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45 Cards in this Set

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Which of the following nursing diagnosis for a child with severe combined immunodeficiency disease (SCID) should be the nurse’s top priority?

a. Risk for delayed growth and development
b. Risk for infection
c. Risk for impaired skin integrity
d. Imbalanced nutrition: less than body requirements
B. Risk for infection

Children with SCID lack both humoral and cellular immunity manifested by lack of appropriately functioning T and B cells. Children are highly susceptible to serious infections. (ch. 22, p 649-651)
A nurse is assessing a child with signs and symptoms of Wiscott-Aldrich syndrome (WAS), which of the following assessment findings would be present in the child with the condition?

a. Failure to thrive
b. Diarrhea
c. Ecchymosis
d. Cyanosis
C. Ecchymosis

Wiskott–Aldrich syndrome (WAS) is a rare X-linked recessive disease characterized by eczema, thrombocytopenia (low platelet count), immune deficiency, and bloody diarrhea (secondary to the thrombocytopenia). The first clinical signs are petechiae, bruising of the skin and bloody diarrhea. (ch. 22, p 652)
A pediatric nurse is caring for a 6-week-old child of a mother who is HIV positive. Which of the following interventions should not be included in the plan of care?

a. Advise mother about avoiding breastfeeding the infant
b. Administer pneumocystic carnii pneumonia prophylaxis (PCP) for the infant
c. Observe contact precautions when providing care
d. Routine antibody tests for the infant
D. Routine antibody tests for the infant

Because an infant born to a mother infected w/ HIV may have maternal antibodies up to 10 months of age, routine antibody tests aren’t helpful for diagnosing HIV infection in infants. (ch. 22, p 653)
A nurse is caring for a pre-school age child diagnosed with AIDS. To prevent pneumonia, which of the following technique would the nurse utilize for the child to promote effective lung expansion?

a. Blowing bubbles
b. Administer humidified oxygen
c. Chest physiotherapy
d. Position child to semi-fowler’s
A. Blowing bubbles

Because many children w/ AIDS develop pneumonia, encourage child to cough and deep breath and use incentive spirometer (or blow bubbles) every 2-4 hours. Chest physiotherapy is directed primarily at promoting airway clearance. (ch. 22, p 658 - 660)
All of the following are included in the plan of care for a child diagnosed w/ AIDS, except:

a. Use normal saline when providing mouth care
b. Administer initial treatment of Nevirapine
c. Encourage frequent small meals
d. Monitor skin turgor
B. Administer initial treatment of Nevirapine

Initial medication therapy should include a combination of several antiretroviral (ARV) drugs. At least 3 drugs from a minimum of 2 different categories should be used. (ch. 22, p 655-656)
A child w/ cancer has a history of experiencing frequent nausea and vomiting from chemotherapy. Which intervention should the nurse perform first to promote optimal nutrition intake?

a. Put patient in a strict liquid diet
b. Administer tube feedings
c. Offer 3 regular meals daily
d. Allow child to choose what to eat
D. Allow child to choose what to eat

Frequent small feedings should be provided, rather than 3 regular meals. It may be helpful to offer the child’s favorite foods at times when nausea and vomiting are decreased. (ch. 24, p 724-725)
A nurse is reviewing lab values for a patient w/cancer receiving chemotherapy. The nurse noted that the patient’s platelet count is 20,000/microliter (low). Based on the finding, what would be the nurse’s next action?

a. Place patient on contact isolation
b. Assess the patient’s LOC
c. Administer stool softener
d. Prepare to administer packed RBC
C. Administer stool softener

Patients who are thrombocytopenic are at high risk for bleeding. Patients should be assessed for signs of bleeding and observe precautions to prevent bleeding such as using soft toothbrushes when providing oral care and administering stool softeners to prevent straining w/ constipation. (ch. 24, p 725-728)
Which of the following assessment findings would not be present in a patient w/ neuroblastoma?

a. Weight loss
b. Irritability
c. Tender, soft abdomen
d. Fever
C. Tender, soft abdomen

Clinical manifestations of neuroblastoma include weight loss, fatigue, fever, and a firm, non-tender abdomen. (ch. 24, p 736-737)
Which of the following should be the priority for a child w/ Wilm’s tumor who just underwent a left nephrectomy?

a. Monitor fluid level
b. CMS assessment proximal to surgical site
c. Increase fluid intake
d. Administer Lasix as ordered
A. Monitor fluid level

Nursing care postrenal surgery focuses on pain management and close monitoring of fluid levels. Monitor fluids closely following surgery to prevent hypovolemia. (ch. 24, p 740)
The parent of a child w/ biliary atresia asked the nurse how the surgery (hepatoportoenterostomy) would help her child. The nurse would state that the primary purpose of the procedure is to:

a. Promote biliary production
b. Promote absorption of fat soluble vitamins
c. Slow the progression of liver disease
d. Promote biliary flow
D. Promote biliary flow

In hepatoportoenterostomy (Kasai procedure), a segment of the intestine is anastomosed to the porta hepatis. The primary purpose of the procedure is to promote bile flow to the liver. (ch. 25, p 794)
The nurse is performing discharge care instructions for the parent of a child w/ celiac disease. Which of the following food items should the nurse teach the parent to include in the child’s diet?

a. Wheat bread and hotdog
b. Corn and baked potato
c. Rice and bologna
d. Oatmeal and rye toast
B. Corn and baked potato

Patients who have celiac disease should adhere to a gluten-free diet. Food products made of wheat, rye, and barley should be avoided. They should also avoid processed foods that contain gluten as filler. (ch. 14, p 354-355)
The nurse is providing discharge care instructions for a parent of a child w/ gastroesophageal reflux (GER). Which of the following should the nurse include in the teaching? [select all that apply]

a. Thin feedings by adding water to formula
b. Sit child in an infant seat while feeding
c. Hold and cuddle child during all feedings
d. Add rice cereal to formula to thicken feedings
e. Suction nose and mouth if vomiting occurs
f. Administer ordered Zantac 1 hour before or after antacid
C. Hold and cuddle child during all feedings

D. Add rice cereal to formula to thicken feedings

E. Suction nose and mouth of vomiting occurs

Seating positioning in an infant seat should be minimized since it increases intra-abdominal pressure and promotes reflux. Antacids are administered 2 hours before or after an H2 antagonist. (ch. 25, p 767-768)
Which of the following assessment findings isn’t present for a child w/ pyloric stenosis?

a. Blood tinged emesis
b. Dehydration
c. Irritable
d. Hypoactive bowel sounds
D. Hypoactive bowel sounds

A child w/ pyloric stenosis will have hyperactive bowel sounds upon auscultation. Emesis may become blood tinged because of repeated irritation to the esophagus. (ch. 25, p 764-766)
The nurse is caring for a child admitted to the pediatric facility for dehydration, projectile vomiting, and weight loss. Further assessment findings include decreased serum potassium and sodium levels. The nurse would anticipate treatment for which potential condition?

a. Lead poisoning
b. Metabolic alkalosis
c. Metabolic acidosis
d. Acetaminophen toxicity
B. Metabolic alkalosis

Projectile vomiting is a classical sign of pyloric stenosis. Patients w/ the condition presents w/ dehydration, weight loss and metabolic alkalosis due to loss of gastric secretions. (ch. 25, p 764-766)
A nurse is assigned to care for a child diagnosed w/ pyloric stenosis. Which of the following should be the nurse’s top priority when caring for the child?

a. Administer antacid before feeding
b. Provide small, frequent feedings
c. Monitor daily weights
d. Prepare child for surgery
D. Prepare child for surgery

Surgery is performed as soon as possible after the child’s fluid and electrolyte balance is restored. Because projectile vomiting will continue until obstruction is relieved by surgery, the child should remain NPO. (ch. 25, p 765-766)
A nurse is providing post-op care for a child with a cleft lip. Which interventions are included in the plan of care for the child? [select all that apply]

a. Remove soft elbow immobilizers every 2 hours
b. Provide child w/ pacifier when not feeding
c. Apply cardiorespiratory monitor
d. Use a long, soft straw for feeding
e. Administer ordered pain medication
f. Avoid positioning child on back or side
A. Remove soft elbow immobilizers every 2 hours

C. Apply cardiorespiratory monitor

E. Administer ordered pain medication

Regular removal of immobilizers allow for skin and neurovascular checks. Child shouldn’t be left unattended when restraints are removed. The monitor enables early detection of abnormal respirations, facilitating prompt intervention. (ch. 25, p 760-762)
A nurse is performing feeding instructions to the parent of a child w/ cleft lip. Which statement made by the parent indicates successful teaching?

a. I have to burp my child after feeding
b. I need to use a special bottle with a short, soft nipple when feeding my child
c. I can continue breastfeeding my child
d. I have to feed my child while lying down to prevent aspiration
C. I can continue breastfeeding my child

Children w/ cleft lip or palate are generally able to breastfeed w/ assistance and education. A bottle with a long, soft nipple should be used for feeding. Frequent burping is needed since children w/ cleft palate tend to swallow air during feedings. (ch. 25, p 760)
Assessment findings for a child w/ biliary atresia include

a. Clay colored stools and bruising
b. Poor weight gain and foul, frothy stools
c. Poor skin turgor and confusion
d. Increased blood glucose levels and polyuria
A. Clay colored stools and bruising

A child w/ biliary atresia may present bruising, prolonged bleeding, and intense itching. Stools have a putty-like consistency and are white or clay colored because of absence of bile pigments. (ch. 25, p 793-794)
A nurse is assigned to care for a child admitted for lead poisoning. Which of the following should the nurse anticipate to administer for the child?

a. Gastric lavage
b. Chelating agents
c. N-acetylcystine
d. IV fluids with sodium bicarbonate
B. Chelating agents

Chelation therapy is administered for children w/ blood lead levels greater than 44 mg/dL. N-acetylcystine (mucomyst) is an antidote for acetaminophen toxicity. (ch. 17, p 464-465)
Interventions included in the plan of care of a child admitted for severe extracellular fluid volume deficit includes: [select all that apply]

a. Take daily weights
b. Assess LOC
c. Measure abdominal girth
d. Administer IV Lactated Ringer’s
e. Place child on clear liquid diet
f. Assess renal function
A. Take daily weights

B. Assess LOC

D. Administer IV lactated Ringer’s

Interventions for a child w/ severe dehydration include weighing the child daily w/ the same scale, carefully assess LOC, pulse rate and quality. When child is severely dehydrated, IV fluids will be given; often lactated Ringer’s often accompanied w/ oral rehydration. (ch. 18, p 480-483)
A 2-year-old child is brought to the ER by her parents for nausea and vomiting, unresponsiveness, and a recent seizure episode. A lumbar puncture is ordered for the child together with other diagnostic tests. The primary reason the lumbar puncture is ordered is to:

a. Reduce an increased intercranial pressure
b. Determine presence of infection
c. Assess CSF glucose level
d. Prevent further brain damage
C. Assess CSF glucose level

A lumbar puncture may be performed to assess the cerebrospinal fluid (CSF) for protein, glucose, or blood cells. (ch. 27, p 852)
A 2-year-old child is brought to the ER by her parents for nausea and vomiting, unresponsiveness, and a recent seizure episode. The parents reported to the nurse that the seizure lasted about 2 minutes, and involved stiffness and eventually lead to jerking motions over the entire body. The nurse would note that the child experienced what type of seizure?

a. Febrile
b. Partial
c. Status epilepticus
d. Generalized
D. Generalized

Tonic-clonic seizure (a type of generalized seizure) occurs as an abrupt-onset seizure and manifested when all muscles contract (tonic phase), the body becomes stiff and rigid and eventually followed by rhythmic jerky motions (clonic phase). (ch. 27, p 856-857)
A nurse performed home care teaching to the parents of a child who had a febrile seizure. Which statement made by the parent indicates a need for further teaching?

a. Anticonvulsants can help reduce my child’s seizure episodes
b. I can give Tylenol when my child has a fever
c. I have to place my child to his side when he’s having a seizure
d. I have to note the duration of a seizure episode if it occurs
A. Anticonvulsants can help reduce my child’s seizure episodes

Children w/ febrile seizures are usually not treated w/ an anticonvulsant because the seizure is usually over before arrival at the emergency department. Long term anticonvulsants aren’t recommended for simple febrile seizures because of their adverse effects. (ch. 27, p 858)
When performing assessment of a patient w/ meningitis, the nurse noted resistance when extending the patient’s leg at the knee. The nurse would document the finding as:

a. Positive Brudzinski sign
b. Positive Kernig sign
c. Nuchal rigidity
d. A normal finding
B. Positive Kernig sign

A positive Kernig sign is noted when the leg is bent at the hip and knee, and subsequent extension in the knee is painful (leading to resistance). (ch. 27, p 864)
The parents of a child diagnosed w/ cerebral palsy (CP) asked the nurse about the condition. The nurse would respond to the parents based on the fact that cerebral palsy is the condition characterized by:

a. A sac-like protrusion on the child’s back
b. Acute inflammatory demyelization of many spinal nerve roots
c. Abnormal muscle tone
d. Involuntary movement, behavior and sensory alterations
C. Abnormal muscle tone

CP is characterized by abnormal muscle tone and lack of coordination w/ spasticity. (ch. 27, p 882-883)
The nurse is preparing the plan of care for a patient who suffered a traumatic brain injury (TBI) from a motor vehicle accident. Which of the following should be included in the plan of care for the patient? [select all that apply]

a. Place patient in lateral recumbent position
b. Administer ordered prednisone to decrease ICP
c. Administer Lasix as scheduled
d. Place patient on seizure precautions
e. Administer high flow oxygen
f. Assess neurologic status frequently
C. Administer Lasix as scheduled

D. Place patient on seizure precautions

F. Assess neurologic status frequently

Pain and sedation management promote comfort and help control the ICP. Corticosteroids aren’t recommended for reducing ICP. The patient’s head should be kept in midline to promote venous drainage from the brain
A nurse instructor is reviewing a nursing student’s care plan for a patient w/ acute bacterial meningitis. Which of the following care plan notes should the instructor question?

a. Administer PO antibiotic as scheduled
b. Order for a blood culture and sensitivity
c. Maintain strict I/O
d. Place patient in droplet isolation
A. Administer PO antibiotic as scheduled

Antibiotics are usually administered as soon as diagnostic tests are obtained. These medications are given IV for 7-21 days depending on the organism and the child’s clinical response. (ch. 27, p 864-867)
A nurse is caring for a child who is suspected to have acute bacterial meningitis. Which of the following should be the nurse’s top priority?

a. Initiate isolation precautions as soon as diagnosis is confirmed
b. Administer antibiotics as scheduled
c. Initiate isolation precautions as soon as causative organism is identified
d. Administer analgesics PRN
B. Administer antibiotics as scheduled

Antibiotics are usually administered as soon as diagnostic tests are obtained. The child should be in isolation precautions until the causative organism is identified and at least after 24 hours of effective treatment. (ch. 27, p 865-867)
A nurse is giving discharge teaching to the parents of a child w/ hydrocephalus who had a recent ventriculoperitoneal shunt placement. Which of the following should not be included in the teaching?

a. Call primary care provider if child experiences drowsiness or irritability
b. Child may develop a seizure disorder
c. Head growth will resume in 6-8 months
d. Practice good hand hygiene
C. Head growth will resume in 6-8 months

After shunt placement, head growth due to brain development may then be noted in 2 – 4 months. If head growth resumes after that, shunt failure may be present. (ch. 27, p 875)
Which of the following interventions should not be included in the plan of care for a newborn w/ myelomeningocele?

a. Measure head circumference
b. Cover sac on newborn’s back w/ sterile saline dressing
c. Keep hips flexed and legs abducted
d. Position newborn in supine position
D. Position newborn in supine position

The infant should be placed in prone position w/ hips slightly flexed and legs abducted to minimize tension on the sac. (ch. 27, p 878)
A 16-year-old female patient is being discharged on an anticonvulsant medication, Tegretol (Carbamazepine). What should the nurse include in the discharge teaching regarding the adverse effects of the medication?

a. Neural birth defects
b. Hyperthyroidism
c. UTI
d. Increased menstrual bleeding
A. Neural birth defects

Adolescent females need to be educated about potential tetragenocity of some anticonvulsants, such as valproic acid and carbamazepine, which are associated w/ neural tube defects and heart defects. (ch. 27, p 861)
A nurse is tasked to perform assessments on a 3-year-old child being evaluated for possible hydrocephalus. Which of the following signs and symptoms should the nurse note as an early sign of the condition?

a. Rapid increasing head circumference
b. Sunsetting eyes
c. Bulging fontanels
d. Nausea and vomiting
D. Nausea and vomiting

Head enlargement and bulging fontanels wouldn’t be present in a child after closure of the sutures/fontanels around 12-18 months. Early signs and symptoms present in the child include headache upon rising w/ nausea and vomiting, fussiness, sleepiness, and loss of interest in daily activities. (ch. 27, p 873)
A nurse educator instructs parents of a child w/ sickle cell disease about prevention of sickle cell crisis. All of the following factors contribute to development of sickle cell crisis, except:

a. Decreased hemoglobin levels
b. Fever
c. Fatigue
d. Excessive exercise
A. Decreased hemoglobin levels

Precipitating factors contributing to sickle cell crisis include fever, dehydration, fatigue, excessive exercise or physical activity, and elevated hemoglobin levels. (ch. 23, p 681)
The home care nurse is caring for a 4-year-old child with sickle cell disease who is scheduled for her scheduled immunizations. The parent is concerned about possible complications of administering immunizations for the sick child. How should the nurse respond?

a. The pneumococcal vaccine will be withheld
b. Regular scheduled immunizations are safe to administer
c. Live attenuated vaccines will have to be withheld
d. We will administer immunizations when child isn’t sick
B. Regular scheduled immunizations are safe to administer

To prevent infection, it is essential that the child w/ sickle cell disease receive recommended immunizations, including pneumococcal vaccine. (ch. 23, p 684)
A nurse in the pediatric facility is assigned to care for a child w/ sickle cell disease. In constructing a care plan for the child, the nurse should note that the primary reason for hospitalization of patients w/ the condition is:

a. Respiratory distress
b. Bacterial infection
c. Acute pain
d. Anemia
C. Acute pain

The most common reason for hospitalization of a child w/ sickle cell anemia is acute painful episodes. Pain results from avascular necrosis of bone marrow typically experienced in the back, abdomen, chest, and joints. (ch. 23, p 683)
A nurse is performing discharge instructions for the parents of a 12-month-old child about proper administration of iron deficiency medication for the child. To facilitate absorption of medication, the nurse would recommend mixing drug with:

a. Formula
b. Cow’s milk
c. Water
d. Orange juice
D. Orange juice

Foods rich in vitamin C such as citrus fruits, broccoli, and orange juice facilitate absorption of iron. Cow’s milk is avoided for the 1st year of life because it can cause GI bleeding in the child. (ch. 23, p 679)
A child w/ sickle cell disease is scheduled for a blood transfusion. The nurse caring for the child should also prepare which IV solution to administer before and after blood transfusion?

a. Lactated Ringer’s
b. Normal saline w/ KCl
c. 0.9% NS
d. D5W
C. 0.9% NS

To prevent hemolysis, IV fluid used before and after blood transfusion should be normal saline rather than D5W. (ch. 23, p 687-688)
A child w/ sickle cell disease is scheduled for a blood transfusion. The nurse caring for the child is also ordered to give deferoxamine (Desferal) for the child. The reason the child is receiving the drug is that the drug:

a. Aids in absorption of iron
b. Prophylaxis for allergic reactions from transfusion
c. Excretes iron from the body
d. Improves fetal hemoglobin levels
C. Excretes iron from the body

Frequent transfusions may result in an overload of iron in the body. Deferoxamine (Desferal) binds excess iron so it can be excreted by the kidneys. (ch. 23, p 685)
A child w/ sickle cell disease is scheduled for a blood transfusion. The nurse should anticipate which blood product to administer for the child?

a. Packed red blood cells
b. Fresh frozen plasma
c. Whole blood
d. Albumin
A. Packed red blood cells

Packed red blood cells increase the number of red blood cells available to carry oxygen to tissue cells. (ch. 23, p 686)
A nurse is assigned to care for a child diagnosed w/ hemophilia. Which of the following interventions should not be included in the plan of care for the patient?

a. Perform ROM exercises
b. Administer ordered Motrin PRN for pain
c. Use peripheral fingerstick to obtain blood samples
d. Refer parents for genetic counseling
B. Administer ordered Motrin PRN for pain

NSAIDs prolong bleeding time and are contraindicated for patients diagnosed w/ hemophilia. When bleeding is controlled, ROM exercises are performed to strengthen muscles and joints to prevent flexion contractures. (ch. 23, p 696-697)
A nurse is performing home care instructions for the parent of a child with atopic dermatitis (eczema). Which of the following statements by the parent indicate successful teaching?

a. I’ll give my child prescribed diphenhydramine before breakfast to control itching
b. Wool fabrics retain moisture and should be worn when outside
c. Emollient should be applied immediately after bath
d. Corticosteroids promote flare ups and should be avoided
C. Emollient should be applied immediately after bath

Applying occlusive topical emollients w/in 3 minutes of leaving water after bathing helps trap moisture in the skin and promotes flexibility of the skin w/out cracking. Diphenhydramine, if given during the day, may cause sleepiness. (ch. 31, p 1044-1047)
During the regular clinic visit, the parent of a child w/ eczema asked the nurse if the child can participate in soccer practices. How should the nurse respond?

a. Acute flare ups occurring during physical activities are contagious
b. Excessive sweating during physical activities predisposes child to secondary infection
c. Child should avoid strenuous physical activities until flare ups are controlled
d. Child can participate in physical activity if tolerated
D. Child can participate in physical activity if tolerated

The child w/ atopic eczema should participate in physical activity, even though sweating further irritates skin. Have child bathe as soon as possible after physical activity and apply emollient to skin afterward. (ch. 31, p 1047)
Which of the following assessment findings are present in a patient w/ impetigo?

a. Rough, scaly papules on exposed skin areas
b. Pearl-like lesions on the face, trunks, and extremities
c. White patches on the oral mucosa
d. Honey-colored crusts around the mouth
D. Honey-colored crusts around the mouth

Impetigo lesions begin as papule and turns into a vesicle. When the vesicle ruptures and forms an erosion, serum liquid forms the characteristic honey-colored crusts. Most common sites are the face, around the mouth, and extremities. (ch. 31, p 1038)
The parents of a child w/ impetigo phoned the local clinic and asked the nurse how to observe for development of crusts on the affected area. When answering the parent’s question, the nurse should know that crusts are:

a. Linear cracks in the skin
b. Dilated, superficial blood vessels
c. Dried residue of serum, pus, or blood
d. Replacement of destroyed tissue w/ fibrous tissue
C. Dried residue of serum, pus, or blood

Crusts are dried serum, pus, or blood usually mixed with epithelial and sometimes bacterial debris. (ch. 31, p 1034)
Discharge instructions for patients w/ impetigo include all of the following, except:

a. Prescribed medications are tapered in frequency to prevent secondary infection
b. Soak crusts in warm water and scrub off with soap
c. Child can return to childcare center after 24hours of treatment
d. Linens and clothing used by the patient should be washed separately
A. Prescribed medications are tapered in frequency to prevent secondary infection

Patients should be advised to continue oral or topical medications for the full number of days prescribed. Primary healthcare provider should be contacted if lesions don’t improve w/in 24 hours of treatment. (ch. 31, p 1038)