VN 34 Test 13

Question 1

1. Autism Spectrum disorder (ASD) manifestations (ch.42 pp slide 4)

Answer 1

 Impaired verbal & nonverbal communication
 Repetitive/ritual behaviors
 Self-injurious behaviors possible
 Disrupted routine may cause distress
 Slow to develop speech, Echolalia (“parrot speech”)
No eye contact

Question 2

2. Iron-deficiency anemia manifestations (pg.779)

Answer 2

 May crave ice chips
 Below average body weight
 Pallor
 Anorexia
 Delayed growth
 Fatigue, lethargy & irritability

Question 3

3. Bulimia Manifestations

Answer 3

 Dental caries
 Erosion from frequent exposure to stomach acid
 Foul smelling breath
 Throat irritation
 Endocrine & Electrolyte imbalances
 Calluses or abrasions on back of hand

Question 4

3. Bulimia Treatment & priority/goal

Answer 4

 Food diaries (to evaluate eating patterns)
 Daily weights after voiding
 Provide privileges when client meets their goal
 SSRI’s antidepressants
 Support groups
 Stay w/client an hr after eating
 Serious cardiac involvement major concern often leads to hospitalization.

 PRIORITY/GOAL: monitor for electrolyte imbalance & getting them medically stable

Question 5

4. Suicide warnings

Answer 5

 Rapid swing in appropriateness of expressed emotions, sudden lift in mood

Question 6

5. Signs of abuse: children, elderly

Answer 6

 Suspect areas of abuse:
-buttocks, genitalia
-thighs, back of knees,
-upper back, inner aspect of arms
-nose, eyes
-distinctive in outline, identifiable marks
-various stages of healing

Question 7

6. Nursing actions for burns in children (pp slide 18)

Answer 7

 Priority: airway
 Preventing infection (surgical asepsis)
 Reducing pain (meds 30 mins prior to treatment)
 Relieving anxiety
 Increasing mobility
 Maintaining adequate nutrition (protein for healing)
 Administer tetanus if indicated

Question 8

7. Pediculosis capitis (lice) manifestations (pp slide 10)

Answer 8

 Nits firmly attached to hair
 Severe itching

Question 9

8. Client education for nystatin

Answer 9

 Swab baby’s mouth, older child can swish, limit feeding for 30 mins after)

Question 10

9. Impetigo manifestations (pp slide 6)

Answer 10

 Red macules w/honey-colored crusts
 Very contagious
 Meticulous hand hygiene
 Keep nails short & limit scratching

Question 11

10. ADHD manifestations and client education

Answer 11

 Hyperactive “restless”
 Attention “reduced ability to focus”
 Impulsiveness “excessive talking”
 Low self-esteem & impaired social skills

Client Education:
 Watch out for appetite & weight
 Loss of sleep, restlessness, give last dose no later than 6pm

Question 12

11. Nursing actions for STIs and the adolescent(pg.891)

Answer 12

 Educate about prevention: abstinence, condoms w/spermicide, and all aspects of the consequences of sexual activity
 Educate about protection but clarify that they are not fail- safe.

Question 13

12. Thrush manifestations, causes, Treatment (pp slide 9)

Answer 13

Manifestations:
 Mouth has white coating that looks like milk curds (candidiasis)

          Causes: 	Often after TX w/antibiotics

      Treatment: 	Nystatin (swab baby’s mouth, older child can swish, limit feeding for 30 mins after)

Question 14

13. Depression nursing actions and manifestations (ch.42 pp slide 27)

Answer 14

 Key sx: overwhelming feeling of being low, down, gloomy or sad most of the time
 Infants & toddlers: withdrawal, poor attachment, delayed development, clingy behavior, low energy, lack of enjoyment in play activities
 Younger children: anger, irritability, changes in appetite & sleep patterns, physical complaints, inattention, difficulty concentrating
 School-aged: grouchy, annoyed, shows lack of interest in school & participating in activities w/friends (school counselor to facilitate meeting w/ped depression)
 Adolescent: Isolation & all of the above

Nursing action (ch.42 pp slide 35:
 Often put on a one-to-one status w/constant observation
 Removal of anything that could be used harm to themselves

Question 15

14. Nursing actions for tinea cruris “ringworm” (pg.877)

Answer 15

 Treated w/antifungals
 Sitz bath may be soothing
 Cotton underwear is recommended

Question 16

15. Miliaria rubra “prickley heat” manifestations (pp slide 4)

Answer 16

 Pinhead-seized erythematous papules (Where sweat glands are concentrated: folds of skin, axilla, around the neck)
 Itching
 Uncomfortable & fretful child

Question 17

16. Seborrheic dermatitis (in infants) manifestations & client education (pp slide 3)

Answer 17

Manifestations:
 Yellowish greasy, scaly, or crusted patches on scalp

Client education/Interventions:
 Cleanse hair & scalp w/baby shampoo
 Apply baby oil for 10mins & rinse flakes away

Question 18

17. Acne vulgaris nursing actions, and treatment (pp slide 7)

Answer 18

 Pregnancy test before client takes Isotretinoin (Accutane)

Question 19

18. Mononucleosis nursing interventions and client education (pp slide 20)

Answer 19

Manifestations:
 Fever
 Enlarged spleen
 Extreme fatigue
 Sore throat
 Swollen lymph nodes
 Sx can very from mild-severe

Client education/nursing care:
 Prevent secondary infections w/rest

Question 20

19. Tick removal client education (pp slide 15)

Answer 20

 Prevent by wearing long pants, long sleeved shirts, using insect repellent when walking in the woods
 Remove w/tweezer (keep intact, don’t crush)

Question 21

20. Eczema (atopic dermatitis) client education/nursing actions (pp slide 14)

Answer 21

 Administer medication
 Cool compresses
 Avoid Allergens

Question 22

21. Anorexia manifestations

Answer 22

 Appear sexually immature
 Amenorrhea
 Malnutrition
 Intolerance to cold
 Constipation
 Anemia
 Bradycardia, Arrythmias
 Low BP
 Electrolyte Imbalance, Dehydration
 Visibly emancipated, almost skeleton like appearance
 Dry skin, brittle nails

Question 23

22. Bullying NTK

Answer 23

 Changes in mood
 Anxiety
 Avoiding certain situations
 Stomachaches, headaches
 Child may try to avoid doing certain things such as taking the school bus or playing on the school playground because that is where the bullying is occurring
 A child who is being bullied may have injuries & bruises but symptoms are often difficult to differentiate from other concerns
 Decreasing school performance
 Eating & sleeping issues