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HESI HINTS Growth and Development Milestones When does birth length double? Answer: By 4 years When does the child sit unsupported? Answer: 8 months When does a child achieve 50% of adult height? Answer: 2 years When does a child throw a ball overhand? Answer: 18 months When does a child speak 2-3 word sentences? Answer: 2 years When does a child use scissors? Answer: 4 years When does a child tie his/her shoes? Answer: 5 years Be aware that a girl’s growth spurt during adolescence begins earlier than boys (as early as 10 years old). Temper tantrums are common in the toddler, i.e., considered “normal,” or average behavior. Be aware that adolescences is a time when the child forms his/her identity and that rebellion against family values is common for this age group. Normal growth and development knowledge is used to evaluate interventions and therapy. For example, “What behavior would indicate that thyroid hormone therapy for a 4-month-old is effective?” You must know what milestones are accomplished by a 4-month-old. One correct answer would be “has steady control” which is an expected milestone for a 4-month-old and indicates that replacement therapy is adequate for growth. Use facts and principles related to growth and development in planning teaching interventions. For example: “What task could a 5-year-old diabetic boy be expected to accomplish by himself?” One correct answer would be to pick the injection sites. This is possible for a preschooler to do and gives the child some sense of control. School-age children are in Erikson’s stage of industry, meaning they like to do and accomplish things. Peers are also becoming important for this age child. Age groups concepts of bodily injury: Infants: After 6 months, their cognitive development allows them to remember pain.


Toddlers: Fear intrusive procedures. Preschoolers: Fear body mutilation. School age: Fear loss of control of their body. Adolescent: Major concern is change in body image. Pertinent history should be obtained prior to administering certain immunizations because reactions to previous immunizations or current health conditions may contraindicate current immunizations: DPT: History of seizures, neurological symptoms after previous vaccine, or systematic allergic reactions. MMR: History of anaphylactic reaction to eggs or neomycin. Pertussis fatalities continue to occur in unimmunized infants in the U.S. Subcutaneous injection, rather than intradermal, invalidates the Mantoux test. The common cold is not contraindication for immunization. Following immunization, what teaching should the nurse provide to the parents? Irritability, fever (<102 degrees F), redness and soreness at injection site for 2-3 days are normal side effects of DPT and IPV administration. Call health care provider if seizures, high fever, or high -pitched crying occur. A warm washcloth on the thigh injection site and “bicycling” the legs w/each diaper change will decrease soreness. Acetaminophen (Tylenol) is administered orally every 4-6 hours (10-15 mg/Kg). Children w/German measles pose a serious threat to their unborn siblings. The nurse should counsel all expectant mothers, especially those w/young children, to be aware of the serious consequences of exposure to German measles during pregnancy. Common childhood problems are encountered by nurses caring for children in the community or hospital settings. The child’s age directly influences the severity and management of these problems. Nutritional Assessment: Teach proper cooking and storage to preserve potency, i.e., cook vegetables in small amount of liquid. Store milk in opaque container. Add potassium to IV fluids ONLY w/adequate urine output. Urinary output for infants and children be 1-2 ml/kg/hour. Use of syrup of ipecac is no longer recommended by the American Academy of Pediatrics. Teach parents that it is NOT recommended to induce vomiting in any way as it may cause more damage.


Child needs 150% of the usual calorie intake for normal growth and development. Do not examine the throat of a child w/epiglottitis due to the risk of completely obstructing the airway, i.e., do not put a tongue blade or any object in the throat. In planning and providing nursing care, a patent airways is always a priority of care, regardless of age! Respiratory disorders are the primary reason most children and their families seek medical care. Therefore, these disorders are frequently tested on the NCLEX-RN. Knowing the normal parameters for respiratory distress in children is essential! The nurses should be sure a PT and PTT have been determined prior to a tonsillectomy. More importantly, the nurse should ask if there has been a history of bleeding, prolonged/excessive, or if there is a history of any bleeding disorders in the family. When calculating a pediatric dosage, the nurse must often change the childâ&#x20AC;&#x2122;s weight from pounds to kilograms. HINT: Weight expressed in kilograms should always be a smaller number than weight expressed in pounds. Polycythemia is common in children w/cyanotic defects. For normal cardiac rates in children, see Respiratory in this chapter. The heart rate of a child will increase w/crying or fever. Infants may require tube feeding to conserve energy. Basic difference between cyanotic and acyanotic defects: Acyanotic: Has abnormal circulation, however, all blood entering the systemic circulation is oxygenated. Cyanotic: Has abnormal circulation w/unoxygenated blood entering systemic circulation. CHF: Congestive heart failure is more often associated w/acyanotic defects. CHF is a common complication of congenital heart disease. It reflects the increased workload of the heart resulting from shunts or obstructions. The two objectives in treating CHF are to reduce the workload of the heart and increase cardiac output. When frequent weighings are required, weigh client on the same scale at same time of day so that accurate comparisons can be made. The nursing goal in caring for children w/Down syndrome is to help the child reach his/her OPTIMAL level of functioning.


Feed infants or child w/cerebral palsy using nursing interventions aimed at preventing aspiration. Position child upright and support the lower jaw. The signs of increased ICP are the opposite of those of shock. Shock: Increased pulse, Decreased blood pressure. Increased ICP: Decreased pulse, Increased blood pressure. Baseline data on the child’s USUAL behavior and level of development is essential so changes associated w/increased ICP can be detected EARLY. Do not pump shunt unless specifically prescribed. The shunt is made up of delicate valves, and pumping changes pressures within the ventricles. Medication noncompliance is the most common cause of increased seizure activity. Do NOT use tongue blade, padded or not, during a seizure. It can cause traumatic damage to mouth/oral cavity. Monitor hydration status and IV therapy carefully. With meningitis, there may be inappropriate ADH secretions causing fluid retention (cerebral edema) and dilutional hyponatremia. Headache upon awakening is the most common presenting symptoms of brain tumors. Most postoperative clients w/infractentorial tumors are prescribed to lie flat and turn to either side. A large tumor may require that the child NOT be turned to the operative side. Suctioning, coughing, straining, and/or turning causes increased ICP. Decreased urinary output is FIRST sign of renal failure. Surgical correction for hypostasis is usually done before preschool years due to achieving sexual identity, castration anxiety, and toilet training. Typical parent/family reactions to a child w/an obvious malformation such as cleft lip/palate are guilt, disappointment, grief, sense of loss, and anger. Children w/cleft lip/palate and those w/pyloric stenosis both have a nursing diagnosis “alteration in nutrition; less than body requirements.” Cleft lip/palate is related to decreased ability to suck. Pyloric stenosis is related to frequent vomiting.


Nutritional needs and fluid and electrolyte balance are key problems for children w/GI disorders. The younger the child, the more vulnerable they are to fluid and electrolyte imbalances and greater is the need for caloric intake required for growth. Take axillary temperature on children w/congenital mega colon. REMEMBER the Hgb norms. Newborn: 14 to 24 g/dl Infant: 10 to 15 g/dl Child: 11 to 16 g/dl TEACH FAMILY ABOUT ADMINISTRATION OF ORAL IRON: Give on empty stomach (as tolerated for better absorption). Give w/citrus juices (vitamin C) for increased absorption. Use dropper or straw to avoid discoloring teeth. Stools will become tarry. Iron can be fatal in severe overdose; keep away from children. Don not give w/dairy products. Inherited bleeding disorders (hemophilia and sickle cell anemia) are often used to test knowledge of genetic transmission patterns. Remember: Autosomal recessive: Both parents must be heterozygous, or carriers of the recessive trait, for the disease to be expressed in their offspring. With each pregnancy, there is a 1:4 chance of the infant having the disease. However, all children of such parents CAN get the disease - NOT 25% of them. This is the transmission for sickle cell anemia, cystic fibrosis, and phenylketonuria (PKU). X-linked recessive trait: The trait is carried on the X chromosome, therefore, usually affects male offspring, e.g., hemophilia. With each pregnancy of a woman who is a carrier there is a 25% chance of having a child w/hemophilia. If the child is male, he has a 50% chance of having hemophilia. If the child is female, she has a 50% chance of being a carrier. Hydration is very important in treatment of sickle cell disease because it promotes hem dilution and circulation of red cells through the blood vessels. Important terms: Heterozygous gene (HgbAS) sickle cell trait. Homozygous gene (HbSS) sickle cell disease. Abnormal hemoglobin (HGBS) disease and trait. Supplemental iron is not given to clients w/sickle cell anemia. The anemia is not caused by iron deficiency. Folic acid is given orally to stimulate RBC synthesis. Have epinephrine and oxygen readily available to treat anaphylaxis when administering I-asparaginase.


Prednisone is frequently used in combination w/antineoplastic drugs to reduce the mitosis of lymphocytes. Allopurinol, a xanthine-oxidase inhibitor, is also administered to prevent renal damage from uric acid build up during cellular lysis. An infant w/hypothyroidism is often described as a “good, quiet baby” by the parents. Early detection of hypothyroidism and phenylketonuria is essential in preventing mental retardation in infants. Knowledge of normal growth and development is important, since a lack of attainment can be used to detect the existence of these metabolic/endocrine disorders and attainment can be used for evaluating the treatment’s effect. NutraSweet (aspartame) contains phenylalanine and should not therefore, be given to a child w/phenylketonuria. Diabetes mellitus (DM) in children was typically diagnosed as insulin dependant diabetes (Type 1) until recently. A marked increase in type 2 DM has occurred recently in the U.S., particularly among NativeAmerican, African-American, and Hispanic children and adolescents. Adolescence frequently causes difficulty w/management since growth is rapid and the need to be like peers makes compliance difficult. Remember to consider the child’s age, cognitive level of development, and psychosocial development when answering NCLEX-RN questions. When child is in ketoacidosis, administer regular insulin IV as prescribed in normal saline. There has been an increase in the number of children diagnosed with Type 2 diabetes. The increasing rate of obesity in children is thought to be a contributing factor. Other contributing factors include lack of physical activity and a family history of Type 2 diabetes. Fractures in older children are common as they fall during play and are involved in motor vehicle accidents. Spiral fractures (caused by twisting) and fractures in infants may be related to child abuse. Fractures involving the epiphyseal plate (growth plate) can have serious consequences in terms of growth of the affected limb. Skin traction for fracture reduction should NOT be removed unless prescribed by healthcare provider. Pin sites can be sources of infection. Monitor for signs of infection. Cleanse and dress pin sites as prescribed. Skeletal disorders affect the infant’s or child’s physical mobility, and typical NCLEX-RN questions focus on appropriate toys or activities for the child who is on bedrest and/or immobilized. Children do not like injections and will deny pain to avoid “shots.”


A brace does not correct the curve of a child w/scoliosis, it only stops or slows the progression. Corticosteroids are used short term in low doses during exacerbations. Long-term use is avoided due to side effects and their adverse effect on growth.


1. The nurse is caring for a 3-year old child who is 2 hours postop from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction? A. B. C. D.

Blood pressure trend is downward and pulse is rapid and irregular. Right foot is cool to the touch and appears pale and blanched. Pulse distal to the femoral artery is weaker on the left foot than right foot. The pressure dressing at right femoral area is moist and oozing blood.

2. Following a motor vehicle collision, a 3-year old girl has a spica cast applied. Which toy is best for the nurse for this 3 year old child? A. B. C. D.

Duck that squeaks. Fashion doll and clothes. Set of cloth and hand puppets. Hand held video game.

3. An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first? A. B. C. D.

Administer morphine sulphate. Start IV fluids. Place the infant in a knee-chest position. Provide 100% oxygen by face mask.

4. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? A. B. C. D.

Metabolic alkalosis. Respiratory acidosis. Respiratory alkalosis. Metabolic acidosis. 5. 7 years old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider?

A. B. C. D.

Gastric output of 100 mL in the last 8 hours. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips. Serum potassium of 3.0 mg/dL. Serum pH of 7.45.

6. The nurse is evaluating diet teaching for a client who has nontropical sprue (celiac disease). Choosing which food indicates that the teaching has been effective?


A. B. C. D.

Creamed corn. Pancakes. Rye crackers. Cooked oatmeal.

7. During a well-baby check, the nurse hides a block under the baby’s blanket, and the baby looks for the block. Which normal growth and development milestone is the baby developing? A. B. C. D.

Separation anxiety. Associative play. Object prehension. Object permanence.

8. The nurse is measuring the frontal occipital circumference (FOC) of a 3-months old infant, and notes that the FOC has increased 5 inches since birth and the child’s head appears large in relation to body size. Which action is most important for the nurse to take next? A. B. C. D.

Measure the infant’s head-to-toe length. Palpate the anterior fontanel for tension and bulging. Observe the infant for sunken eyes. Plot the measurement on the infant’s growth chart.

9. The nurse is preparing a 10 year old with a lacerated forehead for suturing. Both parents and 12 year old sibling are at the child’s bedside. Which instruction best supports family? A. B. C. D.

While waiting for the healthcare provider, only one visitor may stay with the child. All of you should leave while the healthcare provider sutures the child’s forehead. It is best if the sibling goes to the waiting room until the suturing is completed. Please decide who will stay when the healthcare provider begins suturing.

10. The nurse is planning for a 5-month old with gastroesophageal reflux disease whose weight has decreased by 3 ounces since the last clinic visit one month ago. To increase caloric intake and decrease vomiting, what instructions should the nurse provide this mother? A. B. C. D.

Give small amounts of baby food with each feeding. Thicken formula with cereal for each feeding. Dilute the childs formula with equal parts of water. Offer 10 % dextrose in water between most feedings.

11. While teaching a parenting class to new parents the nurse describes the needs of infants and toddlers regarding discipline and limit setting. What is the most important reason for implementing such parenting behaviors?


A. B. C. D.

Children need help in developing social skills. This age child fears loss of self control. They provide the child with a sense of security. Children must to learn to deal with authority.

12. The parents of a newborn infant with hypospadia are concerned about when the surgical correction should occur. What information should the nurse provide? A. B. C. D.

Repair should be done by one month to prevent bladder infection. To form a proper urethra repair, it should be done after sexual maturity. Repairs typically should be done before the child is potty trained. Delaying the repair until school age reduces castration fears.

13. Which drink choice on a hot day indicates to the nurse that a teenager with sickle cell anemia understands dietary consideration related to the disease? A. B. C. D.

Milkshake. Iced tea. Diet cola. Lemonade.

14. The nurse is assessing an infant with diarrhea and lethargy. Which finding should the nurse identify that is consistent with early dehydration? A. B. C. D.

Tachycardia. Bradycardia. Dry mucous membrane. Increased skin turgor.

15. While auscultating the lung sounds of a 5 year old Chinese boy who recently completed antibiotic therapy for pneumonia, the nurse notices symmetrical, round, bruise-like blemishes on his chest. What action is best for the nurse to take? A. B. C. D.

Identify the antibiotic used to treat the pneumonia. Inquire about the use of alternative methods of treatment. Ask the parents if the child has been in a recent accident. Report suspected child abuse to the authorities.

16. A child with acute lymphocytic leukemia (ALL) who is receiving chemotherapy via a subclavian IV infusion, has an oral temperature of 103 degrees. In assessing the IV site, the nurse determines that there are no signs of infection at the site. Which intervention is the most important for the nurse to implement? A. Obtain specimen for blood cultures. B. Assess the CBC.


C. Monitor the oral temperature every hour. D. Administer acetaminophen as prescribed. 17. A child who weights 25 kg is receiving IV ampicillin 300 mg/kg/24 hours in equally divided doses every 4 hours. How many mg should the nurse administer to the child for each dose? 1875mg 18. The nurse is caring for an infant scheduled for reduction of intussusceptions. The day before the scheduled procedure the infant passes a soft-formed brown stool. Which intervention should the nurse implement? A. Instruct the parents that the infant needs to be NPO. B. Notify the healthcare provider of the passage of brown stool. C. Obtain a stool specimen for laboratory analysis. D. Ask the parents about recent changes in the infant’s diet. 19. The mother of a 4-month old asks the nurse for advice in preventing diaper rash. What suggestion should the nurse provide? A. At diaper change generously powder the baby’s diaper area with talcum powder to promote dryness. B. Wash the diaper area every 2 hours with soap and water to help prevent skin breakdown. C. Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change. D. Place a cloth diaper inside the disposable diaper for overnight periods when increased wearing time is likely. 20. Which statement by a school aged client going to summer camp indicates the best understanding of the mode of transmission of Lyme disease? A. B. C. D.

I’ll cover my mouth with a wet cloth if there’s too much dust blowing. Cuts and scrapes need to be washed out and covered right away. I’m not going to swim where the water is standing still or feels too hot. I have to wear long sleeves and pants when we’re hiking around the pond.

21. The nurse is evaluating the effects of thyroid therapy used to treat a 5 months old with hypothyroidism. Which behavior indicates that the treatment has been effective? A. B. C. D.

Laughs readily, turns from back to side. Has strong Moro and tonic neck reflexes. Keeps fists clenched, opens hands when grasping an object. Can lift head, but not chest when lying on abdomen.


22. The HR for a 3 year old with a congenital heart defect has steadily decreased over the last few hours, now itâ&#x20AC;&#x2122;s 76 bpm, the previous reading 4 hours ago was 110 bpm. Which additional finding should be reported immediately to a healthcare provider? A. B. C. D.

Oxygen saturation 94%. RR of 25 breaths/minute. Urine output 20 mL/hr. BP 70/40.

23. 2 year old is admitted to the hospital with possible encephalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure? A. Describe the side-lying, knees to chest position that must be assumed during the procedure. B. Tell the child to expect loud clicking noises during the procedure that may be slightly annoying. C. Reassure the child that there will be no restrictions on activity after the procedure is completed. D. Explain that fluids cannot be taken for 8 hours before the procedure and for 4 hours after the procedure. 24. the parenst of a 3 y/o boy who has Duchenne muscular dystrophy (DMD) ask â&#x20AC;&#x153;how can our son have this disease? We are wondering if we should have any more childrenâ&#x20AC;? What information should the nurse provide these parents? A. This is an inherited X-linked recessive disorder, which primarly affects male children in the family B. The male infant had a viral infectrion that went unnoticed and iuntreated, so mucle damage was incurred C. The XXXX muscle groups of males can be impacted by a lack of the protein dystrophyn in the mother D. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles 25. The nurse finds a 6 month old infant unresponsive and calls for help. After opening the airway and finding the XXXX the infant is still no breathing. Which action should the nurse take? A. Palpate femoral pulse and check for regularity B. Deliver cycles of 30 chest compressions and 2 breaths C. Give two breath that makes the chest rise D. Feel the carotid pulse and check for adequate breathing 26. A 3 year old with HIV infection is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first?


A. Remove the child who has HIV from the foster home B. Report the exposure of the child with HIV to the health department C. Place the chuld who has HIV in reverse isolation D. Review the immunization documentation of the child who has HIV 27. . A 16 y/o female student with a history of asthma controlled with both an oral antihistamine and an albuterol (Provenfil) metere-dose inhaler (MDI) comes to the school nurse. The student complains that she cannot sleep at night, feels shaky and her heart feels like it is “beating a mile per minute” Which information is most important for the nurse to obtain? a. When she last took the antihistamine b. When her last Asthma attack occurred c. Duration of most asthmas attacks d. How often the MDI is used daily 28. The nurse is assessing a child for neurological soft signs, which finding is most likely demonstrated in the child’s behavior? a. Inability to move tongue in a direction b. Presence of vertigo c. Poor coordination and sense of position d. Loss of visual acuity 29. The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant’s clinical picture? a. Metabolic alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Respiratory Alkalosis 30. A 4 month-old girl is brought to the clinic by her mother because she has had a cold for 2 o 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress? a. Bilateral bronchial breath sounds b. Diaphragmatic respiration c. A resting respiratory rate of 35 breathe per minute d. flaring of the nares 31. a two year old boy begins to cry when the mother starts to leave. What is the nurse’s best response in this situation? a. Let me read this book to you b. Two years old usually stop crying the minute the parent leaves c. Now be a big boy. Mommy will be back soon d. Let’s wave bye-bye to mommy


32. A two year old child with a heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin) the nurse obtains an apical heart rate of 128 bpm. What action should the nurse implement? a. Determine the pulse deficit b. Administer the scheduled dose c. calculate the safe dose range d. review the serum digoxin level 33. A child with leukemia is admitted for Chemotherapy and the nursing diagnosis â&#x20AC;&#x153;altered nutrition, less those body requirements related to anorexia, nausea and vomitingâ&#x20AC;? is identified. Which intervention the nurse included in this child plan of care? a. Encourage a variety of large portions of food at every meal b. Allow the child to eat any food desired and tolerated c. Recommended eating the food as sibling eat at home d. Restrict food brought form fast food restaurants 34. a 6 year old who has asthma is demonstrating a prolonged expiratory phase and wheezing and has a35% of personal best peak expiratory flow rate (PEFR) based on these finding, actions should the nurse take first? a. Administer a prescribed bronchodilator b. Encourage the child to cough and deep breath c. Report findings to the heath care provider d. determine what triggers precipitated this attack 35. The nurse plans to administer 10 mcg/kg of digoxin elixir as a loading dose to a child who weights 55 pounds. Digoxin is available as elixir of 50 mcg/ml. How many ml of the digoxin elixir should the nurse administer to this child? 5 ml 36. the nurse observes a mother giving her 11 month-old ferrous sulfate, followed by two onces of orange juice. What should the nurse do next? a. suggest placing the iron drops in the orange juice and feed the infant b. Tell the mother to follow the iron drops with formula instead of orange juice c. instruct the mother to feed the infant nothing in the next 30 minutes after the iron d. Give positive feedback about the way she administered the sulfate 37. Which nursing intervention is most important to include in the plan of care for a child with acute glomerulonephritis A. encourage fluid intake b. promote complete bed rest c. weight the child daily d. administer vitamin supplements


38. During a well baby visit the parents explain that a soft bulge appears in the groin of their 4 month old son when he cries or strain stooling. The infant is schedule for surgical repair of the inguinal; hernia in two weeks. The parent should be instructed to take which measure if the hernia becomes incarcerated prior to the surgery? a. Use rectal thermometer for straining on stool b. Gently manipulate the hernia for reduction c. Offer oral electrolyte fluids for comfort d. Give acetaminophen or aspirin for crying 39. A 16 year old male client who has been treated in the past for a seizure disorder is admitted to the hospital. Immediately after admission he begins to have a grand mal seizure. Which action should the nurse take? a. Obtain assistance in holding him to prevent injury b. Observe him carefully c. Call a CODE d. Place a padded tongue blade between the teeth 40. The mother of a 9 month old who was diagnosed with respiratory syncytial virus yesterday calls the clinic to inquire if it will be all right to take her infant to the first b-day party of a friendâ&#x20AC;&#x2122;s child the following day. What response should the nurse provide this mother? a. The child will not longer be contagious, no need to take any further precaution b. Make sure there are not children under the age of 6 months around the infected child c. The child can be around other children but should wear mask at all times d. Do not expose other children to RSV. It is very contagious even without direct contact 41. When screening a 5 year old for strabism, what action should the nurse take A. Have the child identify colored patterns on polychromatic cards B. Direct the child through the six cardinal position of glaze C. Inspect the child for the setting sun sign D. Observe the child for blank, sunken eyes 42. The nurse is assessing a 6 month old infant. Which response requires further evaluation by the nurse? A. Has doubled birth weight B. Turn head to locate sound C. Plays pick a boo D. Demonstrate startle reflex 43. A child is brought to the clinic complaining of fever and joins pain, and is DX with rheumatic fever. When planning care for this child what is the goal of nursing care? A. Reduce fever B. Maintain fluid and electrolytes C. Prevent cardiac damage D. Maintain join mobility and function


44. The nurse working on the pediatric unit takes two 8-year old girls to the playroom. Which activity is best for the nurse to plan for these girls? A. Selecting a board game B. Playing Doctor and nurse C. Watching cartoon on TV D. Coloring, cutting and pasting 45. The nurse is developing the plan of care for a hospitalized child with von Willebrand disease. What priority nursing intervention should be included in this child plan of care A. Reduce exposure to infection B. Eliminate contact with cold grafts (crafts? Is not legible) C. Guard against bleeding injuries D. Reduce contact with other children 46. How should the nurse instruct the parents of a 4 month old with seborrheic dermatitis (cradle cap) to shampoo the childâ&#x20AC;&#x2122;s hair? A. Use a soft brush and gently scrub the area B. B. Avoid scrubbing the scalp until the scales disappear C. Avoid washing the childâ&#x20AC;&#x2122;s hair more than once a week D. Use soap and water and avoid shampoos 47. Prior to discharge, the parents of a child with cystic fibrosis are demonstrating chest physiotherapy (CPT) that they will perform for their child at home. Which action requires intervention by the nurse? A. Plan to perform CPT when the child awakens in the morning B. A Copped hand is used when percussing the lung field C. A bronchodilator is administered before starting CPT D. The child is placed in a supine position to begin percussion 48. When assessing the breath sounds of an 18 month old child who is crying, what action should the nurse take? A. Document that the assessment is not available because the child is crying B. Ask the parents to quiet the child so breath sounds can be auscultated C. Allow the child to initially play with stethoscope, and distract during auscultation D. Auscultate and document breath sounds, noting that the child was crying at the time 49. The mother of a one month old calls the clinic to report that the back of her infant is flat. How should the nurse respond A. Turn the infant on the left side braced against the crib when sleeping B. Prop the infant in a sitting position with a cushion when no sleeping C. Place a small pillow under the infantâ&#x20AC;&#x2122;s head while lying on the back D. Position the infant on the stomach occasionally when awake and active 50. Which nursing intervention is most important to assist in detecting hypopituitarism and hyperpituitarism in children


A. Carefully recording the height and weight of children to detect inappropriate growth B. Performing head circumference measurements on infants under one year of age C. Assessing for behavioral problems at home and school by interviewing the parents D. Noting a tracked weight gain without a gain in height on a growth chart 51. A 7 year old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history which finding should the nurse expect to obtain? A. High blood cholesterol level on routine screening B. Increased thirst and urination C. A recent strep throat infection D. A recent DPT immunization 52. The nurse plans to screen only the highest risk children for scoliosis. Which group of children should the nurse screen first A. Girls between ages 10 and 14 B. Boys between ages 10 and 14 C. Boys and girls between 12 and 14 D. Boys and girls between 8 and 12 53. In assessing a 10 year old newly diagnosed with osteomyelitis, which information is most for the nurse to obtain A. Recent recurrence of infections B. Cultural heritage and belief C. Family history of bone disorder D. Occurrence of increased fluid intake 54. A 3 year old boy in a daycare facility scratches his head frequently and the nurse confirms the presence if head lice. The nurse washes the child’s hair with permethrin (Nix) shampoo and call his parents. What instructions should the nurse provide to the parents about treatment of head lice? A. Wash the child’s bed linens and clothing In hot soapy water B. Dispose of the child’s brushes, comb’s and other hair accessories C. Rewash the child’s hair following a 24 hour isolation period D. Take the child to a hair salon for a shampoo and shorter haircut 55. The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3 year old son for wetting his pants. What initial action should the nurse take? A. Suggest that the mother consult a pediatric nephrologists B. Provide disposable training pants while calming the mother C. Refer the mother to a community parent education program D. Inform the mother that toilet training is slower for boys


1. To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement? A) Use a happy-face/sad-face pain scale. Feedback: CORRECT B) Ask the mother if she thinks the analgesic is working. Feedback: INCORRECT C) Assess for changes in the child's vital signs. Feedback: INCORRECT D) Teach the child to point to a numeric pain scale. Feedback: INCORRECT Feedback: CORRECT A 4-year-old can readily identify with simple pictures (A) to show the nurse how he/she is feeling. (B) could be used to validate what the child is telling the nurse via the "faces" pain scale, but it is best to elicit the child's assessment of his/her pain level. (C) may not accurately reflect the effectiveness of pain medication as they can also be affected by other variables, such as fear. (D) requires abstract number skills beyond the level of a 4-year-old.

Points Earned:

1.0/1.0

Correct Answer(s): A

2. Which behavior should the nurse expect a two-year-old child to exhibit? A) Build a house with blocks. Feedback: INCORRECT B) Ride a tricycle. Feedback: INCORRECT C) Display possessiveness of toys. Feedback: CORRECT D) Look at a picture book for 15 minutes. Feedback: INCORRECT Feedback: CORRECT Two-year-old children are egocentric and unable to share with other children. (A, B, and D) are behaviors of a preschooler.

Points Earned:

1.0/1.0


Correct Answer(s): C

3. A hospitalized 16-year-old male refuses all visits from his classmates because he is concerned about his distorted appearance. To increase the client's social interaction, what intervention is best for the nurse to initiate? A) Encourage the client to use a hand-held video game that is popular with all his friends. Feedback: INCORRECT B) Assign a 25-year-old female nursing student to offer support to the client. Feedback: INCORRECT C) Arrange for an Internet connection in the client's room for email communication. Feedback: CORRECT D) Encourage the client's mother to arrange a surprise get together in the cafeteria. Feedback: INCORRECT Feedback: CORRECT Body image and peer acceptance are key concerns for the adolescent. (C) allows for social interaction without face to face contact, thus protecting his self-image while also promoting social interaction. (A) does not promote social interaction. (B) does not encourage interaction with his own peer group, which is of greater importance. (D) does not respect the client's concern about his body image.

Points Earned:

1.0/1.0

Correct Answer(s): C

4. The parents of a 3-week-old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain? A) Description of vomiting episodes in past 24 hours. Feedback: CORRECT B) Number of wet diapers in last 24 hours. Feedback: INCORRECT C) Feeding and sleep schedule. Feedback: INCORRECT


D) Amount of formula consumed during the past 24 hours. Feedback: INCORRECT Feedback: CORRECT A description of the vomiting episodes (A) will assist the nurse in determining the reason for the symptoms, which may be helpful in developing a plan of care for this infant. (B and C) provide related information but are not as helpful as (A). (D) may be related to the vomiting, but the nurse should first obtain a better description of the vomiting episodes.

Points Earned:

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Correct Answer(s): A

5. A 6-year-old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child's adjustment to hospitalization? A) Explain hospital schedules to the child, such as mealtimes. Feedback: CORRECT B) Use terms, such as "honey" and "dear," to show a caring attitude. Feedback: INCORRECT C) Provide a list of rules that limits visitation of siblings in the hospital. Feedback: INCORRECT D) Orient the parents to the hospital unit and refreshment areas. Feedback: INCORRECT Feedback: CORRECT Altered daily schedules and loss of rituals are upsetting to children and increase separation anxiety, and active sensitivity to the needs of children can minimize the negative effects of hospitalization. Explaining the hospital schedules (A) and establishing an individual schedule familiarizes the child to the hospital environment and decreases anxiety. (B) depersonalizes the child who should be addressed by name. Family and sibling visitation should be recommended and encouraged without limitation (C). Although (D) should be implemented, the direct involvement of the school-aged child incorporates the child's sense of initiate and cooperation.

Points Earned:

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Correct Answer(s): A

6.


When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement? A) Record weight daily. Feedback: CORRECT B) Assess for signs of anemia. Feedback: INCORRECT C) Document sleeping patterns. Feedback: INCORRECT D) Teach parenting skills. Feedback: INCORRECT Feedback: CORRECT The most definitive measure of improved nutrition in an infant is obtaining the child's daily weight (A). (B, C, and D) may also be useful, but they are not as definitive as a daily weight measurement.

Points Earned:

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Correct Answer(s): A

7. A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information? A) Children need to retain a sense of initiative without impinging on the rights and privileges of others. Feedback: CORRECT B) Negative feelings of doubt and shame are characteristic of 4-year-old children. Feedback: INCORRECT C) Role conflict is a common problem of children this age. She is just wondering where she fits into society. Feedback: INCORRECT D) At this age children compete and like to produce and carry through with tasks. She is just competing with her mother. Feedback: INCORRECT Feedback: CORRECT


Children aged 3 to 6 are in Erickson's "Initiative vs. Guilt" stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative without impinging on the rights of others (A). (B) describes the "Autonomy vs. Shame and Doubt," stage (1 to 3 years of age). (C) describes an adolescent (12 to 18 years of age), the "Identity vs. Role Confusion" stage. (D) describes a child 6 to 12 years of age, the "Industry vs. Inferiority" stage.

Points Earned:

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Correct Answer(s): A

8. A 15-year-old girl tells the school nurse that all of her friends have started their periods and she feels abnormal because she has not. Which response is best for the nurse provide? A) Refer the adolescent to the healthcare provider for a pregnancy screen. Feedback: INCORRECT B) Schedule a conference with her parents to recommend hormone therapy. Feedback: INCORRECT C) Explain that menarche varies and occurs between the ages of 12 and 18 years. Feedback: CORRECT D) Suggest that she use diversions to help her not worry about delayed menarche. Feedback: INCORRECT Feedback: CORRECT The nurse should provide a factual and reassuring explanation that focuses on individual variations of menarche, which can normally occur between 12 and 18 years of age (C). (A) does not address the adolescent's concern and is judgmental. Menarche is influenced by hereditary, general health, and nutritional status, so (B) is not indicated. (D) dismisses the adolescent's concerns and does not offer factual information.

Points Earned:

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Correct Answer(s): C

9. The nurse is planning care for school-aged children at a community care center. Which activity is best for the children? A) Building model airplanes. Feedback: INCORRECT B) Playing follow-the-leader. Feedback: CORRECT


C) Stringing large and small beads. Feedback: INCORRECT D) Playing with Playdough and clay. Feedback: INCORRECT Feedback: CORRECT School-aged children strive for independence and productivity (Erikson's Industry vs. Inferiority) and enjoy individual and group activities related to real-life situations, such as playing follow-the-leader (B). (A) is an individual activity that could contribute to feelings of inferiority and inadequacy if the task is too complex. Although school-aged children enjoy crafts, (C and D) are more appropriate for pre-school children.

Points Earned:

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Correct Answer(s): B

10. A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide? A) Remove all blackheads and follow with an alcohol scrub. Feedback: INCORRECT B) Use medicated cosmetics only to help hide the blemishes. Feedback: INCORRECT C) Wash the hair and skin frequently with soap and hot water. Feedback: CORRECT D) Encourage her to see a dermatologist as soon as possible. Feedback: INCORRECT Feedback: CORRECT Washing the hair and skin with soap and hot water (C) removes oil and debris from the skin and helps prevent and treat acne. Oily skin is especially bothersome during adolescence when hormones cause enlargement of sebaceous glands and increased glandular secretions which predispose the teenager to acne. (A) is contraindicated. Cosmetics ("medicated" or not) should be used sparingly to avoid further blocking sebaceous gland ducts (B). (D) might be indicated at a later time, if healthcare recommendations are not successful.

Points Earned:

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Correct Answer(s): C


11. A 6-month-old boy and his mother are at the healthcare provider's office for a well-baby check-up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today? A) The routine immunizations and schedule another appointment to administer the influenza vaccine. Feedback: INCORRECT B) All the immunizations with the influenza vaccine given at a separate site from any other injection. Feedback: CORRECT C) The influenza vaccine and schedule another appointment to administer the immunizations. Feedback: INCORRECT D) The influenza vaccine and the polio vaccine and schedule another appointment to administer the remaining immunizations. Feedback: INCORRECT Feedback: CORRECT At 6-months of age, the routine immunizations include Hepatitis B, DTaP, Hib (Haemophilus influenza type b), PCV (Pneumococcal), IPV (inactivated poliovirus) and influenza. The influenza vaccine should be given at a separate site from any other injection (B). Scheduling a return visit (A, B, or C) increases the risk that the mother will not bring the child back for the immunizations.

Points Earned:

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Correct Answer(s): B

12. The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums. The mother states, "Yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?" Which recommendation is best for the nurse to provide this mother? A) Paddle him gently as soon as the behavior is initiated. Feedback: INCORRECT B) Immediately put him in "time-out." Feedback: INCORRECT C) Quietly remind him that others are watching him. Feedback: INCORRECT


D) Walk away from him and ignore the behavior. Feedback: CORRECT Feedback: CORRECT The best approach for a toddler is to ignore the attention-seeking behavior (D). The parent should be somewhat nearby, within view of the child but should avoid reinforcing the behavior in any way. Tantrums can sometimes be avoided by talking to the child before the situation occurs. (A, B, and C) would all provide attention for the inappropriate behavior.

Points Earned:

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Correct Answer(s): D

13. A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding? A) Frequency of emesis in the last 8 hours. Feedback: INCORRECT B) Serum BUN and creatinine levels. Feedback: CORRECT C) Current blood sugar level. Feedback: INCORRECT D) Appearance of the stool. Feedback: INCORRECT Feedback: CORRECT Regardless of a client's age, adequate renal function must be present before adding potassium to IV fluids (B). (A) is important in determining the need for fluid replacement. (C) is not indicated. (D) is useful information, but will not impact administration of the prescribed IV solution.

Points Earned:

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Correct Answer(s): B

14. When assessing a child with asthma, the nurse should expect intercostal retractions during A) inspiration. Feedback: CORRECT


B) coughing. Feedback: INCORRECT C) apneic episodes. Feedback: INCORRECT D) expiration. Feedback: INCORRECT Feedback: CORRECT Intercostal retractions result from respiratory effort to draw air into restricted airways (A).

Points Earned:

1.0/1.0

Correct Answer(s): A

15. Which restraint should be used for a toddler after a cleft palate repair? A) Clove hitch. Feedback: INCORRECT B) Mummy. Feedback: INCORRECT C) Elbow. Feedback: CORRECT D) Jacket. Feedback: INCORRECT Feedback: CORRECT Elbow restraints prevent children from bending their arms and bringing their hands to the oral surgical site. (A) restrains the hands, but the child can bend and bring their head to their hands. (B) is used during procedures. (D) restrains the body torso and is not appropriate.

Points Earned:

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Correct Answer(s): C

16.


A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit? A) Choking, coughing, and cyanosis. Feedback: CORRECT B) Projectile vomiting and cyanosis. Feedback: INCORRECT C) Apneic spells and grunting. Feedback: INCORRECT D) Scaphoid abdomen and anorexia. Feedback: INCORRECT Feedback: CORRECT (A) includes the "3 Cs" of esophageal atresia caused by the overflow of secretions into the trachea. Projectile vomiting (B) is characteristic of pyloric stenosis in the infant. Apneic spells often occur with prematurity or sepsis, and grunting (C) is a sign of respiratory distress. A scaphoid abdomen (D) is characteristic of diaphragmatic hernia.

Points Earned:

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Correct Answer(s): A

17. The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit? A) Bradycardia. Feedback: INCORRECT B) Machinery murmur. Feedback: INCORRECT C) Weak pedal pulses. Feedback: INCORRECT D) Clubbed fingers. Feedback: CORRECT Feedback: CORRECT Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and toes (D) due to tissue hypoxia. Tachycardia, not (A), is a manifestation of congenital heart disease. (B) is a classic sign of ventricular septal defect. (C) is characteristic of coarctation of the aorta.


Points Earned:

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Correct Answer(s): D

18. The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction? A) Tell children they should not taste anything but food. Feedback: INCORRECT B) Store all toxic agents and medicines in locked cabinets. Feedback: CORRECT C) Provide special play areas in the house and restrict play in other areas. Feedback: INCORRECT D) Punish children if they open cabinets that contain household chemicals. Feedback: INCORRECT Feedback: CORRECT The only reliable way to prevent poisonings in young children is to make them inaccessible (B). Teaching children not to taste is important (A), but ineffective for young children. (C and D) will not control a child's curiosity.

Points Earned:

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Correct Answer(s): B

19. The vital signs of a 4-year-old child with polyuria are: BP 80/40, Pulse 118, and Respirations 24. The child's pedal pulses are present with a volume of +1, and no edema is observed. What action should the nurse implement first? A) Insert an indwelling urinary catheter. Feedback: INCORRECT B) Start an IV infusion of normal saline. Feedback: CORRECT C) Send a specimen to the lab for urinalysis. Feedback: INCORRECT


D) Document the child's vital signs and pulses. Feedback: INCORRECT Feedback: CORRECT The current vital sign readings and the decreased peripheral pulse volume indicate that the child is experiencing fluid volume deficit due to the polyuria, so the priority action is to restore fluid volume (B). (A) is useful in obtaining a precise urine output measure, but is a lower priority than restoring fluid volume at this time. (C) is not indicated based on the current assessment data, and (D) does not recognize the need for immediate action to combat the fluid volume deficit.

Points Earned:

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Correct Answer(s): B

20. Which action by the nurse is most helpful in communicating with a preschool-aged child? A) Speak clearly and directly to the child. Feedback: INCORRECT B) Use a doll to play and communicate. Feedback: CORRECT C) Approach when a parent is not present. Feedback: INCORRECT D) Play a board game with the child. Feedback: INCORRECT Feedback: CORRECT Communicating through play with a doll (B) or other toy gives time for the child to feel comfortable with a stranger. (A) may frighten some children and is usually not as effective as (B). To provide security and comfort, preschool-aged children should be approached when a parent is present, not (C). (D) is too advanced for a preschooler.

Points Earned:

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Correct Answer(s): B

21. A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention? A) Apical heart rate of 60. Feedback: CORRECT


B) Sweating across the forehead. Feedback: INCORRECT C) Doesn't suck well. Feedback: INCORRECT D) Respiratory rate of 30 breaths per minute. Feedback: INCORRECT Feedback: CORRECT A heart rate of 60 (A) is much lower than normal for a 6-month-old and warrants immediate intervention. The normal heart rate for a 6-month-old is 80 to 150 BPM when awake, and a rate of 70 while sleeping is considered within normal limits. (B and C) are expected symptoms of heart failure in an infant. (D) is within normal limits for an infant.

Points Earned:

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Correct Answer(s): A

22. The nurse is developing a plan of care for a 3-year-old who is scheduled for a cardiac catheterization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement? A) Reassure the parents that 3-year-olds are cooperative and therefore are less likely to be anxious. Feedback: INCORRECT B) Obtain a video film of a cardiac catheterization to show to the child prior to the procedure. Feedback: INCORRECT C) Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there. Feedback: CORRECT D) Obtain a cardiac catheter and demonstrate the procedure by pretending to put the catheter in a doll or stuffed animal. Feedback: INCORRECT Feedback: CORRECT Familiarizing the child and mother with the department (C) will help decrease anxiety of the child and mother (who may have more anxiety than the child). Three is a difficult age to undergo a procedure that requires cooperation. Restraints and possibly sedation may be


required (A). At three, the child is too young to understand why this must be done, and (B) is not indicated. (D) is also not indicated because it is likely to be interpreted as painful.

Points Earned:

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Correct Answer(s): C

23. A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first? A) Slowly pour hydrogen peroxide over the open wound. Feedback: INCORRECT B) Apply ice to the area before rinsing with cold water. Feedback: INCORRECT C) Wash the wound gently with mild soap and water. Feedback: CORRECT D) Gently cleanse with a sterile pad using povidone-iodine. Feedback: INCORRECT Feedback: CORRECT A small, superficial laceration to the skin should be washed gently with mild soap and water (C) for several minutes, followed by thorough rinsing. (A and D) are antiseptics that can be traumatic (painful) when cleaning fresh, open wounds. Applying ice (B) may reduce or prevent further edema, but the wound should be washed with mild soap and water first.

Points Earned:

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Correct Answer(s): C

24. A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client's teaching plan? A) Use sunscreen when lying by the pool. Feedback: CORRECT B) Cleanse the skin at least 4 times a day. Feedback: INCORRECT C) Take the medication with a glass of milk. Feedback: INCORRECT


D) Menstrual periods may become irregular. Feedback: INCORRECT Feedback: CORRECT Photosensitivity is a common side effect of tetracycline HCL (Achromycin V) therapy. Severe sunburn can occur with minimal sun exposure and clients should be instructed to avoid sunlight and to use sunscreen (A). (B and D) are not related to tetracycline HCL (Achromycin V) therapy. (C) should be avoided because dairy products interfere with the absorption of tetracyclines.

Points Earned:

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Correct Answer(s): A

25. As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider? A) A 6-month-old with failure to thrive that has a closed anterior fontanel. Feedback: CORRECT B) A 24-month-old with gastroenteritis that has a closed posterior fontanel. Feedback: INCORRECT C) A 2-month-old with chickenpox that has an open posterior fontanel. Feedback: INCORRECT D) A 28-month-old with hydrocephalus that has an open anterior fontanel. Feedback: INCORRECT Feedback: CORRECT At six months of age the anterior fontanel should be open, and it should not be closed until approximately 18 months of age. (B and C) are normal findings. A child with hydrocephalus may have a delayed closing of the fontanel (D).

Points Earned:

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Correct Answer(s): A

26. A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority? A) Call the healthcare provider immediately if his nail beds appear blue. Feedback: CORRECT


B) Check his fingers hourly for the first 48 hours to see that he is able to move them without pain. Feedback: INCORRECT C) Be sure his arm remains above his heart for the first 24 hours. Feedback: INCORRECT D) Take his temperature q4h for the next two days and call if an elevation is noted. Feedback: INCORRECT Feedback: CORRECT Cyanosis (A) indicates impaired circulation to fingers and should be reported immediately. Although the actions described in (B, C, and D) may be indicated, they are implemented rather excessively--and might tend to frighten the parents. It is not necessary to check the child's ability to move his fingers hourly for 2 days (B). Elevating the arm above the heart will help to decrease swelling but (C) is stated in a frightening way. It is not necessary to take the child's temperature q4h unless indicated by other symptoms.

Points Earned:

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Correct Answer(s): A

27. The mother of a 6-month-old asks the nurse when her baby will get the first measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate? A) 3 to 6 months. Feedback: INCORRECT B) 12 to 15 months. Feedback: CORRECT C) 18 to 24 months. Feedback: INCORRECT D) 4 to 6 years. Feedback: INCORRECT Feedback: CORRECT The first measles, mumps, and rubella (MMR) vaccine should be given no sooner than 12 months of age, and ideally between 12 and 15 months of age (B). (A) should not receive the MMR vaccine due to the presence of maternal antibodies. MMR is not routinely administered at (C), but other immunizations, such as DTaP and Hepatitis B may be given at that time. The second dose of MMR is routinely administered at (D), provided that at


least 4 weeks have elapsed since the first dose, and if both doses were administered beginning at or after 12 months.

Points Earned:

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Correct Answer(s): B

28. When discussing discipline with the mother of a 4-year-old child, the nurse should include which guideline? A) Parental control should be consistent. Feedback: CORRECT B) Children as young as 4 years rarely need reprimand or punishment. Feedback: INCORRECT C) Withdrawal of approval is effective. Feedback: INCORRECT D) Parents should enforce rigid rules to be followed without question. Feedback: INCORRECT Feedback: CORRECT Discipline should be a positive and necessary component of childrearing that is started in infancy and should teach socially acceptable behavior, help children protect themselves from danger, and channel undesirable behavior into constructive activity. Misbehavior may result from inconsistent rules or messages, so parental attention should be clear, reasonable, and consistent (A). (B and C) are not helpful to the child. Children need boundaries that are firm but not rigid (D).

Points Earned:

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Correct Answer(s): A

29. The nurse is teaching the parents of a 5-year-old with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand? A) Perform postural drainage before starting aerosol therapy. Feedback: INCORRECT B) Give respiratory treatments when the child is coughing a lot. Feedback: INCORRECT C) Administer aerosol therapy followed by postural drainage before meals. Feedback: CORRECT


D) Ensure respiratory therapy is done daily during any respiratory infection. Feedback: INCORRECT Feedback: CORRECT Postural drainage for a child with cystic fibrosis is most effective when performed after nebulization and before meals (C) or at least 1 hour after eating to prevent nausea and vomiting. Postural drainage uses gravity to promote mucous removal after nebulization (A) treatments which open the airways. Pulmonary toileting or respiratory treatments should be given 3 to 4 times daily, not episodically (B and D).

Points Earned:

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Correct Answer(s): C

30. An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome? A) Stop the flow of unoxygenated blood into systemic circulation. Feedback: INCORRECT B) Increase the flow of unoxygenated blood to the lungs. Feedback: INCORRECT C) Prevent the return of oxygenated blood to the lungs. Feedback: CORRECT D) Reduce peripheral tissue hypoxia and nailbed clubbing. Feedback: INCORRECT Feedback: CORRECT Closure of VSDs stops oxygenated blood from being shunted from the left ventricle to the right ventricle (C). VSDs are acyanotic defects, which means that no unoxygenated blood enters the systemic circulation (A and B). (D) is common with Tetrology of Fallot, which is a cyanotic defect.

Points Earned:

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Correct Answer(s): C

31. A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child? A) Keep restraints on at all times. Feedback: INCORRECT


B) Remove restraints one at a time and provide range of motion exercises. Feedback: CORRECT C) Remove all restraints simultaneously and provide play activities. Feedback: INCORRECT D) Renew the healthcare provider's prescription for restraints every 72 hours. Feedback: INCORRECT Feedback: CORRECT Removing restraints one at a time (B) is safer than removing all of them at once (C). The child needs to exercise and should not be kept in restraints at all times (A). The renewal of the healthcare provider's prescription varies with hospitals (D), and it does not really answer the question.

Points Earned:

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Correct Answer(s): B

32. A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder? A) Nystatin (Mycostatin). Feedback: CORRECT B) Nitrofurantoin (Macrodantin). Feedback: INCORRECT C) Norfloxacin (Noroxin). Feedback: INCORRECT D) Neomycin sulfate (Mycifradin). Feedback: INCORRECT Feedback: CORRECT Nystatin (Mycostatin) (A) is an antifungal drug that is effective in treating thrush, an oral fungal infection. (B, C, and D) are not indicated for the treatment of oral thrush.

Points Earned:

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Correct Answer(s): A

33.


During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement? A) Start another IV of dextrose solution and stay with the child. Feedback: INCORRECT B) Continue the transfusion and monitor the childâ&#x20AC;&#x2122;s vital signs. Feedback: INCORRECT C) Stop the infusion immediately and notify the healthcare provider. Feedback: CORRECT D) Slow the transfusion and assess for cessation of symptoms. Feedback: INCORRECT Feedback: CORRECT The child is exhibiting signs of a reaction to the blood transfusion. The blood transfusion should be stopped immediately and the healthcare provider notified (C). After the transfusion is discontinued, IV access should be maintained (A) with fluids that do not introduce any more cellular products. (B and D) place the child at risk for further blood reactions.

Points Earned:

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Correct Answer(s): C

34. The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their siblingâ&#x20AC;&#x2122;s repeated hospitalizations. Which is the best response that the nurse should offer? A) Inform the parent that the child is too young to visit the hospital. Feedback: INCORRECT B) Suggest that the child visit a grandmother until the sibling returns home. Feedback: INCORRECT C) Ask the mother if the child asks when the sibling will be discharged. Feedback: INCORRECT D) Encourage the mother to have the children visit the hospitalized sibling. Feedback: CORRECT Feedback: CORRECT Needs of a sibling will be better met with factual information and contact with the ill child, so sibling visitation should be encouraged (D). Parents are experts on their children and


should determine when their children are old enough to visit (A) in the hospital. Separation from family and home (B) may intensify fear and anxiety. Children may have difficulty expressing questions (C), so the support of parents and other caregivers are needed to help alleviate their fears.

Points Earned:

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Correct Answer(s): D

35. The nurse is assessing a 2-year-old. What behavior indicates that the child's language development is within normal limits? A) Is able to name four colors. Feedback: INCORRECT B) Can count five blocks. Feedback: INCORRECT C) Is capable of making a three word sentence. Feedback: INCORRECT D) Half of child's speech is understandable. Feedback: CORRECT Feedback: CORRECT Between approximately 15 and 24 months of age, a child's speech is only half understandable (D). (A and B) usually occur between 3 and 5 years of age. (C) is usually accomplished by 18 months of age.

Points Earned:

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Correct Answer(s): D

36. The nurse is teaching a mother to give 4 ml of a liquid antibiotic to a 10-month-old infant. Which statement by the parent indicates a need for further teaching? A) I will give this antibiotic to my child until it is finished. Feedback: INCORRECT B) Using a teaspoon will help me measure this correctly. Feedback: CORRECT C) I will call the clinic if my child develops a rash or itching. Feedback: INCORRECT


D) My baby should begin to feel better within a few days. Feedback: INCORRECT Feedback: CORRECT The prescribed medication is 4 ml per dosage and is measured with the most accuracy using a syringe, so if the parent uses a teaspoon (B), which is equivalent to 5 ml, further teaching is indicated. (A, C, and D) indicate correct understanding and require no further intervention by the nurse.

Points Earned:

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Correct Answer(s): B

37. A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan? A) Invite other children home to share meals. Feedback: INCORRECT B) Accept that he will eat when he is hungry. Feedback: INCORRECT C) Reward the child with a nap after eating. Feedback: INCORRECT D) Consistently follow a set mealtime routine. Feedback: CORRECT Feedback: CORRECT A 2-year-old child is comforted by consistency (D). (A) is contraindicated because two-yearolds may participate in parallel activities with other children but are too young to feel comfort and support by the presence of other children when anxious or afraid. (B) may or may not be true and does not address the child's fears. The child with reflux should remain upright at least two hours after eating (C) to reduce symptoms.

Points Earned:

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Correct Answer(s): D


• Pediatrics o Bench Marks • Birth wt doubles at 6 months and triples at 12 months • Birth length increases by 50% at 12 months • Post fontanel closes by 8 wks • Ant fontanel closes by 12-18 months • Moro reflex disappears at 4 months • Steady head control achieved at 4 months • Turns over at 5-6 months • Hand to hand transfers at 7 months • Sits unsupported at 8 months • Crawls at 10 months • Walks at 10-12 months • Cooing at 2 months • Monosyllabic Babbling at 3-6 months, Links syllables 6-9 mo • Mama, Dada + a few words at 9-12 months • Throws a ball overhand at 18 months • Daytime toilet training at 18 mo - 2 years • 2-3 word sentences at 2 years • 50% of adult Ht at 2 years • Birth Length doubles at 4 years • Uses scissors at 4 years • Ties shoes at 5 years • Girls’ growth spurt as early at 10 years … Boys catch up ~ Age 14 • Girls finish growing at ~15 … Boys ~ 17 o Autosomal Recessive Diseases • CF, PKU, Sickle Cell Anemia, Tay-Sachs, Albinism, • 25% chance if: AS (trait only) X AS (trait only) • 50% chance if: AS (trait only) X SS (disease) o Autosomal Dominant Diseases • Huntington’s, Marfans, Polydactyl, Achondroplasia, Polycystic Kidney Disease • 50% if one parent has the disease/trait (trait = disease in autosomal dominant) o X-Linked Recessive Diseases • Muscular Dystrophy, Hemophilia A • Females are carriers (never have the disease) • Males have the disease (but can’t pass it on) • 50% chance daughters will be carriers (can’t have disease) • 50% chance sons will have the disease (not a carrier = can’t pass it on) • This translates to an overall 25% chance that each pregnancy will result in a child that has the disease o Scoliosis … Milwaukee Brace – 23 hrs/day, Log rolling after Sx o Down Syndrome = Trisomy 21 … Simian creases on palms, hypotonia, protruding tongue, upward outward slant of eyes o Cerebral Palsy … Scissoring = legs extended, crossed, feet plantar-flexed o PKU … leads to MR … Guthrie Test …Aspartame (NutraSweet) has phenylalanine in it and should not be given to PKU patient


o Hypothyroidism … Leads to MR o Prevent Neural tube disorders with Folic Acid during PG o Myelomeningocele … Cover with moist sterile water dressing and keep pressure off o Hydrocephalus … Signs of increased ICP are opposite of shock … • Shock = Increased pulse and decreased BP • IICP = Decreased pulse and increased BP … (+ Altered LOC = Most sensitive sign) • Infants ... IICP = Bulging fontanels, high pitched cry, increased hd circum, sunset eyes, wide suture lines, lethargy … Treat with peritoneal shunt – don’t pump shunt. Older kids IIPC = Widened pulse pressure • IICP caused by suctioning, coughing, straining, and turning – Try to avoid o Muscular Dystrophy … X-linked Recessive, waddling gait, hyper lordosis, Gower’s Sign = difficulty rising walks up legs (like Minor’s sign), fat pseudohypertrophy of calves. o Seizures … Nothing in mouth, turn hd to side, maintain airway, don’t restrain, keep safe … Treat with Phenobarbitol (Luminol), Phenytoin (Dilantin: TR = 10-20 … Gingival Hyperplasia), Fosphenytoin (Cerebyx), Valproic Acid (Depakene), Carbamazepine (Tegritol) o Meningitis (Bacterial) … Lumbar puncture shows Increased WBC, protein, IICP and decreased glucose • May lead to SIADH (Too much ADH) … Water retention, fluid overload, dilutional hyponatremia o CF Kids taste salty and need enzymes sprinkled on their food o Children with Rubella = threat to unborn siblings (may require temporary isolation from Mom during PG) o Pain in young children measured with Faces pain scale o No MMR Immunization for kids with Hx of allergic rxn to eggs or neomycin o Immunization Side Effects … T < 102, redness and soreness at injection site for 3 days … give Tylenol and bike pedal legs (passively) for child. o Call Physician if seizures, high fever, or high-pitched cry after immunization o All cases of poisoning … Call Poison Control Center … No Ipecac! o Epiglottitis = H. influenza B … Child sits upright with chin out and tongue protruding (maybe Tripod position) … Prepare for intubation or trach … DO NOT put anything into kid’s mouth o Isolate RSV patient with Contact Precautions … Private room is best … Use Mist Tent to provide O2 and Ribavirin – Flood tent with O2 first and wipe down inside of tent periodically so you can see patient o Acute Glomerulonephritis … After B strep – Antigen-Antibody complexes clog up glomeruli and reduce GFR = Dark urine, proteinuria o Wilm’s Tumor = Large kidney tumor … Don’t palpate o TEF = Tracheoesophageal Atresia … 3 C’s of TEF = Coughing, Choking, Cyanosis o Cleft Lip and Palate … Post-Op – Place on side, maintain Logan Bow, elbow restraints o Congenital Megacolon = Hirschsprung’s Disease … Lack of peristalsis due to absence of ganglionic cells in colon … Suspect if no meconium w/in 24 hrs or ribbon-like foul smelling stools


o Iron Deficiency Anemia … Give Iron on empty stomach with citrus juice (vitamin C enhances absorption), Use straw or dropper to avoid staining teeth, Tarry stools, limit milk intake < 32 oz/day o Sickle Cell Disease …Hydration most important …SC Crisis = fever, abd pain, painful edematous hands and feet (hand-foot syndrome), arthralgia …Tx + rest, hydration … Avoid high altitude and strenuous activities o Tonsillitis … usually Strep … Get PT and PTT Pre-Op (ask about Hx of bleeding) … Suspect Bleeding Post-Op if frequent swallowing, vomiting blood, or clearing throat … No red liquids, no straws, ice collar, soft foods … Highest risk of hemorrhage = first 24 hrs and 5-10 days post-op (with sloughing of scabs) o Primary meds for ER for respiratory distress = Sus-phrine (Epinephrine HCl) and Theophylline (Theo-dur) … Bronchodilators o Must know normal respiratory rates for kids … Respiratory disorders = Primary reason for most medical/ER visits for kids … • Newborn … 30-60 • 1-11 mo … 25-35 • 1-3 years … 20-30 • 3-5 years … 20-25 • 6-10 years … 18-22 • 11-16 years …16-20 Cardiovascular Disorders o Acyanotic = VSD, ASD, PDA, Coarc of Aorta, Aortic Stenosis • Antiprostaglandins cause closure of PDA (aorta - pulmonary artery) o Cyanotic = Tetralogy of Fallot, Truncus Arteriosis (one main vessel gets mixed blood), TVG (Transposition of Great Vessels) … Polycythemia common in Cyanotic disorders • 3 T’s of Cyanotic Heart Disease (Tetralogy, Truncus, Transposition) o Tetralogy of Fallot … Unoxygenated blood pumped into aorta • Pulmonary Stenosis • VSD • Overiding Aorta • Right Ventricular Hypertrophy • TET Spells …Hypoxic episodes that are relieved by squatting or knee chest position o CHF can result … Use Digoxin … TR = 0.8-2.0 for kids o Ductus Venosus = Umbelical Vein to Inferior Vena Cava o Ductus Arteriosus = Aorta to Pulmonary Artery o Rheumatic Fever … Acquired Heart Disease … Affects aortic and mitral valves • Preceded by beta hemolytic strep infection • Erythema Marginatum = Rash • Elevated ASO titer and ESR • Chest pain, shortness of breath (Carditis), migratory large joint pain, tachycardia (even during sleep) • Treat with Penicillin G = Prophylaxis for recurrence of RF


Peds HESI Study Guide

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Head lice • Nits hatch in 7 to 10 days • Scratching may result in bacterial infection • Examine with a bright light • Pediculicide shampoo is used. Leave medication on hair for 10 minutes and then rinse off. Retreat in 7 to 10 days. • If it is firmly attached, it is likely a nit, not dandruff. • Check for ragweed allergies and asthma before applying permethrin shampoo Lyme disease • Skin rash is circular with central clearing • S/S: fever, headache, aching, and satellite rash. Later: arthritis, neurological symptoms • Tick removal: Use tweezers, use gloves. If remains in skin, soak skin, then remove the rest. Celiac diet • Gluten-free (avoid wheat, barley, rye) • Can eat oats, but need to be careful of cross-contamination from gluten containing products Kawasaki Disease • Acute febrile inflammation of the vasculature • Can lead to coronary artery aneurysm or MI • Leading cause of acquired heart disease in children • Not contagious • S/S: bacterial conjunctivitis, red lips, strawberry tongue, measleslike rash, cardiac involvement • Diagnosis is through exclusion • High fever not resolved by antipyretics or antibiotics • Salicylate (Aspirin) therapy • Nursing care aimed at symptom relief • Defer live immunizations (MMR, chicken pox) • Educate about lifelong possibility of cardiac disease Precocious Puberty • Early development o Girls <8 o Boys <9


• •

Tanner stage 2 or greater, acne, café au lait spots, advanced bone age, mood swings Give GnRHa (Lupron), but be careful with rebound effect. It’s an IM or SQ injection monthly

GER • • •

Infants should be frequently burped during feedings and placed upright for 30 minutes following feeding Can thicken formula or give AR formula Raise the head of the crib

ANC • High risk of infection with an oncologic disorder • (% Bands + % Segmented cells) x Total WBC count = ANC • If less than 500, client is at high risk for infection. Erikson Stages • Infant: Trust vs. Mistrust • Toddler: Autonomy vs. shame and doubt • Preschool: Initiative vs. guilt • School age: industry vs. inferiority • Adolescent: Identity vs. role confusion • Early adulthood: Intimacy vs. Isolation • Adulthood: Generativity vs. stagnation • Old age: integrity vs. despair Cupping • Device used on skin (usually back) believed to pull toxins out • Child comes in to ER for different issue and you notice red uniform circular marks on back. Differentiate between abuse and cultural practice. Would need to ask parents about this. Hypospadias and the Jewish faith • Cannot be circumcised until after naming ceremony • Need to use foreskin when hypospadias repair is done • Family would need teaching Extrophy of bladder • Pre-op (cover with sterile moist dressing and keep wet and protected from infection) Field of gaze • Strabismus


Inguinal • • • • •

hernia teaching Discourage heavy lifting after repair Watch for bleeding and drainage Notify physician of fever Brace when coughing or deep breathing Strangulation and incarceration can occur if it is not repaired


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Airway obstruct place the thumb side of one fist against the victim’s abdomen in the midline, slightly above the umbilicus and well below the tip of the xiphoid process. The rescuer grasps the fist with the other hand and delivers up to five thrust CPR on 7 y/o In a child between the ages of 1 and 8 years, 12 to 20 breaths per minute are delivered. CPR infant In an infant, the rate of chest compressions is at least 100 times per minute Basic Life Support (BLS) To assess a pulse in an infant (younger than 1 year of age), the pulse is checked at the brachial or femoral artery. The infant’s relatively short fat neck makes palpation of the carotid artery difficult. The popliteal and radial pulses are also difficult to palpate in an infant CPR Blind finger sweeps are not recommended for infants and children because of the risk of forcing the object farther down into the airway. CPR When performing cardiopulmonary resuscitation (CPR) on infants and children, the sternum is depressed one third to one half the depth of the sternum. Erikson’s Psychosocial Development According to Erikson, during school-age years (6 to 12 years of age), the child begins to move toward peers and friends and away from the parents for support. The child also begins to develop special interests that reflect his or her own developing personality instead of the parents Erikson’s Psychosocial Development According to Freud’s psychosexual stages of development, between the ages of 3 and 6 the child is in the phallic stage. At this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns Freud’s Psychosexual DevelopmentGenerally, toilet training occurs during the anal stage of development. According to Freud, the child gains pleasure from the elimination of feces and from their retention. Option 2 relates to the oral stage Piaget’s Cognitive Development In the formal operations stage, the child has the ability to think abstractly and logically. In the concrete operations stage the child develops logical thought patterns. In the sensorimotor stage they begin to understand the environment. In the preoperational stage they have difficulty separating fantasy from reality. Kohlberg’s Moral Development In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient and is not punished, then the child is being moral. The child sees actions as good or bad. If the child’s actions are good, the child is praised. If the child’s actions are bad, the child is punished Erikson’s Psychosocial Development According to Erikson, the caregiver should not try to anticipate the newborn infant’s needs at all times but must allow the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infant’s signal would inhibit the development of trust and lead to mistrust of others. Erikson’s Psychosocial Development According to Erikson, the child focuses on independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents’ wishes. Saying things like no or mine and having temper tantrums are common during this period of development. Being consistent and setting limits on the child’s behavior are necessary elements. Car Safety Seats Children should remain in a booster seat until they are 8 to 12 years old and at least 4 feet, 9 inches tall. An infant should ride in a car in a semireclined, rear-facing position in an infant-only seat or a convertible seat until they weigh at least 20 lb and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kg (20 lb) and 1 year of age. Convertible car safety seats are used until the child weighs at least 40 lb. Vital Signs The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/min. The normal apical rate is 90 to 130 beats/min, and the average blood pressure is 90/56 mm Hg Car Safety Seats Infants who weigh up to 20 lb and are at least 1 year of age should be restrained in a car seat (convertible seat) or infant-only seat in a semireclined, rear-facing position in the back seat of the car Increased Intracranial Pressure The anterior fontanel is diamond-shaped and located on the top of the head. The fontanel should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. Development Level By age 2 years, the child can use a cup and spoon correctly but with some spilling. By age 3 to 4, the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and begin to use a knife for cutting. Behavior The phases through which young children progress when separated from their parents include protest, despair, and denial or detachment. In the stage of protest, when the parents return, the child readily goes to them. In the stage of despair, the child may not approach them readily or may cling to a parent. In denial or detachment, when the parents return, the child becomes cheerful, interested in the environment and new persons (seemingly unaware of the lost parents), friendly with the staff, and interested in developing superficial relationships

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20. Behavior Toddlers often resist going to bed. Bedtime protests may be reduced by establishing a consistent beforebedtime routine and enforcing consistent limits regarding the child’s bedtime behavior. Informing the child of bedtime a few minutes before it is time for bed is the most appropriate option. Most toddlers take an afternoon nap and, until their second birthday, also may require a morning nap. Firm, consistent limits are needed for temper tantrums or when toddlers try stalling tactics. 21. Safe Toys Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some of the appropriate toys. A farm set, a golf set, and jacks with marbles may contain items that the child could swallow. 22. Toilet training Bowel control usually is achieved before bladder control. The child should not be forced to sit for long periods. The ability to remove clothing is one of the physical signs of readiness. The physical ability to control the anal and urethral sphincters is achieved some time after the child is walking, probably between the age of 18 and 24 months. 23. Sleep A toddler should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, or sweetened water because of the risk of nursing (bottle-mouth) caries. If a bottle is allowed at nap time or bedtime, it should contain only water. 24. Traction for Fracture In the preschooler, play is simple and imaginative and includes activities such as crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh. A radio or sports video are most appropriate for the adolescent. Large picture books are most appropriate for the infant. 25. Sleep The adolescent needs about 8 hours of sleep per night. During this age, with an increase in social activities, school commitments, and possibly work activities, it is important that the adolescent receive enough sleep at night 26. Illness in Preschoolers Although the preschooler already may be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want to call the parents. Separation anxiety will increase if the child is put in a private room even if they have their favorite toys in the room. 27. Adolescent G/D Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of their peer group, separation from friends is a source of anxiety. Ideally, the members of the peer group will support their ill friend. 28. Communication Using monosyllabic babbling occurs between 3 and 6 months of age. Using simple words such as “mama” occurs between 9 and 12 months of age. Linking syllables together when communicating occurs between 6 and 9 months of age. Cooing begins at birth and continues until 2 months of age. 29. Car Safety Seats The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kg (20 lb) and 1 year of age. Convertible car safety seats are used until the child weighs at least 40 lb. 30. Vital Signs The normal apical heart rate for a 3 year old is 80 to 120 beats/min. 31. Teaching Toddlers, with their increased mobility and development of motor skills, can reach hot water or hot objects placed on counters and stoves and can reach open fires or stove burners above their eye level. The nurse should encourage parents to remain in the kitchen when preparing a meal, use the back burners on the stove, and turn pot handles inward and toward the middle of the stove. Hot liquids should never be left unattended, and the toddler should always be supervised 32. Psychological Anorexia A toddler has the skills required to feed himself or herself. The parent needs to be instructed not to feed children who can feed themselves and not to force-feed a child. To increase nutritious intake at mealtime, juice intake needs to be limited to less than 12 oz per day. At mealtime, the best option is to offer less than the toddler may eat and let the child ask for more food. 33. Regression In the hospitalized preschooler, the best option is to accept regression if it occurs. Regression is most often a result of the stress of the hospitalization. Parents may be overly concerned about regression and should be told that their child may continue the behavior at home. When regression does occur, the best approach is to ignore it while praising existing patterns of appropriate behavior. Calling the physician is not necessary. 34. Infant Care Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to do so also. Additional interventions include playing a music box, radio, or television, or having a ticking clock or metronome nearby. Hanging a bright shiny object in midline within 20 to 25 cm of the infant’s face and hanging mobiles with contrasting colors, such as black and white, provide visual stimulation. Crying is an infant’s way of communicating; therefore, the nurse would respond to the infant’s crying. The mother is taught to do so also. An infant or child should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, or sweetened water because of the risk of nursing (bottle-mouth) caries. 35. Reye's Syndrome In Reye’s syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral

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tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be in a head-elevated position to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid. 36. Reye's Syndrome "The vomiting that occurs in Reyeâ&#x20AC;&#x2122;s syndrome is caused by cerebral edema and is a symptom of increased intracranial pressure. Small frequent meals will not affect the amount of vomiting but, if vomiting occurs, the parents should contact the health care provider. Decreasing stimuli and providing rest decrease stress on the brain tissue. Checking for jaundice will assist in identifying the presence of liver dysfunction that occurs in Reyeâ&#x20AC;&#x2122;s syndrome.

37. " 38. Generalized Tonic-Clonic Seizures Generalized tonic-clonic seizures cause rigidity of all body muscles, followed by intense jerking movements. Because airway obstruction and increased oral secretions can occur during and after the seizure, airway and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. An emergency cart would not be left at the bedside but would be available in the treatment room or nearby on the nursing unit. 39. Cerebral Palsy Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation. 40. Cerebral Palsy The goals of managing the child with cerebral palsy are early recognition and intervention to maximize the childâ&#x20AC;&#x2122;s abilities. The disorder is not curable. The cause of the disorder cannot be eliminated. Minimizing the occurrence of emotional disturbances is best if possible, but they should not be prevented because expression of emotions is healthy for the child. 41. Autism Autistic disorder is a complex childhood disorder that involves abnormalities in behavior, social interactions, and communication. Autistic children are unable to relate to persons or to respond to social and emotional cues. Characteristically, these children engage in repetitive behaviors, including head banging, twirling in circles, biting themselves, and flapping their hands or arms. Abnormal communication patterns include verbal and nonverbal communication. A child with autism needs decreased stimulation, with limited visual and auditory distractions. A private room would be the best environment, allowing for control of visual and auditory distractions. The semiprivate and four-bed ward rooms would be too stimulating for the child with autism. Autism is not a disorder that requires contact isolation. 42. Basilar Skull Fractures Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the nature of the injury, there is a high risk of secondary infection and the probability of the catheter entering the brain through the fracture. Fluid balance is monitored closely by daily weight, intake and output measurement, and serum osmolality determination to detect early signs of water retention, excessive dehydration, and states of hypertonicity or hypotonicity. The child is maintained on an NPO status or restricted to clear liquids until it is determined that vomiting will not occur. An intravenous line is maintained to administer fluids or medications if necessary. 43. Bacterial Meningitis Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing cerebrospinal fluid obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy cerebrospinal fluid, and elevated leukocyte, elevated protein, and decreased glucose levels. 44. Bacterial Meningitis Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child also is placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Enteric precautions and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when a child has a low neutrophil count. 45. Autism Autistic disorder is a complex childhood disorder that involves abnormalities in behavior, social interactions, and communication. Autistic children are unable to relate to persons or to respond to social and emotional cues. Characteristically, these children engage in repetitive behaviors, including head banging, twirling in circles, biting themselves, and flapping their hands or arms. Abnormal communication patterns include verbal and nonverbal communication.

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46. Abuse: Sexual The most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may indicate physical neglect. Bald spots on the scalp and fear of the parents most likely are associated with physical abuse. 47. Abuse: Physical The primary legal nursing responsibility when child abuse is suspected is to report the case. All states and provinces in North America have laws for mandatory reporting of child maltreatment. Suspected child abuse should be reported to the local authorities. Although documentation of assessment findings, assisting the family, and referring the family to appropriate resources and support groups are important, the primary legal responsibility is to report the suspected case. 48. Spina Bifida (Myelomeningocele type) The newborn with spina bifida is at risk for infection before the closure of the sac. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents. This prevents tearing or breakdown of the skin integrity at the site. Blood pressure may be difficult to assess during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development. A thermometer will be needed to assess temperature, but in this newborn the priority is to maintain sterile normal saline dressings over the sac. 49. Absence Seizures Absence seizures are brief episodes of altered awareness. No muscle activity occurs except eyelid fluttering or twitching. The child has a blank facial expression. These seizures last only 5 to 10 seconds, but they may occur one after another several times a day. Myoclonic seizures are brief random contractions of a muscle group that can occur on one or both sides of the body. Simple partial seizures consist of twitching of an extremity, face, or neck, or the sensation of twitching or numbness in an extremity or face or neck. 50. Increased Intracranial Pressure Decerebrate posturing is characterized by the rigid extension and pronation of the arms and legs 51. Hydrocephalus In infants with hydrocephalus, the head grows at an abnormal rate and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help prevent skin breakdown. Proteinuria is not specific to hydrocephalus. Stimulus should be kept at a minimum because of the increase in intracranial pressure. It is not necessary to check the blood pressure every 30 minutes. 52. Hydrocephalus If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is increased intracranial pressure, which then causes a high-pitched cry in the infant. The infant should not have pressure placed on the shunt side. Skin breakdown and possible compressions to the apparatus could result. This type of shunt affects the gastrointestinal system, not the genitourinary system. An infant refusing food is only a concern if the infant becomes malnourished or dehydrated, which then could raise the body temperature. Otherwise, the infant’s refusing baby food has no direct relationship to the shunt functioning. 53. Spina Bifida (Myelomeningocele type) Newborn infants with spina bifida (myelomeningocele type) are at risk for hydrocephalus; therefore, the head circumference should be measured to obtain a baseline. Options 1, 2, and 3 are incorrect because pulse rate will not be affected with this disorder, the specific gravity can indicate hydration status but it is not priority at this time, and abdominal masses do not occur with this disorder. 54. Increased Intracranial Pressure Late signs of increased intracranial pressure (ICP) include a significant decrease in level of consciousness, bradycardia, and fixed and dilated pupils. A bulging fontanel and dilated scalp veins are early signs of increased ICP and would be noted in an infant, not a 5-year-old child. Nausea is an early sign of increased ICP 55. Seizures During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side will prevent aspiration because saliva will drain out the corner of the child’s mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child’s neck and ensure a patent airway. Nothing is placed into the child’s mouth during a seizure because this action may cause injury to the child’s mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure. 56. Strabismus Strabismus is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see. 57. Strabismus Strabismus is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. In a child diagnosed with strabismus, surgery may be indicated to realign the weakened muscles. Surgery most often is indicated when amblyopia (decreased vision in the deviated eye) is present. The surgery should be performed before the child is 2 years old 58. Myringotomy A myringotomy is the insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated. After myringotomy with insertion of tympanostomy tubes, the child may experience some discomfort. Tylenol can be given to relieve the discomfort. An opioid analgesic is not necessary, and aspirin should not be administered to a child.

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59. Chlamydial Conjunctivitis Conjunctivitis is an inflammation of the conjunctiva. A diagnosis of chlamydial conjunctivitis in a child who is not sexually active should signal the health care provider to assess the child for possible sexual abuse. Allergy, infection, and trauma can cause conjunctivitis, but the causative organism is not likely to be chlamydia 60. Bacterical Conjunctivitis Conjunctivitis is an inflammation of the conjunctiva. Bacterial conjunctivitis is highly contagious, and the nurse should teach infection control measures. These include good hand washing and not sharing towels and washcloths 61. Myringotomy A myringotomy is the insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated. Parents need to be instructed that the child should not blow his or her nose for 7 to 10 days. Bath and lake water are potential sources of bacterial contamination. Diving and swimming in deep water are prohibited. The child’s ears need to be kept dry 62. Tonsillectomy Tonsillectomy – Because the tonsillar area is so vascular, postoperative bleeding is a concern. The prothrombin time, partial thromboplastin time, platelet count, hemoglobin and hematocrit, white blood cell count, and urinalysis are performed preoperatively. The prothrombin time results would identify a potential for bleeding. The creatinine level, sedimentation rate, and blood urea nitrogen would not determine the potential for bleeding. 63. Tonsillectomy Tonsillectomy - In the preoperative period, the child should be observed for the presence of loose teeth to decrease the risk of aspiration during surgery. Options 1 and 3 are incorrect because these are characteristics that may indicate the need for the surgery. Bleeding during surgery will be controlled via packing and suction as needed. 64. Tonsillectomy Tonsillectomy - The child should be placed in a prone or side-lying position following tonsillectomy to facilitate drainage. 65. Tonsillectomy Tonsillectomy - After tonsillectomy, suction equipment should be available, but suctioning is not performed unless there is an airway obstruction because of the risk of trauma to the oropharynx. Monitoring for bleeding is an important nursing intervention following any type of surgery. Milk and milk products are avoided initially because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding. Clear, cool liquids are encouraged. 66. Tonsillectomy Tonsillectomy - Frequent swallowing, restlessness, a fast and thready pulse, and vomiting bright red blood are signs of bleeding. An elevated blood pressure and complaints of discomfort are not indications of bleeding. 67. Myringotomy Myringotomy - A myringotomy is the insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated. The nurse must instruct parents regarding the administration of antibiotics. Antibiotics need to be taken as prescribed, and the full course needs to be completed 68. Tonsillectomy Tonsillectomy - Bad mouth odor is normal following tonsillectomy and may be relieved by drinking more liquids. Options 1, 2, and 3 are incorrect. In addition, mouthwash gargles (option 3) will irritate the throat. 69. Ear Drops Ear Drops - For children younger than age 3, the nurse instructs the parent that the auditory canal is straightened by pulling the lobe down and back. For children older than 3 years, the pinna (option 1) is pulled up and back. 70. Acute Otitis Media Acute Otitis Media - Acute otitis media is usually an infectious inflammation of the middle ear. The child will often have fever, pain, loss of appetite, and possible ear drainage. The child’s fever should be treated with acetaminophen (Tylenol). The child is positioned on his or her affected side to facilitate drainage. A soft diet is recommended during the acute stage to avoid pain that can occur with chewing. Antibiotics are prescribed to treat the bacterial infection and should be administered for the full 10- to 14-day prescribed course. The ear should not be irrigated with normal saline because it can further exacerbate the inflammation. Antihistamines are not recommended. 71. Bronchiolitis w/ Dehydration Dehydration - Weight is the most reliable method of measurement of body fluid loss or gain. A weight change of 1 kg represents 1 L of fluid loss or gain. Although options 2, 3, and 4 identify components of the assessment for dehydration, these are not the most reliable determinants, because they require more subjective interpretation than weight, which is more objectively determined. 72. epiglottitis Epiglottitis - Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward while supported by arms, chin thrust out, mouth open), nasal flaring, tachycardia, a high fever, and a sore throat. Option 4 is an incorrect position. Options 1 and 3 are incorrect because epiglottitis causes a high fever and tachycardia. 73. Bronchiolitis Bronchiolitis – Respiratory syncytial virus (RSV) is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands, and meticulous hand washing is necessary to decrease the spread of organisms. The infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are not necessary. 74. Respiratory Syncytial Virus (RSV) Respiratory Syncytial Virus (RSV) – Ribavirin (Virazole) is an antiviral respiratory medication used mainly for hospitalized children with severe RSV. Administration is via hood, face mask, or oxygen tent. Ribavirin is not administered orally, intramuscularly, or subcutaneously. 75. Asthma Asthma – Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A “silent chest” is an ominous sign during an asthma episode. With treatment, increased

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81. 82.

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86. 87.

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wheezing actually may signal that the child’s condition is improving. Warm, dry skin indicates an improvement in condition, because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats/min. The normal respiratory rate in a 10-year-old is 16 to 20 breaths/min. Pneumonia Pneumonia – Splinting of the affected side by lying on that side may decrease discomfort. To advise the mother to increase the dose or frequency of the acetaminophen is inappropriate. Lying on the left side will not be helpful in alleviating discomfort. Sudden Infant Death Syndrome (SIDS) Sudden Infant Death Syndrome (SIDS) – Nurses should encourage parents to place the infant on the back (supine) for sleep. The infant may have the ability to turn to a prone position from the side-lying position. Infants in the prone position (on the stomach) may be unable to move their heads to the side, thus increasing the risk of suffocation. Cystic Fibrosis Cystic Fibrosis – In a sweat test, sweating is stimulated on the child’s forearm with pilocarpine, the sample is collected on absorbent material, and the amounts of sodium and chloride are measured. A sample of at least 50 mg of sweat is required for accurate results. A chloride level higher than 60 mEq/L is considered to be a positive test result. A chloride level of 40 mEq/L suggests cystic fibrosis and requires a repeat test. A chloride level of less than 40 mEq/L indicates no cystic fibrosis. Cystic Fibrosis Cystic Fibrosis – Adequately protecting children with cystic fibrosis from communicable diseases by immunization is essential. In addition to the basic series of immunizations, a yearly influenza and possibly a pneumococcal vaccine also are recommended for children with cystic fibrosis. Mantoux test Mantoux test – Induration measuring 10 mm or more is considered to be a positive result in children younger than 4 years of age and in those with chronic illness or at high risk for environmental exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for the highest risk groups, such as the child with an immunosuppressive condition or the child with human immunodeficiency virus infection. A reaction of 15 mm or more is positive in children 4 years of age or older without any risk factors. HIV HIV – For children with human immunodeficiency virus infection, a minimum of 12 months of treatment with isoniazid is recommended. Croup Croup – Croup often begins at night and may be preceded by several days of upper respiratory infection symptoms. Croup is characterized by a sudden onset of a harsh, brassy cough, sore throat, and inspiratory stridor. Symptoms usually worsen at night and are better in the day. Croup usually is accompanied by a low-grade fever, but occasionally the temperature may be as high as 104° F. Croup Croup – Antibiotics are not indicated in the treatment of croup unless a bacterial infection is present Croup Croup – If the use of a tent or hood is causing distress, treatment may be more effective if the child is held by the parent and a cool mist is directed toward the child’s face. A mild sedative would not be administered to the child. Crying will aggravate laryngospasm and increase hypoxia, which may cause airway obstruction Bronchiolitis Bronchiolitis – The infant with RSV should be isolated in a private room or in a room with another infant with RSV infection. The infant should be placed in a room near the nurses’ station for easy observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing gloves and a gown) reduce nosocomial transmission of RSV. Aortic stenosis Aortic stenosis – The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods of time. Pallor may be noted but is not specific to this type of disorder alone Cardiac Surgery Cardiac Surgery – The mother should be instructed that lotions and powders should not be applied to the incision site. Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site. Rheumatic Fever Rheumatic Fever – Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child had a sore throat or an unexplained fever within the past 2 months. Rheumatic Fever Rheumatic Fever – Anti-inflammatory agents, including aspirin, may be prescribed for the child with rheumatic fever. Aspirin should not be given to a child who has chickenpox or other viral infections, such as the flu. Joint pain and arthralgia are clinical manifestations of rheumatic fever. Facial edema may be associated with the development of a cardiac complication. Rheumatic Fever Rheumatic Fever – A diagnosis of rheumatic fever is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive antistreptolysin O titer, Streptozyme assay, or an anti-DNase B assay

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91. Kawasaki Disease Kawasaki Disease – Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown origin. An acquired cell-mediated immunodeficiency disorder describes human immunodeficiency virus infection. Option 2 (chronic multisystem autoimmune disease w/ inflammation of connective tissue) describes systemic lupus erythematosus. Option 4 (autoimmune inflammation of the heart, joints, and SQ tissues) describes rheumatic fever. 92. Kawasaki Disease Kawasaki Disease – In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present. 93. CHF CHF – The parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. In addition, the parents should be instructed that if a dose is missed and is not identified until 4 hours later, the dose should not be administered. 94. Tricuspid Atresia Tricuspid Atresia – In tricuspid atresia, no communication exists from the right atrium to the right ventricle. Option 1 (single vessel overrides both ventricles) describes truncus arteriosus. Option 4 (no communication b/t systemic and pulm circulation) describes transposition of the great arteries. Frequent episodes of hypercyanotic spells occur in tetralogy of Fallot. 95. Kawasaki Disease Kawasaki Disease – Immune globulin is administered intravenously to the child with Kawasaki disease to decrease the incidence of coronary artery lesions and aneurysms and to decrease fever and inflammation 96. Tetralogy of Fallot Tetralogy of Fallot – If a hypercyanotic spell occurs, the nurse immediately places the infant in a knee-chest position. This position improves systemic arterial oxygen saturation. 97. CHF CHF – The early signs of congestive heart failure (CHF) include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in CHF as a result of mucosal swelling and irritation but is not an early sign. Pallor may be noted in the infant with CHF but is also not an early sign. 98. CHF CHF – Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures 99. CHF CHF – The most appropriate method for assessing urine output in an infant receiving diuretic therapy is to weigh the diapers. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the amount of output. Although Foley catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant and places the infant at risk for infection. 100. CHF CHF – A weight gain of 0.5 kg (1 lb) in 1 day is caused by the accumulation of fluid. The nurse should assess urine output, assess for evidence of facial or peripheral edema, auscultate lung sounds, and report the weight gain to the physician. Tachypnea and an increased blood pressure would occur with fluid accumulation. Diaphoresis is a sign of CHF but is not specific to fluid accumulation, and usually occurs with exertional activities. 101. CHF CHF – A patent ductus arteriosus is failure of the fetal ductus arteriosus (artery connecting the aorta and the pulmonary artery) to close. A characteristic machinery-like murmur is present and the infant may show signs of congestive heart failure. Aortic stenosis is a narrowing or stricture of the aortic valve. Atrial septal defect is an abnormal opening between the atria. Ventricular septal defect is an abnormal opening between the right and left ventricles. 102. Cleft lip After cleft lip repair, the infant should be positioned supine or on the side lateral to the repair to prevent contact of the suture lines with the bed linens. Placing the infant on the left side rather than supine immediately after surgery is best to prevent the risk of aspiration if the infant vomits. 103. Esophageal Atresia Any child who exhibits the “3 Cs”—coughing and choking with feedings and unexplained cyanosis— should be suspected of tracheoesophageal fistula 104. GERD Small, more frequent feedings with frequent burping often are prescribed in the treatment of gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis. If thickened formula is used, cross-cutting of the nipple may be required. 105. Pyloric Stenosis Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation, and signs of dehydration, including a decrease in urine output. 106. Lactose Intolerance Lactose intolerance is the inability to tolerate lactose, the sugar found in dairy products. Removing milk and other dairy products from the diet can provide adequate relief from symptoms. Additional dietary changes may be required to provide adequate sources of calcium and, in the infant, protein and calories. 107. Celiac Disease Dietary management is the mainstay of treatment in celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn, rice, or millet. Vitamin supplements—especially the fat-soluble vitamins, iron,

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and folic acid—may be needed in the early period of treatment to correct deficiencies. Dietary restrictions are likely to be lifelong, although small amounts of grains may be tolerated after ulcerations have healed. 108. Intussesception Intussusception is a telescoping of one portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. The child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomiting may be present but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly–like stools. Watery diarrhea and ribbon-like stools are not manifestations of this disorder. 109. Lead Poisoning Renal function is monitored closely during the administration of chelation therapy because the medications are excreted via the kidneys. Although it is important to monitor the red blood cell count for the presence of anemia in a child with lead poisoning, this laboratory result is not specific to chelation therapy. 110. Hirschsprung's Disease Hirschsprung’s disease is a congenital anomaly also known as congenital aganglionosis or aganglionic megacolon. It occurs as the result of an absence of ganglion cells in the rectum and other areas of the affected intestine. Chronic constipation beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foulsmelling is a clinical manifestation of this disorder. Delayed passage or absence of meconium stool in the neonatal period is also a sign. Bowel obstruction, especially in the neonatal period, abdominal pain and distention, and failure to thrive are also clinical manifestations 111. Vomiting Vomiting will cause the loss of hydrochloric acid and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea might or might not accompany vomiting. Hyperactive bowel sounds are not necessarily associated with vomiting. 112. Diarrhea Rectal temperature measurements should be avoided if diarrhea is present. Use of a rectal thermometer can stimulate peristalsis and cause more diarrhea. Axillary and tympanic measurements of temperature would be acceptable. Most measurements are done using electronic devices. 113. Cleft Palate The mother is taught the ESSR method of feeding the child with a cleft palate: enlarge the nipple, stimulate the sucking reflex, swallow, and rest to allow the infant to finish swallowing what has been placed in the mouth 114. Imperforated Anus During the newborn assessment, this defect should be identified easily on sight. However, a rectal thermometer or tube may be necessary to determine patency if meconium is not passed in the first 24 hours after birth. Other assessment findings include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum 115. Gastroschisis Gastroschisis occurs when the bowel herniates through a defect in the abdominal wall to the right of the umbilical cord. There is no membrane covering the exposed bowel. Surgical repair will be done as soon as possible because of the risk of infection in the unprotected bowel. Therefore, the highest risk immediately after delivery would be infection. Risk for impaired parenting and risk for disorganized infant behavior are possible later nursing problems, but they would not have priority. Risk for impaired urinary elimination is unlikely because the gastrointestinal tract is affected, not the genitourinary system. 116. Appendectomy In the preoperative period, enemas or laxatives should not be administered. Additionally, heat is not applied to the abdomen. Any of these interventions can cause rupture of the appendix and resultant peritonitis. IV fluids would be started, and the child would be NPO while awaiting surgery. Usually, antibiotics are administered because of the risk of perforation. Prescribed preoperative medications most likely would be administered on call to the operating room. 117. Hepatitis Because hepatitis can be viral, standard precautions should be instituted in the hospital. The child should be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite home schooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the physician. Provision of a low-fat, wellbalanced diet is recommended. Parents are cautioned about administering any medication to the child, because normal doses of many medications may become dangerous because of the liver’s inability to detoxify and excrete them. Hand washing is the single most effective measure in control of hepatitis in any setting and effective hand washing can prevent the compromised child from picking up an opportunistic type of infection. 118. Potassium Chloride The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hr, potassium chloride should not be administered. Although options 1, 2, and 3 are appropriate assessments for the child with dehydration, these assessments are not related specifically to the intravenous (IV) administration of potassium chloride. 119. Diabetes Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic

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ketoacidosis. Instead, hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. Cold, clammy skin, irritability, sweating, and tremors are all signs of hypoglycemia. 120. Phenylketonuria Phenylketonuria is an autosomal recessive disorder. Treatment includes dietary restriction of phenylalanine intake. Phenylketonuria is a genetic disorder that results in central nervous system damage from toxic levels of phenylalanine in the blood 121. Phenylketonuria Phenylketonuria is characterized by blood phenylalanine levels higher than 8 mg/dL. A normal level is lower than 2 mg/dL. A result of 1 mg/dL is a negative test result. 122. Diabetes An extra snack of 15 to 30 g of carbohydrates eaten before activities such as soccer practice will prevent hypoglycemia. Six graham crackers or a cup of orange juice will provide 15 to 30 g of carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be doubled. 123. Diabetes To help decrease variations in absorption from day to day, the adolescent should use one major site for injections for 2 to 3 weeks before changing major sites. The injections are rotated to different locations within that major site. 124. Diabetes When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink calorie-free liquids. Bringing the child to the clinic immediately is not necessary. Insulin doses should not be adjusted or changed. 125. Diabetes Rehydration is the initial step in resolving diabetic ketoacidosis. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose level reaches an acceptable level. Intravenously administered potassium may be required, depending on the potassium level, but would not be part of the initial treatment. 126. Tylenol After administering the acetaminophen, excess clothing and blankets should be removed. The child can be sponged with tepid water, but not cold water, because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin is not administered to a child with fever because of the risk of Reyeâ&#x20AC;&#x2122;s syndrome. Fluids should be encouraged to prevent dehydration, so oral fluids should not be withheld. 127. Fluid Volume Deficit Indicators that fluid volume deficit is resolving would be capillary refill less than 3 seconds, specific gravity of 1.002 to 1.025, urine output of at least 1 mL/kg/hour, and adequate tear production. Therefore, a capillary refill time shorter than 3 seconds is the only indicator that the child is improving. Urine output of less than 1 mL/kg/hr, a specific gravity of 1.030 and no tears would indicate that the deficit is not resolving. 128. Diabetes Hypoglycemia is defined as a blood glucose level lower than 70 mg/dL. Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If possible, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; the rapid-releasing sugar is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums and the blood glucose level is retested if the child does not improve within 15 to 20 minutes; if the reading remains low, additional sugar is administered. If the child remains unconscious, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. Encouraging the child to ambulate and administering regular insulin will result in a lowered blood glucose level. Providing electrolyte replacement therapy intravenously is an intervention to treat diabetic ketoacidosis. Waiting 30 minutes to confirm the blood glucose level delays necessary intervention. 129. Acute Glomerulonephritis Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. In glomerulonephritis, activity is limited and most children, because of fatigue, voluntarily restrict their activities during the active phase of the disease. Catheterization may cause a risk of infection. Fluids should never be forced. Visitors should be limited to allow for adequate rest. 130. Nephrotic Syndrome Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema. Other manifestations include weight gain, periorbital and facial edema that is most prominent in the morning, leg, ankle, labial or scrotal edema, decreased urine output and urine that is dark and frothy, abdominal swelling, and blood pressure that is normal or slightly decreased. 131. Nephrotic Syndrome Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia (hypoproteinemia), and edema. In most cases, medication and diet will control the fluid retention. The nurse must give the mother information that addresses the subject that is the parentâ&#x20AC;&#x2122;s concern. Most children experience remission with treatment. Options 1 and 4 are nontherapeutic and may add to the motherâ&#x20AC;&#x2122;s guilt. Option 2 does not acknowledge the concern and is a stereotypical response. 132. Hemolytic-Uremic Syndrome Hemolytic-uremic syndrome (HUS) is thought to be associated with bacterial toxins, chemicals, and viruses that cause acute renal failure in children. Clinical features of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with hemolytic-uremic syndrome

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undergoing peritoneal dialysis because of anuria will be on fluid restriction. Pain is not associated with hemolytic-uremic syndrome and potassium would be restricted, not encouraged, if the child was anuric. Peritoneal dialysis does not require an AV shunt (only hemodialysis). 133. Nocturnal Enuresis Primary nocturnal enuresis occurs in a child who has never been dry at night for extended periods. The condition is common in children, and most children eventually will outgrow bed-wetting without therapeutic intervention. The child is not able to sense a full bladder and does not awaken to void. The child may have delayed maturation of the central nervous system. The condition is not caused by a psychiatric problem. 134. Cryptorchidism The most common complications associated with orchiopexy are bleeding and infection. The parents are instructed in postoperative home care measures, including preventing infection, pain control, and activity restrictions. Anticholinergics are prescribed for the relief of bladder spasms and are not necessary following orchiopexy. Measurement of intake and output is not required. Cold wet compresses are not prescribed. In addition, the moisture from a wet compress presents a potential for infection. 135. Cryptorchidism All vigorous activities should be restricted for 2 weeks following surgery to promote healing and prevent injury. This will prevent dislodging of the suture, which is internal. Normally, 2-year-olds want to be active; therefore, allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parent should be taught to monitor the temperature, provide analgesics as needed, and monitor the urine output. 136. Epispadias Epispadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. The urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic facilitates entry of bacteria into the urine. 137. Nephrotic Syndrome Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia (hypoproteinemia), and edema. A child with edema from nephrotic syndrome will be at high risk for skin breakdown. Skin surfaces should be cleaned and separated with clothing to prevent irritation and resultant skin breakdown. The child will be anorexic so a risk for imbalanced nutrition, more than body requirements is not a concern. A risk for constipation or ineffective thermoregulation is not a concern with nephrotic syndrome. 138. Hypospadias At the age of 1 year, a childâ&#x20AC;&#x2122;s fears of separation are great because the child is facing the developmental task of trusting others. Options 3 and 4 may be issues if the child was older. No data in the question allow one to determine that siblings exist. 139. Hypospadias Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. 140. Bladder Exstrophy In bladder exstrophy, the bladder is exposed and external to the body. The highest priority is impaired tissue integrity related to the exposed bladder mucosa. Although the infant needs to be monitored for elimination patterns and kidney function, option 3 is not a concern for this condition. Parental knowledge deficit related to the diagnosis and treatment of the condition will need to be addressed but again is not the priority. Although infection related to the anatomical location of the defect is an appropriate nursing diagnosis, it is a potential problem and not an actual one. 141. Bladder Exstrophy In bladder exstrophy, the bladder is exposed and external to the body. In this disorder, one must take care to protect the exposed bladder tissue from drying while allowing the drainage of urine. This is accomplished best by covering the bladder with a nonadhering plastic wrap. The use of petroleum jelly gauze should be avoided because this type of dressing can dry out, adhere to the mucosa, and damage the delicate tissue when removed. Dry sterile dressings and dressings soaked in solutions (that can dry out) also damage the mucosa when removed. 142. Glomerulonephritis Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Group A beta-hemolytic streptococcal infection is a cause of glomerulonephritis. Often, the child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks 143. Glomerulonephritis Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria, resulting in dark, smoky, cola-colored or red-brown urine, is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis. 144. Nephrotic Syndrome Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The child gains weight 145. Burns Sensorium is an accurate guide to determine the adequacy of fluid resuscitation. The burn injury itself does not affect the sensorium, so the child should be alert and oriented. Any alteration in sensorium should be evaluated further. A neurological assessment would determine the level of sensorium in the child

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146. Head lice "Pediculosis capitis is an infestation of the hair and scalp with lice. The nits are visible and firmly attach to the hair shaft near the scalp. The occiput is an area in which nits can be seen. White flaky particles are indicative of dandruff. Maculopapular lesions behind the ears or lesions that extend to the hairline or neck are indicative of an infectious process, not pediculosis. 147. " 148. Eczema Eczema is a superficial inflammatory process involving primarily the epidermis. The major goals of management are to relieve pruritus, lubricate the skin, reduce inflammation, and prevent and control secondary infection. Secondary infection can occur when areas affected by eczema are scratched as a result of the itching because open skin is a portal of entry for pathogens. The lesions are not viral and they do not present as thick white crusty plaques. They appear as red and scaly lesions that can weep, ooze, and crust. They commonly occur in the antecubital and popliteal areas. Throat edema and mouth ulcers are not characteristics of this disorder. 149. Head lice Thorough home cleaning is necessary to remove any remaining lice or nits. Antilice sprays are unnecessary. In addition, they should never be used on a child or on bedding or linens. Bedding and linens should be washed with hot water and dried on a hot setting. Items that cannot be washed should be dry-cleaned or sealed in plastic bags in a warm place for 2 weeks. Combs and brushes should be soaked in a scabicide shampoo or hot water for 1 hour. 150. Scabies Scabies appears as burrows or fine, grayish-red, thread-like lines. They may be difficult to see if they are obscured by excoriation and inflammation. Purple-colored lesions may indicate various disorders, including systemic conditions. Thick, honey-colored crusts are characteristic of impetigo or secondary infection in eczema. Clusters of fluid-filled vesicles are seen in herpesvirus infection. 151. Scabies Permethrin is massaged thoroughly and gently into all skin surfaces (not just the areas that have the rash) from the head to the soles of the feet. Care should be taken to avoid contact with the eyes. The lotion should not be applied until at least 30 minutes after bathing and should be applied only to cool, dry skin. The lotion should be kept on for 8 to 14 hours, and then the child should be given a bath. The child should be clothed during the 8 to 14 hours of treatment contact time. 152. Scabies Lindane is contraindicated for children younger than 2 years. These children have more permeable skin and high systemic absorption may occur, placing the child at risk for central nervous system toxicity and seizures. Lindane also is used with caution in children between the ages of 2 and 10 years. Siblings and other household members also should be treated at the same time. Options 2 and 4 are unrelated to the use of lindane. Lindane is not recommended for use by a breast-feeding woman because the medication is secreted into breast milk. 153. Impetigo Impetigo is most common during hot, humid summer months. Impetigo may begin in an area of broken skin, such as an insect bite or atopic dermatitis. Infection may be caused by Staphylococcus aureus, group A beta-hemolytic streptococci, or a combination of these bacteria. Impetigo is extremely contagious. Lesions usually are located around the mouth and nose but may be present on the hands and extremities. 154. Impetigo The child should not attend school for 24 to 48 hours after the initiation of systemic antibiotics or 48 hours after the use of antibiotic ointment. The school should be notified of the diagnosis. Options 1, 2, and 3 are incorrect time frames. 155. Burns Some pediatric considerations in the care of a burn victim include the following: scarring is more severe in a child than in an adult; a delay in growth may occur following a burn injury; burns involving more than 10% of total body surface area require some form of fluid resuscitation; an immature immune system presents an increased risk of infection for infants and young children; the higher proportion of body fluid to mass in a child increases the risk of cardiovascular problems; and infants and young children are at increased risk for protein and calorie deficiencies because they have smaller muscle mass and less body fat than adults. 156. Fracture An absent pulse to an extremity of an affected limb could mean that the child is developing or experiencing compartment syndrome. This is an emergency situation and the physician should be notified immediately. Applying ice to an extremity with absent perfusion is incorrect. Ice may be prescribed when perfusion is adequate to decrease swelling. Administering analgesics will not improve circulation. The skin traction should not be released without a physician’s order. 157. Scoliosis A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child’s abdominal contents, resulting from lengthening of the child’s body. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or those who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Therefore options 2, 3, and 4 are incorrect. 158. Developmental Dysplasia of the Hip (DDH) In DDH, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. In the Ortolani maneuver, the examiner reduces the dislocated femoral head back into the acetabulum. A positive finding is the palpable click or “clunk” on movement of the femoral head over the acetabular ring. This maneuver does not result in permanent relocation. Its purpose is to note the possibility of correction by means of the Pavlik harness or spica casting. In the

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Barlow maneuver, the examiner pushes the unstable femoral head out of the acetabulum. If it dislocates, it usually relocates immediately. The purpose is to note the presence of instability. Options 1 and 2 are done to assess for the possible presence of DDH. 159. Developmental Dysplasia of the Hip (DDH) The Pavlik harness should be worn 16 to 23 hours a day and should be removed only to check the skin and for bathing. The infant can be moved when out of the harness, but the hips and buttocks should be supported carefully. The harness does not need to be removed for diaper changes or feedings. 160. Fracture When a child is in traction, the nurse would check the physician’s orders to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as ordered, ensure that the weights hang freely, check the ropes for fraying and be sure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms of immobilization. The nurse would provide therapeutic and diversional play activities for the child. 161. Fracture The mother needs to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation. Options 1, 3, and 4 are appropriate instructions. 162. Club Foot Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome. 163. Scoliosis The use of lotions or powders under a brace should be avoided because they can become sticky and cake under the brace, causing irritation. Options 1, 2, and 4 are appropriate interventions in the care of a child with a brace. 164. Developmental Dysplasia of the Hip (DDH) In DDH, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Asymmetrical abduction of the affected hip, when the child is placed supine with the knees and hips flexed, would be an assessment finding in DDH in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity. 165. Juvenile Idiopathis Arthritis (JIA) During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain. Although resting the extremity is appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important. These exercises do not involve joint movement. 166. Fracture While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling and the physician is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment and the physician should be notified. 167. Anemia Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1½ to 2 times the daily requirement to prevent dehydration. 168. Anemia The results of a complete blood cell count in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated. 169. Anemia An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth because the iron will stain the teeth. The parents should be instructed to brush or wipe the child’s teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not added to formula or mixed with cereal or other food items. 170. Hemophilia Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Therefore, abnormal laboratory results in hemophilia indicate a prolonged partial thromboplastin time. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia. 171. Hemophilia Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Children with hemophilia need to avoid contact sports and to take precautions such as wearing elbow and knee pads and helmets with other sports. The safest activity for them is swimming. 172. Thalassemia β-Thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with β-thalassemia major). This disorder is found primarily in individuals of Mediterranean descent. Options 1, 3, and 4 are incorrect.

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173. Thalassemia β-Thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with β-thalassemia major). The major complication of chronic transfusion therapy is hemosiderosis. To prevent organ damage from too much iron in the blood, chelation drug therapy with deferoxamine (Desferal) is used. Deferoxamine is classified as an antidote for acute iron toxicity. Dalteparin is an anticoagulant used as prophylaxis for postoperative deep vein thrombosis. Meropenem is an antibiotic. Metoprolol is a β blocker used to treat hypertension. 174. Anemia Sickle cell anemia is a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape and the cells become rigid and clumped together, obstructing capillary blood flow. All the clinical manifestations of sickle cell anemia result from the sickled cells being unable to flow easily through the microvasculature, and their clumping obstructs blood flow. With reoxygenation, most of the sickled red blood cells resume their normal shape. Options 1, 2, and 3 are incorrect statements. 175. Anemia Sickle cell anemia is a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape and the cells become rigid and clumped together, obstructing capillary blood flow. Therefore, oral and intravenous fluids are an important part of treatment. Meperidine (Demerol) is not recommended for the child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would thus question the order for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain in painful joints, oxygen, and a high-calorie, high-protein diet are also important parts of the treatment plan. 176. von Willebrand disease von Willebrand disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in a protein termed von Willebrand factor (vWF). The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. An elevated creatinine level is not associated with this disorder. 177. Leukemia Immunocompromised children are unable to fight varicella adequately. Chickenpox can be deadly to the immunocompromised child. If an immunocompromised child who has not had chickenpox is exposed to someone with varicella, the child should receive varicella zoster immune globulin within 96 hours of exposure. Options 1, 3, and 4 are incorrect because they do nothing to minimize the chances of developing the disease. 178. Leukemia If a child is severely thrombocytopenic and has a platelet count less than 20,000/μL, bleeding precautions need to be initiated because of the increased risk of bleeding or hemorrhage. The precautions include limiting activity that could result in head injury, using soft toothbrushes or Toothettes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories and rectal temperatures are avoided. Options 1, 2, and 3 are related to the prevention of infection rather than bleeding. 179. Increased Intracranial Pressure The brain, while well protected by the solid bony cranium, is highly susceptible to pressure that may accumulate within the enclosure. Volume and pressure must remain constant within the brain. A change in the size of the brain, such as occurs with edema, or increased volume of intracranial blood or cerebrospinal fluid without a compensatory change, will lead to an increase in intracranial pressure, which may be life-threatening. An early sign of increased intracranial pressure, vomiting, can become excessive as pressure builds up and stimulates the medulla in the brainstem, which houses the vomit center. Children with open fontanels (posterior closes at 2 to 3 months; anterior closes at 12 to 18 months) compensate for intracranial pressure changes by skull expansion and subsequent bulging fontanels. Once the fontanels have closed, nausea, excessive vomiting, diplopia, and headaches become pronounced, with headaches becoming more prevalent in older children. 180. Leukemia The confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate and biopsy. A lumbar puncture may be done to look for blast cells in the spinal fluid that indicate central nervous system disease. The white blood cell count may be normal, high, or low in leukemia. An altered platelet count occurs as a result of the disease but also may occur as a result of chemotherapy and does not confirm the diagnosis. 181. Leukemia The risk of injury to fragile mucous membranes is so high in the child with leukemia that oral, tympanic, or axillary temperature should be taken. Rectal abscesses can occur easily to damaged rectal tissue. No rectal temperatures should be taken. In addition, oral temperature taking should be avoided if the child has oral ulcers. Options 2, 3, and 4 are appropriate measures to prevent infection.

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182. Leukemia For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas aeruginosa, to which these children are susceptible. In addition, fresh fruits and vegetables harbor molds and should be avoided until the white blood cell count rises. 183. Leukemia When the child is nauseated, offering cool, clear liquids is best because they are soothing and better tolerated. One should not offer favorite foods when the child is nauseated because foods eaten during times of nausea will be associated with being sick. Supportive nutritional measures should include oral supplements with high-protein and high-calorie foods. 184. Hodgkin's disease Hodgkin’s disease is a neoplasm of lymphatic tissue. The presence of giant, multinucleated cells (Reed-Sternberg cells) is the hallmark of this disease. The presence of blast cells in the bone marrow indicates leukemia. The Epstein-Barr virus is associated with infectious mononucleosis. Elevated levels of vanillylmandelic acid in the urine may be found in children with neuroblastoma. 185. Hodgkin's disease Clinical manifestations specifically associated with Hodgkin’s disease include painless, firm, and movable adenopathy in the cervical and supraclavicular areas. Hepatosplenomegaly also is noted. Although fever, malaise, anorexia, and weight loss are associated with Hodgkin’s disease, these manifestations are seen in many disorders. 186. Brain Tumor Colorless drainage on the dressing indicates the presence of cerebrospinal fluid and should be reported to the physician immediately. Options 2, 3, and 4 are inaccurate nursing interventions, because they do not address the need for immediate intervention to prevent complications. 187. Brain Tumor The child is never placed in Trendelenburg’s position because it increases intracranial pressure (ICP) and the risk of bleeding. In the event of shock, the physician is notified immediately before changing the child’s position or increasing intravenous fluids. Increasing intravenous fluids can cause an increase in ICP. 188. Wilms' Tumor Wilms’ tumor, or nephroblastoma, is the most common renal tumor in children. Arising from the renal parenchyma of the kidney, this tumor grows rapidly. The tumor may be present unilaterally and localized or bilaterally, sometimes with metastasis to other organs. Options 1, 3, and 4 are incorrect. 189. Wilms' Tumor If Wilms’ tumor is suspected, the tumor mass should not be palpated by the nurse. Excessive manipulation can cause seeding of the tumor and spread of the cancerous cells. Fever, hematuria, and hypertension are clinical manifestations associated with Wilms’ tumor. 190. Osteogenic Sarcoma A clinical manifestation of osteogenic sarcoma is progressive, insidious, and intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor. Options 1, 3, and 4 are accurate regarding osteogenic sarcoma. 191. Brain Tumor Vital signs and neurological status are assessed frequently. Special attention is given to the child’s temperature, which may be elevated because of hypothalamic or brainstem involvement during surgery. A cooling blanket should be in place on the bed or readily available if the child becomes hyperthermic. Options 1 and 3 are related to functional deficits following surgery. Orthostatic hypotension is not a common clinical manifestation following brain surgery. An elevated blood pressure and widened pulse pressure may be associated with increased intracranial pressure, which is a complication following brain surgery. 192. Leukemia A common complication of treatment for leukemia is overwhelming infection secondary to neutropenia. Measures to prevent infection include the use of a private room, strict aseptic technique, restriction of visitors and health care personnel with active infection, strict hand washing, ensuring that anyone entering the child’s room wears a mask, and reducing exposure to environmental organisms by eliminating raw fruits and vegetables from the diet and fresh flowers from the child’s room and by not leaving standing water in the child’s room. The other interventions listed are measures to prevent bleeding. 193. HIV/AIDS Most children infected with HIV develop symptoms within the first 9 months of life. The remainder of these infected children become symptomatic sometime before the age of 3 years. Children, with their immature immune systems, have a much shorter incubation period than adults. Options 1, 2, and 3 are incorrect. 194. HIV/AIDS The multiple complications associated with HIV are accompanied by a high level of pain. Aggressive pain management is essential for the child to have an acceptable quality of life. A nurse must acknowledge the child’s pain and let the child know that everything will be done to decrease the pain. Telling the child that movement or lack thereof will eliminate the pain is not accurate. Allowing a child to think that he or she can control the pain simply by thinking or not thinking about it oversimplifies the pain cycle associated with HIV. Giving false hope by telling the child that the pain will be taken “all away” is neither truthful nor realistic. 195. HIV/AIDS The most common opportunistic infection of children infected with HIV is Pneumocystis jiroveci pneumonia, which occurs most frequently between the ages of 3 and 6 months, when HIV status may be indeterminate. Cytomegalovirus infection is also characteristic of HIV infection; however, it is not the most common opportunistic infection. Although gastrointestinal disturbances and neurological abnormalities may occur in the child with HIV infection, options 1 and 2 are not specific opportunistic infections noted in the HIV-infected child.

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196. HIV/AIDS A child with AIDS who is sick or has a fever should be kept home and not brought to a day care center or other environment. Options 1, 2, and 4 are correct statements and would be actions a caretaker should take when the child has AIDS. 197. HIV/AIDS Immunizations against common childhood illnesses are recommended for all children exposed to or infected with HIV. Pneumococcal and influenza vaccines also are recommended. The varicella (chickenpox) vaccine is avoided in the child who is HIV-infected and severely immunocompromised. The hepatitis B vaccine is administered according to the recommended immunization schedule. Option 4 is not necessary and is inaccurate. 198. HIV/AIDS The preschool child will begin to conceptualize the death process as involving physical harm. A child from birth to 2 years of age will be unable to grasp the concept of illness and death. A school-age child will begin to understand that something is wrong. An adolescent will express fear, withdrawal, and denial. 199. HIV/AIDS The mother should be instructed to use a bleach solution for disinfecting contaminated objects or cleaning up spills from the childâ&#x20AC;&#x2122;s diaper. Options 1, 2, and 4 are accurate instructions related to basic infection control. 200. HIV/AIDS The human immunodeficiency virus (HIV) attacks the immune system by destroying T lymphocytes. Infants born to HIV-positive women test positive for HIV antibody, not HIV virus. This is actually a measure of maternal antibody and is not indicative of true infection in the infant. The virus attacks the immune system. T4 cells are depleted in number and cannot signal B cells to form protective antibodies to fight off the invading virus. 201. HIV/AIDS A positive antibody test in a child younger than 18 months of age indicates only that the mother is infected, because maternal immunoglobulin G antibodies persist in infants for 6 to 9 months and, in some cases, as long as 18 months. A positive enzyme-linked immunosorbent assay (ELISA) does not indicate true HIV infection. 202. HIV/AIDS The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies. The CD4+ cell count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection, such as pneumonia. 203. HIV/AIDS AIDS is a disorder caused by the human immunodeficiency virus (HIV) and is characterized by a generalized dysfunction of the immune system. Home care instructions include the following: frequent hand washing; monitoring for fever, malaise, fatigue, weight loss, vomiting and diarrhea, and notifying the physician if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications and other medications as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; avoiding kissing the child on the mouth; and monitoring weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding sharing eating utensils. Gloves are worn for care, especially when in contact with body fluids and changing diapers (diapers are changed frequently and away from food areas) and soiled disposable diapers are folded inward, tabbed, and disposed in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution (10:1 ratio of water to bleach). 204. Mumps Mumps is transmitted via direct contact with or droplet spread from an infected person. Droplet precautions are indicated during the period of communicability (immediately before and after swelling begins). 205. Chicken Pox The communicable period for chickenpox is 1 to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed. In roseola, the communicable period is unknown. Option 2 describes diphtheria. Option 3 describes rubella. 206. Pertussis Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 3 are components of home care instructions. 207. Vaccines Occasionally, tenderness, redness, or swelling may occur at the site of the DTaP injection. This can be relieved with ice packs for the first 24 hours, followed by warm or cold compresses if the inflammation persists. Bringing the infant back to the clinic is not necessary. Option 1 may be an appropriate intervention but is not specific to the subject of the question. 208. Mononucleosis The parents need to be instructed to notify the physician if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs because this may indicate splenic rupture. Children with enlarged spleens also are instructed to avoid contact sports until splenomegaly resolves. Bed rest is not necessary, and children usually self-limit their activity. Respiratory precautions are not required, although transmission can occur via direct intimate contact or contact with infected blood. Fever is treated with acetaminophen (Tylenol). 209. Pinworms Diagnosis of pinworm infection is confirmed by direct visualization of the worms. Parents can view the sleeping childâ&#x20AC;&#x2122;s anus with a flashlight. The worm is white, thin, about 1/2-inch long, and moves. A simple technique, the tape test, is used to capture worms and eggs. Transparent tape is lightly touched to the anus and then applied to a slide for microscopic examination. The best specimens are obtained as the child awakens, before toileting or bathing. 210. Vaccines Diphtheria, tetanus, acellular pertussis vaccine (DTaP), Haemophilus influenzae type b conjugate vaccine (Hib), inactivated poliovirus vaccine (IPV), and pneumococcal vaccine (PCV) are administered at 4 months of age. DTaP is administered at 2, 4, 6, and between 15 and 18 months of age, and between 4 and 6 years of age. Hib is administered at 2, 4, 6,

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and between 12 and 15 months of age. IPV is administered at 2, 4, and 6 months and between 4 and 6 years of age. PCV is administered at 2, 4, 6, and between 12 and 15 months. The first dose of measles, mumps, rubella vaccine (MMR) is administered between 12 and 15 months of age; the second dose is administered at 4 to 6 years of age (if the second dose was not given by 4 to 6 years of age, it should be given at the next visit). The first dose of hepatitis B vaccine is administered at birth, the second dose is administered at 1 to 2 months, and the third dose is administered between the ages of 6 and 18 months. Varicellazoster vaccine is administered between 12 and 18 months of age. 211. Vaccines MMR vaccine is administered subcutaneously in the outer aspect of the upper arm. The gluteal muscle is not recommended for injections. It is not administered by the intramuscular route. 212. Vaccines IPV contains neomycin. A history of an anaphylactic reaction to neomycin is considered a contraindication to IPV. The presence of a minor illness such as the common cold is not a contraindication. In addition, a history of frequent respiratory infections is not a contraindication to receiving a vaccine. A local reaction to an immunization is not a contraindication to receiving a vaccine. 213. Vaccines A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to a previous dose of hepatitis B vaccine or to a component of the vaccine. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine. 214. Rubeola Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Airborne droplet precautions are required, and those in contact with the child should wear masks. The child is placed in a private room with negative air pressure. Doors remain closed. Gowns and gloves are not necessary, but standard precautions are used. Articles that are contaminated should be bagged and labeled. Special enteric precautions and protective isolation are not indicated in rubeola. 215. Rubeola The communicable period for rubeola ranges from 4 days before to 5 days after the rash appears, mainly during the prodromal stage. Options 1, 2, and 4 are accurate descriptions of rubeola. The small blue-white spots found in this communicable disease are called Koplik’s spots. Option 3, the incorrect option, describes the incubation period for rubella, not rubeola. 216. Roseola The method of transmission of roseola is unknown. Options 2, 3, and 4 are not accurate transmission routes of roseola. 217. Vaccines The general contraindications for vaccines include a previous anaphylactic reaction to a vaccine or a component of a vaccine or the presence of a severe illness. The other items listed are not contraindications to receiving a vaccine. 218. Scarlet Fever Pastia’s sign describes a rash seen in scarlet fever that will blanch with pressure except in areas of deep creases and the folds of joints. The tongue initially is coated with a white furry covering, with red projecting papillae (white strawberry tongue). By the fourth to fifth day, the white strawberry tongue sloughs off, leaving a red swollen tongue (strawberry tongue). The pharynx is edematous and beefy red. Koplik’s spots are associated with rubeola (measles). These are small red spots with a bluish white center and a red base located on the buccal mucosa. Petechial red, pinpoint spots occurring on the soft palate are characteristic of rubella (German measles). 219. Med Cal 220. Med Cal 221. Med Cal 222. Med Cal 223. Med Cal 224. Med Cal 225. Med Cal 226. Med Cal 227. Med Cal 228. Med Cal 229. Hemophilia The nurse needs to stress the importance of immunizations, dental hygiene, and routine well-child care. Options 1, 2, and 3 are appropriate. The parents are also instructed in the measures to implement in the event of blunt trauma, especially trauma involving the joints, and to apply prolonged pressure to superficial wounds until the bleeding has stopped. 230. Croup The mother should be instructed to bring the child to the emergency room if the child develops stridor at rest, cyanosis, severe agitation or fatigue, or moderate to severe retractions, or is unable to take oral fluids. 231. Lactose Intolerance Breast-feeding mothers with lactose intolerance infants need to be encouraged to limit dairy products. Cheese is a dairy product. Alternative calcium sources that can be consumed by the mother include egg yolk, green leafy vegetables, dried beans, cauliflower, and molasses. 232. Conjuntivitis Viral conjunctivitis is extremely contagious. The child should be kept home from school or day care until the child has received antibiotic eye drops for 24 hours.

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233. Conjuntivitis If the child wears contact lenses, he or she should be instructed to discontinue wearing them until the infection has cleared completely. Securing new contact lenses will eliminate the chance of reinfection from contaminated contact lenses and will also lessen the risk of a corneal ulceration. 234. Otitis Media Factors that increase the risk of otitis media include exposure to illness in other children in day care centers, household smoking, bottle-feeding, and congenital conditions such as Down syndrome and cleft palate. The use of a pacifier beyond age 6 months has also been identified as a risk factor. Allergies are also thought to precipitate otitis media. 235. Leukemia A lateral recumbent position, with the knees flexed to the abdomen and the head bent with the chin resting on the chest, is assumed for a lumbar puncture. This position separates the spinal processes and facilitates needle insertion into the subarachnoid space. Options 1, 2, and 4 are incorrect positions. 236. Hodgkin's disease Radiation therapy is usually delayed until a child is 8 years of age, whenever possible, to prevent retardation of bone growth and soft tissue development. Options 1, 3, and 4 are inappropriate responses to the mother. 237. Neuroblastoma Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically, the tumor compresses adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated vanillylmandelic acid (VMA) levels. The presence of blast cells in the bone marrow occurs in leukemia. Projectile vomiting occurring most often in the morning and a positive Babinski’s sign are clinical manifestations of a brain tumor. 238. Pneumonia With viral pneumonia, treatment is supportive. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and IV fluids. Antibiotics are not given. Bacterial pneumonia however, is treated with antibiotic therapy. 239. Cystic Fibrosis Cystic fibrosis (CF) is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait. 240. Transposition of Great Arteries A child with transposition of the great arteries may receive prostaglandin E1 temporarily to increase blood mixing if systemic and pulmonary mixing are inadequate to maintain adequate cardiac output. Options 1, 3, and 4 are incorrect. In addition, tet spells occur in tetralogy of Fallot. 241. Hirschsprung's Disease Hirschsprung’s disease also known as congenital aganglionosis or megacolon. It is the result of an absence of ganglion cells in the rectum and to varying degrees upward in the colon. Options 2, 3, and 4 are incorrect. 242. Imperforated Anus A fresh colostomy stoma will be red and edematous, but this will decrease with time. The colostomy site will then be pink without evidence of abnormal drainage, swelling, or skin breakdown. The nurse would document these findings because this is a normal expectation. Options 1, 3, and 4 are inappropriate interventions. 243. Jaundice Jaundice, if present, is best assessed in the sclera, nail beds, and mucous membranes. Generalized jaundice will appear in the skin throughout the body. Option 4 is not an appropriate area to assess for the presence of jaundice. 244. Aspirin Overdose Initial treatment of salicylate overdose includes the administration of an emetic or gastric lavage. Activated charcoal may be administered to decrease absorption. Fluids and sodium bicarbonate may be administered intravenously to enhance excretion but would not be the initial treatment. Dialysis is used in extreme cases if the child is unresponsive to therapy. Vitamin K is the antidote for warfarin sodium (Coumadin) overdose. 245. Fracture Russell’s traction uses skin traction to realign a fracture in the lower extremity and immobilize the hip and knee in a flexed position. It is important to keep the hip flexion at the prescribed angle to prevent fracture malalignment. The traction may also relieve pain by reducing muscle spasms, but this is not the primary reason for this traction. The child can still move in bed with some restriction as a result of the traction. Traction is never used to restrain a child. 246. Crossed Eyes Strabismus, also called lazy eye, is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. It is normal in the young infant but should not be present after about age 4 months. Options 1, 2, and 3 are not appropriate responses to the mother of a 1-month-old infant. 247. Strabismus Patching may be used in the treatment of strabismus to strengthen the weak eye. In this treatment, the “good” eye is patched. This encourages the child to use the weaker eye. It is most successful when done during the preschool years. The schedule for patching is individualized and is prescribed by the ophthalmologist. 248. Meningitis To test for Kernig’s sign, the leg is raised with the knee flexed. Then, the leg is extended at the knee. If any resistance is noted or pain is felt, the result is a positive Kernig’s sign. This is a common finding in meningitis. Brudzinski’s sign occurs when flexion of the head causes flexion of the hips and knees. Chvostek’s sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau’s sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally.

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249. Myringotomy A myringotomy is the insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated. The size and appearance of the tympanostomy tubes should be described to the parents after surgery. They should be reassured that if the tubes fall out, it is not an emergency, but that the physician should be notified. 250. Vomiting The vomiting child should be placed in an upright or side-lying position to prevent aspiration. Options 2, 3, and 4 will place the child at risk for aspiration if vomiting occurs. 251. Cleft lip Cleft lip repair is usually performed during the first few weeks of life. Early repair may improve bonding and makes feeding much easier. Revisions may be required at a later age. Options 1, 2, and 4 are incorrect 252. Intussesception Intussusception occurs when a proximal segment of the bowel prolapses into a distal segment of the bowel. It is a common cause of acute bowel obstruction in infants and young children. It is not an inflammatory process. 253. Encopresis Encopresis is defined as fecal incontinence and is a major concern if the child is constipated. Signs include evidence of soiling clothing, scratching or rubbing the anal area because of irritation, fecal odor without apparent awareness by the child, and social withdrawal. 254. Seizures During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side will prevent aspiration because saliva will drain out the corner of the child’s mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child’s neck and ensure a patent airway. Nothing is placed into the child’s mouth during a seizure because this could injure the child’s mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure. 255. Ewing Sarcoma Following amputation, phantom limb pain is a temporary condition that some children may experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the child. The child needs to be reassured that the condition is normal and only temporary. Options 2, 3 and 4 are not appropriate responses to the child. 256. Anemia Vitamin C (ascorbic acid) increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or juice high in vitamin C. From the options presented, option 4 is the option that identifies the food highest in vitamin C. 257. Esophageal Atresia In the immediate postoperative period, the gastrostomy tube is elevated, allowing gastric contents to pass into the small intestine and air to escape. This promotes comfort and decreases the risk of leakage at the anastomosis. Options 1, 2, and 3 are incorrect. 258. Med Cal 259. Appendicitis McBurney’s point is midway between the right anterior superior iliac crest and the umbilicus. It is usually the location of greatest pain in the child with appendicitis. 260. Hydrocephalus Hydrocephalus is a condition characterized by an enlargement of the cranium because of an abnormal accumulation of cerebrospinal fluid in the cerebral ventricular system. This characteristic causes the increase in the weight of the infant’s head. The infant may experience significant head enlargement. Care must be exercised so that the head is well supported when the infant is fed or moved to prevent extra strain on the infant’s neck, and measures must be taken to prevent the development of pressure areas. Supporting the infant’s head and neck, when picking up him or her, will prevent the hyperextension of the neck area and the infant from falling backward. The infant should be fed with the head elevated for proper motility of food processing. A helmet could suffocate an unattended infant during rest and sleep times, and hyperextension of the infant’s head could put pressure on the neck vertebrae, causing injury. 261. Seizures Parents are especially concerned about seizures that might go undetected during the night. The nurse needs to decrease parental overprotection and should suggest the use of a baby monitor at night. Options 1 and 3 identify parental understanding of the disorder. Option 4 is a common concern. The parents need to be reminded that, as the child grows, they cannot always observe their child, but that their knowledge of seizure activity and care are appropriate to minimize complications. 262. Imperforated Anus The appropriate position following surgical intervention for an imperforate anus is a side-lying position with the legs flexed, or a prone position to keep the hips elevated. These positions will reduce edema and pressure on the surgical site. Options 2, 3, and 4 will promote pressure at the surgical site. 263. Cleft Palate The mother should be instructed that straws, pacifiers, spoons, or fingers must be kept away from the child’s mouth for 7 to 10 days after surgery. Additionally, the mother should be advised to avoid taking oral temperatures. A short nipple should be placed on the child’s bottle and the mother should be instructed to give the child baby food or baby food mixed with water. A pacifier should not be used for at least 2 weeks following the surgical repair. 264. Pyloric Stenosis Option 3 are classic symptoms of pyloric stenosis. Crying during the evening hours, appearing to be in pain, eating well, and gaining weight are clinical manifestations of colic. An infant who suddenly becomes pale, cries out, and draws the legs up to chest is demonstrating physical signs of intussusception. Stools that are ribbon-like and eating poorly are signs of congenital megacolon (Hirschsprung’s disease).

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265. Erikson's Development A 2½-year-old child, a toddler, is in the Autonomy versus Shame and Doubt stage. In this stage, the toddler develops a sense of control over the self and bodily functions. Trust versus Mistrust characterizes the stage of infancy. Initiative versus Guilt characterizes the preschool age. Industry versus Inferiority characterizes the school-aged child. 266. Respiratory Infection A 10-month-old is in the Trust versus Mistrust stage of psychosocial development according to Erikson. The infant is developing a sense of self, and the nurse should appropriately provide a consistent routine for the child. Hospitalization may have an adverse effect, and the nurse should touch, rock, and cuddle the infant to promote a sense of trust and provide sensory stimulation. Option 2 is an unsafe action. Option 1 will not provide sensory stimulation. The infant should not be restrained. 267. Lead Poisoning Homes that are older than 25 years may have lead paint and will most likely have lead pipes, which can contribute to lead poisoning. Breathing rapidly and diaphoresis are signs of salicylate poisoning. A sweet and fruity odor to the breath is a symptom of ketoacidosis. Pencil lead is made of graphite so it does not present a hazard to the child. Crayons are not toxic. 268. Safety Toys with small loose parts would be the priority concern. Children at this age are likely to place the small toy parts in their mouth, which could lead to aspiration and choking. The water temperature of the hot water heater is a concern but is not the greatest hazard. The mother should be aware of and taught safety measures related to safe water temperatures for bathing the children. A gate placed at the stairs of the second floor is a safety measure. A small dog as a house pet is not necessarily a hazard. 269. Leukemia Aspirin is not administered to the child with ALL because of its anticoagulant properties and because administering aspirin could lead to bleeding in the joints. Heat also would increase the pain by increasing circulation to the area. Diversional activities would not relieve the pain. 270. Dental Care The nurse should instruct the mother that proper dental care for a toddler is important. It is important to instruct the mother to substitute sweets with healthy food items to prevent dental caries. The first dental visit should be made after the first primary tooth erupts and no later than 30 months of age. It will not hurt the child if some of the toothpaste is swallowed. 271. Hemophilia In an acute period, immobilization of the joint would be prescribed. NSAIDs can prolong bleeding time and would not be prescribed for the child. Heat will increase blood flow to the area so it would promote increased bleeding to the area. Range of motion during the acute period can increase the bleeding and would be avoided at this time. 272. Hemophilia The nurse should instruct the mother to remove toys with sharp edges that may cause potential injury. Requiring that the child wear a helmet and elbow pads immediately on awakening and throughout the day is not necessary; however, these items should be worn during activities that could cause injury. It is not necessary that the child be restricted from outdoor play activity, but the activities that the child participates in should be monitored. It is not necessary to restrict play if safety measures have been implemented. 273. Conjuntivitis Bacterial conjunctivitis is highly contagious, and infection control measures should be taught. These measures include frequent hand washing and not sharing towels and washcloths regardless of the bleaching process. Options 2 and 3 are correct treatment measures. 274. Insect in Ear Insects that make their way into an ear often can be coaxed out using a flashlight or a humming noise. If this is unsuccessful, then the insect must be killed before removal. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by means of an ear forceps. The mother should be instructed not to irrigate the ear or attempt to remove the insect by using tweezers because this could damage the ear. If the mother is unsuccessful in coaxing the insect out of the ear, she should be instructed to report to the clinic or the hospital emergency department. 275. Tonsillectomy After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and extremely hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, which causes the child to clear the throat, thereby increasing the risk of bleeding. 276. Fracture A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture that occurs through only a part of the cross section of the bone; one side of the bone is fractured and the other side is bent. A comminuted fracture is a complete fracture across the shaft of the bone with splintering of the bone fragments. A compound fracture, also called an open or a complex fracture, is one in which the skin or mucous membrane has been broken and the wound extends to the depth of the fractured bone. 277. Fracture When a fracture is suspected, it is imperative that the area be splinted and immobilized before the injured person is transferred or moved. The nurse should remain with the child and provide realistic reassurance. The child would not be told that permanent damage will not occur. It is not necessary to notify the radiology department because this would be the responsibility of the emergency department staff when the child arrives, and if it had been determined that the child needs a radiograph. Although it may be necessary to contact the childâ&#x20AC;&#x2122;s pediatrician, this is not the highest priority.

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278. Conjuntivitis Eyedrops should be administered before eye ointment is administered. The child should be placed in a supine position with the neck slightly hyperextended for administration. Blinking will increase the loss of medication. Touching the eye or eyelid during medication administration can contaminate the dropper and also cause eye injury. 279. Respiratory Syncytial Virus (RSV) When an infant is receiving ribavirin, exposure precautions need to be observed. Anyone entering the infant’s room should wear a gown, mask, gloves, and hair covering. Anyone who is pregnant or considering pregnancy and anyone with a history of respiratory problems or airway disease should not care for or visit the infant who is receiving ribavirin. Hand washing is absolutely necessary before leaving the room to prevent the spread of germs. 280. Inguinal Hernia With an inguinal hernia, inguinal swelling occurs when the infant cries or strains. Absence of this swelling would indicate resolution of this problem. Abdominal distention indicates a continuing gastrointestinal problem. A clean, dry incision refers to absence of wound infection after surgery. The flow of urine is not specific to an inguinal hernia. 281. Intussesception After hydrostatic reduction, the nurse observes for the passage of barium or water-soluble contrast material with stools. Options 1 and 2 are clinical indicators of intussusception. Option 4 is a sign of an unresolved gastrointestinal disorder. 282. Diabetes The glycosylated hemoglobin assay measures the glucose molecules that attach to the hemoglobin A molecules and remain there for the life of the red blood cell, approximately 120 days. This is not reversible and cannot be altered by human intervention. Daily glucose logs for the period are useful if they are kept regularly and accurately. However, they reflect only the blood glucose at the time the test was done. A fasting blood glucose test performed on the day of the clinic visit is time-limited in its scope, as is the dietary history. 283. Diabetes Blood glucose levels are a measure of the balance between diet, medication, and exercise. Options 2 and 4 imply that the data analyzed are abnormal. The question presents no data for determining growth and development status, such as height, weight, age, or behavior. Supporting normal growth and development is an important goal in managing diabetes in children, but that is not what is being evaluated here. 284. Celiac Disease The primary nursing consideration in the care of a child with celiac disease is to instruct the child and parents regarding proper dietary management. Although medications may be prescribed for the client with celiac disease, treatment focuses primarily on maintaining a gluten-free diet. Options 1, 3, and 4 are not directly related to the care of a child with celiac disease. 285. Appendicitis The most common symptom of appendicitis is a colicky, periumbilical, or lower abdominal pain located in the right quadrant. The classic signs and symptoms of intussusception are acute, colicky abdominal pain with currant jelly–like stools. Clinical manifestations of Hirschsprung’s disease include constipation, abdominal distention, and ribbon-like, foulsmelling stools. Peritonitis is a complication that can follow perforation or intestinal obstruction. 286. Erikson's Development Adolescents need to identify with their peers and have a strong need to belong to a group. They prefer to dress like the group and wear similar hairstyles, which are different from their parents’. Because Crutchfield tongs require the use of skeletal pins, hair dye is not appropriate. The child should be allowed to wear her own clothes to feel a sense of belonging to the group. Loud music may disturb others in the hospital. The child’s request for a darkened room may indicate a problem with depression that may need further evaluation and intervention. 287. Hernia A warm bath, avoidance of upright positioning, and other comfort measures to reduce crying are all simple measures to reduce a hernia. Coughing and crying increase the strain on the hernia. Likewise, physical activity and enemas of any type would increase the strain on the hernia. 288. Spina Bifida (Myelomeningocele type) A bulging or taut anterior fontanel would indicate the presence of increased intracranial pressure. Blood pressure is difficult to assess during the newborn period and is not the best indicator of intracranial pressure. Urine concentrating ability also is not well developed at the newborn stage of development. Monitoring for signs of dehydration will not provide data related to increased intracranial pressure. 289. Diabetes The child should be instructed to carry a source of glucose for ready use in the event of a hypoglycemic reaction. Hard candies such as LifeSavers will provide a source of glucose. A diet beverage is sugar-free and will not be helpful. If the blood glucose level is 60 mg/dL, a source of glucose may be needed, but it is not necessary to report to the emergency department. Glucagon is not administered if shakiness is felt but is used in an unconscious client or a client unable to swallow who is experiencing a hypoglycemic reaction. 290. Hemophilia Because the kidneys are located in the flank region of the body, trauma to the back area can cause the presence of hematuria, particularly in the child with hemophilia. The nurse would be most concerned about the child’s airway and respiratory rate if the child sustained an injury to the neck region. Headache and slurred speech are associated with head trauma. 291. Heat Loss Heat loss occurs by four different mechanisms. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Evaporation of moisture from a wet body surface dissipates heat along with the moisture. In convection,

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air moving across the infant’s skin will transfer heat to the air. Radiation occurs when heat from the body surface radiates to the surrounding environment. 292. Intussesception A report of severe colicky abdominal pain in a healthy thriving child between 3 and 17 months of age is the classic presentation of intussusception. Typical behavior includes screaming and drawing the knees up to the chest. Options 2, 3, and 4 are important aspects of a health history but are not specific to the diagnosis of intussusception. 293. Scoliosis Scoliosis is defined as an abnormal lateral curvature in any area of the spine. The region of the spine most commonly affected is the right thoracic area, where it results in rib prominence. Scoliosis does not occur as a sequela of inflammation. Option 1 describes kyphosis, which also is known as “humpback.” Option 2 describes lordosis, which usually is exaggerated during pregnancy, in obesity, or in persons with large tumors. 294. Safety If a poisoning occurs, the poison control center should be contacted immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested was a strong corrosive or a petroleum-based product. Calling the pediatrician would not be the immediate action because this would delay treatment. Additionally, the pediatrician would immediately make a referral to the poison control center. The poison control center may advise the mother to bring the child to the emergency department, and if this is the case, the mother should call an ambulance. 295. Cryptorchidism Cryptorchidism (undescended testes) may occur as a result of hormone deficiency, intrinsic abnormality of a testes, or a structural problem. Diagnostic tests for this disorder are performed to assess urinary and kidney function because the kidneys and testes arise from the same germ tissue. Babinski reflex reflects neurological function. Assessing DNA synthesis and a chromosomal analysis are unrelated to this disorder. 296. Urinalysis Although many methods have been devised to collect urine from an infant, the most reliable and appropriate method is use of the urine collection device. This device is a plastic bag with an opening lined with adhesive to allow it to be attached to the perineum. Urine for certain tests, such as specific gravity, may be obtained from a diaper. Urinary catheterization is not to be done unless specifically prescribed because of the risk of infection. With infants, it is not reasonable to monitor urinary patterns and attempt to collect the specimen in a cup during voiding. 297. Glomerulonephritis Guilt is a common reaction of the parents of a child diagnosed with glomerulonephritis. Parents blame themselves for not responding more quickly to the child’s initial symptoms, or they may believe they could have prevented the development of glomerular damage. Options 1, 2, and 4 may be associated with the parents’ reaction to the diagnosis, but they are not common parental reactions. 298. Meningitis The classic signs of meningitis include severe headache, fever, stiff neck, and a change in the level of consciousness. Photophobia also may be a prominent early symptom and is thought to be related to meningeal irritation. Although nausea, confusion, delirium, and back pain may occur in meningitis, these are not the classic signs. 299. Imperforated Anus After surgical intervention for imperforate anus, a side-lying position with the legs flexed or a prone position to keep the hips elevated can reduce edema and pressure on the surgical site. Options 1, 2, and 3 are incorrect positions. 300. Jaundice The parents of a child should be told that the jaundice may appear to get worse before it resolves. Options 1, 2, and 3 are incorrect and inappropriate responses. 301. Diarrhea If mild diarrhea occurs in a child younger than 2 years of age, a soft diet is advised as long as the child is tolerating solids. The ABCs (applesauce, strained bananas, and strained carrots), rice, potatoes, and other bland foods without dairy products are advised. Extra fluids may also be needed and may be given by adding 1 to 2 ounces of additional water to each bottle of formula or juice. 302. Cleft Palate The mother needs to be instructed that straws, pacifiers, spoons, and fingers must be kept away from the child’s mouth for 7 to 10 days. Additionally, the mother should be advised to avoid taking an oral temperature. Options 1, 2, and 4 are accurate measures to implement after cleft palate repair. 303. Esophageal Atresia Esophageal atresia with TEF represents a critical neonatal surgical emergency. While the infant is awaiting transfer to surgery, management centers on prevention of aspiration. The infant is kept supine or prone with the head of the bed elevated to decrease the chance of gastric secretions from entering the lungs. Intravenous fluids are essential. An NG tube must be in place and aspirated every 5 to 10 minutes to keep the proximal pouch clear of secretions. Monitoring the temperature and blood pressure are standard nursing interventions. 304. Hepatitis Assessment findings in a child with hepatitis include right upper quadrant tenderness and hepatomegaly. The stools will be pale and clay-colored, and urine will be dark and “frothy.” Jaundice may be present and will be best assessed in the sclerae, nailbeds, and mucous membranes. 305. Lead Poisoning Paint chips, soil contaminated with lead, lead solder user in plumbing, vinyl blinds, and improperly glazed pottery can be the source of toxic exposure in lead poisoning.

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306. Hirschsprung's Disease Hirschsprung’s disease also is known as congenital aganglionosis or megacolon. It results from the absence of ganglion cells in the rectum and, to various degrees, up into the colon. Option 1 describes celiac disease. Option 2 describes lactose intolerance. Option 4 describes irritable bowel syndrome. 307. Hepatitis Because hepatitis A virus is not infectious 1 week after the onset of jaundice, return to school at that time is permitted if the child feels well enough. Options 1, 2, and 4 are incorrect. 308. Cleft Palate Cleft palate repair is individualized and based on the degree of deformity and size of the child. Cleft palate repair usually is performed between 6 months and 2 years of age, depending on physician preference. Early closure facilitates speech development. Options 2, 3, and 4 are incorrect. 309. Tetralogy of Fallot Children with tetralogy of Fallot, or with physiology similar to that seen with this disorder, may experience hypercyanotic episodes, or “tet spells.” These episodes are characterized by increased respiratory rate and depth and increased hypoxia. Immediate physician notification is not required unless other appropriate nursing interventions are unsuccessful. Options 3 and 4 are unrelated to tetralogy of Fallot. 310. Heart Surgery After heart surgery, the child may return to school in 3 weeks but needs to go half-days for the first few days. The mother also should be told that that the child cannot participate in physical education for 2 months. Options 1, 2, and 4 are incorrect. 311. Safety Medicine should not be referred to as candy. Home safety measures are simple but important. Medications should be stored in child-proof containers. The number of tablets in a container should be limited. Toxic substances should be labeled with green poison stickers on them and should be placed in a locked area out of reach of children. The poison control center telephone number should be visible near all telephones. 312. Increased Intracranial Pressure Transtentorial herniation occurs when part of the brain herniates downward and around the tentorium cerebelli. It can be unilateral or bilateral and may involve anterior or posterior portions of the brain. If a large amount of tissue is involved, the risk of death is increased because vital brain structures are compressed and become unable to perform their function. 313. Level of Consciousness Obtunded indicates that the child sleeps unless aroused and once aroused has limited interaction with the environment. Full consciousness indicates that the child is alert, awake, orientated, and interacts with the environment. Confusion indicates that the ability to think clearly and rapidly is lost, and disorientation indicates that the ability to recognize place or person is lost. 314. Head Injury Decorticate posturing is an abnormal flexion of the upper extremities and an extension of the lower extremities with possible plantar flexion of the feet. Decerebrate posturing is an abnormal extension of the upper extremities with internal rotation of the upper arms and wrists and an extension of the lower extremities with some internal rotation. 315. Head Injury Decorticate posturing indicates a lesion in the cerebral hemisphere or disruption of the corticospinal tracts. Decerebrate posturing indicates damages in the diencephalon, midbrain, or pons. 316. Communication Babbling sounds are common between the ages of 3 and 4 months. Additionally, during this age, crying becomes more differentiated. Between the ages of 1 and 3 months, the infant will produce cooing sounds. An increased interest in sounds occurs between 6 and 8 months, and the use of gestures occurs between 9 and 12 months. 317. Nutrition Breast milk or formula is the main food throughout infancy. Rice cereal mixed with breast milk or formula is introduced at 4 months of age. Strained vegetables, fruits, and meats are introduced one at a time and can begin at 6 months of age. 318. Motor Deverlopment A 24-month-old would be able to open a door using the doorknob. At age 15 months, the nurse would expect that the child could build a tower of two blocks. At age 30 months, the child would be able to snap large snaps and put on simple clothes independently. 319. Play The toddler has increased use of motor skills and enjoys manipulating small objects such as toy people, cars, and animals. Push-pull toys are appropriate for this age. Option 2 is most appropriate for an infant. Option 3 is most appropriate for a school-age child. Option 4 is most appropriate for an adolescent. 320. Lactose Intolerance Lactose intolerance causes frothy stools. Abdominal distention, crampy abdominal pain, and excessive flatus also may occur. Option 2 is a clinical manifestation of celiac disease. Option 3 is a clinical manifestation of Hirschsprung’s disease. Option 4 is a clinical manifestation of irritable bowel syndrome. 321. Celiac Disease Dietary management is the mainstay of treatment for the child with celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies. 322. Constipation Mineral oil is best tolerated when it is given chilled or mixed with cold drinks. Mixing the oil with chocolate milk, blending it with ice cubes and fruit juice, or chilling it helps to disguise the taste. Administering mineral oil before meals will affect the child’s appetite.

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323. Cleft Palate After cleft palate repair, the mouth is rinsed with water after feedings to clean the palate repair site. Rinsing food and residual sugars from the suture line reduces the risk of infection. Options 2, 3, and 4 are incorrect procedures. Hydrogen peroxide, povidone-iodine, and lemon and glycerin are not used because of their harmful effect to oral tissues and the suture site. 324. Pyloric Stenosis Laboratory findings in an infant with hypertropic pyloric stenosis include metabolic alkalosis as a result of the vomiting that occurs in this disorder. Additional findings include decreased serum potassium and sodium levels, increased pH and bicarbonate level, and a decreased chloride level. 325. Increased Intracranial Pressure DI can occur in a child with increased ICP. A urine specific gravity above 1.020, weight gain, and hypertension are indications of the syndrome of inappropriate antidiuretic hormone (SIADH) secretion, not DI. A high urine output would be indicative of DI. 326. Lead Poisoning If the child is receiving an IV infusion of calcium EDTA, the infusion should be stopped for 1 hour before obtaining a blood level lead concentration. Otherwise, the blood lead concentration will indicate a falsely elevated reading. Therefore, options 1, 3, and 4 are incorrect. 327. Anemia Clients with sickle cell anemia are advised to avoid strenuous activities. Quiet activities as tolerated are recommended when the client is feeling well. Increasing fluid intake is encouraged to assist in preventing sickle cell crisis. 328. Otitis Externa The nurse should provide information about ear care to children because it is not uncommon for them to put sharp or small objects, such as cotton swabs, into their ears, and these behaviors can cause injury. A face cloth on a fingertip is safe to use for ear cleaning. Acute otitis externa may cause a low-pitched tinnitus but usually does not cause dizziness unless the condition has progressed to an otitis media. Audiography is performed during a screening done at school usually every year and does not necessarily need to be performed by a special physician. 329. Rheumatic Fever In the presence of rheumatic fever, the child will exhibit leukocytosis, positive result on CRP determination, elevated ASO titer, and elevated ESR. A positive result on ANA testing is used to diagnose a wide variety of connective-tissue, vascular, and immune complex disorders and will be positive with rheumatic fever also. 330. Brain Injury Temporal lobe herniation or uncal herniation refers to a shifting of the temporal lobe laterally across the tentorial notch. This produces compression of the third cranial nerve and ipsilateral pupil dilation. If pressure continues to rise, flaccid paralysis, pupil dilation, pupil fixation, and death will result. 331. Tracheostomy When suctioning a tracheostomy in an infant, it is necessary to limit insertion and suctioning time to 5 seconds to prevent hypoxia. Options 1, 2, and 4 indicate correct suctioning procedures for the infant. 332. Vaccines In a young child, aged 3 to 6 years, the maximum volume of medication that can be safely injected into the ventral gluteal muscle is 1.5 mL. 333. Tylenol The childâ&#x20AC;&#x2122;s rectal vault is not as long as that of an adult, and the distance required to place medications is approximately 1 to 2 cm. After insertion, the buttocks should be held together until the urge to expel the suppository has passed. 334. Ear Drops Because of the internal anatomy of the ear, if the child is 3 years of age or younger, the pinna of the ear is pulled back and down. If the child is older than 3 years, the pinna of the ear is pulled back and up. The child should lie on the unaffected side with the ear to receive the drop facing upward. 335. Pyloric Stenosis Laboratory findings in an infant with hypertrophic pyloric stenosis include metabolic alkalosis due to vomiting. These include increased blood pH and bicarbonate level, decreased serum potassium and sodium levels, and a decreased chloride level. 336. Fracture The mother needs to understand that compartment syndrome is a complication of fracture and casting and can result in permanent limb damage as a result of pressure-related tissue necrosis. The extremity is elevated to prevent swelling, and the physician is notified immediately if any signs of neurovascular impairment develop. Cold fingers could indicate neurovascular impairment and needs to be reported. A heating pad is not applied to the cast or fingers. Skin edges are checked to monitor for irritation and skin breakdown. 337. Fracture Compartment syndrome occurs as a result of pressure buildup within a tissue compartment bounded by anatomical structures such as fascia. With a fracture, this pressure increase may be secondary to the intense inflammatory response or severe bleeding caused by the bone injury, regardless of the fact that diligent nursing care is provided. Pain out of proportion to the injury despite analgesic administration is the classic sign of compartment syndrome. The nurse should constantly assess for this complication and should instruct the caregiver about the manifestations associated with this complication. 338. Scoliosis Braces for treatment of scoliosis usually are worn 16 to 23 hours a day. The skin should be kept clean and dry and inspected for signs of redness or breakdown. Therefore, risk for impaired skin integrity is the nursing diagnosis that should be included in this childâ&#x20AC;&#x2122;s plan of care. The child will not have a risk for delayed growth and development because normal developmental milestones can be met while wearing a brace. The brace assists with posture so mobility is not an issue. The brace does not compromise the respiratory status, so gas exchange is not impaired.

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339. Anemia Sickle cell anemia is a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell: Insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. A diagnosis is established on the basis of a complete blood count, examination for sickled red blood cells in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin level and hematocrit and a decreased platelet count, an increased reticulocyte count, and the presence of nucleated red blood cells. Reticulocyte counts are increased in children with sickle cell disease because the life span of their sickled red blood cells is shortened. 340. Hemophilia Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX. 341. Leukemia Cyclophosphamide (Cytoxan) is an alkylating agent used as a chemotherapeutic agent in children with leukemia and other cancers. Its side effects include bone marrow depression (BMD), but it is platelet sparing. It also causes hemorrhagic cystitis. It does not cause constipation, as vincristine does. Vincristine, a plant alkaloid, also causes BMD. 342. Leukemia A child with myelosuppression is at risk for infection. Good hand-washing technique is necessary to prevent the spread of infection. Complete and strict isolation is not warranted, although a mask and gloves should be worn while in the child’s room. Restricting oral fluids would not be an intervention to reduce the risk of infection and could actually be harmful to the child. Live virus vaccines are not given when the child is myelosuppressed, so assessment of the child’s immune status should be done before administration of immunizations appropriate for age. 343. Brain Tumor If an infratentorial tumor is removed, the child is positioned flat. The pillow is placed behind the child’s back, not the head, because when the pillow is behind the head proper, alignment is not maintained and this misalignment can impair circulation. The child should never be placed in a Trendelenburg position (head down) because this position increases intracranial pressure. Placing the child on the operative side is not recommended because the brain may shift suddenly to that cavity. The head is elevated above the heart when the tumor is a supratentorial one. 344. Leukemia In leukemia, normal bone marrow is replaced by malignant blast cells. As the blast cells take over the bone marrow, eventually red blood cell and platelet production is affected and the child becomes anemic and thrombocytopenic. The Reed-Sternberg cell is found in Hodgkin’s disease. 345. HIV/AIDS Nebulizer pieces are cleaned with warm water after each treatment and allowed to air dry. They are soaked in white vinegar and water for 30 minutes at the end of each day. Options 1, 3, and 4 are inaccurate and would damage the nebulizer equipment. 346. HIV/AIDS The immunocompromised child with an HIV infection should not receive live vaccines. With both the varicella and the MMR vaccinations, live vaccines are given. Once the child’s immune status improves, these vaccinations can then be given. Option 4 is correct because the varicella vaccination would be delayed until the child is not immunocompromised. Option 3 is incorrect because the MMR vaccine would not be administered at this time. The IPV is not a live virus so it can be administered. Option 2 is incorrect because influenza vaccinations do not typically involve live viruses, so the child could receive this vaccination. 347. Pneumonia HAART consists of the combination of two nucleoside analogues, which target viral replication during the reverse transcription phase of the cell cycle, and a protease inhibitor, which targets viral replication at a different phase. Options 1, 3, and 4 are incorrect descriptions. 348. Vaccines A severe febrile illness is a reason to delay immunization but only until the child has recovered from the acute stage of the illness. Minor illness, such as a cold, otitis media, or mild diarrhea, is not a contraindication to immunization. 349. Vaccines The varicella vaccination is recommended to be administered between 12 and 18 months of age. Therefore, options 1, 3, and 4 are incorrect. 350. Vaccines Known altered immunodeficiency from long-term immunosuppressive therapy is a contraindication to MMR (measles-mumps-rubella) immunization because a live vaccine is given. The vaccines identified in options 1, 3, and 4 are not live vaccines and can be administered. 351. Hypospadias After hypospadias repair, the parents are instructed to avoid giving the child a tub bath until the stent has been removed, to prevent infection. Diapers are placed on the child to prevent contamination of the surgical site. Toilet training should not be an issue during this stressful period. Fluids should be encouraged to maintain hydration. 352. Bladder Exstrophy Bladder exstrophy is a congenital anomaly characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. The cause is not known, and a higher incidence is seen in males. Options 1, 2, and 3 are not characteristics of this disorder.

24


353. Growth Hormone Deficiency Synthetic growth hormone comes in a powdered form that must be diluted for administration. It is given as a subcutaneous injection six or seven times per week as prescribed at bedtime. Parents are taught that once diluted, the hormone preparation is to be stored at 36° to 46° F (refrigerated). Injection sites should be rotated. Therefore, option 1 is correct. 354. Diabetes Isophane insulin (NPH) is an intermediate-acting insulin and peaks in approximately 6 to 12 hours. It would peak before supper if given at 7:00 AM. Short-acting insulin would peak after breakfast or mid-morning. Long-acting insulins would peak at bedtime. 355. Diabetes When mixing types of insulin, always withdraw the clear, rapid-acting insulin into the syringe first and then the longacting insulin. This procedure avoids contaminating the short-acting insulin with the longer-acting insulin. Therefore, the Regular insulin would be drawn into the syringe first, followed by the NPH insulin. When a child’s insulin dosage requires the injection of both short- and intermediate-acting insulin at the same time, it is preferable to mix the two and use a single injection. Blood glucose results between 80 and 120 mg/dL are considered to be euglycemic (normal) and the prescribed dose would be administered to maintain euglycemia. 356. Dehydration In moderate dehydration, the fontanels would be slightly sunken, the mucous membranes would be dry, and the skin color would be dusky. Also, oliguria would be present. 357. Nephrotic Syndrome Nephrotic syndrome is a kidney disorder. Clinical manifestations of nephrotic syndrome include edema, proteinuria, hypoalbuminemia, and hypercholesterolemia in the absence of hematuria and hypertension. No fever, bacteriuria, or weight loss would be noted with this syndrome. 358. Glomerulonephritis Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. The child with acute glomerulonephritis will have an excessive accumulation of water and retention of sodium, leading to circulatory congestion and edema. Excess fluid volume would be an appropriate nursing diagnosis for this disease process. No risk for infection is associated with this disease; it is a postinfectious process, usually from a pneumococcal, streptococcal, or viral infection. Hematuria is present, but the loss of blood is not enough to constitute a risk for injury. The disease is acute as opposed to chronic, and almost all children recover completely. 359. Burns A Foley catheter is inserted into the child’s bladder so that urine output can be measured accurately each hour. Although pain medication may be required, the child should not be sedated. Intravenously administered fluids are not restricted and are administered at a rate sufficient to keep the child’s urine output at 1 mL/kg of body mass per hour, thus reflecting adequate tissue perfusion. A nasogastric tube may or may not be required, but this is not the priority intervention. 360. Impetigo Impetigo is a highly contagious bacterial infection of the skin. Fluids are important but are not a component of the main treatment for this infection. Additionally, fluids should never be “forced.” Although impetigo occurs in situations of poor hygiene, a judgmental statement as indicated in option 2 is inappropriate and nontherapeutic. The infection is communicable for 48 hours beyond initiation of antibiotic treatment. 361. Eczema Eczema is a superficial inflammatory process involving primarily the epidermis. The major goals of management are to relieve pruritus, lubricate the skin, reduce inflammation, and prevent or control secondary infections. Keeping the infant content and maintaining adequate nutrition are not priority care for an infant with eczema. Antibiotic ointment should be applied only for treatment of a secondary infection as ordered by a physician. 362. Juvenile Idiopathis Arthritis (JIA) JIA is twice as likely to occur in girls than in boys. Options 1, 2, and 4 are accurate statements regarding this disorder. 363. Med Cal 364. Aspirin Overdose The client who has aspirin toxicity will present with metabolic acidosis with respiratory compensation as seen when the pH is below 7.35 mm Hg, and the HCO3− is below 22 mEq/L. The pH is indicative of the acid-base imbalance. In this case, the pH is acidotic and the HCO3− is decreased, thus indicating metabolic acidosis. The PCO2 is alkalotic, indicating partial compensation. 365. Appendicitis A client with appendicitis is more comfortable when lying in what is traditionally known as the fetal position, with the legs drawn up toward the chest. This flexed positioning assists in decreasing the pain that comes with appendicitis by decreasing the pressure on the abdominal area. Option 1 is incorrect; pain medications are not given to the client with acute appendicitis because they may mask the symptoms that accompany a ruptured appendix. Option 2 describes a nursing intervention that is necessary postoperatively. Option 3 describes an intervention that is contraindicated because heat can lead to a ruptured appendix. 366. Pneumonia Attachment is critical to optimal growth and development of children, particularly in the infant and toddler years. With the addition of oxygen therapy, the hospitalized toddler is at risk of increased anxiety. It is important to maintain the toddler in the oxygen environment at all times. Oxygen therapy is an important component of management of pneumonia and is effective only if it is used appropriately. Critical to that effectiveness is an understanding of the risks that accompany oxygen

25


therapy. Preventing fire is a key nursing intervention. Wool blankets, stuffed wool toys, and many toy cars can produce sparks, which can lead to an oxygen tent’s catching fire. It is important to educate parents and family members not to bring these types of objects to the hospital. 367. Head Injury After a head injury, bleeding from the nose or ears necessitates further evaluation. A watery discharge from the nose (rhinorrhea) that tests positive for glucose is likely to be cerebrospinal fluid (CSF) leaking from a skull fracture. On noting watery discharge from the child’s nose, the nurse would initially test the drainage for glucose using reagent strips such as Dextrostix. If the results of the test are positive, the nurse would then contact the physician. 368. epiglottitis The throat of a child with suspected epiglottitis should not be examined or cultured because any stimulation with a tongue depressor or culture swab could cause laryngospasm, thus completing airway obstruction. Humidified oxygen and antipyretics are components of management. Axillary rather than oral temperatures should be taken. 369. Diabetes A blood glucose below 70 mg/dL indicates hypoglycemia. The child is attending an activity that is different from the normal routine at school. Insulin requirements change with unfamiliar situations. When signs of hypoglycemia occur, the child needs an immediate source of glucose. Regular insulin will lower the blood glucose. Although the child’s mother will need to be notified of the occurrence, this is not the immediate action. There is no reason to take the child to the emergency department. 370. Dislocated Hip Buck’s extension traction is a type of skin traction in which the legs are in an extended position. It is used primarily for short-term immobilization, such as in preoperative management of a child with a dislocated hip. A 90- to 90-degree femoral traction (option 2) is used for femur fractures. In this type of traction, the lower leg is put in a boot cast or supported in a sling, and a skeletal Steinmann pin or Kirschner wire is placed in the distal fragment of the fracture. Russell’s traction (option 3) is used for fractures of the femur or for hip and knee contractures. It uses skin traction on the lower leg with a padded sling under the knee. Balanced suspension (option 4) may be used with or without skin or skeletal traction. It is used for femur, hip, or tibial fractures. The balanced suspension suspends the leg in a desired flexed position to relax the hip and hamstring muscles and does not exert any traction directly on a body part. In balanced suspension, a Thomas splint extends from the groin to midair above the foot, and a Pearson attachment supports the lower leg. 371. Fracture When small fragments of bone are broken from the fracture shaft and lie in the surrounding tissues, the fracture is called comminuted. An open or compound fracture (option 1) is a fracture with an open wound from which the bone protrudes. In an oblique fracture (option 3), a diagonal line across the bone is noted. In a greenstick fracture (option 4), the bone is partly bent and partly broken. 372. Body Surface Area The body surface area of a child can be estimated using the West nomogram. A straight line is drawn on the nomogram between the height and the weight for the child. The point at which the line crosses the surface area column is the estimated body surface area. 373. Dislocated Hip A Pavlik harness is a device that is used to treat congenital hip dislocation. It keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum. The Pavlik harness is worn continuously for 3 to 6 months. It promotes the development of muscle and cartilage, resulting in a stable hip. 374. Leukemia A lateral recumbent position with the knees flexed to the abdomen and the head bent with the chin resting on the chest is assumed for a lumbar puncture. This position separates the spinal processes and facilitates needle insertion into the subarachnoid space. Options 1, 2, and 4 are incorrect positions. 375. Leukemia The CNS is monitored because of the risk of infiltration of blast cells into the CNS. The nurse will check the child’s LOC and also will look for signs of irritability, vomiting, and lethargy. Color, motion, and sensation of the extremities are concerns in a neurovascular assessment. Changes in pupillary reaction most often are noted in conditions related to increased intracranial pressure. The presence of petechiae in the sclera is an objective sign of leukemia. 376. Safety A leading causes of accidental death in the adolescent population is improper use of firearms. Before implementing firearm safety goals, the nurse needs to obtain baseline data about a firearm safety history, which is done in option 3. Option 2 may then be indicated. Option 1 may or may not be effective at some point for this client. Option 4 is unreasonable. 377. Down's Syndrome Children with Down syndrome have an increased risk for developing leukemia compared with the average child. The other statements also could be true, but the nurse should first gather baseline data to determine the cause of the bruising before making other assumptions. 378. Cerebral Palsy Option 4 provides the child with maximum potential in locomotion, self-care, and socialization. The child can move around independently while lying on the abdomen anywhere the child wants to go and can interact with others as desired. Orthoses must be used all the time to aid locomotion (option 3). Option 1 does not provide for maximum socialization and normalization; rather, children with CP need to be mainstreamed as much as cognitive ability permits. Not all children with CP are intellectually challenged. Option 2 does not provide for normalization in self-care. Just as children without CP sit up and use assistive devices when eating, so should children with CP.

26


379. Childhood Development In most communities, free or low-cost after-school programs or activities are available that minimize the amount of time during which school-age children are at home alone. These programs should include adult supervision, which is needed by school-age children. Options 1, 2, and 3 are inappropriate. 380. Scoliosis Bracing can halt the progression of most curvatures, although it is not curative for scoliosis. The statements in options 1, 2, and 3 represent correct understanding on the part of the child. 381. Safety The toddler is at high risk for injury as a result of developmental abilities and an unfamiliar environment. While adaptation, diversion, and consistency are important, protection from injury is the highest priority. 382. Med Cal 383. Cleft Palate Unresponsiveness may be an indication of hearing loss. A child who has a history of cleft palate should be routinely checked for hearing loss. Options 1 and 4 are unrelated to cleft palate after repair. Option 2 is normal behavior for a preschool child. Many preschoolers with vivid imaginations have imaginary friends. 384. Increased Intracranial Pressure The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants physician notification. Options 1, 2, and 4 are inaccurate interpretations. 385. Spina Bifida (Myelomeningocele type) Elevating the head will decrease the chance that cerebrospinal fluid will accumulate in the cranial cavity. The infant needs to be prone for several days to decrease the pressure on the surgical site on the back. Binders and a baby seat should not be used because of the pressure they would exert on the surgical site. 386. Cystic Fibrosis Breathing exercises are recommended for a majority of children with CF, even those with minimal pulmonary involvement. The exercises usually are performed twice daily, and they are preceded by postural drainage. The postural drainage will mobilize secretions, and the breathing exercises will then assist with expectoration. Exercises to assist in assuming correct postures and in maximizing thoracic mobility are included, such as swinging the arms and bending and twisting the trunk. The ultimate aim of these exercises is to establish a good habitual breathing pattern. 387. Diabetes Most children 9 years of age and older can understand the principles of monitoring their own insulin requirements. They usually are responsible enough to determine the appropriate intervention needed to maintain their health. The school teacher will not take responsibility for health care interventions such as this one. Parents, friends, and family cannot always be available. 388. Otitis Media In acute otitis media, symptoms and signs such as acute ear pain, fever, and a bulging yellow or red tympanic membrane usually are present. Nursing interventions focus on relieving pain. Analgesic medications such as acetaminophen (Tylenol) and ibuprofen (Motrin) are used to treat mild pain. The priority nursing diagnosis for this condition would be acute pain. Impaired skin integrity, ineffective breathing pattern, and impaired oral mucous membranes would not be priority nursing diagnoses with this condition. 389. Rheumatic Fever Rheumatic fever usually develops after a group A β-hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff’s bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated antistreptosysin O titer; an elevated C-reactive protein; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin’s disease. 390. Epistaxis Evaluation of the teaching is done by eliciting feedback to ensure parents understand the information. Use of a “hands-on” return demonstration is the best method to encourage mastery of skills and determine if the parents have understood what was taught. Telling the parents the steps to take when a nosebleed occurs, showing a video, and giving a brochure fall under the category of relating information but would not allow the nurse to determine if the parents understood the content. 391. Down's Syndrome Down syndrome is a form of mental retardation and is a congenital condition that results in moderate to severe mental retardation. Most cases are attributable to an extra chromosome (group G)—hence the name trisomy 21. Options 1, 2, and 3 are incorrect characteristics of this syndrome. 392. Blood Pressure Cuff The size of the blood pressure cuff is important. Cuffs that are too small will cause falsely elevated values, and those that are too large will cause inaccurate low values. The cuff should cover two thirds of the distance between the antecubital fossa and the shoulder. 393. Piaget's Cognitive Theory Animism means that all inanimate objects are given living meaning. Egocentric speech occurs when the child talks just for fun and cannot see another’s point of view. Object permanence, the realization that something out of sight still exists, occurs in the later stages of the sensorimotor stage of development. Global organization means that if any part of an object or situation changes, the whole thing has changed. Options 2 and 4 occur during the preoperational stage. 394. Seizures Antiseizure medications are continued for a prolonged time even if seizures are controlled. Periodic reevaluation of the child is important to assess the continued effectiveness of the medication, check serum medication levels, and determine the need to alter the dosage if indicated. Antiseizure medications have potential side effects, and parents should be informed of such effects specific to the medication the child will be taking. Withdrawal of medication follows a predesigned protocol, usually begun when the child has been seizure free for at least 2 years. When a medication is discontinued, the dosage should be reduced gradually over 1 to 2 weeks.

27


395. Med Cal 396. Oral Medication The nurse should administer oral medications with the infant sitting in an upright position to prevent aspiration if the infant cries or resists. Semi-Fowler’s is an upright position. Dorsal recumbent means on the back and flat, so there would be a risk of aspiration with this position. Trendelenburg is on the back with the head lowered, and prone is on the abdomen. Oral medications could not be administered to an infant in either of these positions. 397. Childhood Development The nurse utilizes developmental perspectives when administering medications. The preschool age is when the nurse can make use of “magical thinking” as a strategy to administer medications. Infants and toddlers are too young for this concept, and school-age children are too mature. 398. Thalassemia In thalassemia, immature erythrocytes proliferate, not mature ones. This is a progressive anemia. Defective hemoglobin is produced as a result of genetically deficient β-polypeptide. This hemoglobin is unstable, disintegrates, and damages the erythrocytes. Rapid destruction of the red cells stimulates rapid production of immature red cells, and the net gain is less-than-optimally functioning red cells. Iron from the red blood cell destruction is stored in the tissues, causing multiple problems. The nurse also would note microcytosis and hypochromia. Therefore, options 1, 2, and 4 are incorrect statements. 399. Hemophilia The female offspring of an affected male and a carrier female are at risk for hemorrhage once puberty is attained and menstrual cycles begin, and depending on the severity of the hemophilia, a hysterectomy or ablation may be performed. Options 2, 3, and 4 are incorrect statements. Hemarthrosis is the result of bleeding into the joint cavity, not of aspiration. Aspirin is not given to young children and would not be given to a child with a bleeding disorder because of its effects on platelet aggregation. Seventy-two hours is too long for the joint to be rested, because maintenance of mobility is a primary concern once the bleeding episode has been arrested. 400. Anemia During vaso-occlusive sickle cell crisis, the care focuses on adequate hydration and pain management. Adequate hydration with intravenous normal saline and oral fluids maintains blood flow and decreases the severity of the vaso-occlusive crisis. Analgesics for pain management are necessary during a vaso-occlusive crisis. Splenectomy would not be done with a vaso-occlusive crisis. Acidosis is not present. Oxygen can be administered to increase tissue perfusion, but is not the priority treatment for a vaso-occlusive crisis. Passive range of motion is not recommended; bedrest is prescribed initially. 401. Vaccines The vaccination would be given. Mild fever after the DTaP is not uncommon, and the vaccination would not be withheld for that reason. It is not necessary to notify the physician about this side effect. A vaccination is withheld for true contraindications such as a previous anaphylactic reaction or sensitivity to a product in the vaccination. Drawing blood for determination of a pertussis titer would not be indicated. 402. Rheumatic Fever Rheumatic fever develops after a group A β-hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff’s bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated antistreptosysin O titer; an elevated C-reactive protein level; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin’s disease. 403. Fifth Disease The classic rash of erythema infectiosum, or “fifth disease,” affects the face. The discrete rose-pink maculopapular rash is the rash of exanthema subitum (roseola). The highly pruritic, profuse macule-to-papule rash is the rash of varicella (chickenpox). The discrete pinkish red maculopapular rash is the rash of rubella (German measles). 404. Subdural Hematoma A subdural hematoma can cause pressure on a specific area of the cerebral tissue. Especially if the infant is actively bleeding, such pressure can cause changes in the stimuli responses in the extremities on the opposite side of the body. Option 1 is incorrect because contractures would not occur this soon after delivery. Options 3 and 4 are incorrect. An infant, after delivery, normally would be incontinent of urine. Blood in the urine would indicate abdominal trauma and would not be a result of the hematoma. 405. Dental Care The practice of coating pacifiers with honey or using commercially available hard-candy pacifiers is discouraged. Besides being cariogenic, honey also may cause botulism, and broken-off pieces of the candy pacifier may be aspirated. Additionally, sweet milk or other fluids such as juice in a bottle taken at naptime or bedtime will bathe the teeth, producing caries. Fluoride, an essential mineral for building caries-resistant teeth, is needed, usually beginning at 6 months of age if the infant does not receive adequate fluoride content. A diet that is low in sweets and high in nutritious foods promotes dental health. 406. Fracture The school-aged child becomes organized with more direction with play activities. Such activities include collections, drawing, construction, dolls, pets, guessing games, board games, riddles, hobbies, competitive games, and listening to the radio or television. Options 1 and 2 are appropriate for a preschooler. Option 3 is appropriate for a toddler. 407. Inguinal Hernia Changing diapers as soon as they become damp helps prevent infection at the surgical site. Parents are instructed to change diapers more frequently than usual during the day and once or twice during the night. Parents are instructed to give the infant sponge baths instead of tub baths for 2 to 5 days. No restrictions on the infant’s activity are needed. A fever may indicate the presence of an infection.

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Pediatrics A 1. To take the vital signs of a 4­month­old child, which order provides the most accurate results? A. 

Respiratory rate, heart rate, then rectal temperature.  Correct

B.

Heart rate, rectal temperature, then respiratory rate.

C.

Rectal temperature, heart rate, then respiratory rate.

D.

Rectal temperature, respiratory rate, then heart rate.

ID: 310947676

The respiratory rate should be taken first (A) in infants, since touching them or performing unpleasant procedures usually makes them cry, elevating the heart rate and making respirations difficult to count (B). Rectal temperature is the most invasive procedure, and is most likely to precipitate crying, so should be done last (C and D). Awarded 1.0 points out of 1.0 possible points.

ID: 311013607 2. A 16­year­old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received eight years ago. What action should the nurse take?

A.

Dispense a tetanus antitoxin.

B.

Prepare human tetanus immune globulin.

C.

Administer tetanus toxoid booster. Correct

D.

Delay the tetanus toxoid booster until due.

After the completion of the initial tetanus immunization schedule, the recommended booster for an adolescent or adult is every ten years or less if a traumatic injury occurs that is contaminated by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions, wounds from missiles, burns, or frostbite. The adolescent's injury is considered a contaminated wound requiring prophylactic therapy, so the tetanus toxoid booster should be administered (C). (A, B, and D) are not indicated. Awarded 1.0 points out of 1.0 possible points.


ID: 310946642 3. The mother of a 6­month­old asks the nurse when her baby will get the first measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate?

A.

3 to 6 months.

B.

12 to 15 months.  Correct

C.

18 to 24 months.

D.

4 to 6 years.

The first measles, mumps, and rubella (MMR) vaccine should be given no sooner than 12 months of age, and ideally between 12 and 15 months of age (B). (A) should not receive the MMR vaccine due to the presence of maternal antibodies. MMR is not routinely administered at (C), but other immunizations, such as DTaP and Hepatitis B may be given at that time. The second dose of MMR is routinely administered at (D), provided that at least 4 weeks have elapsed since the first dose, and if both doses were administered beginning at or after 12 months. Awarded 1.0 points out of 1.0 possible points.

ID: 310945284 4. A 2­year­old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome?

A.

Congenital heart disease.  Correct

B.

Fragile X chromosome.

C.

Trisomy 13.

D.

Pyloric stenosis.

Congenital heart disease (A) is the most common associated defect in children with Down syndrome. (C) might have seemed possible since Down syndrome is a trisomal chromosomal abnormality of chromosome 21. (B) is a sex­linked abnormality also causing mental retardation. (D) is not associated with Down syndrome. Awarded 1.0 points out of 1.0 possible points.


5. A 14­year­old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide? A. 

Remove all blackheads and follow with an alcohol scrub.

B.

Use medicated cosmetics only to help hide the blemishes.

C.

Wash the hair and skin frequently with soap and hot water.  Correct

D.

Encourage her to see a dermatologist as soon as possible.  Incorrect

ID: 310985655

Washing the hair and skin with soap and hot water (C) removes oil and debris from the skin and helps prevent and treat acne. Oily skin is especially bothersome during adolescence when hormones cause enlargement of sebaceous glands and increased glandular secretions which predispose the teenager to acne. (A) is contraindicated. Cosmetics ("medicated" or not) should be used sparingly to avoid further blocking sebaceous gland ducts (B). (D) might be indicated at a later time, if healthcare recommendations are not successful. Awarded 0.0 points out of 1.0 possible points.

6. The nurse is caring for a 12­year­old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication? A. 

Poor skin turgor resulting from dehydration.

B.

Changes in level of consciousness. Correct

C.

Premature aging as the disease progresses.

D.

Severe edema from an excess of water and sodium.  Incorrect

ID: 310950702

The child must be monitored for signs and symptoms of hyponatremia, which creates secondary central nervous system alterations such as changes in level of consciousness, seizure, and coma (B). Fluid overload occurs with SIADH, not (A) (which occurs with diabetes insipidus). (C) is caused by hypersecretion of growth hormone, not SIADH. (D) is not found in children with SIADH because edema is caused by an excess of both water and sodium. Awarded 0.0 points out of 1.0 possible points.


7. A three­month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9° F. The nurse determines the daily caloric need for this child is approximately A. 

400 calories per day.

B.

500 calories per day.

C.

600 calories per day.  Correct

D.

700 calories per day.

ID: 310993975

10 lbs 15 oz = 10.9 lbs. Convert lbs to kg by dividing pounds by 2.2; 10.9/2.2 = 4.954 kg, rounded to 5 kg. An infant requires 108 calories/kg/day (108 × 5 = 540 calories/day). However, this infant requires 10% more calories because he has one degree temperature elevation. 10% of 540 is 54 and 540 + 54 = 594. This infant will require approximately 600 calories/day. Tough question! You know that 400 calories are too few and 700 are too much, and a temperature elevation necessitates consumption of more calories, so choose the higher of the two choices left! Awarded 1.0 points out of 1.0 possible points.

8. A 6­year­old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child's adjustment to hospitalization? A. 

Explain hospital schedules to the child, such as mealtimes.  Correct

B.

Use terms, such as "honey" and "dear," to show a caring attitude.

C.

Provide a list of rules that limits visitation of siblings in the hospital.

D.

Orient the parents to the hospital unit and refreshment areas.

ID: 310950708

Altered daily schedules and loss of rituals are upsetting to children and increase separation anxiety, and active sensitivity to the needs of children can minimize the negative effects of hospitalization. Explaining the hospital schedules (A) and establishing an individual schedule familiarizes the child to the hospital environment and decreases anxiety. (B) depersonalizes the child who should be addressed by name. Family and sibling visitation should be recommended and encouraged without limitation (C). Although (D) should be implemented, the direct


involvement of the school­aged child incorporates the child's sense of initiate and cooperation. Awarded 1.0 points out of 1.0 possible points.

9. A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first? A. 

Slowly pour hydrogen peroxide over the open wound.

B.

Apply ice to the area before rinsing with cold water.

C.

Wash the wound gently with mild soap and water.  Correct

D.

Gently cleanse with a sterile pad using povidone­iodine.  Incorrect

ID: 310965939

A small, superficial laceration to the skin should be washed gently with mild soap and water (C) for several minutes, followed by thorough rinsing. (A and D) are antiseptics that can be traumatic (painful) when cleaning fresh, open wounds. Applying ice (B) may reduce or prevent further edema, but the wound should be washed with mild soap and water first. Awarded 0.0 points out of 1.0 possible points.

10. What preoperative nursing intervention should be included in the plan of care for an infant ID: 310951938 with pyloric stenosis? A. 

Monitor for signs of metabolic acidosis.

B.

Estimate the quantity of diarrhea stools.

C.

Place in a supine position after feeding.

D.

Observe for projectile vomiting.  Correct

Projectile vomiting (D), which contributes to metabolic alkalosis (A), is the classic sign of pyloric stenosis. (B) is not indicated. (C) is dangerous, due to the potential for aspiration with frequent vomiting. Awarded 1.0 points out of 1.0 possible points.


11. Which class of antiinfective drugs is contraindicated for use in children under 8 years of age? A. 

Aminoglycosides.

B.

Tetracyclines.  Correct

C.

Penicillins.

D.

Quinolones.

ID: 310959873

Tetracyclines (B) cause enamel hypoplasia and tooth discoloration in children under 8 years of age. (A, C, and D) are not contraindicated for use in children. Awarded 1.0 points out of 1.0 possible points.

ID: 310957463 12. The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction?

A.

Tell children they should not taste anything but food.

B.

Store all toxic agents and medicines in locked cabinets.  Correct

C.

Provide special play areas in the house and restrict play in other areas.

D.

Punish children if they open cabinets that contain household chemicals.

The only reliable way to prevent poisonings in young children is to make them inaccessible (B). Teaching children not to taste is important (A), but ineffective for young children. (C and D) will not control a child's curiosity. Awarded 1.0 points out of 1.0 possible points.

ID: 311041550 13. The nurse reviews the latest laboratory results for a child who received chemotherapy last week and identifies a reduced neutrophil count. Which nursing diagnosis has the highest priority for this child?

A.

Risk for infection.  Correct

B.

Risk for hemorrhage.


C.

Altered skin integrity.

D.

Disturbance in body image.

Chemotherapy (CT) suppresses phagocytotic neutrophils and places the child at risk for infection (A), which is the priority nursing diagnosis. (B, C, and D) may be related to the care of a child receiving CT are not related to neutropenia. Awarded 1.0 points out of 1.0 possible points.

14. Which menu selection by a child with celiac disease indicates to the nurse that the child understands necessary dietary considerations? A. 

Oven­baked potato chips and cola. Correct

B.

Peanut butter and banana sandwich.

C.

Oatmeal­raisin cookies and milk.

D.

Graham crackers and fruit juice.

ID: 310962721

Celiac disease causes an intolerance to the protein gluten found in oats, rye, wheat, and barley. The child should avoid any products containing these ingredients to avoid symptoms such as diarrhea. (A) is the selection which avoids all of these ingredients. (B, C, and D) contain gluten in one form or another. Awarded 1.0 points out of 1.0 possible points.

ID: 310955047 15. A 12­month­old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant?

A.

Give small, frequent feedings of fluids.

B.

Accurately chart observations regarding breath sounds.

C.

Have a bulb syringe readily available to remove secretions.  Correct

D.

Encourage older siblings to visit.

A patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby


increasing the amount of secretions and making (C) the highest priority. (A) maintains hydration and prevent tiring, but an open airway has a higher priority! (B) is important for evaluation of therapy. When asked "priority" questions, REMEMBER MASLOW! Physical needs usually have a higher priority than psychosocial needs (D) and an open airway is the highest physiological need! Awarded 1.0 points out of 1.0 possible points.

16. A 6­month­old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention? A. 

Apical heart rate of 60.  Correct

B.

Sweating across the forehead.

C.

Doesn't suck well.

D.

Respiratory rate of 30 breaths per minute.

ID: 311018771

A heart rate of 60 (A) is much lower than normal for a 6­month­old and warrants immediate intervention. The normal heart rate for a 6­month­old is 80 to 150 BPM when awake, and a rate of 70 while sleeping is considered within normal limits. (B and C) are expected symptoms of heart failure in an infant. (D) is within normal limits for an infant. Awarded 1.0 points out of 1.0 possible points.

17. When assessing a child with asthma, the nurse should expect intercostal retractions during A. 

inspiration.  Correct

B.

coughing.  Incorrect

C.

apneic episodes.

D.

expiration.

Intercostal retractions result from respiratory effort to draw air into restricted airways (A). Awarded 0.0 points out of 1.0 possible points.

ID: 310947664


18. A child with cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding? A. 

Diarrhea.

B.

Rhinorrhea.

C.

Galactorrhea.

D.

Steatorrhea.  Correct

ID: 311041544

Steatorrhea (D) is defined as stools with an abnormally high fat content that are usually foul smelling and float on water. (A, B, and C) do not describe this finding. Awarded 1.0 points out of 1.0 possible points.

19. The nurse receives a lab report stating a child with asthma has a theophylline level of 15 mcg/dl. What action will the nurse take? A. 

Pass the information on in the report. Correct

B.

Notify the healthcare provider because the value is high.

C.

Repeat the lab study because the value is too high.

D.

Hold the next dose of theophylline.

ID: 311018767

The therapeutic level of theophylline is 10 to 20 mcg/dl, so the child's level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse's report (A). (B, C, and D) would be inappropriate actions in view of the laboratory finding. Awarded 1.0 points out of 1.0 possible points.

20. All of the following interventions can be used to evaluate the effectiveness of nursing and ID: 310944504 medical interventions used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20­month­old child? A. 

Weighing diapers.

B.

Assessing fontanels.  Correct


C.

Checking skin turgor.

D.

Observing mucous membranes for moisture.

All of these interventions evaluate fluid status in infants. But, how old is this child? Posterior fontanel closes at 2 months and anterior fontanel closes by 18 months of age (B)! Remember normal growth and development! Awarded 1.0 points out of 1.0 possible points.

21. The nurse is planning care for school­aged children at a community care center. Which activity is best for the children? A. 

Building model airplanes.  Incorrect

B.

Playing follow­the­leader.  Correct

C.

Stringing large and small beads.

D.

Playing with Playdough and clay.

ID: 310946672

School­aged children strive for independence and productivity (Erikson's Industry vs. Inferiority) and enjoy individual and group activities related to real­life situations, such as playing follow­ the­leader (B). (A) is an individual activity that could contribute to feelings of inferiority and inadequacy if the task is too complex. Although school­aged children enjoy crafts, (C and D) are more appropriate for pre­school children. Awarded 0.0 points out of 1.0 possible points.

22. Which restraint should be used for a toddler after a cleft palate repair? A. 

Clove hitch.

B.

Mummy.

C.

Elbow.  Correct

D.

Jacket.

ID: 310955019


Elbow restraints prevent children from bending their arms and bringing their hands to the oral surgical site. (A) restrains the hands, but the child can bend and bring their head to their hands. (B) is used during procedures. (D) restrains the body torso and is not appropriate. Awarded 1.0 points out of 1.0 possible points.

ID: 310999069 23. A burned child is brought to the emergency room. In estimating the percentage of the body burned, the nurse uses a modified "Rule of Nines." Which part of a child's body is calculated as a larger percentage of total body surface than an adult's?

A.

Head and neck.  Correct

B.

Arms and chest.

C.

Legs and abdomen.

D.

Back and abdomen.  Incorrect

A child's head and neck are proportionately larger to their body than an adult's (A). The standard "Rule of Nines" is inaccurate for determining burned body surface areas with children, and must be modified for use with children. Specially designed charts for children are commonly used to determine body surface area involvement. (B, C, and D) are not proportionately different. Awarded 0.0 points out of 1.0 possible points.

ID: 310950716 24. The vital signs of a 4­year­old child with polyuria are: BP 80/40, Pulse 118, and Respirations 24. The child's pedal pulses are present with a volume of +1, and no edema is observed. What action should the nurse implement first?

A.

Insert an indwelling urinary catheter.

B.

Start an IV infusion of normal saline. Correct

C.

Send a specimen to the lab for urinalysis.

D.

Document the child's vital signs and pulses.  Incorrect


The current vital sign readings and the decreased peripheral pulse volume indicate that the child is experiencing fluid volume deficit due to the polyuria, so the priority action is to restore fluid volume (B). (A) is useful in obtaining a precise urine output measure, but is a lower priority than restoring fluid volume at this time. (C) is not indicated based on the current assessment data, and (D) does not recognize the need for immediate action to combat the fluid volume deficit. Awarded 0.0 points out of 1.0 possible points.

25. The nurse is teaching a mother to give 4 ml of a liquid antibiotic to a 10­month­old infant. Which statement by the parent indicates a need for further teaching? A. 

I will give this antibiotic to my child until it is finished.

B.

Using a teaspoon will help me measure this correctly.  Correct

C.

I will call the clinic if my child develops a rash or itching.

D.

My baby should begin to feel better within a few days.  Incorrect

ID: 310957445

The prescribed medication is 4 ml per dosage and is measured with the most accuracy using a syringe, so if the parent uses a teaspoon (B), which is equivalent to 5 ml, further teaching is indicated. (A, C, and D) indicate correct understanding and require no further intervention by the nurse. Awarded 0.0 points out of 1.0 possible points.

ID: 310945716 26. A 4­year­old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority?

A.

B.

Call the healthcare provider immediately if his nail beds appear blue.  Correct

Check his fingers hourly for the first 48 hours to see that he is able to move them without pain.

C.

Be sure his arm remains above his heart for the first 24 hours.

D.

Take his temperature q4h for the next two days and call if an elevation is noted.


Cyanosis (A) indicates impaired circulation to fingers and should be reported immediately. Although the actions described in (B, C, and D) may be indicated, they are implemented rather excessively­­and might tend to frighten the parents. It is not necessary to check the child's ability to move his fingers hourly for 2 days (B). Elevating the arm above the heart will help to decrease swelling but (C) is stated in a frightening way. It is not necessary to take the child's temperature q4h unless indicated by other symptoms. Awarded 1.0 points out of 1.0 possible points.

27. A 3­year­old boy is brought to the emergency room because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first? A. 

Insert N/G tube for gastric lavage.

B.

Determine the child's pulse and respirations.  Correct

C.

Assess the child's level of consciousness. Incorrect

D.

Administer an IV D5/0.25 NS as prescribed.

ID: 311018743

The most important principle in dealing with a poisoning is to treat the child first, not the poison. Initiate immediate life support measures with assessment of vital signs (B), in particular, respirations. Inserting an airway or initiating mechanical ventilation may be necessary. Assessment and identification of the poison should occur prior to (A). (C and D) should occur after assessing the airway. Awarded 0.0 points out of 1.0 possible points.

28. A 3­year­old client with sickle cell anemia is admitted to the Emergency Department with ID: 310978607 abdominal pain. The nurse palpates an enlarged liver, an x­ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis? A. 

Aplastic.

B.

Sequestration.  Correct

C.

Hyperhemolytic.  Incorrect

D.

Vaso­occlusive.


The findings support a sequestration crisis (B), where blood pools in the spleen, and is characterized by abdominal pain and anemia. (A and C) crises produce anemia but no abdominal pain or splenic enlargement. (D) crisis may produce abdominal pain, but no splenic enlargement or exacerbation of anemia. Awarded 0.0 points out of 1.0 possible points.

29. A 2­year­old child with gastro­esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan? A. 

Invite other children home to share meals.

B.

Accept that he will eat when he is hungry.

C.

Reward the child with a nap after eating.

D.

Consistently follow a set mealtime routine. Correct

ID: 311018749

A 2­year­old child is comforted by consistency (D). (A) is contraindicated because two­year­olds may participate in parallel activities with other children but are too young to feel comfort and support by the presence of other children when anxious or afraid. (B) may or may not be true and does not address the child's fears. The child with reflux should remain upright at least two hours after eating (C) to reduce symptoms. Awarded 1.0 points out of 1.0 possible points.

ID: 310972799 30. The nurse is giving preoperative instructions to a 14­year­old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place?

A.

I will read all the literature you gave me before surgery.

B.

I have had surgery before when I broke my wrist in a bike accident, so I know what to expect.

C.

All the things people have told me will help me take care of my back.

D.

I understand that I will be in a body cast and I will show you how you taught me to turn.  Correct


Outcome of learning is best demonstrated when the client not only verbalizes an understanding but can also provide a return demonstration (D). A 14­year­old may or may not follow through with (A), and there is no measurement of that learning. Having previous surgery (B) may help the client understand the surgical process, but wrist surgery is very different from spinal surgery and emergency surgery is different from elective surgery. In (C), the client may be saying what the nurse wants to hear, without expressing any real understanding of what to do after surgery. Awarded 1.0 points out of 1.0 possible points.

31. A 2­year­old child recently diagnosed with hemophilia A is discharged home. What information should the nurse include in a teaching plan about home care?

ID: 311041548

A.

Minimize interactive play with other children to lessen chances for injury.

B.

Give low­dose children's chewable aspirin in orange flavor for joint discomfort.

C.

Use a firm and dry toothbrush to clean teeth at least twice per day.

D.

Apply pressure and ice for bleeding while elevating and resting the extremity.  Correct

Hemophilia, a blood disorder, causes joint bleeding which is treated with rest, ice, compression, and elevation (RICE) (D). (A, B, and C) are inaccurate. Awarded 1.0 points out of 1.0 possible points.

32. The nurse is assessing an 8­month­old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit? A. 

Bradycardia.

B.

Machinery murmur.

C.

Weak pedal pulses.

D.

Clubbed fingers.  Correct

ID: 311002933

Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and toes (D) due to tissue hypoxia. Tachycardia, not (A), is a manifestation of congenital heart disease. (B) is a classic sign of ventricular septal defect. (C) is characteristic of coarctation of the aorta. Awarded 1.0 points out of 1.0 possible points.


ID: 311028943 33. A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents?

A.

Studies have shown that handling a sick newborn is not good for the baby and upsets the parents.

B.

The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her.  Correct

C.

Since your baby has been doing well under oxygen for 24 hours, I can let you hold the baby without oxygen.

D.

You can hold the baby with the oxygen blowing in the baby's face since the level is very close to room air.

The baby is at 35% which is much more than room air (21%) and at this time the baby should not be moved from under the hood. The nurse should offer the parents an alternative such as to stroke and reassure the infant (B). Holding sick babies benefits the infant and the parents (A). The first consideration now has to be the infant's oxygenation. The nurse should not take the baby out from under the hood without a prescription from the healthcare provider, as this could severely compromise the infant (C). A PO2 of 35% cannot be readily achieved with "blow by" oxygen (D). Awarded 1.0 points out of 1.0 possible points.

34. To assess the effectiveness of an analgesic administered to a 4­year­old, what intervention is best for the nurse to implement? A. 

Use a happy­face/sad­face pain scale. Correct

B.

Ask the mother if she thinks the analgesic is working.

C.

Assess for changes in the child's vital signs.

D.

Teach the child to point to a numeric pain scale.

ID: 310965949

A 4­year­old can readily identify with simple pictures (A) to show the nurse how he/she is feeling. (B) could be used to validate what the child is telling the nurse via the "faces" pain scale, but it is best to elicit the child's assessment of his/her pain level. (C) may not accurately reflect the effectiveness of pain medication as they can also be affected by other variables,


such as fear. (D) requires abstract number skills beyond the level of a 4­year­old. Awarded 1.0 points out of 1.0 possible points.

35. When discussing discipline with the mother of a 4­year­old child, the nurse should include ID: 311008987 which guideline? A. 

Parental control should be consistent. Correct

B.

Children as young as 4 years rarely need reprimand or punishment.

C.

Withdrawal of approval is effective.

D.

Parents should enforce rigid rules to be followed without question.

Discipline should be a positive and necessary component of childrearing that is started in infancy and should teach socially acceptable behavior, help children protect themselves from danger, and channel undesirable behavior into constructive activity. Misbehavior may result from inconsistent rules or messages, so parental attention should be clear, reasonable, and consistent (A). (B and C) are not helpful to the child. Children need boundaries that are firm but not rigid (D). Awarded 1.0 points out of 1.0 possible points.

36. The nurse is assessing a 13­year­old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview? A. 

Have you lost any weight in the last month?

B.

Are you experiencing any type of nervousness?  Correct

C.

When was the last time you took your synthroid?

D.

Are you having any problems with your vision?

ID: 310947670

Assessing the client's physiological state upon admission is a priority, and nervousness, apprehension, hyperexcitability, and palpitations are signs of hyperthyroidism (B). Weight loss (even with a hearty appetite) (A) occurs in those with hyperthyroidism, but assessing the client's neurological state has a higher priority. Hormone replacement is not administered to a client who is already producing too much thyroid (C). The client may have exophthalmus (bulging eyes) but hyperthyroidism does not cause vision problems (D).


Awarded 1.0 points out of 1.0 possible points.

ID: 310965995 37. A hospitalized 16­year­old male refuses all visits from his classmates because he is concerned about his distorted appearance. To increase the client's social interaction, what intervention is best for the nurse to initiate?

A.

Encourage the client to use a hand­held video game that is popular with all his friends.

B.

Assign a 25­year­old female nursing student to offer support to the client.

C.

Arrange for an Internet connection in the client's room for email communication. Correct

D.

Encourage the client's mother to arrange a surprise get together in the cafeteria.

Body image and peer acceptance are key concerns for the adolescent. (C) allows for social interaction without face to face contact, thus protecting his self­image while also promoting social interaction. (A) does not promote social interaction. (B) does not encourage interaction with his own peer group, which is of greater importance. (D) does not respect the client's concern about his body image. Awarded 1.0 points out of 1.0 possible points.

38. The nurse is assessing a 2­year­old. What behavior indicates that the child's language development is within normal limits? A. 

Is able to name four colors.

B.

Can count five blocks.

C.

Is capable of making a three word sentence.  Incorrect

D.

Half of child's speech is understandable. Correct

ID: 310993913

Between approximately 15 and 24 months of age, a child's speech is only half understandable (D). (A and B) usually occur between 3 and 5 years of age. (C) is usually accomplished by 18 months of age. Awarded 0.0 points out of 1.0 possible points.


ID: 310950766 39. When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro­esophageal reflux, which intervention is most important for the nurse to implement?

A.

Record weight daily.  Correct

B.

Assess for signs of anemia.

C.

Document sleeping patterns.

D.

Teach parenting skills.

The most definitive measure of improved nutrition in an infant is obtaining the child's daily weight (A). (B, C, and D) may also be useful, but they are not as definitive as a daily weight measurement. Awarded 1.0 points out of 1.0 possible points.

40. A 4­year­old girl continues to interrupt her mother during a routine clinic visit. The mother ID: 310989301 appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information? A. 

B.

Children need to retain a sense of initiative without impinging on the rights and privileges of others.  Correct

Negative feelings of doubt and shame are characteristic of 4­year­old children.

C.

Role conflict is a common problem of children this age. She is just wondering where she fits into society.

D.

At this age children compete and like to produce and carry through with tasks. She is just competing with her mother.  Incorrect

Children aged 3 to 6 are in Erickson's "Initiative vs. Guilt" stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative without impinging on the rights of others (A). (B) describes the "Autonomy vs. Shame and Doubt," stage (1 to 3 years of age). (C) describes an adolescent (12 to 18 years of age), the "Identity vs. Role Confusion" stage. (D) describes a child 6 to 12 years of age, the "Industry vs. Inferiority" stage.


Awarded 0.0 points out of 1.0 possible points.

ID: 310953425 41. An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome?

A.

Stop the flow of unoxygenated blood into systemic circulation.

B.

Increase the flow of unoxygenated blood to the lungs.

C.

Prevent the return of oxygenated blood to the lungs.  Correct

D.

Reduce peripheral tissue hypoxia and nailbed clubbing.

Closure of VSDs stops oxygenated blood from being shunted from the left ventricle to the right ventricle (C). VSDs are acyanotic defects, which means that no unoxygenated blood enters the systemic circulation (A and B). (D) is common with Tetrology of Fallot, which is a cyanotic defect. Awarded 1.0 points out of 1.0 possible points.

ID: 310946616 42. A 5­month­old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding?

A.

Frequency of emesis in the last 8 hours.

B.

Serum BUN and creatinine levels. Correct

C.

Current blood sugar level.  Incorrect

D.

Appearance of the stool.

Regardless of a client's age, adequate renal function must be present before adding potassium to IV fluids (B). (A) is important in determining the need for fluid replacement. (C) is not indicated. (D) is useful information, but will not impact administration of the prescribed IV solution. Awarded 0.0 points out of 1.0 possible points.


ID: 310969421 43. A 6­month­old boy and his mother are at the healthcare provider's office for a well­baby check­up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today?

A.

The routine immunizations and schedule another appointment to administer the influenza vaccine.

B.

All the immunizations with the influenza vaccine given at a separate site from any other injection.  Correct

C.

The influenza vaccine and schedule another appointment to administer the immunizations.

D.

The influenza vaccine and the polio vaccine and schedule another appointment to administer the remaining immunizations.

At 6­months of age, the routine immunizations include Hepatitis B, DTaP, Hib (Haemophilus influenza type b), PCV (Pneumococcal), IPV (inactivated poliovirus) and influenza. The influenza vaccine should be given at a separate site from any other injection (B). Scheduling a return visit (A, B, or C) increases the risk that the mother will not bring the child back for the immunizations. Awarded 1.0 points out of 1.0 possible points.

44. During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing? A. 

Hearing tests.

B.

Eye exams.  Correct

C.

Chest x­rays.

D.

Fasting blood glucose tests.  Incorrect

ID: 310993917

Visual changes leading to blindness can occur in children with JRA. Regular eye exams (B) can help to prevent this complication. (A, C, and D) are not routinely necessary for management of JRA.


Awarded 0.0 points out of 1.0 possible points.

45. When taking the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children? A. 

Hyperactive behavioral traits.

B.

Delay in the eruption of permanent teeth.

C.

Slow sexual development, but within normal range.  Incorrect

D.

Cessation of growth in a child that had been normal.  Correct

ID: 311018707

Since the thyroid gland is responsible for metabolism, cessation of growth (D) which was previously within normal range, is the most common sign for hypothyroidism in children. The child with hypothyroidism is likely to be HYPOactive, not (A). Although (B and C) may occur with hypothyroidism, they are late signs (not early indications) and are signs more often associated with a lack of growth hormone. Awarded 0.0 points out of 1.0 possible points.

46. As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider? A. 

A 6­month­old with failure to thrive that has a closed anterior fontanel.  Correct

B.

A 24­month­old with gastroenteritis that has a closed posterior fontanel.

C.

A 2­month­old with chickenpox that has an open posterior fontanel.

D.

A 28­month­old with hydrocephalus that has an open anterior fontanel.  Incorrect

ID: 311023645

At six months of age the anterior fontanel should be open, and it should not be closed until approximately 18 months of age. (B and C) are normal findings. A child with hydrocephalus may have a delayed closing of the fontanel (D). Awarded 0.0 points out of 1.0 possible points.


ID: 310999065 47. The nurse is teaching a 12­year­old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family?

A.

Polyuria and polydipsia.  Correct

B.

Lethargy and fatigue.

C.

Increased facial hair.  Incorrect

D.

Facial bone structure changes.

Signs and symptoms of diabetes or hyperglycemia (A) need to be reported. Those receiving growth hormone should be monitored to detect elevated blood sugars and glucose intolerance. (B) is associated with any number of heath alterations, but is not associated with the growth hormone therapy. (C and D) are normal changes that occur with 12­year­old males. Awarded 0.0 points out of 1.0 possible points.

48. The parents of a 3­week­old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain? A. 

Description of vomiting episodes in past 24 hours.  Correct

B.

Number of wet diapers in last 24 hours. Incorrect

C.

Feeding and sleep schedule.

D.

Amount of formula consumed during the past 24 hours.

ID: 310999043

A description of the vomiting episodes (A) will assist the nurse in determining the reason for the symptoms, which may be helpful in developing a plan of care for this infant. (B and C) provide related information but are not as helpful as (A). (D) may be related to the vomiting, but the nurse should first obtain a better description of the vomiting episodes. Awarded 0.0 points out of 1.0 possible points.

ID: 310950768 49. An 18­month­old is admitted to the hospital with possible Hirschsprung’s disease. When obtaining a nursing history, the nurse asks about bowel habits. What description of the disease?


A.

Foul­smelling and fatty.

B.

Bile­colored and watery.  Incorrect

C.

Semi­solid and yellow.

D.

Ribbon­like and brown.  Correct

Hirschsprung’s disease is a mechanical obstruction caused by inadequate motility in a part of the intestines. The condition results from failure of ganglion cells to migrate craniocaudally along the GI tract during gestation. The lack of peristalsis in the affected bowel segment causes constipation and small diameter, brown­colored stools (D). (A) is associated with cystic fibrosis. (B) is common in gastroenteritis. (C) is normal in breastfed neonates. Awarded 0.0 points out of 1.0 possible points.

ID: 310944082 50. A 17­year­old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100° F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take?

A.

Tell the student to proceed directly to his regularly scheduled class.  Correct

B.

Call the parent and suggest re­taking the student's temperature at home.

C.

Give the student a glass of cool fluids, then retake his temperature.

D.

Send the student to class, but re­verify his temperature after lunch.

This student has just completed football practice, and increased muscle activity increases body heat production. A temperature of 100° F is normal for this student at this time. The student should attend class (A) since no further nursing action is required. (B) would alarm the parents unnecessarily. (C) would provide a false reading of body temperature. (D) is unnecessary since these findings are within normal limits. Awarded 1.0 points out of 1.0 possible points.


51. Which finding in a 19­year­old female client should trigger further assessment by the nurse? A. 

Menstruation has not occurred.  Correct

B.

Reports no tetanus immunization since childhood.

C.

Denies having any wisdom teeth.

D.

History of painful, inward growth on bottom of foot.

ID: 311008915

Menstruation is an expected secondary sex characteristic that occurs with pubescence and typically occurs by age 18, so (A) should prompt further investigation to determine the cause of this primary amenorrhea. Children receive tetanus as part of the DPT childhood immunization series, and a booster is not typically given until age 16 (B). Wisdom teeth are the third molar teeth of the permanent dentition and are the last to erupt, so (C) is a normal finding. (D) describes a plantar surface wart, harmless but painful because of the pressure with walking or standing. Awarded 1.0 points out of 1.0 possible points.

52. During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement? A. 

Start another IV of dextrose solution and stay with the child.

B.

Continue the transfusion and monitor the child’s vital signs.

C.

Stop the infusion immediately and notify the healthcare provider.  Correct

D.

Slow the transfusion and assess for cessation of symptoms.

ID: 310953451

The child is exhibiting signs of a reaction to the blood transfusion. The blood transfusion should be stopped immediately and the healthcare provider notified (C). After the transfusion is discontinued, IV access should be maintained (A) with fluids that do not introduce any more cellular products. (B and D) place the child at risk for further blood reactions. Awarded 1.0 points out of 1.0 possible points.

ID: 310972757 53. The mother of a 2­year­old boy consults the nurse about her son's increased temper tantrums. The mother states, "Yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?" Which recommendation is best for the


nurse to provide this mother? A. 

Paddle him gently as soon as the behavior is initiated.  Incorrect

B.

Immediately put him in "time­out."

C.

Quietly remind him that others are watching him.

D.

Walk away from him and ignore the behavior.  Correct

The best approach for a toddler is to ignore the attention­seeking behavior (D). The parent should be somewhat nearby, within view of the child but should avoid reinforcing the behavior in any way. Tantrums can sometimes be avoided by talking to the child before the situation occurs. (A, B, and C) would all provide attention for the inappropriate behavior. Awarded 0.0 points out of 1.0 possible points.

ID: 311041542 54. A nurse provides the parents with information on health maintenance for their child with sickle cell disease. Which information reflected by the parents indicates understanding of the child's care?

A.

Daily iron supplements should be given. Incorrect

B.

Plenty of fluids should be consumed daily. Correct

C.

Immunizations should be delayed for a few years.

D.

Protective equipment should be worn for contact sports.

Adequate fluid intake (B) decreases the viscosity of the blood which affects the incidence of vasocclusive crisis. (A and D) are not commonly indicated for a child with sickle cell disease. A routine immunization schedule (C) is recommended for a children with SCD because of their increased susceptibility to infection that predisposes to sickling phenomena. Awarded 0.0 points out of 1.0 possible points.

55. Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.) A. 

Child's height and weight.  Correct

B.

Adult dosage of medication.  Incorrect

ID: 310965927


C.

Body surface area of child.  Correct

D.

Average adult's body surface area. Incorrect

E.

Average pediatric dosage of medication.

F.

Nomogram determined mathematical constant.  Correct

Correct selections are (A, C, and F). The most accurate calculations of pediatric dosages use the child's height and weight (A). The child's BSA is calculated using the square root of weight in kg times height in cm divided by 3600 or the square root of weight in lb times height in inches divided by 3131 (C), then the child's BSA is multiplied by the recommended published dose per BSA. The nomogram (F) is used to plot the child's height and weight, and the point at which they intersect is the BSA mathematical constant used to calculate the child's dose. (B, D, and E) are not used to calculate pediatric dosages. Awarded 0.0 points out of 1.0002 possible points.

56. In developing a teaching plan for a 5­year­old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first? A. 

Food planning and selection.

B.

Administering insulin injections.

C.

Process of glucose testing.  Correct

D.

Drawing up the correct insulin dose.

ID: 310950724

Developmentally, a 5­year­old has the cognitive and psychomotor skills to use a glucometer (C) and to read the number (it is especially helpful if the nurse presents this activity as a game). (A, B, and D) require more advanced cognitive and psychomotor skills and have greater potential for errors. Awarded 1.0 points out of 1.0 possible points.

57. A preschool­age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior?

ID: 310949434


A.

Ability to communicate verbally.

B.

Response to separation from family. Incorrect

C.

Concern for body integrity.  Correct

D.

Socialization with other children.

The preschooler's major stressor is concern for his body integrity (C). He fears that his "insides will leak out." A child undergoing surgery to his genitalia is even more concerned about body integrity. The preschooler is quite verbal, so comprehension of the words he uses or hears may be inaccurate, while his imagination and fears may fantasize the reality (A). (B) is a concern for all children, but of most concern to the toddler. (D) is not a prime concern in this situation. Awarded 0.0 points out of 1.0 possible points.

58. A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client's teaching plan? A. 

Use sunscreen when lying by the pool. Correct

B.

Cleanse the skin at least 4 times a day.

C.

Take the medication with a glass of milk.

D.

Menstrual periods may become irregular.

ID: 310978603

Photosensitivity is a common side effect of tetracycline HCL (Achromycin V) therapy. Severe sunburn can occur with minimal sun exposure and clients should be instructed to avoid sunlight and to use sunscreen (A). (B and D) are not related to tetracycline HCL (Achromycin V) therapy. (C) should be avoided because dairy products interfere with the absorption of tetracyclines. Awarded 1.0 points out of 1.0 possible points.

59. The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider?

ID: 310955065


A.

Pale bluish coloration of the toes. Correct

B.

Skin is warm and dry to the touch.

C.

Toes are wiggled upon command.

D.

Capillary refill less than 3 seconds.

Russell's skin traction is used for fractures of the femur in young children and adolescents whose growth plates remain open and is applied to the lower leg using moleskin and elastic wrap bandages, which can compress the peroneal nerve and arteries that supply the foot.  Assessment of adequare circulation, movement, and sensation of the toes and skin distal to the application is made to identify compromised blood flow, so cyanosis (A) should be reported immediately. (B, C and D) are normal findings. Awarded 1.0 points out of 1.0 possible points.

60. The clinic nurse is taking the history for a new 6­month­old client. The mother reports that ID: 310946652 she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain? A. 

Type of reaction to loud noises.  Correct

B.

Any surgeries on the ears since birth.

C.

Drainage from the infant's ears.

D.

Number of ear infections since birth.

Ototoxicity diminishes hearing acuity and causes symptoms of tinnitus and vertigo in older children who can express subjective symptoms, so assessing an infant's reaction to loud noises (A) helps to determine an infant's risk for a hearing deficit related to a history of the mother taking an ototoxic drug, such as aspirin, while pregnant. (B, C, and D) are not associated with exposure to aspirin in utero. Awarded 1.0 points out of 1.0 possible points.

ID: 311023669 61. At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure reading was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night. What action should the nurse take first?

A.

Give the client her 9 a.m. prescription for an oral diuretic early.


B.

Administer PRN prescription of nifedipine (Procardia) sublingually.  Correct

C.

Notify the healthcare provider and inform the nursing supervisor of the client's condition.

D.

Attempt to calm the client and retake the blood pressure in thirty minutes.  Incorrect

Sublingual Procardia (B) lowers blood pressure very quickly, and this should be done first. (A) may also be done, but oral diuretics do not work as rapidly as the sublingual antihypertensive. When notifying the healthcare provider, the first thing he/she will want to know is if the PRN antihypertensive has been administered (C). (D) does not consider the seriousness of this finding. The nurse should stay with the client until the blood pressure is reduced. Awarded 0.0 points out of 1.0 possible points.

62. A full term infant is admitted to the newborn nursery. After careful assessment, the nurse ID: 310949406 suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit? A. 

Choking, coughing, and cyanosis. Correct

B.

Projectile vomiting and cyanosis.

C.

Apneic spells and grunting.

D.

Scaphoid abdomen and anorexia.

(A) includes the "3 Cs" of esophageal atresia caused by the overflow of secretions into the trachea. Projectile vomiting (B) is characteristic of pyloric stenosis in the infant. Apneic spells often occur with prematurity or sepsis, and grunting (C) is a sign of respiratory distress. A scaphoid abdomen (D) is characteristic of diaphragmatic hernia. Awarded 1.0 points out of 1.0 possible points.

63. Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate? A. 

A trial of adrenocorticotrophic hormone injections.

B.

Frequent stimulation of the cremasteric reflex.

ID: 310946678


C.

A trial of human chorionic gonadotrophic hormone.  Correct

D.

Frequent warm baths to gently dilate the scrotal area.  Incorrect

A trial of HCG (human chorionic gonadotrophic hormone) (C) may aid in testicular descent, but does not replace surgical repair for true undescended testes. Undescended testes (cryptorchidism) may be found in the inguinal canal due to exaggerated cremasteric reflex. (A) is not indicated. Stimulation of the cremasteric reflex causes the testes to ascend rather than descend in the scrotum (B). (D) may relax the cremasteric muscle, but may not cause the testes to descend. Awarded 0.0 points out of 1.0 possible points.

64. Which growth and development characteristic should the nurse consider when monitoring ID: 311041552 the effects of a topical medication for an infant? A. 

A lower sensitivity reactions to skin irritants.

B.

A thin stratum corneum that increases topical absorption.  Correct

C.

A smaller percentage of muscle mass.

D.

A greater body surface area that requires larger dosages.

Infants have a thin outer skin layer (stratum corneum), so the nurse should monitor the infant for a prompt onset and response to the application of topical medication (B). (A, C, and D) are unrelated to topical medication administration. Awarded 1.0 points out of 1.0 possible points.

ID: 310947636 65. The mother of a 4­year­old child asks the nurse what she can do to help her other children cope with their sibling’s repeated hospitalizations. Which is the best response that the nurse should offer?

A.

Inform the parent that the child is too young to visit the hospital.

B.

Suggest that the child visit a grandmother until the sibling returns home.

C.

Ask the mother if the child asks when the sibling will be discharged.

D.

Encourage the mother to have the children visit the hospitalized sibling. Correct

Needs of a sibling will be better met with factual information and contact with the ill child, so


sibling visitation should be encouraged (D). Parents are experts on their children and should determine when their children are old enough to visit (A) in the hospital. Separation from family and home (B) may intensify fear and anxiety. Children may have difficulty expressing questions (C), so the support of parents and other caregivers are needed to help alleviate their fears. Awarded 1.0 points out of 1.0 possible points.

66. The nurse is planning the care of a 2­year­old with severe eczema on the face, neck, and ID: 310945282 scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis? A. 

Obtain gloves for the child's hands.

B.

Apply finger cots on the child's fingers. Incorrect

C.

Place elbow restraints on the child's arms. Correct

D.

Apply soft restraints to the child's wrists.

Elbow restraints (C) prevent arm flexion and scratching of involved areas, but do not inhibit use of the hands for play activities. (A and B) can be easily removed by the child and would restrict hand movement. (D) would be ineffective in preventing the child from scratching because the upper body could be moved within reach of restrained hands, and would also create the greatest restriction of hand movement. Awarded 0.0 points out of 1.0 possible points.

67. When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it A. 

increases salivation.

B.

increases the respiratory rate.

C.

leads to vomiting.

D.

stresses the suture line.  Correct

ID: 310953497

Prevention of stress on the lip suture line (D) is essential for optimum healing and the cosmetic


appearance of a cleft lip repair. Although crying also causes (A, B, and C), these conditions do not create a problem for the child with a cleft lip repair. Awarded 1.0 points out of 1.0 possible points.

68. A 3­week­old newborn is brought to the clinic for follow­up after a home birth. The mother ID: 310989347 reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that apply.) A. 

Monitor the the infant's weight and number of wet diapers per day.  Correct

B.

Increase the infant's intake per feeding by 1 to 2 ounces per week.  Correct

C.

Mix the dose of prophylactic antibiotic in a full bottle of formula.

D.

Allow the infant to rest and refeed on demand or every 2 hours.  Correct

E.

Use a softer nipple or increase the size of the nipple opening.  Correct

Correct responses are (A, B, D, and E). Neonates who have VSD may fatigue quickly during feeding and ingest inadequate amounts. They should be monitored for weight gain and at least 6 wet diapers per day (A). A one­month old infant should ingest 2 to 4 ounces of formula per feeding and progress to about 30 ounces per day by 4­months of age (B). Due to fatigue, the infant should rest, but feed at least every 2 hours to ensure adequate intake (D). A softer (preemie) nipple or a larger slit in the nipple (E) helps to reduce the sucking effort and energy expenditure, thus allowing the infant to ingest more with less effort. Antibiotic prophylaxis is recommended for infants with VSDs, but should not be mixed in a bottle of formula (C) because it is difficult to ensure that the total dose is consumed. Awarded 0.0 points out of 1.0 possible points.

69. The nurse is having difficulty communicating with a hospitalized 6­year­old child. Which approach by the nurse is most helpful in establishing communication? A. 

Engage the child through drawing pictures.  Correct

B.

Suggest that the parent read a book to the child.

ID: 310944556


C.

Provide paper and pencil for the child to keep a diary.

D.

Ask the parent if the child is always uncommunicative.

Drawing pictures (A) is a valuable form of non­verbal communication. As the nurse and child look at the drawings, a verbal story can be told that projects the child's thinking. (B) may distract the child, but does not establish communication with the nurse. (C) is useful for an older child who is able to write. (D) is important, but engaging the child is more effective in establishing communication patterns. Awarded 1.0 points out of 1.0 possible points.

ID: 310993943 70. During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. What action should the nurse take next?

A.

No action required, as this is an expected finding for a school­aged child.  Incorrect

B.

Ask the child if he/she has had a cold, runny nose, or any ear pain lately.  Correct

C.

D.

Send a note home advising the parents to have the child evaluated by a healthcare provider as soon as possible.

Call the parents and have them take the child home from school for the rest of the day.

More information is needed to interpret these findings (B). The tympanic membrane is normally pearly gray, not bulging, and moves when the client blows against resistance or a small puff of air is blown into the ear canal. Since this child's findings are not completely normal, further assessment of history and related signs and symptoms is indicated for accurate interpretation of the findings. (A, C, and D) are inappropriate actions based on the data obtained from the otoscope examination. Awarded 0.0 points out of 1.0 possible points.

ID: 310949404 71. A 15­year­old girl tells the school nurse that all of her friends have started their periods and she feels abnormal because she has not. Which response is best for the nurse provide?

A.

Refer the adolescent to the healthcare provider for a pregnancy screen.


B.

Schedule a conference with her parents to recommend hormone therapy.

C.

Explain that menarche varies and occurs between the ages of 12 and 18 years. Correct

D.

Suggest that she use diversions to help her not worry about delayed menarche.

The nurse should provide a factual and reassuring explanation that focuses on individual variations of menarche, which can normally occur between 12 and 18 years of age (C). (A) does not address the adolescent's concern and is judgmental. Menarche is influenced by hereditary, general health, and nutritional status, so (B) is not indicated. (D) dismisses the adolescent's concerns and does not offer factual information. Awarded 1.0 points out of 1.0 possible points.

72. The nurse is teaching the parents of a 5­year­old with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand? A. 

Perform postural drainage before starting aerosol therapy.

B.

Give respiratory treatments when the child is coughing a lot.

C.

Administer aerosol therapy followed by postural drainage before meals.  Correct

D.

Ensure respiratory therapy is done daily during any respiratory infection.

ID: 310978647

Postural drainage for a child with cystic fibrosis is most effective when performed after nebulization and before meals (C) or at least 1 hour after eating to prevent nausea and vomiting. Postural drainage uses gravity to promote mucous removal after nebulization (A) treatments which open the airways. Pulmonary toileting or respiratory treatments should be given 3 to 4 times daily, not episodically (B and D). Awarded 1.0 points out of 1.0 possible points.

73. The nurse observes a 4­year­old boy in a daycare setting. Which behavior would the nurse consider normal for this child? A. 

Has a temper tantrum when told he must share his toys.  Incorrect

ID: 311028909


B.

Plays by himself most of the day.

C.

Demonstrates aggressiveness by boasting when telling a story.  Correct

D.

Begins to cry and is fearful when separated from his parents.

Four­year­old children are aggressive in their behavior and enjoy "tale telling" (C). Behaviors in (A and D) are typical of toddlers. The play of a preschooler is cooperative, so playing alone (B) is not typical. Awarded 0.0 points out of 1.0 possible points.

74. Preoperative nursing care for a child with Wilms' tumor should include which intervention? A. 

Gently percuss the abdomen for evidence of trapped air.

B.

Observe the abdomen for any noticeable discolorations.  Incorrect

C.

Apply cold compresses to the abdomen to reduce edema.

D.

Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN."  Correct

ID: 311008997

Prevention of abdominal palpation (D) minimizes the risk of rupturing the encapsulated tumor and subsequent metastasis. (A) is unnecessary, and this action could traumatize the tumor in the same manner as palpation. (B and C) are incorrect since the abdomen is not discolored and cold compresses are not indicated. Awarded 0.0 points out of 1.0 possible points.

ID: 310944586 75. The nurse is developing a plan of care for a 3­year­old who is scheduled for a cardiac catheterization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement?

A. B.  C. 

Reassure the parents that 3­year­olds are cooperative and therefore are less likely to be anxious.  Obtain a video film of a cardiac catheterization to show to the child prior to the procedure.  Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there.  Correct


D.

Obtain a cardiac catheter and demonstrate the procedure by pretending to put the catheter in a doll or stuffed animal.

Familiarizing the child and mother with the department (C) will help decrease anxiety of the child and mother (who may have more anxiety than the child). Three is a difficult age to undergo a procedure that requires cooperation. Restraints and possibly sedation may be required (A). At three, the child is too young to understand why this must be done, and (B) is not indicated. (D) is also not indicated because it is likely to be interpreted as painful. Awarded 1.0 points out of 1.0 possible points.

76. A 3­month­old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder? A. 

Nystatin (Mycostatin).  Correct

B.

Nitrofurantoin (Macrodantin).

C.

Norfloxacin (Noroxin).  Incorrect

D.

Neomycin sulfate (Mycifradin).

ID: 310972743

Nystatin (Mycostatin) (A) is an antifungal drug that is effective in treating thrush, an oral fungal infection. (B, C, and D) are not indicated for the treatment of oral thrush. Awarded 0.0 points out of 1.0 possible points.

ID: 311013613 77. The nurse is assigning care for a 4­year­old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that

A.

only an RN should be assigned to monitor this child's temperature.

B.

a tympanic measurement of temperature will provide the most accurate reading. Correct

C.

the licensed practical nurse should be instructed to obtain rectal temperatures on this child.

D.

the healthcare provider should be asked to prescribe the method for measurement of the child's temperatures.


(B) A tympanic membrane sensor is an excellent site because both the eardrum and hypothalamus (temperature­regulating center) are perfused by the same circulation. The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative otitis media does not effect measurement. RULE OF THUMB: for management­­sterile procedures should be assigned to licensed personnel. Management skills will be tested on the NCLEX! An RN is not required (A). Rectal temperature measurement (C) is less accurate because of the possibility of stool in the rectum. (D) is unnecessary. Awarded 1.0 points out of 1.0 possible points.

78. Which behavior would the nurse expect a 2­year­old child to exhibit? A. 

Build a house with blocks.

B.

Ride a tricycle.

C.

Display possessiveness of toys.  Correct

D.

Look at a picture book for 15 minutes.

ID: 311018755

2­year­old children are egocentric and unable to share with other children. (A, B, and D) are behaviors of a preschooler. Awarded 1.0 points out of 1.0 possible points.

79. A child is rescued from a burning house and brought to the emergency room with partial­ thickness burns on the face and chest. Which action should the nurse implemented first? A. 

Insert an indwelling urinary catheter.

B.

Administer IV pain medication.

C.

Collect blood specimen for laboratory studies.

D.

Assess the child's respiratory status. Correct

ID: 311041554

Assessing the airway and the respiratory status is the highest priority (D) since burns to the face and chest place the child at risk for smoke inhalation injury and compromised airway. (A, B, and C) are implemented after (D). Awarded 1.0 points out of 1.0 possible points.


ID: 310957405 80. The mother of a preschool­aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." After reminding the mother to check the label of all over­the­counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question?

A.

If the child's tongue darkens, discontinue the Pepto Bismol immediately.

B.

Do not give if the child has chickenpox, the flu, or any other viral illness.  Correct

C.

Avoid the use of Pepto Bismol until the child is at least 16 years old.  Incorrect

D.

Pepto Bismol may cause a rebound hyperacidity, worsening the "tummy ache."

Pepto Bismol contains aspirin and there is the potential of Reye's syndrome (B). (A) is a common effect of Pepto Bismol and does not warrant discontinuation. Pepto Bismol can be used by children (C). Pepto Bismol does not cause rebound hyperacidity (D), which is a complication of antacids containing calcium. Awarded 0.0 points out of 1.0 possible points.

81. A six­month­old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child? A. 

Keep restraints on at all times.

B.

Remove restraints one at a time and provide range of motion exercises.  Correct

C.

Remove all restraints simultaneously and provide play activities.

D.

Renew the healthcare provider's prescription for restraints every 72 hours.

ID: 311028901

Removing restraints one at a time (B) is safer than removing all of them at once (C). The child needs to exercise and should not be kept in restraints at all times (A). The renewal of the healthcare provider's prescription varies with hospitals (D), and it does not really answer the question. Awarded 1.0 points out of 1.0 possible points.


ID: 310945250 82. The nurse assigning care for a 5­year­old child with otitis media is concerned about the child's increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift?

A.

An RN should be assigned to take temperatures frequently.

B.

Tympanic and oral temperatures are equally accurate.  Correct

C.

The PN should take rectal temperatures on this child.

D.

The pediatrician should decide how to assess the temperature.

A tympanic membrane sensor approximates core temperatures because the hypothalamus and eardrum are perfused by the same circulation. Tympanic readings obtained using proper technique correlated moderately to strongly with oral temperatures in recent research studies (B). The sensor is unaffected by cerumen or the presence of suppurative or unsuppurative otitis media. An RN is not required to take the child's temperature, but must assess readings received from assistive personnel (A). Although rectal readings are highly accurate (C), such an invasive procedure is unnecessary. (D) is not required. Awarded 1.0 points out of 1.0 possible points.

83. The nurse is giving a liquid iron preparation to a 3­year­old child. Which technique should the nurse implement to engage the child's cooperation? A. 

Use a colorful straw.  Correct

B.

Mix the medication in water.

C.

Administer the medication using an oral syringe.

D.

Ask the pharmacy to provide an enteric tablet.

ID: 311041546

A liquid iron preparation administered through a straw may help the child to accept the medication since young children consider drinking from a colorful straw fun (A). (B) may cause staining of the child's teeth. (C) is often used if the child is uncooperative. (D) is ineffective and should be requested from the healthcare provider. Awarded 1.0 points out of 1.0 possible points.

84. Which action by the nurse is most helpful in communicating with a preschool­aged child?

ID: 310972767


A.

Speak clearly and directly to the child.

B.

Use a doll to play and communicate. Correct

C.

Approach when a parent is not present.

D.

Play a board game with the child.

Communicating through play with a doll (B) or other toy gives time for the child to feel comfortable with a stranger. (A) may frighten some children and is usually not as effective as (B). To provide security and comfort, preschool­aged children should be approached when a parent is present, not (C). (D) is too advanced for a preschooler.


TOPICS

PEDIATRIC HESI REVIEW

• PEDIATRIC HEALTH ASSESSMENT • GROWTH & DEVELOPMENT – INFANT – TODDLER – PRESCHOOL – SCHOOL AGE – ADOLESCENT

PEDIATRIC HEALTH ASSESSMENT

PEDIATRIC HEALTH ASSESSMENT

• General considerations for the child: – Introduce self & allow child some warm-up time – Maintain eye contact, bend to child’s level – Child is perceptive of caregiver’s nonverbal communication – Respect child’s responses – Respect need for privacy as appropriate for age – Incorporate play into assessment as appropriate – Use language appropriate to cognitive level

TOPICS • DISORDERS OF CHILDREN – RESPIRATORY DISORDERS – GASTROINTESTINAL DISORDERS – GENITOURINARY TRACT DISORDERS – NEUROLOGIC DISORDERS – NEUROMUSCULAR, MUSCULAR and ARTICULAR DISORDERS – HEMATOLOGIC DISORDERS – CARDIOVASCULAR DISORDERS – CANCER

PEDIATRIC HEALTH ASSESSMENT • General considerations for the family: – Choose quiet setting for assessment – Ask open-ended question to elicit responses – Listen attentively & provide appropriate feedback – Encourage parents to express concerns & ask questions – Communicate importance of parent’s role in conjunction with health team

Pediatric HESI Review 1


DEVELOPMENTAL AGE PERIODS

DEVELOPMENTAL AGE PERIODS

DEVELOPMENTAL AGE PERIODS

• Prenatal: Conception to birth • Infancy: Birth to 12 or 18 months

• • • • •

– Neonatal - Birth to 28 days

• Early Childhood: 1 - 6 years – Toddler: – Preschool:

1 - 3 years 3 - 6 years

Infant Toddler Preschool School-age Adolescent

• Middle Childhood: 6 - 11 years – School age

• Later Childhood: 11 - 19 years – Prepubertal: – Adolescence:

INFANT GROWTH & DEVELOPMENT

10 - 13 years 13 - 18 years

PHYSICAL GROWTH & DEVELOPMENT

PHYSICAL GROWTH & DEVELOPMENT

• General characteristics:

• Gr. & Dev. Milestones:

– Best health indicator is steady & increasing ht., wt., & head & chest circumference – Ht. increases 50% over birth length by 12 mo. – Wt. tripled by 12 mo. – Head & chest circumference equalize during 1st. yr. – Posterior fontanel closes by 2mo. – Anterior fontanel closes by 18 mo.

– 1-2 mo. smiles – 2 mo. lifts head from prone position & briefly holds it erect – 3 mo. vocalizes in response to voices – 4 mo. head control – 4 mo. purposefully grasps objects – 4-5 mo. rolls from abdomen to back – 6-7 mo. sits – 6-7 mo. anything grasped goes into mouth – 6-7 mo. rolls from back to abdomen

Pediatric HESI Review 2


PHYSICAL GROWTH & DEVELOPMENT

DEVELOPMENTAL THEORIES

– 9 mo. crawls rapidly, keeping belly off floor – 9 mo. moves from crawling to sitting position – 9 mo. pulls up – 9 mo. pincer grasp rather than palmar grasp – 10. mo walks with support – 11 mo. stands alone – 12 mo. walks alone

• Psychosocial development: Erikson

DEVELOPMENTAL THEORIES • Cognitive development: Piaget – Sensorimotor stage from birth to 18 mo. – Dev. progresses from reflexive activity to purposeful acts – Dev. of intellect & knowledge of environment gained through the senses – At completion of stage, infant achieves a sense of object permanence • Retains a mental image of the absent object • Sees self as separate from others

– Psychosocial crisis is TRUST vs MISTRUST – Significant other is “maternal” person – Quality of caregiver-child relationship is crucial factor – Attentive care shows that needs will be met promptly & that life is predictable. – Consistent delayed needs gratification fosters uncertainty – Comfort commonly obtained from a security object

SOCIAL DEVELOPMENT • Language: – Crying 1st means of verbal communication – Throaty vocalizations by 5 wks. – By 8 mo. combined syllables (mama, dada – by 1 yr. several short words with meaning – Soothing tone can be comforting

• Play: – Facilitates learning – Learns about environment through senses of touch, taste, hearing, smell, & sight

DEVELOPMENTAL THEORIES • Psychosexual development: Freud – Oral stage of dev. • Erogenous zone is mouth, lips, tongue, & teeth

– Sexual activity takes form of: • Sucking, swallowing, chewing, & biting

– Infant meets world by: • Crying, tasting, sucking, eating, & early vocalization • Grasping & touching to explore tactile variations in the environment

SOCIAL DEVELOPMENT – Dev. motor skills through manipulating toys – Play is basically solitary

• Socialization: – Attachment to significant other begins @ birth & becomes increasingly evident after 6 mo – Stranger anxiety begins around 6 mo. – Caregiver’s cuddling & warmth can help ease fears – Discipline & setting limits begins with negative voice, stern eye contact, or timeout

Pediatric HESI Review 3


NUTRITION & FEEDING

NUTRITION & FEEDING

NUTRITION & FEEDING

• Breast milk has following advantages over cow’s milk:

• Ready to use formula should be refrigerated once open & discarded after 24 hr. • Whole milk should not be given before 12 mo. • By 6 mo. infant ready to have solid foods introduced

• Finger foods between 8-10 mo.

– Immunologic & antibacterial components not in cow’s milk – Less risk of allergies – More easily digested, convenient, & economical

• Ideally, weaning from breast or bottle begins @ age 6 mo • Adequate fluid intake reflected by: – At least 6 wet diapers in 24 hr.

• Never microwave breast milk

IMMUNIZATIONS • Generally follow an age-based schedule • Contraindications include: – Severe febrile illness – Immunodeficiency – Known allergy to the vaccine

• See Nursing Pediatric Seminar

– Introduced progressively and one at a time – Start with cereal with iron (wheat & mixed last) – Next fruits, then veggies, and last meats – Juices after 6 mo.

INJURY PREVENTION • See Nursing 2504 Pediatric Seminar PowerPoint Notes

– Avoid hot dogs, nuts, grapes, carrots, popcorn, peanuts, & hard round candies for fear of choking

• Common food allergies: – Cow’s milk,egg, soy products, peanut, chocolate, corn & wheat

• Common clinical manifestations of food allergies: – Abd. pain, diarrhea, nasal congestion, cough, wheezing, vomiting & rashes

HOSPITALIZATION • Major stressor is Separation Anxiety – Seen between 6 mo & 30 mo – Traumatic for both infant and parent

• Major issue is that of stimulation & regular routine – Without appropriate stimulation, infant exhibits failure to thrive – Experiences mainly painful stimuli and interruption of sleeping & eating routine

Pediatric HESI Review 4


HOSPITALIZATION

SELECTED HEALTH PROBLEMS

• Guidelines for intervention: – Human contact when parent not available – Stimulation through soothing voices, music, being rocked, etc. – Reduce environmental stimulation

• Fever • Iron Deficiency Anemia

• Associated clinical findings provide important indications of seriousness

– Ensure toys safe, clean & large enough so not to be ingested – Assure parents of their importance & abilities as caregivers – Encourage favorite comfort items from home

• Comfort measures: – External cooling • • • •

Remove blankets & clothing Reduction of room temperature Cooling blankets Tepid baths with lukewarm water – Avoid rubbing alcohol as can result in too rapid cooling & chilling

– Antipyretics • Acetaminophen & NSAIDS • Never ASA R/T Reye’s syndrome

– Maintain adequate fluid intake

• Defined as a body temp > than 38.0 C (100.4 F) rectally or 37.8 C (100. F) orally • Common causes in infancy: – UTI – Respiratory tract infections – Otitis media – Viral infections

• Turn off TV • Dim lights • One toy or activity @ time

FEVER

FEVER

– Active with fever of 104.F generally of less concern than lethargic with fever of 102 F

FEBRILE SEIZURES • Defined as transient disorders of children that occur in association with fever • Fever defined as a body temp. > 38 C (100.4 F) rectally or > 37.8 C (100 F) orally – Commonly do not recur after initial occurrence (60%) – Others have 2-3 over the years stopping by age 5 or 6 – Average body temp at which sz occurs is 40C (104F) – Boys more than girls – ↑ susceptibility in families

CARE DURING SEIZURE • Turn child onto side • Do not try to restrain • Do not put anything into the mouth • Allow child to drool – May use a suction bulb to remove saliva or fluids

• Call Dr if any of following occurs: – Sz lasts > 3 min – Another sz occurs – Child’s neck is stiff – Child delirious or difficult to awaken after sz

Pediatric HESI Review 5


IRON DEFICIENCY ANEMIA • Results from inadequate supplies of iron to synthesize hemoglobin adequately • Etiology: – Inadequate dietary intake of iron – Insufficient iron stores

• Pathology: – Full-term's iron stores adequate for 1st. 5-6 mo. – Premie or infant from multiple birth, iron stores adequate for only 2-3 mo. – Occurs around 9 -24 mo.

• • • • •

IRON DEFICIENCY ANEMIA – Usually related to lg. intake of milk & foods that do not contain supplemental iron

• Assessment findings: – Pallor – Tachycardia – Lethargy – Irritability – Hb. < 9 g/dL – ↑ susceptibility to infection – Impaired cognitive ability ( a longterm consequence)

IRON DEFICIENCY ANEMIA • Long-term therapy: – ↑ intake of iron & ↓ consumption of cow’s milk

• Teaching Guidelines: – Provide iron-fortified formula if < 12 mo. – Limit cow’s milk to < 24 oz/d if > 12 mo. – ↑ intake of iron-rich foods – Administer iron in 3 divided doses between meals • Give with vitamin C-rich fluids • administer with dropper placed @ back of mouth, away from teeth • Expect black, tarry stools

OTHER SELECTED HEALTH PROBLEMS

PHYSICAL GROWTH & DEVELOPMENT

Sids Shaken Baby Syndrome Meningitis Atopic Dermatitis (Eczema) Seizures

• General characteristics:

• Refer to RNSG 2504 Pediatric PowerPoint Notes

TODDLER GROWTH & DEVELOPMENT

– Physical growth & weight slower – Characteristic protruding abdomen results from underdeveloped abdominal muscles – Bow-legged since legs bear the wt. of the relatively lg. trunk – Anterior fontanel closes between 12-18 mo. – Fine motor skills include: • Undressing • Drawing simple lines • Building simple things

Pediatric HESI Review 6


PHYSICAL GROWTH & DEVELOPMENT • Gr. & Dev. Milestones: – 12-15 mo. walks – 15 mo. climbs stairs – 18 mo. climbs – 2 yrs. runs – 3 yrs. walks backward & hops on 1 foot – 3 yrs. throws a large ball – 3 yrs. puts on simple clothes – 3 yrs. walks on tiptoe – 3 yrs. achieves fairly good bowel & bladder control

DEVELOPMENTAL THEORIES • Psychosexual development: Freud – Anal stage of dev. • Erogenous zone is anus & buttocks • Sexual activity centers on expulsion & retention of body waste

– Conflict between “holding on” & “letting go” gradually resolves as bowel training progresses

DEVELOPMENTAL THEORIES • Psychosocial development: Erikson – Psychosocial crisis is Autonomy vs Doubt & Shame – Significant other is the “paternal” person – Psychosocial theme is “To hold on; to let go” – Ready to give up dependence to assert his budding sense of control, independence & autonomy – Often continues to seek a familiar security object during times of stress

DEVELOPMENTAL THEORIES • Cognitive development: Piaget – Sensorimotor phase between 12 & 24 mo. – Preoperational phase from about 2 yrs - 4 yrs. – Egocentric thinking – Focuses on the here & now – Absolute thinking - perceives things as good or bad, right or wrong – Increased use of language & dramatic play

DEVELOPMENTAL THEORIES • Erikson, cont: – Begins to master: • • • • •

Differentiation of self from others Separation from parents Control of bodily functions Communication with words Acquisition of socially acceptable behavior • Egocentric interactions with others

– Negativism - often says “no”, even when means “yes” to assert independence – Ritualism helps child venture out & away from safety of parents – Has temper tantrums

DEVELOPMENTAL THEORIES • Moral development: Kohlberg – Makes judgments on basis of avoiding punishment or obtaining a reward – Discipline patterns affect moral development • Physical punishment & withholding privileges tends to give toddler a negative view of morals • Withdrawing love & affections as punishment leads to feeling of guild • Appropriate disciplinary actions include providing simple explanations, praising appropriate behavior, & using distraction when the toddler is heading for danger

Pediatric HESI Review 7


SOCIAL DEVELOPMENT • Language: – Begins to use short sentences – Has a vocabulary of about 300 words by 2 yrs – Tends to ask many “what” questions

• Play: – Is the major socializing medium – Typically parallel – Short attention span causes him to change toys often – Continues to separating from parents

SOCIAL DEVELOPMENT • Guidelines for intervention: – Encourage caregivers to assure child of their return when need to leave & to follow through • Leave a familiar object belonging to them to assure a return

– Medical play kits helpful – Provide for activity in a safe & supportive environment – Use simple explanations to allay fears

SOCIAL DEVELOPMENT • Samples of safe toys to provide opportunities for exploring the environment: – Play dough – Blocks – Housekeeping toys – Containers – Toy telephone – Wooden puzzles – Cloth books – Simple musical instruments

NUTRITION & FEEDING • Most toddlers prefer to feed themselves • At risk for aspiration of small foods not easily chewed • Most experience “food jags” • Most experience episodes of physiologic anorexia R/T alternating periods of fast & slow growth • Feeding suggestions:

SOCIAL DEVELOPMENT • Common Fears: – Loss of parents - Separation Anxiety – Stranger anxiety – Large animals – Loud noises – Going to sleep

• Effects of Hospitalization – Primary issue = Separation – May interpret being in hospital or painful procedures a punishment for something he did “bad” – Regressive behaviors

NUTRITION & FEEDING – Prepare foods attractively – Limit concentrated sweets & empty calories – Set child @ high chair @ family table – Allow sufficient time to eat, but remove food when toddler begins playing with it – Avoid using food as a reward or punishment

– Provide basic 4 food groups in small portions – Offer limited number of foods @ time

Pediatric HESI Review 8


SELECTED HEALTH PROBLEMS

PHYSICAL GROWTH & DEVELOPMENT

• Lead Poisoning

• Refer to RNSG 2504 Pediatric PowerPoint Notes

• General characteristics:

PRESCHOOL GROWTH & DEVELOPMENT

– Coordination & muscle strength ↑ rapidly – Handedness clearly established by 4 yrs. – Appears taller & thinner – Grows 2.5 - 3 inches /yr. – Gains 5 lb/yr – Can use scissors successfully & tie shoelaces – 20 teeth present • By 5 yrs may begin to lose deciduous teeth • By 5 yrs may have first permanent teeth (molars)

DEVELOPMENTAL THEORIES • Psychosocial development: Erikson – Psychosocial crisis of Initiative vs Guilt – Significant other is the family – Psychosocial theme is “To make, to make like, to play” – Dev. a conscience & guilty feelings – Is energetic, enthusiastic, & has an active imagination – Uses simple reasoning & can tolerate longer periods of delayed gratification

DEVELOPMENTAL THEORIES • Psychosexual development: Freud • Phallic stage of development • Sexual pleasure centers on the genitalia & masturbation • Oedipal stage occurs, marked by jealousy & rivalry toward same-sex parent & love of the opposite-sex parent – By late preschool period, this typically resolves & a strong identification with the same-sex parent

DEVELOPMENTAL THEORIES • Cognitive development: Piaget – Still in Preoperational thought • Forms concepts not as complete or logical as adult’s • Makes simple classifications • Reasons from specific to specific

– Thinking remains egocentric, becomes magical – Judgements dominated by perception & are illogical – Magical thinking – Animism • Perception that all objects have life & feeling

Pediatric HESI Review 9


DEVELOPMENTAL THEORIES • Moral development: Kohlberg – Conscience emerges – Obey rules out of self-interest – An “eye for an eye” guides their behavior – Begins to use self-control & tries to be “good” to avoid feelings of guilt – Little understandings of reasons for rules • Decides whether to break rule depending on punishment

– Family’s religious beliefs & customs are important & can be deeply meaningful & comforting

SOCIAL DEVELOPMENT • Common Fears: – Has more fears than @ any other time – The dark – Being left alone, especially @ bedtime – Animals, especially big dogs – Ghosts – Body mutilation – Pain

SOCIAL DEVELOPMENT • Language: – Talks incessantly – Engages in long monologues, even if no one is listening – Asks many “why” questions – Tend to boast & exaggerate – Enjoy rhymes – By 5 yrs. speak in sentences of adult length & use all parts of speech – May stutter as ideas come faster than speech • Usually disappears spontaneously if child not pressured

SOCIAL DEVELOPMENT • Effects of hospitalization: – Primary issue is body mutilation • May think he caused illness or injury because he way “bad” • Feels loss of control over usual routines • May exhibit regressive behaviors

– Fears injury & pain – Afraid of intrusive procedures & have a literal interpretation of words • Often imagine things are worse than they are

SOCIAL DEVELOPMENT • Play: – Big task is learning to relate with age-mates – Play mainly associative – Understands concept of sharing – Needs regular socialization with age-mates – May have an imaginary friend – Play & activity suggestions: • Dress-up clothes • Housekeeping toys • Dolls & other toys that encourage pretending • Bikes & climbing toys for big muscles • Paper & crayons for creativity

SOCIAL DEVELOPMENT • Guidelines for intervention: – Reassure not to blame for hospitalization – Preparation for any medical procedure • Do not overload with too much info

– Medical play – Encourage expressive play • Provide for playroom & toys in room

– Be consistent – Involve parents in care – Allow for regressive behavior – Encourage independence in ADL – Watch medical vocabulary • “Fix” instead of “take out”

Pediatric HESI Review 10


SELECTED HEALTH PROBLEMS • Head Lice • Pin worms • ADHD (Attention-Deficit Hyperactivity Disorder) • Communicable Diseases • Impetigo

PHYSICAL GROWTH & DEVELOPMENT • General characteristics:

SCHOOL-AGE GROWTH & DEVELOPMENT

• Muscles still immature & can be injured from overuse

– Lungs & alveoli fully mature, so ↓ resp. infections – Eustachian tube more downward so ↓ otitis media – All 20 deciduous teeth lost & replaced by 28 of 32 permanent teeth

• Refer to RNSG 2504 Pediatric PowerPoint Notes

PHYSICAL GROWTH & DEVELOPMENT – Puberty begins • Sex education a must – Responsible sexuality & dangers – such as Aids, pregnancy, STDs

– Girls often grow faster than boys – Appears thinner & more graceful than preschoolers – Musculoskeletal growth leads to greater coordination & strength

DEVELOPMENTAL THEORIES • Psychosocial development: Erikson – Psychosocial crisis of industry vs inferiority – Significant others expand to include school & instructive adults – Sense of industry grows out of a desire for real achievement – Engages in tasks & activities he can carry out – Learns rules & how to compete with others – Play is cooperative – School activities important

DEVELOPMENTAL THEORIES • Psychosexual development: Freud – Latency period, extending from about age 5 through 12, represents a stage of relative sexual indifference before puberty & adolescence – Dev. of self-esteem closely linked with a dev. sense of industry in gaining a concept of one’s value & worth

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DEVELOPMENTAL THEORIES • Cognitive development: Piaget – Stage of concrete operations – Marked by inductive reasoning, logical operations – Can distinguish fact from fantasy – Concept of time becomes clear – Does not deal with abstractions or socialized thinking – Asks questions – Collecting & sorting objects (eg., baseball cards, Beanie Babies)

SOCIAL DEVELOPMENT • Play: – Becomes more competitive & complex – Team sports – Secret clubs, gangs – Rules & rituals important – Coordination & motor skills improve as child given opportunity to practice – Enjoy active sports & games as well as crafts & fine motor activities – Enjoy activities requiring balance & strength

DEVELOPMENTAL THEORIES

SOCIAL DEVELOPMENT

• Moral development: Kohlberg

• Peer relationships gain in importance • Group activities, including team sports consume much time & energy • More knowledgeable about body & social dev. centers on body & its capabilities • Formal & informal clubs • School very important; favorite teachers serve as role models

– Increased desire to please others – Observes & to some extent, internalizes standards of others – Wants to be considered “good” by those whose opinions matter to him

SOCIAL DEVELOPMENT • Common Fears: – Failure @ school – Bullies – Intimidating teachers

• Effects of Hospitalization: – Common fears include: • • • •

Disability & possibly death Unknown events & procedures Loss of control & independence Interruption of daily routine

– Primary issue is control – Loss of contact with peers big issue – School routines interrupted

SOCIAL DEVELOPMENT • Guidelines for intervention: – Encourage to talk about interests – Allow to help with self care & treatments – Give opportunities to make choices whenever possible – Still a need for comfort from caregivers & parents – Reassure that crying is OK – Peer interaction important • Cards, visits, etc

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SELECTED HEALTH PROBLEMS • Appendicitis • Rheumatic fever

• Refer to RNSG 2504 Pediatric PowerPoint Notes

DEVELOPMENTAL THEORIES • Psychosocial development: Erikson – Psychosocial crisis is identity vs role confusion – Significant others are the peers – Energy focused within the self, & the adol. is described as egocentric or self-absorbed – Try on new roles in transition & experiment with the environment until finding a role that fits – Lack of commitment R/T changing interests

PHYSICAL GROWTH & DEVELOPMENT • General characteristics:

ADOLESCENT GROWTH & DEVELOPMENT

– Rapid rate of physical – Encompasses puberty • Girls begin between ages 8-14 yrs – Complete within 3 yrs

• Boys begin between ages 9-16 yrs – Complete by age 18 - 20

– Hormonal changes – Sexual maturity reached – Most girls reach “reproductive maturity 2-5 yrs after onset of menstruation – Ultimately ht., wt., & body build influenced by diet, exercise, & heredity

DEVELOPMENTAL THEORIES • Psychosexual development: Freud – In the genital stage – Focus in on genitals as erogenous zone – A time of heightened sexual drive • Experiences conflict between own need for sexual satisfaction & society’s expectations

– Core concerns include body image dev. & acceptance by the opposite sex

DEVELOPMENTAL THEORIES • Cognitive development: Piaget – In developmental stage of formal operations – Moves from deductive to abstract reasoning – Thinks beyond the present & forms theories about everything – Develops a systematic approach to problems

• Illustrated by parents buying expensive equipment & having it given up next yr

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DEVELOPMENTAL THEORIES

SOCIAL DEVELOPMENT

SOCIAL DEVELOPMENT

• Moral development: Kohlberg

• A period of rebellion & uncertainty as the adol. defines an identity separate from parental authority • Peer relationships become all important for advice & support • Being found attractive by members of the opposite sex is important • Group parties & dates occupy much of the social time • Automobile ownership important • A job & earning money important

• Degree of sexual intimacy experienced depends, to a large part, on peer group codes & the adolescent’s expectations & value system

SOCIAL DEVELOPMENT

SOCIAL DEVELOPMENT

– Marked by the development of an individual conscience & a defined set of moral values – Control of conduct is now internal – Dev. a respect for law & order

SOCIAL DEVELOPMENT • Effects of Hospitalization: – Primary issue is body image • Self-esteem, independence & body image are negatively impacted when hospitalized

– Fears loss of control through enforced dependency & loss of identity – Fears bodily injury & pain – Inability to gain independence from family – Adjustment required R/T separation from peers & lack of emotional support

• Guidelines for intervention: – Allow to participate in treatment decisions & have as much control as possible – Respect privacy & confidentiality – Provide opportunities for expression of feelings – arrange for age-compatible roommate, if possible – Have phone @ bedside – Encourage to wear own clothing – Use scientific & medical terminology to prepare for procedures

– Needs accurate, complete information on sexual matters – Must know how pregnancy occurs and how it is prevented

• Common fears: – Relationships with persons of opposite sex – Homosexual tendencies – Ability to assume adult roles

• When possible, provide for special activity area limited to adolescent use • Allow favorite foods to be brought in • Approach with caring, understanding, & acceptance

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INJURY PREVENTION • Are risk-takers & often do not consider safety before acting • Contribute substantially to the number of motor vehicle accidents through: – Inexperience & poor judgment – Reckless driving or speeding – Driving under the influence of alcohol or other drugs – Failure to use safety belts – Peer pressure for unsafe driving practices

INJURY PREVENTION • Particularly prone to swimming & diving accidents, and safety of these areas must be taught • Needs instruction as to how to avoid sports injuries • Smoking & use of alcohol & other drugs should be discouraged • Other issues:

SELECTED HEALTH PROBLEMS • Acne • Mono

• Refer to RNSG 2504 Pediatric PowerPoint Notes

– Body piercing – Tattoos – Suntanning

DISORDERS

DISORDERS OF CHILDREN

• RESPIRATORY DISORDERS • GASTROINTESTINAL DISORDERS • GENITOURINARY TRACT DISORDERS • NEUROLOGIC DISORDERS • NEUROMUSCULAR, MUSCULAR & ARTICULAR DISORDERS • HEMATOLOGIC DISORDERS • CARDIOVASCULAR DISORDERS • CANCER

RESPIRATORY DISORDERS OF CHILDREN

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OVERVIEW

RESPIRATORY SYSTEM OVERVIEW

• Resp. infections easily spread from one structure to another within the resp. tract – R/T the contiguous nature of the mucous membrane lining the entire tract

• Resp infections account for the majority of acute illness in children – Etiology influenced by age, season, living conditions, & preexisting medical problems

• Most infections caused by viruses

OVERVIEW • Poor tolerance of nasal congestion - esp. in infants who are obligatory nose breathers until 2-4 mo. • Increased susceptibility to ear infection R/T shorter, broader, & more horizontally positioned eustachian tubes • Increased severity of resp. symptoms R/T smaller airway diameters • Resp. rate higher

OVERVIEW • Infants ↓ 3 mo have lower infection rate R/T protective function of maternal antibodies • Rate ↑ between 3- 6 mo, & continues to remain high during toddler & preschool yrs. – Amount of lymphoid tissue ↑ throughout middle childhood & repeated exposure to organisms gives increasing immunity as children grow older

• Children exhibit a response to resp. infection with systemic symptoms (diarrhea, fever, etc)

ASSESSMENT • Fever:

RESPIRATORY SYSTEM ASSESSMENT: ASSOCIATED SIGNS & SYMPTOMS

– May be absent in the NB – Greatest @ 6 mo to 3 yrs. – May be high, even with mild infections – May dev. febrile sz. • Uncommon after 3 - 4 yr.

• Anorexia: – Common – Freq. initial evidence of illness – Often extends into convalescence

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ASSESSMENT • Vomiting: – Sm. Children vomit readily with illness – May be a clue to onset of infection • May precede other signs by several hr.

• Diarrhea: – Usually mild, but may become severe – Often accompanies viral resp, infections – Is a frequent cause of dehydration

ASSESSMENT • Sore Throat: – Frequent complaint of older children – Young children (unable to describe sym.) may not complain even when highly inflamed – Often leads to refusal to take oral fluids or solids

ASSESSMENT • Abdominal Pain: – Common complaint

• Nasal Blockage – Sm. passages of infants easily blocked by mucosal swelling & exudation – Can interfere with respiration & feeding in infants – May irritate upper lip & skin surrounding nose

• Cough:

ASSESSMENT • Respiratory Sounds: – Sounds associated with respiratory disease: • • • • •

Cough Hoarseness Grunting Stridor Wheezing

– Auscultation: • Wheezing • Crackles • Absence of sound

– Common feature – May persist several months after disease

ASSESSMENT

ASSESSMENT

• Overall physical should focus on following:

– Dyspnea, stridor, grunting, nasal flaring, head bobbing (infant) – Sputum – Bad breath

– Alertness, changes in mental status – Activity level & complaints of fatigue – Skin color changes, particularly cyanosis – Respiratory rate & pattern & apnea – Retractions: presence, location, & severity – Adventitious lung sounds – Cough, productive or nonproductive

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ASSESSMENT

ASSESSMENT

• NURSING ALERTS

• NURSING ALERTS

• Advise family to seek medical evaluation is: – Breathing becomes difficult – Abdominal pain develops – Sore throat pain is so severe that child is unable to eat or drink

• Prolonged fever or appearance of fever during early convalescence is a sign of secondary bacterial infection & should be reported ASAP

IMPLEMENTATION • Ease respiratory efforts – Moisture to soothe inflamed membranes – Hummidification / nebulilization / p – Use of O2 – Parent at bedside

• Promote rest • Promote comfort – Nose drops & throat irrigations – Decongestants – Use of either hot or cold compresses – Antipyretics – Cough suppressants

• Children with severe respiratory distress should not be given anything by mouth to prevent aspiration & to ↓ the work of breathing • Early signs of inpending airway obstruction include:

RESPIRATORY SYSTEM NURSING IMPLEMENTATIONS & THERAPEUTIC MANAGEMENT

– ↑ P&R – Retractions – Flaring of nares in infants – ↑ restlessness

IMPLEMENTATION • Prevent spread of infection – Careful handwashing! – Remove affected children from contact with other children – Isolation procedures – Antibiotic therapy if indicated – Encourage good chest physiotherapy

• Reduce temperature – Antipyretics, (ibuprofen or acetaminophen) – Cool environment – Remove clothing & blankets

IMPLEMENTATION • Promote hydration – IV fluids if not able to maintain adequate po fluids – Encourage adequate fluid intake • Sm. amts. of favorite fluids @ freq. intervals • Use of high-calorie liquids – Juices – Water flavored with Jello, etc – (Do not use if diarrhea present)

• Oral rehydration solutions – Infalyte or Pedialyte for infants – Sports drinks such as Gatorade for older

– Do not awaken to give fluids – Observe freq. of voiding – Strict I&O

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IMPLEMENTATION

RESPIRATORY DISORDERS

• Provide nutrition – IV fluids while loss of appetite – Do not urge food on anorexic children as may precipitate N&V or an aversion to feeding – Offer sm. feedings of foods such as gelatin, soup, & puddings

SELECTED RESPIRATORY DISORDERS OF CHILDREN

• Family support & home care – Recognize parental concern & need for info. & support – Explain therapy & child’s behavior – Encourage family-centered care – Ensure family knows S&S of Resp. complications

• • • • • • •

Asthma Cystic fibrosis Croups Otitis media Pneumonia Respiratory Syncytial Virus Tonsillitis

• Refer to RNSG 2504 Pediatric PowerPoint Notes

OVERVIEW

GASTROINTESTINAL DISORDERS OF CHILDREN

GASTROINTESTINAL SYSTEM OVERVIEW

• Dysfunction of the GI tract can cause significant problems with the exchange of fluids, electrolytes & nutrients • Problems can affect overall health, growth & development • Children easily become dehydrated if vomiting &/or diarrhea a symptom • Meeting nutritional needs a major goal – Use ht & wt to determine – Many conditions chronic & extend over lifetime

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OVERVIEW

ASSESSMENT

• Diarrhea & vomiting occur more frequently in children

• Most important basic nursing assessments:

– More prone to fluid & electrolyte imbalances

• Dehydration most commonly results from abnormal fluid losses such as from excessive vomiting or diarrhea

GI SYSTEM ASSESSMENT: ASSOCIATED SIGNS & SYMPTOMS

ASSESSMENT • NURSING ALERT • In any instance in which severe abd. pain is observed, the nurse must be aware of the danger of administering laxatives or enemas as such measures stimulate bowel motility & ↑ the risk of perforation

– Measurements of intake & output – Measurements of height & weight – Abdominal examination – Stool & urine tests – Abdominal pain – Bowel sounds – Urinary output – Stool output – Fever – Dietary history

IMPLEMENTATION GI SYSTEM NURSING IMPLEMENTATIONS & THERAPEUTIC MANAGEMENT

• Obtain accurate weights • IV fluids / TPN if unable to ingest sufficient fluid/foods orally • Monitor IV replacement therapy, checking IV site frequently • Monitor hydration status with strict I&O • Maintain skin integrity – Provide good hygiene – Skin care – Carefully washing & drying diaper area with every change

• Promote comfort

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IMPLEMENTATION

IMPLEMENTATION

• If postoperative, monitor for wound infection • Note & record frequency & characteristics of stools • Monitor abdominal girth to assess for increasing distention

• Support parents by encouraging them to express feelings & concerns • Promote a positive self-concept in older child by allowing to express feelings about the disorder &/or dietary restrictions • Offer pacifier while infant is NPO • Prevent infection by good handwashing & appropriate isolation • Refer parents & child to nutritional counseling & various appropriate community agencies

– Distended abd. ↓ resp. efforts

• Prepare child & parents for procedures & treatments – Surgery – Ostomies – Enemas – Bowel preps – TPN, etc

GASTROINTESTINAL DISORDERS • • • • • • • • • • • •

Megacolon Biliary atresia Gastroesophageal reflux Celiac disease Lactose intolerance Failure to thrive Intussusception Necrotizing enterocolitis Intussusception Cleft lip & palate Crohn’s disease Ulcerative colitis

SELECTED GI DISORDERS OF CHILDREN

GASTROINTESTINAL DISORDERS • • • •

Pyloric stenosis Rotavirus Esophageal atresia Anorectal malformations

GENITOURINARY TRACT DISORDERS OF CHILDREN

• Refer to RNSG 2504 Newborn Congenital Conditions and Pediatric PowerPoint Notes

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OVERVIEW • Kidney development not complete until end of 1st. year

GENITOURINARY SYSTEM OVERVIEW

– Can’t concentrate or dilute urine well – Newborn more prone to developing severe acidosis – Sodium excretion ↓ in infancy

• In the newborn, urinary tract disorders generally associated with malformations of other body systems

ASSESSMENT • Health history findings possibly pointing to renal dysfunction in the neonate: – Poor feeding – Failure to thrive – Frequent urination – Crying on urination – Poor urinary stream – Dehydration – Convulsions – Rapid respirations (acidosis) – Enlarged kidneys or bladder – Other anomalies

ASSESSMENT • Health history findings possibly pointing to renal dysfunction in the infant: – Same findings as neonate PLUS: • • • • •

Persistent diaper rash Foul-smelling urine Straining on urination Pallor Fever

GENITOURINARY TRACT ASSESSMENT: ASSOCIATED SIGNS & SYMPTOMS

ASSESSMENT • Health history findings possibly pointing to renal dysfunction in the older child: – Poor appetite – Vomiting – Excessive thirst – Incontinence – Frequent urination – Painful urination – Bloody urine – Fatigue – Abd., flank, or back pain – Swelling of the face

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ASSESSMENT • Older child (cont.) – Edema – Hypertension – Growth failure – Seizures

ASSESSMENT • Physical assessment might reveal signs & symptoms suggestive of renal dysfunction such as: – Abnormal rate & depth of respirations – Hypertension – Fever – Growth retardation – Abdominal distention – Signs of circulatory congestion • • • •

Peripheral cyanosis Slow cap refill time Pallor Peripheral edema

ASSESSMENT • NURSING ALERTS • A child who exhibits the following should be evaluated for UTI: – Incontinence in a toilet-trained child – Strong-smelling urine – Frequency &/or urgency

• Use of Fleet enemas in children with acute or chronic renal failure is potentially lethal R/T hyperphosphatemia

ASSESSMENT • Physical assessment cont. – Early signs of uremic encephalopathy • Lethargy • Poor concentration • Confusion

– Signs of congenital anomalies • Hypospadias or Epispadias • Ear anomalies (low-set, floppy, malformed) • Prominent epicanthal folds • Beak-like nose • Small chin

IMPLEMENTATION GU SYSTEM NURSING IMPLEMENTATIONS & THERAPEUTIC MANAGEMENT

• Accurate measurement of weights • Accurate measurement of blood pressure • Accurate measurement of intake & output • Prepare children & parents for tests, collection of urine samples, & other procedures • Observe characteristics of urine collected & perform tests on urine collected • Administer meds as ordered

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IMPLEMENTATION

IMPLEMENTATION

IMPLEMENTATION

– Assess for fluid volume deficit by monitoring:

• Assess urinary status by observing appearance & color of urine, & noting S&S such as:

• Help improve child’s selfconcept by providing positive feedback, emphasizing strengths, & encouraging social interaction & pursuit of interests • Refer child & family to community health resources

• • • • •

↑ edema Daily abdominal girth Daily weight Daily I&O Blood pressure

– Frequency – Burning – Enuresis – Urinary retention – Flank pain

– Prevent skin breakdown • Frequent position changes • Providing good skin care • Scrotal supports in boys

– Maintain or improve nutritional status – Monitor for signs of infection

• If post-op, monitor for wound infection • Provide support to family by answering question & providing information about diagnosis, tests, & treatments

GENITOURINARY TRACT DISORDERS

SELECTED GU DISORDERS OF CHILDREN

• • • • • • •

Exstrophy of bladder Vesicoureteral reflux (VUR) Undescended testicle Hypospadias Epispadias Nephrotic syndrome Acute glomerulonephritis

NEUROLOGIC DISORDERS OF CHILDREN

• Refer to RNSG 2504 Pediatric PowerPoint Notes

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OVERVIEW

CENTRAL NERVOUS SYSTEM OVERVIEW

• In 1st year of extrauterine life, the number of brain neurons ↑ rapidly • Brain weight doubles by end of first year & triples by age 6 yrs. • CNS myelinization, which enables progressive neuromuscular function, follows the cephalocaudal & proximodistal sequence

ASSESSMENT • Components of pedi. neuro. exam: – General • Affect • Social interaction • Denver Developmental Screening Test • Emotional state

– Head circumference – Fontanel assessment in infants – Mental status • • • •

LOC Orientation Reasoning ability Memory

NERVOUS SYSTEM ASSESSMENT: ASSOCIATED SIGNS & SYMPTOMS

ASSESSMENT – Sensory status • • • • •

Vision Hearing Taste Smell & touch Cranial nerve function

– Motor function • • • •

Muscle tone Strength Gait abnormalities Posture

– Cerebellar status • Balance • Coordination

– Reflexes

ASSESSMENT • Periodic neurologic checks should include: – Vital signs – LOC – Eyes: • • • • • •

Pupil size Equality Reaction to light Extraocular movements Corneal reflex Visual disturbances

– Motor & sensory function – Head circumference & fontanel inspection in infants – Reflexes

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ASSESSMENT

ASSESSMENT

ASSESSMENT

• Clinical manifestations of ↑ ICP in an infant & young child commonly include:

• Clinical manifestation of ↑ ICP in an older child commonly include:

• NURSING ALERTS

– Irritability & restlessness – Tense, bulging anterior fontanel in child < 18 mo. – High-pitched cry – Change in feeding habits – ↑ Occipital frontal circumference – Crying with cuddling & rocking – “Setting sun” sign – Macewen’s (“cracked pot”) sign in an infant with unfused crainal sutures

– Headache – Anorexia – Vomiting, often projectile without nausea – Cognitive, personality, & behavioral changes – Diplopia, blurred vision – Seizures

ASSESSMENT • NURSING ALERTS • When opioids are used, bowel elimination must be closely monitored because of their constipating effect

• Lack of response to painful stimuli is abnormal & must be reported immediately • The sudden appearance of a fixed & dilated pupil is a neurosurgical emergency • 3 key reflexes that demonstrate neurologic health in infants are: – Moro – Tonic-neck – Withdrawal reflexes

IMPLEMENTATION NEUROLOGIC SYSTEM NURSING IMPLEMENTATIONS & THERAPEUTIC MANAGEMENT

• Monitor vital signs • Measure occipital frontal circumference as ordered • Assess neurologic status & assess all signs of ↑ ICP • Encourage parents to express their feelings, fears, & anxieties • Promote parent-infant relationship: – Encourage parent participation with ADLs – Encourage cuddling & tactile stimulation

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IMPLEMENTATION • Provide family teaching with special emphasis of: – Infection control – Recognizing early S&S of ↑ ICP – Bladder & bowel management – Shunt management – Developmental needs – Effects of immobilization & ways to minimize them – Need for lifelong care

IMPLEMENTATION • Help prevent skin / sac breakdown • If post-op, monitor for wound infection • Institute procedures for Latex allergy prevention

SELECTED NEUROLOGIC DISORDERS OF CHILDREN

• Assess family’s ability to care for infant, & refer for further assistance if necessary

NEUROLOGIC DISORDERS • Neural tube defects – Spina bifida occulta – Meningocele – Myelomeningocele

• Hydrocephalus • Down syndrome

NEUROMUSCULAR, MUSCULAR & ARTICULAR DISORDERS OF CHILDREN

NEROMUSCULAR, MUSCULAR & ARTICULAR DISORDERS OF CHILDREN: OVERVIEW

• Refer to RNSG 2504 Newborn Congenital Conditions & Pediatric PowerPoint Notes

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OVERVIEW • The most frequent reasons for immobility are congenital defects • The major effects of immobilization are: – Loss of muscle strength, endurance, & muscle mass – Bone demineralization leading to osteoporosis – Loss of joint mobility & contractures – Decreased metabolism

• Muscle disuse, over time, affects all other systems of body

OVERVIEW • Treatment for these disorders often involves immobility – Casts – Traction – Body frames

• Impact of immobility depends in large part on the child’s developmental level • Play, social interaction, & selfcare help the immobilized child gain self-esteem & independence & promote normal growth & development

OVERVIEW • Bone growth occurs at the epiphyseal plate, a very vascular area – These cells highly sensitive to the influence of growth hormone, estrogen, & testosterone – During adolescence, the epiphyseal plate converts to bone & growth stops – This is an area susceptible to injury through fracture, crushing or slippage – Damage to this area can disrupt bone growth

OVERVIEW • Because a child’s bones are still growing: – Some bony deformities due to injury can be remodeled or straightened – Some deformities can progress with growth

• Because a child’s bones are more plastic: – More force required to fracture a bone

• A child’s bones heal much faster than adult’s

OVERVIEW • Psychological effects of immobilization commonly include: – Altered body image – Altered perception of external environment – Sensory deprivation – Impaired mastery of developmental psychosocial tasks

NEUROMUSCULAR, MUSCULAR & ARTICULAR SYSTEM ASSESSMENT

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ASSESSMENT

ASSESSMENT

ASSESSMENT

• Initial assessment should obtain a complete health history of problems pertaining to this system, focusing on:

• Clinical manifestations of prolonged immobilization may include:

• NURSING ALERTS

– Trauma – Delayed walking or other developmental abnormalities – Pain – Structural abnormalities – Any physical limitations or lifestyle alterations imposed by the problem – Mobility aids used

ASSESSMENT

– Joint contractures & pain – Muscle atony & weakness – Fatigue – Diminished reflexes – Delayed healing – Orthostatic hypotension – S&S of thrombus formation – Anorexia – Constipation

• Numbness, tingling, change in sensation & loss of motion are sym. of neurologic impairment & should be evaluated immediately • The 5 “Ps” of ischemia from vascular (circulatory) injury are: – Pain – Pallor – Pulselessness

Paralysis Paresthesia

ASSESSMENT

• NURSING ALERTS

• NURSING ALERTS

• A fracture should be strongly suspected in a small child who refuses to walk • Skeletal traction is NEVER released by the nurse, nor are weights lifted that are applying traction • A plastic bag of frozen veg.such as peas, serves as a convenient ice pack for soft tissue injuries

• The classic S&S of Pulmonary Emboli are: – Chest pain – Dyspnea – Petechial hemorrhages of the chest & shoulders

NEUROMUSCULAR, MUSCULAR, & ARTICULAR SYSTEMS IMPLEMENTATIONS & THERAPEUTIC MANAGEMENT

• Treat the dyspnea by elevating the head & administering O2

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IMPLEMENTATION

IMPLEMENTATION

IMPLEMENTATION

• Protect skin integrity by turning frequently & inspecting for early signs of breakdown • Promote adequate hydration by offering favorite drinks • Promote good nutrition by offering high-protein, high caloric foods in sm., freq., & attractively arranged servings • Promote normal bowel elimination by keeping child well hydrated, including fiber in diet, & providing for privacy @ toilet

• Promote normal urinary elimination by monitoring freq. & amt. of urination & assessing for bladder distention • Promote normal activity as condition & restrictive devices allow • Provide diversional activities spaced with adequate rest • Help prevent respiratory complications through good hydration & changing position freq.

• Help maintain adequate cardiac output by changing position freq., & providing active or passive range of motion exercises • Help prevent urinary tract infections through good hydration, promotion of frequent voiding, provision of acid-ash foods ( cereal, fish, poultry, cranberry or apple juice & meats)

IMPLEMENTATION

IMPLEMENTATION

• Prevent contractures by maintaining proper body alignment, minimizing flexed positions, & providing active & passive ROM • Promote self-care by allowing child to help plan daily routines, select foods, determine the time for bathing, select clothing, etc. • Promote normal growth & dev. by providing regular social contact & diversional activities

• Promote effective coping by providing play therapy, anticipatory teaching, & explanations of physical restrictions & restraining devices • Provide patient & family teaching while in hospital & for home care • Prepare child & family for each procedure & planned therapy • Refer family to support organizations

SELECTED NEUROMUSCULAR, MUSCULAR & ARTICULAR DISORDERS OF CHILDREN

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DISORDERS

DISORDERS

• Developmental dysplasia of the hip (DDH) • Clubfoot • Cerebral palsy • Muscular dystrophy • Juvenile rheumatoid arthritis • Scoliosis • Legg-Calve’ Perthes disease • Osteomyelitis • Fractures • Traction

• Refer to RNSG 2504 Newborn Congenital Conditions and Pediatric PowerPoint Notes

OVERVIEW • Blood consists of liquid plasma & formed elements:

HEMATOLOGIC SYSTEM OVERVIEW

– Erythrocytes – Leukocytes – Thrombocytes

• RBCs primarily transport O2 to & CO2 away from body tissues • Typical lifespan of RBC = 120 days • WBCs protect the body against infection • There are 5 types of WBCs

HEMATOLOGICAL DISORDERS OF CHILDREN

OVERVIEW • Platelets contain coagulation factors & help regulate homeostasis through a sequence of events known as the coagulation process • The major blood-forming organs are bone marrow, the lymphatic system & the reticuloendothelial system • Children with hematological dysfunction commonly undergo a multitude of invasive diagnostic tests, procedures, & treatments

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OVERVIEW • Children with hematological dysfunction commonly depend on others for care & support • During the 1sr. 6 mo. of life, fetal hemoglobin is gradually replaced by adult hemoglobin, & it is only after this that hemoglobin disorders can be diagnosed

ASSESSMNET

HEMATOLOGIC SYSTEM ASSESSMENT

• Health history questions should focus on: – Bleeding or bruising tendencies – Medication use – Family history of bleeding problems

• Physical assessment findings of possible hematologic problems include: – Skin: • Pallor, flushing, jaundice, purpura, petechiae, ecchymoses, cyanosis, brownish discoloration

ASSESSMENT – Eyes: • Jaundiced sclera, conjunctival pallor, retinal hemorrhage, blurred vision

– Mouth: • Gingival & mucosal pallor

– Lymph nodes:

ASSESSMENT – Gastrointestinal: • Anorexia, hepatomegaly, splenomegaly

– Musculoskeletal: • Weight loss, decreased muscle mass, bone pain, joint swelling, pain

ASSESSMENT • NURSING ALERTS • Never administer aspirin or any aspirin-containing compound to the child with hemophilia

• Lymphadenopathy, tenderness

– Cardiac: • Tachycardia, murmurs, signs & symptoms of congestive heart failure

– Pulmonary: • Tachypnea, orthopnea, dyspnea

– Neurologic: • Headache, vertigo, irritability, depression, impaired thought processes, lethargy

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HEMATOLOGICAL SYSTEM NURSING IMPLEMENTATIONS & THERAPEUTIC MANAGEMENT

IMPLEMENTATION

IMPLEMENTATION

• Relieve pain by assessing the child’s need for pain medication & provide prescribed medication • Position the child for maximum comfort • Implement therapeutic measures as appropriate which may include:

– Application of pressure &/or cold – Administration of factor VIII or other substances

– Oral & IV fluids – Electrolyte replacement to counter acidosis caused by hypoxia – O2 therapy to promote adequate oxygenation – Immobilization devices

IMPLEMENTATION – Home management of chronic condition – Prevention of crisis or bleeding episode ( Injury prevention ) – Measures to control bleeding – Pain control

• Encourage child & family to lead as normal a lifestyle as possible • Refer the family to support groups

• Monitor for signs of infection • Encourage optimal nutrition • Support the child & family by allowing them to ventilate their fears, concerns & anger • Provide patient & family teaching, covering: – Disease process, including genetic aspects & early recognition

HEMATOLOGICAL DISORDERS SELECTED HEMATOLOGICAL DISORDERS OF CHILDREN

• Sickle cell anemia • Hemophilia

• Refer to RNSG 2504 Pediatric PowerPoint Notes

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OVERVIEW

CARDIAC DISORDERS IN CHILDREN

CARDIAC SYSTEM OVERVIEW

OVERVIEW

OVERVIEW

• Developmental delays often occur in children with cardiac disorders, particularly cyanotic heart defects • Activity limitations may be essential, but may be difficult to impose • With many defects, an older child may be allowed to self-limit activities according to how he feels • Surgical procedures will be required to repair the defect

• Heart defects are described as either Acyanotic Heart Defects or Cyanotic Heart Defects • Acyanotic heart defects are congenital defects in which no deoxygenated (or poorly oxygenated) venous blood enters systemic arterial circulation • Oxygenated blood is shunted from systemic to pulmonary circulation

• Congenital heart disease is the most common form of cardiac disease in children • The cardiovascular system’s basic function is to pump oxygenated blood to tissues & remove metabolic waste products from tissues • Valves within the heart & pressure differences between the four heart chambers regulate blood flow through the heart & into systemic circulation

OVERVIEW – Any time there is a defect connecting systemic & pulmonary circulation,blood will go from high to low pressure (path of least resistance) – Normally pressure is higher in systemic circulation, so blood will be shunted from systemic to pulmonary circulation – Blood leaving aorta is completely oxygenated – Increased blood volume on right side of heart results in hypertrophy of right ventricle – Most acyanotic heart defects will result in CHF

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OVERVIEW • Types of acyanotic defects include: – Left to right shunting through an abnormal opening: • PDA, ASD, VSD

– Obstructive lesions that restrict ventricular outflow: • Aortic valvular stenosis, pulmonic stenosis, coarctation of aorta

OVERVIEW • Cyanotic heart defects are congenital heart defects in which deoxygenated blood enters systemic arterial circulation • Blood entering peripheral tissues has much lower O2 • Types of cyanotic defects include:

OVERVIEW • In over 90% of congenital heart defects, the exact etiology is unknown • The primary cause of congestive heart failure in the 1st 3 years of life is congenital heart disease

– Tetralogy of Fallot, Tricuspid atresia, transposition of the great vessels, truncus arterios, – total anomalous pulmoary venous communication, hypoplastic left heart syndrome

OVERVIEW • The reasons for CHF are basically : – 1. The heart is unable to meet the body’s oxygenation & nutritional needs due to: • Excessive volume • Excessive pressure load on the heart

– 2. Diminished myocardial functioning

OVERVIEW • The major diagnostic test for cardiac disorders is cardiac Catheterization which provides the following information: – O2 saturation in heart chambers – Pressures within chambers – Changes in cardiac output – Anatomic abnormalities

OVERVIEW – Check pressure dressing over site for bleeding – Monitor heart rate for signs of Bradycardia, tachycardia, & dysrhythmia – Monitor intake & output

• Post-Catheterization care: – Check extremity distal to cath site for color, temp., pulse, & cap. refill – Keep extremity distal to cath. site extended for 6-8 hr.

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ASSESSMENT • Health history findings of significance include:

CARDIAC SYSTEM ASSESSMENT

ASSESSMENT – Activity intolerance – Hypotension or unequal blood pressure in arms & legs – Abdominal distention, hepatomegaly, splenomegaly – Clubbing of fingers & toes – Murmurs, bruits, thrills – Squatting – Hypoxic spells (“tet” spells R/T transient cerebral ischemia)

– Family history of congenital heart disorders – Presence of murmurs & age @ which first noted – Feeding problems, including fatigue or diaphoresis during feeding & poor weight gain – Respiratory difficulties, including tachypnea, dyspnea. SOB, cyanosis & freq. URI – Chronic fatigue or exercise intolerance

ASSESSMENT • Significant physical assessment findings may include: – Failure to thrive – Frequent resp. infections – Cyanosis – Periorbital & peripheral edema – Respiratory difficulties – Color changes: • Pallor or cyanosis – Persistent or intermittent

– Pulse alterations • Tachycardia or bradycardia • Dysrhythmias • Diminished peripheral pulses

ASSESSMENT

ASSESSMENT

• NURSING ALERTS

• NURSING ALERTS

• Electrodes for cardiac monitoring are often color coded: white for right, green (or red) for ground, & black for left • O2 is a drug & is only administered with an appropriate order • Therapeutic serum digoxin levels range from 0.8-2 ug/L. Signs of toxicity - bradycardia & vomiting

• Infants rarely receive > than 1 ml (50ug or 0.05 mg) of Digoxin. A higher dose is an immediate warning of a dosage error • Chest tube drainage > than 3 ml/kg/hr for more than 3 consecutive hours is excessive & may indicate post-op hemorrhage

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ASSESSMENT • NURSING ALERTS • The early signs of CHF are: – Tachycardia, especially during rest & slight exertion – Tachypnea – Profuse scalp sweating, especially in infants – Fatigue & irritability – Sudden weight gain – Respiratory distress

IMPLEMENTATION CARDIAC SYSTEM NURSING IMPLEMENTATIONS & THERAPEUTIC MANAGEMENT

• Help ↓ cardiac workload – Organize nursing care to provide for periods of uninterrupted rest – Prevent excessive crying in infants – Provide diversional activities that involve limited energy expenditure for older children – Encourage parents to stay with infant to provide holding, rocking, & cuddling to help infant sleep more soundly – Minimize stressors – Keep warm

• Observe for & assist in managing CHF

IMPLEMENTATION • Help maintain optimal nutritional status by: – Provide small, frequent meals if child tires easily – In infants use soft nipples to ↓ work during feeding; gavage feedings may be necessary • Limit feedings to 45 min or< • Anticipate infant’s hunger to avoid crying • Feed in semi-erect position • Burp frequently • Observe for vomiting & diarrhea if high-caloric formula ordered • Daily weights

IMPLEMENTATION • Prepare child/family for diagnostic studies & surgery • Help prevent infections – Careful handwashing – Avoid contact will sick persons – Ensure immunizations up to date

• Promote normal growth & development • Administer meds & monitor for side effects • Help ↓ child’s & family’s anxiety & ↑ understanding by providing information on medical & surgical treatments

IMPLEMENTATION • Evaluate fluid status – Strict I&O – Daily weights – Assessing for edema & severe diaphoresis – Monitor electrolyte values

• Provide family members with appropriate discharge teaching – Medications – Activity restrictions – When to call doctor – Diet & nutrition – Wound care – Follow-up appointments

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IMPLEMENTATION • Observe for & assist in managing resp. distress : cough, tachypnea, tachycardia, retractions, grunting, nasal flaring,cyanosis – Administer O2 as ordered – Positioning to ease breathing – Administer meds as ordered

CANCER IN CHILDREN

CANCER OVERVIEW

OVERVIEW

OVERVIEW

• Administer meds as ordered • Monitor fluid status – Strict I&O – Daily weights

• Prevent infections

OVERVIEW • Cancer is the leading cause of death from disease in children from 1-14 yrs • Leukemia is the most frequent type of childhood cancer, followed by tumors of the CNS • In recent years survival rates have ↑ so that > 70% of all children with malignant neoplasms treated @ major centers will survive > 5 years

• Classification is by tissue of origin: – Blood & related cells: • Leukemias • Lymphomas

– Connective tissue: • Fibrosarcoma - originating in fibrous tissue • Osteosarcoma - originating in boneproducing cells • Ewing’s sacroma, originating in midshaft of long bones & flat bones

– Muscle tissue • Rhabdomyosarcoma

– Nerve tissue: • Neuroblastoma - originating from neural crest during embryonic dev. • Glioblastoma - originating from glial cells • Retinoblastoma - originating in the retinal tissue

– Renal tissue: • Wilm’s tumor (nephroblastoma) originating in the kidneys

• The child & family adjust to the process of living with a lifethreatening illness • Child’s reaction depends on his age

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OVERVIEW • Interventions used: – Surgery: • Useful for diagnosis • Used for tumor removal • Often used in conjunction with radiation &/or chemotherapy

– Chemotherapy: • Primary form of treatment • Protocols combine drugs to allow for optimum cell cycle destruction with minimum toxic effects & ↓ resistance by cells to the agent

– Radiation: • May be curative or palliative

OVERVIEW – Biologic Response Modifiers (BRMs): • Uses monoclonal antibodies and other agents • Changes host’s biologic response to tumor cells

– Bone marrow transplant: • Transfused marrow or stem cells produce functioning nonmalignant blood cells • Types: – Autologous - transplanted with own harvested marrow – Syngeneic - transplanted between identical twins – Allogeneic - transplanted from a nonidentical donor

OVERVIEW

• Stages of treatment consist of: – Induction • Goal to remove most of tumor • Often the most intensive phase • Side effects of treatment potentially life-threatening

– Consolidation • Goal is to eliminate any remaining cells

– Maintenance • Goal is to keep child cancer free • Uses chemo & may last for several yrs.

ASSESSMENT

– Observation • Goal is to monitor @ intervals for evidence of recurrent disease & complications of treatment • Treatment is complete: may continue in this stage indefinitely

OVERVIEW

ASSESSMENT OF THE CHILD WITH CANCER

• Specific clinical findings vary depending on particular body system involvement • Cardinal S&S of cancer in children include: – Unusual mass or swelling – Unexplained paleness & loss of energy – Sudden tendency to bruise – Persistent, localized pain or limping – Prolonged, unexplained fever or illness

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ASSESSMENT – Frequent headaches, often with vomiting – Sudden eye or vision changes – Excessive, rapid weight loss

IMPLEMENTATION

CANCER IMPLEMENTATIONS & THERAPEUTIC MANAGEMENT

• Help child cope with intrusive procedures – Provide information geared to developmental level & emotional readiness – Use medical play – Allow child some control in situations where possible

• Provide patient & family teaching covering: – Diagnosis & nature of disorder – All treatments & procedures – Side effects of chemo & radiation

IMPLEMENTATION • Support child & parents – Acknowledge feelings & encourage communication – Provide contact with another parents or an organized support group – Try to keep life as normal as possible – Always tell the truth

• Minimize effects of treatment: – Skin breakdown • Keep clean & dry • Do opt wash off radiation markings • Avoid topical agents with alcohol

IMPLEMENTATION – Bone marrow suppression: • Decreased RBCs – Provide frequent rest activities

• Decreased WBCs – – – –

Monitor temperature elevations Evaluate any potential site of infection Good handwashing a MUST Isolate from children with known communicable disease

• Decreased platelets – Make environment safe – Avoid use of salicylates – Select activities that are physically safe

– Interpret peripheral blood counts to guide specific interventions & precautions

IMPLEMENTATION – Nausea & vomiting • Administer antiemetics as ordered before chemo & repeat PRN • Ensure adequate oral intake or administer IV fluids as necessary

– Alopecia • Advise to buy wig before hair falls out • Help choose caps or hats to wear

– Stomatitis • Inspect mouth & rectum daily • Meticulous oral hygiene • Use soft-sponge toothbrush, cottontipped application “Toothettes” to avoid trauma • Apply lip balm • Local anesthetics to ulcerated areas

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IMPLEMENTATION • No juices containing ascorbic acid & hot or spicy foods • Avoid lemon glycerin swab ( irritate eroded tissue • Avoid hydrogen peroxide (delays healing by breaking down protein) • Administer meds as ordered (antiinfectives & analgesics) • Wash perineal area after each toileting • Apply protective skin barriers to perineal area • No rectal or oral temps

IMPLEMENTATION – Nutritional deficits • Measure height & weight frequently • Provide small, frequent meals • Provide high-calorie, high-protein supplements

BIBLIOGRAPHY

• Assist child in interacting with peers • Assist family discuss fears & anxiety about procedures & prognosis

• Lippincott’s Review Series. (1992) Pediatric Nursing. Philadelphia, Lippincott • Wong, Donna (1999). Nursing Care of Infants and Children . (6th ed). St Louis, Mosby • Ashwill, J.& Droske, S. (1997) Nursing Care of Children: Principles and Pracatice. Philadelphia, W.B. Saunders Company

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