1 is the closure of the tricuspid and mitral valves, and S2 is the closure of the pulmonic and aortic valves. S3 is a normal heart sound sometimes heard in children. S4 is rarely heard as a normal heart sound. If it is heard, medical evaluation is required. Physiologic splitting is the distinction of the two sounds in S2, which widens on inspiration. It is a significant normal finding.
The nurse is assessing heart sounds on a school-age child. Which should the nurse document as abnormal findings if found on the assessment? (Select all that apply.)
S4 heart sound S3 heart sound Grade II murmur S1 louder at the apex of the heart S2 louder than S1 in the aortic area
S4 heart sound
Grade II murmur
S2 louder than S1 in the aortic area
S4 is rarely heard as a normal heart sound; it usually indicates the need for further cardiac evaluation. A grade II murmur is not normal; it is slightly louder than grade I and is audible in all positions. S3 is normally heard in some children. Normally, S1 is louder at the apex of the heart in the mitral and tricuspid area, and S2 is louder near the base of the heart in the pulmonic and aortic area.
A bone marrow aspiration and biopsy are needed on a school-age child. The most appropriate action to provide analgesia during the procedure is which?
Administer TAC (tetracaine, adrenalin, and cocaine) 15 minutes before the procedure.
Use a combination of fentanyl and midazolam for conscious sedation.
Apply EMLA (eutectic mixture of local anesthetics) 1 hour before the procedure.
Apply a transdermal fentanyl (Duragesic) “patch” immediately before the procedure.
Use a combination of fentanyl and midazolam for conscious sedation.
A bone marrow biopsy is a painful procedure. The combination of fentanyl and midazolam should be used to provide conscious sedation. TAC provides skin anesthesia about 15 minutes after it is applied to nonintact skin. The gel can be placed on a wound for suturing. It is not sufficient for a bone marrow biopsy. EMLA is an effective topical analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. For this procedure, systemic analgesia is required. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control.
An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough. These manifestations are most suggestive of what complication?
Air embolism
Allergic reaction
Hemolytic reaction
Circulatory overload
Circulatory overload
The signs of circulatory overload include distended neck veins, hypertension, crackles, a dry cough, cyanosis, and precordial pain. Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Urticaria, pruritus, flushing, asthmatic wheezing, and laryngeal edema are signs and symptoms of allergic reactions. Hemolytic reactions are characterized by chills, shaking, fever, pain at infusion site, nausea, vomiting, tightness in chest, flank pain, red or black urine, and progressive signs of shock and renal failure.
What preparation should the nurse consider when educating a school-age child and the family for heart surgery?
Unfamiliar equipment should not be shown.
Let the child hear the sounds of a cardiac monitor, including alarms.
Explain that an endotracheal tube will not be needed if the surgery goes well.
Discussion of postoperative discomfort and interventions is not necessary before the procedure.
Let the child hear the sounds of a cardiac monitor, including alarms.
The child and family should be exposed to the sights and sounds of the intensive care unit (ICU). All positive, nonfrightening aspects of the environment are emphasized. The family and child should make the decision about a tour of the unit if it is an option. The child should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous lines, incision, endotracheal tube, expected discomfort, and management strategies.
What describes nonpharmacologic techniques for pain management?
They may reduce pain perception.
They usually take too long to implement.
They make pharmacologic strategies unnecessary.
They trick children into believing they do not have pain.
They may reduce pain perception.
Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. The nonpharmacologic strategy should be matched with the child’s pain severity and be taught to the child before the onset of the painful experience. Tricking children into believing they do not have pain may mitigate the child’s experience with mild pain, but the child will still know the discomfort was present.
When teaching a mother how to administer eye drops, where should the nurse tell her to place them?
At the lacrimal duct
On the sclera while the child looks to the outside
In the conjunctival sac when the lower eyelid is pulled down
Carefully under the eyelid while it is gently pulled upward
In the conjunctival sac when the lower eyelid is pulled down
The lower eyelid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area. The medication should not be administered directly on the eyeball. The lacrimal duct is not the appropriate placement for the eye medication. It will drain into the nasopharynx, and the child will taste the drug.
When the nurse interviews an adolescent, which is especially important?
Focus the discussion on the peer group.
Allow an opportunity to express feelings.
Use the same type of language as the adolescent.
Emphasize that confidentiality will always be maintained.
Allow an opportunity to express feelings.
Adolescents, like all children, need opportunities to express their feelings. Often they interject feelings into their words. The nurse must be alert to the words and feelings expressed. The nurse should maintain a professional relationship with adolescents. To avoid misunderstanding or misinterpretation of words and phrases used, the nurse should clarify the terms used, what information will be shared with other members of the health care team, and any limits to confidentiality. Although the peer group is important to this age group, the interview should focus on the adolescent.
What methods should the nurse use to measure compliance to a treatment plan? (Select all that apply.)
Pill counts Chemical assays Direct observation Third-party reporting Monitoring therapeutic response
Pill counts
Chemical assays
Direct observation
Monitoring therapeutic response
Assessment of compliance must include direct measurement techniques. Pill counts, chemical assays, direct observation, and monitoring therapeutic response are direct measurement techniques. Third-party reporting would not always be available and would not be a method to measure compliance.
What is an advantage of the ventrogluteal muscle as an injection site in young children?
Easily accessible from many directions
Free of significant nerves and vascular structures
Can be used until child reaches a weight of 9 kg (20 lb)
Increased subcutaneous fat, which provides sustained drug absorption
Free of significant nerves and vascular structures
Being free of significant nerves and vascular structure is one of the advantages of the ventrogluteal site. In addition, it is considered less painful than the vastus lateralis. The major disadvantage is lack of familiarity by health professionals and controversy over whether the site can be used before weight bearing. The vastus lateralis is a more accessible site. The ventrogluteal muscle site has safely been used from newborn through adulthood. Clinical guidelines address the need for the child to be walking. The site has less subcutaneous tissue, which facilitates intramuscular deposition of the drug rather than subcutaneous.
The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first?
Introduce him- or herself.
Make the family comfortable.
Give assurance of privacy.
Explain the purpose of the interview.
Introduce him- or herself.
The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. Clarification of the purpose of the interview and the nurse’s role is the second thing that should be done. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. The interview also should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality.
What sign/symptom is a major clinical manifestation of rheumatic fever (RF)?
Fever
Polyarthritis
Osler nodes
Janeway spots
Polyarthritis
Polyarthritis, which is swollen, hot, red, and painful joints, is a major clinical manifestation. The affected joints will change every 1 or 2 days. The large joints are primarily affected. Fever is considered a minor manifestation of RF. Osler nodes and Janeway spots are characteristic of bacterial endocarditis.
The nurse is planning pain control for a child. Which is the advantage of administering pain medication by the intravenous (IV) bolus route?
Less expensive than oral medications
Produces a first-pass effect through the liver
Does not need to be administered frequently
Provides most rapid onset of effect, usually in about 5 minutes
Provides most rapid onset of effect, usually in about 5 minutes
The advantage of pain medication by the IV bolus route is that it provides the most rapid onset of effect, usually in about 5 minutes. IV medications are more expensive than oral medications, and the IV route bypasses the first-pass effect through the liver. Pain control with IV bolus medication needs to be repeated hourly for continuous pain control.
Selective cholesterol screening is recommended for children older than the age of 2 years with which risk factor?
Body mass index (BMI) = 95th percentile
Blood pressure = 50th percentile
Parent with a blood cholesterol level of 200 mg/dl
Recently diagnosed cardiovascular disease in a 75-year-old grandparent
Body mass index (BMI) = 95th percentile
Obesity is an indication for cholesterol screening in children. A BMI in the 95th percentile or higher is considered obese. Children who are hypertensive meet the criteria for screening, but blood pressure in the 50th percentile is within the normal range. A parent or grandparent with a cholesterol level of 240 mg/dl or higher places the child at risk. Early cardiovascular disease in a first- or second-degree relative is a risk factor. Age 75 years is not considered early.
A child with sickle cell disease is in a vasoocclusive crisis. What nonpharmacologic pain intervention should the nurse plan?
Exercise as a distraction
Heat to the affected area
Elevation of the extremity
Cold compresses to the affected area
Heat to the affected area
Frequently, heat to the affected area is soothing. Cold compresses are not applied to the area because doing so enhances vasoconstriction and occlusion. Bed rest is usually well tolerated during a crisis, although the actual rest obtained depends a great deal on pain alleviation and the use of organized schedules of nursing care. Although the objective of bed rest is to minimize oxygen consumption, some activity, particularly passive range of motion exercises, is beneficial to promote circulation. Usually the best course is to let children determine their activity tolerance. Elevating the extremity will not help in sickle cell disease.
What interventions should the nurse implement to prevent a pressure ulcer in a critically ill child? (Select all that apply.)
Nutrition consults Using skin moisturizers Turning the child every 2 hours Using plastic disposable underpads Using draw sheets to minimize shear
Nutrition consults
Using skin moisturizers
Turning the child every 2 hours
Using draw sheets to minimize shear
Interventions found to prevent pressure ulcers in critically ill children include nutrition consults, using skin moisturizers, turning the child every 2 hours, and using draw sheets to minimize shear. Dryweave underpads, not underpads with plastic, should be used to reduce moisture.
The nurse is giving discharge instructions to the parents of a 5-year-old child who had a tonsillectomy 4 hours ago. What statement by the parent indicates a correct understanding of the teaching?
“I can use an ice collar on my child for pain control along with analgesics.”
“My child should clear the throat frequently to clear the secretions.”
“I should allow my child to be as active as tolerated.”
“My child should gargle and brush teeth at least three times per day.
can use an ice collar on my child for pain control along with analgesics.”
Pain control after a tonsillectomy can be achieved with application of an ice collar and administration of analgesics. The child should avoid clearing the throat or coughing and does not need to gargle and brush teeth a certain number of times per day and should avoid vigorous gargling and toothbrushing. Also, the child’s activity should be limited to decrease the potential for bleeding, at least for the first few days.
What statement is descriptive of most cases of hemophilia?
X-linked recessive deficiency of platelets causing prolonged bleeding
X-linked recessive inherited disorder in which a blood clotting factor is deficient
Autosomal dominant deficiency of a factor involved in the blood-clotting reaction
Y-linked recessive inherited disorder in which the red blood cells become moon shaped
X-linked recessive inherited disorder in which a blood clotting factor is deficient
The inheritance pattern in 80% of all the cases of hemophilia is X-linked recessive. The two most common forms of the disorder are factor VIII deficiency (hemophilia A, or classic hemophilia) and factor IX deficiency (hemophilia B, or Christmas disease). The disorder involves coagulation factors, not platelets. The disorder does not involve red blood cells or the Y chromosome.
A 3-year-old is brought to the emergency department with symptoms of stridor, fever, restlessness, and drooling. No coughing is observed. Based on these findings, the nurse should be prepared to assist with what action?
Throat culture
Nasal pharynx washing
Administration of corticosteroids
Emergency intubation
Emergency intubation
Three clinical observations that are predictive of epiglottitis are absence of spontaneous cough, presence of drooling, and agitation. Nasotracheal intubation or tracheostomy is usually considered for a child with epiglottitis with severe respiratory distress. The throat should not be inspected because airway obstruction can occur, and steroids would not be done first when the child is in severe respiratory distress.
Using knowledge of child development, what approach is best when preparing a toddler for a procedure?
Avoid asking the child to make choices.
Plan for a teaching session to last about 20 minutes.
Demonstrate on a doll how the procedure will be done.
Show the necessary equipment without allowing child to handle it.
Demonstrate on a doll how the procedure will be done.
Prepare toddlers for procedures by using play. Demonstrate on a doll but avoid the child’s favorite doll because the toddler may think the doll is really “feeling” the procedure. In preparing a toddler for a procedure, the child is allowed to participate in care and help whenever possible. Teaching sessions for toddlers should be about 5 to 10 minutes. Use a small replica of the equipment and allow the child to handle it.
A family requires home care teaching with regard to preventative measures to use at home to avoid an asthmatic episode. What strategy should the nurse teach?
Use a humidifier in the child’s room.
Launder bedding daily in cold water.
Replace wood flooring with carpet.
Use an indoor air purifier with HEPA filter.
Use an indoor air purifier with HEPA filter.
One of the goals for children with asthma is to maintain the child’s normal functioning. What principle of treatment helps to accomplish this goal?
Limit participation in sports.
Reduce underlying inflammation.
Minimize use of pharmacologic agents.
Have yearly evaluations by a health care provider
Reduce underlying inflammation.
Children with asthma are often excluded from exercise. This practice interferes with peer interaction and physical health. Most children with asthma can participate provided their asthma is under control. Inflammation is the underlying cause of the symptoms of asthma. By decreasing inflammation and reducing the symptomatic airway narrowing, health care providers can minimize exacerbations. Pharmacologic agents are used to prevent and control asthma symptoms, reduce the frequency and severity of asthma exacerbations, and reverse airflow obstruction. It is recommended that children with asthma be evaluated every 6 months.
A 5-year-old child is admitted with bacterial pneumonia. What signs and symptoms should the nurse expect to assess with this disease process?
Fever, cough, and chest pain
Stridor, wheezing, and ear infection
Nasal discharge, headache, and cough
Pharyngitis, intermittent fever, and eye infection
Fever, cough, and chest pain
Children with bacterial pneumonia usually appear ill. Symptoms include fever, malaise, rapid and shallow respirations, cough, and chest pain. Ear infection, nasal discharge, and eye infection are not symptoms of bacterial pneumonia.
The parents of a young child with heart failure (HF) tell the nurse that they are nervous about giving digoxin. The nurse’s response should be based on which knowledge?
It is a safe, frequently used drug.
Parents lack the expertise necessary to administer digoxin.
It is difficult to either overmedicate or undermedicate with digoxin.
Parents need to learn specific, important guidelines for administration of digoxin.
Parents need to learn specific, important guidelines for administration of digoxin.
Digoxin has a narrow therapeutic range. The margin of safety between therapeutic, toxic, and lethal doses is very small. Specific guidelines are available for parents to learn how to administer the drug safely and to monitor for side effects. Parents may lack the expertise to administer the drug at first, but with discharge preparation, they should be prepared to administer the drug safely.
When caring for a child after a tonsillectomy, what intervention should the nurse do?
Watch for continuous swallowing.
Encourage gargling to reduce discomfort.
Apply warm compresses to the throat.
Position the child on the back for sleeping.
Watch for continuous swallowing.
Continuous swallowing, especially while sleeping, is an early sign of bleeding. The child swallows the blood that is trickling from the operative site. Gargling is discouraged because it could irritate the operative site. Ice compresses are recommended to reduce inflammation. The child should be positioned on the side or abdomen to facilitate drainage of secretions.
Guidelines for intramuscular administration of medication in school-age children include what standard?
Inject medication as rapidly as possible.
Insert needle quickly, using a dartlike motion.
Have the child stand if at all possible and if the child is cooperative.
Penetrate the skin immediately after cleansing the site while the skin is moist.
Insert needle quickly, using a dartlike motion.
The needle should be inserted quickly in a dartlike motion at a 90-degree angle unless contraindicated. Inject medications slowly. Allow skin preparation to dry completely before the skin is penetrated. Place the child in a lying or sitting position.
What interventions can the nurse teach parents to do to ease respiratory efforts for a child with a mild respiratory tract infection? (Select all that apply.)
Cool mist Warm mist Steam vaporizer Keep child in a flat, quiet position Run a shower of hot water to produce steam
Cool mist
Warm mist
Steam vaporizer
Run a shower of hot water to produce steam
Warm or cool mist is a common therapeutic measure for symptomatic relief of respiratory discomfort. The moisture soothes inflamed membranes and is beneficial when there is hoarseness or laryngeal involvement. A time-honored method of producing steam is the shower. Running a shower of hot water into the empty bathtub or open shower stall with the bathroom door closed produces a quick source of steam. Keeping a child in this environment for 10 to 15 minutes may help ease respiratory efforts. A small child can sit on the lap of a parent or other adult. The child should be quiet but upright, not flat. The use of steam vaporizers in the home is often discouraged because of the hazards related to their use and limited evidence to support their efficacy.
