Child Health Nursing, 3E Jane W. Ball Test Bank.pdf (22)

A child is admitted to the hospital with a diagnosis of “rule out” urinary tract infection. A clean-catch urine specimen is submitted to the lab. When the results return, the nurse evaluates the findings. Which finding woul the nurse question?

1. 2+ White blood cells 2. 1+ red blood cells 3. Urine appearance: cloudy 4. Specific gravity: 1009 Correct Answer: 4 Rationale 1: White blood cells are expected.

Rationale 2: Red blood cells are common in the urine of a child with a urinary tract infection.

Rationale 3: With white blood cells in the urine, this is a common finding.

Rationale 4: This is a very dilute urine. With WBCs, RBCs, and bacteria in the urine, you would expect the urine to contain more solutes.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-2

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Ball, Child Health Nursing, 3/E Chapter 32 Question 1 Type: MCSA

The home health nurse is visiting a three-month-old who has been diagnosed with congenital hypothyroidism a is taking daily thyroxine. The baby is on soy formula and is at the 50th percentile for height and weight. It is important that the mother understands that: 1. Parents may stop the thyroxine as long as the baby remains in the 50th percentile for height and weight.

2. Soy-based formula can interfere with the absorption of thyroxine.

3. Dairy-based formula is contraindicated when an infant is taking thyroxine.

4. As long as the baby is growing along the same growth curve, no interventions are necessary.

Correct Answer: 2 Rationale 1: To ensure adequate growth and development, the hormone must be taken throughout life.

Rationale 2: Soy-based formula can interfere with the absorption of thyroxine.

Rationale 3: Dairy-based formula does not interfere with thyroxine.

Rationale 4: Frequent checks must be done to assess the baby for inadequate growth.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-2

Question 2 Type: MCMA The nurse is providing information to a teenager newly diagnosed with diabetes and his parents. The nurse teac them that the signs of diabetic ketoacidosis (DKA) include:

Standard Text: Select all that apply.

1. Change in mental status.

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2. Tachycardia.

3. Fruity breath odor.

4. Rapid, shallow respirations.

5. Abdominal pain.

Correct Answer: 1,3,5 Rationale 1: A change in mental state can be associated with DKA. Rationale 2: Tachycardia is not a typical symptom of DKA. Rationale 3: A fruity breath odor is common when the client is in a state of ketoacidosis.

Rationale 4: Respirations are rapid, but deep (Kussmaul's breathing) in DKA. Rationale 5: Abdominal pain is commonly seen with DKA. Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-3 Question 3 Type: MCSA A child weighing 18.2 kg with a history of diabetes insipidus has been admitted to the hospital. Which of the physician's orders would the nurse question?

1. Stat electrolytes 2. Urine specific gravity with each void 3. DDAVP (desmopressin) PO 4. Restrict oral fluids to 500 mL every 24 hours.

Correct Answer: 4 Rationale 1: Stat electrolytes would be an appropriate order to check for hypernatremia.

Rationale 2: Urine specific gravity is checked because it is often low.

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Rationale 3: DDAVP is the drug of choice for a child with DI. Rationale 4: Fluid replacement, not fluid restriction, is necessary for child with DI. Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-3

Question 4 Type: MCSA A five-year-old with a history of being treated for hypopituitarism comes to the physician with complaints of rig hip and leg pain. The nurse understands that this symptom might be related to which medication that is used to treat hypopituitarism?

1. Daily growth hormone 2. Insulin before meals and bedtime 3. DDAVP (desmopressin acetate) at HS 4. Cortisone injections Correct Answer: 1

Rationale 1: Growth hormone injections and hypopituitarism have been associated with slipped capital femoral epiphysis, which manifests with complaints of hip or knee pain.

Rationale 2: Insulin is not used to treat hypopituitarism.

Rationale 3: DDAVP reduces urinary output. It does not cause slipped capital femoral epiphysis.

Rationale 4: Cortisone is not used for hypopituitarism.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-4

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 5 Type: MCSA

An adolescent female with untreated Graves' disease is admitted to the hospital. The nurse expects to find whic signs and symptoms in this client?

1. Hyperglycemia, ketonuria, and glucosuria 2. Weight gain, hirsutism, and muscle weakness 3. Tachycardia, fatigue, and heat intolerance 4. Dehydration, metabolic acidosis, and hypertension Correct Answer: 3 Rationale 1: Hyperglycemia, ketonuria, and glucosuria are signs of diabetes.

Rationale 2: Weight gain, hirsutism, and muscle weakness are seen in clients with Cushing's disease.

Rationale 3: Clinical manifestations of Graves' disease are tachycardia, fatigue, and heat intolerance, seen with hyperthyroidism.

Rationale 4: Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-5 Question 6 Type: MCSA A hospitalized child has been diagnosed with SIADH (syndrome of inappropriate antidiuretic hormone), a complication of his meningitis. What would the nurse expect to see on this child’s lab results?

1. Hyponatremia 2. Hypocalcemia 3. Hyperglycemia 4. Hypernatremia Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1

Rationale 1: SIADH is associated with increased permeability in distal renal tubes, leading to water intoxication and low sodium.

Rationale 2: Hypocalcemia is not seen with SIADH. Rationale 3: Hyperglycemia is not related to SIADH. Rationale 4: Hypernatremia is seen with DI, not SIADH. Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-5

Question 7 Type: MCSA The nurse is giving discharge instructions to the parents of a child whose adrenal glands have been removed du to a tumor. The nurse knows that the mother needs more instructions when the mother states:

1. "I will call the doctor if my child has restlessness and confusion."

2. "If my child has any gastric irritation, I will give him antacids."

3. "If my child has vomiting and diarrhea, I will hold his hydrocortisone."

4. "I will give my child his hydrocortisone in the morning."

Correct Answer: 3 Rationale 1: Restlessness and confusion can be signs of adrenal insufficiency, and the physician would need to know these symptoms. No further instruction is needed.

Rationale 2: Hydrocortisone can cause gastric irritation, and antacids are given between meals. No further instruction is needed.

Rationale 3: If the child is ill and can't take hydrocortisone by mouth, the child would need to have an injection.

Failure to give hydrocortisone could lead to severe illness and cardiovascular collapse. The mother needs additional instruction.

Rationale 4: The child should have hydrocortisone in the morning, which mimics the normal diurnal pattern of cortisol secretion. No further instruction is needed.

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Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 32-6 Question 8 Type: MCSA The nurse is caring for a child just admitted with diabetic ketoacidosis (DKA). Which of the physician’s orders should the nurse question?

1. Neurological checks hourly 2. Insert urinary catheter and measure output hourly.

3. NPH insulin IV at 0.1 units/kg per hour 4. Stat serum electrolytes Correct Answer: 3 Rationale 1: Hourly neuro checks are an appropriate order.

Rationale 2: Urinary catheter and hourly outputs are appropriate.

Rationale 3: NPH insulin is never administered IV. A short-acting insulin needs to be ordered.

Rationale 4: Stat electrolytes are an appropriate order.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32-8 Question 9 Type: MCSA

A teenager has arrived in the emergency department (ED) with confusion. The physician suspects diabetic ketoacidosis (DKA). A stat serum glucose is done, and the result is 76l5 mg/dL. The nurse expects that this teen has which symptoms?

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1. Tachycardia, dehydration, and abdominal pain 2. Sweating, photophobia, and tremors 3. Dry mucous membranes, blurred vision, and weakness 4. Dry skin, shallow rapid breathing, and dehydration Correct Answer: 3 Rationale 1: Tachycardia is seen in hypoglycemia.

Rationale 2: Sweating, photophobia, and tremors are indicative of hypoglycemia.

Rationale 3: Dry mucous membranes, blurred vision, and weakness are seen with hyperglycemia.

Rationale 4: Dry skin and dehydration are signs of hyperglycemia, but shallow breathing is a sign of hypoglycemia.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-7 Question 10 Type: MCSA A 12-year-old has been selected to be a cheerleader for her middle school. This child has been recently diagno with type 1 diabetes. In teaching this child's mother about care for her child, the nurse wants the mother to understand that with increased physical activity, the child will need:

1. Decreased food intake.

2. Increased doses of insulin.

3. Increased food intake.

4. Decreased doses of insulin.

Correct Answer: 3 Rationale 1: Decreased food intake would increase the chance of hypoglycemia.

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Rationale 2: Increased dose of insulin would cause hypoglycemia. Exercise causes insulin to be used more efficiently by the body, so an increase in insulin would not be needed.

Rationale 3: An increase in physical activity requires an increase in caloric intake to prevent hypoglycemia.

Rationale 4: A decreased dose of insulin would not allow the sugar to enter the cells where it is needed during exercise.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-8

Question 11 Type: MCSA The nurse is teaching a teenage client newly diagnosed with type 1diabetes about complications of the disease The nurse explains that clients with type 1 diabetes can avoid lipoatrophy by: 1. Rotating injection sites.

2. Checking blood sugars at mealtime and bedtime.

3. Using a sliding scale for additional coverage.

4. Administration of insulin via insulin pump.

Correct Answer: 1 Rationale 1: Lipoatrophy is caused by using the same insulin injection site.

Rationale 2: Checking blood sugars does not influence lipoatrophy.

Rationale 3: A sliding scale does not influence lipoatrophy.

Rationale 4: Insulin administration via pump doesn't influence lipoatrophy.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 32-8 Question 12 Type: MCMA The nurse is teaching the caregiver of a child who is newly diagnosed with type 1 diabetes mellitus how to minimize pain with insulin injections. Which interventions to minimize pain will the nurse include in the teaching?

Standard Text: Select all that apply.

1. Do not reuse needles.

2. Remove all bubbles from the syringe before injecting.

3. Have the child flex the muscle during injection.

4. Inject insulin when it is cold.

5. Do not change the direction of the needle during insertion or withdrawal.

Correct Answer: 1,2,5 Rationale 1: Reusing needles leads to more pain on injection.

Rationale 2: Removing bubbles from the syringe minimizes pain.

Rationale 3: Flexing or tensing muscles during injection causes more discomfort.

Rationale 4: Insulin should be injected when it is at room temperature to minimize pain.

Rationale 5: Keeping the direction of the syringe constant will minimize pain.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts:Nursing Process: Implementation Learning Outcome: 32-8 Question 13 Type: MCSA

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The nurse is caring for a hospitalized three-year-old admitted with a history of syndrome of inappropriate antidiuretic hormone (SIADH). He has just received his breakfast tray. Which food should the nurse remove from his tray?

1. Oatmeal 2. Yogurt 3. Biscuit 4. Cantaloupe Correct Answer: 4 Rationale 1: A child with SAIDH may have carbohydrates and fiber, such as in oatmeal.

Rationale 2: A child with SIADH may have dairy products, such as yogurt. Rationale 3: A child with SIADH may have carbohydrates, such as in a biscuit. Rationale 4: A child with SIADH is on a fluid restriction.

Cantaloupe contains significant fluid volume, so it would not be a good food for this child to consume.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-3 Question 14 Type: MCSA Mandatory testing in the newborn nursery determines that the infant has hypothyroidism. When discussing the treatment with the new mother, the mother states that she doesn’t believe in taking medications. The nurse would explain that failure to treat the infant with the appropriate medication will result in: 1. Heart disease.

2. Mental retardation.

3. Renal failure.

4. Thyroid storm.

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Correct Answer: 2 Rationale 1: If the hypothyroidism is left untreated, the child will experience bradycardia but will not develop heart disease.

Rationale 2: Untreated hypothyroidism will lead to mental retardation.

Rationale 3: Untreated hypothyroidism does not lead to renal failure.

Rationale 4: Thyroid storm is a complication of hyperthyroidism, not hypothyroidism.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-2 Question 15

Type: MCMA The school nurse has noticed an increase in the number of children in the school being diagnosed with type 2 diabetes. Which changes could the nurse implement at school to help reduce students’ risk for developing type diabetes?

Standard Text: Select all that apply.

1. Increase the amount of daily physical activity.

2. Meet with all parents and explain the risk that is associated with obesity.

3. Test each child’s urine monthly.

4. Teach the parents to avoid administering aspirin to their children.

5. Work with the cafeteria to decrease the amount of fat in the foods served.

Correct Answer: 1,2,5 Rationale 1: Increased physical activity will decrease a child’s risk of developing type 2 diabetes.

Rationale 2: Obese children have an increased risk of type 2 diabetes. Working with the parents, the nurse can reduce the obesity in the school.

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Rationale 3: Testing urine will not decrease the risk of developing type 2 diabetes, although it may lead to earlie diagnosis of the disease.

Rationale 4: Aspirin administration is not related to type 2 diabetes.

Rationale 5: A diet high in fat is associated with type 2 diabetes.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32-8

Question 16 Type: MCSA The child was diagnosed with phenylketonuria shortly after birth and has been treated by the endocrine clinic fo the last four years. The mother has missed the last three appointments. When the child keeps the next appoint the mother assures the nurse that the child has followed the dietary restrictions. Which finding would make the nurse question this statement?

1. The child’s body has a musty odor.

2. This child is a blue-eyed blond.

3. The child appears sleepy and uninterested in the surroundings.

4. The child has a sunburn over his entire body.

Correct Answer: 1 Rationale 1: The odor is caused by the excretion of phenylketone by-products through the skin and would indicate noncompliance with the dietary restrictions.

Rationale 2: While this is a characteristic of most children with PKU, it is not related to dietary intake or restrictions.

Rationale 3: This is not a symptom of untreated phenylketonuria.

Rationale 4: Photophobia is not associated with PKU. The child with untreated PKU has an eczema rash.

Global Rationale: Cognitive Level: Analyzing Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts:Nursing Process: Assessment Learning Outcome: 32-3 Question 17 Type: MCSA

Based on physical findings, including a webbed neck and low hairline, the newborn female infant is suspected o having Turner’s syndrome. The baby is in the newborn nursery while preparations are made for further evaluati including karyotyping. The nurse will want to monitor this baby for common associated conditions including: 1. Club foot (talipes equinovarus).

2. Congenital heart anomalies.

3. Hyperbilirubinemia due to liver abnormalities.

4. Diaphragmatic hernia.

Correct Answer: 2 Rationale 1: Club foot is not associated with Turner’s syndrome.

Rationale 2: Congenital heart anomalies, including coarctation of the aorta, frequently are associated with Turner’s syndrome.

Rationale 3: The girl with Turner’s syndrome has the normal risk for hyperbilirubinemia. It is not associated with Turner’s syndrome.

Rationale 4: Diaphragmatic hernias are not associated with Turner’s syndrome.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-3 Question 18

Type: MCSA A three-year-old child was born with congenital adrenal insufficiency and is being treated with oral hydrocortisone. When the child develops pneumonia and is admitted to the hospital, the nurse would expect th dose of hydrocortisone to be: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

1. Stopped.

2. Reduced by 50%.

3. Continued as previously prescribed.

4. Increased.

Correct Answer: 4

Rationale 1: Hydrocortisone is the glucocorticoid that helps the body deal with stress. It would be inappropriate to stop the medication.

Rationale 2: The drug dosage would not be decreased.

Rationale 3: During periods of stress, the child will need additional corticosteroids.

Rationale 4: During periods of stress including illness and surgery, the dose of steroids needs to be increased.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-6

Question 19 Type: MCSA During the hospital stay in the newborn nursery, the infant is tested for galactosemia. When the test is positive, parents are educated about treatment for galactosemia. The infant will be placed on what type of infant feeding

1. Goat’s milk formula 2. Breast milk 3. Cow’s milk-based formula 4. Meat-based formula such as Nutramigen Correct Answer: 4 Rationale 1: Goat’s milk formula contains galactose and is excluded from the infant’s diet.

Rationale 2: Breast milk contains galactose and is excluded from the infant’s diet.

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Rationale 3: Cow’s milk-based formula contains galactose and is excluded from the infant’s diet.

Rationale 4: The meat-based formula does not contain galactose and is appropriate for the infant’s diet.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-9

Question 20 Type: MCSA When the newborn female is born with ambiguous genitalia, the follow-up investigation discovers adrenogenita syndrome (also called congenital adrenal hyperplasia). The parents question why the baby’s genitalia looks mo male than female. The nurse would explain that: 1. The disorder caused the infant to be a hermaphrodite with both male and female sex organs.

2. The changes in the genitalia are due to increased androgens secondary to deficient cortisol.

3. The excessive cortisol caused the enlargement of the female tissue, creating a male appearance.

4. The child has only one sex chromosome resulting in an XO configuration.

Correct Answer: 2 Rationale 1: This statement is incorrect. The child’s internal organs will be ovaries only.

Rationale 2: Deficient cortisol causes the amount of ACTH to be high, over stimulating the adrenal production o androgens which causes the pseudo-masculinization.

Rationale 3: The cortisol level is decreased, not increased.

Rationale 4: XO sex chromosomes describe Turner’s syndrome, not CAH. Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-9

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Ball, Child Health Nursing, 3/E Chapter 33 Question 1 Type: MCSA

The nurse is doing an assessment on a four-month-old infant. Which assessment finding would the nurse consi abnormal?

1. The posterior fontanel is open.

2. The infant has good head control when held upright.

3. The infant is able to roll only from abdomen to back.

4. The anterior fontanel is open and soft.

Correct Answer: 1 Rationale 1: The posterior fontanel closes between two and three months of age.

Rationale 2: Good head control is expected at four months of age.

Rationale 3: Rolling from abdomen to back is a skill the four-month-old should be learning.

Rationale 4: An open anterior fontanel, which is soft, is a normal finding at four months.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-1 Question 2

Type: MCSA The nurse has received a child from the emergency department with a diagnosis of decreased level of consciousness secondary to increased intracranial pressure. Which physician’s order would the nurse question 1. Passive range-of-motion exercises 2. Oxygen at 2L nasal cannula to keep saturation above 95% Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

3. Hourly vital signs and neuro checks 4. Elevate head of bed 30 degrees Correct Answer: 1 Rationale 1: Range-of-motion exercises would not be done. It is imperative to keep the child with increased intracranial pressure quiet, with as little stimulation as possible.

Rationale 2: Oxygen should be ordered to keep the child's O2 saturation above 95%.

Rationale 3: Hourly vital signs and neuro checks are appropriate to watch for changes in this child's condition.

Rationale 4: The head is elevated 30 degrees to help decrease increased intracranial pressure.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33-2

Question 3 Type: MCSA A four-year-old with intractable seizures has been on a ketogenic diet for the last six months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. The nurse knows that possible complications of the ketogenic diet include:

1. Appendicitis.

2. Bowel obstruction.

3. Urinary tract infection.

4. Kidney stones.

Correct Answer: 4 Rationale 1: Appendicitis does not occur as a result of the ketogenic diet.

Rationale 2: The ketogenic diet does not cause a bowel obstruction.

Rationale 3: Urinary tract infections are not a result of a ketogenic diet.

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Rationale 4: Kidney stones are seen in 5% of children on a ketogenic diet.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-3 Question 4 Type: MCSA A child with a history of seizures arrives in the emergency department in status epilepticus. What is the nurse’s initial action?

1. Take vital signs.

2. Establish an intravenous line.

3. Perform rapid neurological assessment.

4. Maintain patent airway.

Correct Answer: 4 Rationale : Taking vital signs is important, but airway always comes first.

1

: Once the airway is secure, securing an IV is vital.

Rationale : A rapid neurological assessment is appropriate once the airway is secure.

2

: Airway is always the priority of care.

Rationale Global Rationale: 3 Cognitive Level: Analyzing Client Need: Rationale Client Need Sub: Nursing/Integrated Concepts:Nursing Process: Planning 4 Learning Outcome: 33-3 Question 5 Type: MCSA

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The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child has been pu on valproic acid (Depakote) for control of seizures. The nurse knows that the mother does not understand the effects of valproic acid when she states: 1. "I will not use carbonated beverages to dilute his medication."

2. "I will give his medicine on an empty stomach so he will absorb it better."

3. "I will not let him chew his tablet."

4. "I will bring him to the physician office for regular blood work to check bleeding times."

Correct Answer: 2 Rationale 1: Carbonated beverages should never be used to dilute valproic acid.

Rationale 2: Valproic acid (Depakote) should be given with foods to decrease GI irritation.

Rationale 3: This child should not be allowed to chew a valproic acid tablet.

Rationale 4: It is appropriate to have periodic blood studies to check bleeding times and platelet count.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 33-3 Question 6 Type: MCSA

A young child admitted to the pediatric unit has fever, irritability, and vomiting. The physician suspects bacteria meningitis. The nurse would expect the cerebrospinal fluid (CSF) to show: 1. Decreased protein count.

2. Clear, straw-colored fluid.

3. Positive for RBCs. 4. Decreased glucose level.

Correct Answer: 4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Bacterial meningitis causes CSF protein levels to be elevated due to swelling and obstruction of CS flow.

Rationale : In bacterial meningitis, the fluid is often cloudy with WBCs. 2

: The nurse would expect WBCs to be elevated due to the infection. The RBCs may indicate a bloody

tap.

Rationale Rationale 4: Glucose levels are low in CSF when a child has bacterial meningitis.

3 Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-4

Question 7 Type: MCSA The nurse is planning care for a child with bacterial meningitis. What is the priority nursing diagnosis?

1. Impaired gas exchange 2. Infection, risk for 3. Anxiety (parental) 4. Acute pain Correct Answer: 1 Rationale 1: Impaired gas exchange would be the priority to ensure patent airway and adequate gas exchange.

Rationale 2: The child already has an infection.

Rationale 3: The parents will be anxious about the outcome for their child, but this is not the priority diagnosis.

Rationale 4: Pain management is important but not the priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 33-4 Question 8 Type: MCSA The nurse is caring for a nine-month-old who just returned from the PACU after a shunt placement for hydrocephalus. Which of the physician's orders would the nurse question?

1. Vital signs and neuro checks hourly 2. Small, frequent formula feedings 3. Elevate head of bed 4. Daily head circumference Correct Answer: 3 Rationale 1: Frequent vital signs and neuro checks are needed postoperatively.

Rationale 2: Small, frequent feedings are appropriate to decrease the chance of vomiting.

Rationale 3: The nine-month-old should be placed in a flat position so that CSF drainage is not too rapid.

Rationale 4: Daily head circumferences are needed to help evaluate shunt functioning.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33-5 Question 9 Type: MCSA A baby just born with a meningomyelocele is to have surgery in the morning. The nurse knows the care of this newborn includes: 1. Applying a diaper to prevent contamination of sac.

2. Positioning the newborn in a side-lying position.

3. Encouraging the mother to hold the newborn, because she will not be able to pick him up after surgery.

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4. Positioning the newborn in a prone position.

Correct Answer: 4 Rationale 1: A diaper is not used because it also puts pressure on the sac.

Rationale 2: A side-lying position would be contraindicated because it would place pressure on the sac.

Rationale 3: The mother should not hold the baby because that would put too much pressure on the sac.

Rationale 4: The newborn should be placed in a prone position to keep pressure off the sac.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-5 Question 10 Type: MCMA In caring for a hospitalized eight-year-old child with myelodysplasia, the nurse should remember to: Standard Text: Select all that apply.

1. Expect the child to have normal intelligence.

2. Use latex precautions.

3. Allow the child to do her own self-catheterization.

4. Ensure that the child has a low-fiber diet.

5. Encourage the child to shift positions hourly when in her wheelchair.

Correct Answer: 1,2,3,5

Rationale 1: Many children with myelodysplasia have normal intellect. They should be treated according to thei intellectual level rather than their motor development.

Rationale 2: Children with myelodysplasia are at great risk for latex allergy. It is important to use latex-free

products.

Rationale 3: Self-catheterization fosters independence in this child. It is important to maintain the same schedu as much as possible when this child is hospitalized.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 4: Children with myelodysplasia need a high-fiber diet to maintain adequate stool and bowel function Rationale 5: Due to decreased sensation in the buttocks and lower extremities, it is very important for the child shift positions while she is in her wheelchair to prevent pressure sores.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-5

Question 11 Type: MCSA The nurse is teaching the kindergarten teacher about a five-year-old with cerebral palsy who will be starting school. The child has a continuous baclofen pump. The nurse informs the teacher of possible side effects of this drug, including:

1. Diarrhea.

2. Hypertonia.

3. Hypotonia.

4. Restlessness.

Correct Answer: 3 Rationale 1: Continuous baclofen infusion does not cause diarrhea.

Rationale 2: Hypertonia is not seen as a side effect of baclofen infusion.

Rationale 3: Hypotonia is possible if the child is getting too much baclofen.

Rationale 4: Restlessness is not seen with baclofen; rather, these children can be drowsy and sleepy.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-6 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 12 Type: MCSA A nine-month-old who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby?

1. Hypotonia and muscle instability 2. Hypertonia and persistence primitive reflexes 3. Tremors and exaggerated posturing 4. Hemiplegia and hypertonia Correct Answer: 1 Rationale 1: Hypotonia in infancy and muscle instability are seen in ataxic cerebral palsy.

Rationale 2: Hypertonia and persistent primitive reflexes are seen in spastic CP. Rationale 3: Tremors and exaggerated posturing are seen in dyskinetic cerebral palsy.

Rationale 4: Hemiplegia and hypertonia are seen in spastic cerebral palsy.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-6 Question 13

Type: MCSA A seven-year-old with a head injury is hospitalized after losing consciousness when he was hit in the head with bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, BP 148/74, respiratory rate 28 and irregular. The nurse suspects that these vital signs are: 1. A sign that this child has a spinal cord injury.

2. A sign of increased intracranial pressure.

3. Typical for a sleeping child at this age.

4. A sign that the child’s condition is improving.

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Correct Answer: 2 Rationale 1: These vital signs are a sign of increased intracranial pressure. If it were a spinal cord injury, and neurogenic shock were suspected, the child would be hypotensive.

Rationale 2: These vital signs show increased BP, with a wide pulse pressure, slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure.

Rationale 3: Normal sleeping pulse at this age is 60-90 bpm.

Rationale 4: Without previous vital signs, there is no way to determine the changes in the vital signs.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 33-7 Question 14 Type: MCSA A child has been diagnosed with a basilar skull fracture. The nurse should monitor this child for:

1. Periorbital ecchymosis.

2. Subdural hematoma.

3. Protruding bone.

4. Epidural hematoma.

Correct Answer: 1 Rationale 1: Periorbital ecchymosis, also called raccoon eyes, is seen with a basilar fracture.

Rationale 2: Subdural hematoma might be seen with a linear fracture.

Rationale 3: Protruding bone might be seen with a compound fracture.

Rationale 4: Epidural hematoma is seen with linear fracture.

Global Rationale: Cognitive Level: Applying Client Need:

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Client Need Sub: Nursing/Integrated Concepts:Nursing Process: Assessment Learning Outcome: 33-7 Question 15 Type: MCSA

The teacher is speaking to the school nurse about one of the girls in the fifth grade. The girl has always been a good student but lately seems to be daydreaming a lot. The teacher says, “Sometimes when I ask her a questio she will just stare at me for 15 seconds, then blink and ask me to repeat the question. What do you think is goin on with her?” Based on this data, the nurse will suspect: 1. The girl has a crush on a boy in the class.

2. The girl has increased intracranial pressure.

3. The child may have had a head injury.

4. The girl is experiencing absence seizures.

Correct Answer: 4 Rationale 1: There is no data to suspect a childhood crush is creating the situation.

Rationale 2: There is no indication of increased intracranial pressure.

Rationale 3: There is no indication of a head injury.

Rationale 4: Absence seizures may cause staring and blinking; they are more common in girls in this age group and often are first noticed by the classroom teacher.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-3 Question 16 Type: MCSA

Following an outbreak of chicken pox in the school, the school nurse is concerned that children are at risk for Reye syndrome. The nurse sends home letters reminding the parents not to administer aspirin and describes th initial symptoms of Reye syndrome which are:

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1. Nausea, vomiting, and confusion.

2. Headache, vomiting, and seizures.

3. Sore throat, moist respirations, and cough.

4. Fever, rash, and photophobia.

Correct Answer: 1 Rationale 1: These are the early symptoms of Reye syndrome.

Rationale 2: These symptoms are associated with a malfunctioning shunt and not the early symptoms of Reye syndrome.

Rationale 3: These symptoms are more likely to indicate pneumonia, not Reye syndrome.

Rationale 4: These are not the early symptoms of Reye syndrome.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-2

Question 17 Type: MCMA The mother brings her five-month-old infant to the clinic for a well-child visit. The mother tells the nurse that th baby’s father had febrile seizures when he was an infant. The mother says she is concerned her baby will have a febrile seizure and wants to know what she should do to prevent it. The nurse explains:

Standard Text: Select all that apply.

1. That the baby has no more risk of febrile seizures than any other baby.

2. When the infant has a fever, the mother should give the baby dose-appropriate aspirin.

3. That the baby should be sponged with cold water.

4. The mother should increase the child’s fluid intake.

5. That after the tepid bath, the child should be patted dry.

Correct Answer: 4,5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Febrile seizures run in families and are more common in males.

Rationale 2: Aspirin should be avoided due to the risk for Reye syndrome.

Rationale 3: Cold water may cause shivering, which will increase the body temperature.

Rationale 4: Fluid intake will help heat loss.

Rationale 5: A tepid bath will bring down the temperature; patting, instead of rubbing, will help keep the child’s temperature down.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-3

Question 18 Type: MCMA The pregnant woman has had no prenatal care and arrives at the hospital fully dilated. Assessment of the newb indicates a probable gestational age of 35 weeks combined with intrauterine growth restriction. The nurse will monitor the infant for signs of neonatal abstinence syndrome, including:

Standard Text: Select all that apply.

1. Poor feeding.

2. Difficult to arouse.

3. Constipation.

4. Seizures.

5. Yawning.

Correct Answer: 1,4,5 Rationale 1: This is a symptom of neonatal abstinence syndrome.

Rationale 2: These infants are usually restless and irritable, not sleepy.

Rationale 3: The infant is more likely to have diarrhea.

Rationale 4: Seizures are common in the child with neonatal abstinence syndrome.

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Rationale 5: The infant with neonatal abstinence syndrome yawns frequently.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-2 Question 19 Type: MCSA

When the home health nurse visits the home of a 10-month-old child, she observes the environment for risks fo injury to the child. Which observation will the nurse discuss with the mother?

1. The mother leaves the filled mop bucket on the floor while in another room.

2. The mother turns all pan handles to the back of the stove.

3. The mother fills the bath tub before bringing the baby into the bathroom.

4. When riding in a car, the child is in a car seat in the middle of the back seat.

Correct Answer: 1 Rationale 1: Toddlers can drown in a minimum amount of water. The child may look in the bucket and fall in head first. Because of mobility limitations, the child may not be able to get out of the bucket without help.

Rationale 2: This is appropriate to reduce the risk of injury.

Rationale 3: This allows the mother to adjust the temperature of the bath water and reduces the risk of burns.

Rationale 4: This is the safest place for the child.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-9

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Ball, Child Health Nursing, 3/E Chapter 34 Question 1 Type: MCMA The nurse is assessing a four-year-old child with a possible alteration in mental health. Which findings indicate need for further investigation?

Standard Text: Select all that apply.

1. Fails to make eye contact 2. Flinches when touched on the arm 3. History of limited prenatal care and precipitant delivery 4. Head circumference has not changed in over one year 5. Flat facial expressions Correct Answer: 1,2,3,5

Rationale 1: Making eye contact with the nurse and caregiver is part of the child's overall affect and social skills A child who fails to make eye contact may have an alteration in mental health.

Rationale 2: Flinching may indicate a desire to avoid contact; this can indicate a mental health issue and should be further evaluated.

Rationale 3: History of prenatal care and delivery can help determine potential alterations in mental health in a child.

Rationale 4: Head circumference is not measured in a four-year-old.

Rationale 5: Affect can be determined by facial expression and response to the nurse, helping to determine mental health.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts:Nursing Process: Assessment Learning Outcome: 34-1 Question 2 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Type: MCSA

The mother of a six-year-old brings her son to the physician because his teacher thinks he might have attention deficit/hyperactivity disorder (ADHD). The nurse is interviewing the mother about the child's history. The nurse knows that which factors could be associated with ADHD? 1. Measles, mumps, and rubella vaccine 2. Advanced parental age 3. Prenatal exposure to smoke 4. Immune response Correct Answer: 3 Rationale 1: Measles, mumps, and rubella vaccine has been thought to be associated with autism spectrum disorder, though a relationship has never been established through research.

Rationale 2: Advanced parental age has been associated with autism spectrum disorders.

Rationale 3: Research shows that a mother's use of cigarettes during pregnancy can increase the risk for ADHD Rationale 4: Immune response can be associated with autism spectrum disorders.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-3 Question 3 Type: MCMA The nurse at a high school is screening students for mental health issues. The nurse would want to refer the adolescent for depression if the child shows which symptoms of depression?

Standard Text: Select all that apply.

1. Agoraphobia 2. Somatic complaints 3. Focus on violence Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

4. Poor self-care 5. Poor school performance Correct Answer: 3,4,5

Rationale 1: Agoraphobia, which is a fear of being in places or situations from which escape might be difficult or embarrassing, is seen in children with a panic disorder, not with depression.

Rationale 2: Somatic complaints are more commonly associated with depression in the younger school-age chi Rationale 3: Focus on violence can be associated with depression in the adolescent.

Rationale 4: Poor self-care can be associated with depression in an adolescent.

Rationale 5: Poor school performance is associated with depression in the adolescent with depression.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-3

Question 4 Type: MCSA The nurse knows that the mother of a six-year-old needs more teaching about her son's diagnosis of ADHD whe she states:

1. "I will develop a reward system for desired behaviors.”

2. "I will take my child to the physician every three months for a weight and height check."

3. "I will let him do his homework while he is watching his favorite television show."

4. "I will stick to the same routine each day after school."

Correct Answer: 3 Rationale 1: A reward system is a part of behavior modification and is appropriate to help the child behave appropriately.

Rationale 2: Children with ADHD should be screened regularly for height and weight to monitor growth, which can be affected by medication.

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Rationale 3: This child should do homework in a quiet environment, away from distractions.

Rationale 4: Maintaining the same daily routine helps the child know expectations, and a nighttime routine help counteract insomnia.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 34-3 Question 5 Type: MCSA A child with autism is being admitted to the hospital with dehydration. Upon admission, the nurse should:

1. Encourage the parents to avoid bringing favorite toys from home that might be lost.

2. Take the child on a tour of the pediatric unit.

3. Assign the child to his single-bed hospital room.

4. Take the child to the playroom for arts and crafts.

Correct Answer: 3 Rationale 1: Children with autism often carry a special toy. This should be kept with the child.

Rationale 2: Taking a child with autism on a tour of the pediatric unit would be too much stimulation for this child. A quiet, controlled environment is best for a child with autism.

Rationale 3: A single room is the best place for an autistic child if the child must be hospitalized.

Rationale 4: Arts and crafts might be appropriate for an autistic child if they are done in the child's room. Going to the playroom would be too much stimulation for this child.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-4

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Question 6 Type: MCSA A nine-year-old has been diagnosed with a learning disorder that is characterized by problems with manual dexterity and coordination. The nurse teaches parents that this disorder is called: 1. Dysgraphia.

2. Dyscalculia.

3. Dyspraxia.

4. Dyslexia.

Correct Answer: 3 Rationale 1: Children with dysgraphia have difficulty with writing, spelling, and composition.

Rationale 2: Children with dyscalculia have problems with mathematics and computation problems.

Rationale 3: Children with dyspraxia have problems with manual dexterity and coordination.

Rationale 4: Children with dyslexia have difficulty with writing, reading, and spelling.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-5 Question 7 Type: MCSA The nurse is assessing a child with Down syndrome. The child is at greater risk of developing which illness than children who do not have Down syndrome?

1. Rheumatic heart disease 2. Glomerulonephritis 3. Leukemia 4. Hepatitis Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Correct Answer: 3 Rationale 1: Heart defects might be seen with Down syndrome, but not rheumatic heart disease, which is associated with Group A beta-hemolytic streptococcus infection.

Rationale 2: Glomerulonephritis is not seen in association with Down syndrome.

Rationale 3: Children with Down syndrome have a significantly higher than average risk of developing leukemia Rationale 4: Hepatitis is not associated with Down syndrome.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-5

Question 8 Type: MCMA A nurse is performing a developmental assessment on several children in a clinic setting. Which children exhibi delay in meeting developmental milestones?

Standard Text: Select all that apply.

1. An 18-month-old toddler who is unable to speak in sentences 2. A two-year-old who is unable to cut with scissors 3. A two-year-old who cannot recite her phone number 4. A six-year-old who is unable to sit still for a short story 5. A five-year-old who is unable to button his shirt Correct Answer: 4,5

Rationale 1: An 18-month-old is not usually able to speak in sentences. This is a skill to be accomplished by the age of two-and-a-half years.

Rationale 2: A child who cannot cut with scissors by kindergarten age is considered abnormal.

Rationale 3: A two-year-old is not expected to be able to recite a phone number.

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Rationale 4: A six-year-old should be able to sit still for a short story. A three- to five-year-old should be able to sit still through a short story.

Rationale 5: A five-year-old should be able to button his shirt.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-5 Question 9 Type: MCMA A seven-year-old girl has been clinging to her mother and refusing to go to school. The child is diagnosed with separation anxiety disorder, and the treatment plan will include cognitive-behavioral therapy (CBT). The nurse would explain to the parents that CBT will include: Standard Text: Select all that apply.

1. Self-talking.

2. Relaxation.

3. Hypnosis.

4. Anti-depressant medications.

5. Recognition of feelings.

Correct Answer: 1,2,5 Rationale 1: Self-talking helps a child to focus the inner thoughts on the desired behavior.

Rationale 2: Teaching self-relaxation skills can help the child to reduce anxiety.

Rationale 3: Hypnosis is not a component of cognitive-behavioral therapy.

Rationale 4: Although medications may be a part of the treatment plan, it is not a component of cognitivebehavioral therapy.

Rationale 5: Recognition and acceptance of feelings helps the child to move forward toward a desired behavior Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 34-4 Question 10 Type: MCSA The nurse is working with the mother of a child with autism. The goal of the session is to plan strategies to

increase the child’s socialization. The nurse is explaining behavior modification as a treatment process. The nur will encourage the mother to:

1. Create a reward system when the child interacts with a person.

2. Punish the child when the child’s social behaviors are inappropriate.

3. Use dolls to demonstrate appropriate social interactions to the child.

4. Enroll the child in a day care to encourage interaction with other children.

Correct Answer: 1 Rationale 1: This is appropriate treatment involving behavior modification.

Rationale 2: Behavior modification uses positive, not negative, reinforcement to encourage the desired behavio Rationale 3: This activity would be a component of play therapy.

Rationale 4: Enrolling the child in a day care may help with interactions, but this is not a description of behavior modification.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-7 Question 11 Type: MCSA The waiting room of the mental health clinic is full of children with various mental health issues. The nurse watches the children and notes that which child is displaying symptoms of autism?

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1. Four-year-old girl who doesn’t make eye contact with mother and resists the mother’s touch 2. Three-year-old boy who joins one group of children then moves to another group of children without joining their activities 3. 18-month-old child who walks around the area using the furniture to provide balance 4. Six-year-old boy who chatters constantly to anyone who will listen Correct Answer: 1

Rationale 1: Although boys are affected more often than girls, lack of eye contact and resistance to physical touch are common symptoms of autism.

Rationale 2: Although this child is not interacting with other children, it is obvious that the child is aware of othe children and interested in their activities, actions that are not indicative of autism.

Rationale 3: This child may be developmentally delayed, as this behavior is typical of a 10- to 12-month-old child.

Rationale 4: Children with autism often have language delays and impairment. This child does not have any obvious language issues.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-5 Question 12 Type: MCMA The school nurse and teacher are working on a plan to improve the behavior and learning of a child recently diagnosed with attention deficit/hyperactivity disorder (ADHD). Which activities will the nurse suggest be included in the plan?

Standard Text: Select all that apply.

1. Asking the mother to seek a prescription for methylphenidate (Ritalin) for the child 2. Placing the child’s desk at the back of the room to reduce distractions 3. Developing a consistent routine for the classroom 4. Limiting the decorations in the classroom Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

5. Determining areas where the child performs well and using these areas to promote self-esteem Correct Answer: 3,4,5 Rationale 1: It is not the nurse’s or teacher’s place to suggest medications for this child.

Rationale 2: The child’s desk should be placed at the front of the room to promote attention.

Rationale 3: Consistency is important for the child with ADD/ADHD and reduces impulsive behavior.

Rationale 4: Decorations are distracting and should be limited.

Rationale 5: This is appropriate and will help reduce “acting out” behaviors.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-6

Question 13 Type: MCSA A mother brings her 11-year-old son to the pediatric clinic for investigation of stomach complaints. The mother says that for the last two months, the child has complained of abdominal pain three to four mornings per week.

The mother states the child usually complains on school days and always seems to be better by afternoon. The child was able to attend a weekend Boy Scout camp without difficulty but has missed several days of school du to complaints. The nurse would suspect which mental health disorder?

1. Separation anxiety 2. Depression 3. School phobia 4. Bipolar disorder Correct Answer: 3

Rationale 1: Separation anxiety is most common in girls between the ages of seven and nine and may be accompanied by depression when separated. The child was able to successfully separate for a non-school activ Rationale 2: Depression is often manifested by sleep issues, avoidance of social interactions, and low energy.

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Rationale 3: The child is using somatic complaints to avoid attending school.

Rationale 4: Bipolar disorder involves periods of hyperactivity alternating with periods of lethargy.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-3

Question 14 Type: MCSA The school nurse notices a sixth-grade girl with bald patches in her hair. The hair itself is clean and shiny. Prior t referring the girl to her healthcare provider for alopecia, the nurse would want to watch the child for signs of: 1. Lice.

2. Dietary imbalances.

3. Schizophrenia.

4. Trichotillomania.

Correct Answer: 4 Rationale 1: Lice cause attachments of nits to the hair shaft, not hair loss. Rationale 2: The nurse can assess height, weight, and BMI but will not be able to determine if dietary imbalances is the cause of the problem.

Rationale 3: Schizophrenia is a psychotic disorder whose symptoms include flat affect, loose associations, delusions, and hallucinations.

Rationale 4: Trichotillomania is the term for a condition where children pull out their hair during periods of stress.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-3

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Question 15 Type: MCSA

A mother brings her 22-month-old child to the well-child clinic for an evaluation. The mother states that this ch does not seem to be developing like her sister’s child of the same age. The nurse will perform which screening test that may provide information about the child’s development?

1. MRI of the head 2. An EEG 3. A Denver II 4. Chromosomal study Correct Answer: 3 Rationale 1: The MRI is a diagnostic test, not a screening test, and it is not performed by the nurse.

Rationale 2: An electroencephalogram evaluates brains wave activity of the brain. It does not evaluate the child behavior.

Rationale 3: The Denver Developmental Screening Test II is a tool used by the nurse that evaluates language an development.

Rationale 4: A chromosomal test is not a screening test but a diagnostic test. It is not performed to determine developmental delay.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-6

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Ball, Child Health Nursing, 3/E Chapter 35 Question 1 Type: MCSA The nurse in the newborn nursery is doing the admission assessment on a neonate. Which assessment finding would lead the nurse to suspect unilateral congenital hip dysplasia?

1. Lordosis 2. Trendelenburg sign 3. Asymmetry of the gluteal and thigh fat folds 4. Telescoping of the affected limb Correct Answer: 3 Rationale 1: Lordosis does not occur with hip dysplasia.

Rationale 2: Trendelenburg sign and telescoping of the affected limb are signs that present in an older child wit congenital hip dysplasia.

Rationale 3: A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat fold

Rationale 4: Trendelenburg sign and telescoping of the affected limb are signs that present in an older child wit congenital hip dysplasia.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-1 Question 2 Type: MCMA A school health nurse is screening for scoliosis. For what assessment findings would the nurse look?

Standard Text: Select all that apply.

1. Lordosis Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

2. Prominent scapula 3. Pain 4. A one-sided rib hump 5. Uneven shoulders and hips Correct Answer: 2,4,5 Rationale 1: Lordosis is not present with scoliosis.

Rationale 2: The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula.

Rationale 3: Pain generally is not present with scoliosis unless it is severe.

Rationale 4: The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula.

Rationale 5: The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-1 Question 3 Type: MCSA The nurse has completed parent education related to treatment for a child with congenital clubfoot.

The nurse knows that parents need further teaching when they state:

1. "We're getting a special car seat to accommodate the casts."

2. "We'll watch for any swelling of the feet while the casts are on."

3. "We'll keep the casts dry."

4. "We're happy this is the only cast our baby will need."

Correct Answer: 4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Using a car seat is the law. Special car seats to accommodate the casts are available and should be utilized.

Rationale 2: Parents should be watching for swelling while the casts are on.

Rationale 3: Keeping the casts dry is important to prevent complications Rationale 4: Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every one to two weeks until the corrected foot position is achieved.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 35-2 Question 4 Type: MCSA A child must wear a brace for correction of scoliosis. Which nursing diagnosis takes priority at this time?

1. Impaired gas exchange, risk for 2. Altered growth and development, risk for 3. Impaired skin integrity, risk for 4. Impaired mobility, risk for Correct Answer: 3 Rationale 1: Risk for impaired gas exchange is a late effect of scoliosis and would not be the priority. If the patient is compliant with wearing the brace, the risk should be minimized.

Rationale 2: The diagnosis of altered growth and development would not be the priority and should be correcte by the wearing of the brace.

Rationale 3: The skin should be monitored for breakdown in any area where the brace might rub against the ski Rationale 4: The diagnosis of impaired mobility would not be the priority and should be corrected if the patient compliant with wearing the brace.

Global Rationale: Cognitive Level: Analyzing Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts:Nursing Process: Diagnosis Learning Outcome: 35-2 Question 5 Type: MCSA An adolescent has just returned from surgery after spinal fusion surgery. Which assessment finding would take priority at this time?

1. Sleeps when not bothered but arouses easily with stimuli 2. Impaired color, sensitivity, and movement to lower extremities 3. Nausea 4. Pain Correct Answer: 2 Rationale 1: This is a normal response postanesthesia.

Rationale 2: When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movemen to lower extremities.

Rationale 3: Nausea in the postoperative period is not uncommon, but it is not the priority at this time.

Rationale 4: Pain is a common finding in the postoperative period and should be addressed, but impaired color, sensitivity, and movement of the lower extremities is the priority at this time.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35-4

Question 6 Type: MCSA The nurse has completed discharge teaching for the family of a child diagnosed with Legg-Calvé-Perthes diseas The nurse knows further teaching is needed about the condition if the family states:

1. "We're glad this will only take about six weeks to correct."

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2. "We understand abduction of the affected leg is important."

3. "We know to watch for areas on the skin that the brace might rub."

4. "We understand swimming is a good sport for Legg-Calvé-Perthes."

Correct Answer: 1 Rationale 1: The treatment for Legg-Calvé-Perthes disease takes approximately two years.

Rationale 2: The leg should be kept in the abducted position to prevent damage to the head of the femur due to Legg-Calvé-Perthes disease.

Rationale 3: A brace is a component of the treatment of Legg-Calve-Perthes disease and is worn to prevent damage to the head of the femur, so skin irritation should be monitored.

Rationale 4: Swimming is a good activity to increase mobility in a child with Legg-Calvé-Perthes disease.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 35-4 Question 7 Type: MCSA Which of the following would take priority when teaching the family how to care for an infant with osteogenesis imperfecta?

1. Teaching the family how to care for an infant in a cast 2. Teaching the family that the trunk and extremities should always be supported when moving this infant 3. Teaching the family how to care for an infant postop spinal surgery 4. Teaching the family how to care for an infant in traction Correct Answer: 2 Rationale 1: Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta.

Rationale 2: With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones ar fragile, the entire body must be supported when the child is moved.

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Rationale 3: Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta.

Rationale 4: Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-4 Question 8 Type: MCSA An infant has just returned from surgery for correction of bilateral congenital clubfeet. The infant has bilateral long-leg casts. The toes on both feet are edematous, but there is color, sensitivity, and movement to them. What should the nurse do first?

1. Apply a warm, moist pack to the feet.

2. Elevate the infant’s legs on pillows.

3. Encourage movement of the toes.

4. Call the physician to report the edema.

Correct Answer: 2 Rationale 1: Warm, moist heat will increase swelling and the moisture may cause the cast to disintegrate.

Rationale 2: The infant’s legs should be elevated on a pillow for 24 hours to promote healing and help with venous return. This is the priority action.

Rationale 3: An infant would not be able to follow directions to move the toes, and in this case it would not be a effective as would elevating the legs on pillows.

Rationale 4: Some amount of swelling can be expected, so it would not be appropriate to notify the physician, especially if the color, sensitivity, and movement to the toes remained normal.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 35-5 Question 9 Type: MCSA The nurse is teaching a family how to care for their infant in a Pavlik harness to treat congenital developmental

dysplasia of the hip. Which instruction is appropriate for the nurse to include in parental education in relation to the Pavlik harness?

1. Apply lotion or powder to minimize skin irritation.

2. Check at least two or three times a day for red areas under the straps.

3. Put clothing over the harness for maximum effectiveness of the device.

4. Place a diaper over the harness, preferably using a thin, superabsorbent, disposable diaper.

Correct Answer: 2 Rationale 1: Lotion or powder can contribute to skin breakdown and should not be used.

Rationale 2: The skin underneath the straps of the brace should be checked two or three times a day for red are which might indicate skin breakdown.

Rationale 3: A light layer of clothing should be worn under the brace to assist in preventing skin breakdown, not over the brace.

Rationale 4: The diaper should be placed under the brace, along with a light layer of clothing.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35-5 Question 10 Type: MCSA A child has experienced a sprain of the right ankle. The school nurse should:

1. Leave the ankle open to the air and avoid compressing the area to allow tissue swelling as necessary.

2. Perform passive range-of-motion to the extremity.

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3. Lower the extremity below the level of the heart.

4. Apply ice to the extremity.

Correct Answer: 4 Rationale 1: For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed.

Therefore, the nurse should apply a compression bandage to the extremity.

Rationale 2: For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed.

Therefore, the nurse should rest the extremity rather than perform range-of-motion.

Rationale 3: For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed.

Therefore, the nurse should elevate the extremity.

Rationale 4: For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed.

Therefore, the nurse should apply ice to the extremity.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-5

Question 11 Type: MCMA A nurse is assessing a child after an open reduction of a fractured femur. Which signs indicate that compartmen syndrome could be occurring?

Standard Text: Select all that apply.

1. Pink, warm extremity 2. Dorsalis pedis pulse present 3. Prolonged capillary refill time 4. Pain not relieved by pain medication 5. Paresthesia of the leg Correct Answer: 3,4,5 Rationale 1: Pink, warm extremity is a normal finding post-fracture reduction.

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Rationale 2: A present dorsalis pedis pulse would be a normal finding post-fracture reduction.

Rationale 3: A prolonged capillary refill time is a sign of compartment syndrome.

Rationale 4: A prolonged capillary refill time with loss of paresthesia and pain not relieved by medication are signs of compartment syndrome.

Rationale 5: Paresthesia is tingling and numbness of the affected extremity and is a sign of compartment syndrome.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-6

Question 12 Type: MCSA A six-year-old boy is admitted to the hospital with a diagnosis of osteomyelitis of the left femur. The plan of car includes a two-week round of intravenous antibiotics. The father questions why the child must be hospitalized a why the child cannot receive oral antibiotics. The nurse explains:

1. The antibiotic of choice is not available in oral form.

2. Blood flow to bones is limited, and parenteral administration is necessary to get appropriate blood levels.

3. Because the child is older now, it is harder to get the child to cooperate with oral antibiotics.

4. Because two weeks of therapy is necessary, the intravenous route will produce fewer side effects.

Correct Answer: 2 Rationale 1: Most antibiotics are available in multiple forms.

Rationale 2: This is accurate information.

Rationale 3: The older child can understand the reason for antibiotics and cooperate.

Rationale 4: Both oral and intravenous antibiotics may have side effects.

Global Rationale: Cognitive Level: Applying Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts:Nursing Process: Implementation Learning Outcome: 35-3 Question 13 Type: MCSA A two-year-old child is placed in balanced Bryant’s traction for a fractured right femur. Which finding by the nurse should be reported to the surgeon?

1. The child keeps trying to turn and lay on his belly.

2. The ropes are unequal in length.

3. The child’s buttocks are resting on the bed.

4. The ace bandage wrapping the legs is wrinkled.

Correct Answer: 3 Rationale 1: This child needs a jacket restraint to maintain appropriate positioning if someone cannot stay with him. It does not require notifying the surgeon.

Rationale 2: In balanced traction, the ropes and pulleys determine the traction and the length of the rope is unimportant.

Rationale 3: In order to provide adequate counter-traction, the buttocks should be slightly elevated off the bed The surgeon should be notified.

Rationale 4: This is not a significant finding.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 35-5 Question 14 Type: MCMA When assigned to the patient on complete bed rest for spinal fusion secondary to scoliosis, the nurse will want intervene to prevent common complications of immobility. Nursing interventions will include:

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Standard Text: Select all that apply.

1. Encouraging use of the spirometer every two hours while the child is awake.

2. Log-rolling the patient every two hours while awake.

3. Increasing intake of milk to maintain bone calcium.

4. Increasing fruit and grains in the diet.

5. Limiting fluid intake to reduce the need to void.

Correct Answer: 1,2,4 Rationale 1: Respiratory complications are a common complication of immobility.

Rationale 2: Turning the patient frequently will reduce pressure on bony prominences.

Rationale 3: Calcium will be pulled from the bones due to immobility. Adding additional calcium in the form of milk will increase the risk of kidney stones.

Rationale 4: Fruit and grains will provide extra fiber to reduce the risk of complication.

Rationale 5: Fluid intake should be increased to “flush” the kidneys.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-5

Question 15 Type: MCSA While at recess, a child falls and hurts his arm. The school nurse is called and suspects a fractured arm. The nur will apply a splint before transporting the child to the hospital. The nurse will ensure that:

1. The splint is applied firmly enough to prevent swelling.

2. The arm is fully extended in the splint.

3. The splint is fully padded to prevent skin damage.

4. The joints above and below the suspected fracture are immobilized.

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Correct Answer: 4 Rationale : The purpose of the splint is not to prevent swelling.

1 : The nurse will not want to manipulate the arm, so the nurse will splint the arm in the position it is found.

Rationale Rationale 3: The splint does not need to be padded.

2 Rationale 4: This is the important concept in splinting—immobilizing the joint above and below the fracture to prevent movement of the bones.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-6

Question 16 Type: MCSA An 18-month-old child is admitted to the hospital unit for weakness of the lower extremities. Duchenne muscu dystrophy is suspected. Which assessment finding on the admission history and physical is indicative of this disorder?

1. Infant was post-mature by almost two weeks.

2. The child seems very muscular.

3. The child walked early and without support at 10 months.

4. The child’s older sister developed scoliosis in the fourth grade.

Correct Answer: 2 Rationale 1: Post-maturity is not related to Duchenne muscular dystrophy.

Rationale 2: Duchenne muscular dystrophy is also called pseudohypertrophic due to the enlarged appearance o the muscle. The pathophysiology is infiltration of the muscle fibers with fatty tissue.

Rationale 3: This finding is not indicative of Duchenne muscular dystrophy.

Rationale 4: The older sister’s scoliosis is not related to MD. Duchenne MD is sex-linked recessive and affects only boys.

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Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-3 Question 17 Type: MCMA An infant returns to the unit following casting of the leg for talipes equinovarus. Standing orders include monitoring the neurovascular status. In addition to color, for what will the nurse monitor the infant’s foot?

Standard Text: Select all that apply.

1. Warmth 2. Capillary refill 3. Pedal pulse 4. Sensation 5. Movement of the toes Correct Answer: 1,2,4,5 Rationale 1: The temperature of the foot of the casted leg should be compared to the temperature of the other Rationale 2: This indicates blood return to the tissues and is an important finding.

Rationale 3: The pedal pulse cannot be reached in the casted foot.

Rationale 4: Nerve function is evaluated by touching the toes and noting the child’s response.

Rationale 5: The child is encouraged to wiggle the toes. If the patient is an infant, tickling will cause the child to respond with movement.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-5 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Ball, Child Health Nursing, 3/E Chapter 36 Question 1 Type: MCSA The nurse is examining a 12-month-old who was brought to the clinic for persistent diaper rash. The nurse finds perianal This is inflammation with bright red, scaly plaques and small papules. Satellite lesions are also present. most likely caused by which of the following?

1. Candida albicans (yeast) 2. Impetigo (staph) 3. Infrequent diapering 4. Urine and feces Correct Answer: 1 Rationale 1: Candida albicans is frequently the underlying cause of severe diaper rash. When a primary or secondary infection with Candida albicans occurs, the rash has bright red, scaly plaques with sharp margins.

Small papules and pustules might be seen, along with satellite lesions.

Rationale 2: Even though diaper dermatitis can be caused by impetigo, urine, feces, and infrequent diapering, th lesions and persistent characteristics are common for Candida.

Rationale 3: Infrequent diapering, along with urine and feces, can cause diaper dermatitis, but the persistence a characteristics of the lesions are common for Candida.

Rationale 4: Urine and feces can cause diaper dermatitis, but the persistence and characteristics of the lesions common for Candida.

Global Rationale:

Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts:Nursing Process: Assessment Learning Outcome: 36-2 Question 2 Type: MCSA

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The school nurse is conducting pediculosis capitis (head lice) checks. Which finding would indicate a "positive" head check?

1. White, flaky particles throughout the entire scalp region 2. Lesions on the scalp that extend to the hairline or neck 3. Maculopapular lesions behind the ears 4. Silver/white sacs attached to the hair shafts in the occipital area Correct Answer: 4 Rationale 1: Lice and nits must be distinguished from dandruff, which appears as white, flaky particles.

Rationale 2: Lesions might be present from itching, but the positive sign of head lice is evidence of nits.

Rationale 3: Lesions might be present from itching, but the positive sign of head lice is evidence of nits.

Rationale 4: Evidence of pediculosis capitis includes silver/white sacs (nits) that are attached to the hair shafts, frequently in the occiput area.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-2 Question 3 Type: MCSA The 10-year-old child is admitted to the hospital following an accident at school that resulted in a puncture wound of the abdomen. Two days after the injury, the child continues in the inflammation phase of healing. What would 1.

The wound is contracting, and the edges are growing together. the nurse expect to see while changing the child’s dressing and assessing the wound?

2. A blood clot has formed, sealing the wound.

3. Epithelial cells are growing into the wound.

4. The wound is pale and weepy.

Correct Answer: 2 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: Wound contraction and inward movement of the wound edge occur during the reconstruction phas of wound healing.

Rationale 2: Clot formation to seal the wound with fibrin and trapped cells and platelets occurs during the inflammation phase of wound healing, in the first three to five days.

Rationale 3: Epithelial cells growing into the wound occurs in the reconstruction phase of wound healing.

Rationale 4: During the initial phase of healing, there is increased blood flow, giving the area an “inflamed” appearance.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-3 Question 4 Type: MCMA A child had an appendectomy and was discharged home at 48 hours postoperative. A week later the child is readmitted for delayed wound healing. Which causes of delayed wound healing will the nurse review prior to assessing the child?

Standard Text: Select all that apply.

1. Infection 2. Predisposing chronic condition, such as diabetes 3. Hypervolemia 4. Inadequate nutrition 5. Hypoxemia 6. Corticosteroid therapy Correct Answer: 1,2,4,5,6 Rationale 1: Infection can affect healing and cause excessive scarring.

Rationale 2: Conditions such as diabetes affect circulating blood volume and are known to affect healing.

Rationale 3: Hypovolemia, not hypervolemia, would inhibit inflammation due to low circulating blood volume.

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Rationale 4: Poor nutrition without proper protein and calorie intake will affect healing.

Rationale 5: Hypoxemia makes tissues susceptible to infection due to insufficient oxygenation.

Rationale 6: Corticosteroid therapy or other immunocompromising therapy will prevent macrophages from migrating to the site of injury and suppress epithelialization.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-3

Question 5 Type: MCSA The nurse is planning care for a three-month-old infant with eczema. Which intervention would take top priority in this infant's care?

1. Applying antibiotics to lesions 2. Keeping the baby content 3. Maintaining adequate nutrition 4. Preventing infection of lesions Correct Answer: 4 Rationale 1: Antibiotics are not routinely applied to the lesions since the lesions are not related to infection.

However, impaired skin barrier function and cutaneous immunity place the infant at greater risk for the development of skin infection.

Rationale 2: Keeping the infant content is not as high a priority as is prevention of infection. An infant with eczema is at a greater risk for the development of skin infection.

Rationale 3: Maintaining adequate nutrition is important, but it is not as high a priority. Due to impaired skin barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infection.

Rationale 4: Nursing care should focus on preventing infection of lesions. Due to impaired skin barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms.

Global Rationale: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36-4 Question 6 Type: MCSA An infant has a severe case of oral thrush (Candida albicans). Which is the priority nursing diagnosis for this infant?

1. Ineffective infant feeding pattern related to discomfort 2. Ineffective breathing pattern related to oral thrush 3. Activity intolerance related to oral thrush 4. Ineffective airway clearance related to mucus Correct Answer: 1

Rationale 1: An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern.

Rationale 2: Ineffective breathing pattern is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary that a normal feeding pattern can be resumed.

Rationale 3: Activity intolerance is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary so tha normal feeding pattern can be resumed.

Rationale 4: Ineffective airway clearance is not usually associated with oral thrush. An infant with oral thrush

might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary that a normal feeding pattern can be resumed.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 36-6 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Question 7 Type: MCSA

Parents understand the teaching a nurse has done with regard to care of their child with tinea capitis (ringworm the scalp) if they state: 1. "We will give the griseofulvin with milk or peanut butter."

2. "We're glad ringworm isn't transmitted from person to person."

3. "Once the lesion is gone, we can stop the griseofulvin."

4. “Well, at least we don’t have to worry about the family cat getting the ringworm.”

Correct Answer: 1

Rationale 1: Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption.

Rationale 2: All members of the family and household pets should be assessed for fungal lesions because perso to-person transmission is common.

Rationale 3: The medication must be used for the entire prescribed period, even if the lesions are gone.

Rationale 4: Dogs and cats can develop the fungal lesions and be sources of spread of the organism.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36-6 Question 8 Type: MCSA

A nurse is applying a 5% permethrin lotion to a toddler with scabies. Which instruction describes the best way t apply this lotion?

1. Apply the lotion over the entire body from the chin down, as well as on the scalp and forehead.

2. Apply the lotion only on the areas with evidence of scabies activity.

3. Apply the lotion only to the hands.

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4. Apply the lotion to the scalp only.

Correct Answer: 1 Rationale 1: Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down. The scabicide is also applied to the scalp and forehead of younger children, avoiding the rest of the face.

Rationale 2: Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, as well as the scalp and forehead.

Rationale 3: Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, including the scalp and forehead.

Rationale 4: Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, as well as the scalp and forehead.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-6

Question 9 Type: MCSA A child has sustained a minor burn. Which of the following should be included in increased amounts in the child diet?

1. Protein 2. Minerals 3. Carbohydrates 4. Fats Correct Answer: 1

Rationale 1: Parents should be taught that management of a minor burn requires a high-calorie, high-protein di This is necessary to meet the increased nutritional requirements of healing.

Rationale 2: A high-calorie, high-protein diet is required to meet the increased nutritional requirements for healing.

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Rationale 3: The family should be taught that a high-calorie, high-protein diet is best to meet the increased nutritional requirements for healing.

Rationale 4: A high-calorie, high-protein diet is best to meet the increased nutritional requirements for healing.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-7 Question 10 Type: MCSA Which would be the priority nursing diagnosis during the acute phase of burn injury for a child who has a thirddegree circumferential burn of the right arm?

1. Altered tissue perfusion, risk for 2. Infection, risk for 3. Impaired physical mobility 4. Altered nutrition: less than body requirements, risk for Correct Answer: 1

Rationale 1: Circumferential burns can restrict blood flow due to edema, resulting in tissue hypoxia. Altered tissue perfusion to the extremity is the greatest risk and therefore the priority diagnosis.

Rationale 2: When the burn is circumferential, blood flow can become restricted due to edema and can result in tissue hypoxia; therefore, the priority diagnosis is altered tissue perfusion, risk for to the extremity. Risk of infection would be a secondary priority in this case.

Rationale 3: Impaired physical mobility is a secondary priority for the child with a circumferential burn. Edema to the area can result in restricted blood flow and tissue hypoxia, making the priority diagnosis altered tissue perfusion, risk for.

Rationale 4: Infection, nutrition, and mobility would have secondary priority in this case.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 36-7 Question 11 Type: MCSA The toddler pulled a pot of boiling water off the stove and suffered partial and full thickness burns to the chest.

EMS arrived, stabilized the child, and transported him to the hospital burn unit. The child is now in the recovery management phase of burn treatment. Which is the most common complication seen in this period?

1. Asphyxia 2. Metabolic acidosis 3. Shock 4. Burn-wound infection Correct Answer: 4

Rationale 1: Asphyxia is not a common complication during the recovery-management phase of burn treatment Infection of the burned area is a frequent complication.

Rationale 2: Metabolic acidosis is not common in the recovery-management phase of burn treatment. Infection the burned area is a frequent complication.

Rationale 3: Shock is not the most common complication during the recovery-management phase of burn treatment. Infection of the burned area is a frequent complication.

Rationale 4: Infection of the burned area is a frequent complication in the recovery-management phase. A goal burn-wound care is protection from infection.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-7 Question 12 Type: MCSA The nurse explains to the parents of a child with a severe burn that wearing an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help prevent which complication?

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1. Pain 2. Hypertrophic scarring 3. Poor circulation 4. Formation of thrombus in the burn area Correct Answer: 2

Rationale 1: The Jobst stockings or pressure garments do not prevent pain. They are used to prevent developm of hypertrophic scarring and contractures.

Rationale 2: During the rehabilitation stage, Jobst stockings or pressure garments are used to reduce developm of hypertrophic scarring and contractures.

Rationale 3: The Jobst pressure garments are used to prevent or minimize the development of hypertrophic scarring and contractures.

Rationale 4: The elastic pressure garments are used to prevent development of hypertrophic scarring and contractures. They do not prevent the formation of thrombus in the burn area.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36-7 Question 13 Type: MCSA Nursing care of the child with a snake bite involves assessment of the child for initial and progressive signs of envenomation. Which is the priority nursing action at this time?

1. Measure the circumference of the extremity containing the bite every 20 to 30 minutes.

2. Assess immunization status.

3. Assess the need for emergency breathing interventions.

4. Assess neurovascular status and vital signs.

5. Assess pain and the child's response to pain medication.

Correct Answer: 3 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: In order to track progression in swelling and response to treatment, the extremity with the bite is measured every 20 to 30 minutes. However, this does not take priority over airway, breathing, and circulation.

Rationale 2: Immunization status is important information to obtain, but the more immediate need is for airway breathing, and circulation.

Rationale 3: Emergency intervention for airway, breathing, and circulation take priority and has a high probability of occurrence.

Rationale 4: Vital signs and neurovascular status of the distal extremities should be monitored but do not take priority over airway, breathing, and circulation.

Rationale 5: Pain medication will need to be given and the response to the treatment monitored; however, this should not take priority over airway, breathing, and circulation.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-8

Question 14 Type: MCSA The nurse is teaching strategies to prevent insect bites and stings to the parents of a small child. Which stateme made by the parents indicates a need for further teaching?

1. "If my child wears bright colors and floral prints when outdoors, she will blend in with the surroundings, and the stinging insects will not sting her."

2. "We should remove any items with standing water from our yard and surrounding area to prevent mosquito reproduction."

3. "My child can use insect repellent containing DEET of 10% or less."

4. "My child should avoid heavy colognes, perfumes, and soaps so that insects are not attracted to them."

Correct Answer: 1

Rationale 1: Bright-colored clothing and floral prints attract the insects. White and light-colored clothing should be worn. This statement requires clarification.

Rationale 2: Standing water is a breeding ground for mosquitoes. Rid yards of all bird baths, stagnant pools, and any standing water that mosquitoes could use for breeding. No clarification is needed.

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Rationale 3: DEET is an appropriate insect repellent and can be used in children. A concentration of 10% or less is recommended due to neurotoxic effects at greater concentrations. No clarification is needed.

Rationale 4: Heavy colognes, perfumes, soaps, and detergents resemble flowers and plants and will attract the stinging insects. This statement is correct.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36-8 Question 15 Type: MCSA Following an automobile accident, a teenager is left paraplegic. The child is being prepared for discharge. The nurse is reviewing instructions to avoid decubitus ulcers on the buttocks and instructs the teenager to:

1. Contract the buttock muscles five times every two hours.

2. Increase fat in the diet to provide a protective coating over the boney prominences.

3. Do wheelchair push-ups every 15 to 30 minutes.

4. Avoid use of sheepskin as it prevents air from reaching the area.

Correct Answer: 3 Rationale 1: The child is a paraplegic and therefore unable to contract the buttock muscles.

Rationale 2: Extra weight will add to pressure on the boney prominences and should be avoided.

Rationale 3: Lifting the buttocks with the arms can help with blood flow to the buttocks and reduce the risk of breakdown.

Rationale 4: Sheepskin can reduce pressure on the buttocks; it is one of many pressure reducing materials available.

Global Rationale: Cognitive Level: Applying Client Need: Client Need Sub: Nursing/Integrated Concepts:Nursing Process: Implementation Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Learning Outcome: 36-3 Question 16 Type: MCMA While preparing for the day in the integument clinic, the nurse notices that a number of the patients being seen

that day have conditions with a genetic component. Which skin conditions have a genetic or inherited compone Standard Text: Select all that apply.

1. Atopic dermatitis 2. Seborrheic dermatitis 3. Epidermolysis bullosa 4. Molluscum contagiosum 5. Psoriasis Correct Answer: 1,3,5 Rationale 1: Atopic dermatitis is an allergic skin disorder. Allergies have an inherited component.

Rationale 2: Seborrheic dermatitis is thought to be an overgrowth of yeast and is influenced by hormones. It is not inherited.

Rationale 3: Epidermolysis bullosa is inherited either as autosomal dominant or autosomal recessive depending on type.

Rationale : Mulluscum is caused by a poxvirus and is transmitted person to person.

4

: Psoriasis is usually seen in patients with a family history. A multifactorial inheritance is suspected.

Rationale Global Rationale: 5 Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts:Nursing Process: Assessment Learning Outcome: 36-4 Question 17 Type: MCSA

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

The mother of several children is talking with the nurse. She asks the nurse why her younger child seems to sunburn easier than her older children. The nurse would explain that the skin of younger children: 1. Is thinner than that of adolescents.

2. Has less melanin.

3. Has smaller, nonfunctional apocrine sweat glands.

4. More readily absorbs chemicals.

Correct Answer: 2 Rationale 1: The skin of infants is thinner than adolescents, but that does not explain why they are more susceptible to sunburns.

Rationale 2: Melanin determines skin color and serves as a shield against ultraviolet radiation, the cause of sunburns.

Rationale 3: Although accurate information, it does not explain why the child is more prone to sunburns.

Rationale 4: While true, this does not explain why infants are more prone to sunburns.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-1 Question 18 Type: MCSA

The clinic nurse has completed teaching the teenager about skin care and acne prevention. Which statement by teenager indicates the need for additional teaching?

1. “I shouldn’t squeeze my blackheads or pimples.”

2. “I need to watch my diet and cut out all chocolates.”

3. “I should avoid applying drying materials, such as astringents, to my face” 4. “I should wash my hands frequently and avoid touching my face.”

Correct Answer: 2,4 Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Rationale 1: This practice can introduce organisms into the lesions and should be avoided. This statement need no clarification.

Rationale 2: There has been no research that connects diet to acne. A healthy diet with protein is recommended but chocolate does not have to be excluded. This statement needs to be clarified.

Rationale 3: This statement is accurate and needs no clarification.

Rationale 4: This is an important means of reducing facial irritation.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36-5 Question 19 Type: MCSA A three-year-old is admitted to the hospital unit with cellulitis of the neck. The nurse will expect medical treatment to include:

1. Topical antibiotics.

2. Intravenous antibiotics.

3. Incision and drainage.

4. Intravenous corticosteroids.

Correct Answer: 2 Rationale 1: This is an infection of the deeper tissues including the dermis and supporting connective tissues.

Topical antibiotics will not reach the infection.

Rationale 2: This infection usually requires parenteral antibiotics.

Rationale 3: The infection is not consolidated into an abscess, so an incision and drainage would not be performed.

Rationale 4: Corticosteroids are anti-inflammatories and would not be used to treat this infection.

Global Rationale: Cognitive Level: Analyzing Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.

Client Need: Client Need Sub: Nursing/Integrated Concepts:Nursing Process: Planning Learning Outcome: 36-6 Question 20 Type: MCMA

There has been an outbreak of tinea pedis among the high school football team. The school nurse meets with th team and discusses preventative activities to reduce spread of the organism. The nurse will instruct the team members to: Standard Text: Select all that apply.

1. Wear 100% white cotton socks, changed twice a day.

2. Use talc on feet daily.

3. Use an over-the-counter corticosteroid cream to treat the area.

4. Wear foot covers such as flip flops in the locker room and shower.

5. Apply heat to the area twice a day.

Correct Answer: 1,2,4 Rationale 1: The socks will wick moisture away from the feet to promote healing.

Rationale 2: This process will help keep the feet dry.

Rationale 3: Corticosteroids will not destroy the organism. An antifungal medication is required.

Rationale 4: This will reduce the spread of the organism among team members.

Rationale 5: Heat will not treat the problem. Antifungal medications are required.

Global Rationale: Cognitive Level: Analyzing Client Need: Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-6

Ball, Child Health Nursing, 3/E Copyright 2014 by Pearson Education, Inc.