Quiz 3 Flashcards
The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease. Assessment of the newborn reveals slight respiratory distress and tachycardia. Which should the nurse’s first action be?
a. Notify practitioner.
b. Stop the transfusion.
c. Administer calcium gluconate.
d. Monitor vital signs electronically.
b. Stop the transfusion.
A nurse is caring for a school-age child who has leukemia.
Which of the following assessment findings should the nurse report to the provider?
Select the 6 findings that should be reported to the provider.
Respiratory rate
WBC count
Hemoglobin
Retractions
Breath sounds
Skin assessment
Upper respiratory infection
Oxygen saturation
Respiratory rate
WBC count
Retractions
Skin assessment
Upper respiratory infection
Oxygen saturation
What are expected findings of bacterial meningitis?
nuchal rigidity
headache (pain)
high fever
sensitive to light (photophobia)
neck pain/inflammation
malaise
irritable
How do you test for bacterial meningitis?
spinal tap tests cells on spinal fluid
CSF = cloudy, increased WBC/protein, decreased glucose
Which of the following are laboratory test results indicative of bacterial meningitis? (Select all that apply)
A. Cloudy color
B. Elevated WBC count
C. Positive gram stain
D. Normal glucose content
E. Elevated protein content
A. Cloudy color
B. Elevated WBC count
C. Positive gram stain
E. Elevated protein content
The nurse is evaluating the laboratory results on cerebral spinal fluid (CSF) from a 3-year-old child with bacterial meningitis. Which findings confirm bacterial meningitis? (Select all that apply.)
a. Elevated white blood cell (WBC) count
b. Decreased glucose
c. Normal protein
d. Elevated red blood cell (RBC) count
a. Elevated white blood cell (WBC) count
b. Decreased glucose
What are the expected findings of bacterial encephalitis?
nuchal rigidity
headache
low grade fever
sensitive to light (photophobia)
high protein
increased leukocytes
What will the babinski reflex be in a 1 year old?
positive
What will the nurse do for a 1 year old patient with head trauma due to a subdural hematoma? Why?
measure head circumference - check for swelling
check pupils - may be unresponsive or slow
do not stabilize spine at first
Will a nurse encourage a 1 year old patient with head trauma due to a subdural hematoma to eat?
NO
What will you see in the fontanels of a patient with a subdural hematoma?
bulging
Describe the changes a child with cancer can develop after chemo?
tumor lysis syndrome - yes
retinopathy - no
neuropathy - yes
diarrhea - no
alopecia - yes
spontaneous hemorrhage - yes
rheumatoid arthritis - no
priapism - no
What medication would you look at therapeutic levels to see if the levels are within range? How? What else should be watched for?
dilantin
labwork
watch for seizures
How can a nurse teach a patient with hemophilia to control a minor bleeding episode?
cold compress
Who is a part of a palliative care team?
nurse
doctor
anesthesiologist
What will a surgeon tell the patient’s parents in addition to telling them their child has a stage 4 neuroblastoma?
if you need me, i’ll be outside
give alone time
Describe severe combined immunodeficiency
What can be seen in their blood work to protect against infections?
not immune to a lot of things
T cells and B cells
What position should a patient be placed in if they are having a seizure and vomiting?
side lying
What would you include in the plan for a child who has spastic cerebral palsy (hemiplegia)?
- prepare the home for safety
- modify environment as needed
What is a complication of near drowning in a child?
aspiration
What would determine the outcomes of a child in a near drowning/submersion injury?
- time underwater
- temp
- resuscitation efforts
Which nursing consideration is important when caring for a child with impetigo contagiosa?
a. Apply topical corticosteroids to decrease inflammation.
b. Carefully remove dressings so as not to dislodge undermined skin, crusts, and
debris.
c. Carefully wash hands and maintain cleanliness when caring for an infected child.
d. Examine child under a Wood lamp for possible spread of lesions.
c. Carefully wash hands and maintain cleanliness when caring for an infected child.
What will a nurse teach a parent about impetigo contagiosa caused by staph?
child will have their own utensils and towels
Which is usually the only symptom of pediculosis capitis (head lice)?
a. Itching
b. Vesicles
c. Scalp rash
d. Localized inflammatory response
a. Itching
What will be seen in a child who has pediculosis capitis?
little white eggs in hair
parasite on hair follicles
What will you see in an assessment for a child with bacterial meningitis?
fever
headache
irritable (don’t care if you touch them or not)
How will Guillain barre syndrome present?
Bilateral ascending paralysis
How will tetanus present?
lock jaw
muscle rigidity
The nurse is providing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse includes which of the following instructions?
a. Call the physician if the infant is fussy.
b. Expect an increased urine output from the shunt.
c. Call the physician if the infant has a high-pitched cry.
d. Position the infant on the side of the shunt when the infant is put to bed.
c. Call the physician if the infant has a high-pitched cry.
An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should be included in the child’s postoperative care? (Select all that apply.)
a. Observe closely for signs of infection.
b. Pump the shunt reservoir to maintain patency.
c. Administer sedation to decrease irritability.
d. Maintain Trendelenburg position to decrease pressure on the shunt.
e. Maintain an accurate record of intake and output.
f. Monitor for abdominal distention.
a. Observe closely for signs of infection.
e. Maintain an accurate record of intake and output.
f. Monitor for abdominal distention.
What is a complication of stem cell transplantation?
graft vs host disease
What is an effective treatment option for acute leukemia?
stem cell transplant
What is the highest priority for a child with chemo who is experiencing nausea and vomiting?
fluid and electrolytes
Parents of a school-age child with hemophilia ask the nurse, “Which sports are recommended for children with hemophilia?” Which sports should the nurse recommend? (Select all that apply.)
a. Soccer
b. Swimming
c. Basketball
d. Golf
e. Bowling
b. Swimming
d. Golf
e. Bowling
How can a nurse disguise ferrous sulfate medications for a child?
in orange juice
Which is a common clinical manifestation of Hodgkin disease?
a. Petechiae
b. Bone and joint pain
c. Painful, enlarged lymph nodes
d. Enlarged, firm, nontender lymph nodes
d. Enlarged, firm, nontender lymph nodes
What will be seen in a patient with Hodgkin’s disease?
fatigue
weakness
enlarged lymph nodes
What would you expect to see in a child with a brain tumor?
unsteady gait
What is the most common solid tumor in a child that is NOT in the brain?
neuroblastoma
A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching?
A. “I’m glad my child will have normal bowel movements now.
B. “I want to learn how to use my child’s feeding tube as soon as possible
C. “I’m glad that my child’s ostomy is only temporary
D. I want to learn how to empty my child’s urinary catheter bag
C. “I’m glad that my child’s ostomy is only temporary
13 year old LRQ pain, nausea, fever, IV running 97ml/hr, increased WBC count, increased C- reactive protein, pain is 6/10, emesis
What would the nurse suspect? what actions to take?
Appendicitis
- NPO
- Antibiotic IV
- Ultrasound
- Tylenol for pain
A nurse is caring for a 6 month old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which fluid should a nurse select for the infant?
A. Oral electrolyte solution
B. Half-strength infant formula
C. Half-strength orange juice
D. Sterile water
A. Oral electrolyte solution
18 month old with jelly like stools; knee chest position.
What is suspected? What should the nurse do and monitor?
Intussusception
action: NPO, air enema
monitor: stools, pain
Newborn weight is 16 pounds, distended abdomen with jelly like stools, what will the nurse do?
- Start IV
- NG tube
2 month old irritable, hard to console, vomits within 30 mins of feeding, HR 130, RR 28, Birth weight 6lb now 7lb, olive mass, hypoactive bowel sounds in all four quadrants
What is suspected? What should the nurse do and monitor?
Pyloric stenosis
action: abd ultrasound, insert NG
monitor: I&O, electrolytes
Preschooler in ER with nausea and vomiting, diarrhea, belly ache, cant keep food down, irritable dry lips and mucous membranes
What should the nurse give?
- Oral rehydration therapy
- Antiemetic
A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8-hour period. The child weighs 33 lb.
Which of the following actions should the nurse take?
A. Notify the provider.
B. Continue to monitor the client.
C. Perform a bladder scan at the bedside.
D. Provide oral rehydration fluids.
B. Continue to monitor the client.
A nurse is caring for a school-age child with acute glomerulonephritis who has peripheral edema and is producing 35 mL of urine per hr. The client should be placed on which of the following diets?
a. Low-protein, low-potassium diet
b. Low-sodium, fluid-restricted
c. Low-carbohydrate, low protein diet
d. Regular diet, no added salt
b. Low-sodium, fluid-restricted
A nurse is assessing a 1-year-old toddler who notices a large abdominal mass and pink-tinged urine on the diaper. Which of the following disorders should the nurse suspect?
A. Nephritic syndrome
B. Wilms tumor
C. Pyloric stenosis
D. Intussusception
B. Wilms tumor
During an assessment of a newborn infant, the nurse suspects the infant has pyloric stenosis. What finding would cause the nurse to suspect this?
a.Projectile vomiting
b.Hypoactive bowel activity
c.Palpable olive-sized mass in the right lower quadrant
d.Pronounced peristaltic waves crossing from right to left
a.Projectile vomiting
When assessing a child with Wilm’s tumor, the nurse should keep in mind that it is most important to avoid which of the following?
A. Measuring the child’s chest circumference
B. Palpating the child’s abdomen
C. Placing the child in an upright position
D. Measuring the child’s occipitofrontal circumference
B. Palpating the child’s abdomen
A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect?
A. Irritability
B. Tetany
C. slow, bounding pulse
D.Decreased temperature
A. Irritability
