Child Health Nursing Partnering with Children and Families, 2E Jane W. Ball Test Bank.pdf (22)

Ball and Bindler

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4. A diagnosis of cancer affects the whole family, and initial feelings experienced by the sibling might be anger and guilt.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 29.5 Plan care for children and adolescents of all ages who have a diagnosis of leukemia.

15. A child is receiving chemotherapy induction for acute lymphocytic leukemia (ALL).

Taking common side effects into consideration, which nursing diagnoses would be appropriate during the induction chemotherapy? Select all that apply.

1. Risk for infection 2. Skin Integrity: Impaired mucous membrane 3. Injury, risk for: hemorrhagic cystitis 4. Fluid and electrolyte Impairment: Nausea and vomiting 5. Impaired sleep pattern 6. Patterns of Elimination, Altered: diarrhea

Answer: 2, 3, 4, 6 Rationale: 1. Bone marrow suppression does not peak until 7–10 days post-induction. This nursing diagnosis would be appropriate at that time.

2. Mouth sores are a common early side effect of chemotherapy, and usually occur 2–5 days after the administration of chemotherapy.

3. Hemorrhagic cystitis is a common early side effect of chemotherapy, and is usually prevented with large amount of IV fluids to adequately protect the kidneys.

4. Nausea and vomiting are common early side effects of chemotherapy.

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Ball and Bindler

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5. Impaired sleep patterns are not directly related to chemotherapy.

6. Diarrhea is a common early side effect of chemotherapy.

Cognitive Level: Analysis Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Planning Learning Outcome 29.5 Plan care for children and adolescents of all ages who have a diagnosis of leukemia.

16. A child with leukemia has a granulocyte count of 250/mm3 and a platelet count 150, 000/mm3. Nursing intervention would include which of the following?

1. Strict isolation 2. Good handwashing 3. Fluid restriction 4. Avoidance of mouth care

Answer: 2 Rationale: 1. The child should be isolated from anyone infectious, but strict isolation is not necessary.

2. Handwashing is vital for preventing the spread of infection.

3. Fluids should continue to be encouraged.

4. Platelet count is normal; mouth care should include brushing with a soft toothbrush and frequent rinsing.

Cognitive Level: Application Client Need: Physiological Integrity: Reduction of Risk Potential Nursing Process: Planning

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Learning Outcome 29.5 Plan care for children and adolescents of all ages who have a diagnosis of leukemia.

17. A child with rhabdomyosarcoma is to undergo radiation therapy after surgical removal of the tumor. The parents should be taught to: 1. Apply sunscreen to the area when the child is exposed to sunlight.

2. Vigorously scrub the area when bathing the child.

3. Remove any markings left after each radiation treatment.

4.

Apply lotion to the area before radiation therapy.

Answer: 1 Rationale: 1. Radiation therapy causes the skin in that area to be sensitive. Sunscreen should be applied, so that sunburns are avoided.

2. Vigorous scrubbing is not recommended.

3. Removing the radiation markings is not recommended.

4. Lotion can increase the chance of a radiation burn when applied before the treatment.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 29.6 Recognize the most common soft tissue tumors in children, describe their treatment, and plan comprehensive care.

18. The child has been admitted to the hospital unit newly diagnosed with retinoblastoma.

The nurse would expect to see:

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Ball and Bindler

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1. A red reflex.

2. Yellow sclera.

3. A white reflex.

4.

Blue-tinged sclera.

Answer: 3 Rationale: 1. Red reflex is absent in retinoblastoma.

2. Yellow sclera is a sign of jaundice, not retinoblastoma.

3. The first sign of retinoblastoma is a white pupil. The red reflex is absent. This is known as leukocoria, or “cat’s eye” reflex.

4. Blue-tinged sclera is a sign of osteogenesis imperfecta, not of retinoblastoma.

Cognitive Level: Comprehension Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 29.6 Recognize the most common soft tissue tumors in children, describe their treatment, and plan comprehensive care.

19. The nurse is performing a physical exam on a child who presents with enlarged lymph nodes and general malaise. Differential diagnosis for diagnosis of Hodgkin’s lymphoma would include which of the following assessment findings?

1. Fever and joint pain 2. Bruising and petechiae 3. Firm and non-tender lymph nodes 4. Enlarged and painful lymph nodes Answer:

3

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Rationale: 1. Fever and joint pain are not physical findings in Hodgkin’s disease.

2. Bruising and petechiae are not physical findings in Hodgkin’s disease.

3. Firm, non-tender lymph nodes are classic findings in Hodgkin’s disease.

4. Lymph nodes are usually not painful with Hodgkin’s disease.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 29.6 Recognize the most common soft tissue tumors in children, describe their treatment, and plan comprehensive care.

20. The nurse works in an oncology clinic. A preschool-age child is being seen in the clinic, and the nurse anticipates a diagnosis of cancer. The nurse prepares for which of the common reactions preschool-age children have following illnesses and hospitalizations?

1. Acceptance, especially if able to discuss the disease with children their own age 2. Thoughts that they caused their illness, and are being punished 3. Understanding of what cancer is and how it is treated 4.

Unawareness of the illness and its severity

Answer: 2 Rationale: 1. Immediate acceptance will not occur with children of any age. Adolescents find contact with others who have gone through their experience helpful.

2. Preschool-age children are egocentric, and have magical thinking, and thus might believe they caused their own illness.

3. School-age children can understand a diagnosis of cancer.

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4. Infants and toddlers are unaware of the severity of the disease.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 29.7 Describe the impact of cancer survival on children, and use this information to plan for ongoing physiological and psychosocial care in the children’s future.

21. A 5-year-old has a brain tumor that has not responded to treatment. The child asks his mother what will happen when he dies. The mother asks the nurse how she should respond to her son’s question. Which of the following would be the best response to the mother?

1. “Have your minister provide all communication regarding death to the child.”

2. “Have the nurse tell the child that angels will carry him to heaven.”

3. “Assure the child that he will not be alone at the time of death.”

4. “Tell the child that death is just like going to sleep.”

Answer: 3 Rationale: 1. The child should talk to someone he trusts and is close to. Even if he is close to his minister, at age 5, this type information should come from parents, with assistance if necessary.

2. This answer provides an inappropriate and possible disturbing image.

3. Preschoolers need reassurance that they will not be abandoned.

4. The child will be afraid to go to sleep in the future.

Cognitive Level: Application Client Need: Psychosocial Integrity

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Ball and Bindler

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Nursing Process: Implementation Learning Outcome 29.7 Describe the impact of cancer survival on children, and use this information to plan for ongoing physiological and psychosocial care in the children’s future.

22. The nurse is caring for a 15-year-old male who has had a below-the-knee amputation as treatment for osteogenic sarcoma. The teen asks the nurse if he will be able to play sports again. Which of the following would be an appropriate nursing response?

5. “Children often play sports again with modifications or assistive equipment.”

6. “You will never be able to play sports again.”

7. “You will be able to watch sports on television with your friends.”

8. “Would you like me to find you another hobby?”

Answer: 1 Rationale: 1. This answer is honest and positive, looking at the future, which is how the nurse should respond to such a question from an adolescent.

1. This answer provides incorrect information. Those with below-the-knee amputations are able to play sports with assistive devices.

2. This answer does not meet the teen’s needs.

3. This response doesn’t answer the question, and is degrading.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation

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Learning Outcome 29.7 Describe the impact of cancer survival on children, and use this information to plan for ongoing physiological and psychosocial care in the children’s future.

23. A 6-year-old child is being admitted with newly diagnosed acute lymphocytic leukemia. The multidisciplinary team is meeting to plan care for this child and family.

Which statement by the parents should receive priority in the nursing planning process?

1. “We are afraid that the dog will dislodge his central line.”

2. “How are we going to pay for parking?”

3. “Can we go out of town for the summer?”

4. “His brother is upset about the amount of time we are away from home.”

Answer:

1

Rationale: 1. This is an imminent, potentially life-threatening concern.

2. Although a significant concern, this would not take precedence.

3. Should be addressed, but is not an acute issue.

4. This is a realistic concern, but not acute or life-threatening.

Cognitive Level: Evaluation Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 29.8 Develop methods for the oncology team, including nurses, social workers, psychologists, and child life therapists, to partner with school personnel, children and adolescents, families, and others to meet the many needs of children with cancer.

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Ball and Bindler

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24. After years of treatment with chemotherapy and radiation, a child with a brain tumor is shown to be refractory to treatment, and a DNR (Do Not Resuscitate) has been obtained. The mother has reached the stage of acceptance; the father is angry that the medical and nursing team has not been able to “save” his child. How would the multidisciplinary team best support this family?

1. Contact the on-call chaplain for consultation with the entire family, and ask him to take the father aside for additional assistance.

2. Initiate a Social Services referral.

3. Continue to include the family in planning care, and assure them that the child will be kept comfortable in the days to come.

4. Tell the father that he should have brought his child in earlier for treatment.

Answer: 3 Rationale: 1. Isolating the father would only increase his anger and make him feel belittled.

Contacting the chaplain would be appropriate if the family desired this.

2. This is not within the scope of Social Services.

3. Being informed and involved will be the best way to assist the father at this point.

Families also might need repeated and ongoing reassurances throughout the death process.

4. Increasing the father’s sense of guilt will not help diminish his anger.

Cognitive Level: Evaluation Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome 29.8 Develop methods for the oncology team, including nurses, social workers, psychologists, and child life therapists, to partner with school personnel, children and adolescents, families, and others to meet the many needs of children with cancer.

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Ball and Bindler

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25. During rounds, the interdisciplinary team is discussing the care of a child with a newly diagnosed Wilms’ tumor. The nurse describes the mother as being angry and upset that they are not caring properly for her child. What behavior probably is the cause of the mother’s anger?

1. The nurses are negligent in providing safe care for the child.

2. The mother does not have adequate support from Social Services.

3. The mother is feeling guilty for not recognizing that the child was ill.

4. The mother is beginning the stages of grief over loss of her previously well child.

Answer: 4 Rationale: 1. The mother is in the anger stage of grief, and it is not reflective of the nursing care.

2. This is not evident in the question.

3. This is not evident in the question 4. Anger is the first stage of the grief process, and can be applied in this instance to the mother’s loss of a normal child and potential death.

Cognitive Level: Evaluation Client Need: Psychosocial Integrity Nursing Process: Evaluation Learning Outcome 29.8 Develop methods for the oncology team, including nurses, social workers, psychologists, and child life therapists, to partner with school personnel, children and adolescents, families, and others to meet the many needs of children with cancer.

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Test Bank

1. Which of the following is an anatomic difference between the GI tract of the child and that of the adult?

1. The capacity of the stomach is less in the child as compared with the adult.

2. The emptying time of the stomach increases with age.

3. Saliva production is less in children as compared with adults.

4. The rate of digestion is faster in infants than in adults.

Answer: 1 Rationale: 1. Stomach capacity of the newborn is very small, and stomach capacity increases with age.

2. Emptying time of the stomach decreases with age.

3. Saliva production diminishes with age.

4. Infants have fewer enzymatic enzymes, and therefore have a slower rate of digestion that the adult. As enzymes increase with age, rate of digestion increases.

Cognitive Level: Knowledge Client Need: Physiological Assessment Nursing Process: Assessment Learning Outcome 30.1 Describe the anatomic and physiologic characteristics of the developing gastrointestinal system.

2. Which of the following describes the correct sequence of food entering the digestive system and being digested without the system?

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Test Bank 1. Mouth, esophagus, stomach, duodenum, jejunum, ileum, ascending colon, transverse colon, descending colon, and rectum 2. Mouth, esophagus, stomach, jejunum, ileum, duodenum, transverse colon, descending colon, and rectum 3. Mouth, esophagus, stomach, ileum, ascending colon, transverse colon, descending colon, and rectum 4. Mouth, esophagus, stomach, duodenum, ileum, jejunum, transverse colon, descending colon, ascending colon, and rectum

Answer: 1 Rationale: 1. This is the correct sequence of digestion 2. The sequence of small and large bowel is out of order, and ascending colon is missing.

3. The duodenum and jejunum are missing.

4. The sequence is incorrect.

Cognitive Level: Knowledge Client Need: Physiological Assessment Nursing Process: Assessment Learning Outcome 30.1 Describe the anatomic and physiologic characteristics of the developing gastrointestinal system.

3. Which of the following are functions of the GI tract? Select all that apply.

1. Digestion and absorption of nutrients and water 2. Production of ADH 3. Elimination of waste products 4. Secretion of rennin 5. Production of hormones that aid in bone marrow production

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Test Bank

Answer: 1, 3 Rationale: 1. Digestion and absorption of water are primary functions of the GI tract.

2. ADH is produced in the renal system.

3. The elimination of waste products is a function of the GI system.

4. This is a function of the renal system.

5. This is not a function of the GI system.

Cognitive Level: Knowledge Client Need: Physiological Assessment Nursing Process: Assessment Learning Outcome 30.1 Describe the anatomic and physiologic characteristics of the developing gastrointestinal system.

4. The nurse is administering several medications to an infant with neurologic impairment and delay secondary to a MVA. Which of the following medications is a proton pump inhibitor administered for gastroesophageal reflux?

1. Omeprazole (Prilosec) 2. Ranitidine (Zantac) 3. Phenytoin (Dilantin) 4.

Glycopyrrolate (Robinul)

Answer: 1 Rationale: 1. Omeprazole (Prilosec) is the proton pump inhibitor that blocks the action of acidproducing cells and is used to treat gastroesophageal reflux.

2. Ranitidine (Zantac) causes the stomach to produce less acid, and may be used to treat

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Test Bank gastroesophageal reflux, but it is a histamine-2 receptor blocker.

3. Phenytoin (Dilantin) is an anticonvulsant used to treat seizures.

4. Glycopyrrolate (Robinul) is an anticholinergic agent used to inhibit excessive salivation.

Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Comprehension Learning Outcome 30.2 Differentiate between different classifications of gastrointestinal disorders.

5. A child with inflammatory bowel disease is taking prednisone daily. The family should be taught to administer the prednisone at what time?

1. Between meals 2. One hour before meals 3. At bedtime 4.

With meals

Answer: 4 Rationale: 1. Prednisone can cause gastric irritation, and should not be given on an empty stomach.

2. Prednisone can cause gastric irritation, and should not be given on an empty stomach.

3. Prednisone can cause gastric irritation, and should not be given on an empty stomach.

4. Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.

Nursing Process: Implementation

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Test Bank Client Need: Physiological Integrity Cognitive Level: Application Learning Outcome 30.2 Differentiate between different classifications of gastrointestinal disorders.

6. A child is suspected of having Hirschsprung’s disease. Which of the following assessment factors would support such a medical diagnosis?

1. History of constipation with large, foul-smelling stools 2. Continual bouts of foul-smelling diarrhea 3. Passage of a large amount of meconium in the newborn period 4. Clay-colored stools Answer: 1 Rationale: 1. This is the primary symptom of Hirschsprung’s disease.

2. Diarrhea is not typical; obstruction is more likely.

3. Hirschsprung’s disease is not associated with meconium.

4. Clay-colored stools do not occur with Hirschsprung’s disease.

Cognitive Level: Comprehension Client Need: Physiological Assessment Nursing Process: Assessment Learning Outcome 30.2 Differentiate between different classifications of gastrointestinal disorders.

7. The nurse is evaluating an infant’s tolerance of a feeding post-pyloromyotomy. Which finding indicates the infant is not tolerating the feeding?

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Test Bank 1. Need for frequent burping 2. Irritability during feeding 3. Passing of gas 4.

Emesis after two feedings

Answer: 4 Rationale: 1. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy, and would indicate tolerance of the feeding.

2. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy, and would indicate tolerance of the feeding.

3. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy, and would indicate tolerance of the feeding.

4. An infant is not tolerating feedings after a pyloromyotomy if emesis is present.

Nursing Process: Evaluation Client Need: Physiological Integrity Cognitive Level: Analysis Learning Outcome 30.3 Identify signs and symptoms that might indicate a disorder of the gastrointestinal system.

8. A child with severe gastroenteritis is being admitted to a semi-private room on the pediatric unit. The nurse in charge should place this client with which roommate?

1. An infant with meningitis 2. A child with fever and neutropenia 3. Another child with gastroenteritis 4.

A child recovering from an appendectomy

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Test Bank Rationale: 1. Because meningitis is contagious, this infant should be placed on isolation, and not placed in a semi-private room.

2. A child with neutropenia is susceptible to viral illness, and should not be placed in a room with a child who has gastroenteritis.

3. Gastroenteritis can be viral or bacterial, and can be infectious. It is best to cohort children with this infectious process. Good handwashing is essential to prevent the spread.

4. A child recovering from an appendectomy should not be placed with another child with an infectious process.

Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Analysis Learning Outcome 30.3 Identify signs and symptoms that might indicate a disorder of the gastrointestinal system.

9. An adolescent complains of abdominal pain with diarrhea and bloody stools. The nurse should recognize these as symptoms of which inflammatory bowel disease?

1. Appendicitis 2. Crohn’s disease 3. Ulcerative colitis 4. Necrotizing enterocolitis Answer: 3 Rationale: 1. Appendicitis is not associated with bloody stools, and usually not with diarrhea.

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Test Bank 2. The teen with Crohn’s disease might have abdominal pain and diarrhea, but stools usually do not have blood in them.

3. Diarrhea and bloody stools are typical symptoms of UC. 4. Necrotizing enterocolitis is usually seen in premature infants, and not generally in an adolescent patient.

Cognitive Level: Comprehension Client Need: Physiological Assessment Nursing Process: Assessment Learning Outcome 30. 3 Identify signs and symptoms that might indicate a disorder of the gastrointestinal system.

10. The nurse is measuring an abdominal girth on a child with abdominal distension.

Identify the area on the child’s abdomen where the tape measure should be placed for an accurate abdominal girth.

1. Just above the umbilicus, around the largest circumference of the abdomen 2. Below the umbilicus 3. Just below the sternum 4.

Just above the pubic bone

Answer: 1 Rationale: 1. An abdominal girth should be taken around the largest circumference of the abdomen—in this case, just above the umbilicus.

2. The circumference below the umbilicus, just below the sternum, or above the pubic bone would not be an accurate abdominal girth.

3. The circumference below the umbilicus, just below the sternum, or above the pubic bone would not be an accurate abdominal girth.

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Test Bank 4. The circumference below the umbilicus, just below the sternum, or above the pubic bone would not be an accurate abdominal girth.

Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Learning Outcome 30.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing non-operative management.

11. The nurse is planning postoperative care for an infant after a cleft lip repair. Which of the following should the nurse include in this infant’s plan of care?

1. Prone positioning 2. Suctioning with a tonsil tip (Yankauer) device 3. Supine or side-lying positioning 4.

Avoidance of soft elbow restraints

Answer: 3 Rationale: 1. The prone position should be avoided to prevent tension or rubbing of the suture line.

2. A tonsil tip (Yankauer) suction device is made of hard plastic, and, if used, could cause trauma to the suture line. Suctioning should be done with a small, soft-suction catheter.

3. Integrity of the suture line is essential for postoperative care of cleft lip repair. The infant should be placed in a supine or side-lying position to avoid rubbing the suture line on the bedding.

4. Soft elbow restraints should be used to prevent the infant from touching the surgical area.

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Test Bank Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Analysis Learning Outcome 30.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing non-operative management.

12. An infant has been born with an esophageal atresia and tracheoesophageal fistula.

What is a priority preoperative nursing diagnosis?

1. Aspiration, risk for related to regurgitation 2. Acute Pain related to esophageal defect 3. Ineffective Infant Feeding Pattern related to uncoordinated suck and swallow 4.

Ineffective Tissue Perfusion: Gastrointestinal, related to decreased circulation

Answer: 1 Rationale: 1. This is the most common type of esophageal atresia and tracheoesophageal fistula, where the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea.

2. Pain is not usually experienced preoperatively with this condition.

3. The infant is always kept n.p.o. (nothing by mouth) preoperatively, so ineffective feeding pattern would not apply.

4. Tissue perfusion is not a primary problem with this condition.

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Test Bank Nursing Process: Diagnosis Client Need: Physiological Integrity Cognitive Level: Analysis Learning Outcome 30.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing non-operative management.

13. An infant born with an omphalocele defect is being admitted to the intensive care nursery. Which of the following should the nurse in charge instruct the nursing technician to prepare?

1. Radiant warmer 2. Crib 3. Formula for feeding 4.

Bilirubin light

Answer: 1 Rationale: 1. Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The infant loses heat through the viscera; a warmer is indicated to prevent hypothermia.

2. The crib would not provide adequate maintenance of temperature control.

3. The infant is n.p.o. (nothing by mouth) preoperatively.

4. The need for a bilirubin light is not directly related to an abdominal wall defect.

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Test Bank Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Application Learning Outcome 30.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing non-operative management.

14. The nurse is preparing to ambulate an 11-year-old child who has had an appendectomy. In addition to pharmacological pain management, which of the following non-pharmacological pain management strategies would be appropriate for this child?

1. A heating pad 2. A warm, moist pack 3. A splint pillow against the abdomen when moving or coughing 4.

An ice pack

Answer: 3 Rationale: 1. Heat and ice are not used on the incision area, as they can impair the healing process of the wound.

2. Heat and ice are not used on the incision area, as they can impair the healing process of the wound.

3. A splint pillow placed on the abdomen is a non-pharmacological strategy to decrease discomfort after an appendectomy.

4. Heat and ice are not used on the incision area, as they can impair the healing process of the wound.

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Test Bank Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Learning Outcome 30.5 Analyze developmentally appropriate approaches for nursing management of gastrointestinal disorders in the pediatric population.

15. A neonate is being fed 20 mL every three hours by orogastric lavage. At the beginning of this feeding, the nurse aspirates 15 mL of gastric residual. Which of the following would be the most appropriate action by the nurse?

1. Withhold the feeding and notify the physician.

2. Replace the residual and continue with the full feeding.

3. Replace the residual, but only give 5 mL of the feeding.

4.

Withhold the feeding and check the residual in three hours.

Answer: 1 Rationale: 1. Residual of more than half the amount of feeding indicates delayed emptying, and could be a sign of necrotizing enterocolitis. Early detection of enterocolitis is essential, and aggressive management is required. Therefore, the physician should be notified of this finding.

2. The amount of residual is too much to replace and continue with the feeding.

3. The amount of residual is too much to replace and continue with the feeding.

4. Waiting for three hours to recheck the residual could delay treatment of a serious condition.

Nursing Process: Evaluation

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Test Bank Client Need: Physiological Integrity Cognitive Level: Analysis Learning Outcome 30.5 Analyze developmentally appropriate approaches for nursing management of gastrointestinal disorders in the pediatric population.

16. The nurse has taught the parents of a child with celiac disease about foods that are allowed in the child’s diet. Which of the following would have been included in the education as an allowed meal?

1. Pizza with milk 2. Spaghetti and meat sauce with juice 3. Hot dog on a bun with a shake 4.

Fruit plate with Gatorade

Answer: 4 Rationale: 1. A child with celiac disease needs a gluten-free diet. Foods this child should not have are those that include wheat, rye, barley, and oats. These foods would include bread, cake, doughnuts, cookies, crackers, and many processed foods that can contain hidden gluten.

2. A child with celiac disease needs a gluten-free diet. Foods this child should not have are those that include wheat, rye, barley, and oats. These foods would include bread, cake, doughnuts, cookies, crackers, and many processed foods that can contain hidden gluten.

3. A child with celiac disease needs a gluten-free diet. Foods this child should not have are those that include wheat, rye, barley, and oats. These foods would include bread, cake, doughnuts, cookies, crackers, and many processed foods that can contain hidden gluten.

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Test Bank 4. Foods allowed include fruits, meats, rice, and vegetables. Therefore, the child would be allowed to have the fruit plate with Gatorade.

Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Learning Outcome 30.5 Analyze developmentally appropriate approaches for nursing management of gastrointestinal disorders in the pediatric population.

17. Which of the following statements indicates that parents have understood the nurse’s teaching with regard to colostomy stoma care for their infant?

1. “We will change the colostomy bag with each wet diaper.”

2. “We will use adhesive enhancers when we change the bag.”

3. “We will watch for skin irritation around the stoma.”

4.

“We will expect a moderate amount of bleeding after cleansing the area around

the stoma.”

Answer: 3 Rationale: 1. Physical or chemical skin irritation can occur if the appliance is changed too frequently, or with each wet diaper.

2. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin.

3. Skin irritation around the stoma should be assessed; it could indicate leakage.

4. Bleeding is usually attributable to excessive cleaning.

Nursing Process: Evaluation Client Need: Health Promotion and Maintenance

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Test Bank Cognitive Level: Analysis Learning Outcome 30.6 Discuss nursing management of the child with an injury to the abdomen.

18. A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which of the following equipment should the nurse prepare for use?

1. Equipment for intubation 2. Appropriate bag-valve-mask system 3. Sterile gauze and saline 4.

Soft arm restraints

Answer: 1 Rationale: 1. A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so that the newborn’s respiratory status can be stabilized.

2. A bag-valve-mask or ambu bag could push air into the stomach and cause abdominal distension, increase pressure on the diaphragm, and impair breathing.

3. The defect is not external, so sterile gauze and saline are not needed.

4. Soft arm restraints might be necessary, but at are not an immediate concern.

Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Analysis Learning Outcome 30.6 Discuss nursing management of the child with an injury to the abdomen.

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19. A child returns from exploratory abdominal surgery following a gunshot wound to the abdomen. Which of the following nursing interventions would the nurse omit from the plan of care for this child?

1. Frequent assessment of the surgical site 2. N.p.o. status until bowel sounds return 3. Monitor rectal temperature every hour.

4. Allow parents at the bedside as soon as possible.

Answer: 3 Rationale: 1. The surgical site must be visualized frequently for bleeding.

2. This is standard postop care.

3. Rectal temperature is not indicated, and should never be done as frequently as q1h.

4. This describes family-centered care; parents should be involved as much as possible and should be present before the child wakes up.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 30.6 Discuss nursing management of the child with an injury to the abdomen.

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Ball 2e

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1. The nurse teaches parents that the anticholinergic drug used to treat enuresis is: 1.

Desmopressin acetate (DDAVP).

2.

Oxybutynin (Ditropan).

3.

Imipramine (Tofranil).

4.

Spironolactone (Aldactone).

Answer: 2 Rationale: 1. Desmopressin acetate (DDAVP), as the name implies, is a vasopressin.

2. Oxybutynin (Ditropan) is an anticholinergic that relaxes the smooth muscle of the bladder, allowing for an increase in bladder capacity and a delay in the initial desire to void.

3. Imipramine (Tofranil) is a tricyclic antidepressant.

4. Spironolactone (Aldactone) is a potassium-sparing diuretic.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Intervention Learning Outcome 31-1 Describe the pathophysiologic processes associated with genitourinary disorders in the pediatric population.

2. A child has been admitted to the hospital unit with a diagnosis of minimal change nephrotic syndrome (MCNS). The clinical manifestations will include which of the following?

1.

Hematuria, bacteriuria, and weight gain

2.

Gross hematuria, albuminuria, and fever

3.

Massive proteinuria, hypoalbuminemia, and edema

4.

Hypertension, weight loss, and proteinuria

Answer: 3

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Rationale: 1 Bacteriuria and fever are associated with a urinary tract infection. Because of the edema, a weight gain, not a weight loss, would be seen.

2

Gross hematuria and hypertension are associated with glomerulonephritis.

3 Nephrotic syndrome is an alteration in kidney function secondary to increased glomerular basement membrane permeability to plasma protein. It is characterized by massive proteinuria, hypoalbuminemia, and edema.

4

While hematuria and hypertension might be present, they are not pronounced.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 31-1 Describe the pathophysiologic processes associated with genitourinary disorders in the pediatric population.

3. A child with nephritic syndrome is severely edematous. The primary health care provider has placed the child on bedrest. An important nursing intervention for this child would be to: 1 Reposition the child every two hours.

2 Monitor BP every 30 minutes.

3 Encourage fluids.

4 Limit visitors.

Answer: 1 Rationale: 1. A child with severe edema, on bedrest, is at risk for altered skin integrity. To prevent skin breakdown, the child should be repositioned every two hours.

2. Vital signs are taken every four hours.

3. Fluids need to be monitored, and should not be encouraged.

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4. The child needs social interaction, so visitors should not be limited.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 31-1 Describe the pathophysiologic processes associated with genitourinary disorders in the pediatric population.

4. A child with nephritic syndrome has been placed on prednisone. The nurse knows that for this syndrome, the administration will be: 1.

Daily for six weeks and then alternate-day doses for six weeks.

2.

Daily for one week.

3.

On a short-burst schedule.

4.

Infrequent.

Answer: 1 Rationale: 1. Prednisone, a corticosteroid with anti-inflammatory action that is frequently used to treat nephritic syndrome, is administered daily for six weeks and then in alternate-day doses for six weeks.

2. Daily for one week would not be effective for treating nephritic syndrome.

3. Short-burst therapy would not be effective for treating nephritic syndrome.

4. Infrequent dosing would not be effective for treating nephritic syndrome.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 31-1 Describe the pathophysiologic processes associated with genitourinary disorders in the pediatric population.

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5. A child is admitted with acute glomerulonephritis. The nurse would expect the urinalysis during this acute phase to show which of the following?

1.

Bacteriuria and hematuria

2.

Hematuria and proteinuria

3.

Bacteriuria and increased specific gravity

4.

Proteinuria and decreased specific gravity

Answer: 2 Rationale: 1. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Bacteriuria is not present.

2. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. The clinical manifestation of glomerulonephritis is grossly bloody hematuria with mild-to-moderate proteinuria, and because the urine is concentrated, the specific gravity is increased.

3. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Bacteriuria is not present. But because the urine is concentrated, the specific gravity is increased.

4. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Because the urine is concentrated, the specific gravity is increased.

Cognitive Level: Analysis Nursing Process: Assessment Client Need: Physiological Integrity Learning Outcome 31-1 Describe the pathophysiologic processes associated with genitourinary disorders in the pediatric population.

6. A 4-year-old has acute glomerulonephritis, and is admitted to the hospital. An appropriate nursing diagnosis for this child would be: 1.

Injury, risk for related to loss of blood in urine.

2.

Fluid Volume Excess related to decreased plasma filtration.

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3.

Infection, risk for related to hypertension.

4.

Altered Growth and Development related to a chronic disease.

Answer: 2 Rationale: 1. There is no risk for injury, because the blood loss in the urine is not sufficient to cause anemia.

2. The fluid is excessive, and fluid and electrolyte balance should be monitored.

3. While a risk for infection might be present, it is not related to the hypertension.

4. Growth and development are not normally affected, because this is an acute process, not a chronic one.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome 31-1 Describe the pathophysiologic processes associated with genitourinary disorders in the pediatric population.

7. A child with acute glomerulonephritis is in the playroom, and experiences blurred vision and headache. Which of the following actions should be taken by the nurse?

1.

Check the urine to see if hematuria has increased.

2.

Obtain a BP on the child; notify the physician.

3.

Reassure the child, and encourage bedrest until the headache improves.

4.

Obtain serum electrolytes, and send a urinalysis to the lab.

Answer: 2 Rationale: 1. Blurred vision and headache could be signs of encephalopathy, a serious complication of acute glomerulonephritis. Delay in treatment to check urine for hematuria could mean lethargy and seizures.

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2. Blurred vision and headache could be signs of encephalopathy, a complication of acute glomerulonephritis. A BP should be obtained, and the physician notified. The physician might decide to order an antihypertensive to bring down the BP. 3. This is a serious complication, and delay in treatment could mean lethargy and seizures. Reassurance and bedrest do not directly address the potential problem of encephalopathy.

4. Blurred vision and headache could be signs of encephalopathy, a serious complication of acute glomerulonephritis. Delay in treatment to check electrolytes and a urinalysis could mean lethargy and seizures.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome 31-1 Describe the pathophysiologic processes associated with genitourinary disorders in the pediatric population.

8. A nurse is preparing to admit a child with possible obstructive uropathy. What labs should the nurse expect to draw on this child?

1. Platelet count 2. Blood urea nitrogen (BUN) and creatinine 3. Blood culture 4. Partial thromboplastin time (PTT) Answer: 2 Rationale: 1. Platelet count is drawn when a bleeding disorder is suspected 2. The blood urea nitrogen (BUN) and creatinine are serum lab tests for kidney function. Obstructive uropathy is a structural or functional abnormality of the urinary system that interferes with urine flow and results in urine backflow into the kidneys; therefore, the BUN and creatinine will be elevated.

3. A blood culture is done when an infectious process is suspected.

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4. Partial thromboplastin time (PTT) are drawn when a bleeding disorder is suspected.

Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 31-2 Discuss the collaborative care and nursing management of the child with a structural defect of the genitourinary system.

9. Discharge instructions for care of a child who has just had an orchiopexy should include: 1.

Information to the parents that the child can resume normal vigorous activities.

2.

Discussion with the parents about the low incidence of testicular malignancy and

no further need for any follow-up.

3.

Explanation to the parents about the need for loose, non-restrictive clothing.

4.

Reassurance to the parents that infertility is not a future risk.

Answer: 3 Rationale: 1. Vigorous activities such as straddling toys, riding bicycles, or rough play should be avoided for up to two weeks following surgery to promote healing and prevent injury.

2. The risk of testicular cancer is 35–50 times greater in men with a history of cryptorchidism. Long-term planning includes teaching the child to perform monthly testicular examinations once puberty has been reached.

3. Orchiopexy is the surgical correction of cryptorchidism (failure of the testes to descend into the scrotal sac). Discharge instructions should include information about the need for loose, non-restrictive clothing to avoid pressure on the postoperative site.

4. A discussion of fertility and the possible need for fertility testing is important, since cryptorchidism increases the risk of infertility.

Cognitive Level: Application

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Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 31-2 Discuss the collaborative care and nursing management of the child with a structural defect of the genitourinary system.

10. Which of the following sets of symptoms are characteristic of a preschool-age child with a urinary tract infection?

1.

Foul-smelling urine, elevated BP, and hematuria

2.

Severe flank pain, nausea, and headache

3.

Headache, hematuria, and vertigo

4.

Urgency, dysuria, and fever

Answer: 4 Rationale: 1. While foul-smelling urine and hematuria can be present, there is no elevated BP, headache, or vertigo.

2. There could be flank pain, although the preschooler might be unable to describe it.

There will be no complaints of headache.

3. Hematuria might be present, but there will be no complaints of headache or vertigo.

4. Clinical manifestations of a urinary tract infection (UTI) in a preschool-age child include fever, urgency, and dysuria.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome 31-3 Develop a nursing care plan for the child with a urinary tract infection.

11. A child has undergone a kidney transplant, and is receiving cyclosporine. The parents

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ask the nurse about the reason for the cyclosporine. The nurse should explain that the drug is given to: 1.

Boost immunity.

2.

Suppress rejection.

3.

Decrease pain.

4.

Improve circulation.

Answer: 2 Rationale: 1. Cyclosporine doesn’t boost immunity. 2. Cyclosporine is given to suppress rejection. 3. Cyclosporine doesn’t decrease pain.

4. Cyclosporine doesn’t affect circulation.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Intervention

Learning Outcome 31-4Discuss the growth and development issues for the child with chronic renal failure.

12. A child in renal failure has hyperkalemia. The nurse plans to instruct the child and her parents to avoid which of the following foods?

1.

Carrots and green, leafy vegetables

2.

Chips, cold cuts, and canned foods

3.

Spaghetti and meat sauce, and breadsticks

4.

Hamburger on a bun, and cherry gelatin

Answer: 1 Rationale: 1. Carrots and green, leafy vegetables are high in potassium.

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2. Chips, cold cuts, and canned foods are high in sodium, but not necessarily in potassium.

3. Spaghetti and meat sauce with breadsticks would be acceptable choices for a lowpotassium diet.

4. Hamburger on a bun with cherry gelatin would be acceptable choices for a lowpotassium diet.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Planning

Learning Outcome 31-5 Summarize dietary restrictions for the child with a renal disorder.

13. A child is scheduled for a kidney transplant. The nurse has completed the preoperative teaching to prepare the child and parents for the surgery and postoperative considerations. The nurse will know the parents realistically understand the transplantation process that is involved with a kidney transplant if they state: 1.

“We know it’s important to see that our child takes prescribed medications after

the transplant.”

2.

“We’ll be glad we won’t have to bring our child in to see the doctor again.”

3.

“We’re happy our child won’t have to take any more medicine after the

transplant.”

4.

“We understand our child won’t be at risk anymore for catching colds from other

children at school.”

Answer: 1

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Rationale: 1. It is important that the nurse emphasize compliance with treatments that will need to be followed after the transplant.

2. Follow-up appointments will be necessary, as well as medications and general health promotion.

3. Medications and general health promotion will be necessary.

4. The child will be on immunosuppressing drugs, and will be at increased risk for colds and other illnesses.

Cognitive level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 31-6 Describe psychosocial issues for the child requiring surgery on the genitourinary tract.

14. A child is undergoing hemodialysis. The child should be monitored closely for: (Select all that apply.)

Shock.

1.

Hypotension.

2.

Infections.

3.

Migraines.

4.

5.

Fluid overload.

Answer: 1, 2, 3 Rationale: 1. Rapid changes in fluid and electrolyte balance during hemodialysis can lead to shock.

2. Rapid changes in fluid and electrolyte balance during hemodialysis can lead to hypotension.

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3. Infection is another complication that may occur during hemodialysis.

4. Migraines is not a clinical manifestation associated with hemodialysis.

5. Fluid overload is not a clinical manifestation associated with hemodialysis.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 31-7 Develop a nursing care plan for the child with acute and chronic renal failure on peritoneal dialysis.

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1. The anterior pituitary secretes: (Select all that apply.)

1. Oxytocin.

2. Antidiuretic hormone (ADH).

3. Growth hormone (somadotropin).

4. Thyroid-stimulating hormone (TSH).

5. Adrenocorticotropic hormone (ACTH).

Answer: 3, 4, 5 Rationale: 1. Oxytocin is secreted by the posterior pituitary.

2. ADH is secreted by the posterior pituitary.

3. Growth hormone is secreted by the anterior pituitary.

4. TSH is secreted by the anterior pituitary.

5. ACTH is secreted by the anterior pituitary.

Cognitive level: Knowledge Client Need: Health Promotion and Maintenance Nursing process: Diagnosis Learning Outcome: 32:1. Describe the general function of the endocrine system.

2. Parathyroid hormone:

1. Increases metabolic rate.

2. Acts on the kidney to increase synthesis of vitamin D. 3. Stimulates the hypothalamus to secrete gonadotropin-releasing hormone.

4. Affects protein and carbohydrate metabolism, and protects against stress.

Answer: 2 Rationale: 1. Thyroid hormone is responsible for maintaining metabolic rate.

2. Parathyroid hormone acts on the kidneys to increase synthesis of vitamin D. 3. Parathyroid hormone does not stimulate the hypothalamus.

4. Glucocorticoids affect protein and carbohydrate metabolism, and protect against stress.

Cognitive Level: Knowledge Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome: 32-1 Describe the general function of the endocrine system.

3. The home health nurse is visiting a 3-month-old who has been diagnosed with congenital hypothyroidism and 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. Dairy-based formula is contraindicated when an infant is taking thyroxine.

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

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

4. Parents may stop the thyroxine as long as the baby remains in the 50th percentile for height and weight.

Answer: 2 Rationale: 1. Dairy-based formula does not interfere with thyroxine.

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

3. Frequent checks must be done to assess the baby for inadequate growth.

4. To ensure adequate growth and development, the hormone must be taken throughout life.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Evaluation Learning Outcome: 32-2 Identify the function of important hormones of the endocrine system.

4. The nurse teaches the teenager and his parents that the signs of diabetic ketoacidosis (DKA) include which of the following? Select all that apply.

1. Tachycardia 2. Abdominal pain 3. Fruity breath odor 4. Change in mental status 5. Rapid, shallow respirations

Answer: 2, 3, 4 Rationale: 1. Tachycardia is not a typical symptom of DKA. 2. Abdominal pain is commonly seen with DKA. 3. A fruity breath odor is common when the client is in a state of ketoacidosis.

4. A change in mental state can be associated with DKA. 5. Respirations are rapid, but deep (Kussmaul’s breathing) in DKA. Cognitive Level: Application Client Need: Health Promotion and Maintenance.

Nursing Process: Planning Learning Outcome: 32-3 Identify signs and symptoms that might indicate a disorder of the endocrine system.

5. A child weighing 18.2 kg with a history of diabetes insipidus has been admitted to the hospital. Which of the following physician’s orders would the nurse question?

1. Stat electrolytes 2. Restrict oral fluids to 500 mL every 24 hours.

3. Urine specific gravity with each void 4. DDAVP (desmopressin) p.o.

Answer: 2 Rationale:

1. Stat electrolytes would be an appropriate order to check for hypernatremia.

2. Fluid replacement, not fluid restriction, is necessary for child with DI. 3. Urine specific gravity is checked because it is often low.

4. DDAVP is the drug of choice for a child with DI. Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 32-3 Identify signs and symptoms that might indicate a disorder of the endocrine system.

6. The nurse is assessing a 6-week-old female admitted to the hospital with fever. The nurse notes the infant has a webbed neck and lymphedema of both hands and feet. The nurse suspects that this infant might have: 1. Hypothyroidism.

2. Cushing’s disease.

3. Turner’s syndrome.

4. Klinefelter’s syndrome.

Answer: 3 Rationale: 1. Early signs of hypothyroidism are prolonged jaundice, bradycardia, and hypothermia, and symptoms are not seen until the first few months of life.

2. The typical symptoms of Cushing’s disease are not seen until a child is 2–5 years old.

Symptoms include moon face and fat pads over the shoulders and back, referred to a buffalo hump.

3. Turner’s syndrome is characterized by a webbed neck, lymphedema, and a low hairline in the infant.

4. Klinefelter’s syndrome is seen in boys.

Cognitive Level: Evaluation Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning objective: 32-4 Identify three conditions for which short stature is a sign.

7. A 5-year-old with a history of hypopituitarism comes to the physician with complaints of right hip and leg pain. The nurse understands that this symptom might be related to: 1. Daily growth hormone.

2. DDAVP (desmopressin acetate) at HS. 3. Insulin before meals and bedtime.

4. Cortisone injections.

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.

2. DDAVP reduces urinary output. It does not cause slipped capital femoral epiphysis.

3. Insulin is not used to treat hypopituitarism.

4. Cortisone is not used for hypopituitarism.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome: 32-4 Identify three conditions for which short stature is a sign.

8. An adolescent female with Graves’ disease is admitted to the hospital. The nurse expects to find which of the following signs and symptoms in this client?

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

2. Clinical manifestations of Graves’ disease are tachycardia, fatigue, and heat intolerance, seen with hyperthyroidism.

3. Weight gain, hirsutism, and muscle weakness are seen in clients with Cushing’s disease.

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

Cognitive Level: Analysis Client Need: Physiological Integrity

Nursing Process: Assessment Learning Objective: 32-5 Develop a nursing care plan for each type of acquired metabolic disorder.

9. A hospitalized child has been diagnosed with SIADH (syndrome of inappropriate antidiuretic hormone), a complication of his meningitis. The nurse would expect this child’s labs to show: 1. Hypernatremia.

2. Hyperglycemia.

3. Hyponatremia.

4. Hypocalcemia.

Answer: 3 Rationale: 1. Hypernatremia is seen with DI, not SIADH. 2. Hyperglycemia is not related to SIADH. 3. SIADH is associated with increased permeability in distal renal tubes, leading to water intoxication and low sodium.

4. Hypocalcemia is not seen with SIADH. Cognitive Level: Synthesis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 32-5 Develop a nursing care plan for each type of acquired metabolic disorder.

10. The nurse is caring for a child with hyperthyroidism. This child is on thiomide therapy, and is taking propranolol (Inderal) as adjunct therapy. The nurse knows that this child is taking the propranolol to relieve symptoms of: 1. Insomnia.

2. Tachycardia.

3. Emotional liability.

4. Muscle weakness.

Answer: 2 Rationale: 1. Propranolol is a beta-blocker. It does not affect insomnia.

2. Propranolol is used to relieve symptoms of tachycardia, tremors, lid lag, and excessive sweating.

3. Propranolol does not treat emotional liability.

4. Muscle weakness is not treated with propranolol.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 32:5 Develop a care plan for each type of acquired metabolic disorder.

11. In a newborn with congenital adrenal hyperplasia, the nurse knows that a sign of acute adrenal insufficiency is:

1. Hypocalcemia.

2. Hypercalcemia.

3. Hyponatremia.

4. Hypernatremia.

Answer: 3 Rationale: 1. Hypocalcemia is not seen with adrenal insufficiency.

2. Hypercalcemia is not seen with adrenal insufficiency.

3. Hypernatremia is not seen with adrenal insufficiency.

4. Hyponatremia is seen in adrenal insufficiency.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Objective: 32-6 Develop a family education plan for the child who needs lifelong cortisol replacement.

12. The nurse is giving discharge instructions to the parents of a child who has had removal of adrenal glands due to a tumor. The nurse knows that the mother needs more instructions when the mother states: 1. “I will give my child his hydrocortisone in the morning.”

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

3. “I will call the doctor if my child has restlessness and confusion.”

4. “If my child has vomiting and diarrhea, I will hold his hydrocortisone.”

Answer: 4 Rationale: 1. The child should have hydrocortisone in the morning, which mimics the normal diurnal pattern of cortisol secretion.

2. Hydrocortisone can cause gastric irritation, and antacids are given between meals.

3. Restlessness and confusion can be signs of adrenal insufficiency, and the physician would need to know these symptoms.

4. 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.

Cognitive Level: Evaluation Client Need: Safe, Effective Care Environment Nursing Process: Evaluation Learning Outcome: 32-6 Develop a family education plan for the child who needs lifelong cortisol replacement.

13. The nurse is caring for a child just admitted with diabetic ketoacidosis (DKA). The nurse should question which of the following physician’s orders?

1. Stat serum electrolytes 2. Neurological checks hourly

3. NPH insulin IV at 0.1 units/kg per hour.

4. Insert urinary catheter and measure output hourly.

Answer: 3 Rationale: 1. Stat electrolytes are an appropriate order.

2. Hourly neuro checks are an appropriate order.

3. NPH insulin would not be ordered IV. A short-acting insulin needs to be ordered.

4. Urinary catheter and hourly outputs are appropriate.

Cognitive Level: Synthesis Client Need: Physiological Integrity: Reduction of Risk Potential Nursing Process: Planning Learning Outcome: 32-7 Distinguish between the nursing care of the child with type I and the child with type II diabetes.

14. 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 765mg/dL. The nurse expects that this teen has which of the following symptoms?

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

Rationale: 1. Dry skin and dehydration are signs of hyperglycemia, but shallow breathing is a sign of hypoglycemia.

2. Tachycardia is seen in hypoglycemia.

3. Sweating, photophobia, and tremors are indicative of hypoglycemia.

4. Dry mucous membranes, blurred vision, and weakness are seen with hyperglycemia.

Cognitive Level: Application Client Need: Physiological Assessment Nursing process: Assessment Learning Outcome: 32-7 Distinguish between the nursing care of the child with type I and the child with type II diabetes.

15. A 12-year-old has been selected to be a cheerleader for her middle school. This child has been recently diagnosed with type I 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. Increased food intake.

2. Decreased food intake.

3. Increased doses of insulin.

4. Decreased doses of insulin.

Answer: 1 Rationale:

1. An increase in physical activity requires an increase in caloric intake to prevent hypoglycemia.

2. Decreased food intake would increase the chance of hypoglycemia.

3. 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.

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

Cognitive Level: Synthesis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 32-8 Describe collaborative management for the child with type I or type II diabetes.

16. The nurse is doing discharge teaching with the parents of a newly diagnosed type I diabetic.

The nurse knows that the mother needs more teaching when she states: 1. “I will give my child insulin if she experiences shakiness, pallor, and sweating.”

2. “I will give my child a snack before she practices afterschool soccer.”

3. “I will bring my child to the doctor every three months to have her HbA1c checked.”

4. “I understand my child might be experiencing hyperglycemia if she has thirst and flushed skin.”

Answer: 1 Rationale:

1. A child with shakiness, pallor, and sweating is exhibiting symptoms of hypoglycemia.

Giving insulin would make this situation worse.

2. The child needs a snack before practicing soccer to prevent hypoglycemia.

3. Diabetic children need to have an HbA1c done every three months.

4. A diabetic child with hyperglycemia might experience thirst and flushed skin.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Evaluation Learning Outcome: 32-8. Describe collaborative management for the child with type I or type II diabetes.

17. Lipoatrophy can be avoided in the type I diabetic by: 1. Rotating injection sites.

2. Administration of insulin via insulin pump.

3. Using a sliding scale for additional coverage.

4. Checking blood sugars at mealtime and bedtime.

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

2. Insulin administration via pump doesn’t influence lipoatrophy.

3. A sliding scale does not influence lipoatrophy.

4. Checking blood sugars does not influence lipoatrophy.

Cognitive Level: Application Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Learning Outcome: 32-8 Describe the collaborative management for the child with type I or type II diabetes.

18. The nurse is teaching the caregiver of a newly diagnosed type I diabetic ways to minimize pain with insulin injections. The nurse teaches the caregiver that which of the following interventions is helpful to minimize pain? Select all that apply.

1. Do not reuse needles.

2. Inject insulin when it is cold.

3. Have the child flex the muscle during injection.

4. Remove all bubbles from the syringe before injecting.

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

Answer: 1, 4, 5 Rationale: 1. Reusing needles leads to more pain on injection.

2. Insulin should be injected when it is at room temperature, to minimize pain.

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

4. Removing bubbles from the syringe minimizes pain.

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

Cognitive Level: Analysis Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Learning Outcome: 32-8. Describe collaborative management for the child with type I or type II diabetes.

19. The mother asks the nurse why her newborn baby needs a blood test for phenylketonuria (PKU) before she could take her home. The nurse explains to the mother: 1. “It is because you have a family history of this disease.”

2. “This test is done on in the U.S. on all babies who are 48 hours old.”

3. “Your baby was overdue (42 weeks’ gestation), and so has a greater chance of developing PKU.” 4. “This is done because you have chosen to feed your baby formula, so she is not protected against PKU.” Answer: 2 Rationale: 1. PKU testing is not done because of family history.

2. Neonatal screening for PKU is mandated by state law in all 50 states.

3. PKU does not occur from a longer-than-40-weeks gestation.

4. PKU does not occur because the newborn is formula-fed.

Cognitive Level: Application Client Need: Health Promotion and Maintenance

Nursing Process: Intervention Learning Outcome: 32-9 Develop a nursing care plan for the child with an inherited metabolic disorder.

20. The nurse is caring for a hospitalized 3-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. Biscuit 2. Yogurt 3. Oatmeal 4. Cantaloupe Answer: 4 Rationale: !. A child with SIADH may have carbohydrates, such as in a biscuit.

2. A child with SIADH may have dairy products, such as yogurt 3. A child with SAIDH may have carbohydrates and fiber, such as in oatmeal.

4. A child with SIADH is on a fluid restriction. Cantaloupe contains significant fluid volume, and so would not be a good food for this child to consume.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 32:9 Develop a nursing care plan for the child with an inherited metabolic disorder.

21. A newborn weighing 3.8 kg has been diagnosed with congenital hypothyroidism. The dose of levothyroxine prescribed by the physician is 10/mcg/kg daily by mouth. The oral syrup comes in 50 mcg per 2 mL. The dose the nurse needs to teach the mother to give is _________________ ml.

Answer: 1.5 Rationale: The infant’s weight is multiplied by 10 mcg to find the daily dose, which is 38 mcg/day. The bottle contains 50 mcg in 2 ml. 38 mcg is divided by 50 mcg, and this answer is multiplied by 2 ml to find the dose to be given to the infant. (The formula is dose divided by what is on hand times quantity.)

Cognitive Level: Application Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Learning Outcome: 32-9 Develop a nursing care plan for the child with an inherited metabolic disorder.

1. The nurse is doing an assessment on a 4-month-old infant. Which of the following assessment findings would the nurse consider abnormal?

1. The posterior fontanel is open.

2. The anterior fontanel is open and soft.

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

4. The infant has good head control when held upright Answer: 1 Rationale: 1. The posterior fontanel closes between 2 and 3 months of age.

2. An open anterior fontanel, which is soft, is a normal finding at 4 months.

3. Rolling from abdomen to back is a skill the 4-month-old should be learning.

4. Good head control is expected at 4 months of age.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Objective: 33-1 Describe the anatomy and physiology of the neurologic system.

2. A child with a motor response subscale of 5 from the Glasgow Coma Scale indicates: 1. Decorticate posturing.

2. Probable pediatric brain injury.

3. Total neurological unresponsiveness.

4. Purposeful movement, able to localize pain.

Answer: 2 Rationale: 1. Decorticate posturing is seen with a motor response of 3.

2. A Glasgow Coma Scale, motor response subscale score of 5 is strongly correlated with pediatric brain injury.

3. A score of 3 from the motor response subscale indicates total neurological unresponsiveness.

4. Purposeful movement and being able to localize pain is seen with a score of 5 in the motor response.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Objective: 33-2 Describe the nursing assessment process and tools for infants and children with altered levels of consciousness and other neurologic conditions.

3. The nurse has received a child from the Emergency Department with a diagnosis of decreased level of consciousness secondary to increased intracranial pressure. The nurse would question which of the following physician’s order?

1. Hourly vital signs and neuro checks 2. Passive range-of-motion exercises 3. Elevate head of bed 30 degrees.

4. Oxygen at 2L nasal cannula to keep saturation above 95% Answer: 2 Rationale: 1. Hourly vital signs and neuro checks are appropriate to watch for changes in this child’s condition.

2. 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.

3. The head is elevated 30 degrees to help to decrease increased intracranial pressure.

4. Oxygen should be ordered to keep the child’s O2 saturation above 95%.

Cognitive Level: Synthesis Client Need: Physiological Integrity Nursing Process: Planning Learning Objective: 33-2 Describe the nursing assessment process and tools for infants and children with altered levels of consciousness and other neurologic conditions.

4. A 4-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. Kidney stones.

3. Bowel obstruction.

4. Urinary tract infection.

Answer: 2 Rationale: 1. Appendicitis does not occur as a result of the ketogenic diet.

2. Kidney stones are seen in 5% of children on a ketogenic diet.

3. Ketogenic diet does not cause a bowel obstruction.

4. Urinary tract infections are not a result of a ketogenic diet.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Evaluation Learning Objective: 33-2 Describe the nursing assessment process and tools for infants and children with altered levels of consciousness and other neurologic conditions.

5. A child with a history of seizures arrives in the Emergency Department in status epilepticus. The nurse’s initial response is to: 1. Take vital signs.

2. Maintain patent airway.

3. Establish an intravenous line.

4. Perform rapid neurological assessment.

Answer: 2 Rationale: 1. Taking vital signs is important, but airway always comes first.

2. Airway is always the priority of care.

3. Once the airway is secure, then securing an IV is vital.

4. A rapid neurological assessment is appropriate once the airway is secure.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 33-3 Differentiate between the signs in infants and children who have epilepsy and status epilepticus, and describe appropriate nursing management for each condition.

6. The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child has been put 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 let him chew his tablet.”

2. “I will not use carbonated beverages to dilute his medication.”

3. “I will give his medicine on any empty stomach so he will absorb it better.”

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

Answer: 3 Rationale: 1. This child should not be allowed to chew a valproic acid tablet.

2. Carbonated beverages should never be used to dilute valproic acid.

3. Valproic acid (Depakote) should be given with foods to decrease GI irritation.

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

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Evaluation

Learning Objective: 33-3 Differentiate between the signs in infants and children who have epilepsy and status epilepticus, and describe appropriate nursing management for each condition.

7. A 3-year-old previously was diagnosed with febrile seizures. This child has been coughing, and now has become febrile with a temperature of 102.8°F. The mother knows she needs to give her child acetaminophen. This child weighs 32 pounds. The safe dose of acetaminophen is 10–15mg/kg/dose. The dose of acetaminophen for this child is: (Round dose to the nearest tenth.) ___________________________ Answer: 145–218 mg Rationale: This child weighs 32 pounds, which divided by 2.2 equals 14.5 kg. 14.5 kg multiplied by 10 mg/kg (the lower end of the safe dose) equals 145 mg of acetominophen. 14.5 mg multiplied by 15 mg/kg (the higher end of the safe dose equals 217.5 mg of acetominophen, which can be rounded to 218 mg.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Objective: 33-3 Differentiate between the signs in infants and children who have epilepsy and status epilepticus, and describe appropriate nursing management for each condition.

8. A young child admitted to the Pediatric unit has fever, irritability, and vomiting. The physician suspects bacterial meningitis. The nurse would expect the cerebrospinal fluid (CSF) to show: 1. Protein count of 50 mg/dL. 2. Increased glucose level.

3. Decreased glucose level.

4. Negative Gram stain.

Answer: 3 Rationale: 1. Bacterial meningitis causes CSF protein levels to be above 80 mg/dL. 2. Glucose levels are low in CSF when a child has bacterial meningitis 3. Glucose levels are low in CSF when a child has bacterial meningitis.

4. The Gram stain would be positive in bacterial meningitis.

Cognitive Level: Synthesis Client Need: Physiological Integrity Nursing Process: Evaluation Learning Objective: 33-4 Differentiate between signs of bacterial meningitis, viral meningitis, encephalitis, and Guillain-Barré syndrome in infants and children.

9. The nurse is planning care for a child with bacterial meningitis. The priority nursing diagnosis is: 1. Acute pain.

2. injury, Risk for.

3. infection, Risk for.

4. Impaired Gas Exchange.

Answer: 4 Rationale: 1. Management of pain is important, though not the priority.

2. Risk for injury is not the priority.

3. Risk for infection is not the priority.

4. Impaired gas exchange would be the priority to ensure patent airway and adequate gas exchange.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning

Learning Outcome: 33-4. Differentiate between signs of bacterial meningitis, viral meningitis, encephalitis, and Guillain-Barré syndrome in infants and children.

10. The nurse is caring for a 9-month-old who just returned from the PACU after a shunt placement for hydrocephalus. Which of the following physician’s orders would the nurse question?

1. Elevate head of bed.

2. Daily head circumference 3. Small, frequent formula feedings 4. Vital signs and neuro checks hourly Answer: 1 Rationale: 1. The 9-month-old should be placed in a flat position so that CSF drainage is not too rapid.

2. Daily head circumferences are needed to help evaluate shunt functioning.

3. Small, frequent feedings are appropriate to decrease the chance of vomiting.

4. Frequent vital signs and neuro checks are needed postoperatively.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Objective: 33-5 Develop a nursing care plan for the child with myelodysplasia and hydrocephalus.

11. The nurse is giving discharge teaching to the mother of a 3-year-old who has had a shunt revision. The nurse teaches the mother that which of the following are signs of shunt malformation? Select all that apply.

1. Fever 2. Vomiting 3. Dizziness 4. Bulging fontanel

5. Personality change Answer: 1, 2, 5 Rationale: 1. Fever can be a sign of shunt malfunction.

2. Vomiting can be a sign of shunt malfunction, and might indicate increased intracranial pressure.

3. Dizziness is not necessarily seen with a shunt malfunction, and can be difficult to assess in a 3-year-old.

4. Fontanels are closed in a 3-year-old.

5. Personality change can be indicative of a shunt malfunction.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Objective: 33-5 Develop a nursing care plan for the child with myelodysplasia and hydrocephalus.

12. A baby just born with a meningomyelocele is to have surgery in the morning. The nurse knows the care of this newborn includes: 1. Positioning the newborn in a prone position.

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

2. Applying a diaper to prevent contamination of sac.

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

Answer: 1 Rationale: 1. The newborn should be placed in a prone position to keep pressure off the sac.

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

3. A diaper is not used, because it also puts pressure on the sac.

4. The mother should not hold the baby, because that would put too much pressure on the sac.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Objective: 33-5 Develop a nursing care plan for the child with myelodysplasia and hydrocephalus.

13. In caring for a hospitalized 8-year-old child with myelodysplasia, the nurse should remember to: (Select all that apply.)

1. Use latex precautions.

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

3. Expect the child to have normal intelligence.

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

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

Answers: 1, 3, 4, 5 Rationale: 1. Children with myelodysplasia are at great risk for latex allergy. It is important to use latexfree products.

2. Children with myelodysplasia need a high-fiber diet to maintain adequate stool and bowel function.

3. Many children with myelodysplasia have normal intellect. They should be treated according to their intellectual level, rather than their motor development.

4. Self-catheterization fosters independence in this child. It is important to maintain the same schedule as much as possible when this child is hospitalized.

5. Due to decreased sensation in the buttocks and lower extremities, it is very important for the child to shift positions while she is in her wheelchair, to prevent pressure sores.

Cognitive level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Objective 33-5 Develop a nursing care plan for the child with myelodysplasia and hydrocephalus.

14. The nurse is teaching the kindergarten teacher about a 5-year-old who will be starting school and has cerebral palsy. She has a continuous Baclofen pump. The nurse informs the teacher of possible side effects of this drug, including: 1. Diarrhea.

2. Hypotonia.

3. Restlessness.

4. Hypertonia.

Answer: 2 Rationale: 1. Continuous Baclofen infusion does not cause diarrhea.

2. Hypotonia is possible if the child is getting too much Baclofen.

3. Restlessness is not seen with Baclofen; rather, these children can be drowsy and sleepy.

4. Hypertonia is not seen as a side effect of Baclofen infusion.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Objective: 33-6 Describe the focus of community-based nursing care for the child with cerebral palsy.

15. A nurse is caring for a child who recently was diagnosed with cerebral palsy (CP). The major goals of therapy for this child will include: 1. Curing the underlying defect.

2. Increase the child’s IQ level.

3. Promoting optimum development.

4. Reversal of the degenerative processes that have occurred.

Answer: 3 Rationale: 1. CP is caused from a probable brain insult, and cannot be cured.

2. The majority of children with CP have normal IQs, but might have behavior or perceptual problems.

3. Promoting optimal development in all areas is the goal of therapy with children with CP.

4. CP is caused from an irreversible brain insult that cannot be reversed.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing process: Planning Learning Objective: 33-6 Describe the focus of community-based nursing care for the child with cerebral palsy.

16. A 9-month-old who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which of the following clinical manifestations would the nurse expect to see in the baby?

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

2. Hypotonia in infancy and muscle instability are seen in ataxic cerebral palsy.

3. Tremors and exaggerated posturing are seen in dyskinetic cerebral palsy.

4. Hypertonia and persistent primitive reflexes are seen in spastic CP. Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Objective: 33-7 Differentiate between the assessment findings of children with mild, moderate, and severe traumatic brain injury, and plan the appropriate initial nursing management for each.

17. The leading cause of death and disability during childhood is:

1. Cerebral palsy.

2. Myelodysplasia.

3. Infections of the brain.

4. Traumatic brain injury.

Answer: 4 Rationale: 1. CP can cause disability, but children with CP live to be adults. 2.

Myelodysplasia can cause disability, but death in childhood is not common. 3. Infections of the brain can cause disability and death, but because of immunizations, these diseases are less common than is traumatic brain injury. 4. Traumatic brain injuries are the most common injuries in childhood, and are the leading cause of death and disability during childhood.

Cognitive Level: Knowledge Client Need: Safe, Effective Care Environment Nursing Process: Diagnosis Learning Objective: 33-7 Differentiate between the assessment findings of children with mild, moderate, and severe traumatic brain injury, and plan the appropriate initial nursing management for each.

18. The nurse expects worsening cerebral edema to occur for ____________ hours after the primary injury.

1. 24 2. 36 3. 48 4. 72 Answer: 4 Rationale: 1. Cerebral edema increases for 72 hours after injury.

2. Cerebral edema increases for 72 hours after injury.

3. Cerebral edema increases for 72 hours after injury.

4. Cerebral edema increases for 72 hours after injury

Cognitive Level: Comprehension Client need: Physiological Integrity Nursing process: Assessment Learning Objective: 33-7 Differentiate between the assessment findings of children with mild, moderate, and severe traumatic brain injury, and plan the appropriate initial nursing management for each.

19. A 7-year-old with a head injury is hospitalized after losing consciousness when he was hit in the head with a 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. Probably normal for this child.

2. A sign of increased intracranial pressure.

3. A sign that this child has a spinal cord injury.

4. Typical for a sleeping child at this age.

Answer: 2 Rationale: 1. Normal heart rate for an awake child at this age is 70–110. Normal blood pressure is 92– 126/55–86. Normal respirations are 20 and regular.

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.

3. 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.

4. Normal sleeping pulse at this age is 60–90 bpm.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Evaluation Learning Objective: 33-7 Differentiate between the assessment findings of children with mild, moderate, and severe traumatic brain injury, and plan the appropriate initial nursing management for each.

20. A child has been diagnosed with a basilar skull fracture. The nurse should monitor this child for: 1. Protruding bone.

2. Epidural hematoma.

3. Periorbital ecchymosis.

4. Subdural hematoma.

Answer: 3 Rationale: 1. Protruding bone might be seen with a compound fracture.

2. Epidural hematoma is seen with linear fracture.

3. Periorbital ecchymosis, also called raccoon eyes, is seen with a basilar fracture.

4. Subdural hematoma might be seen with a linear fracture.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Objective: 33-7 Differentiate between the assessment findings of children with mild, moderate, and severe traumatic brain injury, and plan the appropriate initial nursing management for each.

1. The nurse is assessing a 4-year-old child with a possible alteration in mental health. Which of the following could indicate such an alteration? Select all that apply.

1. Eye contact 2. Appearance 3. Facial expressions 4. Head circumference 5. History of prenatal care and delivery 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. This could be altered in a child who has an alteration in mental health.

2. Appearance evaluates a child’s affect, and the nurse must determine whether the appearance is appropriate for age and developmental level.

3. Affect can be determined by facial expression and response to nurse, helping to determine mental health.

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

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

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Objective: 34:1 Define mental health and describe major mental health alterations in childhood.

2. The mother of a 6-year-old has brought 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 of the following factors could be associated with ADHD? 1. Immune response 2. Advanced parental age 3. Prenatal exposure to smoke 4. Measles, mumps, and rubella vaccine Answer: 3 Rationale: 1. Immune response can be associated with autism spectrum disorders.

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

3. Research shows that a mother’s use of cigarettes during pregnancy can increase the risk for ADHD. 4. Measles, mumps, and rubella vaccine has been thought to be associated with autism spectrum disorder, though a relationship has never been established through research.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Objective: 34-1 Define mental health and describe major mental health alterations in childhood.

3. The nurse is performing a developmental screening on a toddler. The nurse would expect this child to be able to express two-word phrases by: 1. 18 months.

2. 24 months.

3. 30 months.

4. 36 months.

Answer: 2 Rationale: 1. The 18-month-old is not expected to be able to use two-word phases.

2. The 24-month-old should be able to use two-word phrases.

3. A child should be able to use two-word phrases by 24 months. 30 months is outside of expected normal development.

4. A child should be able to use two-word phrases by 24 months. 36 months is outside of expected normal development.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Objective: 34-1 Define mental health and describe major mental health alterations in childhood.

4. Which of the following symptoms are commonly seen in an adolescent with depression?

Select all that apply.

1. Agoraphobia 2. Poor self-care 3. Focus on violence

4. Somatic complaints 5. Poor school performance Answer: 2, 3, 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.

2. Poor self-care can be associated with depression in an adolescent.

3. Focus on violence can be associated with depression in the adolescent.

4. Somatic complaints are more commonly associated with depression in the younger school-age child.

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

Cognitive level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Objective: 34-2 Discuss the clinical manifestations of major health alterations of childhood and adolescence.

5. The nurse is taking a history from the mother of a child who has been diagnosed with pediatric autoimmune neuropsychiatric disorder associated with streptococci (PANDAS). Which of the following might have led to this diagnosis?

1. Coprolalia 2. An episode of trauma

3. Group A hemolytic strep 4. Group B hemolytic strep Answer: 3 Rationale: 1. Coprolalia, which is the involuntary utterance of obscenities, profanities, and/or racial slurs, is seen in children with Tourette’s syndrome.

2. An episode of trauma is a precursor to post-traumatic stress disorder (PTSD), not PANDAS. 3. Group A hemolytic strep is associated with pediatric autoimmune neuropsychiatric disorder (PANDAS).

4. Group B hemolytic strep is not associated with PANDAS. Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Analysis Learning Objective: 34-2 Discuss the clinical manifestations of the major mental health alterations of childhood and adolescent.

6. The nurse explains to parents of a child diagnosed with separation anxiety disorder that the peak age for this diagnosis is: 1. 9 months of age.

2. 2–3 years of age.

3. 5–7 years of age.

4. 7–9 years of age.

Answer: 4 Rationale: 1. The phase of separation anxiety that is seen in a 9-month-old is normal development.

2. The separation anxiety that is seen in a toddler follows separation from a familiar caregiver, lasts only for a short time, and is a normal developmental response at this age.

3. The peak age for occurrence of separation anxiety disorder is not 5–7 years.

4. The peak age for occurrence of separation anxiety disorder is 7–9 years.

Cognitive Level: Comprehension Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Objective: 34-2 Discuss the clinical manifestations of the major mental health alterations of childhood and adolescent.

7. The nurse knows that the mother of a 6-year-old needs more teaching about her son’s diagnosis of ADHD when she states: 1. “I will give him his ADHD medication with his meals” 2. “I will stick to the same routine each day after school.”

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

4. “I will take my child to the physician every three months for a weight and height check.”

Answer: 3

Rationale: 1. Giving ADHD medication with meals will help counteract anorexia associated with this medication.

2. Maintaining the same daily routine helps the child know expectations, and a nighttime routine helps counteract insomnia.

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

4. Children with ADHD should be screened regularly for height and weight to monitor growth.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Evaluation Learning Outcome: 34-3 Plan for the nursing management of children and adolescents with mental health alterations in the hospital and community settings.

8. A child with autism is being admitted to the hospital with dehydration. Upon admission, the nurse should: 1. Take the child on a tour of the Pediatric unit.

2. Orient the child to his single-bed hospital room.

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

4. Orient the child to a four-bed unit so he will have company.

Answer: 2 Rationale:

1. 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.

2. Orienting a child with autism to a new environment is important, though this must be done in a quiet, controlled environment. A single room is the best place for an autistic child if the child must be hospitalized.

3. Arts and crafts might be appropriate for an autistic child if done in the child’s room.

Going to the playroom would be too much stimulation for this child.

4. An autistic child should be in a single room, if possible, away from distractions.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Intervention Learning objective: 34-3 Plan for the nursing management of children and adolescents with mental health alterations in the hospital and community settings.

9. A child with attention-deficit hyperactivity disorder (ADHD) wants to play soccer. Which of the following is appropriate for the school nurse to do?

1. Encourage the child to play soccer.

2. Discourage the child from playing a team sport like soccer.

3. Ask the child’s mother to get permission from the child’s physician to play soccer.

4. Recommend that the child become active in an individual sport, rather than a team sport.

Answer: 1

Rationale: 1. The child should be encouraged to play soccer. Participation in a team sport will assist the child with ADHD to expend some energy while cooperating with others and following game rules. Participating in a team sport can help promote self-esteem in the child with ADHD and encourage connectedness with other children.

2. The child should be encouraged to play soccer. There is no reason for a child with ADHD not to play sports.

3. The mother would not need physician approval for her son to play soccer. Vigorous physical activity is encouraged for all children with ADHD. 4. Some of the benefits of participating in a team sport would not be available with individual sports.

Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Intervention Learning Objective: 34-3 Plan for the nursing management of children and adolescents with mental health alterations in the hospital and community settings.

10. Which of the following antidepressants is approved for use in pediatric patients with depression?

1. Sertraline HCL (Zoloft) 2. Fluoxetine HCL (Prozac) 3. Clomipramine HCL (Anaframil) 4. Fluvoxamine maleate (Luvox) Answer: 2

Rationale: 1. Sertraline HCL is approved for obsessive-compulsive disorder, not depression.

2. Fluoxetine is approved for use in pediatrics for treatment of depression.

3. Clomipramine HCL has been approved for treatment of obsessive-compulsive disorder, not depression.

4. Fluvoxamine maleate is approved for treatment of obsessive-compulsive disorder, not depression.

Cognitive Level: Knowledge Client Need: Psychosocial Integrity Nursing Process: Planning Learning Objective: 34-3 Plan for the nursing management of children and adolescents with mental health alterations in the hospital and community settings.

11. A child weighing 66 pounds has been diagnosed with obsessive-compulsive disorder. The physician prescribes sertraline (Zoloft) for this child. The maximum recommended dose for children is 3 mg/kg/day. For this child, the maximum dose is _________ mg per day.

Answer: 90 Rationale: Divide 66 pounds by 2.2 to find that this child weighs 30 kg. Multiply 30 kg by 3 mg, which equals 90 mg/day.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation

Learning objective: 34-3 Plan for the nursing management of children and adolescents with mental health alterations in the hospital and community settings.

12. To which of the following would learning disabilities most likely be related?

1. Trisomy 21 2. Low birth weight 3. Maternal alcohol use 4. Prenatal exposure to smoke Answer: 2 Rationale: 1. Trisomy 21 is associated with Down syndrome, and also associated with mental retardation.

2. Low birth weight is a common factor associated with learning disabilities.

3. Maternal alcohol use is seen with fetal alcohol syndrome.

4. Prenatal exposure to smoke is not associated with learning disabilities.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Objective: 34-4 Describe characteristics of common cognitive alterations of childhood.

13. A 9-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. Dyslexia.

2. Dyspraxia.

3. Dysgraphia.

4. Dyscalculia.

Answer: 2 Rationale: 1. Children with dyslexia have difficulty with writing, reading, and spelling.

2. Children with dyspraxia have problems with manual dexterity and coordination.

3. Children with dysgraphia have difficulty with writing, spelling, and composition.

4. Children with dyscalculia have problems with mathematics and computation problems.

Cognitive Level: Application Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Objective: 34-4 Describe characteristics of common cognitive alterations of childhood.

14. The nurse is assessing a child with Down syndrome. Which of the following is this child at a greater risk to develop when compared with children who do not have Down syndrome?

1. Hepatitis 2. Thyroid disease 3. Glomerulonephritis 4. Rheumatic heart disease

Answer: 2 Rationale: 1. Hepatitis is not associated with Down syndrome.

2. Thyroid disease, as well as other autoimmune diseases, is more commonly seen in those with Down syndrome.

3. Glomerulonephritis is not seen in association with Down syndrome.

4. Heart defects might be seen with Down syndrome, but not rheumatic heart disease, which is associated with Group A beta-hemolytic streptococcus infection.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Analysis Learning Objective: 34-5 Plan nursing management for children with cognitive disorders.

15. A child admitted to the hospital with a diagnosis of pneumonia has a history of severe retardation. The nurse recognizes that the IQ of this child is: 1. 50–70.

2. 35–50.

3. 20–35.

4. Below 20.

Answer: 3 Rationale:

1. IQ of 50–70 is mild mental retardation.

2. IQ of 35–50 is moderate mental retardation.

3. IQ of 20–35 is severe mental retardation.

4. IQ below 20 is profound mental retardation.

Cognitive Level: Comprehension Client Level: Psychosocial Integrity Nursing Assessment: Assessment Learning Objective: 34-6 Establish and evaluate expected outcomes of care for the child with a cognitive alteration.

16. A nurse is performing a developmental assessment on several children in a clinic setting.

Which children exhibit a delay in meeting developmental milestones? Select all that apply.

1. A 5-year-old who is unable to button his shirt 2. A 2-year-old who is unable to cut with scissors 3. A 2-year-old who cannot recite her phone number 4. A 6-year-old who is unable to sit still for a short story 5. An 18-month-old toddler who is unable to speak in sentences Answer: 1, 4 Rationale: 1. A 5-year-old should be able to button his shirt.

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

3. A 2-year-old is not expected to be able to recite a phone number.

4. A 6-year-old should be able to sit still for a short story. A 3–5-year-old should be able to sit still through a short story.

5. An 18-month-old is not usually able to speak in sentences. This is a skill to be accomplished by the age of 2½ years.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Objective: 34-6 Establish and evaluate expected outcomes of care for the child with a cognitive alteration.

Test Bank

1. The nurse in the newborn nursery is doing the admission assessment on a neonate.

Congenital hip dysplasia will be suspected when the nurse observes: 1.

Asymmetry of the gluteal and thigh fat folds.

2.

Trendelenburg sign.

3.

Telescoping of the affected limb.

4.

Lordosis.

Answer: 1 Rationale: 1. A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat folds.

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

3. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia.

4. Lordosis does not occur with hip dysplasia.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 35-1 Describe pediatric variations in the musculoskeletal system.

2. A school health nurse is screening for scoliosis. For what assessment findings would the nurse look? Select all that apply.

1.

Uneven shoulders and hips

2.

A one-sided rib hump

3.

Prominent scapula

4.

Lordosis

5.

Pain

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Test Bank Answer: 1, 2, 3 Rationale: 1. The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula.

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

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

4. Lordosis is not present with scoliosis.

5. Pain generally is not present with scoliosis unless it is severe.

Cognitive Level: Comprehension Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 35-1 Describe pediatric variations in the musculoskeletal system.

3. 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 happy this is the only cast our baby will need.”

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 getting a special car seat to accommodate the casts.”

Answer: 1 Rationale: 1. Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every 1–2 weeks until the corrected foot position is achieved.

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

3. Keeping the casts dry is important to prevent complications 4. Using a car seat is the law. Special car seats to accommodate the casts are available, and should be utilized.

Cognitive Level: Analysis Client Need: Physiological Integrity

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Test Bank Nursing Process: Evaluation Learning Outcome 35-2 Plan nursing care for children with structural deformities of the foot, hip, and spine.

4. A child must wear a brace for correction of scoliosis. Which of the following nursing diagnoses takes priority at this time?

1.

Impaired Skin Integrity, risk for

2.

Altered Growth and Development, risk for

3.

Impaired Mobility, risk for

4.

Impaired Gas Exchange, risk for

Answer: 1 Rationale: 1. The skin should be monitored for breakdown in any area where the brace might rub against the skin.

2. The diagnosis of altered growth and development would not be the priority, and should be corrected by the wearing of the brace.

3. The diagnosis of impaired mobility would not be the priority, and should be corrected if the patient is compliant with wearing the brace.

4. 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.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome 35-2 Plan nursing care for children with structural deformities of the foot, hip, and spine.

5. An adolescent has just returned from surgery after spinal fusion surgery. Which of the following assessments would be priority at this time?

1.

Increased intracranial pressure

2.

Seizure activity

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Test Bank 3.

Impaired pupillary response during neurological checks

4.

Impaired color, sensitivity, and movement to lower extremities

Answer: 4 Rationale: 1. Increased intracranial pressure is not a great risk following spinal fusion surgery.

Impaired color, sensitivity, and movement to the lower extremities are greater risks.

2. Seizure activity is not typically seen following spinal fusion. There is a risk for impaired color, sensitivity, and movement to the lower extremities.

3. Pupillary response is not affected after spinal fusion surgery. There is a risk for impaired color, sensitivity, and movement to the lower extremities.

4. When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities. The other signs are neurological impairment, and are not high-risk with spinal surgery.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 35-2 Plan nursing care for children with structural deformities of the foot, hip, and spine.

6. A child has been admitted to the hospital with osteomyelitis. The nurse would expect to administer which intravenous antibiotic for this child?

1.

Ampicillin or penicillin

2.

Vancomycin or clindamycin

3.

Gentamycin or tobramycin

4.

Rifadin or rifampin

Answer: 2 Rationale: 1. Medical management of osteomyelitis begins with intravenous administration of a broad-spectrum antibiotic. Since there is a possibility of methicillin-resistant Staphylococcus aureus (MRSA), beginning antibiotics are typically vancomycin or clindamycin.

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Test Bank 2. Medical management of osteomyelitis begins with intravenous administration of a broad-spectrum antibiotic. Treatment is influenced by the possibility of methicillinresistant Staphylococcus aureus (MRSA), so beginning antibiotics are usually vancomycin or clindamycin.

3. Medical management of osteomyelitis begins with intravenous administration of a broad-spectrum antibiotic. Due to the possibility of methicillin-resistant Staphylococcus aureus (MRSA), the beginning drugs of choice are typically vancomycin or clindamycin. Gentamycin and tobramycin are aminoglycosides.

4. Rifampin is used to treat diseases such as tuberculosis, and would not likely be effective in treating osteomyelitis. The beginning drugs of choice are usually vancomycin or clindamycin.

Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome 35-3 Recognize signs and symptoms of infectious musculoskeletal disorders, and refer for appropriate care.

7. The nurse has completed discharge teaching for the family of a child diagnosed with Legg-Calvé-Perthes disease. 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.”

2.

“We understand swimming is a good sport for Legg-Calvé-Perthes.”

3.

“We know to watch for areas on the skin that the brace might rub.”

4.

“We understand abduction of the affected leg is important.”

Answer: 1 Rationale: 1. The treatment for Legg-Calvé-Perthes disease takes approximately two years. 2. Swimming is a good activity to increase mobility in a child with Legg-Calvé-Perthes

disease.

3. A brace might be worn to correct Legg-Calvé-Perthes disease, so skin irritation should be monitored.

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Test Bank 4. The leg should be kept in the abducted position to correct Legg-Calvé-Perthes disease.

Evaluation Physiological Integrity Analysis Cognitive Level: Application Client Need: Safe effective care environment Nursing Process: Evaluation Learning Outcome 35-4 Partner with families to plan care for children with musculoskeletal conditions that are chronic or require long-term care.

8. A nurse notes blue sclera during a newborn assessment. The infant should be checked for: 1.

Marfan’s syndrome.

2.

Achondroplasia.

3.

Osteogenesis imperfecta.

4.

Muscular dystrophy.

Answer: 3 Rationale: 1. The blue sclera seen during a newborn assessment could be a clinical manifestation of osteogenesis imperfect. Blue sclera is not associated with Marfan’s syndrome.

2. Clinical manifestations of osteogenesis imperfecta include blue sclera. Blue sclera is not associated with achondroplasia.

3. Clinical manifestations of osteogenesis imperfecta include blue sclera.

4. The blue sclera noted on a newborn assessment is a clinical manifestation of osteogenesis imperfecta. This is not present in muscular dystrophy.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment

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Test Bank Learning Outcome 35-4 Partner with families to plan care for children with musculoskeletal conditions that are chronic or require long-term care.

9. Which of the following would take priority when teaching the family how to care for an infant with osteogenesis imperfecta?

1.

The trunk and extremities should always be supported when moving this infant.

2.

Teaching the family how to care for an infant in traction

3.

Teaching the family how to care for an infant in a cast

4.

Teaching the family how to care for an infant postop spinal surgery

Answer: 1 Rationale: 1. With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones are fragile, the entire body must be supported when the child is moved.

2. Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta.

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

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

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation

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Test Bank Learning Outcome 35-4 Partner with families to plan care for children with musculoskeletal conditions that are chronic or require long-term care.

10. A 12-year-old boy with Duchenne’s muscular dystrophy is being seen in the clinic for a routine health visit. Which of the following would be an appropriate nursing diagnosis for this patient?

1.

Impaired Mobility, risk for related to hypertrophy of muscles

2.

Infection, risk for related to altered immune system

3.

Impaired Skin Integrity, risk for related to paresthesia

4.

Altered Comfort, risk for related to effects of the illness

Answer: 1 Rationale: 1. Nursing care for muscular dystrophy (MD) focuses on promoting independence and mobility for this progressive, incapacitating disease.

2. Risk for infection in a child with muscular dystrophy is not related to the immune system, and would not be as high a priority as risk for impaired mobility.

3. Risk for impaired skin integrity is not as high a priority as is risk for impaired mobility.

4. Risk for altered comfort is not as high a priority as is risk for impaired mobility.

Nursing care focuses on promoting independence and mobility.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Diagnosis Learning Outcome 35-4 Partner with families to plan care for children with musculoskeletal conditions that are chronic or require long-term care.

11. 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. Which of the following should the nurse do first?

1.

Call the physician to report the edema.

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Test Bank 2.

Elevate the legs on pillows.

3.

Apply a warm, moist pack to the feet.

4.

Encourage movement of toes.

Answer: 2 Rationale: 1. Some amount of swelling can be expected, so it would not be appropriate to notify the physician, especially if the color, sensitivity, and movement remained normal to the toes.

2. The legs should be elevated on a pillow for 24 hours to promote healing and help with venous return.

3. Ice should be applied, not heat.

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

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 35-5 Plan nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery.

12. 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 of the following 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.

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

3.

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

4.

Place a diaper over the harness, preferably using a thin, superabsorbent,

disposable diaper. Answer: 3 Rationale: 1. Lotion or powder can contribute to skin breakdown, and should not be used.

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Test Bank 2. A light layer of clothing should be worn under the brace to assist in preventing skin breakdown, not over the brace.

3. The skin underneath the straps of the brace should be checked two or three times a day for red areas, which might indicate skin breakdown.

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

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 35-5 Plan nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery.

13. A child has experienced a sprain of the right ankle. The school nurse should: 1.

Apply ice to the extremity.

2.

Apply a warm, moist pack to the extremity.

3.

Perform passive range-of-motion to the extremity.

4.

Lower the extremity below the level of the heart.

Answer: 1 Rationale: 1. 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.

2. 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.

3. 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 rangeof-motion.

4. For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed. Therefore, the nurse should elevate the extremity.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation

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Test Bank Learning Outcome 35-5 Plan nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery.

14. A nurse is assessing a child after an open reduction of a fractured femur. Which of the following are signs that compartment syndrome could be occurring? Select all that apply.

1.

Pink, warm extremity

2.

Pain not relieved by pain medication

3.

Dorsalis pedis pulse present

4.

Prolonged capillary refill time with paresthesia

Answer: 2, 4 Rationale: 1. Pink, warm extremity is a normal finding post–fracture reduction.

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

3. A present dorsalis pedis pulse would be a normal finding post–fracture reduction.

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

Cognitive Level: Analy sis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 35-6 Provide nursing care for fractures, including teaching for injury prevention and nursing implementations for the child who has sustained a fracture.

15. The nurse is caring for a child in Bryant’s skin traction. Which of the following is an appropriate nursing intervention for this child?

1.

Remove the adhesive traction straps daily to prevent skin breakdown.

2.

Check the traction frequently to ensure that proper alignment is

3.

maintained. Place the child in a prone position to maintain good

4.

alignment. Move the child as infrequently as possible to maintain traction.

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Test Bank Answer: 2 Rationale: 1. The adhesive straps should not be removed. Removing these straps would release the traction.

2. The traction apparatus should be checked frequently to ensure that proper alignment is maintained, so that appropriate traction is applied.

3. The child should be placed in a supine position while in Bryant’s traction.

4. Frequent repositioning is necessary to prevent complications of immobility.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 35-6 Provide nursing care for fractures, including teaching for injury prevention and nursing implementations for the child who has sustained a fracture.

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Ball 2e

Test Bank

1. Vernix caseosa covers a newborn’s skin in utero and has the following properties: (Select all that apply.)

1. Anti-infective 2. Anti-oxidant 3. Moisturizer 4. Wound-healing 5. Anti-diarrheal 6. Skin-toughening Answer: 1, 2, 3, 4 Rationale: 1. Vernix caseosa is composed of shed cells, serving to cover and protect the fetus from amniotic fluid and urine. Vernix caseosa has properties of anti-infection, anti-oxidants, and moisturizer, and includes wound-healing agents.

2. Vernix caseosa is composed of shed cells, serving to cover and protect the fetus from amniotic fluid and urine. Vernix caseosa has properties of anti-infection, anti-oxidants, and moisturizer, and includes wound-healing agents.

3. Vernix caseosa is composed of shed cells, serving to cover and protect the fetus from amniotic fluid and urine. Vernix caseosa has properties of anti-infection, anti-oxidants, and moisturizer, and includes wound-healing agents.

4. Vernix caseosa is composed of shed cells, serving to cover and protect the fetus from amniotic fluid and urine. Vernix caseosa has properties of anti-infection, anti-oxidants, and moisturizer, and includes wound-healing agents.

5. Vernix caseosa is composed of shed cells, serving to cover and protect the fetus from amniotic fluid and urine. Vernix caseosa has properties of anti-infection, anti-oxidants, and moisturizer, and includes wound-healing agents. It does not have anti-diarrheal properties.

6. Vernix caseosa is composed of shed cells, serving to cover and protect the fetus from amniotic fluid and urine. Vernix caseosa has properties of anti-infection,

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Ball 2e

Test Bank anti-oxidants, and moisturizer, and includes wound-healing agents. It does not toughen skin.

Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 36-1 Describe important differences in the anatomy and physiology of the skin of infant, child and adolescent.

2. An infant has thin skin and little subcutaneous fat. Which of the following could be a result of these properties of an infant?

1. Increased absorption of harmful medications and chemical substances 2. Decreased absorption of topical medications 3. Retaining heat for longer periods of time 4. Easily regulated body temperature Answer: 1 Rationale: 1. Thin skin and less subcutaneous fat cause the infant to have an increased absorption of harmful chemical substances and topical medications. Doses will need to be adjusted accordingly.

2. Thin skin and less subcutaneous fat cause the infant to have an increased absorption of harmful chemical substances and topical medications. Doses will need to be adjusted accordingly.

3. Thin skin and less subcutaneous fat cause the infant to become easily chilled, to lose heat rapidly, and to have difficulty regulating body temperature. They have an increased absorption of harmful chemical substances and topical medications.

4. Thin skin and less subcutaneous fat cause the infant to become easily chilled, to lose heat rapidly, and to have difficulty regulating body temperature. They have an increased absorption of harmful chemical substances and topical medications.

Cognitive Level: Application

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Ball 2e

Test Bank

Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 36-1 Describe important differences in the anatomy and physiology of the skin of infant, child and adolescent.

3. The nurse is examining a 12-month-old who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with bright red, scaly plaques and small papules. Satellite lesions are also present. This is most likely caused by which of the following?

1. Impetigo (staph) 2. Candida albicans (yeast) 3. Urine and feces 4.

Infrequent diapering

Answer: 2 Rationale: 1. Even though diaper dermatitis can be caused by impetigo, urine, feces, and infrequent diapering, the lesions and persistent characteristics are common for Candida.

2. 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.

3. Urine and feces can cause diaper dermatitis, but the persistence and characteristics of the lesions are common for Candida.

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

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 36-2 Identify the characteristics of different skin lesions by their cause, including those caused by irritants, drug reactions, infestation, infection, and injury.

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Ball 2e

Test Bank

4. The school nurse is conducting pediculosis capitis (head lice) checks. Which of the following findings would indicate a “positive” head check?

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

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

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

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

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 36-2 Identify the characteristics of different skin lesions by their cause, including those caused by irritants, drug reactions, infestation, infection, and injury.

5. Which of the following is characteristic of the inflammation phase of wound healing?

1. Wound contraction and inward movement of the wound edge 2. Clot formation to seal the wound 3. Decreased blood flow and capillary permeability, causing swelling 4. Regeneration of destroyed cells Answer: 2 Rationale:

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Ball 2e

Test Bank

1. Wound contraction and inward movement of the wound edge occur during the reconstruction phase of wound healing.

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 3–5 days.

3. Increased blood flow to the area and increased capillary permeability occur, causing swelling and inflammation.

4. Regeneration of destroyed cells occurs in the reconstruction phase of wound healing.

Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 36-3 Describe the stages of wound healing.

6. From the list below, identify causes of delayed or dysfunctional wound healing. Select all that apply.

1. Predisposing chronic condition, such as diabetes 2. Hypoxemia 3. Hypervolemia 4. Overweight or obesity 5. Prolonged infection 6. Corticosteroid therapy Answer: 1, 2, 5, 6 Rationale: 1. Conditions such as diabetes affect circulating blood volume, and are known to affect healing.

2. Hypoxemia makes tissues susceptible to infection due to insufficient oxygenation.

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

4. Overweight and obesity themselves might not affect wound healing. However, poor nutrition without proper protein and calorie intake will affect healing.

5. Prolonged infection can affect healing and cause excessive scarring.

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Ball 2e

Test Bank

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

Cognitive Level: Comprehension Client Need: Health Promotion and Maintenance Nursing Process: Assessment Learning Outcome 36-3 Describe the stages of wound healing.

7. The nurse is planning care for a 3-month-old infant with eczema. Which of the following would take top priority in this infant’s care?

1.

Maintaining adequate nutrition

2. Keeping the baby content 3. Preventing infection of lesions 4. Applying antibiotics to lesions Answer: 3 Rationale: 1. Maintaining adequate nutrition is important, but 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.

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.

3. 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.

4. 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.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 36-4 Plan nursing interventions for the child with a chronic skin disorder.

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Ball 2e

Test Bank

8. A child has eczema. Which of the following would be an appropriate nursing intervention to include in the care of this child? 1. Applying hydrocortisone ointment 1% per order 2. Applying nystatin topical ointment per order 3. Applying lotrimin ointment per order 4. Applying silvadene cream per order Answer: 1 Rationale: 1.

Topical corticosteroids are used to reduce inflammation when the child has eczema.

Hydrocortisone 1% is usually the drug of choice.

2. Nystatin and lotrimin ointments are used to treat fungal infections. Topical corticosteroids, such as hydrocortisone 1%, are used to reduce inflammation in the child with eczema.

3. Nystatin and lotrimin ointments are used to treat fungal infections. Topical corticosteroids, such as hydrocortisone 1%, are used to reduce inflammation in the child with eczema.

4. Silvadene cream is used for burns. Topical corticosteroids, such as hydrocortisone 1%, are used to reduce inflammation in the child with eczema.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 36-4 Plan nursing interventions for the child with a chronic skin disorder.

9. The nurse is teaching a group of adolescents about care for acne vulgaris. Which of the following should be included in this teaching session? Select all that apply.

1. Wash skin with mild soap and water twice a day.

2. Use astringents and vigorous scrubbing.

3. Avoid picking or squeezing the lesions.

4. Apply tretinoin (Retin-A) liberally.

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Ball 2e

Test Bank

5. Avoid sun exposure if on tetracycline.

Answer: 1, 3, 5 Rationale: 1. The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline.

2. Using astringents and scrubbing vigorously can exacerbate acne.

3. The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline.

4. Tretinoin (Retin-A) should be applied sparingly (pea-size doses).

5. The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 36-5 Develop an education plan for adolescents with acne to promote self-care.

10. An infant, aged 2 months, has a Candidal diaper rash. Which of the following medications will the nurse most likely apply to this rash?

1.

Bacitracin ointment

2.

Hydrocortisone ointment

3.

Desitin

4.

Nystatin given topically and orally

Answer: 4 Rationale: 1. Bacitracin is for an infection caused by staphylococcus. 2. Moderate diaper rash is treated with hydrocortisone ointment. 3. Mild diaper rash is treated with a barrier such as Desitin.

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Ball 2e

Test Bank

4. Diaper candidiasis is treated with an antifungal cream (nystatin). An oral antifungal agent may be given to clear the candidiasis from the intestines.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome 36-6 Describe the nursing care for the child with acute skin disorders, including dermatitis, infectious disorders, infestations, and injuries to the skin.

11. A child has been hospitalized with a severe case of impetigo contagiosa. What antibiotic will the nurse expect to be prescribed?

1. Dicloxacillin (Pathocil) 2. Rifampin (Rifadin) 3. Sulfamethoxazole and trimethoprim (Bactrim) 4. Metronidazole (Flagyl) Answer: 1 Rationale: 1. A systemic antibiotic will be given for severe impetigo because it is a bacterial infection. Dicloxacillin is used in treatment of skin and soft tissue infections. It is specific for treating staphylococcal infections.

2. Rifampin is an antitubercular agent. Dicloxacillin is used to treat skin and soft tissue infections, and is specific for treating staphylococcal infections.

3. Sulfamethoxazole and trimethoprim are used as prophylaxis against Pneumocystis carinii pneumonia (PCP), and therefore would not be effective in this case.

Dicloxacillin is used to treat skin and soft-tissue infections, and is specific for treating staphylococcal infections.

4. Metronidazole is used to treat anaerobic and protozoic infections, and would not be effective against staphylococcal skin and soft tissue infections. Dicloxacillin would be the better choice.

Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Planning

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Ball 2e

Test Bank

Learning Outcome 36-6 Describe the nursing care for the child with acute skin disorders, including dermatitis, infectious disorders, infestations, and injuries to the skin.

12. An infant has a severe case of oral thrush (Candida albicans). Which of the following is the priority nursing diagnosis for this infant?

1. Activity Intolerance related to oral thrush 2. Ineffective Airway Clearance related to mucus 3. Ineffective Infant Feeding Pattern related to discomfort 4. Ineffective Breathing Pattern related to oral thrush Answer: 3 Rationale: 1. 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 that a normal feeding pattern can be resumed.

2. 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 so that a normal feeding pattern can be resumed.

3. 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.

4. 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 so that a normal feeding pattern can be resumed.

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process : Diagnosis Learning Outcome 36-6 Describe the nursing care for the child with acute skin disorders, including dermatitis, infectious disorders, infestations, and injuries to the skin.

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Ball 2e

Test Bank

13. Parents understand the teaching a nurse has done with regard to care of their child with tinea capitis (ringworm of the scalp) if they state: 1.

“We will give the griseofulvin on an empty stomach.”

2.

“We’re glad ringworm isn’t transmitted from person to person.”

3.

“Once the lesion is gone, we can stop the griseofulvin.”

4.

“We will give the griseofulvin with milk or peanut butter.”

Answer: 4 Rationale: 1. Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. It should not be given on an empty stomach.

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

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

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

Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Evaluation Learning Outcome 36-6 Describe the nursing care for the child with acute skin disorders, including dermatitis, infectious disorders, infestations, and injuries to the skin.

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

1. Apply the lotion to the scalp only.

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

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

4. Apply the lotion only to the hands.

Answer: 2

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Rationale: 1. 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.

2. 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.

3. 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.

4. 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.

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 36-6 Describe the nursing care for the child with acute skin disorders, including dermatitis, infectious disorders, infestations, and injuries to the skin.

15. A child has sustained a severe burn. Place the following nursing interventions in the order of what would be done for this child when the medical team arrived on the scene.

1. Start intravenous fluids.

2. Provide for relief of pain.

3. Establish an airway.

4. Place a Foley catheter.

Answer: 3, 1, 2, 4 Rationale: The first step in burn care is to ensure that the child has an airway, is breathing, and has a pulse. Due to the severity of the burn, establishing IV access and starting resuscitation fluids would be next; then the area of pain should be addressed, followed by the insertion of a Foley catheter.

Nursing Process: Implementation Client Need: Safe, Effective Care Management Cognitive Level: Analysis

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Learning Outcome 36-7 Develop a nursing care plan for the child with a full-thickness burn injury.

16. A child has sustained a minor burn. Which of the following should be included in increased amounts in the child’s diet?

1. Fats 2. Protein 3. Minerals 4. Carbohydrates Answer: 2 Rationale: 1. A high-calorie, high-protein diet is best to meet the increased nutritional requirements for healing.

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

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

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

Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome 36-7 Develop a nursing care plan for the child with a full-thickness burn injury.

17. Which of the following would be the priority nursing diagnosis during the acute phase of burn injury for a child who has a third-degree circumferential burn of the right arm?

1. Infection, risk for 2. Altered Tissue Perfusion, risk for

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3. Altered Nutrition: Less Than Body Requirements, risk for 4. Impaired Physical Mobility Answer: 2 Rationale: 1. 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.

2. 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.

3. Infection, nutrition, and mobility would have secondary priority in this case.

4. 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.

Cognitive Level: Analysis Client Need: Safe, Effective Care environment Nursing Process: Diagnosis Learning Outcome 36-7 Develop a nursing care plan for the child with a full-thickness burn injury.

18. Which of the following is the most common complication seen in children during the recovery-management phase of burn treatment?

1. Shock 2. Metabolic acidosis 3. Burn-wound infection 4. Asphyxia Answer: 3 Rationale: 1. Shock is not the most common complication during the recovery-management phase of burn treatment. Infection of the burned area is a frequent complication.

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

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

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

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 36-7 Develop a nursing care plan for the child with a full-thickness burn injury.

19. 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 with the prevention of: 1. Poor circulation.

2. Hypertrophic scarring.

3. Pain.

4. Formation of thrombus in the burn area.

Answer: 2 Rationale: 1. The Jobst pressure garments are used to prevent or minimize the development of hypertrophic scarring and contractures.

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

3. The Jobst stockings or pressure garments do not prevent pain. They are used to prevent development of hypertrophic scarring and contractures.

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.

Cognitive Level: Application

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Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome 36-7 Develop a nursing care plan for the child with a full-thickness burn injury.

20. Nursing care of the child with a snake bite involves assessment of the child for initial and progressive signs of envenomation. Which of the following is the priority nursing action at this time?

1. Assess the need for emergency breathing interventions.

2. Assess neurovascular status and vital signs.

3. Assess pain and the child’s response to pain medication.

4. Measure the circumference of the extremity containing the bite every 20–30 minutes.

5. Assess immunization status.

Answer: 1 Rationale: 1. Emergency intervention for airway, breathing, and circulation take priority, and has a high probability of occurrence.

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

3. 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.

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

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

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome 36-8 Identify preventive strategies to reduce the risk of injury from burns, hypothermia, bites, and stings.

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21. The nurse is teaching the parents of a small child strategies to prevent insect bites and stings. Which statement 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. “My child should avoid heavy colognes, perfumes, and soaps, so that insects are not attracted to them.”

3. “We should remove any items with standing water from our yard and surrounding area to prevent mosquito reproduction.”

4. “My child can use insect repellent containing DEET of 10% or less.”

Answer: 1 Rationale: 1. Bright-colored clothing and floral prints attract the insects. White and light-colored clothing should be worn.

2. Heavy colognes, perfumes, soaps, and detergents resemble flowers and plants, and will attract the stinging insects.

3. Standing water is a breeding ground for mosquitoes. Rid yards of all bird baths, stagnant pools, any standing water that mosquitoes could use for breeding.

4. 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.

Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Evaluation Learning Outcome 36-8 Identify preventive strategies to reduce the risk of injury from burns, hypothermia, bites, and stings.

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