Unit J-Congenital Heart Defects

Question 1

Which complication should the nurse asses for when caring for a child post cardiac
catheterization?
a. Cardiac arrhythmia
b. Hypostatic pneumonia
c. Congestive heart failure
d. Rapidly increasing blood pressure

Answer 1

ANS: A
Because a catheter is introduced into the heart, a risk exists of catheter-induced arrhythmias
occurring during the procedure. These are usually transient. Hypostatic pneumonia,
congestive heart failure, and rapidly increasing blood pressure are not risks usually associated
with cardiac catheterization.

Question 2

José is 4 year old. Preoperative teaching for a 4-year-old child scheduled for a cardiac
catheterization should be done with what primary consideration in mind?
a. Directed at his parents because he is too young to understand.
b. Detailed in regard to the actual procedures so he will know what to expect.
c. Done several days before the procedure so that he will be prepared.
d. Adapted to his level of development so that he can understand

Answer 2

ANS: D
Preoperative teaching should always be directed at the child’s stage of development. The
caregivers also benefit from the same explanations. The parents may ask additional questions,
which should be answered, but the child needs to receive the information based on
developmental level. This age-group does not understand in-depth descriptions. Preschoolers
should be prepared close to the time of the cardiac catheterization

Question 3

The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells
the nurse that her bandage is “too wet.” The nurse finds the bandage and bed soaked with
blood. What is the most appropriate initial nursing action?
a. Notify the physician.
b. Apply a new bandage with more pressure.
c. Place the child in the Trendelenburg position.
d. Apply direct pressure above the catheterization site

Answer 3

ANS:D
If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the
percutaneous skin site to localize pressure over the vessel puncture. Notifying the physician
and applying a new bandage with more pressure can be done after pressure is applied. The
nurse can have someone else notify the physician while the pressure is being maintained. The
Trendelenburg position would not be helpful; it would increase the drainage from the lower
extremities

Question 4

Which defect results in increased pulmonary blood flow?

a. Pulmonic stenosis
b. Tricuspid atresia
c. Atrial septal defect
d. Transposition of the great arteries

Answer 4

ANS: C
Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left
atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the
pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles.
Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great
arteries results in mixed blood flow.

Question 5

Which structural defects constitute tetralogy of Fallot?
a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy
b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy
c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular
hypertrophy

Answer 5

ANS: A
Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal
defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not
aortic stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular
hypertrophy, is present in tetralogy of Fallot. There is a ventricular septal defect, not an atrial
septal defect, and overriding aorta, not aortic hypertrophy, is present.

Question 6

What is best described as the inability of the heart to pump an adequate amount of blood to
the systemic circulation at normal filling pressures?
a. Pulmonary congestion
b. Congenital heart defect
c. Heart failure
d. Systemic venous congestion

Answer 6

ANS: C
The definition of heart failure is the inability of the heart to pump an adequate amount of
blood to the systemic circulation at normal filling pressures to meet the metabolic demands of
the body. Pulmonary congestion is an excessive accumulation of fluid in the lungs. Congenital
heart defect is a malformation of the heart present at birth. Systemic venous congestion is an
excessive accumulation of fluid in the systemic vasculature.

Question 7

Which term is used to describe a clinical manifestation of the systemic venous congestion that
can occur with congestive heart failure?
a. Tachypnea
b. Tachycardia
c. Peripheral edema
d. Pale, cool extremities

Answer 7

ANS: C
Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous
congestion. Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale,
cool extremities are clinical manifestations of impaired myocardial function

Question 8

What beneficial effect is achieved by administering digoxin?

a. Decreases edema
b. Decreases cardiac output
c. Increases heart size
d. Increases venous pressure

Answer 8

ANS: A
Digoxin has a rapid onset and is useful in increasing cardiac output, decreasing venous
pressure, and as a result decreasing edema. Heart size is decreased by digoxin.

Question 9

Which drug is an angiotensin-converting enzyme (ACE) inhibitor?

a. Captopril
b. Furosemide
c. Spironolactone
d. Chlorothiazide

Answer 9

ANS: A
Capoten is an ACE inhibitor. Lasix is a loop diuretic. Aldactone blocks the action of
aldosterone. Diuril works on the distal tubules.

Question 10

What is a common sign of digoxin toxicity?

a. Seizures
b. Vomiting
c. Bradypnea
d. Tachycardia

Answer 10

ANS: B
Vomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin
toxicity. The child will have a slower heart rate, not respiratory rate.

Question 11

The parents of a young child with congestive heart failure tell the nurse that they are
“nervous” about giving digoxin. The nurse’s response should be based on knowing what
information?
a. It is a safe, frequently used drug.
b. It is difficult to either overmedicate or undermedicate with digoxin.
c. Parents lack the expertise necessary to administer digoxin.
d. Parents must learn specific, important guidelines for administration of digoxin.

Answer 11

ANS: D
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 monitor for side effects. Digoxin is a frequently used drug, but
it has a narrow therapeutic range. Very small amounts of the liquid are given to infants, which
makes it easy to overmedicate or undermedicate. Parents may lack the necessary expertise to
administer the drug at first, but with discharge preparation they should be prepared to
administer the drug safely.

Question 12

As part of the treatment for congestive heart failure, the child takes the diuretic furosemide.
As part of teaching home care, the nurse encourages the family to give the child foods such as
bananas, oranges, and leafy vegetables. These foods are recommended because they are high
in what electrolyte?
a. Chlorides
b. Potassium
c. Sodium
d. Zinc

Answer 12

ANS: B
Diuretics that work on the proximal and distal renal tubules contribute to increased losses of
potassium. The child’s diet should be supplemented with potassium.

Question 13

An 8-month-old infant becomes hypercyanotic while blood is being drawn. What should be
the nurse’s first action?
a. Assess for neurologic defects
b. Place the child in the knee-chest position
c. Begin cardiopulmonary resuscitation
d. Prepare the family for imminent death

Answer 13

ANS: B
The first action is to place the infant in the knee-chest position. Blow-by oxygen may be
indicated. Neurologic defects are unlikely. The child should be assessed for airway, breathing,
and circulation. Often calming the child and administering oxygen and morphine can alleviate
the hypercyanotic spell; cardiopulmonary resuscitation is not necessary, and death is unlikely

Question 14

The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The
nurse recognizes that a risk of cerebrovascular accidents (strokes) exists. An important
objective to decrease this risk is to achieve what result?
a. Minimize seizures
b. Prevent dehydration
c. Promote cardiac output
d. Reduce energy expenditure

Answer 14

ANS: B
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.

Question 15

Parents of a 3-year-old child diagnosed with congenital heart disease are afraid to let their
child play with other children because of possible overexertion. The nurse’s reply should be
based on what knowledge?
a. The child needs opportunities to play with peers.
b. The child needs to understand that peers’ activities are too strenuous.
c. Parents can meet all the child’s needs.
d. Constant parental supervision is needed to avoid overexertion.

Answer 15

ANS: A
The child needs opportunities for social development. Children usually limit their activities if
allowed to set their own pace and regulate their activities. The child will limit activities as
necessary. Parents must be encouraged to seek appropriate social activities for the child,
especially before kindergarten. The child needs to have activities that foster independence.

Question 16

What should the nurse consider when preparing a school-age child and the family for heart
surgery?
a. Not showing unfamiliar equipment
b. Letting child hear the sounds of an electrocardiograph monitor
c. Avoiding mentioning postoperative discomfort and interventions
d. Explaining that an endotracheal tube will not be needed if the surgery goes well

Answer 16

ANS: B
The child and family should be exposed to the sights and sounds of the intensive care unit. All
positive, nonfrightening aspects of the environment are emphasized. The child should be
shown unfamiliar equipment, and its use should be demonstrated on a doll. Carefully prepare
the child for the postoperative experience, including intravenous lines, incision, and
endotracheal tube.

Question 17

Seventy-two hours after cardiac surgery, a young child has a temperature of 37.7° C (101° F).
The nurse should initially implement which intervention?
a. Keep the child warm with blankets
b. Apply a hypothermia blanket
c. Record the temperature on nurses’ notes
d. Report findings to physician

Answer 17

ANS: D
In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7° C (100°
F) as part of the inflammatory response to tissue trauma. If the temperature is higher or an
elevated temperature continues after this period, it is most likely a sign of an infection and
immediate investigation is indicated. Blankets should be removed from the child to keep the
temperature from increasing. A hypothermia blanket is not indicated for this level of
temperature. The temperature should be recorded, but the physician must be notified for
evaluation.

Question 18

What is an important nursing consideration when suctioning a young child who has had heart
surgery?
a. Perform suctioning at least every hour.
b. Suction for no longer than 30 seconds at a time.
c. Administer supplemental oxygen before and after suctioning.
d. Expect symptoms of respiratory distress when suctioning.

Answer 18

ANS: C
If suctioning is indicated, supplemental oxygen is administered with a manual resuscitation
bag before and after the procedure to prevent hypoxia. Suctioning should be done only as
indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at
one time. Symptoms of respiratory distress are to be avoided by using the appropriate
technique.

Question 19

The nurse is caring for a child after heart surgery. What intervention should the nurse
implement immediately if evidence is found of cardiac tamponade?
a. Increase analgesia
b. Apply warming blankets
c. Immediately report this to the physician
d. Encourage the child to cough, turn, and breathe deeply

Answer 19

ANS: C
If evidence is noted of cardiac tamponade (blood or fluid in the pericardial space constricting
the heart), the physician is notified immediately of this life-threatening complication.
Increasing analgesia may be done before the physician drains the fluid, but the physician must
be notified. Warming blankets are not indicated at this time. Encouraging the child to cough,
turn, and breathe deeply should be deferred until after the evaluation by the physician.

Question 20

What intervention should be implemented prior to the removal of a child’s chest tubes?

a. Explain that it is not painful.
b. Explain that only a Band-Aid will be needed.
c. Administer analgesics before the procedure.
d. Educate the patient to expect bright red drainage for several hours after removal.

Answer 20

ANS: C
It is appropriate to prepare the child for the removal of chest tubes with analgesics.
Short-acting medications can be used that are administered through an existing intravenous
line. It is not a pain-free procedure. A sharp, momentary pain is felt, and this should not be
misrepresented to the child. A petroleum gauze/airtight dressing is needed. Little or no
drainage should be found on removal.

Question 21

What is the most common causative agent of bacterial endocarditis?

a. Staphylococcus albus
b. Streptococcus hemolyticus
c. Staphylococcus albicans
d. Streptococcus viridans

Answer 21

ANS: D
Staphylococcus viridans is the most common causative agent in bacterial (infective)
endocarditis. Staphylococcus albus, Streptococcus hemolyticus, and Staphylococcus albicans
are not common causative agents

Question 22

What term is used to describe the painful, tender, pea-sized nodules that may appear on the
pads of the fingers or toes in cases of bacterial endocarditis?
a. Osler’s nodes
b. Janeway lesions
c. Subcutaneous nodules
d. Aschoff’s nodules

Answer 22

ANS:A
Osler’s nodes are red, painful, intradermal nodes found on pads of the phalanges in bacterial
endocarditis. Janeway lesions are painless hemorrhagic areas on palms and soles in bacterial
endocarditis. Subcutaneous nodules are nontender swellings located over bony prominences,
commonly found in rheumatic fever. Aschoff’s nodules are small nodules composed of cells
and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis.

Question 23

What is the primary nursing intervention necessary to prevent bacterial endocarditis?

a. Institute measures to prevent dental procedures.
b. Counsel parents of high risk children about prophylactic antibiotics.
c. Observe children for complications such as embolism and heart failure.
d. Encourage restricted mobility in susceptible children.

Answer 23

ANS: B
The objective of nursing care is to counsel the parents of high risk children about both the
need for prophylactic antibiotics for dental procedures and the necessity of maintaining
excellent oral health. The child’s dentist should be aware of the child’s cardiac condition.
Dental procedures should be done to maintain a high level of oral health. Prophylactic
antibiotics are necessary. Observing for complications and encouraging restricted mobility in
susceptible children should be done, but maintaining good oral health and using prophylactic
antibiotics are most important.

Question 24

What is a common, serious complication of rheumatic fever?

a. Seizures
b. Cardiac arrhythmias
c. Pulmonary hypertension
d. Cardiac valve damage

Answer 24

ANS: D
Cardiac valve damage is the most significant complication of rheumatic fever. Seizures,
cardiac arrhythmias, and pulmonary hypertension are not common complications of rheumatic
fever.

Question 25

What is a major clinical manifestation of rheumatic fever?

a. Polyarthritis
b. Osler’s nodes
c. Janeway spots
d. Splinter hemorrhages of distal third of nails

Answer 25

ANS: A
Polyarthritis is swollen, hot, red, and painful joints. The affected joints will change every 1 to
2 days. Primarily the large joints are affected. Osler’s nodes, Janeway spots, and splinter
hemorrhages are characteristic of infective endocarditis.

Question 26

When discussing hyperlipidemia with a group of adolescents, the nurse should explain that
high levels of what substance are thought to protect against cardiovascular disease?
a. Cholesterol
b. Triglycerides
c. Low-density lipoproteins (LDLs)
d. High-density lipoproteins (HDLs)

Answer 26

ANS: D
HDLs contain very low concentrations of triglycerides, relatively little cholesterol, and high
levels of proteins. It is thought that HDLs protect against cardiovascular disease. Cholesterol,
triglycerides, and LDLs do not protect against cardiovascular disease

Question 27

What is the leading cause of death after heart transplantation?

a. Infection
b. Rejection
c. Cardiomyopathy
d. Congestive heart failure

Answer 27

ANS: B
The posttransplantation course is complex. The leading cause of death after cardiac
transplantation is rejection. Infection is a continued risk secondary to the immunosuppression
necessary to prevent rejection. Cardiomyopathy is one of the indications for cardiac
transplant. Congestive heart failure is not a leading cause of death

Question 28

When caring for the child with Kawasaki disease, the nurse should understand that principle
of care?
a. The child’s fever is usually responsive to antibiotics within 48 hours.
b. The principal area of involvement is the joints.
c. Aspirin is contraindicated.
d. Therapeutic management includes administration of gamma globulin and aspirin.

Answer 28

ANS: D
High-dose intravenous gamma globulin and aspirin therapy are indicated to reduce the
incidence of coronary artery abnormalities when given within the first 10 days of the illness.
The fever of Kawasaki disease is unresponsive to antibiotics and antipyretics. Involvement of
mucous membranes and conjunctiva, changes in the extremities, and cardiac involvement are
seen.

Question 29

What is one of the most frequent causes of hypovolemic shock in children?

a. Myocardial infarction
b. Blood loss
c. Anaphylaxis
d. Congenital heart disease

Answer 29

ANS: B
Blood loss and extracellular fluid loss are two of the most frequent causes of hypovolemic
shock in children. Myocardial infarction is rare in a child; if it occurred, the resulting shock
would be cardiogenic, not hypovolemic. Anaphylaxis results in distributive shock from
extreme allergy or hypersensitivity to a foreign substance. Congenital heart disease tends to
contribute to hypervolemia, not hypovolemia.

Question 30

What type of shock is characterized by a hypersensitivity reaction causing massive
vasodilation and capillary leaks, which may occur with drug or latex allergy?
a. Neurogenic shock
b. Cardiogenic shock
c. Hypovolemic shock
d. Anaphylactic shock

Answer 30

ANS: D
Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance.
Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal
transmission that occurs from a spinal cord injury. Cardiogenic shock is decreased cardiac
output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing
blood pressure, and low central venous pressure.

Question 31

Which clinical changes occur as a result of septic shock?

a. Hypothermia
b. Increased cardiac output
c. Vasoconstriction
d. Angioneurotic edema

Answer 31

ANS: B
Increased cardiac output, which results in warm, flushed skin, is one of the manifestations of
septic shock. Fever and chills are characteristic of septic shock. Vasodilation is more common
in septic shock. Angioneurotic edema occurs as a manifestation in anaphylactic shock

Question 32

child is brought to the emergency department experiencing an anaphylactic reaction to a bee
sting. While an airway is being established, what medication should the nurse prepare for
immediate administration?
a. Diphenhydramine
b. Dopamine
c. Epinephrine
d. Calcium chloride

Answer 32

ANS: C
After the first priority of establishing an airway, epinephrine is the drug of choice.
Diphenhydramine is not a strong enough antihistamine for this severe a reaction. Dopamine
and calcium chloride are not appropriate drugs for this type of reaction.

Question 33

Which postoperative intervention should be questioned for a child after a cardiac
catheterization?
a. Continue intravenous (IV) fluids until the infant is tolerating oral fluids.
b. Check the dressing for bleeding.
c. Assess peripheral circulation on the affected extremity.
d. Keep the affected leg flexed and elevated.

Answer 33

ANS: D
The child should be positioned with the affected leg straight for 4 to 6 hours after the
procedure. IV fluid administration continues until the child is taking and retaining adequate
amounts of oral fluids. The insertion site dressing should be observed frequently for bleeding.
The nurse should also look under the child to check for pooled blood. Peripheral perfusion is
monitored after catheterization. Distal pulses should be palpable, although they may be
weaker than in the contralateral extremity.

Question 34

In which situation is there the greatest risk that a newborn infant will have a congenital heart
defect (CHD)?
a. Trisomy 21 detected on amniocentesis
b. Family history of myocardial infarction
c. Father has type 1 diabetes mellitus
d. Older sibling born with Turner’s syndrome

Answer 34

ANS: A
The incidence of congenital heart disease is approximately 50% in children with trisomy 21
(Down syndrome). A family history of congenital heart disease, not acquired heart disease,
increases the risk of giving birth to a child with CHD. Infants born to mothers who are insulin
dependent have an increased risk of CHD. Infants identified as having certain genetic defects,
such as Turner’s syndrome, have a higher incidence of CHD.

Question 35

Which intervention should be included in the plan of care for an infant with the nursing
diagnosis of Excess Fluid Volume related to congestive heart failure?
a. Weigh the infant every day on the same scale at the same time.
b. Notify the physician when weight gain exceeds more than 20 g/day.
c. Put the infant in a car seat to minimize movement.
d. Administer digoxin as ordered by the physician.

Answer 35

ANS:A
Excess fluid volume may not be overtly visible. Weight changes may indicate fluid retention.
Weighing the infant on the same scale at the same time each day ensures consistency. An
excessive weight gain for an infant is an increase of more than 50 g/day. With fluid volume
excess, skin will be edematous. The infant’s position should be changed frequently to prevent
undesirable pooling of fluid in certain areas. Digoxin is used in the treatment of congestive
heart failure to improve cardiac function. Diuretics will help the body get rid of excess fluid.

Question 36

The nurse assessing a premature newborn infant auscultates a continuous machinery-like

murmur. This finding is associated with which congenital heart defect?
a. Pulmonary stenosis
b. Patent ductus arteriosus
c. Ventricular septal defect
d. Coarctation of the aorta

Answer 36

ANS: B
The classic murmur associated with patent ductus arteriosus is a machinery-like one that can
be heard throughout both systole and diastole. A systolic ejection murmur that may be
accompanied by a palpable thrill is a manifestation of pulmonary stenosis. The characteristic
murmur associated with ventricular septal defect is a loud, harsh, holosystolic murmur. A
systolic murmur that is accompanied by an ejection click may be heard on auscultation when
coarctation of the aorta is present.

Question 37

What is an expected assessment finding in a child with coarctation of the aorta?

a. Orthostatic hypotension
b. Systolic hypertension in the lower extremities
c. Blood pressure higher on the left side of the body
d. Disparity in blood pressure between the upper and lower extremities

Answer 37

ANS: D
The classic finding in children with coarctation of the aorta is a disparity in pulses and blood
pressures between the upper and lower extremities. Orthostatic hypotension is not present
with coarctation of the aorta. Systolic hypertension may be detected in the upper extremities.
The left arm may not accurately reflect systolic hypertension because the left subclavian
artery can be involved in the coarctation.

Question 38

A child with pulmonary atresia exhibits cyanosis with feeding. On reviewing this child’s
laboratory values, the nurse is not surprised to notice which abnormality?
a. Polycythemia
b. Infection
c. Dehydration
d. Anemia

Answer 38

ANS:A
Polycythemia is a compensatory response to chronic hypoxia. The body attempts to improve
tissue oxygenation by producing additional red blood cells and thereby increases the
oxygen-carrying capacity of the blood. Infection is not a clinical consequence of cyanosis.
Although dehydration can occur in cyanotic heart disease, it is not a compensatory mechanism
for chronic hypoxia. It is not a clinical consequence of cyanosis. Anemia may develop as a
result of increased blood viscosity. Anemia is not a clinical consequence of cyanosis.

Question 39

What is the nurse’s first action when planning to teach the parents of an infant with a
congenital heart defect (CHD)?
a. Assess the parents’ anxiety level and readiness to learn
b. Gather literature for the parents
c. Secure a quiet place for teaching
d. Discuss the plan with the nursing team

Answer 39

ANS: A
Any effort to organize the right environment, plan, or literature is of no use if the parents are
not ready to learn or have high anxiety. Decreasing their level of anxiety is often needed
before new information can be processed. A baseline assessment of prior knowledge should
be taken into consideration before developing any teaching plan. Locating a quiet place for
meeting with parents is appropriate; however, an assessment should be done before any
teaching is done. Discussing a teaching plan with the nursing team is appropriate after an
assessment of the parents’ knowledge and readiness.

Question 40

A nurse is teaching an adolescent about essential hypertension. The nurse knows that which of
the following is correct?
a. Primary hypertension should be treated with diuretics as soon as it is detected.
b. Congenital heart defects are the most common cause of primary hypertension.
c. Primary hypertension may be treated with weight reduction.
d. Primary hypertension is not affected by exercise.

Answer 40

ANS: C
Essential hypertension in children may be treated with weight reduction and exercise
programs. If ineffective, pharmacologic intervention may be needed. Primary hypertension is
considered an inherited disorder

Question 41

hat is the initial goal for the treatment of secondary hypertension?

a. Weight control and diet
b. Treating the underlying disease
c. Administration of digoxin
d. Administration of -adrenergic receptor blockers

Answer 41

ANS:B
Identification of the underlying disease should be the first step in treating secondary
hypertension. Weight control and diet are nonpharmacologic treatments for primary
hypertension. Digoxin is indicated in the treatment of congestive heart failure. -Adrenergic
receptor blockers are indicated in the treatment of primary hypertension

Question 42

The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which
statement by the adolescent would indicate a need for further teaching?
a. “I should avoid tub baths but may shower.”
b. “I have to stay on strict bed rest for 3 days.”
c. “I should remove the pressure dressing the day after the procedure.”
d. “I may attend school but should avoid exercise for several days.”

Answer 42

ANS: B
Encourage rest and quiet activities for the first 3 days and avoid strenuous exercise. The child
does not need to be on strict bed rest for 3 days. Showers are recommended; children should
avoid a tub bath. The pressure dressing is removed the day after the catheterization and
replaced by an adhesive bandage to keep the area clean.

Question 43

Surgical closure of the ductus arteriosus would bring about what desired effect?

a. Stop the loss of unoxygenated blood to the systemic circulation.
b. Decrease the edema in legs and feet.
c. Increase the oxygenation of blood.
d. Prevent the return of oxygenated blood to the lungs

Answer 43

ANS: D
The ductus arteriosus allows blood to flow from the higher-pressure aorta to the
lower-pressure pulmonary artery, causing a right-to-left shunt. If this is surgically closed, no
additional oxygenated blood (from the aorta) will return to the lungs through the pulmonary
artery. The aorta carries oxygenated blood to the systemic circulation. Because of the higher
pressure in the aorta, blood is shunted into the pulmonary artery and the pulmonary
circulation. Edema in the legs and feet is usually a sign of heart failure. This repair would not
directly affect the edema. Increasing the oxygenation of blood would not interfere with the
return of oxygenated blood to the lungs.

Question 44

A nurse is teaching nursing students the physiology of congenital heart defects. Which defect
results in decreased pulmonary blood flow?
a. Atrial septal defect
b. Tetralogy of Fallot
c. Ventricular septal defect
d. Patent ductus arteriosus

Answer 44

ANS:B
Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis
increases the pressure in the right ventricle, causing the blood to go from right to left across
the interventricular septal defect. Atrial and ventricular septal defects and patent ductus
arteriosus result in increased pulmonary blood flow.

Question 45

The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which
statement about feeding the child is correct?
a. “You may need to increase the caloric density of your infant’s formula.”
b. “You should feed your baby every 2 hours.”
c. “You may need to increase the amount of formula your infant eats with each
feeding.”
d. “You should place a nasal oxygen cannula on your infant during and after each
feeding.”

Answer 45

ANS: A
The metabolic rate of infants with heart failure is greater because of poor cardiac function and
increased heart and respiratory rates. Their caloric needs are greater than those of the average
infants, yet their ability to take in the calories is diminished by their fatigue. Infants with heart
failure should be fed every 3 hours; a 2-hour schedule does not allow for enough rest, and a
4-hour schedule is too long. Fluids must be carefully monitored because of the heart failure.
Infants do not require supplemental oxygen with feedings.

Question 46

The nurse is admitting a child with rheumatic fever. Which therapeutic management should
the nurse expect to implement?
a. Administering penicillin
b. Avoiding salicylates (aspirin)
c. Imposing strict bed rest for 4 to 6 weeks
d. Administering corticosteroids if chorea develops

Answer 46

ANS: A
The goal of medical management is the eradication of the hemolytic streptococci. Penicillin is
the drug of choice. Salicylates can be used to control the inflammatory process, especially in
the joints, and reduce the fever and discomfort. Bed rest is recommended for the acute febrile
stage, but it does not need to be strict. The chorea is transient and will resolve without
treatment.

Question 47

Which action by the school nurse is important in the prevention of rheumatic fever?

a. Encourage routine cholesterol screenings.
b. Conduct routine blood pressure screenings.
c. Refer children with sore throats for throat cultures.
d. Recommend salicylates instead of acetaminophen for minor discomforts.

Answer 47

ANS: C
Nurses have a role in prevention—primarily in screening school-age children for sore throats
caused by group A -hemolytic streptococci. They can achieve this by actively participating
in throat culture screening or by referring children with possible streptococcal sore throats for
testing. Cholesterol and blood pressure screenings do not facilitate the recognition and
treatment of group A -hemolytic streptococci. Salicylates should be avoided routinely
because of the risk of Reye’s syndrome after viral illnesses.

Question 48

A preschool child is scheduled for an echocardiogram. Parents ask the nurse whether they can
hold the child during the procedure. The nurse should answer with which response?
a. “You will be able to hold your child during the procedure.”
b. “Your child can be active during the procedure, but can’t sit in your lap.”
c. “Your child must lie quietly; sometimes a mild sedative is administered before the
procedure.”
d. “The procedure is invasive so your child will be restrained during the
echocardiogram.”

Answer 48

ANS: C
Although an echocardiogram is noninvasive, painless, and associated with no known side
effects, it can be stressful for children. The child must lie quietly in the standard
echocardiographic positions; crying, nursing, being held, or sitting up often leads to diagnostic
errors or omissions. Therefore, infants and young children may need a mild sedative; older
children benefit from psychologic preparation for the test. The distraction of a video or movie
is often helpful.

Question 49

The nurse is caring for an infant diagnosed with congestive heart disease (CHD). The nurse
should plan which intervention to decrease cardiac demands?
a. Organize nursing activities to allow for uninterrupted sleep
b. Allow the infant to sleep through feedings during the night
c. Wait for the infant to cry to show definite signs of hunger
d. Discourage parents from rocking the infant

Answer 49

ANS: A
The infant requires rest and conservation of energy for feeding. Every effort is made to
organize nursing activities to allow for uninterrupted periods of sleep. Whenever possible,
parents are encouraged to stay with their infant to provide the holding, rocking, and cuddling
that help children sleep more soundly. To minimize disturbing the infant, changing bed linens
and complete bathing are done only when necessary. Feeding is planned to accommodate the
infant’s sleep and wake patterns. The child is fed at the first sign of hunger, such as when
sucking on fists, rather than waiting until he or she cries for a bottle because the stress of
crying exhausts the limited energy supply. Because infants with CHD tire easily and may
sleep through feedings, smaller feedings every 3 hours may be helpful.

Question 50

Nursing interventions for the child after a cardiac catheterization include which of the
following? (Select all that apply.)
a. Allow ambulation as tolerated.
b. Monitor vital signs every 2 hours.
c. Assess the affected extremity for temperature and color.
d. Check pulses above the catheterization site for equality and symmetry.
e. Remove pressure dressing after 4 hours.
f. Maintain a patent peripheral intravenous catheter until discharge.

Answer 50

ANS: C, F
The extremity that was used for access for the cardiac catheterization must be checked for
temperature and color. Coolness and blanching may indicate arterial occlusion. The child
should have a patent peripheral intravenous line to ensure adequate hydration. Allowing
ambulation, monitoring vital signs every 2 hours, checking pulses, and removing the pressure
dressing after 4 hours are interventions that do not apply to a child after a cardiac
catheterization.

Question 51

Which clinical manifestations would the nurse expect to see as shock progresses in a child and
decompensated develops? (Select all that apply.)
a. Thirst and diminished urinary output
b. Irritability and apprehension
c. Cool extremities and decreased skin turgor
d. Confusion and somnolence
e. Normal blood pressure and narrowing pulse pressure
f. Tachypnea and poor capillary refill time

Answer 51

ANS: C, D, F
Cool extremities, decreased skin turgor, confusion, somnolence, tachypnea, and poor capillary
refill time are beginning signs of decompensated shock.

Question 52

A nurse is conducting discharge teaching to parents about the care of their infant after cardiac
surgery. The nurse instructs the parents to notify the physician if what conditions occur?
(Select all that apply.)
a. Respiratory rate of 36 breaths/minute at rest
b. Appetite slowly increasing
c. Temperature above 37.7° C (100° F)
d. New, frequent coughing
e. Turning blue or bluer than normal

Answer 52

ANS: C, D, E
The parents should be instructed to notify the physician after their infant’s cardiac surgery for
a temperature above 37.7° C (100° F); new, frequent coughing; and any episodes of the infant
turning blue or bluer than normal. A respiratory rate of 36 breaths/minute at rest for an infant
is within normal expectations, and it is expected that the appetite will increase slowly

Question 53

The nurse is conducting discharge teaching about signs and symptoms of heart failure to
parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the
nurse include? (Select all that apply.)
a. Warm flushed extremities
b. Weight loss
c. Decreased urinary output
d. Sweating (inappropriate)
e. Anorexia

Answer 53

ANS: C, D, E
The signs and symptoms of heart failure include decreased urinary output, sweating, and poor
feeding. Other signs include pale, cool extremities, not warm and flushed, and weight gain,
not weight loss.

Question 54

What is the primary result of anemia?

a. Increased blood viscosity.
b. Depressed hematopoietic system.
c. Presence of abnormal hemoglobin.
d. Decreased oxygen-carrying capacity of blood.

Answer 54

ANS: D
Anemia is a condition in which the number of red blood cells or hemoglobin concentration is
reduced below the normal values for age. This results in a decreased oxygen-carrying capacity
of blood. Increased blood viscosity is usually a function of too many cells or of dehydration,
not of anemia. A depressed hematopoietic system or abnormal hemoglobin can contribute to
anemia, but the definition depends on the deceased oxygen-carrying capacity of the blood

Question 55

Several blood tests are ordered for a preschool child with severe anemia. She is crying and
upset because she remembers the venipuncture done at the clinic 2 days ago. The nurse should
explain that:
a. venipuncture discomfort is very brief.
b. only one venipuncture will be needed.
c. topical application of local anesthetic can eliminate venipuncture pain.
d. most blood tests on children require only a finger puncture because a small amount
of blood is needed.

Answer 55

ANS: C
Preschool children are very concerned about both pain and the loss of blood. When preparing
the child for venipuncture, a topical anesthetic will be used to eliminate any pain. This is a
very traumatic experience for preschool children. They are concerned about their bodily
integrity. A local anesthetic should be used, and a bandage should be applied to maintain
bodily integrity. A promise that only one venipuncture will be needed should not be made in
case multiple attempts are required. Both finger punctures and venipunctures are traumatic for
children. Both require preparation.

Question 56

What is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia?

a. Activity intolerance related to generalized weakness
b. Decreased cardiac output related to abnormal hemoglobin
c. Risk for injury related to depressed sensorium
d. Risk for Injury related to dehydration and abnormal hemoglobin

Answer 56

ANS:A
The basic pathology in anemia is the decreased oxygen-carrying capacity of the blood. The
nurse must assess the child’s activity level (response to the physiologic state). The nursing
diagnosis would reflect the activity intolerance. In generalized anemia no abnormal
hemoglobin may be present. Only at a level of very severe anemia does cardiac output become
altered. No decreased sensorium exists until profound anemia occurs. Dehydration and
abnormal hemoglobin are not usually part of anemia.

Question 57

Which statement best explains why iron deficiency anemia is common during toddlerhood?

a. Milk is a poor source of iron.
b. Iron cannot be stored during fetal development.
c. Fetal iron stores are depleted by age 1 month.
d. Dietary iron cannot be started until age 12 months.

Answer 57

ANS: A
Children between the ages of 12 and 36 months are at risk for anemia because cow’s milk is a
major component of their diet, and it is a poor source of iron. Iron is stored during fetal
development, but the amount stored depends on maternal iron stores. Fetal iron stores are
usually depleted by age 5 to 6 months. Dietary iron can be introduced by breastfeeding,
iron-fortified formula, and cereals during the first 12 months of life.

Question 58

When teaching the mother of a 9-month-old infant about administering liquid iron
preparations, the nurse should include that information?
a. They should be given with meals.
b. They should be stopped immediately if nausea and vomiting occur.
c. Adequate dosage will turn the stools a tarry green color.
d. Preparation should be allowed to mix with saliva and bathe the teeth before
swallowing.

Answer 58

ANS: C
The nurse should prepare the mother for the anticipated change in the child’s stools. If the iron
dose is adequate, the stools will become a tarry green color. The lack of the color change may
indicate insufficient iron. The iron should be given in two divided doses between meals, when
the presence of free hydrochloric acid is greatest. Iron is absorbed best in an acidic
environment. Vomiting and diarrhea may occur with iron administration. If these occur, the
iron should be given with meals, and the dosage reduced and gradually increased as the child
develops tolerance. Liquid preparations of iron stain the teeth. They should be administered
through a straw, and the mouth rinsed after administration.

Question 59

Iron dextran is ordered for a young child with severe iron deficiency anemia. What nursing
consideration should be considered?
a. Administering with meals
b. Administering between meals
c. Injecting deeply into a large muscle
d. Massaging injection site for 5 minutes after administration of drug

Answer 59

ANS: C
Iron dextran is a parenteral form of iron. When administered intramuscularly, it must be
injected into a large muscle using the Z-track method. Iron dextran is for intramuscular or
intravenous administration; it is not taken orally. The site should not be massaged to prevent
leakage, potential irritation, and staining of the skin. The administration has no relationship to
food since it is not being given orally.

Question 60

What intervention should the nurse share with parents on how to prevent iron deficiency
anemia in a healthy, term, breastfed infant?
a. Iron (ferrous sulfate) drops after age 1 month
b. Iron-fortified commercial formula can be used by ages 4 to 6 months
c. Iron-fortified solid foods are introduced at 3 months
d. Iron-fortified infant cereal can be introduced at approximately 6 months of age

Answer 60

ANS: D
Breast milk supplies inadequate iron for growth and development after age 5 months.
Supplementation is necessary at this time. Iron supplementation or the introduction of solid
foods in a breastfed baby is not indicated. Introducing iron-fortified infant cereal at 2 months
should be done only if the mother is choosing to discontinue breastfeeding.

Question 61

What term is used to identify the condition in which the normal adult hemoglobin is partly or
completely replaced by abnormal hemoglobin?
a. Aplastic anemia
b. Sickle cell anemia
c. Thalassemia major
d. Iron deficiency anemia

Answer 61

ANS: B
Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in
which normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a
lack of cellular elements being produced. Hemophilia refers to a group of bleeding disorders
in which there is deficiency of one of the factors necessary for coagulation. Iron deficiency
anemia affects size and depth of color of hemoglobin and does not involve abnormal
hemoglobin.

Question 62

Which statement most accurately describes the pathologic changes of sickle cell anemia?

a. Sickle-shaped cells carry excess oxygen
b. Sickle-shaped cells decrease blood viscosity
c. Increased red blood cell destruction occurs
d. Decreased red blood cell destruction occurs

Answer 62

ANS: C
The clinical features of sickle cell anemia are primarily the result of increased red blood cell
destruction and obstruction caused by the sickle-shaped red blood cells. Sickled red cells have
decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low
oxygen tension. When the sickle cells change shape, they increase the viscosity in the area
where they are involved in the microcirculation.

Question 63

Which clinical manifestation should the nurse expect when a child diagnosed with sickle cell
anemia experiences an acute vaso-occlusive crisis?
a. Circulatory collapse
b. Cardiomegaly, systolic murmurs
c. Hepatomegaly, intrahepatic cholestasis
d. Painful swelling of hands and feet, painful joints

Answer 63

ANS: D
A vaso-occlusive crisis is characterized by severe pain in the area of involvement. If in the
extremities, painful swelling of the hands and feet is seen; if in the abdomen, severe pain
resembles that of acute surgical abdomen; and if in the head, stroke and visual disturbances
occur. Circulatory collapse results from sequestration crises. Cardiomegaly, systolic murmurs,
hepatomegaly, and intrahepatic cholestasis result from chronic vaso-occlusive phenomena

Question 64

The parents of a child hospitalized with sickle cell anemia tell the nurse that they are
concerned about narcotic analgesics causing addiction. The nurse should provide what
explanation in response to the parent’s concern?
a. Narcotics are often ordered but not usually needed.
b. Narcotics rarely cause addiction when they are medically indicated.
c. Narcotics are given as a last resort because of the threat of addiction.
d. Narcotics are used only if other measures such as ice packs are ineffective.

Answer 64

ANS: B
The pain of sickle cell anemia is best treated by a multidisciplinary approach.
Mild-to-moderate pain can be controlled by ibuprofen and acetaminophen. When narcotics are
indicated, they are titrated to effect and given around the clock. Patient-controlled analgesia
reinforces the patient’s role and responsibility in managing the pain and provides flexibility in
dealing with pain. Few if any patients who receive opioids for severe pain become
behaviorally addicted to the drug. Narcotics are often used because of the severe nature of the
pain of vaso-occlusive crisis. Ice is contraindicated because of its vasoconstrictive effects.

Question 65

Which statement correctly describes -thalassemia major (Cooley’s anemia)?

a. All formed elements of the blood are depressed.
b. Inadequate numbers of red blood cells are present.
c. Increased incidence occurs in families of Mediterranean extraction.
d. Increased incidence occurs in persons of West African descent.

Answer 65

ANS: C
Individuals who live near the Mediterranean Sea and their descendants have the highest
incidence of thalassemia. An overproduction of red cells occurs. Although numerous, the red
cells are relatively unstable. Sickle cell disease is common in blacks of West African descent

Question 66

Chelation therapy is begun on a child with -thalassemia major with what expected result?

a. Treatment of the disease.
b. Elimination of excess iron.
c. Decreasing the risk of hypoxia.
d. Managing nausea and vomiting.

Answer 66

ANS: B
A complication of the frequent blood transfusions in thalassemia is iron overload. Chelation
therapy with deferoxamine (an iron-chelating agent) is given with oral supplements of vitamin
C to increase iron excretion. Chelation therapy treats the side effects of disease management.
Decreasing the risk of hypoxia and managing nausea and vomiting are not the purposes of
chelation therapy.

Question 67

In which condition are all the formed elements of the blood simultaneously depressed?

a. Aplastic anemia
b. Sickle cell anemia
c. Thalassemia major
d. Iron deficiency anemia

Answer 67

ANS: A
Aplastic anemia refers to a bone marrow-failure condition in which the formed elements of
the blood are simultaneously depressed. Sickle cell anemia is a hemoglobinopathy in which
normal adult hemoglobin is partly or completely replaced by abnormal sickle hemoglobin.
Thalassemia major is a group of blood disorders characterized by deficiency in the production
rate of specific hemoglobin globin chains. Iron deficiency anemia results in a decreased
amount of circulating red cells.

Question 68

As related to inherited disorders, which statement is descriptive of most cases of hemophilia?
a. Autosomal dominant disorder causing deficiency in a factor involved in the
blood-clotting reaction
b. X-linked recessive inherited disorder causing deficiency of platelets and prolonged
bleeding
c. X-linked recessive inherited disorder in which a blood-clotting factor is deficient
d. Y-linked recessive inherited disorder in which the red blood cells become moon shaped

Answer 68

ANS: C
The inheritance pattern in 80% of all of 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 cells or the Y
chromosome

Question 69

What name is given to identify an acquired hemorrhagic disorder that is characterized by
excessive destruction of platelets?
a. Aplastic anemia
b. Thalassemia major
c. Disseminated intravascular coagulation
d. Immune thrombocytopenia

Answer 69

ANS: D
Immune thrombocytopenia is an acquired hemorrhagic disorder characterized by an excessive
destruction of platelets, discolorations caused by petechiae beneath the skin, and a normal
bone marrow. Aplastic anemia refers to a bone marrow failure condition in which the formed
elements of the blood are simultaneously depressed. Thalassemia major is a group of blood
disorders characterized by deficiency in the production rate of specific hemoglobin globin
chains. Disseminated intravascular coagulation is characterized by diffuse fibrin deposition in
the microvasculature, consumption of coagulation factors, and endogenous generation of
thrombin and plasma.

Question 70

Which condition is caused by a virus that primarily infects a specific subset of T lymphocytes,
the CD4+ T-cells?
a. Wiskott-Aldrich syndrome
b. Idiopathic thrombocytopenic purpura (ITP)
c. Acquired immunodeficiency syndrome (AIDS)
d. Severe combined immunodeficiency disease

Answer 70

ANS: C
AIDS is caused by the human immunodeficiency virus, which primarily attacks the CD4+
T-cells. Wiskott-Aldrich syndrome, ITP, and severe combined immunodeficiency disease are
not viral illnesses.

Question 71

A young child with human immunodeficiency virus is receiving several antiretroviral drugs.
What is the expected outcome of these drug therapies?
a. Cure the disease
b. Delay disease progression
c. Prevent spread of disease
d. Treat Pneumocystis jiroveci pneumonia

Answer 71

ANS: B
Although not a cure, these antiviral drugs can suppress viral replication, preventing further
deterioration of the immune system, and delay disease progression. At this time cure is not
possible. These drugs do not prevent the spread of the disease. Pneumocystis jiroveci
prophylaxis is accomplished with antibiotics.

Question 72

Which immunization should be given with caution to children infected with human
immunodeficiency virus?
a. Influenza
b. Varicella
c. Pneumococcus
d. Inactivated poliovirus

Answer 72

ANS: B
The children should be carefully evaluated before giving live viral vaccines such as varicella,
measles, mumps, and rubella. The child must be immunocompetent and not have contact with
other severely immunocompromised individuals. Influenza, pneumococcus, and inactivated
poliovirus are not live vaccines.

Question 73

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 associated adverse reaction?
a. Air embolism
b. Allergic reaction
c. Hemolytic reaction
d. Circulatory overload

Answer 73

ANS: D
The signs of circulatory overload include distended neck veins, hypertension, crackles, dry
cough, cyanosis, and precordial pain. Signs of air embolism are sudden difficulty breathing,
sharp pain in the chest, and apprehension. Allergic reactions are manifested by urticaria,
pruritus, flushing, asthmatic wheezing, and laryngeal edema. 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

Question 74

The parents of a child diagnosed with aplastic anemia tell the nurse that a bone marrow
transplant (BMT) may be necessary. What should the nurse recognize as important when
discussing this with the family?
a. BMT should be done at time of diagnosis.
b. Parents and siblings of child have a 25% chance of being a suitable donor.
c. Finding a suitable donor involves matching antigens from the human leukocyte antigen (HLA) system.
d. If BMT fails, chemotherapy or radiotherapy must be continued

Answer 74

ANS: C
The most successful BMTs come from suitable HLA-matched donors. The timing of a BMT
depends on the disease process involved. It usually follows intensive high-dose chemotherapy
and/or radiation therapy. Usually parents only share approximately 50% of the genetic
material with their children. A one-in-four chance exists that two siblings will have two
identical haplotypes and will be identically matched at the HLA loci. Discussing the
continuation of chemotherapy or radiotherapy is not appropriate when planning the BMT.
That decision will be made later.

Question 75

What is the priority nursing intervention for a child hospitalized with hemarthrosis resulting
from hemophilia?
a. Immobilization and elevation of the affected joint
b. Administration of acetaminophen for pain relief
c. Assessment of the child’s response to hospitalization
d. Assessment of the impact of hospitalization on the family system

Answer 75

ANS: A
Immobilization and elevation of the joint will prevent further injury until bleeding is resolved.
Although acetaminophen may help with pain associated with the treatment of hemarthrosis, it
is not the priority nursing intervention. Assessment of a child’s response to hospitalization is
relevant to all hospitalized children; however, in this situation, psychosocial concerns are
secondary to physiologic concerns. A priority nursing concern for this child is the
management of hemarthrosis. Assessing the impact of hospitalization on the family system is
relevant to all hospitalized children; however, it is not the priority in this situation.

Question 76

What is the most common mode of transmission of human immunodeficiency virus (HIV) in
the pediatric population?
a. Perinatal transmission
b. Sexual abuse
c. Blood transfusions
d. Poor hand washing

Answer 76

ANS: A
Infected women can transmit the virus to their infants across the placenta during pregnancy, at
delivery, and through breastfeeding. Cases of HIV infection from sexual abuse have been
reported; however, perinatal transmission accounts for most pediatric HIV infections. In the
past some children became infected with HIV through blood transfusions; however, improved
laboratory screening has significantly reduced the probability of contracting HIV from blood
products. Poor hand washing is not an etiology of HIV infection.

Question 77

The nurse is planning activity for a 4-year-old child with anemia. Which activity should the
nurse plan for this child?
a. Game of “hide and seek” in the children’s outdoor play area
b. Participation in dance activities in the playroom
c. Puppet play in the child’s room
d. A walk down to the hospital lobby

Answer 77

ANS: C
Because the basic pathologic process in anemia is a decrease in oxygen-carrying capacity, an
important nursing responsibility is to assess the child’s energy level and minimize excess
demands. The child’s level of tolerance for activities of daily living and play is assessed, and
adjustments are made to allow as much self-care as possible without undue exertion. Puppet
play in the child’s room would not be overly tiring. Hide and seek, dancing, and walking to
the lobby would not conserve the anemic child’s energy.

Question 78

A school-age child is admitted in vaso-occlusive sickle cell crisis. The child’s care should
include which intervention? (Select all that apply.)
a. Correction of acidosis
b. Adequate hydration
c. Pain management
d. Administration of heparin
e. Replacement of factor VIII

Answer 78

ANS: B, C
The management of crises includes adequate hydration, minimizing energy expenditures, pain
management, electrolyte replacement, and blood component therapy if indicated. The acidosis
will be corrected as the crisis is treated. Heparin and factor VIII are not indicated in the
treatment of vaso-occlusive sickle cell crisis.

Question 79

The nurse is caring for a child with aplastic anemia. Which nursing diagnoses are appropriate?
(Select all that apply.)
a. Acute Pain related to vaso-occlusion
b. Risk for Infection related to inadequate secondary defenses or immunosuppression
c. Ineffective Protection related to thrombocytopenia
d. Ineffective Tissue Perfusion related to anemia
e. Ineffective Protection related to abnormal clotting

Answer 79

ANS:B,C,D
These are appropriate nursing diagnosis for the nurse planning care for a child with aplastic
anemia. Aplastic anemia is a condition in which the bone marrow ceases production of the
cells it normally manufactures, resulting in pancytopenia. The child will have varying degrees
of the disease depending on how low the values are for absolute neutrophil count (affecting
the body’s response to infection), platelet count (putting the child at risk for bleeding), and
absolute reticulocyte count (causing the child to have anemia). Acute Pain related to
vaso-occlusion is an appropriate nursing diagnosis for sickle cell anemia for the child in
vaso-occlusive crisis, but it is not applicable to a child with aplastic anemia. Ineffective
Protection related to abnormal clotting is an appropriate diagnosis for a child with hemophilia.

Question 80

The nurse is planning care for a school-age child admitted to the hospital with hemophilia.
Which interventions should the nurse plan to implement for this child? (Select all that apply.)
a. Fingersticks for blood work instead of venipunctures
b. Avoidance of intramuscular (IM) injections
c. Acetaminophen for mild pain control
d. Soft toothbrush for dental hygiene
e. Administration of packed red blood cells

Answer 80

ANS: B, C, D
Nurses should take special precautions when caring for a child with hemophilia to prevent the
use of procedures that may cause bleeding, such as IM injections. The subcutaneous route is
substituted for IM injections whenever possible. Venipunctures for blood samples are usually
preferred for these children. There is usually less bleeding after the venipuncture than after
finger or heel punctures. Neither aspirin nor any aspirin-containing compound should be used.
Acetaminophen is a suitable aspirin substitute, especially for controlling mild pain. A soft
toothbrush is recommended for dental hygiene to prevent bleeding from the gums. Packed red
blood cells are not administered. The primary therapy for hemophilia is replacement of the
missing clotting factor. The products available are factor VIII concentrates.

Question 81

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

Answer 81

ANS:B,D,E
Because almost all persons with hemophilia are boys, the physical limitations in regard to
active sports may be a difficult adjustment, and activity restrictions must be tempered with
sensitivity to the child’s emotional and physical needs. Use of protective equipment, such as
padding and helmets, is particularly important, and noncontact sports, especially swimming,
walking, jogging, tennis, golf, fishing, and bowling, are encouraged. Contact sports such as
soccer and basketball are not recommended.

Question 82

Which should the nurse teach about prevention of sickle cell crises to parents of a preschool
child with sickle cell disease? (Select all that apply.)
a. Limit fluids at bedtime.
b. Notify the health care provider if a fever of 38.5° C (101.3° F) or greater occurs.
c. Give penicillin as prescribed.
d. Use ice packs to decrease the discomfort of vaso-occlusive pain in the legs.
e. Notify the health care provider if your child begins to develop symptoms of cold.

Answer 82

ANS: B, C, E
The most important issues to teach the family of a child with sickle cell anemia are to (1) seek
early intervention for problems, such as a fever of 38.5° C (101.3° F) or greater; (2) give
penicillin as ordered; (3) recognize signs and symptoms of splenic sequestration, as well as
respiratory problems that can lead to hypoxia; and (4) treat the child normally. The nurse
emphasizes the importance of adequate hydration to prevent sickling and to delay the
adhesion-stasis-thrombosis-ischemia cycle. It is not sufficient to advise parents to “force
fluids” or “encourage drinking.” They need specific instructions on how many daily glasses or
bottles of fluid are required. Many foods are also a source of fluid, particularly soups, flavored
ice pops, ice cream, sherbet, gelatin, and puddings. Increased fluids combined with impaired
kidney function result in the problem of enuresis. Parents who are unaware of this fact
frequently use the usual measures to discourage bed-wetting, such as limiting fluids at night.
Enuresis is treated as a complication of the disease, such as joint pain or some other symptom,
to alleviate parental pressure on the child. Ice should not be used during a vaso-occlusive pain
crisis because it vasoconstricts and impairs circulation even more.