TEST 6: The Child with Health Problems of the Urinary System

Question 1

1. A father brings his 4-week-old son to the clinic for a checkup, stating that he believes his son’s
   testicle is missing. Which of the following explanations would be most appropriate?
2. “Although the testes should have descended by now, it is not a cause for worry.”
3. “The testes often do not descend until age 6 months, but let’s check to see whether the testes are
   present.”
4. “The testes are present in the scrotal sac at birth, but surgery can remedy the situation.”
5. “Although the testes normally descend by 1 year of age, I can understand your concern.”

Answer 1

The Client with Cryptorchidism
1. 4. Normally the testes descend by 1 year of age; failure to do so may indicate a problem with
patency or a hormonal imbalance. By age 4 weeks, descent may not have occurred. However, telling
the father that lack of descent is not a cause for worry is inappropriate and uncaring. Additionally, a
statement such as this may be false reassurance. By acknowledging the father’s concern, the nurse
indicates acceptance of his feelings. If the testes have not descended, then they will not be palpable in
the scrotal sac. Surgery is not discussed until after a full assessment is completed.
CN: Health promotion and maintenance; CL: Synthesize

Question 2

2. While preparing to examine a 6-week-old infant’s scrotal sac and testes for possible
   undescended testes, which of the following would be most important for the nurse to do?
3. Check the diaper for recent urination.
4. Give the infant a pacifier.
5. Ensure that the room is kept warm.
6. Tap lightly on the left inguinal ring.

Answer 2

2. 3. A cold environment can cause the testes to retract. Cold and touch stimulate the cremasteric
      reflex, which causes a normal retraction of the testes toward the body. Therefore, the nurse should
      warm the hands and make sure that the environment also is warm. Checking the diaper for urination
      provides information about the infant’s voiding and urinary function, not information about the testes.
      Giving the infant a pacifier may help to calm the infant and possibly make the examination easier, but
      the concern here is with the temperature of the environment. Tapping on the inguinal ring would not be
      helpful in assessing the infant.
      CN: Health promotion and maintenance; CL: Synthesize

Question 3

3. While the nurse is examining the infant for presence of testes, the father paces around the room
   shaking his head. Which of the following would be the most appropriate response by the nurse?
4. “I’m sure everything will work out for the best, and he’ll be fine.”
5. “You seem upset; please tell me how you’re feeling.”
6. “Don’t worry; his testes will probably descend on their own.”
7. “Would you like to talk with a parent of a child who has the same problem?”

Answer 3

3. 2. The nurse needs more information about the father’s perceptions and feelings before
      providing any information or taking action. Determining the exact nature of the father’s concern rather
      than making an assumption about it is essential. Therefore, the nurse should identify what is observed
      and ask the father how he is feeling. Telling the father that everything will be fine or not to worry is
      inappropriate and provides false reassurance. It also devalues the father’s concern. Later on, it may
      be appropriate for the father to talk to a parent of a child with the same problem for support.
      CN: Psychosocial integrity; CL: Synthesize

Question 4

4. When assessing an infant with an undescended testis, the nurse should be alert for which of the
following?
1. Abnormal lower extremity reflexes.
2. A history of frequent emesis.
3. A bulging in the inguinal area.
4. Poor weight gain.

Answer 4

4. 3. When an anomaly is found in one system, such as the genitourinary system, that system
      requires a more focused assessment to reveal other conditions that also may be occurring. A bulging
      in the inguinal area may suggest an inguinal hernia. Also, hydrocele or an upper urinary tract anomaly
      may occur on the same side as the undescended testis. A neuromuscular problem, not a genitourinary
      problem such as undescended testes, would most likely be the cause of abnormal lower extremity
      reflexes. A history of frequent emesis may be caused by pyloric stenosis or viral gastroenteritis. Poor
      weight gain might suggest a metabolic or a feeding problem.
      CN: Health promotion and maintenance; CL: Analyze

Question 5

5. When explaining the plan of care to the parents of an infant with an undescended testis, the
   nurse should tell the parents about which of the following as a nonsurgical treatment method?
6. A trial of human chorionic gonadotrophic hormone.
7. A trial of adrenocorticotropic hormone.
8. Frequent stimulation of the cremasteric reflex.
9. Use of several warm baths each day.

Answer 5

5. 1. A trial of human chorionic gonadotrophin may be given to stimulate descent of the affectedtestis. A trial of adrenocorticotropic hormone will not cause the testis to descend. The cremasteric
      reflex results in the testis being drawn up, the opposite of the intended effect. Application of warmth,
      such as warm baths, although soothing and relaxing for the infant, would have little or no effect on
      stimulating the testis to descend.
      CN: Pharmacological and parenteral therapies; CL: Apply

Question 6

6. When developing the preoperative teaching plan for a 14-month-old child with an
   undescended testis who is scheduled to have surgery, which of the following methods is appropriate?
7. Telling the child that his penis and scrotum will be “fixed.”
8. Explaining to the parents how the defect will be corrected.
9. Telling the child that he will not see any incisions after surgery.
10. Using an anatomically correct doll to show the child what will be “fixed.”

Answer 6

6. 2. Preoperative teaching would be directed at the parents, because the child is too young to
      understand the teaching. Telling the child that his penis and scrotum will be “fixed,” telling the child
      he will not see incisions after surgery, and using a doll to illustrate the surgery are appropriate
      interventions for a preschool-age child.
      CN: Psychosocial integrity; CL: Create

Question 7

7. An adolescent with a history of surgical repair for an undescended testis comes to the clinic
   for a sports physical. Anticipatory guidance for the parents and adolescent should focus on which ofthe following as most important?
8. The adolescent’s sterility.
9. The adolescent’s future plans.
10. Technique for monthly testicular self-examinations.
11. Need for a lot of psychological support.

Answer 7

7. 3. Because the incidence of testicular cancer is increased in adulthood among children who
      have had undescended testes, it is extremely important to teach the adolescent how to perform the
      testicular self-examination monthly. The undescended testicle is removed to reduce the risk of cancer
      in that testicle. Removal of a testis would not necessarily make the adolescent sterile because the
      other testicle remains. Although discussing the adolescent’s future plans is important, it is not the
      priority at this time. Because the adolescent has been dealing with the situation for a long time, the
      need for a sports physical at this time should not be a cause of emotional distress requiring a lot of
      psychological support.
      CN: Health promotion and maintenance; CL: Synthesize

Question 8

The Client with Hydrocele
8. When explaining to the parents of a child with a hydrocele about the possible cause of the
condition, the nurse bases this explanation on the interpretation that a hydrocele is most likely the
result of which condition?
1. Blockage in the inguinal canal that allows fluid to accumulate in epididymis and ductus
deferens.
2. Failure of the upper part of the processus vaginalis to atrophy, allowing accumulation of fluid
in the testicle and the peritoneal cavity.
3. A patent processus vaginalis that results in the collection of fluid along the spermatic cord or
tunica vaginalis of the testicle.
4. An obliterated processus vaginalis that allows fluid to accumulate in the scrotal sac.

Answer 8

The Client with Hydrocele
8. 3. A hydrocele is a collection of fluid in the tunica vaginalis of the testicle or along the
spermatic cord that results from a patent processus vaginalis. Failure of the upper part of the
processus vaginalis to atrophy allows the accumulation of fluid in the testicle and the peritoneal
cavity, causing an inguinal hernia.
CN: Physiological adaptation; CL: Apply

Question 9

9. During a clinic visit, the mother of an infant with hydrocele states that the infant’s scrotum is
   smaller now than when he was born. After teaching the mother about the infant’s condition, which of
   the following statements by the mother indicates that the teaching has been effective?
10. “I guess keeping his bottom up has helped.”
11. “Massaging his groin area is working.”
12. “It seems like the fluid is being reabsorbed.”
13. “Keeping him quiet and in an infant seat has helped.”

Answer 9

9. 3. A hydrocele is a collection of fluid in the tunica vaginalis of the testicle or along the
      spermatic cord that results from a patent processus vaginalis. Because scrotal size is decreasing, the
      fluid is being absorbed. Elevation of the infant’s bottom, massage, or keeping the infant quiet or in an
      infant seat would have no effect in promoting fluid reabsorption in hydrocele.
      CN: Physiological adaptation; CL: Evaluate

Question 10

10. Shortly after an infant is returned to his room following hydrocele repair, the infant’s mother
    tells the nurse that the child’s scrotum looks swollen and bruised. Which of the following responses
    by the nurse would be most appropriate?
11. “Let me see if the doctor has prescribed aspirin for him. If he did, I’ll get it right away.”
12. “Why don’t you wait in his room? Then you can ask me any questions when I get there.”
13. “What you are describing is unusual after this type of surgery. I’ll let the doctor know.”
14. “This is normal after this type of surgery. Let’s look at it together just to be sure.”

Answer 10

10. 4. Some swelling and bruising are normal postoperatively. By assessing the area with the
       mother, the nurse is conveying acceptance of the mother’s concern. In addition, the nurse needs to
       inspect the area to determine if what the mother is describing is accurate. Doing so also provides an
       opportunity for teaching. Aspirin is not usually prescribed for children because of the link between
       aspirin and Reye’s syndrome. Acetaminophen is commonly administered for fever or pain relief.
       Asking the mother to wait in the child’s room ignores the mother’s concerns. There is no need to notify
       the doctor at this time.
       CN: Psychosocial integrity; CL: Synthesize

Question 11

The Client with Hypospadias
11. The parents of a neonate with hypospadias and chordee wish to have him circumcised. Which
of the following explanations should the nurse incorporate into the discussion with the parents
concerning the recommendation to delay circumcision?
1. The associated chordee is difficult to remove during circumcision.
2. The foreskin is used to repair the deformity surgically.
3. The meatus can become stenosed, leading to urinary obstruction.
4. The infant is too small to have a circumcision.

Answer 11

The Client with Hypospadias11. 2. The condition in which the urethral opening is on the ventral side of the penis or below the
glans penis is referred to as hypospadias. Chordee refers to a ventral curvature of the penis that
results from a fibrous band of tissue that has replaced normal tissue. Circumcision is delayed because
the foreskin, which is removed with a circumcision, often is used to reconstruct the urethra. The
chordee is corrected when the hypospadias is repaired. Circumcision is performed at the same time.
Urethral meatal stenosis, which can occur in circumcised infants, results from meatal ulceration,
possibly leading to urinary obstruction. It is not associated with hypospadias or circumcision. The
infant is not too small to have a circumcision, which is commonly performed on the first or the second
day of life.
CN: Reduction of risk potential; CL: Apply

Question 12

12. The nurse is caring for an infant with hypospadias. Identify the area where the nurse would
    assess for this condition.

Answer 12

12. In hypospadias, the urethral opening is on the ventral side of the penis.
    CN: Physiological adaptation; CL: Apply

Question 13

13. A 1-year-old child is scheduled for surgery to correct hypospadias and chordee. The nurse
    explains to the parents that this is the preferred time for surgical repair based on which of the
    following?
14. At this age, the child will experience less pain.
15. The child is too young to have developed castration anxiety.
16. The child will not remember the surgical experience.
17. The repair is easier to perform after the child is toilet trained.

Answer 13

13. 2. The preferred time for surgery is between the ages of 6 and 18 months, before the child
       develops castration and body image anxiety. Children learn early on about society’s emphasis on the
       importance of genitals. Pain is different for each child and is not related to the preferred time for
       repair of the hypospadias or chordee. Although the child will probably not remember the experience,
       this is not the basis for having the surgery at this age. If the condition is not repaired, the child will
       have difficulty with toilet training because urine is not eliminated through the tip of the penis.
       CN: Physiological adaptation; CL: Apply

Question 14

14. A 6-month-old child is discharged with a urinary stent after a procedure to repair a
    hypospadias. The nurse should tell the parents to:
15. Avoid tub baths until the stent is removed.
16. Measure output in the urinary bag.
17. Avoid drinking fruit juice.
18. Clean the tip of the penis three times a day with soap and water

Answer 14

14. 1. The parents should keep the penis as dry as possible until the stent is removed. Soaking in a
       tub bath is not recommended. Children this age typically go home voiding directly into a diaper.
       Infants may be started on juice at 6 months of age. Parents are advised to keep their child well
       hydrated after a hypospadius repair. Therefore, there is no reason to avoid juice. Cleaning the tip of
       the penis three times a day may cause unnecessary irritation.
       CN: Safety and infection control; CL: Synthesize

Question 15

15. After teaching the parents about the urethral catheter placed after surgical repair of their son’s
    hypospadias, the nurse determines that the teaching was successful when the mother states that the
    catheter in her child’s penis accomplishes which of the following?
16. Decreases pain at the surgical site.2. Keeps the new urethra from closing.
17. Measures his urine correctly.
18. Prevents bladder spasms.

Answer 15

15. 2. The main purpose of the urethral catheter is to maintain patency of the reconstructed
       urethra. The catheter prevents the new tissue inside the urethra from healing on itself. However, the
       urethral catheter can cause bladder spasms. Recently, stents have been used instead of catheters. The
       urethral catheter will have no effect on the child’s pain level. In fact, because bladder spasms are
       associated with its use, the child’s problems of pain may actually increase. Urine output can bemeasured through the suprapubic catheter because it provides an alternative route for urinary
       elimination, thus keeping the bladder empty and pressure-free.
       CN: Reduction of risk potential; CL: Evaluate

Question 16

16. While assessing the penis of a child who has had surgery for repair of a hypospadias, the
    nurse observes the appearance of the penis. The nurse should report which aspect to the surgeon?
17. Swollen.
18. Dusky blue at the tip.
19. Somewhat misshapen.
20. Pink.

Answer 16

16. 2. A dusky blue color at the tip of the penis may indicate a problem with circulation, and the
       nurse should notify the surgeon. Following surgery, it is normal for the penis to be swollen and pink.
       The penis may be misshapen and is unlikely to look normal even after reconstruction.
       CN: Physiological adaptation; CL: Analyze

Question 17

17. When developing the teaching plan for the parents of a 12-month-old infant with hypospadias
    and chordee repair, which of the following should the nurse expect to include as most important?
18. Assisting the child to become familiar with his dressings so he will leave them alone.
19. Encouraging the child to ambulate as soon as possible by using a favorite push toy.
20. Forcing fluids to at least 2,500 mL/day by offering his favorite juices.
21. Preventing the child from disrupting the catheters by using soft restraints.

Answer 17

17. 4. The most important consideration for a successful outcome of this surgery is maintenance of
       the catheters or stents. A 12-month-old infant likes to explore his environment but must be prevented
       from manipulating his dressings or catheters through the use of soft restraints. Allowing the infant to
       become familiar with the dressings will not prevent him from pulling at them. After surgery the child
       is allowed limited activity, possibly with sitting in the parent’s lap. A 12-month-old infant may or may
       not be walking. If he is, most likely he will be clumsy and possibly injure himself. Although
       increasing fluids is important, 2,500 mL/day is an excessive amount for a 12-month-old. Fluid
       requirements would be 115 mL/kg.
       CN: Physiological adaptation; CL: Create

Question 18

18. The physician prescribes a urinalysis for a child who has undergone surgical repair of a
    hypospadias. Which of the following results should the nurse report to the physician?
19. Urine specific gravity of 1.017.
20. Ten red blood cells per high-powered field.
21. Twenty-five white blood cells per high-powered field.
22. Urine pH of 6.0.

Answer 18

18. 3. A normal white blood cell count in a urinalysis is 1 to 2 cells/mL. A white blood cell count
       of 25 per high-powered field indicates a urinary tract infection. A urine specific gravity of 1.017 is
       within the normal range of 1.002 to 1.030. After urologic surgery, it is not unusual for a small number
       of red blood cells to appear in the urine. The child’s urine pH is within the normal range of 4.6 to 8.
       CN: Reduction of risk potential; CL: Analyze

Question 19

The Client with Urinary Tract Infection
19. A 4-year-old with a history of urinary reflux returned from surgery for bilateral urethral
reimplants 2 days ago. Which assessment finding is most concerning?
1. Intermittent bladder spasms.
2. Small amounts of blood-tinged urine.
3. Decreased oral intake.
4. Continuous drainage from a Foley catheter.

Answer 19

The Client with Urinary Tract Infection
19. 3. Children with bilateral ureteral implants often have pain with urination due to bladder
spasms. Some children will avoid drinking in order to avoid the pain associated with urination, thus
putting the child at risk for dehydration. Intermittent bladder spasms are common after ureteral
reimplant surgery and can be treated with Ditropan (oxybutynin) to decrease discomfort. Small
amounts of blood tinged urine, bladder spasms, urinary frequency, and urinary incontinence are
common following ureteral reimplant surgery.
CN: Physiological adaptation; CL: Analyze

Question 20

20. The health care provider has prescribed a sterile urine specimen on a 3-year-old boy with a
    history of recurrent urinary tract infections. The family is upset because the last time the child was
    catheterized the procedure was very painful and traumatic. The nurse should tell the family:
21. “I will request a prescription for a sedative to help him relax.”
22. “I can’t do anything to reduce the pain, but you can hold him during the procedure.”
23. “I will get a prescription for a lidocaine-based lubricant to make the procedure more
    comfortable.”
24. “I can apply a topical anesthetic 20 minutes before placing the catheter.”

Answer 20

20. 3. Two percent lidocaine lubricants have been found to significantly reduce the pain of urinary
       catheter insertion in children. If the unit does not have a standing protocol to use the lubricant, the
       nurse should request a prescription. A sedative would carry with it additional risks that could be
       avoided with the use of other methods to reduce pain. The parents should be encouraged to hold the
       child in addition to other pain relief methods. Frequent urination would make the use of topical
       anesthetics that must be left in place for a period of time impractical.
       CN: Basic care and comfort; CL: Synthesize

Question 21

21. The parents of a child on sulfamethoxazole and trimethoprim for a urinary tract infection
    report that the child has a red, blistery rash. The nurse should tell the parents to:
22. Apply lotion to the affected areas.
23. Discontinue the medicine and come for immediate further evaluation.
24. Use sunblock while on the medication.
25. Increase the child’s fluid intake.

Answer 21

21. 2. Sulfonamides have been associated with severe adverse reactions. A blistering rash may be
       a sign of Stevens-Johnson syndrome, a severe allergic reaction that manifests as skin lesions. This
       reaction is life threatening and requires immediate attention. Lotion should not be applied to skin with
       blisters. Sulfamethoxazole and trimethoprim may cause photosensitivity, but this usually appears as amild red rash, not blisters. Increasing the child’s fluid intake may help the urinary tract infection, but
       does not address the rash.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 22

22. A recent history of which of the following should alert the nurse to gather additional
    information about the possibility of a urinary tract infection in a 2-year-old child who is exhibiting
    fever and fussiness?
23. Abdominal pain.
24. Swollen lymph glands.
25. Skin rash.
26. Back pain.

Answer 22

22. 1. Abdominal pain frequently accompanies urinary tract infection in children 2 years of age
       and older. Other associated signs and symptoms include decreased appetite, vomiting, fever, and
       irritability. The presence of swollen lymph glands (lymphadenopathy) is unrelated to urinary tract
       infections. Lymphadenopathy is associated with a systemic infection or possibly cancer. Skin rash is
       associated with exposure to allergens or irritants (eg, poison ivy or harsh soaps); prolonged contact
       with urine (eg, diaper dermatitis); or illnesses such as measles, rheumatic fever, or juvenile
       rheumatoid arthritis. Flank or back pain is associated with urinary tract infection in children older
       than 2 years of age and in adults.
       CN: Physiological adaptation; CL: Analyze

Question 23

23. A father of a child with a urinary tract infection calls the clinic and explains, “My wife and I
    are concerned because our child refuses to obey us concerning the preventions you told us about. Our
    child refuses to take the medication unless we buy a present. We don’t want to use discipline because
    of the illness, but we’re worried about the behavior.” Which response by the nurse is best?
24. “I sympathize with your difficulties, but just ignore the behavior for now.”
25. “I understand it’s hard to discipline a child who is ill, but things need to be kept as normal as
    possible.”
26. “I understand that things are difficult for you right now, but your child is ill and deserves
    special treatment.”
27. “I understand your concern, but this type of behavior happens all the time; your child will get
    over it when feeling better.

Answer 23

23. 2. To ensure appropriate psychosocial development, a child needs to have normal patterns
       maintained as much as possible during illness. It is tempting to give ill children special treatment and
       to relax discipline. However, family routines and discipline should be kept as normal as possible.
       The child needs to know the limits to ensure feelings of security. When they are ill, children
       commonly attempt to stretch the rules and limits. If this occurs, returning to the previous well-
       behavior patterns will take time.
       CN: Health promotion and maintenance; CL: Synthesize

Question 24

24. A nurse is teaching the parents of a child diagnosed with a urinary tract infection secondary to
    vesicoureteral reflux. How should the nurse explain how the reflux contributes to the infection?
25. “It prevents complete emptying of the bladder.”
26. “It causes urine backflow into the kidney.”
27. “It results in painful bladder spasms.”
28. “It causes painful urination.”

Answer 24

24. 1. The reason that urinary tract infections are a problem in children with vesicoureteral reflux
       is that urine flows back up the ureter, past the incompetent valve, and back into the bladder after the
       child has finished voiding. This incomplete emptying of the bladder results in stasis of urine,
       providing a good medium for bacterial growth and subsequent infection. Vesicoureteral reflux does
       not cause bladder spasms or painful urination. However, the child may experience painful urination
       with a urinary tract infection.
       CN: Physiological adaptation; CL: Apply

Question 25

The Client with Glomerulonephritis
25. A 15-year-old has been diagnosed with acute glomerulonephritis and has been in the hospital
for 1 day. Which of the following findings requires immediate action?
1. Large amount of generalized edema.
2. Urine specific gravity of 1.030.
3. Large amount of albumin in the urine.
4. 24-hour output of 1,500 mL.

Answer 25

The Client with Glomerulonephritis
25. 2. An adolescent with acute glomerulonephritis has a high urine specific gravity related to
oliguria caused by inflammation of the glomeruli. The client will have periorbital edema, but not the
generalized edema that occurs in nephrotic syndrome. In glomerulonephritis, there is some albumin in
the urine, but there are large amounts of red blood cells, giving the urine a brown color. The urine in
glomerulonephritis is scanty, averaging about 400 mL in 24 hours, which leads to fluid volume excess
and hypertension.
CN: Physiological adaptation; CL: Synthesize

Question 26

26. Which of the following meals would be most appropriate for a 15-year-old with
    glomerulonephritis with severe hypertension?
27. Egg noodles, hamburger, canned peas, milk.
28. Baked ham, baked potato, pear, canned carrots, milk.
29. Baked chicken, rice, beans, orange juice.
30. Hot dog on a bun, corn chips, pickle, cookie, milk.

Answer 26

26. 3. The best selection of food would include no added salt or salty food. Because sodium
       cannot be excreted due to the oliguria and to avoid increasing the hypertension, a low-salt diet is
       recommended. Most canned foods have sodium added as a preservative. Hamburger, ham, hot dogs,
       canned peas, canned carrots, corn chips, pickles, and milk are high in sodium.
       CN: Health promotion and maintenance; CL: Synthesize

Question 27

27. A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse
should immediately:
1. Put the client to bed.
2. Obtain the child's blood pressure.
3. Notify the physician.
4. Administer acetaminophen (Tylenol).

Answer 27

27. 2. Hypertension occurs with acute glomerulonephritis. The symptoms of headache and blurredvision may indicate an elevated blood pressure. Hypertension in acute glomerulonephritis occurs due
       to the inability of the kidneys to remove fluid and sodium; the fluid is reabsorbed, causing fluid
       volume excess. The nurse must verify that these symptoms are due to hypertension. Calling the
       physician before confirming the cause of the symptoms would not assist the physician in his treatment.
       Putting the client to bed may help treat an elevated blood pressure, but first the nurse must establish
       that high blood pressure is the cause of the symptoms. Administering Tylenol for high blood pressure
       is not recommended.
       CN: Physiological adaptation; CL: Synthesize

Question 28

28. Which of the following questions should the nurse ask first when obtaining a history from the
    mother of a 10-year-old child with a fever, malaise, and swelling around the eyes?
29. “Has the child had a sore throat recently?”
30. “Is the child playing with friends as usual?”
31. “Does the child urinate as much as usual?”
32. “Is the urine pale in color?”

Answer 28

28. 3. Most likely, the nurse suspects that the child is exhibiting signs and symptoms of
       glomerulonephritis, such as periorbital edema and fever. Other signs and symptoms include loss of
       appetite, dark-colored urine, pallor, headaches, and abdominal pain. To confirm this suspicion, the
       nurse would ask about the child’s urinary elimination patterns. Typically the child with
       glomerulonephritis experiences a decrease in urine output. Asking about any recent sore throat would
       provide additional information to confirm the suspicion of glomerulonephritis, because the most
       common type is acute poststreptococcal glomerulonephritis, which follows a strep throat by 10 to 14
       days. Frequently, the children have only mild cold symptoms and do not realize they have a
       streptococcal infection. Asking whether the child plays with friends as usual is important and gives
       the nurse information about how the child feels in general. However, this is a general question that
       would be appropriate to ask later on in the history. Although asking the mother about the color of the
       child’s urine is important, the nurse needs to determine whether there is any change in the child’s
       urinary output first.
       CN: Physiological adaptation; CL: Analyze

Question 29

29. A school-age client admitted to the hospital because of decreased urine output and periorbital
    edema is diagnosed with acute poststreptococcal glomerulonephritis. Which of the following actions
    should receive the highest priority?
30. Assessing vital signs every 4 hours.
31. Monitoring intake and output every 12 hours.
32. Obtaining daily weight measurements.
33. Obtaining serum electrolyte levels daily.

Answer 29

29. 3. The child with acute poststreptococcal glomerulonephritis experiences a problem with
       renal function that ultimately affects fluid balance. Because weight is the best indicator of fluid
       balance, obtaining daily weights would be the highest priority.
       CN: Physiological adaptation; CL: Analyze

Question 30

30. When developing the plan of care for a school-age child with acute poststreptococcal
    glomerulonephritis who has a fluid restriction of 1,000 mL/day, which of the following fluids should
    the nurse consider as most appropriate for the client’s condition and effective for preventing
    excessive thirst?
31. Diet cola.
32. Ice chips.
33. Lemonade.
34. Tap water

Answer 30

30. 2. The most appropriate and effective choice would be ice chips, because they help moisten
       the mouth and lips while keeping fluid intake low. However, ice chips must still be counted as intake
       with the fluid restriction. Sweet beverages, such as diet cola or lemonade, commonly increase thirst.
       Tap water effectively relieves thirst but does not help keep fluid intake low.
       CN: Physiological adaptation; CL: Synthesize

Question 31

31. The nurse is planning interventions for a school-aged child in need of diversional activity.
    Which of the following activities should the nurse expect to include?
32. Playing a card game with someone the same age.
33. Putting together a puzzle with mother.
34. Playing video games with a 4-year-old.
35. Watching a movie with a younger brother.

Answer 31

31. 1. Generally, school-age children enjoy activities with their peers first, then family members,
       and lastly younger children. School-age children like to be busy but also to accomplish something.
       This helps to meet their task of industry versus inferiority, feeling good about what they are able to
       accomplish.
       CN: Health promotion and maintenance; CL: Create

Question 32

32. A 10-year-old child hospitalized with acute poststreptococcal glomerulonephritis during the
    acute stage has elevated blood pressure and low urine output for 14 hours. The nurse should next:
33. Assess the child’s neurologic status.
34. Encourage the child to drink more water.
35. Advise the child to eat a low-sodium breakfast.
36. Help the client to ambulate in the hallway.

Answer 32

32. 1. The nurse should assess the child’s neurologic status, because hypertensive encephalopathy
       is a major potential complication of the acute phase of glomerulonephritis. Seizure precautions also
       should be instituted. Hypertensive encephalopathy can result in transient loss of vision, hemiparesis,
       disorientation, and grand mal seizures. Encouraging the child to drink more water is inappropriate
       because the child has had a low urine output for 14 hours. Typically, in this situation, fluids would be
       restricted. Although a low-sodium diet is encouraged, it is not the priority action at this time. Initially,bed rest, not ambulation, is advocated during the acute phase of glomerulonephritis.
       CN: Reduction of risk potential; CL: Synthesize

Question 33

33. When developing the discharge plan for a school-age child diagnosed with acute
    poststreptococcal glomerulonephritis, which instruction should the nurse plan to discuss?
34. Restricting dietary protein.
35. Monitoring pulse rate and rhythm.
36. Preventing respiratory infections.
37. Restricting foods high in potassium.

Answer 33

33. 3. Children recovering from glomerulonephritis need to avoid exposure to all types of
       infections. Glomerulonephritis is caused by group A beta-hemolytic streptococcus, a common cause
       of sore throat. As the child recovers, he or she may be susceptible to a recurrence if exposed to the
       organism again. During convalescence from glomerulonephritis, fluid and dietary restrictions are no
       longer indicated because the kidneys are now functioning normally. There is no need for the parents to
       assess the child’s vital signs.
       CN: Physiological adaptation; CL: Synthesize

Question 34

An adolescent with a history of losing weight and fatigue is admitted to the hospital with a diagnosis
of stage I chronic renal failure. The chart shows:
INTAKE AND OUTPUT
Day 1: Intake 1850 ml Output 1550 ml
Day 2: Intake 2200 ml Output 1150 ml
Based on these findings, the nurse should:
1. Continue monitoring intake and output.
2. Notify the physician.
3. Restrict the client’s fluids.
4. Increase the client’s fluids.

Answer 34

34. 2. The nurse would expect a person with a normal GFR to have approximately equal inputs
       and outputs. Chronic renal failure has five stages. In stage I, the glomerular filtration rate (GFR) is
       approximately ≥90 mL/min/1.73 m 2 . In stage II, the GFR decreases to approximately 60 to 89
       mL/min/1.73 m 2 . The decreased urine output may indicate worsening disease and should be reported.
       Assessing the client’s intake and output is still important, but notifying the provider is the priority.
       Fluids are restricted based on decreased sodium. Clients are encouraged to drink to thirst. Therefore,
       there is not enough information to suggest increasing or restricting fluids.
       CN: Physiological adaptation; CL: Synthesize

Question 35

35. A parent of a child with acute poststreptococcal glomerularnephritis (APSGN) asks how a
    strep infection caused their child to have a kidney problem. What is the nurse’s best response?
36. “The streptococcal infection spread through the bloodstream to your child’s kidneys.”
37. “Your child made excessive antibodies to fight the infection that are now attacking the
    kidneys.”
38. “By-products of immune complexes that fought the infection are depositing in the kidneys.”
39. “The strep infection weakened your child’s immune system, making him susceptible to a
    secondary infection.”

Answer 35

35. 3. APSGN is an immune complex disease. Large antigen-antibody complexes are formed that
       deposit in the glomerular capillary loops leading to obstruction. APSGN is considered an
       autoimmune disorder, not an infection. Antibodies do not attack the kidneys in this disorder.
       CN: Physiologic adaptation; CL: Analyze

Question 36

The Client with Nephrotic Syndrome
36. A child with nephrosis is taking prednisone. The nurse should teach the caregivers to report
which of the following adverse effects? Select all that apply.
1. Increased urinary output.
2. Hematemesis.
3. Respiratory infection.
4. Bleeding gums.
5. Vision problems.

Answer 36

The Client with Nephrotic Syndrome
36. 2, 3. Adverse effects of steroid therapy include edema of the face and trunk, increased
susceptibility to infection, gastric and intestinal mucosal bleeding, sodium and water retention, and
hypertension. Urinary output is decreased due to the retention of sodium. Bleeding gums do not result
from steroids. Steroid therapy does not cause vision problems.
CN: Pharmacological and parenteral therapies; CL: Create

Question 37

The nurse is caring for a 5-year-old boy who is taking prednisolone for nephrotic syndrome. The
child is at the 75th percentile for height and has a blood pressure of 114/73. The nurse compares the
reading to the below blood pressure levels for boys age and height percentiles.
The nurse determines that the blood pressure represents a change and notifies the primary care
provider of the assessment of:
1. Hypotension.
2. Prehypertension.
3. Hypertension.
4. Hypertension stage II.

Answer 37

37. 3. Reading at or above the 95th percentile are considered indicative of hypertension. Here,
       both the systolic and diastolic readings are at the 95th percentile for a boy who is at the 75th
       percentile for height. This blood pressure may be a side effect of the medication or part of the disease
       process and needs to be reported. The charts do not define hypotension. Readings below the 90th
       percentile are considered normal. Blood pressures at the 90th percentile, but below the 95th are
       considered prehypertension. Blood pressures at the 99th percentile are considered stage II
       hypertension and are most likely to need antihypertensive medications.
       CN: Reduction of risk potential; CL: Analyze

Question 38

38. Which of the following statements by the mother of a toddler diagnosed with nephrotic
    syndrome indicates that the mother has understood the nurse’s teaching about this disease?
39. “My child really likes chips and bologna. I guess we’ll have to find something else.”
40. “We’ll have to encourage lots of liquids. Did you say about 4 L every day?”
41. “We worry about the surgery. Do you think we should do direct donation of blood?”
42. “We understand the need for antibiotics. I just wish the antibiotics could be given by mouth.”

Answer 38

38. 1. Children with nephrotic syndrome usually require sodium restriction. Because potato chips
       and bologna are high in sodium, the mother’s statement about finding something else reflects
       understanding of this need. Although fluid intake is not restricted in children with nephrotic syndrome,
       4 L is an excessive amount for a toddler. The typical fluid requirement for a toddler is 115 mL/kg.
       Surgical intervention and antibiotic therapy are not parts of the treatment plan for nephrotic syndrome.CN: Physiological adaptation; CL: Evaluate

Question 39

39. A toddler diagnosed with nephrotic syndrome has a fluid volume excess related to fluid
    accumulation in the tissues. Which measure should the nurse anticipate including in the child’s plan of
    care?
40. Limiting visitors to 2 to 3 hours a day.
41. Maintaining strict bed rest.
42. Testing urine specific gravity every shift.
43. Weighing the child before breakfast.

Answer 39

39. 4. The best indicator of fluid balance is weight. Therefore, daily weight measurements help
       determine fluid losses and gains. Although limiting visitors to 2 to 3 hours per day or maintaining
       strict bed rest would help to ensure that the child gets adequate rest, this is unrelated to the child’s
       fluid balance. In nephrotic syndrome, urine is tested for protein, not specific gravity.
       CN: Physiological adaptation; CL: Synthesize

Question 40

40. The mother of a toddler with nephrotic syndrome asks the nurse what can be done about the
    child’s swollen eyes. Which measure should the nurse suggest?
41. Applying cool compresses to the child’s eyes.
42. Elevating the head of the child’s bed.
43. Applying eye drops every 8 hours.
44. Limiting the child’s television watching.

Answer 40

40. 2. The child’s swollen eyes are caused by fluid accumulation. Elevating the head of the bed
       allows gravity to increase the downward flow of fluids in the body, away from the face. Applying
       cool compresses or eye drops, or limiting television, may be comforting but will not relieve the
       swelling.
       CN: Physiological adaptation; CL: Synthesize

Question 41

41. The nurse determines that interventions for decreasing fluid retention have been effective
    when the child with nephrotic syndrome demonstrates evidence of which of the following?
42. Decreased abdominal girth.
43. Increased caloric intake.
44. Increased respiratory rate.
45. Decreased heart rate.

Answer 41

41. 1. Fluid accumulates in the abdomen and interstitial spaces owing to hydrostatic pressure
       changes. Increased abdominal fluid is evidenced by an increase in abdominal girth. Therefore,
       decreased abdominal girth is a sign of reduced fluid in the third spaces and tissues. When fluid
       accumulates in the abdomen and interstitial spaces, the child does not feel hungry and does not eat
       well. Although increased caloric intake may indicate decreased intestinal edema, it is not the best and
       most accurate indicator of fluid retention. Increased respiratory rate may be an indication of
       increasing fluid in the abdomen (ascites) causing pressure on the diaphragm. Heart rate usually stays
       in the normal range even with excessive fluid volume.
       CN: Physiological adaptation; CL: Evaluate

Question 42

42. The toddler with nephrotic syndrome exhibits generalized edema. Which of the following
    measures should the nurse institute for this child with impaired skin integrity related to edema?
43. Ambulate every shift while awake.
44. Apply lotion on opposing skin surfaces.
45. Apply powder to skinfolds.
46. Separate opposing skin surfaces with soft cloth.

Answer 42

42. 4. Placing soft cloth between opposing skin surfaces absorbs moisture and keeps the area dry,
       thus preventing any further breakdown. The child with nephrotic syndrome and severe edema is
       usually maintained on bed rest. Therefore, ambulation is not appropriate. Applying lotion or powder
       to edematous surfaces that touch increases moisture and can lead to maceration, causing further
       breakdown.
       CN: Basic care and comfort; CL: Synthesize

Question 43

A child with nephrosis is placed on prednisone. The dose is 2 mg/kg/day to be administered twice a
day. The child weighs 25 lb (11.3 kg). How many milligrams will the child receive at each dose?
______________________ mg.

Answer 43

43. 11.3 mg
44. KG X 2 MG = 22.7 MG
45. 7 MG / 2 = 11.3 MG PER DOSE

CN: Pharmacological and parenteral therapies; CL: Apply

Question 44

44. The toddler with nephrotic syndrome responds to treatment and is ready to go home. When
    helping the family plan for home care, which of the following instructions should the nurse include in
    the teaching?
45. Administer pain medication as needed.
46. Keep the child away from others with an infection.
47. Notify the physician if there is an increase in the child’s urine output.
48. Administer acetaminophen (Tylenol) daily.

Answer 44

44. 2. A child recovering from nephrotic syndrome should be protected from infection. Therefore,
       the nurse would teach the parents to keep the child away from others with an infection. Because pain
       is not associated with this disorder, pain medication typically is not needed. The physician should be
       notified if urine output decreases, not increases. In children recovering from nephrotic syndrome,
       there is no reason to administer acetaminophen daily.
       CN: Reduction of risk potential; CL: Synthesize

Question 45

45. The nurse is planning care with the parents of a child who requires continuous peritoneal
    dialysis. Which finding should be discussed with the physician?
46. The family lives a long distance from the medical facility.
47. The child attends a large public school.
48. The child reports having a previous surgery for a ruptured appendix.
49. The family feels the child cannot self-regulate to wake at night and change bags.

Answer 45

The Client with Acute or Chronic Renal Failure
45. 3. A client who has had a ruptured appendix may have peritoneal scarring that may alter the
effectiveness of treatment. Living a long distance from a medical facility is typically a reason to
select peritoneal dialysis. Attending a large school is not a problem, but the school nurse needs to beincluded as part of the health care team. Typically the treatment schedule can be planned to allow for
uninterrupted sleep at night.
CN: Management of care; CL: Create

Question 46

46. While performing daily peritoneal dialysis and catheter exit site care with the mother of a
    child with chronic renal failure, which of the following would be an important step to emphasize to
    the mother?
47. Applying an occlusive dressing after cleaning the site.
48. Changing the dressing when the peritoneal space is dry.
49. Examining the site for signs of infection while cleaning the area.
50. Pulling on the catheter to hold taut while cleaning the skin.

Answer 46

46. 3. Until it heals, the catheter exit site is particularly vulnerable to invasion by pathogenic
       organisms. Therefore, the site must be monitored for signs of infection. An occlusive dressing is not
       needed because there is no danger of air being sucked in or out of the peritoneal space. Furthermore,
       the catheter used is designed with a cuff, so that the skin grows around the catheter, sealing off the
       area. Site care may be done at any time, but the child may experience abdominal discomfort if the
       peritoneal space is dry during site care. Holding the catheter taut or pulling on it may cause irritation
       of the skin at the exit site, which could lead to infection.
       CN: Safety and infection control; CL: Synthesize

Question 47

47. When developing the discharge teaching plan for a child with chronic renal failure and the
    family, the nurse should emphasize restriction of which of the following nutrients?
48. Ascorbic acid.
49. Calcium.
50. Magnesium.
51. Phosphorus.

Answer 47

47. 4. With minimal or absent kidney function, the serum phosphate level rises, and the ionized
       calcium level falls in response. This causes increased secretion of parathyroid hormone, which
       releases calcium from the bones. Therefore, the intake of foods high in phosphorus is restricted.
       Because renal failure results in decreased erythropoietin production, an increase in ascorbic acid
       intake is needed. Because magnesium is minimally affected by renal failure, its intake need not be
       restricted.
       CN: Physiological adaptation; CL: Apply

Question 48

48. After emphasizing to an adolescent with renal failure the importance of maintaining a positive
    self-concept, which of the following behaviors by the adolescent should the nurse identify as an
    indicator that the plan is working?
49. Reports of headaches, abdominal pain, and nausea.
50. Insistence on making diet choices even if the foods chosen are restricted.
51. Verbalization of plans to quit all after-school activities when returning home.
52. Demonstration of desire to do the dressing changes and take care of the medications.

Answer 48

48. 4. Demonstration of desire to do the dressing changes and manage medications implies
       compliance with the medical regimen and acceptance of the condition, thereby indicating a positive
       self-image. Diffuse somatic symptoms could indicate anxiety or problems with coping, with a
       negative effect on self-concept. Insistence on choosing restricted foods implies that the adolescent has
       not accepted the diagnosis and is noncompliant, possibly indicating a negative self-concept. Social
       withdrawal from activities may indicate depression, possibly negatively affecting the self-concept.
       CN: Physiological adaptation; CL: Evaluate

Question 49

49. Which of the following diet plans would be appropriate for the nurse to discuss with the
    family of a child with acute renal failure?
50. High carbohydrate and protein.
51. High fat and carbohydrate.
52. Low fat and protein.
53. Low in carbohydrate and fat.

Answer 49

49. 2. The child with acute renal failure needs extra calories to reduce tissue catabolism,
       metabolic acidosis, and uremia. Using a high-fat and carbohydrate diet helps to supply the necessary
       extra calories. If the child is able to tolerate oral foods, concentrated food sources that are high in
       carbohydrate and fat but low in protein, potassium, and sodium may be provided.
       CN: Physiological adaptation; CL: Apply

Question 50

50. An adolescent with chronic renal failure is scheduled to go home with a peritoneal dialysis
    catheter in place. When developing the discharge teaching plan for the client and the family focusing
    on psychosocial needs, which of the following areas should be a top priority to include?
51. Advantages of limiting social activities and contacts for the first few months.
52. Not disclosing information about the peritoneal dialysis to people outside the family.
53. Possible effect on body image of the presence of an abdominal catheter.
54. Importance of relying on parents to do the dialysis and dressing changes.

Answer 50

50. 3. For an adolescent, body image is a major concern. The presence of an abdominal catheter
       can greatly affect the client’s body image. The adolescent needs opportunities to discuss feelings
       about altered body image due to the catheter. Adolescents need to be with their peers and to maintain
       social activities and contacts in order to meet the developmental tasks for this age group. The
       adolescent client may choose to confide in friends for both psychological health and physical safety.
       Because peers are most important to adolescents, they will confide in their peers before confiding in
       family members. Another major developmental need of the adolescent is achieving independence.
       Relying on the parents would interfere with the adolescent’s ability to do so.
       CN: Psychosocial integrity; CL: Create

Question 51

51. During a home visit, the public health nurse assesses the peritoneal catheter exit site of a
    child with chronic renal failure. Which of the following findings should lead the nurse to determine a
    client has an infection?
52. Dialysate leakage.
53. Granulation tissue.
54. Increased time for drainage.
55. Tissue swelling.

Answer 51

51. 4. Tissue swelling, pain, redness, and exudate indicate infection. Dialysate leakage is
       associated with improper catheter function, incomplete healing at the insertion site, or excessiveinstillation of dialysate. Granulation tissue indicates healing around the exit site, not infection.
       Increased time for drainage may indicate that the tube is kinked, suggesting an obstruction.
       CN: Reduction of risk potential; CL: Analyze

Question 52

52. After teaching the mother of a young child with a peritoneal catheter about the signs and
    symptoms of peritonitis, the nurse determines that the mother has understood the teaching when she
    identifies which of the following as an important sign?
53. Cloudy dialysate drainage return.
54. Distended abdomen.
55. Shortness of breath.
56. Weight gain of 3 lb (1.36 kg) in 2 days.

Answer 52

52. 1. Normally, dialysate drainage return should be clear. With peritonitis, large numbers of
       bacteria, white blood cells, and fibrin cause the dialysate to appear cloudy. Abdominal distention is
       unrelated to peritonitis. However, it might suggest an obstruction. Weight gain and shortness of breath
       are associated with fluid excess, not infection.
       CN: Physiological adaptation; CL: Evaluate

Question 53

53. The nurse assesses the child with chronic renal failure who is receiving peritoneal dialysis
    for edema. Which finding is expected for this child?
54. Absence of pulmonary crackles.
55. Increased dialysate outflow.
56. Normal blood pressure.
57. Pallor.

Answer 53

53. 4. With edema, pallor can occur owing to hemodilution as intestinal fluid moves to the
       vascular space. The child would exhibit pulmonary crackles secondary to pulmonary congestion and
       edema. Dialysate outflow would decrease, not increase, as the body attempts to conserve fluid. The
       child’s blood pressure would be increased because of excessive fluid volume.
       CN: Physiological adaptation; CL: Analyze

Question 54

54. The mother of a child with chronic renal failure who is receiving peritoneal dialysis at home
    asks the nurse what she can do if both inflow and drain times are increased. Which of the following
    instructions would be most appropriate for the nurse to include when responding to the mother?
55. Assess the child for constipation.
56. Decrease the amount of dialysate infused for each dwell.
57. Incorporate the increased inflow and drain times into the dialysis schedule.
58. Monitor the child for shoulder pain during inflow and drain times.

Answer 54

54. 1. Accumulation of hard stool in the bowel can cause the distended intestine to block the holes
       of the catheter. Consequently, the dialysate cannot flow freely through the catheter. Decreasing the
       dialysate infusion may make the dialysis less effective. Altering fluid, electrolyte, and waste product
       removal can cause fluid and electrolyte imbalance and increased levels of blood urea nitrogen and
       creatinine. Incorporating the increased times into the dialysis may make the dialysis less effective
       because fewer cycles can be scheduled. Shoulder pain, which may occur occasionally, can be caused
       by air in the peritoneal space and diaphragmatic irritation. However, it is unrelated to inflow and
       drain times.
       CN: Physiological adaptation; CL: Synthesize

Question 55

55. The nurse judges that the mother understands the diet restrictions for her child with chronic
    renal failure who is receiving peritoneal dialysis when she reports providing a diet involving which
    of the following?
56. Sodium and water restrictions.
57. High protein and carbohydrates.
58. High potassium and iron.
59. Protein and phosphorous restrictions.

Answer 55

55. 4. Regulation of the diet is the most effective means, besides dialysis, for reducing renal
       excretion. Dietary phosphorus is restricted, which reduces the protein load on the kidneys. Clients are
       also given substances to bind phosphorus in the intestines to prevent absorption. Limited protein in
       the diet should include foods high in essential amino acids. Foods high in fat and carbohydrate are
       used to increase caloric intake. Sodium and water may not be restricted because of the continual loss
       of sodium and water through the dialysate. Iron-rich foods are commonly high in protein.
       CN: Physiological adaptation; CL: Evaluate

Question 56

The Client with Wilms’ Tumor
56. A 3-year-old child receiving chemotherapy after surgery for a Wilms’ tumor has developed
neutropenia. The parent is trying to encourage the child to eat by bringing extra foods to the room.
Which food would not be appropriate for this child?
1. Fudge.
2. French fries.
3. Fresh strawberries.
4. A milk shake.

Answer 56

The Client with Wilms’ Tumor
56. 3. When a client receiving chemotherapy develops neutropenia, eating uncooked fruits and
vegetables may pose a health risk due to possible bacterial contamination. All other foods are either
cooked or pasteurized and would not produce a health risk.
CN: Safety and infection control; CL: Apply

Question 57

57. When assessing a 2-year-old child with Wilms’ tumor, the nurse should avoid?
58. Measuring the child’s chest circumference.
59. Palpating the child’s abdomen.
60. Placing the child in an upright position.
61. Measuring the child’s occipitofrontal circumference.

Answer 57

57. 2. The abdomen of the child with Wilms’ tumor should not be palpated because of the danger
       of disseminating tumor cells. Techniques such as measuring the occipitofrontal circumference (which
       is done in children younger than 18 months of age because the anterior fontanel closes between 12
       and 18 months of age), upright positioning, and measuring chest circumference are not necessarily
       contraindicated; however, the child with Wilms’ tumor should always be handled gently and carefully.
       CN: Physiological adaptation; CL: Analyze

Question 58

58. Which statement by the mother of a child with Wilms’ tumor tells the nurse that the mother
    understands what stage II tumor means?
59. “The tumor has extended beyond the kidney but was completely removed.”
60. “Although the tumor was in the kidney, it has spread to the lung, liver, and bone.”
61. “The tumor has extended outside the kidney to the lungs and the liver.”
62. “The tumor was solely located in the kidney but it was totally removed.”

Answer 58

58. 1. A stage II tumor is one that extends beyond the kidney but is completely resected. The tumor
       staging is verified during surgery to maximize treatment protocols. The following criteria for staging
       are commonly used: stage I, tumor is limited to the kidney and completely resected; stage II, tumor
       extends beyond the kidney but is completely resected; stage III, residual nonhematogenous tumor is
       confined to the abdomen; stage IV, hematogenous metastasis occurs, with deposits beyond stage III
       (lung, bone and brain, liver); stage V, bilateral renal involvement is present at diagnosis.
       CN: Physiological adaptation; CL: Evaluate

Question 59

59. A child diagnosed with Wilms’ tumor undergoes successful surgery for removal of the
    diseased kidney. When the child returns to the room, the nurse should place the child in which
    position?
60. Modified Trendelenburg.
61. Sims’.
62. Semi-Fowler’s.
63. Supine.

Answer 59

59. 3. The child who has undergone abdominal surgery is usually placed in a semi-Fowler’s
       position to facilitate draining of abdominal contents and promote pulmonary expansion. The modified
       Trendelenburg position is used for clients in shock. The Sims’ position is likely to be uncomfortable
       for this child because of the large transabdominal incision. The supine position, without the head
       elevated, puts the child at increased risk for aspiration.
       CN: Reduction of risk potential; CL: Synthesize

Question 60

60. After a child undergoes nephrectomy for a Wilms’ tumor, the nurse should assess the child
    postoperatively for which early sign of a complication?
61. Increased abdominal distention.
62. Elevated blood pressure.
63. Increased respiratory rate.
64. Increased urine output.

Answer 60

60. 1. Children who have undergone abdominal surgery are at risk for intestinal obstruction from
       a dynamic ileus. Indications of intestinal obstruction include abdominal distention, decreased or
       absent bowel sounds, and vomiting. Later signs of intestinal obstruction include tachycardia, fever,
       hypotension, increased respirations, shock, and decreased urinary output.
       CN: Reduction of risk potential; CL: Analyze

Question 61

61. When developing the discharge plan for a child who had a nephrectomy for a Wilms’ tumor,
    the nurse identifies outcomes to prevent damage to the child’s remaining kidney and accomplish which
    of the following?
62. Minimize pain.
63. Prevent dependent edema.
64. Prevent urinary tract infection.
65. Minimize sodium intake.

Answer 61

61. 3. Because the child has only one kidney, measures should be recommended to prevent urinary
       tract infection and injury to the remaining kidney. Severe pain and dependent edema are not
       associated with surgery for Wilms’ tumor. Dietary sodium is not restricted because function in the
       remaining kidney is not impaired.
       CN: Reduction of risk potential; CL: Create

Question 62

Managing Care Quality and Safety
The nurse reads the new medications prescriptions for a 4-year-old child with nephrotic syndrome on
the chart below:
D/C Prednisolone 40 mg PO Daily
Prednisolone 30mg PO QOD

The nurse should:

1. Discontinue the prednisolone 40 mg and give the 30-mg dose today.
2. Check the medication record first to see when the last dose of prednisolone was given.
3. Start the 30-mg dose tomorrow.
4. Contact the prescriber for clarification.

Answer 62

Managing Care Quality and Safety
62. 4. There are many problems with this medication prescription. The abbreviation QOD is
ambiguous and open to various interpretations. The abbreviation D/C may be interpreted as
“discontinue” or “discharge.” The prescriber should have specifically stated when to start the lower
dose because the nurse could reason beginning the medication that day, the next, or even the day after
that. The only safe thing to do is call for clarification.
CN: Safety and infection control; CL: Synthesize

Question 63

63. The charge nurse finds the mother of a child with a chronic bladder condition requiring clean
    intermittent catheterization (CIC) visibly upset. The mother states, “That other nurse said parents are
    not allowed to perform CIC in the hospital because of increased infection risk.” The charge nurse
    should tell the parent:
64. “Your child is exposed to additional bacterial in the hospital that makes CIC unsafe.”
65. “You can catheterize your child as long as you use sterile technique.”
66. “You can use CIC on your child. I will talk with your nurse to clarify the policy.”
67. “I can tell you are having a conflict with this nurse. I will switch assignments.”

Answer 63

63. 3. The charge nurse should assure the parent that it is okay to use CIC and discuss the
       conversation with the nurse. It is possible that the nurse was unaware of current research findings or
       unit policies. The charge nurse should also determine if the parent has the supplies and uses a new
       catheter each time, but the insertion principles would not change. Parents are frequently taught how to
       do CIC while a child is in the hospital. Therefore, the rationale that it now becomes unsafe, or that
       sterile technique is needed, is faulty. Switching nurses will not solve the underlying problem.
       CN: Management of care; CL: Synthesize

Question 64

64. The parent of an 18-year-old with chronic renal disease states, “My son has so many
    problems. I’m really worried that he will not get the right care if he gets sick at college.” The nurse
    should tell the parent:
65. “I can have his records sent to the school’s health center.”
66. “Make sure your son always carries his nephrologist’s phone number.”
67. “Your son can make an e-health history to facilitate his care if he gets sick away from home.”
68. “Your son is going to need to learn to manage his own disease.”

Answer 64

64. 3. Access to a well-constructed e-history will facilitate care if the adolescent becomes ill
       while at college. Because the client is 18, legally the nurse cannot transfer the records to the school
       without permission. Also, the adolescent may need to seek treatment in facilities other than the healthcenter. Instructing the adolescent to always carry the nephrologist’s phone number is not bad advice,
       but compliance may vary and there is no guarantee the provider will be available in all instances.
       Telling the parent that the son must learn to manage his own disease does not address the parent’s
       concern.
       CN: Management of care; CL: Synthesize