TEST BANK for Pediatric Physical Examination 3rd Edition by Karen Duderstadt

TEST BANK for Pediatric Physical Examination 3rd Edition by Duderstadt Chapter 1: Approach to Care and Assessment of Children and Adolescents MULTIPLE CHOICE 1. A nurse is reviewing developmental concepts for infants and children. Which statement best describes development in infants and children? a. Development, a predictable and orderly process, occurs at varying rates within normal limits. b. Development is primarily related to the growth in the number and size of cells. c. Development occurs in a proximodistal direction with fine muscle development occurring first. d. Development is more easily and accurately measured than growth.

ANS: A Development, a continuous orderly process, provides the basis for increases in the childs function and complexity of behavior. The increases in rate of function and complexity can vary normally within limits for each child. An increase in the number and size of cells is a definition for growth. Development proceeds in a proximodistal direction with fine muscle organization occurring as a result of large muscle organization. Development is a more complex process that is affected by many factors; therefore, it is less easily and accurately measured. Growth is a predictable process with standard measurement methods.

2. Frequent developmental assessments are important for which reason? a. Stable developmental periods during infancy provide an opportunity to identify any delays or deficits. b. Infants need stimulation specific to the stage of development. c. Critical periods of development occur during childhood. d. Child development is unpredictable and needs monitoring.

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ANS: C Critical periods are blocks of time during which children are ready to master specific developmental tasks. Children can master these tasks more easily during particular periods of time in their growth and developmental process. Infancy is a dynamic time of development that requires frequent evaluations to assess appropriate developmental progress. Infants in a nurturing environment will develop appropriately and will not necessarily need stimulation specific to their developmental stage. Normal growth and development are orderly and proceed in a predictable pattern on the basis of each individuals abilities and potentials.

3. Which factor has the greatest influence on child growth and development? a. Culture b. Environment c. Genetics d. Nutrition ANS: C Genetic factors (heredity) determine each individuals growth and developmental rate. Although factors such as environment, culture, nutrition, and family can influence genetic traits, they do not eliminate the effect of the genetic endowment, which is permanent. Culture is a significant factor that influences how children grow toward adulthood. Culture influences both growth and development but does not eliminate inborn genetic influences. Environment has a significant role in determining growth and development both before and after birth. The environment can influence how and to which extent genetic traits are manifested, but environmental factors cannot eliminate the effect of genetics. Nutrition is critical for growth and plays a significant role throughout childhood.

4. A nurse is planning a teaching session with a child. According to Piagetian theory, the period of cognitive development in which the child is able to distinguish fact from fantasy is the period of cognitive development. a. sensorimotor

b. formal operations c. concrete operations d. preoperational ANS: C Concrete operations is the period of cognitive development in which childrens thinking is shifted from egocentric to being able to see anothers point of view. They develop the ability to distinguish fact from fantasy. The sensorimotor stage occurs in infancy and is a period of reflexive behavior. During this period, the infants world becomes more permanent and organized. The stage ends with the infant demonstrating some evidence of reasoning. Formal operations is a period in development in which new ideas are created through previous thoughts.

Analytic reason and abstract thought emerge in this period. The preoperational stage is a period of egocentrism in which the childs judgments are illogical and dominated by magical thinking and animism.

5. The theorist who viewed developmental progression as a lifelong series of conflicts that need resolution is: a. Erikson. b. Freud. c. Kohlberg. d. Piaget.

ANS: A Erik Erikson viewed development as a series of conflicts affected by social and cultural factors.

Each conflict must be resolved for the child to progress emotionally, with unsuccessful resolution leaving the child emotionally disabled. Sigmund Freud proposed a psychosexual theory of development in which certain parts of the body assume psychological significance as foci of sexual energy. The foci shift as the individual moves through the different stages (oral, anal, phallic, latency, and genital) of development. Lawrence Kohlberg described moral development as having three levels (preconventional, conventional, and postconventional). His

theory closely parallels Piagets. Jean Piagets cognitive theory interprets how children learn and think and how this thinking progresses and differs from adult thinking. Stages of his theory include sensorimotor, preoperations, concrete operations, and formal operations.

6. What does the nurse need to know when observing chronically ill children at play? a. Play is not important to hospitalized children. b. Children need to have structured play periods. c. Childrens play is an indication of a childs response to treatment. d. Play is to be discouraged because it tires hospitalized children.

ANS: C Play for all children is an activity woven with meaning and purpose and is a mechanism for mastering their environment. For chronically ill children, play can indicate their state of wellness and response to treatment. Play is important to all children in all environments. Although childrens play activities appear unorganized and at times chaotic, play has purpose and meaning.

Imposing structure on play interferes with the tasks being worked on. Children who have fewer energy reserves still require play. For these children, less-active play activities will be important.

7. Which child is most likely to be frightened by hospitalization? a. A 4-month-old infant admitted with a diagnosis of bronchiolitis b. A 2-year-old toddler admitted for cystic fibrosis c. A 9-year-old child hospitalized with a fractured femur d. A 15-year-old adolescent admitted for abdominal pain ANS: B Toddlers are most likely to be frightened by hospitalization because their thought processes are egocentric, magical, and illogical. They feel very threatened by unfamiliar people and strange environments. Young infants are not as likely to be frightened as toddlers by hospitalization because they are not as aware of the environment. The 9-year-old childs cognitive ability is

sufficient enough for the child to understand the reason for the hospitalization. The 15-year-old adolescent has the cognitive ability to interpret the reason for the hospitalization.

8. Which statement made by a 15-year-old adolescent with a diagnosis of neurofibromatosis (an autosomal dominant genetic disorder) best demonstrates an understanding of the mechanism of inheritance for the disease? a. My babies will probably not have neurofibromatosis. b. My babies have a 50% chance of having neurofibromatosis. c. Whether my babies have problems depends on the father. d. My babies have a 25% chance of having neurofibromatosis.

ANS: B Neurofibromatosis is an autosomal dominant genetic disorder that occurs when the abnormal gene is carried on the affected chromosome with a normal gene. Because the abnormal gene is dominant, an individual with the defective gene has a 50% chance of transmitting the defect to an infant with each pregnancy. Neurofibromatosis is not a sex-linked genetic disease; therefore, either the father or the mother genetically transfers it to the infant. A parent with the defective gene will genetically transfer either a normal or abnormal gene to an infant. Because the defective gene is dominant, there is a 50% probability of the child inheriting the disease.

9. During a routine healthcare visit, a parent asks the nurse why her 9-month-old infant is not walking as her older child did at the same age. Which response by the nurse best demonstrates an understanding of child development? a. Shes a little slow. b. If she is pulling up, you can help her by holding her hand. c. Babies progress at different rates. Your infants development is within normal limits. d. Maybe she needs to see a behavioral specialist.

ANS: C

Ninety percent of infants walk by 14 months of age. The infant is within normal developmental limits. It is inappropriate for the nurse to state that the infant is a little slow. Infants will walk when they are developmentally ready. Hurrying an infant does not result in the developmental task being achieved at an earlier time period. Consulting a behavioral specialist for diagnostic evaluation is indicated when a child demonstrates developmental delays. The child has no evidence of a delay.

10. Which expected outcome would be developmentally appropriate for a hospitalized 4-year-old child? a. The child will be dressed and fed by the parents. b. The child will independently ask for play materials or other personal needs. c. The child will be able to verbalize an understanding of the reason for the hospitalization. d. The child will have a parent stay in the room at all times.

ANS: B Erikson identifies initiative as a developmental task for the preschool child. Initiating play activities and asking for play materials or assistance with personal needs demonstrate developmental appropriateness. Parents need to foster appropriate developmental behavior in the 4-year-old child. Dressing and feeding the child do not encourage independent behavior. A 4year-old child cannot be expected to cognitively understand the reason for his or her hospitalization. Expecting the child to verbalize an understanding for the hospitalization is an inappropriate outcome. Parents staying with the child throughout a hospitalization is an inappropriate outcome. Although children benefit from parental involvement, parents may not have the support structure to stay in the room with the child at all times.

11. A nurse has completed a teaching session with parents of preschool aged children. Which statement made by the parent identifies an appropriate level of language development for a 4year-old child? a. The child has a vocabulary of 300 words and uses simple sentences. b. The child uses correct grammar in sentences.

c. The child is able to pronounce consonants clearly. d. The child uses language to express abstract thought.

ANS: B The 4-year-old child is able to use correct grammar in sentence structure and typically has difficulty in pronouncing consonants. Simple sentences and a 300-word vocabulary are appropriate for a 2-year-old child. The use of language to express abstract thought is developmentally appropriate for the adolescent.

12. Which should the nurse evaluate before administering the Denver Developmental Screening Test II (DDST-II)? a. The childs height and weight b. The parents ability to comprehend the results c. The childs mood d. The parentchild interaction ANS: C The results of the screening test are valid if the child acted in a normal and expected manner. The childs height and weight are not relevant to the DDST-II screening process. The parents ability to understand the results of the screening is not relevant to the validity of the test. The parentchild interaction is not significantly relevant to the test results.

13. Which children are at greater risk for not receiving immunizations? a. Children who attend licensed day care programs b. Children entering school c. Children who are home schooled d. Young adults entering college ANS: C

Home schooled children are at risk for being underimmunized and need to be monitored. All states require immunizations for children in day care programs and entering school. Most colleges require a record of immunizations as part of a health history.

14. Which developmental assessment instrument is appropriate to assess a 5-year-old child? a. Brazelton Behavioral Scale b. Denver Developmental Screening Test II (DDST-II) c. Dubowitz Scale d. New Ballard Scale ANS: B The DDST-II is used for infants and children between birth and 6 years of age. Brazeltons Behavioral Scale is used for newborn assessment. The Dubowitz Scale is used for estimation of gestational age. The New Ballard Scale is used for newborn screening.

15. A 2-month-old child has not received any immunizations. Which immunizations should the nurse give? a. DTaP, Hib, HepB, IPV, varicella b. DTaP, Hib, HepB, MMR, IPV c. DTaP, Hib, HepB, PCV, IPV, rotavirus d. DTaP, Hib, HepB, PCV, IPV, HepA ANS: C DTaP, Hib, HepB, PCV, IPV, and rotavirus are appropriate immunizations for an unimmunized 2-month-old child. The child should not receive varicella until at or after 12 months of age.

MMR is not given to children until at or after 12 months of age. HepA is recommended for all children at 1 year of age.

16. You are preparing immunizations for a 12-month-old child who is immunocompromised.

Which immunization cannot be given?

a.

DTaP

b.

HepA

c. IPV d. Varicella ANS: D Children who are immunologically compromised should not receive live viral vaccines. Varicella is a live vaccine, and should not be given except in special circumstances. DTaP, HepA, and IPV can be safely given.

17. Which immunization can cause fever and rash to occur 1 to 2 weeks after administration? a.

HepB

b.

DTaP

c. Hib d. MMR ANS: D MMR is a live virus vaccine and can cause fever and rash 1 to 2 weeks after administration.

HepB, DTaP, and Hib do not cause fever or rash.

18. A nurse is teaching an adolescent about Tanner stages. Which statement best describes Tanner staging? a. Predictable stages of puberty that are based on chronological age b. Staging of puberty based on the initiation of menarche and nocturnal emissions c. Predictable stages of puberty that are based on primary and secondary sexual characteristics d. Staging of puberty based on the initiation of primary sexual characteristics ANS: C

Tanner sexual-maturing ratings are based on the development of stages of primary and secondary sexual characteristics. They are not based on chronological age. The age at which an adolescent enters puberty is variable. The puberty stage in girls begins with breast development. The puberty stage in boys begins with genital enlargement. Primary sexual characteristics are not the basis of Tanner staging.

19. Which behavior suggests appropriate psychosocial development in the adolescent? a. The adolescent seeks validation for socially acceptable behavior from older adults. b. The adolescent is self-absorbed and self-centered and has sudden mood swings. c. Adolescents move from peers and enjoy spending time with family members. d. Conformity with the peer group increases in late adolescence.

ANS: B During adolescence, energy is focused within. Adolescents concentrate on themselves in an effort to determine who they are or who they will be. Adolescents are likely to be impulsive and impatient. The peer group validates acceptable behavior during adolescence. Adolescents move from family and enjoy spending time with peers. Adolescents also spend time alone; they need this time to think and concentrate on themselves. Conformity becomes less important in late adolescence.

20. The parents of a 14-year-old girl are concerned that their adolescent spends too much time looking in the mirror. Which statement is the most appropriate for the nurse to make? a. Your teenager needs clearer and stricter limits about her behavior. b. Your teenager needs more responsibility at home. c. During adolescence, this behavior is not unusual. d. The behavior is abnormal and needs further investigation.

ANS: C

Narcissistic behavior is normal during this period of development. The teenager is seeking a personal identity. Stricter limits are not an appropriate response for a behavior that is part of normal development. More responsibility at home is not an appropriate response for this situation.

21. Which factor contributes to early adolescents engaging in risk-taking behaviors? a. Peer pressure b. A desire to master their environment c. Engagement in the process of separation from their parents d. A belief that they are invulnerable ANS: D During early to middle adolescence, children feel that they are exempt from the consequences of risk-taking behaviors: they believe negative consequences happen only to others. Impressing peers is more typically the factor influencing behavior of older school-age children. Mastering the environment is the task of young school-age children. Emancipation is a major issue for the older adolescent. The process is accomplished as the teenager gains an education or vocational training.

22. Which statement is the most appropriate advice to give parents of a 16-year-old teenager who is rebellious? a. You need to be stricter so that your teenager feels more secure. b. You need to allow your teenager to make realistic choices while using consistent and structured discipline. c. Increasing your teens involvement with his peers will improve his self-esteem. d. Allow your teenager to choose the type of discipline that is used in your home.

ANS: B Allowing teenagers to choose between realistic options and offering consistent and structured discipline typically enhances cooperation and decreases rebelliousness. Setting stricter limits

typically does not decrease rebelliousness or increase feelings of security. Increasing peer involvement does not typically increase self-esteem. Allowing teenagers to choose the method of discipline is not realistic and typically does not reduce rebelliousness.

MULTIPLE RESPONSE 1. The nurse is preparing immunizations for a healthy 11-year-old boy who has received all his primary immunizations. Which immunizations will the nurse consider? Select all that apply. a. Meningococcal b. DTaP c. OPV d. Smallpox ANS: A, B Meningococcal conjugate vaccine should be given to all children at age 11 to 12 years. The American Academy of Pediatrics recommends one dose of DTaP vaccine for children at age 11 to 12 years, as long as they have received the primary DTaP series. Oral polio vaccine is no longer administered in the U.S. The current smallpox vaccine is not recommended for healthy, low-risk children younger than 18 years of age.

2. Parents of a 4-month-old child ask the nurse what they can do to help relieve the discomfort of teething. The nurse should include which suggestions for the parents? Select all that apply. a. Provide warm liquids. b. Rub the gums with aspirin. c. Over-the-counter topical medications for gum pain relief can be used as directed. d. Administer acetaminophen (Tylenol) as directed. e. Provide a hard food such as a frozen bagel for chewing.

ANS: C, D, E To help parents cope with teething, nurses can suggest that they provide cool liquids and hard foods (e.g., dry toast, Popsicles, frozen bagels) for chewing. Hard, cold teethers and ice wrapped in cloth may also provide comfort for inflamed gums. Nurses should explain to parents that overthe-counter topical medications for gum pain relief should be used only as directed. Home remedies, such as rubbing the gums with whiskey or aspirin, should be discouraged, but acetaminophen administered as directed for the childs age can relieve discomfort.

OTHER 1. Place in order the gross motor developmental milestones a nurse expects to assess in an infant.

Begin with the earliest gross motor milestone expected and progress to the last gross motor milestone attained. a. Turns from abdomen to back b. Lifts head off of bed when in a prone position c. Walks holding on to furniture d. Turns from back to abdomen e. Sits unsupported ANS: B, A, D, E, C The infant lifts its head off of the bed when in a prone position at 3 months, turns from abdomen to back at 4 to 5 months, turns from back to abdomen at 6 to 7 months, sits unsupported at 8 to 9 months, and can walk holding on to furniture at 10 to 12 months.

Chapter 2. Physical Assessment Parameters MULTIPLE CHOICE 1. The nurse is performing an abdominal assessment on a child. When percussing over the stomach, the nurse should hear which sound? a. Tympany b. Resonance c. Flatness d. Dullness ANS: A Tympany is a high-pitched, loud-intensity sound heard over air-filled body parts such as the stomach and bowel. Resonance is a low-pitched, low-intensity sound elicited over hollow organs such as the lungs. Flatness is a high-pitched, soft-intensity sound elicited by percussing over solid masses such as bone or muscle. Dullness is a medium-pitched, medium-intensity sound elicited when percussing over high-density structures such as the liver.

2. A nurse is preparing to begin an assessment on a newly admitted child. The nurse should be aware that the single most important component of a pediatric physical examination is: a. assessment of heart and lungs. b. measurement of height and weight. c. documentation of parental concerns. d. obtaining an accurate history.

ANS: D An accurate history is most helpful in identifying problems and potential problems. Heart and lung assessment and documentation of parental concerns are not as important as an accurate history. A single measurement of height and weight is not as significant as determining growth over time. The childs growth pattern can be elicited from the history.

3. In which section of the health history should the nurse record that the parent brought the infant to the clinic today because of frequent diarrhea? a. Review of systems b. Chief complaint c. Lifestyle and life patterns d. Health history ANS: B The chief complaint is documented using the childs or parents words for the reason the child was brought to the healthcare center. The review of systems includes past health functions of body systems. Lifestyle and life patterns include the childs interaction with the social, psychological, physical, and cultural environment. Health history includes birth history, growth and development, common childhood illnesses, immunizations, hospitalizations, injuries, and allergies.

4. A nurse is reviewing pediatric physical assessment techniques. Which statement about performing a pediatric physical assessment is correct? a. Physical examinations proceed systematically from head to toe unless developmental considerations dictate otherwise. b. The physical examination should be done with parents in the examining room for children of any age. c. Measurement of head circumference is done until the child is 5 years old. d. The physical examination is done only when the child is cooperative.

ANS: A Physical assessment usually proceeds from head to toe; however, developmental considerations with infants and toddlers dictate that the least threatening assessments be done first to obtain accurate data. Having parents in the examining room with adolescents is not appropriate. Head circumference is routinely measured until 36 months of age. Children will not always be

cooperative during the physical examination. The examiner will need to incorporate communication and play techniques to facilitate cooperation.

5. A nurse is conducting an assessment on a child during a well-child visit. Which of the following includes the components of a complete pediatric history? a. Statistical information, client profile, health history, family history, review of systems, and lifestyle and life patterns b. Vital signs, chief complaint, and a list of previous problems c. Chief complaint, including body location, quality, quantity, time frame, and alleviating and aggravating factors d. Pertinent developmental and family information ANS: A Statistical information, client profile, health history, family history, review of systems, and lifestyle and life patterns are included in a complete pediatric history. Vital signs, chief complaint, and list of previous problems do not constitute a complete history. A problemoriented history includes specific information about the chief complaint. Pertinent developmental and family information are part of the complete history.

6. At what age can the nurse expect a childs head and chest circumference to be almost equal? a. Birth b. 6 months c. 1 year d. 3 years ANS: C Head and chest measurements are almost equal at 1 year of age. Head circumference is larger than chest circumference until approximately 1 year of age. By 3 years of age, the chest circumference exceeds the head circumference.

7. A nurse is teaching unlicensed assistive personnel (UAP) how to take accurate blood pressure on children. The nurse knows the UAPs have understood the teaching if they state that to obtain an accurate measurement of a childs blood pressure, the cuff should cover which portion of the childs upper arm? a. Two-thirds b. Three-fourths c. One-half d. One-third ANS: A The blood pressure cuff should cover two-thirds of the childs upper arm to get an accurate reading. A cuff that covers more than two-thirds of the childs upper arm will result in a false low reading. A cuff that covers less than two-thirds of the childs upper arm will result in a false high reading.

8. Which chart should the nurse use to assess the visual acuity of an 8-year-old child? a. Lea chart b. Snellen chart c. HOTV chart d. Tumbling E chart ANS: B The Snellen chart is used to assess the vision of children older than 6 years of age. The Lea chart tests vision using four different symbols designed for use with preschool children. The HOTV chart tests vision by using graduated letters and is designed for use with children ages 3 to 6 years. The Tumbling E chart uses the letter E in various directions and is designed for use with children ages 3 to 6 years.

9. Which action is appropriate when the nurse is assessing breath sounds of an 18-month-old crying child? a. Ask the parent to quiet the child so the nurse can listen. b. Auscultate breath sounds and chart that the child was crying. c. Encourage the child to play with the stethoscope to distract and to calm down the child before auscultating. d. Document that data are not available because of noncompliance.

ANS: C Distracting the child with an interesting activity can assist the child to calm down so an accurate assessment can be made. Asking a parent to quiet the child may or may not work. Auscultating while the child is crying typically results in less than optimal data. Documenting that the child is not compliant is not appropriate. An assessment needs to be completed.

10. Which is the most appropriate site for the nurse to use to measure a pulse rate on a 1-year-old child? a. Apical b.

Radial

c.

Carotid d. Femoral ANS: A Apical pulse rates are taken in children younger than 2 years. Radial pulse rates may be taken in children older than 2 years. It is difficult to palpate the carotid pulse in an infant. The femoral pulse is palpated when comparing peripheral pulses, but it is not used to measure an infants pulse rate.

11. What is the most appropriate action for the nurse to take when a crying toddler has a blood pressure measurement of 120/70 mm Hg?

a. Notify the physician of the measurement. b. Document the blood pressure reading and check it again in 4 hours. c. Quiet the child and retake the blood pressure. d. Ask the parent if the child has a history of hypertension.

ANS: C Blood pressure is elevated when a child is upset and crying. Quieting the child before retaking the blood pressure is appropriate. Notifying the physician is not necessary until accurate data are obtained. Documenting the blood pressure and waiting 4 hours before taking another measurement is inappropriate because this reading is not within the normal range. Asking the parent about a history of hypertension is irrelevant when a child is upset and crying as blood pressure is elevated.

12. What term should be used in the nurses documentation to describe auscultation of breath sounds that are short, popping, and discontinuous on inspiration? a. Pleural friction rub b. Bronchovesicular sounds c. Crackles d. Wheeze ANS: C Crackles are short, popping, discontinuous sounds heard on inspiration. A pleural friction rub has a grating, coarse, low-pitched sound. Bronchovesicular sounds are auscultated over mainstem bronchi. They are clear, without any adventitious sounds. Wheezes are musical, high-pitched, predominant sounds heard on expiration.

13. Which strategy should be the best approach when initiating the physical examination of a 9month-old infant? a. Undress the infant and do a head-to-toe examination.

b. Have the parent hold the child on his or her lap. c. Put the infant on the examination table and begin assessments at the head. d. Ask the parent to leave because the infant will be upset.

ANS: B Infants 6 months and older feel stranger anxiety. It is easier to do most of the examination on the parents lap to decrease anxiety. The head-to-toe approach needs to be modified for the infant.

Uncomfortable procedures, such as the otoscopic examination, should be left until last. The infant may feel less fearful if placed in the parents lap or with the parent within visual range if placed on the examining table. There is no reason to ask a parent to leave when an infant is being examined. Having the parent with the infant will make the experience less upsetting for the infant.

14. Which strategy is not always appropriate for a pediatric physical examination? a. Take the history in a quiet, private place. b. Examine the child from head to toe. c. Exhibit sensitivity to cultural needs and differences. d. Perform frightening procedures last.

ANS: B The classic approach to a physical examination is to begin at the head and proceed through the entire body to the toes. When examining a child, however, the examiner must tailor the physical assessment to the childs age and developmental level. The nurse should collect the childs health history in a quiet, private area and painful or frightening procedures should be left to the end of the examination. The nurse should always be sensitive to cultural needs and differences among children.

15. Which assessment should the nurse perform last when examining a 5-year-old child? a. Heart

b. Lungs c. Abdomen d. Throat ANS: D Examination of the mouth and throat is considered to be more invasive than other parts of a physical examination. For preschool children, invasive procedures should be left to the end of the examination. The nurse may proceed from head to toe with preschool age children. Assessment of the abdomen and lungs is not considered to be frightening.

16. When would be the most appropriate time to inspect the genital area during a well-child examination of a 14-year-old female? a. It is not necessary to inspect the genital area. b. Examine the genital area first. c. After the abdominal assessment. d. Do the genital inspection last.

ANS: C It is best to incorporate the genital assessment into the middle of the examination. This allows ample time for questions and discussion. If possible, proceed from the abdominal area to the genital area. A visual inspection of all areas of the body is included in a physical examination.

Examination of the genital area can be embarrassing. It would not be appropriate to begin the examination of this area. Assessing the genital area earlier in the examination allows more time for the adolescent to ask questions and engage in discussion.

17. Which measurement is not indicated for a 4-year-old well-child examination? a. Blood pressure b. Weight c. Height

d. Head circumference ANS: D Head circumference is measured on all children from birth to 3 years. Blood pressure measurements are taken on all children at every ambulatory visit. Weight and height are measured at every well-child examination.

18. The nurse inspecting the skin of a dark-skinned child notices an area that is a dusky red or violet color. This skin coloration is associated with which? a.

Cyanosis

b.

Erythema

c. Vitiligo d. Nevi ANS: B In dark-skinned children, erythema appears as dusky red or violet skin coloration. Cyanosis in a dark-skinned child would appear as a black coloration of the skin. Vitiligo refers to areas of depigmentation. Nevi are areas of increased pigmentation.

19. The nurse palpated the anterior fontanel of a 14-month-old infant and found that it was closed. What would this finding indicate? a. This is a normal finding. b. This finding indicates premature closure of cranial sutures. c. This is an abnormal finding and the child should have a developmental evaluation. d. This is an abnormal finding and the child should have a neurological evaluation.

ANS: A

The anterior fontanel should be completely closed by 12 to 18 months of age. A closed anterior fontanel at 14 months of age does not indicate premature closure of cranial sutures, is not abnormal, and does not indicate the need for a neurological examination.

20. A nurse is conducting vision screening on preschool children. Which of the following corresponds with the normal range for visual acuity of a 4-year-old child? a.

20/50 to 20/80

b.

20/40 to 20/70

c.

20/30 to 20/40

d. 20/20 to 20/30 ANS: C 20/30 to 20/40 is the normal range for visual acuity at 4 years of age. 20/50 to 20/80 is the normal range for visual acuity at 4 months of age. 20/40 to 20/70 is the normal range for visual acuity at 1 year of age. 20/20 to 20/30 is the normal range for visual acuity at 5 years of age.

21. A child begins to squirm and giggle when the nurse begins to palpate the abdomen. What is the best approach for the nurse to use with a child who is ticklish? a. Skip the abdominal palpation. b. Touch the abdomen firmly as the child takes short, quick breaths. c. Press the abdomen with the child bearing down and holding the breath. d. Palpate with the childs hand under the examiners hand.

ANS: D Placing the childs hand on the abdomen and the examiners hand on top of the childs hand with fingers touching the abdomen gives the child some control and reduces the sensation of tickling.

Abdominal palpation should not be eliminated from the physical assessment. To help the child relax, the nurse would ask the child to take deep breaths. Bearing down and holding the breath would tighten the abdominal muscles.

22. Which cranial nerve is assessed when the child is asked to imitate the examiners wrinkled frown, wrinkled forehead, smile, and raised eyebrow? a. Accessory b. Hypoglossal c. Trigeminal d. Facial ANS: D The facial nerve is assessed as described in the question. To assess the accessory nerve, the examiner palpates and notes the strength of the trapezius and sternocleidomastoid muscles against resistance. To assess the hypoglossal nerve, the examiner asks the child to stick out the tongue. To assess the trigeminal nerve, the child is asked to identify a wisp of cotton on the face.

The corneal reflex and temporal and masseter muscle strength are evaluated.

23. Which assessment finding is considered a neurological soft sign in a 7-year-old child? a. Plantar reflex b. Poor muscle coordination c. Stereognostic function d. Graphesthesia ANS: B Poor muscle coordination is a neurological soft sign. The plantar reflex is a normal response.

When the lateral aspect of the sole of the foot is stroked in a movement curving medially from the heel to the ball, the response will be plantar flexion of the toes. Stereognostic function refers to the ability to identify familiar objects placed in each hand. Graphesthesia is the ability to identify letters or numbers traced on the palm or back of the hand with a blunt point.

MULTIPLE RESPONSE

1. A nurse is performing an assessment on a newborn. Which vital signs indicate a normal finding for this age group? Select all that apply. a. Pulse of 80 to 125 a minute b. B/P of systolic 65 to 95 and diastolic 30 to 60 c.

Temperature of 36.5 to 37.3 Celsius (axillary)

d. Temperature of 36.4 to 37 Celsius (axillary) e. Respirations of 30 to 60 a minute ANS: B, C, E The normal vital signs for a newborn are temperature 36.5 to 37.3 Celsius (axillary), pulse rate of 120 to 160 a minute, respiratory rate of 30 to 60 a minute, systolic B/P of 65 to 95, and diastolic B/P of 30 to 62. A temperature of 36.4 to 37 Celsius is normal for an older child. A pulse rate of 80 to 125 is normal for a 4-year-old child.

2. A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis? Select all that apply. a. Pain with deep palpation of the spinal column b. Unequal shoulder heights c. The trouser pant leg length appears shorter on one side d. Inability to bend at the waist e. Unequal waist angles ANS: B, C, E The assessment findings associated with scoliosis include unequal shoulder heights, trouser pant leg length appearing shorter on one side meaning unequal leg length, and unequal waist angles.

Scoliosis is a nonpainful curvature of the spine so pain is not expected and the child is able to bend at the waist adequately.

Chapter 3. Developmental Surveillance and Screening 1. Which body system does the nurse assess primarily by inspection? a. Respiratory b. Gastrointestinal c. Skin d. Cardiovascular ANS: C Feedback A The respiratory system is assessed primarily using auscultation, but also percussion and inspection when observing pale or cyanotic skin from hypoxia.

B The gastrointestinal system is assessed primarily by auscultation and palpation, but also with inspection when looking at the contour of the abdomen.

C Skin is assessed primarily using inspection, but also palpation.

D The cardiovascular system is assessed primarily with auscultation and palpation, but also by inspection when looking at the color of extremities for evidence of perfusion or edema.

2. A patient is sitting slightly forward bracing his arms on his knees in a tripod position. This position is associated with which symptom? a. Abdominal pain b. Spinal deformity c. Back pain d. Breathing difficulty ANS: D Feedback A Positions used by patients with abdominal pain vary depending upon what organ is involved.

For example, patients with appendicitis tend to lie very still; those with acute pancreatitis prefer the fetal position for pain relief.

B Spinal deformity usually affects the patients gait or causes a slumped posture.

C Back pain usually affects the patients gait or causes a slumped posture.

D Breathing difficulty is associated with the tripod position, which allows maximal expansion of

the muscles of respiration.

3. The temperature of a patient is measured every 6 hours at 6 AM, 12 PM, 6 PM, and 12 AM. Which temperature reading is expected to be low due to a normal variation? a. The measurement at 6 AM b. The measurement at 12 PM c. The measurement at 6 PM d. The measurement at 12 AM ANS: A Feedback A Early in the morning is the time of the lowest temperature of the day due to circadian rhythms.

B A low temperature due to circadian rhythms is not expected at this time.

C The highest temperature occurs in the late afternoon and early evening due to circadian rhythms.

D A low temperature due to circadian rhythms is not expected at this time.

4. Which statement is correct regarding taking or interpreting axillary temperatures? a. Axillary temperatures should not be used in patients less than 2 years of age. b. Readings may be less accurate. c. The thermometer is left in place for no more than 3 minutes. d. The thermometer is placed in the axilla with the shoulder abducted.

ANS: B Feedback A The axilla is a common site for temperature measurement on infants and children.

B Multiple studies have shown temperature measurements at the axillary site are less accurate compared with alternative sites.

C The thermometer is left in place until the audible signal occurs and the temperature appears on the screen.

D Place the probe in the middle of the axilla, with the arm held against the body (adducted).

5. A temperature of 99.8 F taken in the axilla is equivalent to which temperature value taken orally? a. 100.8 F b. 99.8 F c. 98.8 F d. 97.8 F ANS: A Feedback A Normal temperature readings from the axilla are about 1 F below the normal oral temperature.

B Normal temperature readings from the axilla are about 1 F below the normal oral temperature.

C Normal temperature readings from the axilla are about 1 F below the normal oral temperature.

D Normal temperature readings from the axilla are about 1 F below the normal oral temperature.

6. The nurse suspects an irregularity in the rhythm of the patients radial pulse. What is the most appropriate action for this nurse to take at this time? a. Document this rhythm as normal for the patient. b. Use a Doppler to check the brachial pulse. c. Count the patients apical pulse for a full minute. d. Count the radial pulse again for 15 seconds and multiply by 4.

ANS: C Feedback A An irregular rhythm is not a normal finding. The pulsation between each beat should be the same or regular.

B A Doppler is not indicated in this case; it is used when the pulse cannot be palpated.

C When an irregular pulse is palpated, the nurse counts the number of pulsations for a full minute.

D Counting the radial pulse again for 15 seconds and multiplying by 4 may reconfirm the initial findings, but does not provide additional data for the nurse on this patient.

7. The patient with a respiratory rate that is within normal limits is the rate is

breaths/min.

a. 16-month-old; 36

whose respiratory

b. 6-year-old; 20 c. 14-year-old;26 d. 40-year-old; 10 ANS: B Feedback A A toddlers respiratory rate ranges from 24 to 32.

B A school-age childs respiratory rate ranges from 18 to 26.

C An adolescents respiratory rate ranges from 12 to 16.

D An adults respiratory rate ranges from 12 to 20.

8. A nurse is taking vital signs of an adult patient whose oxygen saturation is 96%. The patients temperature is 102 F, blood pressure is 130/86, pulse is 100 beats/min, and respiratory rate is 26 breaths/min. Which factor may be contributing to the elevated respiratory rate? a. The patients temperature b. The patients oxygen saturation c. The patients pulse rate d. The patients blood pressure ANS: A Feedback A Fever is a factor that may increase respiratory rate, and this patients temperature is 102 F. B The patients oxygen saturation is a measure of the oxygen carried by hemoglobin and it is within expected limitsabove 90%.

C The patients pulse rate may be due to the high temperature, but a pulse of 100 does not contribute to an elevated respiratory rate in this case.

D The patients blood pressure is higher than normal, but does not contribute to an elevated respiratory rate in this case.

9. Nurses understand that a patients diastolic pressure represents which physiologic function? a. The pressure needed to open the aortic and pulmonic valves b. The pressure in blood vessels when the ventricles contract

c. The pressure of the blood returning to the heart from the venous system d. The pressure in blood vessels when the ventricles are relaxed ANS: D Feedback A The pressure needed to open the aortic and pulmonic valves is called the afterload.

B The pressure in blood vessels when the ventricles contract is the definition of the systolic pressure.

C The pressure of the blood returning to the heart from the venous system is incorrect.

D The pressure in blood vessels when the ventricles are relaxed is the definition of the diastolic pressure.

10. According to research findings, which site is preferred for measuring blood pressure when the nurse is unable to use the patients upper arms? a. Ankle b. Thigh c. Calf d. Wrist ANS: A Feedback A A study comparing accuracy among sites recommended the ankle as an alternative site for blood pressure measurement.

B The thigh is an alternative site, but the ankle is the preferred site.

C A study comparing accuracy among sites recommended the ankle site in preference to the calf as an alternative site for blood pressure measurement if the upper arm is unavailable.

D Approaches to measuring blood pressure using the wrist and finger sites have been developed, but these lack acceptable accuracy and cost efficiency to be recommended for clinical practice.

11. A patients blood pressure has been averaging 120/72 when using the upper arms. Today the nurse uses this patients thigh to measure the blood pressure. What is the expected systolic pressure using the thigh that is equivalent to a systolic pressure of 120?

a. A systolic reading of 110 mm Hg b. A systolic reading of 120 mm Hg c. A systolic reading of 140 mm Hg d. A systolic reading of 170 mm Hg ANS: C Feedback A A systolic reading of 110 mm Hg is too low.

B A systolic reading of 120 mm Hg is too low.

C Normally the systolic blood pressure is 10 to 40 mm Hg higher in the leg than in the arm.

D A systolic reading of 170 mm Hg is too high.

12. A nurse notices that the patient has gained 11 lb. If this increase in weight is related to fluid retention, the patient is retaining approximately how many liters of fluid? a. 1 L b. 5 L c. 11 L d. 24 L ANS: B Feedback A Every kg equals a liter of fluid. Thus, 11 lb 2.2 = 5 L. B Every kilogram (kg) equals a liter of fluid. Thus, 11 lb 2.2 = 5 L. C Every kg equals a liter of fluid. Thus, 11 lb 2.2 = 5 L. D Every kg equals a liter of fluid. Thus, 11 lb 2.2 = 5 L. This answer is obtained by multiplying 11 by 2.2 instead of dividing.

MULTIPLE RESPONSE 1. Which method of temperature measurement indirectly reflects inner core temperature?

Select all that apply. a. Axillary temperature b. Oral temperature

c. Tympanic temperature d. Rectal temperature e. Temporal artery temperature ANS: B, E Correct: Inner core temperature is measured indirectly because the probe is placed near an artery.

For oral temperature, the probe is placed near the carotid artery and the temporal artery is used for the temporal artery temperature.

Incorrect: For axillary, tympanic, and rectal temperatures, the probe is not placed close to any major blood vessels.

2. Which method of temperature measurement does a nurse choose when assessing children?

Select all that apply. a. Axillary temperature b. Rectal temperature c. Temporal artery temperature d. Oral temperature e. Tympanic membrane temperature ANS: A, C, D, E Correct: Axillary, temporal artery, oral, and tympanic membrane temperatures are appropriate for children.

Incorrect: Rectal temperature measurement is considered safe and accurate for adults only.

3. Which action by the nurse results in the patients blood pressure measurement being falsely high? Select all that apply. a. Using a blood pressure cuff that is too narrow for the patients upper arm b. Deflating the blood pressure cuff too rapidly c. Wrapping the blood pressure cuff too loosely d. Reinflating the blood pressure cuff before it completely deflates e. Positioning the patients arm above the level of the heart ANS: A, C, D, E Correct: Using a blood pressure cuff that is too narrow for the patients upper arm, wrapping the cuff too loosely, reinflating the cuff before it completely deflates, and positioning the patients arm above the level of the heart all result in readings that are falsely high.

Incorrect: Deflating the blood pressure cuff too rapidly causes the blood pressure reading to be falsely low.

4. Which action by the nurse results in the patients blood pressure measurement being falsely low? Select all that apply. a. Using a blood pressure cuff that is too wide for the patients arm b. Not inflating the blood pressure cuff enough c. Positioning the patients arm above the level of the heart d. Wrapping the cuff too loosely around the arm e. Deflating the cuff too rapidly ANS: A, B, E Correct: Using a blood pressure cuff that is too wide for the patients arm, not inflating the blood pressure cuff enough, and deflating the cuff too rapidly could result in a false low reading.

Incorrect: Positioning the patients arm above the level of the heart and wrapping the cuff too loosely around the arm causes the blood pressure to be falsely high.

5. The nurse taking a patients blood pressure recognizes that several factors may cause an increased blood pressure reading. Which factors below can increase blood pressure? Select all that apply. a. The patient rates pain at a level of 7 on a scale of 0 to 10. b. The cuff was reinflated before being completely deflated. c. The patient drank cold milk just before the reading. d. The time of day is late afternoon. e. The cuff is too wide for the extremity.

ANS: A, B, D Correct: Rating pain at a level of 7 on a scale of 0 to 10, reinflating the cuff before being completely deflated, and taking the reading in late afternoon are all factors that can increase blood pressure.

Incorrect: Drinking cold milk just before the reading will not affect blood pressure, but drinking caffeine such as coffee or cola may increase blood pressure. A wide cuff makes the reading lower than it actually is rather than higher.

COMPLETION

1. A female patient admitted with fluid retention has been in diuretic therapy to remove fluid.

She weighed 187 lb on admission. Today she weighs 179 lb. Since admission, this patient has lost L from fluid loss.

ANS: 3.6 1 kg (2.2 lb) = 1 L; 187 179 = 8 lb weight loss divided by 2.2 = 3.6 L.

Chapter 4. Comprehensive Health Gathering 1. The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? a. To provide an opportunity for interaction between the patient and the nurse b. To provide a form for obtaining the patients biographic information c. To document the normal and abnormal findings of a physical assessment d. To provide a database of subjective information about the patients past and current health ANS: D The purpose of the health history is to collect subjective datawhat the person says about him or herself. The other options are not correct.

2. When the nurse is evaluating the reliability of a patients responses, which of these statements would be correct? The patient: a. Has a history of drug abuse and therefore is not reliable. b. Provided consistent information and therefore is reliable. c. Smiled throughout interview and therefore is assumed reliable. d. Would not answer questions concerning stress and therefore is not reliable.

ANS: B A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct.

3. A 17-year-old patient tells the nurse that he has ulcerative colitis. He has been having black stools for the last 24 hours. How would the nurse best document his reason for seeking care? a. J.M. is a 17-year-old man seeking treatment for ulcerative colitis. b. J.M. came into the clinic complaining of having black stools for the past 24 hours. c. J.M. is a 17-year-old who states that he has ulcerative colitis and wants it checked. d. J.M. is a 17-year-old man who states that he has been having black stools for the past 24 hours.

ANS: D

The reason for seeking care is a brief spontaneous statement in the persons own words that describes the reason for the visit. It states one (possibly two) signs or symptoms and their duration. It is enclosed in quotation marks to indicate the persons exact words.

4. A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurses best response? a. Can you point to where it hurts? b. Well talk more about that later in the interview. c. What have you had to eat in the last 24 hours? d. Have you ever had any surgeries on your abdomen?

ANS: A A final summary of any symptom the person has should include, along with seven other critical characteristics, Location: specific. The person is asked to point to the location.

5. A 16-year-old tells the nurse that she has excruciating pain in her back. Which would be the nurses appropriate response to the womans statement? a. How does your family react to your pain? b. The pain must be terrible. You probably pinched a nerve. c. Ive had back pain myself, and it can be excruciating. d. How would you say the pain affects your ability to do your daily activities?

ANS: D The symptom of pain is difficult to quantify because of individual interpretation. With pain, adjectives should be avoided and the patient should be asked how the pain affects his or her daily activities. The other responses are not appropriate.

6. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a. Patient denies usual childhood illnesses. b. Patient states he was a very healthy child. c. Patient states his sister had measles, but he didnt. d. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.

ANS: D Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat.

Avoid recording usual childhood illnesses because an illness common in the persons childhood may be unusual today (e.g., measles).

7. A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? a. P-6, B-4, (S)Ab-2

b. Grav 6, Term 4, (S)Ab-2, Living 4 c. Patient has had four living babies. d. Patient has been pregnant six times.

ANS: B Obstetric history includes the number of pregnancies (gravidity), number of deliveries in which the fetus reached term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (abortions), and number of children living (living). This is recorded: Grav Term

Preterm

Ab

Living

. For any incomplete pregnancies, the

duration is recorded and whether the pregnancy resulted in a spontaneous (S) or an induced (I) abortion.

8. A patient tells the nurse that he is allergic to penicillin. What would be the nurses best response to this information? a. Are you allergic to any other drugs? b. How often have you received penicillin? c. Ill write your allergy on your chart so you wont receive any penicillin. d. Describe what happens to you when you take penicillin.

ANS: D Note both the allergen (medication, food, or contact agent, such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, or difficulty breathing). With a drug, this symptom should not be a side effect but a true allergic reaction.

9. The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: a. Emphysema. b. Head trauma. c. Mental illness.

d. Fractured bones.

ANS: C Questions concerning any family history of heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast and ovarian cancers, colon cancer, sickle cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and tuberculosis should be asked.

10. The review of systems provides the nurse with: a. Physical findings related to each system. b. Information regarding health promotion practices. c. An opportunity to teach the patient medical terms. d. Information necessary for the nurse to diagnose the patients medical problem.

ANS: B The purposes of the review of systems are to: (1) evaluate the past and current health state of each body system, (2) double check facts in case any significant data were omitted in the present illness section, and (3) evaluate health promotion practices.

11. Which of these statements represents subjective data the nurse obtained from the patient regarding the patients skin? a. Skin appears dry. b. No lesions are obvious. c. Patient denies any color change. d. Lesion is noted on the lateral aspect of the right arm.

ANS: C The history should be limited to patient statements or subjective datafactors that the person says were or were not present.

12. The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? a. Do you perform testicular self-examinations? b. Have you ever noticed any pain in your testicles? c. Have you had any problems with passing urine? d. Do you have any history of sexually transmitted diseases?

ANS: A Health promotion for a man would include the performance of testicular self-examinations. The other questions are asking about possible disease or illness issues.

13. Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? a. I broke my right leg in a car accident 2 weeks ago. b. The pain is decreasing, but I still need to take acetaminophen. c. I check the color of my toes every evening just like I was taught. d. Im able to transfer myself from the wheelchair to the bed without help.

ANS: D Functional assessment measures a persons self-care ability in the areas of general physical health or absence of illness. The other statements concern health or illness issues.

14. In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? a. This has been a difficult year for you. b. I dont know how anyone could handle that much stress in 1 year! c. What did you do to cope with the loss of both your husband and mother?

d. That is a lot of stress; now lets go on to the next section of your history.

ANS: C Questions about coping and stress management include questions regarding the kinds of stresses in ones life, especially in the last year, any changes in lifestyle or any current stress, methods tried to relieve stress, and whether these methods have been helpful.

15. In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information? a. This information is necessary to determine the patients reliability. b. Alcohol can interact with all medications and can make some diseases worse. c. The nurse needs to be able to teach the patient about the dangers of alcohol use. d. This information is not necessary unless a drinking problem is obvious.

ANS: B Alcohol adversely interacts with all medications and is a factor in many social problems such as child or sexual abuse, automobile accidents, and assaults; alcohol also contributes to many illnesses and disease processes. Therefore, assessing for signs of hazardous alcohol use is important. The other options are not correct.

16. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? a. Maybe she is just teething. b. I will check her ear for an ear infection. c. Are you sure she is really having pain? d. Describe what she is doing to indicate she is having pain.

ANS: D

With a very young child, the parent is asked, How do you know the child is in pain? A young child pulling at his or her ears should alert parents to the childs ear pain. Statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination.

17. During an assessment of a patients family history, the nurse constructs a genogram. Which statement best describes a genogram? a. List of diseases present in a persons near relatives b. Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members c. Drawing that depicts the patients family members up to five generations back d. Description of the health of a persons children and grandchildren ANS: B A genogram (or pedigree) is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations (parents, grandparents, siblings). The other options do not describe a genogram.

Chapter 5. Environmental Health History 1. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? a. Childs birth weight b. Age at which he crawled c. Whether the child has had the measles d. Childs reactions to previous hospitalizations ANS: D How the child reacted to previous hospitalizations and any complications should be assessed. If the child reacted poorly, then he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure.

2. As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? a. No further MMR immunizations are needed. b. MMR vaccination needs to be repeated at 4 to 6 years of age. c. MMR immunization needs to be repeated every 4 years until age 21 years. d. A recommendation cannot be made until the physician is consulted.

ANS: B Because of recent outbreaks of measles across the United States, the American Academy of Pediatrics recommends two doses of the MMR vaccine, one at 12 to 15 months of age and one at age 4 to 6 years.

3. In obtaining a review of systems on a healthy 7-year-old girl, the health care provider knows that it would be important to include the: a. Last glaucoma examination. b. Frequency of breast self-examinations. c. Date of her last electrocardiogram. d. Limitations related to her involvement in sports activities.

ANS: D

When reviewing the cardiovascular system, the health care provider should ask whether any activity is limited or whether the child can keep up with her peers. The other items are not appropriate for a child this age.

4. When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed? a. Family history b. Review of systems c. Functional assessment d. Reason for seeking care ANS: C Functional assessment includes interpersonal relationships and home environment. Family history includes illnesses in family members; a review of systems includes questions about the various body systems; and the reason for seeking care is the rationale for requesting health care.

5. The nurse is obtaining a health history on an 17-year-old woman. Which of the following areas of questioning would be most useful at this time? a. Sexual history b. Childhood illnesses c. General health for the past 10 years d. Current health promotion activities ANS: D It is important for the nurse to recognize positive health measures, such as what the person has been doing to help him or herself stay well and to live to an older age. The other responses are not pertinent to a patient of this age.

6. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? a. The functional assessment assesses how the individual is coping with life at home.

b. It determines how children are meeting developmental milestones. c. The functional assessment can identify any problems with memory the individual may be experiencing. d. It helps determine how a person is managing day-to-day activities.

ANS: D The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.

7. The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? a. Chest pain b. Clammy skin c. Serum potassium level at 4.2 mEq/L d. Body temperature of 100 F ANS: A A symptom is a subjective sensation (e.g., chest pain) that a person feels from a disorder. A sign is an objective abnormality that the examiner can detect on physical examination or in laboratory reports, as illustrated by the other responses.

8. A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? a. It is a sharp, burning pain in my stomach. b. I also have the sweats and nausea when I feel this pain. c. I think this pain is telling me that something bad is wrong with me. d. This pain happens every time I sit down to use the computer.

ANS: D

The setting describes where the person is or what the person is doing when the symptom starts.

Describing the pain as sharp and burning reflects the character or quality of the pain; stating that the pain is telling the patient that something bad is wrong with him reflects the patients perception of the pain; and describing the sweats and nausea reflects associated factors that occur with the pain.

9. During an assessment, the nurse uses the CAGE test. The patient answers yes to two of the questions. What could this be indicating? a. The patient is an alcoholic. b. The patient is annoyed at the questions. c. The patient should be thoroughly examined for possible alcohol withdrawal symptoms. d. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.

ANS: D The CAGE test is known as the cut down, annoyed, guilty, and eye-opener test. If a person answers yes to two or more of the four CAGE questions, then the nurse should suspect alcohol abuse and continue with a more complete substance abuse assessment.

10. The nurse is incorporating a persons spiritual values into the health history. Which of these questions illustrates the community portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? a. Do you believe in God? b. Are you a part of any religious or spiritual congregation? c. Do you consider yourself to be a religious or spiritual person? d. How does your religious faith influence the way you think about your health?

ANS: B The community is assessed when the nurse asks whether a person is part of a religious or spiritual community or congregation. The other areas assessed are faith, influence, and addressing any religious or spiritual issues or concerns.

11. The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins?

a. Please stay during the interview; you can answer for her if she does not know the answer. b. It would help to interview the three of you together. c. While I interview your daughter, will you please stay in the room and complete these family health history questionnaires? d. While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?

ANS: D The girl should be interviewed alone. The parents can wait outside and fill out the family health history questionnaires.

12. The nurse is assessing a new patient who has recently immigrated to the United States.

Which question is appropriate to add to the health history? a. Why did you come to the United States? b. When did you come to the United States and from what country? c. What made you leave your native country? d. Are you planning to return to your home?

ANS: B Biographic data, such as when the person entered the United States and from what country, are appropriate additions to the health history. The other answers do not reflect appropriate questions.

MULTIPLE RESPONSE 1. The nurse is assessing a patients headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply. a. Where is the headache pain? b. Did you have these headaches as a child? c. On a scale of 1 to 10, how bad is the pain? d. How often do the headaches occur? e. What makes the headaches feel better? f.

Do you have any family history of headaches?

ANS: A, C, D, E The mnemonic PQRSTU may help the nurse remember to address the critical characteristics that need to be assessed: (1) P: provocative or palliative; (2) Q: quality or quantity; (3) R: region or radiation; (4) S: severity scale; (5) T: timing; and (6) U: understand the patients perception.

Asking, Where is the pain? reflects region. Asking the patient to rate the pain on a 1 to 10 scale reflects severity. Asking How often reflects timing. Asking what makes the pain better reflects provocative. The other options reflect health history and family history.

2. The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply. a. How much junk food does your child eat? b. How many teeth has he lost, and when did he lose them? c. Is he able to tie his shoelaces? d. Does he take a childrens vitamin? e. Can he tell time? f.

Does he have any food allergies?

ANS: B, C, E

Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history.

Chapter 6 Newborn Assessment 1. 1. A mother brings her 9 month infant in for a routine visit. What milestone would be appropriate for the doctor to ask if the infant is meeting?

1. Walking 2. Speaking in two word phrases 3. Rolls back to stomach and stomach to back 4. All of the above ANS: 3 Feedback 1. Between 1012 months of age, an infant can walk 2. Between 1416 months of age, an infant can speak two word phrases 3.Between 6 and 9 months of age, an infant can roll from back to stomach and stomach to back.

4. Many infants will not be walking at this age. It is too soon for word phrases to be developed. The child should be rolling.

1. 2. A 5 day old infant comes in for a newborn checkup. On assessment of the newborn, you note that the skin is jaundice in color. The anterior fontanel is slightly sunken. Per mom, the infant has only had 2 diapers today. The infant is strictly breastfed and this is moms first child. She states baby is having trouble latching on. A bilirubin level is sent and comes back at 18. You identify this newborn to be dehydrated and is most likely to have breast milk jaundice. Which nursing intervention(s) will be required for this baby?

1. 1. Phototherapy 2. 2. Providing support and education for the lactating mother 3. 3. Strict monitoring of intake and output 4. 4. All of the above ANS 4 Feedback 1.Phototherapy will be required to help decrease the level of bilirubin.

2.It is important to provide the mother with support and education and offer a lactation specialist.

3. This infant is dehydrated so it will be necessary to monitor strict I & Os. 4.Breast Milk Jaundice occurs in 12% of breastfed babies. At early onset there are poor feeding patterns and bilirubin levels may spike to 19. It is important to provide the mother with support and education and offer a lactation specialist. This infant is dehydrated so it will be necessary to monitor strict I & Os. Phototherapy will be required to help decrease the level of bilirubin.

1. 3. Apgar scores measure heart rate, respiratory rate, reflex irritability, color and : 1. 1. Rigidity 2. 2. Muscle tone 3. 3. Birth weight 4. 4. Capillary refill ANS: 2 Feedback 1. Not assessed for the APGAR score 2. Apgar scores measure 5 areas: respiratory rate, heart rate, muscle tone,

color and reflex irritability. The higher score indicates adequate adaptation. Scores are done at 1 minute and 5 minutes after birth.

3. Not assessed for the APGAR score 4.Not assessed the APGAR score 1. 4. A mother on the postpartum unit asked to have her infant back from the nursery so that she can breastfeed. The nurse brings the newborn to the room and hands the baby to the mother. She asks the mother to let her know how long the baby feeds. What vital step did the nurse forget to take before giving the baby to the mother?

1. 1. The nurse should have made sure that the baby was latching correctly 2. 2. The nurse should have identified the babys ID band with the mothers 3. 3. The nurse should have the mother speak with a lactation consultant 4. 4. The nurse should have asked the mother how long she planned to feed ANS: 2 Feedback 1. It is vital that ID bands are checked with baby and mother before leaving the infant.

2. It is vital that ID bands are checked with baby and mother before leaving the infant.

3. Safety of the baby is the first priority 4.Safety of the baby is the first priority 5. Excessive heat loss results in which of these?

1. RDS 2. Depletion of glucose levels 3. Jaundice 4. Increase in surfactant levels ANS: 2 Feedback

1. Cold stress is excessive heat loss resulting in an increase in heart rate,

respiratory rate, oxygen consumption, metabolic acidosis, depletion of glucose levels, and surfactant levels 2. Cold stress is excessive heat loss resulting in an increase in heart rate, respiratory rate, oxygen consumption, metabolic acidosis, depletion of glucose levels, and surfactant levels 3. Cold stress is excessive heat loss resulting in an increase in heart rate, respiratory rate, oxygen consumption, metabolic acidosis, depletion of glucose levels, and surfactant levels 4. Surfactant levels decrease 6. A mother has just delivered her new baby a few hours ago. She asks the nurse if she can bathe the baby because he has blood on him. The best response from the nurse would be.

1. Sure, let me get you some soap and washcloths 2. Why dont you get some rest, there will be lots of time for bathing 3. Its important that we not bathe the baby too soon after birth. Lets wait till later in the day.

4. Sure, but why dont you feed the baby ANS: 3 Feedback 1.A nursing intervention to prevent hypothermia is to delay the first bath until the infant has regulated and stabilized core body temperature.

2.Avoids the mothers question and an explanation should occur 3.A nursing intervention to prevent hypothermia is to delay the first bath until the infant has regulated and stabilized core body temperature.

4.Avoids the mothers question and an explanation should occur 7. A 4 week old infant is brought to the ED. Mom states that the baby hasnt been eating well and has had decreased diapers for 2 days. The baby has been sleeping more and has been hard to wake up. On assessment, you find that the baby is difficult to arouse, is hypotonic and temperature is 35.4 rectally. What is an important lab value to check? Choose the best answer.

1. Complete metabolic panel 2. Liver panel 3. Blood glucose 4. PTT ANS: 3 Feedback 1.Not the first choice due to the length of time to have results for a CPM 2.The signs and symptoms do not indicate the need for a liver panel 3.Lethargy, poor feeding, hypotonic and temperature instability are all

signs of hypoglycemia 4.The sign and symptoms do not indicate a need for a PTT 8. A pregnant woman with a history of a clotting disorder is required to self-administer heparin during her pregnancy. After delivery, the infant will be at greater risk for: 1. Low blood sugar 2. Decrease Vitamin K 3. Increased Vitamin K 4. High blood sugar ANS: 2 Feedback 1. Anticoagulants do not effect blood sugar 2. An infant of a mother who is treated with anticoagulants are at risk for

decreased vitamin K levels 3. Anticoagulants have the opposite effect on vitamin K

4.Anticoagulants do not effect blood sugar 9. A part of injury prevention is making and keeping infant appointments. The required checkups and vaccinations are at: 1. 3 months, 6 months, 9 months 2. 2 months, 4 months, 6 months and 1 year 3. 2 months, 4 months, 6 month, 9 months and 1 year 4. 2 months, 4 months, 9 months and 1 year ANS: 3 Feedback 1. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age.

2. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age.

3. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age.

4. It is recommended that a routine check-up with vaccinations be done at

2 months, 4 months, 6 months, 9 months and 1 year of age.

10. You are taking care of an infant who was admitted with dehydration. His weight is 6kg. You have been watching his I & Os. What would you expect the infants urinary output to be in order to maintain adequate hydration?

1. 0.52 ml/kg/hr 2. 0.52.5 ml/kg/hr 3. 13 ml/kg/hr 4. As long as he is having wet diapers it doesnt matter ANS: 3 Feedback 1.Urine output is not in normal range 2.Urine output is not in normal range 3. Urine output for the newborn/infant should be 13 cc/kg/hr, in the hospital, to maintain adequate fluid maintenance 4. Measuring I & O is important to assess kidney function in a dehydrated patient 11. A mother brings her newborn daughter to the ER with concerns that she is having vaginal bleeding. You know this is normal and called what?

1. Pseudomenstruation 2. Milia 3. Vernix caseosa 4. Toxicum ANS: 1 Feedback 1. Pseudomenstruation is thin white or blood tinged mucus that may be

present due to maternal withdrawal of hormones.

2. Incorrect term 3.Incorrect term 4.Incorrect term

12. While interviewing the mother of an infant, you note that the mother gets frustrated as she explains that her baby has been up all night crying at least 3 times a week for the last 2 weeks. She states that she has tried everything and feels hopeless. What would be the BEST response from you as the nurse?

1. Believe me, I know. I have a newborn too.

2. Have you tried warm milk?

3. Its ok to be frustrated and feel overwhelmed.

4. You are doing nothing wrong. This can be a common occurrence in infants and you should not feel guilty.

ANS: 4 Feedback 1. It is important that education is provided to the mother or caregiver so

that they know the irritability is not a reflection of their parenting skills.

2. Infants do not have the enzyme to absorb milk thus would cause more

stomach upset 3. Acknowledgement of the mothers feelings is important. Mother needs

educated about Infant Colic.

4. The mother is describing Infant Colic. This can be very frustrating for mothers. They can feel helpless, hopeless and like a terrible mother. It is important that education is provided to the mother or caregiver so that they know the irritability is not a reflection of their parenting skills.

13. The benefits of breast-feeding are 1. Decreased risk of obesity 2. Convenience 3. Promotes positive bonding with infant and mother 4. All of the above ANS: 4 Feedback 1.Improves nutritional outcomes for the infant 2.Breastfeeding requires no bottle preparation 3.Positive bonding occurs in breastfeeding 4.Breastfeeding is the optimal method of feeding because it provides all nutrients, minerals, and vitamins needed. There is no bottle required and baby and mother can bond.

14. The AAPs recommendations for length of breastfeeding is 1. 6 months

2. 6 months with the first child 3. 1 year 4. 9 month ANS: 3 Feedback 1. The American Academy of Pediatrics recommends breastfeeding for a full year. It reduces cost and preparation time, is on demand and has been shown to decrease obesity.

2. The American Academy of Pediatrics recommends breastfeeding for a full year. It reduces cost and preparation time, is on demand and has been shown to decrease obesity.

3. The American Academy of Pediatrics recommends breastfeeding for a full year. It reduces cost and preparation time, is on demand and has been shown to decrease obesity.

4. The American Academy of Pediatrics recommends breastfeeding for a full year. It reduces cost and preparation time, is on demand and has been shown to decrease obesity.

15. When interviewing the mother of an infant the nurse asks some questions about how the baby is fed. What statement tells you that the mother will need further education?

1. I always use the ready to feed because it is easier.

2. I burp Junior at the end of his bottle.

3. I rock him while he feeds.

4. I just bought this great bottle warmer.

ANS: 2 Feedback 1. The mother has found a feeding technique that fits her lifestyle and gives adequate nutrition to the infant.

2. It is important to burp the infant frequently (about every ounce) to prevent emesis d/t swallowed air.

3. Rocking can be a comfort measure for feeding 4. The mother understands about warming the bottle prior to feeding 16. The physician is discussing feeding habits and schedule with a mother of a 4 month old.

Which statement from the mother would warrant the need for further teaching and education?

1. I just recently introduced table foods.

2. I feed him every 3 hours.

3. I dont wake him for feeds throughout the night if he will sleep.

4. All of the above ANS: 1 Feedback 1. An infant is ready for solid foods around 6 months of age. All foods should be placed on a spoon not in the bottle. Baby rice cereal is usually indicated for the first solid food.

2. Feeding every three hours during the day is adequate for this age 3.A four month old does not need to be awakened during the night for feedings 4.One statement is not applicable 17. Research has shown that endogenous opioid pathways that result in calming and painrelieving effects are activated by: 1. Tylenol 2. Kangaroo care 3. Sucrose 4. Nonnutritive sucking 5. Choice 3 and 4 ANS: 5 Feedback 1. Does not produce an endogenous response 2. While this comforts a neonate it does not have an endogenous opioid pathway 3. The administration of sucrose and the application of nonnutritive sucking are theorized to activate endogenous opioid pathways (natural pain relievers produced in the brain) with resulting calming and painrelieving effects.

4. The administration of sucrose and the application of nonnutritive sucking are theorized to activate endogenous opioid pathways (natural pain relievers produced in the brain) with resulting calming and painrelieving effects.

5. The administration of sucrose and the application of nonnutritive sucking are theorized to activate endogenous opioid pathways (natural pain relievers produced in the brain) with resulting calming and painrelieving effects.

18. A mother of a newborn baby boy is unsure of whether or not to have her son circumcised.

She asks the nurse what is recommended by the AAP. The nurse tells her that as of 1999, the AAPs recommendation is: 1. They highly recommend routine circumcisions

2. They strongly recommend circumcision only if the parents are worried about infections 3. They have no current stance 4. They do not recommend routine circumcisions ANS: 4 Feedback 1. The current position statement issued in 1999 does not recommend routine circumcision of the newborn.

2. The infection rate does not change with a circumcision 3. The current position statement issued in 1999 does not recommend routine circumcision of the newborn.

4. The current position statement issued in 1999 does not recommend routine circumcision of the newborn.

19. Which of the following interfere with the absorption of some medications in neonates and infants?

1. Immature kidney function 2. Absence of hydrochloric acid 3. Less pancreatic enzymes 4.All of the above Feedback 1.Immature kidney function influences absorption 2.The lack of hydrochloric acid influences absorption 3.A neonate has less pancreatic enzymes 4.In neonates there is an absence of hydrochloric acid, and in infants, less pancreatic enzymes and immature kidney function which may interfere with absorption of some medications.

20. The nurse is doing discharge teaching and instructs the parents to notify their healthcare provider with any of these important concerns regarding the newborn/infant.

1. Temperature over 99.3 degrees Fahrenheit 2. Vomiting 3. Decreased wet diapers 4. All of the above

ANS: 4 Feedback 1.A temperature greater than 99.3 degrees Fahrenheit, especially in a newborn, may be a sign of sepsis 2.Vomiting and decreased wet diapers can be a sign on dehydration 3.Vomiting and decreased wet diapers can be a sign on dehydration 4.A temperature greater than 99.3 degrees Fahrenheit, especially in a newborn, may be a sign of sepsis. Vomiting and decreased wet diapers can be a sign on dehydration. Infants and children have less reserve than adults and can become dehydrated quickly.

21. The nurse is assessing pain on a 1 year old. What is the appropriate pain scale to use?

1. NIPS 2. FACES 3. FLACC 4. CHOPS ANS: 3 Feedback 1.Not recommended for this age range 2.Not recommended for this age range 3. FLACC or the Face, Legs, Activity, Cry, Consolability scale is a measurement used to assess pain for children between the ages of 2 months-7 years or until the child is able to understand the concept of pain (then the FACES scale can be used).

4. Not recommended for this age range 22. On assessment of a 6 month old infant you note that the anterior fontanel is flat and soft and the posterior fontanel is no longer palpable. This is an appropriate finding because the posterior fontanel closes at: 1. 6 months 2. 4 months 3. 2 months 4. 5 months ANS: 4 Feedback

1. The posterior fontanel is triangular in shape, 12 cm and closes in the 2nd

month.

2. The posterior fontanel is triangular in shape, 12 cm and closes in the 2nd

month.

3. The posterior fontanel is triangular in shape, 12 cm and closes in the 2nd

month.

4. The posterior fontanel is triangular in shape, 12 cm and closes in the

2nd month.

23. A mother is concerned that every time she leaves the hospital room to take a break, her 8 month old cries. The nurse explains to the mother that this is normal behavior and that her infant is experiencing 1. Safety issues 2. Separation anxiety 3. Irritability 4. Colic ANS: 2 Feedback 1. The child is too young to know about safety issues 2. Between the ages of 6 and 9 months, infants suffer from separation anxiety and can be sensitive to caregiver cues 3. The child only cries when the mother leaves, if irritable the child would cry more often 4. The child is past the age of colic occurring 24. Highlights in education for promoting safety in infants involves 1. Burns and car seat safety 2. Preventing choking and poisoning 3. Safe Sleep 4. All the above ANS: 4 Feedback 1. These 5 topics are important for parents and caregivers to be aware of

when it comes to infant safety. It is helpful to provide anticipatory guidance to parents at time of discharge so that they can prepare for their childs growth.

2. These 5 topics are important for parents and caregivers to be aware of when it comes to infant safety. It is helpful to provide anticipatory guidance to parents at time of discharge so that they can prepare for their childs growth.

3. These 5 topics are important for parents and caregivers to be aware of

when it comes to infant safety. It is helpful to provide anticipatory guidance to parents at time of discharge so that they can prepare for their childs growth.

4. These 5 topics are important for parents and caregivers to be aware of when it comes to infant safety. It is helpful to provide anticipatory guidance to parents at time of discharge so that they can prepare for their childs growth.

25. During her interview with the mother, the nurse asks sleep related questions. She finds out that the infant is placed on her belly for sleep. The nurse beings to explain safe sleep measures and includes: 1. Placing the infant in a side lying position after feeds 2. Placing the infant propped on a pillow for comfort 3. Placing the infant on her belly for only naps 4. Placing the infant on her back in a bare naked crib ANS: 4 Feedback 1.AAP recommends that all infants be placed on their backs for sleep in a bare naked crib. This means just a fitted sheet, no bumpers, blankets, pillows or toys. These are all suffocation hazards. The infant should not be tightly swaddled and arms should be free. Tightly swaddled infants are at risk for overheating and at greater risk for SIDS. 2.A pillow can increase the chance for suffocation 3. The infant should only be placed on her belly when awake and supervised 4. AAP recommends that all infants be placed on their backs for sleep in a bare naked crib. This means just a fitted sheet, no bumpers, blankets, pillows or toys. These are all suffocation hazards. The infant should not be tightly swaddled and arms should be free. Tightly swaddled infants are at risk for overheating and at greater risk for SIDS.

Chapter 7. Skin 1. What should be included in teaching a parent about the management of small red macules and vesicles that become pustules around the childs mouth and cheek? a. Keep the child home from school for 24 hours after initiation of antibiotic treatment. b. Clean the rash vigorously with Betadine three times a day. c. Notify the physician for any itching. d. Keep the child home from school until the lesions are healed.

ANS: A To prevent the spread of impetigo to others, the child should be kept home from school for 24 hours after treatment is initiated. Good hand washing is imperative in preventing the spread of impetigo. The lesions should be washed gently with a warm soapy washcloth three times a day.

Washcloth should not be shared with other members of the family. Itching is common and does not necessitate medical treatment. Rather, parents should be taught to clip the childs nails to prevent maceration of the lesions. The child may return to school 24 hours after initiation of antibiotic treatment.

2. When taking a history of a child with cellulitis, which information would be most pertinent for the nurse to assess? a. Any medication the child is taking b. Enlarged, mobile, and nontender lymph nodes c. Childs urinalysis results d. Recent infections or signs of infection ANS: D Cellulitis may follow an upper respiratory infection, sinusitis, otitis media, or a tooth abscess.

The affected area is red, hot, tender, and indurated. Medication history is important, but the history of recent infections is more relevant to the diagnosis. Lymph nodes may be enlarged (lymphadenitis), but they are not mobile and are nontender. Lymphangitis may be seen, with red streaking of the surrounding area. An abnormal urinalysis result is not usually associated with cellulitis.

3. Which statement made by a parent indicates an understanding about the management of a child with cellulitis? a. I am supposed to continue the antibiotic until the redness and swelling disappear.

b. I have been putting ice on my sons arm to relieve the swelling. c. I should call the doctor if the redness disappears. d. I have been putting a warm soak on my sons arm every 4 hours.

ANS: D Warm soaks applied every 4 hours while the child is awake increase circulation to the infected area, relieve pain, and promote healing. The parent should not discontinue antibiotics when signs of infection disappear. To ensure complete healing, the parent should understand that the entire course of antibiotics should be given as prescribed. A warm soak is indicated for the treatment of cellulitis. Ice will decrease circulation to the affected area and inhibit the healing process. The disappearance of redness indicates healing and is not a reason to seek medical advice.

4. What should the parents of an infant with thrush (oral candidiasis) be taught about medication administration? a. Give nystatin suspension with a syringe without a needle. b. Apply nystatin cream to the affected area twice a day. c. Give nystatin just before the infant is fed. d. Rub nystatin suspension onto the oral mucous membranes with a gloved finger after feedings.

ANS: D It is important to apply the nystatin suspension to the affected areas, which is best accomplished by rubbing it onto the gums and tongue, after feedings, every 6 hours, until 3 to 4 days after symptoms have disappeared. Medication may not reach the affected areas when it is squirted into the infants mouth. Rubbing the suspension onto the gum ensures contact with the affected areas.

Nystatin cream is used for diaper rash caused by Candida. To prolong contact with the affected areas, the medication should be administered after a feeding.

5. What beverage should the parents of a child with ringworm be taught to give along with the prescribed griseofulvin (Fulvicin)? a. Water b. A carbonated drink c. Milk d. Fruit juice ANS: C Griseofulvin is insoluble in water. Giving the medication with a high-fat meal or milk increases

absorption. Carbonated drinks do not contain fat, which aids in the absorption of griseofulvin.

Fruit juice does not contain any fat; fat aids absorption of the medication.

6. Which assessment is applicable to the care of a child with herpetic gingivostomatitis? a. Comparison of range of motion for the upper and lower extremities b. Urine output, mucous membranes, and skin turgor c. Growth pattern since birth d. Bowel elimination pattern ANS: B The child with herpetic gingivostomatitis is at risk for fluid volume deficit. Painful lesions on the mouth make drinking unpleasant and undesirable, with subsequent dehydration becoming a real danger. An oral herpetic infection does not affect joint function. Herpetic gingivostomatitis is not a chronic disorder that would affect the childs long-term growth pattern. Although constipation could be caused by dehydration, it is more important to assess urine output, skin turgor, and mucous membranes to identify dehydration before constipation is a problem.

7. Parents of the child with lice infestation should be instructed carefully in the use of antilice products because of which potential side effect? a. Nephrotoxicity b. Neurotoxicity c. Ototoxicity d. Bone marrow depression ANS: B Because of the danger of absorption through the skin and potential for neurotoxicity, antilice treatment must be used with caution. A child with many open lesions can absorb enough to cause seizures. Antilice products are not known to be nephrotoxic or ototoxic. Products that treat lice are not known to cause bone marrow depression.

8. When assessing the child with atopic dermatitis, the nurse should ask the parents about a history of which problem? a. Asthma b. Nephrosis c. Lower respiratory tract infections

d. Neurotoxicity ANS: A Most children with atopic dermatitis have a family history of asthma, hay fever, or atopic dermatitis and up to 80% of children with atopic dermatitis have asthma or allergic rhinitis.

Complications of atopic dermatitis relate to the skin. The renal system is not affected by atopic dermatitis. There is no link between lower respiratory tract infections and atopic dermatitis.

Atopic dermatitis does not have a relationship to neurotoxicity.

9. What should the nurse teach an adolescent who is taking tretinoin (Retin-A) for treatment acne? a. The medication should be taken with meals. b. Apply sunscreen before going outdoors. c. Wash with benzoyl peroxide before application. d. The effect of the medication should be evident within 1 week.

ANS: B Tretinoin causes photosensitivity and sunscreen should be applied before sun exposure. Tretinoin is a topical medication. Application is not affected by meals. If applied together, benzoyl peroxide and tretinoin have reduced effectiveness and a potentially irritant effect. Optimal results from tretinoin are not achieved for 3 to 5 months.

10. When changing an infants diaper, the nurse notices small bright red papules with satellite lesions on the perineum, anterior thigh, and lower abdomen. This rash is characteristic of which condition? a. Primary candidiasis b. Irritant contact dermatitis c. Intertrigo d. Seborrheic dermatitis

ANS: A Small red papules with peripheral scaling in a sharply demarcated area involving the anterior thighs, lower abdomen, and perineum are characteristic of primary candidiasis. A shiny, parchment-like erythematous rash on the buttocks, medial thighs, mons pubis, and scrotum, but not in the folds, is suggestive of irritant contact dermatitis. Intertrigo is identified by a red macerated area of sharp demarcation in the groin folds. It can also develop in the gluteal and neck folds. Seborrheic dermatitis is recognized by salmon-colored, greasy lesions with a yellowish scale found primarily in skin-fold areas or on the scalp.

11. The depth of a burn injury may be classified as: a. localized or systemic. b. superficial, superficial partial thickness, deep partial thickness, or full thickness. c. electrical, chemical, or thermal. d. minor, moderate, or major.

ANS: B The vocabulary to classify the depth of burn is superficial, partial thickness, or full thickness.

These terms refer to the effect of the burn injury. For example, is there a reaction in the area of the burn (localized) or throughout the body (systemic)? Electrical, chemical, or thermal are terms that refer to the cause of the burn injury. Minor, moderate, or major are terms that refer to the severity of the burn injury.

12. What is the major difference between caring for an infant with burns and an adolescent with burns? a. An increased risk of cardiovascular problems in the infant b. A decreased need for caloric intake in the infant c. An increased risk for hypervolemia in the adolescent d. A decreased need for electrolyte replacement in the infant

ANS: A The higher proportion of body fluid to body mass in infants increases the risk of cardiovascular problems because of a less effective cardiovascular response to changing intravascular volume.

Infants are at an increased risk for protein and calorie deficiency because they have smaller muscle mass and lower body fat. Hypovolemia is a risk for all burn patients; however, the risk is higher for the infant than for the adolescent. There is an increased risk for electrolyte loss in the infant because of the larger body surface area.

13. Which procedure is contraindicated in the care of a child with a minor partial-thickness burn injury wound? a.

Cleaning the affected area with mild soap and water

b.

Applying antimicrobial ointment to the burn wound

c. Changing dressings daily d. Leaving all loose tissue or skin intact ANS: D All loose skin and tissue should be debrided because it can become a breeding ground for infectious organisms. Cleaning with mild soap and water is important to the healing process.

Antimicrobial ointment is used on the burn wound to fight infection. Clean dressings are applied daily to prevent wound infection. When dressings are changed, the condition of the burn wound can be assessed.

14. The process of burn shock continues until which physiological mechanism occurs? a. Heart rate returns to normal. b. Airway swelling decreases. c. Body temperature regulation returns to normal. d. Capillaries regain their seal.

ANS: D

Within minutes of the burn injury, the capillary seals are lost with a massive fluid leakage into the surrounding tissue, resulting in burn shock. The process of burn shock continues for approximately 24 to 48 hours, when capillary seals are restored. The heart rate will be increased throughout the healing process because of increased metabolism. Airway swelling subsides over a period of 2 to 5 days after injury. Body temperature regulation will not be normal until healing is well under way.

15. To assess the child with severe burns for adequate perfusion, the nurse monitors which area? a. Distal pulses b. Skin turgor c. Urine output d. Mucous membranes ANS: C Urine output reflects the adequacy of end-organ perfusion. Distal pulses may be affected by many variables. Urine output is the most reliable indicator of end-organ perfusion. Skin turgor is often difficult to assess on burn patients because the skin is not intact. Mucous membranes do not reflect end-organ perfusion.

16. Which medication would be best for the nurse to administer before a dressing change for the severely burned child? a. Codeine b. Benadryl c. Morphine d. Acetaminophen ANS: C Morphine is the drug of choice for pain management in the severely burned child. It should be administered intravenously. Codeine may be used to diminish pain between dressing changes.

Benadryl is administered to relieve discomfort from itching. Acetaminophen can be given for discomfort between painful procedures.

17. Which nursing assessment and care holds the highest priority in the initial care of a child with a major burn injury? a. Establishing and maintaining the childs airway b. Establishing and maintaining intravenous access c. Insertion of a catheter to monitor hourly urine output d. Insertion of a nasogastric tube into the stomach to supply adequate nutrition ANS: A Establishing and maintaining the childs airway are always the priority focus for assessment and care. Establishing intravenous access is the second priority in this situation, after the airway has been established. Inserting a catheter and monitoring hourly urine output are the third most important nursing intervention. Nasogastric feedings are not begun initially on a child with major or severe burns. The initial assessment and care focus for a child with major burn injuries are the ABCs. MULTIPLE RESPONSE 1. A nurse is teaching parents about prevention of diaper dermatitis. Which should the nurse include in the teaching plan? Select all that apply. a. Clean the diaper area gently after every diaper change with a mild soap. b. Use a protective ointment to clean dry intact skin. c. Use a steroid cream after each diaper change. d. Use rubber or plastic pants over the diaper. e. Wash cloth diapers in hot water with a mild soap and double rinse.

ANS: A, B, E

Prompt, gentle cleaning with water and mild soap (Dove, Neutrogena Baby Soap) after each voiding or defecation rids the skin of ammonia and other irritants and decreases the chance of skin breakdown and infection. A bland, protective ointment (A&D, Balmex, Desitin, zinc oxide) can be applied to clean, dry, intact skin to help prevent diaper rash. If cloth diapers are laundered at home, the parents should wash them in hot water, using a mild soap and double rinsing.

Occlusion increases the risk of systemic absorption of steroid; thus steroid creams are rarely used for diaper dermatitis because the diaper functions as an occlusive dressing. Rubber or plastic pants increase skin breakdown by holding in moisture and should be used infrequently.

MSC: Health Promotion and Maintenance 2. A nurse is instructing parents on treatment of pediculosis (head lice). Which should the nurse include in the teaching plan? Select all that apply. a. Bedding should be washed in warm water and dried on a low setting. b. After treating the hair and scalp with a pediculicide, shampoo the hair with regular shampoo. c. Retreat the hair and scalp with a pediculicide in 7 to 10 days. d. Items that cannot be washed should be dry cleaned or sealed in plastic bags for 2 to 3 weeks. e. Combs and brushes should be boiled in water for at least 10 minutes.

ANS: C, D, E An over-the-counter pediculicide, permethrin 1% (Nix, Elimite, Acticin), kills head lice and eggs with one application and has residual activity (i.e., it stays in the hair after treatment) for 10 days.

Nix Creme Rinse is applied to the hair after it is washed with a conditioner-free shampoo. The product should be rinsed out after 10 minutes. The hair should not be shampooed for 24 hours after the treatment. Even though the kill rate is high and there is residual action, retreatment should occur after 7 to 10 days. Combs and brushes should be boiled or soaked in antilice shampoo or hot water [greater than 60 C (140 F)] for at least 10 minutes. Advise parents to wash clothing (especially hats and jackets), bedding, and linens in hot water and dry at a hot dryer setting.

Chapter 8. Heart and Vascular System 1. A nurse is conducting a class for nursing students about fetal circulation. Which statement is accurate about fetal circulation and should be included in the teaching session? a. Oxygen is carried to the fetus by the umbilical arteries. b. Blood from the inferior vena cava is shunted directly to the right ventricle through the foramen ovale. c. Pulmonary vascular resistance is high because the lungs are filled with fluid. d. Blood flows from the ductus arteriosus to the pulmonary artery.

ANS: C Resistance in the pulmonary circulation is very high because the lungs are collapsed and filled with fluid. Oxygen and nutrients are carried to the fetus by the umbilical vein. The inferior vena cava empties blood into the right atrium. The direction of blood flow and the pressure in the right atrium propel most of this blood through the foramen ovale into the left atrium. Most of the blood in the pulmonary artery flows though the ductus arteriosus into the descending aorta.

2. Which postoperative intervention should be questioned for a child after a cardiac catheterization? a. Continue intravenous (IV) fluids until the infant is tolerating oral fluids. b. Check the dressing for bleeding. c. Assess the peripheral circulation on the affected extremity. d. Keep the affected leg flexed and elevated.

ANS: D The child should be positioned with the affected leg straight for 4 to 6 hours after the procedure.

IV fluid administration continues until the child is taking and retaining adequate amounts of oral fluids. The insertion site dressing should be observed frequently for bleeding. The nurse should also look under the child to check for pooled blood. Peripheral perfusion is monitored after

catheterization. Distal pulses should be palpable, although they may be weaker than in the contralateral extremity.

3. Which information should be included in the nurses discharge instructions for a child who underwent a cardiac catheterization earlier in the day? a. The pressure dressing is changed daily for the first week. b. The child may soak in the tub beginning tomorrow. c. Contact sports can be resumed in 2 days. d. The child can return to school on the third day after the procedure.

ANS: D The child can return to school on the third day after the procedure. It is important to emphasize follow-up with the cardiologist. The day after the cardiac catheterization, the pressure dressing is removed and replaced with a Band-Aid. The catheter insertion site is assessed daily for healing.

Any bleeding or sign of infection, such as drainage, must be reported to the cardiologist. Bathing is limited to a shower, sponge bath, or a brief tub bath (no soaking) for the first 1 to 3 days after the procedure. Strenuous exercise such as contact sports, swimming, or climbing trees is avoided for up to 1 week after the procedure.

4. A nurse is preparing to assess a 9-month-old infant admitted to the hospital for further evaluation of an atrial septal defect (ASD). Which should the nurse do first for the cardiac assessment? a. Percussion b. Palpation c. Auscultation d. History and inspection ANS: D

The assessment should begin with the least threatening interventionsthe history and inspection.

Assessment progression includes inspection, auscultation, and palpation because each step includes more touching. Percussion of the chest is usually deferred. Palpation can be threatening to the child because it requires a significant amount of physical contact. For this reason it is not the initial step in a cardiac assessment. Auscultation requires touching the child and is not the initial step in a cardiac assessment.

5. In which situation is there a risk that a newborn infant will have a congenital heart defect (CHD)? a. Trisomy 21 detected on amniocentesis b. Family history of myocardial infarction c. Father has type 1 diabetes mellitus d. Older sibling was born with Turners syndrome ANS: A The incidence of congenital heart disease is approximately 50% in children with trisomy 21 (Down syndrome). A family history of congenital heart disease, not acquired heart disease, increases the risk of giving birth to a child with CHD. Infants born to mothers who are insulin dependent have an increased risk of CHD. Infants identified as having certain genetic defects, such as Turners syndrome, have a higher incidence of CHD. A family history is not a risk factor.

6. Before giving a dose of digoxin (Lanoxin), the nurse checked an infants apical heart rate and it is 114 beats per minute. What should the nurse do next? a. Administer the dose as ordered. b. Hold the medication until the next dose. c. Wait and recheck the apical heart rate in 30 minutes. d. Notify the physician about the infants heart rate.

ANS: A

The infants heart rate is above the lower limit for which the medication is held. The dose can be given. It is unnecessary to recheck the heart rate at a later time. A dose of Lanoxin is withheld for a heart rate less than 100 beats per minute in an infant and a physician should be notified.

7. Which intervention should be included in the plan of care for an infant with the nursing diagnosis Fluid volume excess related to congestive heart failure? a. Weigh the infant every day on the same scale at the same time. b. Notify the physician when weight gain exceeds more than 20 g/day. c. Put the infant in a car seat to minimize movement. d. Administer digoxin (Lanoxin) as ordered by the physician.

ANS: A Excess fluid volume may not be overtly visible. Weight changes may indicate fluid retention.

Weighing the infant on the same scale at the same time each day ensures consistency. An excessive weight gain for an infant is an increase of more than 50 g/day. With fluid volume excess, skin will be edematous. The infants position should be changed frequently to prevent undesirable pooling of fluid in certain areas. Lanoxin is used in the treatment of congestive heart failure to improve cardiac function. Diuretics will help the body get rid of excess fluid.

8. The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur. This finding is associated with which congenital heart defect? a. Pulmonary stenosis b. Patent ductus arteriosus c. Ventricular septal defect d. Coarctation of the aorta ANS: B The classic murmur associated with patent ductus arteriosus is a machinery-like one that can be heard throughout both systole and diastole. A systolic ejection murmur that may be accompanied

by a palpable thrill is a manifestation of pulmonary stenosis. The characteristic murmur associated with ventricular septal defect is a loud, harsh holosystolic murmur. A systolic murmur that is accompanied by an ejection click may be heard on auscultation when coarctation of the aorta is present.

9. Which is an expected assessment finding in a child with coarctation of the aorta? a. Orthostatic hypotension b. Systolic hypertension in the lower extremities c. Blood pressure higher on the left side of the body d. Disparity in blood pressure between the upper and lower extremities ANS: D The classic finding in children with coarctation of the aorta is a disparity in pulses and blood pressures between the upper and lower extremities. Orthostatic hypotension is not present with coarctation of the aorta. Systolic hypertension may be detected in the upper extremities. The left arm may not accurately reflect systolic hypertension because the left subclavian artery can be involved in the coarctation.

10. A nurse is assessing an infant with chronic hypoxia due to tetralogy of Fallot. Which finding does the nurse expect to assess? a. Polycythemia b. Pulmonary hypotension c. Dehydration d. Anemia ANS: A The body attempts to improve tissue oxygenation by producing additional red blood cells and thereby increases the oxygen-carrying capacity of the blood. Pulmonary hypertension is a clinical consequence of cyanosis. Dehydration can occur rapidly in cyanotic heart disease. It is

not a compensatory mechanism to chronic hypoxia. Anemia may develop as a result of increased blood viscosity.

11. Which statement made by a parent indicates understanding of activity restrictions for a child after cardiac surgery? a. My child needs to get extra rest for a few weeks. b. My son is really looking forward to riding his bike next week. c. Im so glad we can attend services as a family this coming Sunday. d. I am going to keep my child out of day care for 6 weeks.

ANS: D Settings in which large groups of people are present should be avoided for 4 to 6 weeks after discharge, including day care. The child should resume his regular bedtime and sleep schedule after discharge. Activities during which the child could fall, such as riding a bicycle, are avoided for 4 to 6 weeks after discharge. Large crowds of people should be avoided for 4 to 6 weeks after discharge, including public worship.

12. A child had a ventricular septal defect surgically repaired 3 months ago. Which antibiotic prophylaxis is indicated for an upcoming dental procedure? a. No antibiotic prophylaxis is necessary. b. Amoxicillin is taken orally 1 hour before the procedure. c. Oral penicillin is given for 7 to 10 days before the procedure. d. Parenteral antibiotics are administered for 4 to 8 weeks after the procedure.

ANS: B The standard prophylactic agent is amoxicillin given orally 1 hour before the procedure.

Antibiotic prophylaxis is indicated for the first 6 months after surgical repair. Antibiotic prophylaxis is not given for this period of time. The treatment for infective endocarditis involves parenteral antibiotics for 4 to 8 weeks.

13. A nurse is assessing a 7-day-old infant. The nurse detects a soft murmur. The nurse notifies the primary care physician because the nurse is aware that fetal shunts are closed in the infant at what point in time? a. When the umbilical cord is cut b. Within several days of birth c. Within a month after birth d. By the end of the first year of life ANS: B In the normal neonate, fetal shunts functionally close in response to pressure changes in the systemic and pulmonary circulations and to increased oxygen content. This process may take several days to complete. With the neonates first breath, gas exchange is transferred from the placenta to the lungs. The separation of the fetus from the umbilical cord does not contribute to the establishment of neonatal circulation.

14. When assessing a child for possible congenital heart defects, where should the nurse measure blood pressure? a. The right arm b. The left arm c. All four extremities d. Both arms while the child is crying ANS: C When a congenital heart defect is suspected, the blood pressure should be measured in all four extremities while the child is quiet. Discrepancies between upper and lower extremities may indicate cardiac disease. Blood pressure measurements when the child is crying are likely to be elevated; thus, the readings will be inaccurate. Blood pressure measurements for upper and lower extremities are compared during an assessment for congenital heart defects.

15. What should be the nurses first action when planning to teach the parents of an infant with a congenital heart defect? a. Assess the parents readiness to learn. b. Gather literature for the parents. c. Secure a quiet place for teaching. d. Discuss the plan with the nursing team.

ANS: A Any effort to organize the right environment, plan, or literature is of no use if the parents are not ready to learn. A baseline assessment of prior knowledge should be taken into consideration before developing any teaching plan. Locating a quiet place for meeting with parents is appropriate; however, an assessment should be done before any teaching is done. Discussing a teaching plan with the nursing team is appropriate after an assessment of the parents knowledge and readiness.

16. A nurse is explaining a patent ductus arteriosus defect to the parents of a preterm infant. The parents indicate understanding of the defect when they state that a patent ductus arteriosus: a. involves a defect that results in a right-to-left shunting of blood in the heart. b. involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close. c. is a stenotic lesion that must be surgically corrected at birth. d. causes an abnormal opening between the four chambers of the heart.

ANS: B Patent ductus arteriosus is failure of the fetal shunt between the aorta and the pulmonary artery to close. A patent ductus arteriosus allows blood to flow from the high-pressure aorta to the lowpressure pulmonary artery, resulting in a left-to-right shunt. Patent ductus arteriosus is not a stenotic lesion. Patent ductus arteriosus can be closed both medically and surgically.

Atrioventricular defect occurs when fetal development of the endocardial cushions is disturbed, resulting in abnormalities in the atrial and ventricular septa and the atrioventricular valves.

17. Why might a newborn infant with a cardiac defect, such as coarctation of the aorta resulting in a right-to-left shunt, receive prostaglandin E ? a. To decrease inflammation b. To control pain c. To decrease respirations d. To keep the ductus arteriosus patent ANS: D Prostaglandin E1 is given to infants with a right-to-left shunt to keep the ductus arteriosus patent to increase pulmonary blood flow.

18. Which congenital heart defect results in increased pulmonary blood flow? a. Ventricular septal defect b. Coarctation of the aorta c. Tetralogy of Fallot d. Pulmonary stenosis ANS: A Ventricular septal defect causes a left-to-right shunting of blood, thus increasing pulmonary blood flow. Coarctation of the aorta is a stenotic lesion that causes increased resistance to blood flow from the proximal to distal aorta. The defects associated with tetralogy of Fallot result in a right-to-left shunting of blood, thus decreasing pulmonary blood flow. Pulmonary stenosis causes obstruction of blood flow from the right ventricle to the pulmonary artery. Pulmonary blood flow is decreased.

19. Which statement suggests that a parent understands how to correctly administer digoxin?

a. I measure the amount I am supposed to give with a measuring spoon. b. I put the medicine in the babys bottle. c. When she spits up right after I give the medicine, I give her another dose. d. I give the medicine at 8 in the morning and evening every day.

ANS: D For maximum effectiveness, the medication should be given at the same time every day and should be measured with a syringe. The medication should not be mixed with formula or food. It is difficult to judge whether the child received the proper dose if the medication is placed in food or formula. To prevent toxicity, the parent should not repeat the dose without contacting the childs physician.

20. What nursing action is appropriate to take when an infant with a congenital heart defect has an increased respiratory rate and sweating and is not feeding well? a. Check the infants temperature. b. Alert the physician. c. Withhold oral feeding. d. Increase the oxygen rate.

ANS: B An increased respiratory rate, sweating, and not feeling well are signs of early congestive heart failure and the physician should be notified; they do not suggest a febrile process. Withholding the infants feeding is an incomplete response to the problem. Increasing oxygen may alleviate symptoms, but medications such as digoxin and furosemide are necessary to improve heart function and fluid retention.

21. Nursing care for the child in congestive heart failure includes which action? a. Counting the number of saturated diapers b. Putting the infant in the Trendelenburg position

c. Removing oxygen while the infant is crying d. Organizing care to provide rest periods ANS: D Nursing care should be planned to allow for periods of undisturbed rest. Diapers must be weighed for an accurate record of output. The head of the bed should be raised to decrease the work of breathing. Oxygen should be administered during stressful periods such as when the child is crying.

22. Which strategy is appropriate when feeding the infant with congestive heart failure? a. Continue the feeding until a sufficient amount of formula is taken. b. Limit feedings to no more than 30 minutes. c. Always bottle feed every 4 hours. d. Feed larger volumes of concentrated formula less frequently.

ANS: B The infant with congestive heart failure may tire easily so the feeding should not continue beyond 30 minutes. If inadequate amounts of formula are taken, gavage feedings should be considered. Infants with congestive heart failure may be breast-fed or fed a smaller volume of concentrated formula. Feedings every 3 hours is a frequently used interval. If the infant were fed less frequently than every 3 hours, more formula would need to be consumed and would tire the infant.

23. A nurse is teaching an adolescent about primary hypertension. Which statement made by the adolescent indicates an understanding about primary hypertension? a.

Primary hypertension should be treated with diuretics as soon as it is detected.

b. Congenital heart defects are the most common cause of primary hypertension. c. Primary hypertension may be treated with weight reduction. d. Primary hypertension is not affected by exercise.

ANS: C Primary hypertension in children may be treated with weight reduction and exercise programs. If ineffective, pharmacological intervention may be needed. Primary hypertension is considered to be an inherited disorder.

24. A nurse is planning care for a child with secondary hypertension. The nurse plans to include which initial treatment of secondary hypertension? a. Weight control and diet b. Treating the underlying disease c. Administration of digoxin d. Administration of beta-adrenergic receptor blockers ANS: B Identification of the underlying disease should be the first step in treating secondary hypertension. Weight control and diet are a nonpharmacological treatment for primary hypertension. Digoxin is indicated in the treatment of congestive heart failure. Beta-adrenergic receptor blockers are indicated in the treatment of primary hypertension.

25. Which should the nurse include in discharge teaching for the child with a cardiac arrhythmia? a. CPR instructions b. Repeating digoxin if the child vomits c. Resting if dizziness occurs d. Checking the childs pulse after digoxin administration ANS: A The parents and significant others in the childs life should have CPR training. The digoxin dose is not repeated if the child vomits. Dizziness is a symptom the child should be taught to report to adults so the physician can be notified. The childs pulse should be counted before the medication is given. The dose is withheld if the pulse is below the parameters set by the physician.

26. A nurse is assigned to care for an infant with an unrepaired tetralogy of Fallot. What should the nurse do first when the baby is crying and becomes severely cyanotic? a. Place the infant in a knee-chest position. b. Administer oxygen. c. Administer morphine sulfate. d. Notify the physician.

ANS: A Placing the infant in a knee-chest position will decrease venous return so that smaller amounts of highly saturated blood reach the heart. Administering oxygen is indicated after placing the infant in a knee-chest position. Administering morphine sulfate calms the infant. It is indicated after the infant has been placed in a knee-chest position. The physician should be notified after the infant has been placed in a knee-chest position.

27. The nurse caring for a child with a diagnosis of rheumatic fever should assess the child for which finding? a. Sore throat b. Elevated blood pressure c. Desquamation of the fingers and toes d. Tender, warm, inflamed joints ANS: D Arthritis, characterized by tender, warm, erythematous joints, is one of the major manifestations of rheumatic fever. The child may have had a sore throat previously associated with a group A beta-hemolytic streptococcal infection a few weeks earlier. A sore throat is not a manifestation of rheumatic fever. Hypertension is not associated with rheumatic fever. Desquamation of the fingers and toes is a manifestation of Kawasaki syndrome.

28. A nurse is caring for a child admitted to the hospital with Kawasaki disease. Which cardiac complication of Kawasaki disease should the nurse monitor for? a. Cardiac valvular disease b. Cardiomyopathy c. Coronary aneurysm d. Rheumatic fever ANS: C Coronary aneurysm formation begins early in the second phase of Kawasaki syndrome.

Coronary artery aneurysms are seen in 20% of children with untreated Kawasaki disease.

Cardiac valvular disease can occur in rheumatic fever. Cardiomyopathies are diseases of the heart muscle, which can occur as a result of congenital heart disease, coronary artery disease, or other systemic disease. Rheumatic fever is not a complication of Kawasaki syndrome.

MULTIPLE RESPONSE 1. Which congenital heart disease causes cyanosis when not repaired? Select all that apply. a. Patent ductus arteriosus (PDA) b. Tetralogy of Fallot c. Pulmonary atresia d. Transposition of the great arteries ANS: B, C, D Tetralogy of Fallot is a cyanotic lesion with decreased pulmonary blood flow. The hypoxia results in baseline oxygen saturations as low as 75% to 85%. Even with oxygen administration, saturations do not reach the normal range. Pulmonary atresia is a cyanotic lesion with decreased pulmonary blood flow. The hypoxia results in baseline oxygen saturations as low as 75% to 85%. Even with oxygen administration, saturations do not reach the normal range. Transposition of the great arteries is a cyanotic lesion with increased pulmonary blood flow. PDA is failure of

the fetal shunt between the aorta and the pulmonary artery to close. PDA is not classified as a cyanotic heart disease. Prostaglandin E1 is often given to maintain ductal patency in children with cyanotic heart diseases.

2. A child has a total cholesterol level of 180 mg/dL. What dietary recommendations should the nurse make to the child and the childs parents? Select all that apply. a. Replace whole milk for 2% or 1% milk b. Increase servings of red meat c. Increase servings of fish d. Avoid excessive intake of fruit juices e. Limit servings of whole grain ANS: A, C, D A low-fat diet includes using nonfat or low-fat dairy products, limiting red meat intake, and increasing intake of fish, vegetables, whole grains, and legumes. Children should avoid excessive intake of fruit juices and other sweetened drinks, sugars, and saturated fats.

3. A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if which occurs? Select all that apply. a. Respiratory rate of 36 at rest b. Appetite slowly increasing c. Temperature above 37.7 C (100 F). d. New, frequent coughing e. Turning blue or bluer than normal ANS: C, D, E The parents should be instructed to notify the physician after their infants cardiac surgery for a temperature above 37.7 C; new, frequent coughing; and any episodes of the infant turning blue

or bluer than normal. A respiratory rate of 36 at rest for an infant is within normal expectations and it is expected that the appetite will increase slowly.

Chapter 9. Chest and Respiratory System 1. A nurse in the labor and delivery room is assessing respirations on a newborn. The nurse understands that which change in the respiratory system occurs postnatally? a. Respirations are stimulated by hypoxemia. b. It takes up to 48 hours for most of the alveoli to expand. c. Surfactant in the lungs interferes with lung expansion. d. Pulmonary blood flow decreases after birth.

ANS: A A postnatal change in the respiratory system is the stimulation of respiration by hypoxemia, hypercarbia, cold, tactile stimulation, and a possible decrease in the concentration of prostaglandin E2. Inflation of the normal lung is complete within a few breaths, and most alveoli have expanded within the first hour of life. Surfactant in the lungs lowers surface tension and facilitates lung expansion. Pulmonary blood flow increases after birth.

2. Which information should the nurse teach families about reducing exposure to pollens and dust? a. Replace wood and tile floors with wall-to-wall carpeting. b. Do not use an air conditioner. c. Put dust-proof covers on pillows and mattresses. d. Keep humidity in the house above 60%.

ANS: C Covering mattresses and pillows with dust-proof covers will reduce exposure to dust. Carpets retain dust. To reduce exposure to dust, carpeting should be replaced with wood, tile, slate, or vinyl. These floors can be cleaned easily. For anyone with pollen allergies, it is best to keep windows closed and to run the air conditioner. A humidity level above 60% promotes dust mites.

It is recommended that household humidity be kept between 40% and 50% to reduce dust mites inside the house.

3. A child has had cold symptoms for more than 2 weeks, a headache, nasal congestion with purulent nasal drainage, facial tenderness, and a cough that increases during sleep. The nurse recognizes these symptoms are characteristic of which respiratory condition? a. Allergic rhinitis b. Bronchitis

c. Asthma d. Sinusitis ANS: D Sinusitis is characterized by signs and symptoms of a cold that do not improve after 14 days, a low-grade fever, nasal congestion and purulent nasal discharge, headache, tenderness, a feeling of fullness over the affected sinuses, halitosis, and a cough that increases when the child is lying down. The classic symptoms of allergic rhinitis are watery rhinorrhea, itchy nose, eyes, ears, and palate, and sneezing. Symptoms occur as long as the child is exposed to the allergen. Bronchitis is characterized by a gradual onset of rhinitis and a cough that is initially nonproductive but may change to a loose cough. The manifestations of asthma may vary, with wheezing being a classic sign. The symptoms presented in the question do not suggest asthma.

4. The child with chronic otitis media with effusion should be evaluated for which problem? a. Brain abscess b. Meningitis c. Hearing loss d. Perforation of the tympanic membrane ANS: C Chronic otitis media with effusion is the most common cause of hearing loss in children. The infection of acute otitis media can spread to surrounding tissues, causing a brain abscess or meningitis. Inflammation and pressure from acute otitis media may result in perforation of the tympanic membrane.

5. The nurse should expect the initial plan of care for a 9-month-old child with an acute otitis media infection to include: a. symptomatic treatment and observation for 48 to 72 hours after diagnosis. b. an oral antibiotic, such as amoxicillin, several times a day for 7 days. c. pneumococcal conjugate vaccine. d. myringotomy with tympanoplasty tubes.

ANS: A For select children 6 months of age or older with acute otitis media, as an alternative to initiating antibiotic therapy, once diagnosed, acute otitis media is treated by initiating symptomatic treatment and observation for 48 to 72 hours. Acute otitis media may be treated with a 5- to 10-

day course of oral antibiotics. When treatment is indicated, amoxicillin at a divided dose of 80 to 90 mg/kg/day given either every 8 or 12 hours for 5 to 10 days may be ordered. Pneumococcal conjugate vaccine helps to prevent ear infections but is not included in the initial plan of care for a child with acute otitis media. Surgical intervention is considered when the child has persistent ear infections despite antibiotic therapy or with otitis media with effusion that persists for more than 3 months and is associated with hearing loss.

6. Which statement made by a parent indicates understanding about treatment of streptococcal pharyngitis? a. I guess my child will need to have his tonsils removed. b. A couple of days of rest and some ibuprofen will take care of this. c. I should give the penicillin three times a day for 10 days. d. I am giving my child prednisone to decrease the swelling of the tonsils.

ANS: C Streptococcal pharyngitis is best treated with oral penicillin two to three times daily for 10 days.

Surgical removal of the tonsils is a controversial issue. It may be warranted in cases of recurrent tonsillitis. It is not indicated for the treatment of acute tonsillitis. Comfort measures such as rest and analgesics are indicated, but these will not treat the bacterial infection. Corticosteroids are not used in the treatment of streptococcal pharyngitis.

7. A nurse is planning care for a child with laryngomalacia. Which symptom should the nurse plan to assess that is characteristic of laryngomalacia? a. Stridor b.

High-pitched cry

c.

Nasal congestion

d. Irritability ANS: A Stridor is usually present at birth but may begin as late as 2 months. Symptoms increase when the infant is supine or crying. High-pitched cries are consistent with neurological abnormalities and are not usually respiratory in nature. Nasal congestion is nonspecific in relation to laryngomalacia. Irritability often occurs with respiratory illnesses; however, it is not the most characteristic symptom of laryngomalacia.

8. The nurse should assess a child who has had a tonsillectomy for which problem?

a. Frequent swallowing b. Inspiratory stridor c. Rhonchi d. Elevated white blood cell count ANS: A Frequent swallowing is indicative of postoperative bleeding. Inspiratory stridor is characteristic of croup. Rhonchi are lower airway sounds indicating pneumonia. Assessment of blood cell counts is part of a preoperative workup.

9. A nurse is teaching parents about manifestations of spasmodic croup. Which is a distinguishing manifestation of spasmodic croup that should be included in the teaching session? a. It has a gradual onset. b. It is characterized a harsh barky cough. c. It is bacterial in nature. d. The child has a high fever.

ANS: B Spasmodic croup is viral in origin with a sudden onset usually at night of a harsh, metallic, barky cough, sore throat, inspiratory stridor, and hoarseness. A gradual onset is indicative of laryngotracheobronchitis. A high fever is not usually present.

10. Which intervention for treating croup at home should be taught to parents? a. Have a decongestant available to give the child when an attack occurs. b. Have the child sleep in a dry room. c. Sit with the child in the bathroom with the shower on when an attack occurs. d. Give the child an antibiotic at bedtime.

ANS: C Sitting in the bathroom with the shower on provides humidity for the child, which usually improves symptoms in croup. Decongestants are inappropriate for croup, which affects the mid airway level. A dry environment may contribute to symptoms. Croup is caused by a virus.

Antibiotic treatment is not indicated.

11. A 5-year-old child is brought to the emergency department with copious drooling and a croaking sound on inspiration. Her mother states that the child is very agitated and only wants to sit upright. What should be the nurses first action in this situation? a. Prepare intubation equipment and call the physician. b. Examine the childs oropharynx and call the physician. c. Obtain a throat culture for respiratory syncytial virus (RSV). d. Obtain vital signs and listen to breath sounds.

ANS: A The 5-year-old child has symptoms of epiglottitis, is acutely ill, and requires emergency measures. If epiglottitis is suspected, the nurse would never examine the childs throat. Inspection of the epiglottis is done only by a physician because it could trigger airway obstruction. A throat culture could precipitate a complete respiratory obstruction. Vital signs can be assessed after emergency equipment is readied.

12. Which action for care can be taught to the parents of a 3-year-old child with pneumonia who is not hospitalized? a. Offer the child only cool liquids. b. Offer the child a favorite warm liquid drink. c. Use a warm mist humidifier. d. Call the physician for a respiratory rate less than 28 breaths/minute.

ANS: B Offering the child favorite fluids will facilitate oral intake. Warm liquids are preferable as they help loosen secretions. Cool mist humidifiers are preferred to warm mist humidifiers. Warm mist is a safety concern and could cause burns if touched by the child. Typically parents are not taught to count their childrens respirations and report abnormalities to the physician. Even if this were the case, a respiratory rate of less than 28 breaths/minute is normal for a 3-year-old child. The expected respiratory rate for a 3-year-old child is 20 to 30 breaths/minute.

13. Which sign is indicative of respiratory distress in infants? a. Nasal flaring b. Respiratory rate of 55 breaths/minute c. Irregular respiratory pattern d. Abdominal breathing ANS: A Infants have difficulty breathing through their mouths; therefore, nasal flaring is usually accompanied by extra respiratory efforts. It also allows more air to enter as the nares flare. A respiratory rate of 55 breaths/minute would be a normal assessment for an infant. Tachypnea would be a respiratory rate of 60 to 80 breaths/minute. Irregular respirations are normal in the infant. Abdominal breathing is common because the diaphragm is the neonates major breathing muscle.

14. Once an allergen is identified in a child with allergic rhinitis, what would be the treatment of choice? a. Use appropriate medications. b. Begin desensitization injections. c. Eliminate the allergen. d. Remove the adenoids.

ANS: C The first priority is to attempt to remove the causative agent from the childs environment.

Medications are not a first-line treatment but can be helpful in controlling allergic rhinitis.

Immunotherapy is usually the final component of controlling allergic rhinitis. Adenoids are tissues that can swell with constant rhinitis; however, a surgical procedure is not indicated for allergic rhinitis. Dealing with the cause is the first priority.

15. A child has returned to the postsurgical floor after having had a tonsillectomy. Which assessment finding should the nurse report to the physician? a. Vomiting bright red blood b. Pain at the surgical site c. Pain on swallowing d. The ability to only take small sips of liquids ANS: A Vomiting bright red blood and swallowing frequently are signs of bleeding postoperatively and should be reported to the physician. It is normal for the child to have pain at the surgical site and on swallowing. Only clear liquids are offered immediately after surgery, and small sips would be preferred.

16. Teaching safety precautions with the administration of antihistamines is important due to which common side effect? a.

Dry mouth

b.

Excitability

c. Drowsiness d. Dry mucous membranes ANS: C Drowsiness is a safety hazard when alertness is needed, especially with a teenage driver.

Nonsedating brands should be used. A dry mouth is not a safety issue. Excitability may affect rest or sleep, but drowsiness is the most important safety hazard. Dry mucous membranes are not a safety issue.

17. Which is an appropriate beverage for the nurse to give to a child who had a tonsillectomy earlier in the day?

a. Chocolate ice cream b. Orange juice c. Fruit punch d. Apple juice ANS: D The child can have clear, cool liquids when fully awake. The child can have full liquids on the second postoperative day. Citrus drinks are not offered because they can irritate the throat. Red liquids are avoided because they give the appearance of blood if vomited.

18. Which intervention should the nurse implement as a priority in the management of a child with epiglottitis? a. Adequate hydration b. Maintaining a patent airway c. Cessation of coughing d. Decreasing fever ANS: B Epiglottitis can rapidly progress to complete airway obstruction and death. The goal of treatment is to maintain a patent airway. The child with epiglottitis will not be able to take fluids orally.

Hydration is a concern, but not the priority. Cough is not a symptom of epiglottitis. The child with epiglottitis will have an elevated temperature. Reducing fever is not the priority of care.

19. What information should the nurse teach workers at a day care center about respiratory syncytial virus (RSV)? a. RSV is transmitted through particles in the air. b. RSV can live on skin or paper for up to a few seconds after contact. c. RSV can survive on nonporous surfaces for about 60 minutes.

d. Frequent hand washing can decrease the spread of the virus.

ANS: D Meticulous hand washing can decrease the spread of organisms. RSV infection is not airborne. It is acquired mainly through contact with contaminated surfaces. RSV can live on skin or paper for up to 1 hour and can live on cribs and other nonporous surfaces for up to 6 hours.

20. Which intervention is appropriate for the infant hospitalized with bronchiolitis? a. Position on the side with neck slightly flexed. b. Administer antibiotics as ordered. c. Restrict oral and parenteral fluids if tachypneic. d. Give cool, humidified oxygen.

ANS: D Cool, humidified oxygen is given to relieve dyspnea, hypoxemia, and insensible fluid loss from tachypnea. The infant should be positioned with the head and chest elevated at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. The etiology of bronchiolitis is viral. Antibiotics are given only if there is a secondary bacterial infection. Tachypnea increases insensible fluid loss. If the infant is tachypneic, fluids are given parenterally to prevent dehydration.

21. The nurse is caring for a child hospitalized for status asthmaticus. Which assessment finding suggests that the childs condition is worsening? a. Hypoventilation b. Thirst c. Bradycardia d. Clubbing ANS: A

The nurse would assess the child for signs of hypoxia, including restlessness, fatigue, irritability, and increased heart and respiratory rate. As the child tires from the increased work of breathing hypoventilation occurs leading to increased carbon dioxide levels. The nurse would be alert for signs of hypoxia. Thirst would reflect the childs hydration status. Bradycardia is not a sign of hypoxia; tachycardia is. Clubbing develops over a period of months in response to hypoxia. The presence of clubbing does not indicate the childs condition is worsening.

22. Which finding is expected when assessing a child hospitalized for asthma? a. Inspiratory stridor b. Harsh, barky cough c. Wheezing d. Rhinorrhea ANS: C Wheezing is a classic manifestation of asthma. Inspiratory stridor is a clinical manifestation of croup. A harsh, barky cough is characteristic of croup. Rhinorrhea is not associated with asthma.

23. Which statement indicates that a parent of a toddler needs more education about preventing foreign body aspiration? a. I keep objects with small parts out of reach. b. My toddler loves to play with balloons. c. I wont permit my child to have peanuts. d. I never leave coins where my child could get them.

ANS: B Latex balloons account for a significant number of deaths from aspiration every year. Keeping toys with small parts and other small objects out of reach can prevent foreign body aspiration.

Peanuts are just one of the foods that pose a choking risk if given to young children. Small objects, such as coins, need to be put out of the small childs reach.

24. A nurse is teaching a class to parents on respiratory distress syndrome (RDS). Which statement about RDS indicates the parents understood the teaching? a. Factors causing chronic fetal stress increase the incidence of RDS. b. RDS is the leading cause of respiratory failure in premature infants. c. RDS is caused by an overproduction of surfactant in fetal development. d. The incidence of RDS is significantly lower as gestational age decreases.

ANS: B RDS is the leading cause of respiratory failure in premature infants. Things that tend to cause chronic fetal stress, such as maternal hypertension, drug abuse, and prolonged rupture of membranes, decrease the incidence of hyaline membrane disease. RDS occurs in infants with insufficient amounts of surfactant or immature lung development. The incidence of RDS increases as gestational age decreases.

25. What is a common trigger for asthma attacks in children? a. Febrile episodes b. Dehydration c. Exercise d. Seizures ANS: C Exercise is one of the most common triggers for asthma attacks, particularly in school-age children. Febrile episodes are consistent with other problems, for example, seizures. Dehydration occurs as a result of diarrhea; it does not trigger asthma attacks. Viral infections are triggers for asthma. Seizures can result from a too-rapid intravenous infusion of theophyllinea therapy for asthma.

26. Which child would require a Mantoux test?

a. The child who has episodes of nighttime wheezing and coughing b. The child who has a history of allergic rhinitis c. The child whose babysitter is diagnosed with tuberculosis d. The premature infant who is being treated for apnea of infancy ANS: C The Mantoux test is the initial screening mechanism for patients exposed to tuberculosis.

Nighttime wheezing and coughing are consistent with a diagnosis of asthma. Allergic rhinitis would require an allergy workup. The premature infant who is being treated for apnea of infancy would require a sleep study as part of the evaluation.

27. What explanation should the nurse give to a parent of a child with asthma about using a peak flowmeter? a. It is used to monitor the childs breathing capacity. b. It measures the childs lung volume. c. It will help the medication reach the childs airways. d. It measures the amount of air the child breathes in.

ANS: A The peak flowmeter is a device used to monitor breathing capacity in the child with asthma; it measures the flow of air in a forced exhalation in liters per minute. A child with asthma would have a pulmonary function test to measure lung volume. A spacer used with a metered dose inhaler prolongs medication transit so medication reaches the airways.

28. What is the best nursing response to the parent of a child with asthma who asks if his child can still participate in sports? a. Children with asthma are usually restricted from physical activities. b. Children can usually play any type of sport if their asthma is well controlled.

c. Avoid swimming because breathing underwater is dangerous for people with asthma. d. Even with good asthma control, I would advise limiting the child to one athletic activity per school year.

ANS: B Sports that do not require sustained exertion, such as gymnastics, baseball, and weight lifting, are well tolerated. Children can usually play any type of sport if their asthma is well controlled.

Children with asthma should not be restricted from physical activity. Swimming is recommended as the ideal sport for children with asthma because the air is humidified and exhaling underwater prolongs exhalation and increases end-expiratory pressure.

29. Which response indicates that a school-age child understands the interpretation of peak flowmeter results? a. When my peak flow is in the green zone, I need more medication. b. The red zone means my peak flow is 80% to 100%. c. When my peak flow is in the yellow zone, I might need to take more medicine. d. The yellow zone means I need to take albuterol right away.

ANS: C The yellow zone indicates caution. The childs peak flow is 50% to 80% of his personal best. A temporary increase in medication may be indicated. The green zone indicates all clear. There are no asthma symptoms present. The childs exhalation is 80% to 100% of his personal best. The red zone is interpreted as a medical alert. The childs exhalation is below 50% of his personal best.

The child should use a bronchodilator immediately. The child would take an immediate bronchodilator if his peak flow is in the red zone.

30. A nurse is admitting a client with an asthma exacerbation. Which drug should the nurse be prepared to administer to relieve an acute asthma episode? a. Systemic corticosteroids

b. Inhaled corticosteroids c. Leukotriene blockers d. Long-acting bronchodilators ANS: A Systemic corticosteroids decrease airway inflammation in an acute asthma attack. They are given for short burst courses of 5 to 7 days. Inhaled corticosteroids are used for long-term, routine control of asthma. Leukotriene blockers diminish the mediator action of leukotrienes and are used for long-term, routine control of asthma in children older than 12 years. A long-acting bronchodilator would not relieve acute symptoms.

31. The nurse is getting an end-of-shift report on a child with status asthmaticus. Which intervention should the nurse question? a. Administer oxygen at 6 liters by nasal cannula. b. Assess intravenous (IV) maintenance fluids and site every hour. c.

Notify the physician for signs of increasing respiratory distress.

d. Organize care to allow for uninterrupted rest periods.

ANS: A Supplemental oxygen should not exceed 2 L/min and 6 L/min exceeds the recommended flow rate for a nasal cannula. Administration of oxygen to a child with chronic carbon dioxide retention may lead to respiratory depression by decreasing the stimulus to breathe. When the child cannot take oral fluids because of respiratory distress, IV fluids are administered. The child with a continuous IV infusion must be assessed hourly to prevent complications. A physician should be notified of any changes indicating increasing respiratory distress. A child in respiratory distress is easily fatigued. Nursing care should be organized so the child can get needed rest without being disturbed.

32. Which intervention should be included in the plan of care for a child hospitalized for an exacerbation of cystic fibrosis?

a. Perform chest physiotherapy 30 minutes after meals. b. Administer low-flow oxygen (less than 2 L/min). c. Position with the head lower than the rest of the body. d. Provide privacy during coughing episodes.

ANS: B Low-flow oxygen is administered because in children who are chronically hypoxic, too much oxygen can depress respirations. Chest physiotherapy should be scheduled at least 1 hour before or 2 hours after meals to reduce gastrointestinal upset. The head of the bed should be elevated and the child positioned upright to facilitate breathing. The nurse should stay with the child during coughing episodes.

33. What should the nurse teach a child about using an albuterol metered-dose inhaler for exercise-induced asthma? a.

Take two puffs every 6 hours around the clock.

b. Use the inhaler only when he is short of breath. c. Use the inhaler 15 minutes before exercise. d. Take one to two puffs every morning on awakening.

ANS: C The appropriate time to use an inhaled beta2-agonist or cromolyn is before an event that could trigger an attack. Two puffs every 6 hours around the clock will not relieve exercise-induced asthma. Waiting until symptoms are severe is too late to begin using a metered-dose inhaler. One to two puffs every morning on awakening may be the childs usual schedule for medication. If exercise causes symptoms, additional medication is indicated.

34. A preterm infant is being discharged from the hospital. Which immunization should the nurse prepare to administer to protect the infant from the respiratory syncytial virus (RSV)? a. Pavilizumab (Synagis)

b. Ribaviran (Virazole) c. Hemophilus influenza type B (HIB) d. Pneumococcal (Prevnar) ANS: A Intramuscular pavilizumab (Synagis) is the immunization administered monthly throughout the RSV season for premature infants (less than 35 weeks of gestation) younger than 6 months.

Ribaviran is an antiviral medication used for treatment of severe cases of RSV. The HIB immunization is given to prevent infections caused by Hemophilus influenza type B. The Prevnar vaccination prevents pneumonia by the pneumococcal virus.

35. Which statement, if made by parents of a child with cystic fibrosis, indicates that they understood the nurses teaching on pancreatic enzyme replacement? a. Enzymes will improve my childs breathing. b. I should give the enzymes 1 hour after meals. c. Enzymes should be given with meals and snacks. d. The enzymes are stopped if my child begins wheezing.

ANS: C Children with cystic fibrosis need to take enzymes with all food for adequate absorption of nutrients. Pancreatic enzymes do not affect the respiratory system and are taken within 30 minutes of eating all meals and snacks. Giving the medication 1 hour after meals is inappropriate and ineffective for absorption of nutrients. Wheezing is not a reason to stop taking enzyme replacements.

36. Which vitamin supplements are necessary for children with cystic fibrosis? a. Vitamin C and calcium b. Vitamins B6 and B12 c. Magnesium

d. Vitamins A, D, E, and K ANS: D Fat-soluble vitamins are poorly absorbed because of deficient pancreatic enzymes in children with cystic fibrosis; therefore, supplements are necessary. Vitamin C and calcium are not fat soluble. B6 and B12 are not fat-soluble vitamins. Magnesium is not a vitamin.

37. Why do infants and young children develop respiratory distress more quickly in acute and chronic alterations of the respiratory system? a. They have a widened, shorter airway. b. There is a defect in their sucking ability. c. The gag reflex increases mucus production. d. Mucus and edema obstruct small airways.

ANS: D The airway in infants and young children is narrower, not wider; respiratory distress can occur quickly because mucus and edema can cause obstruction to their small airways. Sucking is not necessarily related to problems with the airway. The gag reflex is necessary to prevent aspiration.

It does not produce mucus.

38. Which statement made by a parent would indicate an understanding about the genetic transmission of cystic fibrosis (CF)? a. Only one parent carries the cystic fibrosis gene. b. Both parents are carriers of the cystic fibrosis gene. c. The presence of the disease is most likely the result of a genetic mutation. d. The mother is usually the carrier of the cystic fibrosis gene.

ANS: B

Cystic fibrosis follows a pattern of autosomal recessive transmission. Both parents must be carriers of the gene for the disease to be transmitted to the child. If both parents carry the CF gene, each pregnancy has a 25% chance of producing a CF-affected child. Cystic fibrosis will not be present if only one parent is a carrier of the cystic fibrosis gene and is known to have a definite pattern of transmission. It is transmitted as an autosomal recessive trait. A carrier parent can transmit the carrier gene to the child. The disease is present when the carrier gene is transmitted from both parents.

39. A small child with cystic fibrosis cannot swallow pancreatic enzymes capsules. The nurse would teach parents to mix enzymes with which food? a. Macaroni and cheese b. Tapioca c. Applesauce d. Hot chocolate ANS: C Enzymes can be mixed with a small amount of nonprotein foods, such as applesauce. Macaroni and cheese and tapioca are not good choices because enzymes are inactivated by heat and starchy foods. Enzymes are less effective if mixed with foods that are hot, such as hot chocolate.

40. The nurse should teach parents of a child with cystic fibrosis to adjust enzyme dosage according to which indicator? a. Stool formation b. Vomiting c. Weight d. Urine output ANS: A

When there is constipation, less enzyme is needed; with steatorrhea, more enzyme is needed for digestion of nutrients. Vomiting does not affect enzyme dosaging. The childs weight does not affect enzyme dosaging. Urine output is not relevant to enzyme replacement.

Chapter 10. Head and Neck 1. Head circumference is measured in children with known or suspected hydrocephalus and

children less than how many months old? a.

40

c.

32

b.

36

d.

24

ANS: D Feedback

A

B

C D

Incorrect. Head circumference is no longer measured in children after they are 24 months old, not 40.

Incorrect. Head circumference is no longer measured in children after they are 24 months old, not 36.

Incorrect. Head circumference is no longer measured in children after they are 24 months old, not 32.

Correct. Head circumference is measured in children with known or suspected hydrocephalus and children less than 24 months old.

2. The mother of a 9-month-old infant is concerned that the head circumference of her baby is

greater than the chest circumference. The best response by the nurse is: a.

This is normal until the age of 1 year, and then the chest will be greater.

b.

Perhaps your baby was small for gestational age or premature.

c.

Let me ask you a few questions, and perhaps we can figure out the cause of this difference.

d.

These circumferences normally are the same, but in some babies this just differs.

ANS: A Feedback Correct. From birth to about 1 year, the head circumference is greater than the chest

A

circumference.

Incorrect. In response to the expressed concern by the mother of a 9-month-old infant that the head circumference of her baby is greater than the chest circumference, the best response by the nurse is not: Perhaps your baby was small for gestational age or premature.

B Incorrect. In response to the expressed concern by the mother of a 9-month-old infant that the head circumference of her baby is greater than the chest circumference, the best response by the nurse is not: Let me ask you a few questions, and perhaps we can figure out the cause of this difference.

C

D

Incorrect. In response to the expressed concern by the mother of a 9-month-old infant that the head circumference of her baby is greater than the chest circumference, the best response by the nurse is not: These circumferences normally are the same, but in some babies this just differs.

3. The nurse is assessing an 8-month-old infant for head lag, pulling the infant by the hands from

a supine to a sitting position. The head does not stay in line with the body then being pulled forward. Which of the following statements best represents the significance of this finding?

a.

This is a normal finding, as the infants head will not stay in line until after 8 months of age.

b.

The nurse has not conducted the test correctly and must do it again using proper technique.

c.

Significant head lag after the age of 6 months may indicate brain injury and needs further investigations.

d.

Head lag should not be tested until the child is over 1 year of age.

ANS: C Feedback

A

B

Incorrect. Since the head does not stay in line with the body then being pulled forward into a sitting position, the nurse assesses that this is not normal.

Incorrect. Pulling the infant by the hands from a supine to a sitting position is the correct means to test for head lag.

Correct. Significant head lag indicates head control is not keeping pace with normal development, and after 6 months of age may indicate brain injury and should be

C

further investigated.

Incorrect. Testing for head lag should begin as early as 3 months, no later than 4 months.

D

4. While working in a public health clinic, the nurse assesses a child who is 3 years old. The

nurse finds an open and wide anterior fontanel. The nurse is aware that an open anterior fontanel at this age most likely is: a.normal

c.due to disease, such as rickets

b.a result of prolonged dehydrationd.due to a congenital disorder

ANS: C

Feedback AIncorrect. The finding of an open and wide anterior fontanel in a 3 year old child is not normal.

BIncorrect. The finding of an open and wide anterior fontanel in a 3 year old child is not the result of prolonged dehydration, but a sunken depressed fontanel points to improper hydration.

CCorrect. A wide anterior fontanel in a child older than 2 1/2 years is an abnormal finding. An anterior fontanel that remains open after 2 1/2 years of age may indicate disease such as rickets.

DIncorrect. The finding of an open and wide anterior fontanel in a 3 year old child is not due to a congenital disorder.

5. While palpating the fontanels of a 1-month-old infant, the nurse finds the posterior fontanel to

be 2 to 3 cm. The nurse is aware that this finding occurs with which of the following conditions or disorders? a.diabetes

c.cerebral palsy

b.premature birthd.congenital hypothyroidism

ANS: D

Feedback AIncorrect. A posterior fontanel greater than 1.5 cm in diameter is abnormal but does not occur with diabetes.

BIncorrect. A posterior fontanel greater than 1.5 cm in diameter is abnormal but does not occur

with premature birth.

CIncorrect. A posterior fontanel greater than 1.5 cm in diameter is abnormal but does not occur with cerebral palsy.

DCorrect. A posterior fontanel greater than 1.5 cm in diameter is abnormal and occurs with congenital hypothyroidism.

6. Which of the following best defines craniosynostosis?

a.premature ossification of suture lines resulting in early fusion of the bones of the skull b.sinus openings into the cranium allowing for changes in intracranial pressure c.wider spaces than normal between the bones of the cranium d.changes in the size and shape of the skull due to the absence of lymph and sinus openings

ANS: A

Feedback ACorrect. Craniosynostosis is premature ossification of suture lines, thereby there is early formation and fusion of skull bones. Craniosynostosis may be caused by metabolic disorders or may be a secondary consequence of Microcephaly.

BIncorrect. Craniosynostosis is not defined as sinus openings into the cranium allowing for changes in intracranial pressure.

CIncorrect. Craniosynostosis is not defined as wider spaces than normal between the bones of the cranium.

DIncorrect. Craniosynostosis is not defined as changes in the size and shape of the skull due to the absence of lymph and sinus openings.

7. While palpating the outer layer of the cranial bones behind and above the ears, the nurse finds

a softening of this area and has the sensation of pressing on a table-tennis ball then palpating the area. The nurse knows this finding is indicative of: a.shaken baby syndromec.craniotabes b.skull fracture

d.crepitus

ANS: C

Feedback AIncorrect. The findings of a softening of the cranial bones behind and above the ears is not

associated with shaken baby syndrome.

BIncorrect. The findings of a softening of the cranial bones behind and above the ears is not associated with a skull fracture.

CCorrect. A softening of the outer layer of cranial bones behind and above the ears combined with a ping-pong ball sensation as the area is pressed in gently with the fingers is indicative of craniotabes, an abnormal finding. Craniotabes is associated with rickets, syphilis, hydrocephaly, or hypervitaminosis.

DIncorrect. The findings of a softening of the cranial bones behind and above the ears is not associated with crepitus (flatulence).

8. The caregivers notice a swelling over the cranial bones of their newborn. The nurse examines

the baby and tells the caregivers that this appears to be a cephalhematoma and will disappear with time. The nurse is reasonably certain this is a cephalhematoma and not some other abnormality because the: a.mother had a forceps delivery

c.color is the same as a cephalhematoma

b.swelling does not cross suture linesd.swelling is over a large area of the head

ANS: B

Feedback AIncorrect. The means of delivery may or may not involve a cephalhematoma, but would not be the only possibility.

BCorrect. Another abnormal finding in a newborn is a cephalhematoma, a localized, subcutaneous swelling over one of the cranial bones. The swelling does not cross suture lines.

CIncorrect. Cephalhematoma swelling does not present a differing color.

DIncorrect. Cephalhematoma swelling is localized, not swelling over a large area of the head.

9. Swelling over the occipitoparietal region of the skull is called by which of the following terms?

a.occipitocapus

c.edematous capitus

b.caput succedaneumd.parietus sepitus

ANS: B

Feedback

AIncorrect. Swelling over the occipitoparietal region of the skull is not called occipitocapus.

BCorrect. Another variation in the newborn that causes the shape of the skull to look markedly

asymmetric is caput succedaneum or swelling over the occipitoparietal region of the skull.

CIncorrect. Swelling over the occipitoparietal region of the skull is not called edematous capitus.

DIncorrect. Swelling over the occipitoparietal region of the skull is not called parietus sepitus.

Chapter 11. Lymphatic System 1. A nurse in a well-child clinic is teaching parents about their childs immune system. Which statement, made by the nurse, is correct?

a. The immune system distinguishes and actively protects the bodys own cells from foreign substances. b. The immune system is fully developed by 1 year of age. c. The immune system protects the child against communicable diseases in the first 6 years of life. d. The immune system responds to an offending agent by producing antigens.

ANS: A

The immune system responds to foreign substances, or antigens, by producing antibodies and storing information. Intact skin, mucous membranes, and processes such as coughing, sneezing, and tearing help maintain internal homeostasis. Children up to the age of 6 or 7 years have limited antibodies against common bacteria. The immunoglobins reach adult levels at different ages. Immunization is the basis from which the immune system activates protection against some communicable diseases. Antibodies are produced by the immune system against invading agents, or antigens.

2. A nurse is teaching parents about the importance of immunizations for infants because of immaturity of the immune system. The parents demonstrate that they understand the teaching if they make which statement?

a. The spleen reaches full size by 1 year of age. b. IgM, IgE, and IgD levels are high at birth. c. IgG levels in the newborn infant are low at birth.

d. Absolute lymphocyte counts reach a peak during the first year.

ANS: D Absolute lymphocyte counts reach a peak during the first year. The spleen reaches its full size during adulthood. IgM, IgE, and IgD are normally in low concentration at birth. IgM, IgE, IgA, and IgD do not cross the placenta. The term newborn infant receives an adult level of IgG as a result of transplacental transfer from the mother.

3. Which statement is true regarding how infants acquire immunity? a. The infant acquires humoral and cell-mediated immunity in response to infections and immunizations. b. The infant acquires maternal antibodies that ensure immunity up to 12 months of age. c. Active immunity is acquired from the mother and lasts 6 to 7 months. d. Passive immunity develops in response to immunizations.

ANS: A Infants acquire long-term active immunity from exposure to antigens and vaccines. Immunity is acquired actively and passively. The term infants passive immunity is acquired from the mother and begins to dissipate during the first 6 to 8 months of life. Active immunity develops in response to immunizations.

4. A nurse is teaching parents about transmission of human immunodeficiency virus (HIV) in the pediatric population. The nurse should relate that the most common mode of transmission of HIV virus is: a. Perinatal transmission b. Sexual abuse c. Blood transfusions d. Poor hand washing

ANS: A Perinatal transmission accounts for the highest percentage of HIV infections in children. Infected women can transmit the virus to their infants across the placenta during pregnancy, at delivery, and through breast-feeding. Cases of HIV infection from sexual abuse have been reported; however, perinatal transmission accounts for most pediatric HIV infections. Although in the past some children became infected with HIV through blood transfusions, improved laboratory screening has significantly reduced the probability of contracting HIV from blood products. Poor hand washing is not an etiology of HIV infection.

5. A nurse is preparing to administer routine immunizations to an infant who is HIV positive.

What is the American Academy of Pediatrics recommendation for immunizing infants who are HIV positive? a. Follow the routine immunization schedule. b. Routine immunizations are administered. Assess CD4+ counts before administering the MMR and varicella vaccinations. c. Do not give immunizations because of the infants altered immune status. d. Eliminate the pertussis vaccination because of the risk of convulsions.

ANS: B Routine immunizations are appropriate. CD4+ cells are monitored when deciding whether to provide live virus vaccines. If the child is severely immunocompromised, the MMR vaccine is not given. The varicella vaccine can be considered on the basis of the childs CD4+ counts. Only inactivated polio (IPV) should be used for HIV-infected children. Immunizations are given to infants who are HIV positive. The pertussis vaccination is not eliminated for an infant who is HIV positive.

6. Which recommendation by the nurse is appropriate for a mother who has a preschool child who refuses to take the medications for HIV infection? a. Mix medications with chocolate syrup or follow with chocolate candy. b. Mix the medications with milk or an essential food.

c. Skip the dose of medication if the child protests too much. d. Mix the medication in a syringe, hold the child down firmly, and administer the medication.

ANS: A Liquid forms of HIV medications may be foul tasting or have a gritty texture. Chocolate would help to make these foods more palatable and is liked by most children. Medications should be mixed with nonessential foods. Doses of medication should never be skipped. Fighting with the child or using force should be avoided. A nonessential food that will make the taste of the medication more palatable for the child should be the correct action. The administration of medications for the child with HIV becomes part of the familys everyday routine for years.

7. What is the primary nursing concern for a hospitalized child with HIV infection? a. Maintaining growth and development b. Eating foods that the family brings to the child c. Consideration of parental limitations and weaknesses d. Resting for 2 to 3 hours twice a day ANS: A Maintaining growth and development is a major concern for the child with HIV infection.

Frequent monitoring for failure to thrive, neurological deterioration, or developmental delay is important for HIV-infected infants and children. Nutrition, which contributes to a childs growth, is a nursing concern; however, it is unnecessary for family members to bring food to the child.

Although an assessment of parental strengths and weaknesses is important, it will be imperative for healthcare providers to focus on the parental strengths not weaknesses. This is not as important as the frequent assessment of the childs growth and development. Rest is a nursing concern, but it is not as high a priority as maintaining growth and development. Rest periods twice a day for 2 to 3 hours may not be appropriate.

8. What should the nurse include in a teaching plan for a mother of a toddler who will be taking prednisone for several months?

a. The medication should be taken between meals. b. The medication needs to be discontinued because of the risks associated with long-term usage. c. The medication should not be stopped abruptly. d. The medication may lower blood glucose so the mother needs to observe the child for signs of hypoglycemia.

ANS: C The dosage must be tapered before the drug is discontinued to allow the gradual return of function in the pituitary-adrenal axis. Prednisone should be taken with food to minimize or prevent gastrointestinal bleeding. Although there are adverse effects from long-term steroid use, the medication must not be discontinued without consulting a physician. Acute adrenal insufficiency can occur if the medication is withdrawn abruptly. The dosage needs to be tapered.

The medication puts the child at risk for hyperglycemia, not hypoglycemia.

9. A nurse assesses a child on long-term systemic corticosteroid therapy for which condition? a. Hypotension b. Dilation of blood vessels in the cheeks c. Growth delays d. Decreased appetite and weight loss ANS: C Growth delay is associated with long-term steroid use related to protein catabolism and decreased growth hormone. Hypertension is a clinical manifestation of long-term systemic steroid administration. Dilation of blood vessels in the cheeks is associated with an excess of topically administered steroids. Increased appetite and weight gain are clinical manifestations of excess systemic corticosteroid therapy.

10. Which statement by the parent of a 5-year-old child with acquired immunodeficiency syndrome (AIDS) regarding prescribed antiretroviral agents indicates that she has a good understanding of disease management?

a. When my childs pain increases, I double the recommended dosage of antiretroviral medication. b. Addiction is a risk, so I use the medication only as ordered. c. Doses of the antiretroviral medication are selected on the basis of my childs age and growth. d. By the time my child is an adolescent, she will not need her antiretroviral medications any longer.

ANS: C Doses of antiretroviral medication to treat HIV infection for infants and children are based on individualized age and growth considerations. Antiretroviral medications are not administered for pain relief. Doubling the recommended dosage of any medication is not appropriate without an order from the physician. Addiction is not a realistic concern with antiretroviral medications.

Antiretroviral medications are still needed during adolescence. Doses for adolescents are based on pubertal status by Tanner staging.

11. A mother of a child in the terminal stages of AIDS tells the nurse that her child wants to celebrate his birthday early because he wont be here on his birthday. Which is the best response the nurse can make to this mother? a. What does your husband think about giving the party for the child? b. How does the family feel about your giving in to the child? c. Ill children can be very manipulative. d. Is this the first time he has spoken about death?

ANS: D Dying children know they are dying. Disclosure of awareness of death comes in various ways and needs to be identified by the family and the nurse. The major concern is the childs disclosure of awareness of death, not the husbands reaction. Making statements such as giving in is inappropriate when seeking information. Manipulation is not a major concern during the terminal stage of disease.

12. Which intervention is appropriate for a child receiving high doses of steroids? a. Limit activity and receive home schooling. b. Decrease the amount of potassium in the diet. c. Administer a killed virus vaccine. d. Monitor for seizure activity.

ANS: C The child on high doses of steroids should not receive live virus vaccines because of immunosuppression. Limiting activity and home schooling are not routine for a child receiving high doses of steroids. The child receiving steroids is at risk for hypokalemia and needs potassium in the diet. Children on steroids are not typically at risk for seizures.

13. The nurse observes a red rash that spreads across the childs cheeks and nose. This assessment finding is characteristic of which of the following conditions? a. Systemic lupus erythematosus (SLE) b. Rheumatic fever c. Kawasaki disease d. Anaphylactic reaction ANS: A A red, flat, or raised malar butterfly rash over the cheeks and bridge of the nose is a clinical manifestation of SLE. A major manifestation of rheumatic fever is erythema marginatum, which appears as red skin lesions spread peripherally over the trunk. An erythematous rash, induration of the hands and feet, and erythema of the palms and soles are manifestations of Kawasaki disease. Initial symptoms of anaphylaxis include severe itching and rapid development of erythema.

14. What is the major nursing concern for a child having an anaphylactic reaction?

a. Identifying the offending allergen b. Ineffective breathing pattern c. Increased cardiac output d. Positioning to facilitate comfort ANS: B Laryngospasms resulting in ineffective breathing patterns are a life-threatening manifestation of anaphylaxis. The primary action is to assess airway patency, respiratory rate and effort, level of consciousness, oxygen saturation, and urine output. Determining the cause of an anaphylactic reaction is important to implement the appropriate treatment, but the primary concern is the airway. During anaphylaxis, the cardiac output is decreased. During the acute period of anaphylaxis, the nurses primary concern is the childs breathing. Positioning for comfort is not a primary concern during a crisis.

15. What is the drug of choice the nurse would administer in the acute treatment of anaphylaxis? a. Diphenhydramine (Benadryl) b. Cimetidine (Tagamet) c. Epinephrine (Adrenaline) d. Albuterol (Ventolin) ANS: C Epinephrine is the first drug of choice in the immediate treatment of anaphylaxis. Treatment must be initiated immediately because it may only be a matter of minutes before shock occurs.

Although diphenhydramine and a histamine inhibitor such as cimetidine may be indicated, epinephrine is the first drug of choice in the immediate treatment of anaphylaxis. Albuterol is not usually indicated for the treatment of anaphylaxis.

MULTIPLE RESPONSE

1. Which home care instructions should the nurse provide to the parents of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. a. Give supplemental vitamins as prescribed. b. Avoid yearly influenza vaccination. c. Administer trimethoprim-sulfamethoxazole (Bactrim) as prescribed. d. Notify the physician if child develops a cough or congestion. e. Missed doses of antiretroviral medication do not need to be recorded.

ANS: A, C, D The parents should be taught that supplemental vitamins will be prescribed to aid in nutritional status. Bactrim is administered to prevent the opportunistic infection of Pneumocystis pneumonia. The physician should be notified if the child with AIDS develops a cough and congestion. The yearly influenza vaccination is recommended and any missed doses of antiretroviral medication need to be recorded and reported.

OTHER 1. A child is having an anaphylactic response. Place in order the interventions a nurse should perform beginning with the initial (highest priority) intervention and ending with the lowest priority intervention. Use the following format for your answers: A, B, C, D a. Administer steroids and antihistamines as prescribed. b. Ensure an adequate airway. c. Administer epinephrine as prescribed. d. Administer oxygen. e. Determine the cause of the reaction.

ANS:

B, C, D, A, E The airway should be stabilized first and then the epinephrine administered. Oxygen would be given next and the steroids and antihistamines given after the airway, epinephrine, and oxygen are initiated. Determining the cause of the reaction should be done last.

Chapter 12. Eyes 1. When examining the eye, the nurse notices that the patients eyelid margins approximate completely. The nurse recognizes that this assessment finding: a. Is expected. b. May indicate a problem with extraocular muscles. c. May result in problems with tearing. d. Indicates increased intraocular pressure.

ANS: A The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding.

2. During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: a. Decreased in the older adult. b. Impaired in a patient with cataracts. c. Stimulated by cranial nerves (CNs) I and II. d. Stimulated by CNs III, IV, and VI. ANS: D Movement of the extraocular muscles is stimulated by three CNs: III, IV, and VI. 3. The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? a. The outer layer of the eye is very sensitive to touch. b. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated. d. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.

ANS: A The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting

internally. The trigeminal nerve (CN V) and the facial nerve (CN VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses.

4. When examining a patients eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: a. Causes pupillary constriction. b. Adjusts the eye for near vision. c. Elevates the eyelid and dilates the pupil. d. Causes contraction of the ciliary body.

ANS: C Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict.

The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision.

The ciliary body controls the thickness of the lens.

5. The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? a. Thickness or bulging of the lens b. Posterior chamber as it accommodates increased fluid c. Contraction of the ciliary body in response to the aqueous within the eye d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber ANS: D Intraocular pressure is determined by a balance between the amount of aqueous produced and the resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.

6. The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true? a. The right side of the brain interprets the vision for the right eye. b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. c. Light rays are refracted through the transparent media of the eye before striking the pupil. d. Light impulses are conducted through the optic nerve to the temporal lobes of

the brain.

ANS: B The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the right eye.

7. The nurse is testing a patients visual accommodation, which refers to which action? a. Pupillary constriction when looking at a near object b. Pupillary dilation when looking at a far object c. Changes in peripheral vision in response to light d. Involuntary blinking in the presence of bright light ANS: A The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

8. A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: a. The eyes converge to focus on the light. b. Light is reflected at the same spot in both eyes. c. The eye focuses the image in the center of the pupil. d. Constriction of both pupils occurs in response to bright light.

ANS: D The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct.

9. A mother asks when her newborn infants eyesight will be developed. The nurse should reply: a. Vision is not totally developed until 2 years of age. b. Infants develop the ability to focus on an object at approximately 8 months of age. c. By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object.

d. Most infants have uncoordinated eye movements for the first year of life.

ANS: C Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate simultaneously on a single image with both eyes.

10. The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? a. Degeneration of the cornea b. Loss of lens elasticity c. Decreased adaptation to darkness d. Decreased distance vision abilities ANS: B The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

11. Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? a. Increased night vision b. Dark retinal background c. Increased photosensitivity d. Narrowed palpebral fissures ANS: B An ethnically based variability in the color of the iris and in retinal pigmentation exists, with darker irides having darker retinas behind them.

12. The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? a. Perform the confrontation test.

b. Ask the patient to read the print on a handheld Jaeger card. c. Use the Snellen chart positioned 20 feet away from the patient. d. Determine the patients ability to read newsprint at a distance of 12 to 14 inches.

ANS: C The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.

13. A patients vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: a. At 30 feet the patient can read the entire chart. b. The patient can read at 20 feet what a person with normal vision can read at 30 feet. c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye. d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.

ANS: B The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

14. A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? a. Refer the patient to an ophthalmologist or optometrist for further evaluation. b. Assess whether the patient can count the nurses fingers when they are placed in front of his or her eyes. c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again.

d. Shorten the distance between the patient and the chart until the letters are seen, and record that distance.

ANS: D If the person is unable to see even the largest letters when standing 20 feet from the chart, then the nurse should shorten the distance to the chart until the letters are seen, and record that distance (e.g., 10/200). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but the nurse must first assess the visual acuity.

15. A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient: a. Has poor vision. b. Has acute vision. c. Has normal vision. d. Is presbyopic.

ANS: A Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer the vision.

16. When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 oclock in each eye. The nurse should: a. Consider this a normal finding. b. Refer the individual for further evaluation. c. Document this finding as an asymmetric light reflex. d. Perform the confrontation test to validate the findings.

ANS: A Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.

17. The nurse is performing the diagnostic positions test. Normal findings would be which of these results?

a. Convergence of the eyes b. Parallel movement of both eyes c. Nystagmus in extreme superior gaze d. Slight amount of lid lag when moving the eyes from a superior to an inferior position ANS: B A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates a weakness of an extraocular muscle or dysfunction of the CN that innervates it.

18. During an assessment of the sclera of a black child, the nurse would consider which of these an expected finding? a. Yellow fatty deposits over the cornea b. Pallor near the outer canthus of the lower lid c. Yellow color of the sclera that extends up to the iris d. Presence of small brown macules on the sclera ANS: D Normally in dark-skinned people, small brown macules may be observed in the sclera.

19. During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? a. Presence of tears along the inner canthus b. Blocked nasolacrimal duct in a newborn infant c. Slight swelling over the upper lid and along the bony orbit if the individual has a cold d. Absence of drainage from the puncta when pressing against the inner orbital rim ANS: D No swelling, redness, or drainage from the puncta should be observed when it is pressed.

Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal glands are not functional at birth.

20. When assessing the pupillary light reflex, the nurse should use which technique?

a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.

ANS: C To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

21. The nurse is assessing a patients eyes for the accommodation response and would expect to see which normal finding? a. Dilation of the pupils b. Consensual light reflex c. Conjugate movement of the eyes d. Convergence of the axes of the eyes ANS: D The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct.

22. In using the ophthalmoscope to assess a patients eyes, the nurse notices a red glow in the patients pupils. On the basis of this finding, the nurse would: a. Suspect that an opacity is present in the lens or cornea. b. Check the light source of the ophthalmoscope to verify that it is functioning. c. Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. d. Continue with the ophthalmoscopic examination, and refer the patient for further evaluation.

ANS: C The red glow filling the persons pupil is the red reflex and is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina. The other responses are not correct.

23. The nurse is examining a patients retina with an ophthalmoscope. Which finding is considered normal? a. Optic disc that is a yellow-orange color b. Optic disc margins that are blurred around the edges c. Presence of pigmented crescents in the macular area d. Presence of the macula located on the nasal side of the retina ANS: A The optic disc is located on the nasal side of the retina. Its color is a creamy yellow-orange to a pink, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black and is due to the accumulation of pigment in the choroid.

24. A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would: a. Consider this a normal finding. b. Assess the pupillary light reflex for possible blindness. c. Continue with the examination, and assess visual fields. d. Expect that a 2-week-old infant should be able to fixate and follow an object.

ANS: A By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate and follow a bright light or toy.

25. The nurse is assessing color vision of a male child. Which statement is correct? The nurse should: a. Check color vision annually until the age of 18 years. b. Ask the child to identify the color of his or her clothing. c. Test for color vision once between the ages of 4 and 8 years. d. Begin color vision screening at the childs 2-year checkup.

ANS: C Test boys only once for color vision between the ages of 4 and 8 years. Color vision is not tested in girls because it is rare in girls. Testing is performed with the Ishihara test, which is a series of

polychromatic cards.

26. The nurse is performing an eye-screening clinic at a daycare center. When examining a 2year-old child, the nurse suspects that the child has a lazy eye and should: a. Examine the external structures of the eye. b. Assess visual acuity with the Snellen eye chart. c. Assess the childs visual fields with the confrontation test. d. Test for strabismus by performing the corneal light reflex test.

ANS: D Testing for strabismus is done by performing the corneal light reflex test and the cover test. The Snellen eye chart and confrontation test are not used to test for strabismus.

27. In a child who has anisocoria, the nurse would expect to observe: a. Dilated pupils. b. Excessive tearing. c. Pupils of unequal size. d. Uneven curvature of the lens.

ANS: C Unequal pupil size is termed anisocoria. It normally exists in 5% of the population but may also be indicative of central nervous system disease.

28. A child comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a: a. Chalazion. b. Hordeolum (stye). c. Dacryocystitis. d. Blepharitis.

ANS: B A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin. A chalazion is a nodule protruding on the lid, toward the inside, and is nontender, firm, with discrete swelling.

Dacryocystitis is an inflammation of the lacrimal sac. Blepharitis is inflammation of the eyelids

29. During a physical education class, a student is hit in the eye with the end of a baseball bat.

When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of: a. Hypopyon. b. Hyphema. c. Corneal abrasion. d. Pterygium.

ANS: B Hyphema is the term for blood in the anterior chamber and is a serious result of blunt trauma (a fist or a baseball) or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma. (See Table 14-7 for descriptions of the other terms.)

Chapter 13. Ears 1. The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?

It is unusual for a small child to have frequent ear infections unless something else is a.

wrong.

We need to check the immune system of your son to determine why he is having so

b.

many ear infections.

Ear infections are not uncommon in infants and toddlers because they tend to have

c.

more cerumen in the external ear.

Your sons eustachian tube is shorter and wider than yours because of his age, which

d.

ANS: D

allows for infections to develop more easily.

The infants eustachian tube is relatively shorter and wider than the adults eustachian tube, and its position is more horizontal; consequently, pathogens from the nasopharynx can more easily migrate through to the middle ear. The other responses are not appropriate.

2. While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history?

a.

Does your baby seem to startle with loud noises?

b.

Has your baby had any surgeries on her ears?

c.

Have you noticed any drainage from her ears?

d.

How many ear infections has your baby had since birth?

ANS: A Children at risk for a hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella or to maternal ototoxic drugs.

3. In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would:

a.

Omit the otoscopic examination if the child has a fever.

b.

Pull the ear up and back before inserting the speculum.

c.

Ask the mother to leave the room while examining the child.

d.

Perform the otoscopic examination at the end of the assessment.

ANS: D In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for an illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination.

4. The mother of a 2-year-old toddler is concerned about the upcoming placement of tympanostomy tubes in her sons ears. The nurse would include which of these statements in the teaching plan?

a.

The tubes are placed in the inner ear.

b.

The tubes are used in children with sensorineural loss.

c.

The tubes are permanently inserted during a surgical procedure.

d.

The purpose of the tubes is to decrease the pressure and allow for drainage.

ANS: D Polyethylene tubes are surgically inserted into the eardrum to relieve middle ear pressure and to promote drainage of chronic or recurrent middle ear infections. Tubes spontaneously extrude in 6 months to 1 year.

5. When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child:

a.

Most likely has serous otitis media.

b.

Has an acute purulent otitis media.

c.

Has evidence of a resolving cholesteatoma.

d.

Is experiencing the early stages of perforation.

ANS: A An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Air or fluid or bubbles behind the tympanic membrane are often visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. These findings most likely suggest that the child has serous otitis media. The other responses are not correct.

6. The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure? a.

Pulling the pinna down

b.

Pulling the pinna up and back

c.

Slightly tilting the childs head toward the examiner

d.

Instructing the child to touch his chin to his chest

ANS: A

For an otoscopic examination on an infant or on a child under 3 years of age, the pinna is pulled down. The other responses are not part of the correct procedure.

7. The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections?

a.

Family history

b.

Air conditioning

c.

Excessive cerumen

d.

Passive cigarette smoke

ANS: D Exposure to passive and gestational smoke is a risk factor for ear infections in infants and children.

8. The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections? a.

Family history

b.

Air conditioning

c.

Excessive cerumen

d.

Passive cigarette smoke

ANS: D Exposure to passive and gestational smoke is a risk factor for ear infections in infants and children.

9. While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate a(n): d.

Prolonged use of a bottle can increase the risk for tooth decay and ear infections.

ANS: D

a.

Fungal infection.

b.

Acute otitis media.

c.

Perforation of the eardrum.

d.

Cholesteatoma.

ANS: B Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media. (See Table 15-5 for descriptions of the other conditions.)

Chapter 14. Nose, Mouth, and Throat 1. In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings? a.

Refer the patient to a throat specialist.

b.

No response is needed; this appearance is normal for the tonsils.

c.

Continue with the assessment, looking for any other abnormal findings.

d.

Obtain a throat culture on the patient for possible streptococcal (strep) infection.

ANS: B The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.

2. While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, It makes a great pacifier. The best response by the nurse would be: a.

Youre right. Bottles make very good pacifiers.

b.

Using a bottle as a pacifier is better for the teeth than thumb-sucking.

c.

Its okay to use a bottle as long as it contains milk and not juice.

Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.

3. The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. During an inspection of his mouth, the nurse should look for:

a.

Swollen, red tonsils.

b.

Ulcerations on the hard palate.

c.

Bruising on the buccal mucosa or gums.

d.

Small yellow papules along the hard palate.

ANS: C The nurse should notice any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.

4. The nurse is assessing a 3 year old for drainage from the nose. On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next?

a.

Refer to the physician for an antibiotic order.

b.

Have the mother bring the child back in 1 week.

c.

Perform an otoscopic examination of the left nares.

d.

Tell the mother that this drainage is normal for a child of this age.

ANS: C Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt.

5. A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurses best response would be:

a.

How many teeth did you have at this age?

b.

All 20 deciduous teeth are expected to erupt by age 4 years.

c.

This is a normal number of teeth for an 18 month old.

d.

Normally, by age 2 years, 16 deciduous teeth are expected.

ANS: C The guidelines for the number of teeth for children younger than 2 years old are as follows: the childs age in months minus the number 6 should be equal to the expected number of deciduous

teeth. Normally, all 20 teeth are in by 2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected.

6. During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate? a.

This condition is a cleft palate and is common in Native Americans.

b.

A bifid uvula may occur in some Native-American groups.

c.

This condition is due to an injury and should be reported to the authorities.

d.

A bifid uvula is palatinus, which frequently occurs in Native Americans.

ANS: B Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some Native-American groups.

7. MULTIPLE RESPONSE 1. The nurse is teaching a health class to high-school boys. When discussing the topic of using smokeless tobacco (SLT), which of these statements are accurate? Select all that apply.

One pinch of SLT in the mouth for 30 minutes delivers the equivalent of one a.

cigarette.

b.

Using SLT has been associated with a greater risk of oral cancer than smoking.

c.

Pain is an early sign of oral cancer.

d.

Pain is rarely an early sign of oral cancer.

e.

Tooth decay is another risk of SLT because of the use of sugar as a sweetener.

f.

SLT is considered a healthy alternative to smoking.

ANS: B, D, E One pinch of SLT in the mouth for 30 minutes delivers the equivalent of three cigarettes. Pain is rarely an early sign of oral cancer. Many brands of SLT are sweetened with sugars, which promotes tooth decay. SLT is not considered a healthy alternative to smoking, and the use of SLT has been associated with a greater risk of oral cancer than smoking.

Chapter 15. Abdomen and Rectum 1. Which is the best nursing response to a mother asking about the cause of her infants bilateral cleft lip?

a. Did you have trouble with this pregnancy? b. Do you know of anyone in your or the fathers family born with cleft lip or palate problems? c. This defect is associated with intrauterine infection during the second trimester. d. Was your husband in the military and involved in chemical warfare?

ANS: B

Cleft lip and palate result from embryonic failure resulting from multiple genetic and environmental factors. A genetic pattern or familial risk seems to exist. A troublesome pregnancy has not been associated with bilateral cleft lip. The defect occurred at approximately 6 to 8 weeks of gestation. Second-trimester intrauterine infection is not a known cause of bilateral cleft lip. Chemical warfare is not significantly associated with bilateral cleft lip and palate.

2. Which nursing intervention is most helpful to parents of a neonate with bilateral cleft lip? a. Assure the parents that the correction will be immediate and uncomplicated. b. Show the parents before-and-after pictures of an infant whose cleft lip has been successfully repaired. c. Teach the parents about long-term enteral feedings. d. Refer the parents to a community agency that addresses this problem.

ANS: B Showing the parents pictures of successful lip repair promotes bonding and enhances coping ability. Correction is usually done around 4 weeks but may be done as early as 2 to 3 days after birth. The infant with a bilateral cleft lip can be fed orally using a compressible, longer nipple, and by making a larger hole in the nipple. Long-term enteral feedings are not usually indicated.

A community agency referral is not appropriate at this time and may not be indicated long term.

3. The postoperative care plan for an infant with surgical repair of a cleft lip includes which intervention?

a. A clear liquid diet for 72 hours b. Nasogastric feedings until the sutures are removed c. Elbow restraints to keep the infants fingers away from the mouth d. Rinsing the mouth after every feeding ANS: C Keeping the infants hands away from the incision reduces potential complications at the surgical site. The infants diet is advanced from clear liquid to soft foods within 48 hours of surgery. After surgery, the infant can resume preoperative feeding techniques. Rinsing the mouth after feeding is an inappropriate intervention. Feeding a small amount of water after feedings will help keep the mouth clean. A cleft lip repair site should be cleansed with a wet sterile cotton swab after feedings.

4. A nurse is teaching a group of parents about tracheoesophageal fistula. Which statement, made by the nurse, is accurate about tracheoesophageal fistula (TEF)? a. This defect results from an embryonal failure of the foregut to differentiate into the trachea and esophagus. b. It is a fistula between the esophagus and stomach that results in the oral intake being refluxed and aspirated. c. An extra connection between the esophagus and trachea develops because of genetic abnormalities. d. The defect occurs in the second trimester of pregnancy.

ANS: A When the foregut does not differentiate into the trachea and esophagus during the fourth to fifth week of gestation, a TEF occurs. TEF is an abnormal connection between the esophagus and trachea. There is no connection between the trachea and esophagus in normal fetal development.

Tracheoesophageal fistula occurs early in pregnancy during the fourth to fifth week of gestation.

5. Which maternal assessment is related to the infants diagnosis of TEF? a. Maternal age more than 40 years b.

First term pregnancy for the mother

c.

Maternal history of polyhydramnios

d. Complicated pregnancy ANS: C

A maternal history of polyhydramnios is associated with TEF. Advanced maternal age is not a risk factor for TEF. The first term pregnancy is not a risk factor for an infant with TEF. Complicated pregnancy is not a risk factor for TEF. 6. What clinical manifestation should a nurse should be alert for when a diagnosis of esophageal atresia is suspected? a. A radiograph in the prenatal period indicates abnormal development. b. It is visually identified at the time of delivery. c. A nasogastric tube fails to pass at birth. d. The infant has a low birth weight.

ANS: C Atresia is suspected when a nasogastric tube fails to pass 10 to 11 centimeters beyond the gum line. Abdominal radiographs will confirm the diagnosis. Prenatal radiographs do not provide a definitive diagnosis. The defect is not externally visible. Bronchoscopy and endoscopy can be used to identify this defect. Infants with esophageal atresia may have been born prematurely and with a low birth weight, but neither is suggestive of the presence of an esophageal atresia.

7. The nurse admits an infant with vomiting and the diagnosis of hypertrophic pyloric stenosis.

Which metabolic alteration should the nurse plan to assess for with this infant? a. Metabolic alkalosis b. Metabolic acidosis c. Respiratory acidosis d. Respiratory alkalosis ANS: A Frequent projectile vomiting, characteristic of pyloric stenosis, results in a loss of nonvolatile acids that decreases hydrogen ion concentration. This results in an excess of bicarbonate that increases arterial pH above 7.45 (metabolic alkalosis). Metabolic acidosis, respiratory acidosis, and respiratory alkalosis do not result from vomiting.

8. What is the most important information to be included in the discharge planning for an infant with gastroesophageal reflux? a. Teach the parents to position the infant on the left side. b. Reinforce the parents knowledge of the infants developmental needs.

c. Teach the parents how to do infant cardiopulmonary resuscitation (CPR). d. Have the parents keep an accurate record of intake and output.

ANS: C Risk of aspiration is a priority nursing diagnosis for the infant with gastroesophageal reflux. The parents must be taught infant CPR. Correct positioning minimizes aspiration. The correct position for the infant is on the right side after feeding and supine for sleeping. Knowledge of developmental needs should be included in discharge planning for all hospitalized infants but is not the most important in this case. Keeping a record of intake and output is not a priority and may not be necessary.

9. Which information does the nurse include when teaching the parents of a 5-week-old infant about pyloromyotomy? a. The infant will be in the hospital for a week. b. The surgical procedure is routine and no big deal. c. The prognosis for complete correction with surgery is good. d. They will need to ask the physician about home care nursing.

ANS: C Pyloromyotomy is the definitive treatment for pyloric stenosis. Prognosis is good with few complications. These comments reassure parents. The infant will remain in the hospital for a day or two postoperatively. Although the prognosis for surgical correction is good, telling the parents that surgery is no big deal minimizes the infants condition. Home care nursing is not necessary after pyloromyotomy.

10. A nurse has admitted a child to the hospital with a diagnosis of rule out peptic ulcer disease.

Which test will the nurse expect to be ordered to confirm the diagnosis of a peptic ulcer? a. A 24-hour dietary history b. A positive Hematest result on a stool sample

c. A fiberoptic upper endoscopy d. An abdominal ultrasound ANS: C Endoscopy provides direct visualization of the stomach lining and confirms the diagnosis of peptic ulcer. Dietary history may yield information suggestive of a peptic ulcer, but the diagnosis is confirmed through endoscopy. Blood in the stool indicates a gastrointestinal abnormality, but it does not conclusively confirm a diagnosis of peptic ulcer. An abdominal ultrasound is used to rule out other gastrointestinal alterations such as gallstones, tumor, or mechanical obstruction.

11. What should the nurse teach a school-age child and his parents about the management of ulcer disease? a. Eat a bland, low-fiber diet in small frequent meals. b. Eat three balanced meals a day with no snacking between meals. c. The child needs to eat alone to avoid stress. d. Do not give antacids 1 hour before or after antiulcer medications.

ANS: D Antacids can interfere with antiulcer medication if given less than 1 hour before or after antiulcer medications. A bland diet is not indicated for ulcer disease. The diet should be a regular diet that is low in caffeine, and the child should eat a meal or snack every 2 to 3 hours. Eating alone is not indicated.

12. Which prescribed formula should the nurse plan to provide for an infant with lactose intolerance? a. Isomil b. Enfamil c. Similac d. Good Start

ANS: A The treatment for lactose intolerance is removal of lactose from the diet. Formulas that do not contain lactose (Isomil, Nursoy, Nutramigen, Prosobee, and other soy-based formulas) may be given to the infant suspected of having lactose intolerance. Enfamil, Similac, and Good Start are all milk-based formulas.

13. Which dietary foods high in calcium should the nurse encourage a lactose intolerant child to eat? a. Yogurt b. Green leafy vegetables c. Cheese d. Rice ANS: B The child between 1 and 10 years requires a minimum of 800 milligrams of calcium daily.

Because high-calcium dairy products containing lactose are restricted from the childs diet, alternate sources such as egg yolk, green leafy vegetables, dried beans, and cauliflower must be provided to prevent hypocalcemia. Yogurt and cheese contain lactose. Rice is not high in calcium.

14. Which food choice by a parent of a 2-year-old child with celiac disease indicates a need for further teaching? a. Oatmeal b. Rice cake c. Corn muffin d. Meat patty ANS: A The child with celiac disease is unable to fully digest gluten, the protein found in wheat, barley, rye, and oats. Oatmeal contains gluten and is not an appropriate food selection. Rice is an appropriate choice because it does not contain gluten. Corn is digestible because it does not contain gluten. Meats do not contain gluten and can be included in the diet of a child with celiac disease.

15. Which assessment finding should the nurse expect in an infant with Hirschsprungs disease? a. Currant jelly stools b. Constipation with passage of foul-smelling, ribbon-like stools c. Foul-smelling, fatty stools d. Diarrhea ANS: B Constipation results from the absence of ganglion cells in the rectum and colon and is present since the neonatal period with passage of frequent foul-smelling, ribbon-like, or pellet-like stools. Currant jelly stools are associated with intussusception. Foul-smelling, fatty stools are associated with cystic fibrosis and celiac disease. Diarrhea is not typically associated with Hirschsprungs disease but may result from impaction.

16. Which would be an expected outcome for the parents of a child with encopresis? a. The parents will give the child an enema daily for 34 months. b. The parents will develop a plan to achieve control over incontinence. c. The parents will have the child launder soiled clothes. d. The parents will supply the child with a low-fiber diet.

ANS: B Parents of the child with encopresis often feel guilty and believe that encopresis is willful on the part of the child. The family functions effectively by openly discussing problems and developing a plan to achieve control over incontinence. Stool softeners or laxatives, along with dietary

changes, are typically used to treat encopresis. Enemas are indicated when a fecal impaction is present. Having the child launder soiled clothes is a punishment and will increase the childs shame and embarrassment. The child should not be punished for an action that is not willful.

Increasing fiber in the diet and fluid intake results in greater bulk in the stool, making it easier to pass.

17. Which intervention should be included in the nurses plan of care for a 7-year-old child with encopresis who has cleared the initial impaction? a. Have the child sit on the toilet 30 minutes when he gets up in the morning and at bedtime. b. Increase sugar in the childs diet to promote bowel elimination. c. Use a Fleet enema daily. d. Give the child a choice of beverage to mix with a laxative.

ANS: D Offering realistic choices is helpful in meeting the school-age childs sense of control. To facilitate bowel elimination, the child should sit on the toilet for 5 to 10 minutes after breakfast and dinner. Decreasing the amount of sugar in the diet will help keep stools soft. Daily Fleet enemas can result in hypernatremia and hyperphosphatemia and are used only during periods of fecal impaction.

18. A nurse is assisting a child with inflammatory bowel disease to choose items from the dietary menu. Which dietary item should be avoided because it is high in residue? a. Eggs b.

Cheese

c.

Grapes

d. Jello ANS: C

Fruits with skins or seeds should be avoided because they are high in residue. Cooked or canned fruits and vegetables without skins are allowed. Eggs, cheese, and Jello would be allowed on a low residue diet.

19. What is an expected outcome for the child with irritable bowel disease? a. Decreasing symptoms b. Adherence to a low-fiber diet c. Increasing milk products in the diet d. Adapting the lifestyle to the lifelong problems ANS: A Management of irritable bowel disease is aimed at identifying and decreasing exposure to triggers and decreasing bowel spasms, which will decrease symptoms. Management includes maintenance of a healthy, well-balanced, moderate-fiber, lower-fat diet. A moderate amount of fiber in the diet is indicated for the child with irritable bowel disease. No modification in dairy products is necessary unless the child is lactose intolerant. Irritable bowel syndrome is typically self-limiting and resolves by age 20 years.

20. An infant has been admitted to the Neonatal Intensive Care Unit (NICU) with a congenital gastroschisis. Which intervention should the nurse perform first upon admission to the unit? a. Place the infant flat and prone. b. Cover the defect with sterile warm, moist gauze and wrap with plastic. c. Begin a gestational age assessment. d. Wrap the infant in a warm blanket and allow the father to hold the infant briefly.

ANS: B Gastroschisis is the protrusion of intraabdominal contents through a defect in the abdominal wall lateral to the umbilical ring. There is no peritoneal sac. The defect should be immediately wrapped in warm, moist, sterile gauze and covered with plastic to keep moist. The infant cannot

be placed prone as more damage could occur to the defect. Movement of the infant should be minimized so gestational age assessment and parental holding would be done after the infant is stabilized.

21. What is an appropriate statement for the nurse to make to parents of a child who has had a barium enema to correct an intussusception? a. I will call the physician when the baby passes his first stool. b. I am going to dilate the anal sphincter with a gloved finger to help the baby pass the barium. c. I would like you to save all the soiled diapers so I can inspect them. d. Add cereal to the babys formula to help him pass the barium.

ANS: C The nurse needs to inspect diapers after a barium enema because it is important to document the passage of barium and note the characteristics of the stool. The physician does not need to be notified when the infant passes the first stool. Dilating the anal sphincter is not appropriate for the child after a barium enema. After reduction, the infant is given clear liquids and the diet is gradually increased.

22. Which is the best response for the nurse to make to parents who ask why their infant has a nasogastric tube to intermittent suction after abdominal surgery? a. The nasogastric tube decompresses the abdomen and decreases vomiting. b. We can keep a more accurate measure of intake and output with the nasogastric tube. c. The tube is used to decrease postoperative diarrhea. d. Believe it or not, the nasogastric tube makes the baby more comfortable after surgery.

ANS: A

The nasogastric tube provides decompression and decreases vomiting. A nursing responsibility when a patient has a nasogastric tube is measurement of accurate intake and output, but this is not why nasogastric tubes are inserted. Nasogastric tube placement does not decrease diarrhea.

The presence of a nasogastric tube can be perceived as a discomfort by the patient.

23. Which stool characteristic should the nurse expect to assess with a child diagnosed with intussusception? a. Ribbon-like stools b. Hard stools positive for guaiac c. Currant jelly stools d. Loose, foul-smelling stools ANS: C Pressure on the bowel from obstruction leads to passage of currant jelly stools. Ribbon-like stools are characteristic of Hirschsprungs disease. With intussusception, passage of bloody mucus stools occurs. Stools will not be hard. Loose, foul-smelling stools may indicate infectious gastroenteritis.

24. Which is a priority concern for a 14-year-old child with inflammatory bowel disease? a. Compliance with antidiarrheal medication therapy b. Long-term complications c. Dealing with the embarrassment and stress of diarrhea d. Home schooling ANS: C Embarrassment and stress from chronic diarrhea are real concerns for the adolescent with inflammatory bowel disease. Antidiarrheal medications are not typically ordered for a child with inflammatory bowel disease. Long-term complications are not a priority concern for the adolescent with inflammatory bowel disease. Exacerbations may interfere with school

attendance, but home schooling is not a usual consideration for the adolescent with inflammatory bowel disease.

25. A nurse is conducting a teaching session to adolescents about Crohns disease. Which statement, made by the nurse, is the most accurate? a. Crohns disease is responsive to dietary modifications. b. Crohns disease can occur anywhere in the gastrointestinal tract. c. Edema usually accompanies this disease. d. Symptoms of Crohns disease usually disappear by late adolescence.

ANS: B Crohns disease can occur anywhere in the GI tract from the mouth to the anus and is most common in the terminal ileum. Maintaining a low-fiber, low-residue, and milk-free diet may give the child some relief; however, strict restrictions may not alleviate symptoms. Diarrhea and malabsorption from Crohns disease cause weight loss, anorexia, dehydration, and growth failure.

Edema does not accompany this disease. Crohns disease is a long-term health problem.

Symptoms do not typically disappear by adolescence.

26. A child is admitted to the pediatric floor for appendicitis. Which assessment finding will the nurse monitor that indicates the appendix has ruptured? a. Abdominal pain shifts from the left to the right side. b. Vomiting and diarrhea become more intense. c. Elevated temperature decreases to normal. d. Abdominal pain is relieved.

ANS: D Abdominal pain is relieved when appendix rupture occurs. Pain in the right lower quadrant is suggestive of appendicitis. Abdominal pain does not shift from one side to the other. The child with appendicitis may have vomiting and diarrhea. A rupture does not intensify symptoms.

Because peritonitis is associated with a ruptured appendix, the temperature would be elevated in the presence of infection.

27. What is the most important action to prevent the spread of gastroenteritis in a daycare setting? a. Administering prophylactic medications to children and staff b. Frequent hand washing c. Having parents bring food from home d. Directing the staff to wear gloves at all times ANS: B Hand washing is the most the important measure to prevent the spread of infectious diarrhea.

Prophylactic medications are not helpful in preventing gastroenteritis. Bringing food from home will not prevent the spread of infectious diarrhea. Gloves should be worn when changing diapers, soiled clothing, or linens. They do not need to be worn for interactions that do not involve contact with secretions.

28. What is an expected outcome for a 1-month-old infant with biliary atresia? a. Correction of the defect with the Kasai procedure b. Adequate nutrition and age-appropriate growth and development c. Increased blood pressure and adherence to a salt-free diet d. Adequate protein intake ANS: B Adequate nutrition, preventing skin breakdown, adequate growth and development, and family education and support are expected outcomes in an infant with biliary atresia. The goal of the Kasai procedure is to allow for adequate growth until a transplant can be done. It is not a curative procedure. Although blood pressure typically is elevated, a modified salt diet is appropriate.

Protein intake may need to be restricted to avoid hepatic encephalopathy.

29. Which assessment findings would be significant for a child with cirrhosis? a. Weight loss b. Change in level of consciousness c. Soft, smooth skin d. Pallor and cyanosis ANS: B The child with cirrhosis must be assessed for encephalopathy, which is characterized by a change in level of consciousness. Encephalopathy can result from a buildup of ammonia in the blood from the incomplete breakdown of protein. One complication of cirrhosis is ascites. The child needs to be assessed for increasing abdominal girth and edema. A child who is retaining fluid will not exhibit weight loss. Biliary obstruction can lead to intense pruritus. The skin will be irritated from frequent scratching. A skin assessment would likely reveal jaundice. Pallor and cyanosis are associated with a cardiac problem.

30. Which nursing diagnosis has the highest priority for the child with celiac disease? a. Pain related to chronic constipation b. Altered growth and development related to obesity c. Fluid volume excess related to celiac crisis d. Imbalanced nutrition: Less than body requirements related to malabsorption ANS: D Imbalanced nutrition: Less than body requirements related to malabsorption is the highest priority nursing diagnosis because celiac disease causes gluten enteropathy, a malabsorption condition. The pain associated with celiac disease is associated with diarrhea, not constipation.

Celiac disease causes altered growth and development associated with malnutrition, not obesity.

Celiac crisis causes fluid volume deficit.

31. The nurse notes on assessment that a 1-year-old child is underweight, with abdominal distention, thin legs and arms, and foul-smelling stools. The nurse suspects failure to thrive associated with which condition? a. Celiac disease b. Intussusception c. Irritable bowel syndrome d. Imperforate anus ANS: A These are classic symptoms of celiac disease. Intussusception is not associated with failure to thrive or underweight, thin legs and arms, and foul-smelling stools. Stools are like currant jelly.

Irritable bowel syndrome is characterized by diarrhea and pain, and the child does not typically have thin legs and arms. Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum. Symptoms are evident in early infancy.

32. A 10-year-old boy is admitted to the hospital with a diagnosis of appendicitis. He is nauseated, febrile, and complaining of severe abdominal pain radiating to the right lower quadrant. During a routine nursing check, he states that his stomach doesnt hurt anymore. The nurse should suspect that: a. he is anxious about surgery. b. his appendix has ruptured. c. he does not communicate effectively about pain. d. his nausea and vomiting have decreased, thereby relieving his abdominal pain.

ANS: B A classic symptom indicating appendix rupture is the sudden relief of pain. The boy may be anxious, but this will not cause his pain to disappear. There is no evidence to substantiate the assumption that he does not communicate effectively about pain. His nausea and vomiting have not decreased, nor will this affect his abdominal pain.

33. The nurse caring for a child with suspected appendicitis should question which physician prescriptions? a. Keep patient NPO. b. Start IV of D5/0.45 normal saline at 60 mL/hr. c. Apply K-pad to abdomen prn for pain. d. Obtain CBC on admission to the nursing unit.

ANS: C A K-pad (moist heat device) is contraindicated for suspected appendicitis because it may contribute to the rupture of the appendix. NPO status is appropriate for the potential appendectomy client. An IV is appropriate both as a preoperative intervention and to compensate for the short-term NPO status. Because appendicitis is frequently reflected in an elevated WBC, laboratory data are needed.

34. Which order should the nurse question when caring for a child after surgery for Hirschsprungs disease? a. Monitor rectal temperature every 4 hours and report an elevation greater than 38.5 C. b. Assess stools after surgery. c. Keep the child NPO until bowel sounds return. d. Maintain IV fluids at an ordered rate.

ANS: A Rectal temperatures should not be taken after this surgery. Rectal temperatures are generally not the route of choice for children because of the routes traumatic nature. Assessing stools after surgery is an appropriate intervention postoperatively. Stools should be soft and formed. Keeping the child NPO until bowel sounds return is an appropriate intervention postoperatively.

Maintaining IV fluids at an ordered rate is an appropriate postoperative order.

35. Which diagnosis has the highest priority for the child with irritable bowel syndrome?

a. Alteration in nutrition: Less than body requirements related to malabsorption b. Altered growth and development related to inadequate nutrition c. Pain related to hyperperistalsis d. Constipation related to maldigestion ANS: C Diffuse abdominal pain unrelated to activity or meals is a common clinical manifestation of irritable bowel syndrome. Normal physical growth and development usually occur with this disorder. Constipation may occur with irritable bowel syndrome, usually alternating with diarrhea.

36. A 7-year-old child is admitted to the hospital with severe abdominal pain, bloody currant jelly diarrhea, and fever. What is his probable diagnosis? a. Hirschsprungs disease b. Celiac disease c. Ruptured appendix d. Intussusception ANS: D Severe abdominal pain, bloody currant jelly diarrhea, and fever are common clinical manifestations of intussusception. Hirschsprungs disease usually manifests as bowel obstruction.

Severe abdominal pain, bloody currant jelly diarrhea, and fever are not common symptoms of celiac disease. Although a child with a ruptured appendix will probably be febrile, the other symptoms are not indicative of a ruptured appendix.

37. Which goal has the highest priority for a child with malabsorption associated with lactose intolerance? a. The child will experience no abdominal spasms.

b. The child will not experience constipation associated with malabsorption syndrome. c. The child will not experience diarrhea associated with malabsorption syndrome. d. The child will receive adequate nutrition as evidenced by a weight gain of 1 kg/day.

ANS: C The highest priority goal is that the child will not experience diarrhea associated with malabsorption syndrome; this goal is correct for a child with malabsorption associated with lactose intolerance. A child usually has abdominal cramping, pain, and distention rather than spasms. The child usually has diarrhea, not constipation. One kilogram a day is too much weight gain with no time parameters.

38. What would be an appropriate meal for a school-age child with celiac disease? a. Baked chicken and cornbread b. Hot dog and bun c. Bean with barley soup and rice cakes d. Cheeseburger on rye bread ANS: A Children with celiac disease must eliminate all wheat, rye, barley, oats, and hydrolyzed vegetable proteins from their diet. Cornbread does not contain glutens. Most buns, barley, and rye bread contain glutens.

39. What should the nurse stress in a teaching plan for the mother of an 11-year-old boy with ulcerative colitis? a. Preventing the spread of illness to others b. Nutritional guidance and preventing constipation c. Teaching daily use of enemas

d. Coping with stress and adjusting to a chronic illness ANS: D Coping with the stress of a chronic illness and the clinical manifestations associated with ulcerative colitis (diarrhea, pain) are important teaching foci. Ulcerative colitis is not infectious.

Although nutritional guidance is a priority teaching focus, diarrhea is a problem with ulcerative colitis, not constipation. Teaching daily use of enemas is not part of the therapeutic plan of care.

40. An infant with Hirschsprungs disease has a temporary colostomy. Which statement by the infants mother indicates she understands how to care for the infants colostomy at home? a. I need to be careful to check the skin around the colostomy for breakdown and be sure I keep it clean. b. Ill call my home health nurse if the colostomy bag needs to be changed. c. Ill call the doctor if I notice that the colostomy stoma is pink. d. Ill have my mother help me with the care of the colostomy.

ANS: A Preventing skin breakdown is a priority concern when caring for a colostomy. The mother should be taught the basics of colostomy care, including how to change the appliance. The colostomy stoma should be pink in color, not pale or discolored. There is no evidence that her mother knows how to care for a colostomy.

41. Careful hand washing before and after contact can prevent the spread of and school settings. a. irritable bowel syndrome b. ulcerative colitis c. hepatic cirrhosis d. hepatitis A ANS: D

in day care

Hepatitis A is spread person to person, by the fecal-oral route and through contaminated food or water. Good hand washing is critical in preventing its spread. The virus can survive on contaminated objects for weeks. Irritable bowel syndrome is the result of increased intestinal motility and is not contagious. Ulcerative colitis and cirrhosis are not infectious.

MULTIPLE RESPONSE 1. Which interventions should a nurse implement when caring for a child with hepatitis? Select all that apply. a. Provide a well-balanced low-fat diet. b. Schedule play time in the playroom with other children. c. Teach parents not to administer any over-the-counter medications. d. Arrange for home schooling as the child will not be able to return to school. e. Instruct parents on the importance of good hand washing.

ANS: A, C, E The child with hepatitis should be placed on a well-balanced low-fat diet. Parents should be taught to not give over-the-counter medications because of impaired liver function. Hand hygiene is the most important preventive measure for the spread of hepatitis. The child will be in contact isolation in the hospital so play time with other hospitalized children is not scheduled.

The child will be on contact isolation for at least 1 week after the onset of jaundice, but after that period, will be allowed to return to school.

2. The nurse is providing home care instructions to the parents of an infant being discharged after repair of a bilateral cleft lip. Which instructions should the nurse include? Select all that apply. a. Acetaminophen (Tylenol) should not be given to your infant. b. Feed your infant in an upright position. c. Place your infant prone for a period of time each day. d. Burp your child frequently during feedings.

e. Apply antibiotic ointment to the lip as prescribed.

ANS: B, D, E After cleft lip surgery the parents are taught to feed the infant in an upright position to decrease the chance of choking. The parents are taught to burp the infant frequently during feedings because excess air is often swallowed. Parents are taught to cleanse the suture line area with a cotton swab using a rolling motion and apply antibiotic ointment with the same technique.

Tylenol is used for pain and the child should never be placed prone as that can damage the suture line.

Chapter 16. Male Genitalia 1. Which intervention is appropriate when examining a male infant for cryptorchidism?

a.

Cooling the examiners hands

b.

Taking a rectal temperature

c.

Placing the infant on the examination table

d.

Warming the room

ANS: D For the infants comfort, the infant should be examined in a warm room with the examiners hands warmed. Testes can retract into the inguinal canal if the infant is upset or cold. Examining the infant with cold hands is uncomfortable for the infant and is likely to cause the infants testes to retract into the inguinal canal. It may also cause the infant to be uncooperative during the examination. A rectal temperature yields no information about cryptorchidism. When possible, the infant should be examined in the caregivers lap to elicit cooperation and avoid upsetting the infant.

2. During a physical assessment of a hospitalized 5-year-old, the nurse notes that the foreskin has been retracted and is very tight on the shaft of the penis; the nurse is unable to return it over the head of the penis. The nurse should:

a.

Forcibly push the foreskin down over the head of the penis.

b.

Place a warm compress on the penis.

c.

Notify the charge nurse.

d.

Wait a few hours and try again.

ANS: C Notify the charge nurse of this occurrence of paraphimosis. The tight foreskin can impede blood flow to the penis; this should be remedied immediately.

3. The nurse understands that the adolescents avid sexual orientation to be based on Freuds theory, which describes adolescence as the

a.

Conceptual

b.

Genital

c.

Glandular

d.

Pubertal

stage.

ANS: B Freud describes the adolescent period as genital.

4. The parents of a 4-year-old boy are concerned because they have noticed him frequently touching his penis. The nurse would base a response on the knowledge that: a.

This behavior indicates a normal curiosity about sexuality.

b.

Masturbation suggests the boy has an excessive fear of castration.

c.

It is usually a result of discomfort from a penile rash or irritation.

d.

The behavior is abnormal and the child should be referred for counseling.

ANS: A Masturbation at this age is common and indicates that the preschooler has a normal curiosity about sexuality.

5. The nurse is assisting the pediatric provider with a newborn examination. The provider notes that the infant has hypospadias. The nurse understands that hypospadias refers to:

a.

Absence of a urethral opening.

b.

Penis shorter than usual for age.

c.

Urethral opening along dorsal surface of penis.

d.

Urethral opening along ventral surface of penis.

ANS: D Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis. The urethral opening is present, but not at the glans.

Hypospadias does not refer to the size of the penis. When the urethral opening is along the dorsal surface of the penis, it is known as epispadias.

6. The narrowing of the preputial opening of the foreskin is called: a.

Chordee.

c.

Epispadias.

b.

Phimosis.

d.

Hypospadias.

ANS: B Phimosis is the narrowing or stenosis of the preputial opening of the foreskin. Chordee is the ventral curvature of the penis. Epispadias is the meatal opening on the dorsal surface of the penis. Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis.

Chapter 17. Male and Female Breast MULTIPLE CHOICE 1. In teaching a patient about breast self-examination, why does the nurse emphasize palpation of the axillary areas? a. Because deep muscles in that area can mask changes b. Because some patients avoid this area because of tenderness c. Because most lymph draining from the breast flows through this area d. Because supporting ligaments in this area may present as tissue changes ANS: C

Feedback A Because deep muscles in that area can mask changes. This answer is incorrect. Palpating the axilla for enlarged lymph nodes is very important.

B Because some patients avoid this area because of tenderness. This answer is incorrect.

Palpating the axilla for enlarged lymph nodes is very important.

C Because most lymph draining from the breast flows through this area. More than 75% of lymph drainage from the breast flows outward toward the axillary lymph node.

D Because supporting ligaments in this area may present as tissue changes. This answer is incorrect. Palpating the axilla for enlarged lymph nodes is very important.

2. In reviewing the charts of several patients in the clinic, a nurse recognizes which patient as being at highest risk of breast cancer? a. A woman who had her first child at age 26 b. A woman who reached menopause at age 58 c. A woman who breastfed all four of her children d. A woman who states that she reached menarche at age 14 ANS: B

Feedback A A woman who had her first child at age 26 has a low risk.

B A woman who reached menopause at age 58. A long menstrual history (menopause after age 50) increases risk.

C A woman who breastfed all four of her children has a low risk.

D A woman who states that she reached menarche at age 14 has a low risk because the menarche

was after 12 years of age.

3. While giving a presentation about breast health, a nurse informs patients about which recommendation? a. Women in their 30s should have annual clinical breast examinations. b. Women at high risk of breast cancer should have semiannual mammograms. c. Women who are postmenopausal require clinical breast examination every 5 years. d. A screening mammogram is recommended for all women beginning at age 50 years.

ANS: D

Feedback A Clinical breast examinations are recommended as part of a periodic health examination at least every 3 years for average-risk, asymptomatic women in their 20s and 30s, and annually for asymptomatic women age 40 and older.

B Having semiannual mammograms is more often than necessary.

C Clinical breast examinations are recommended as part of a periodic health examination at least every 3 years for average-risk, asymptomatic women in their 20s and 30s, and annually for asymptomatic women age 40 and older.

D This is the recommendation of the U.S. Preventive Services Task Force.

4. Based on the history, a nurse determines that the patient with which finding requires further assessment? a. Occasional discharge from nipples b. Supernumerary nipples along the milk line c. Rash in the axillae associated with change in deodorant d. Mild breast swelling that fluctuates with the menstrual cycle ANS: A

Feedback A Nipple discharge is usually an abnormal finding. A specimen of the discharge should be collected.

B Supernumerary nipples along the milk line are a normal finding in some women.

C A rash in the axillae associated with change in deodorant can be solved by changing deodorant and treating the rash.

D Mild breast swelling that fluctuates with the menstrual cycle is consistent with fibrocystic breast disease.

5. During a breast examination of a healthy female, the nurse recognizes which finding as normal? a. Asymmetrical venous pattern b. Unequal nipple size c. Supernumerary nipples along the milk line d. Pink discharge from one nipple when manipulated ANS: C

Feedback A The venous patterns should be bilaterally similar.

B Nipple size should be symmetric.

C Supernumerary nipples are considered a normal variation, although they are uncommon.

D Nipple discharge is usually considered an abnormal finding.

6. A patient comes to the clinic complaining of a new onset of nipple discharge. After inspection of the breast and discharge, what action of the nurse has the highest priority? a. Palpating both breasts comparing amount of discharge b. Asking the patient about breast pain c. Asking the patient to raise her arms and comparing the movement of the breasts d. Obtaining a specimen of the discharge for cytology ANS: D Feedback A Getting a specimen is more important than palpating breasts at this time.

B Asking the patient about breast pain is not a priority action at this time.

C Asking the patient to raise her arms and comparing the movement of the breasts is not a

priority action at this time.

D If a patient has nipple discharge, a specimen should be collected for cytologic examination to detect malignant cells.

7. What is the purpose of asking a female to lean forward during the breast examination? a. To accentuate the Montgomery glands b. To observe for symmetry of the suspensory ligaments c. To compare nipple symmetry d. To identify any breast masses in the subcutaneous tissues ANS: B

Feedback A Montgomery glands are located within the areolar surface and would be difficult to inspect when the patient leans forward.

B Observing these ligaments can be accomplished with the patient leaning forward.

C Nipple symmetry is better evaluated with the patient sitting up or lying supine.

D Palpation is a better way to identify a breast mass in subcutaneous tissue.

8. Which technique does a nurse use to palpate the patients axillary lymph nodes? a. With the patient sitting, the nurse places fingers of both hands deep into the axilla, one hand on either side, and firmly pushes the axillary tissue toward the center to feel for enlarged nodes. b. With the patient lying supine with arms at the sides, the nurse uses the tips of the fingers of one hand to palpate the axilla moving from the posterior to the anterior aspect of the axilla to feel for enlarged nodes. c. With the patient lying supine with the hand behind the head of the side being assessed, the nurse uses the pads of fingers of one hand to systematically palpate the axilla using small circular motions to feel for enlarged nodes. d. With the patient sitting, the nurse places fingers of one hand deep into the axilla and firmly slides the fingers along the patients middle, anterior, and posterior of the axilla to feel for enlarged nodes.

ANS: D

Feedback A This is incorrect technique.

B This is incorrect technique.

C This is incorrect technique.

D This is the correct technique.

9. When examining the lymph nodes of an adult female patient, the nurse recognizes which finding as normal? a. Visible superficial nodes b. Palpable supraclavicular nodes c. Nonpalpable lymph nodes in the axilla d. Enlarged, fixed nodes in the neck ANS: C

Feedback A Lymph nodes are not normally palpable or visible.

B Lymph nodes are not normally palpable. Enlarged supraclavicular nodes often indicate a malignancy.

C Lymph nodes are not normally palpable.

D Lymph nodes are not normally palpable.

10. A nurse performing a breast examination on a female patient places the patient in a supine position, places a pillow under the right shoulder, and asks the patient to place her right lower arm above her head. What is the reason for this position? a. Flatten the breast tissue evenly over the chest wall. b. Help the patient to relax and feel more comfortable. c. Reveal lumps deep in the breast more easily. d. Expose any drainage from the nipples.

ANS: A

Feedback A This is the reason for the position.

B Flattening the breast tissue, not relaxation, is the reason.

C Lumps are detected by palpation rather than inspection.

D Drainage is revealed by palpation of the nipples.

11. What instructions does the nurse give a female patient when she is learning to perform breast self-examination? a. Press the pads of the fingers firmly to compress breast tissue against the rib cage. b. Lie in front of a mirror and observe for dimpling of the skin. c. Lift the fingers from the chest wall during palpation to better define the breast tissue. d. Apply gentle pressure while moving the fingers in a pattern across the breast.

ANS: D Feedback A Gentle rather than firm pressure is used.

B A patient stands in front of a mirror to inspect symmetry; she does not lie in front of a mirror.

C The fingers should not be lifted from the breast to prevent breaking the continuity of palpation.

D This is appropriate technique.

12. In assessing the breast of a male patient, the nurse places him in which position? a. Standing with hands over the head b. Supine with the hand on the side being examined placed behind the head c. Sitting with arms at the side d. Bending forward 45 degrees at the waist ANS: C

Feedback A This is part of the examination for female patients.

B This is part of the examination for female patients.

C This is the appropriate position for the male breast examination.

D This is part of the examination for female patients.

13. During a breast examination of a male patient, the nurse recognizes which finding as normal? a. Bilateral nontender flat breasts with symmetric nipple and areolar areas b. A fibrous layer of subcutaneous breast tissue that is thicker than in women c. Breast tenderness on the dominant side but not on the other side d. Bilateral symmetry of breasts with absence of hair in the areolar areas ANS: A

Feedback A This is a description of a normal finding.

B This is not a normal finding.

C This is not a normal finding.

D This is not a normal finding.

14. Which statement by a 17-year old would be most indicative of possible breast cancer? a. I had embarrassing breast enlargement when I was a teenager. b. I think I felt a hard spot in my left breast, but it does not hurt. c. My right breast has always been a little smaller than the left. d. My fathers breasts got larger after he was older.

ANS: B

Feedback A This describes gynecomastia.

B A breast malignancy usually manifests in one breast as a hard, painless, irregular nodule, often fixed.

C One larger breast is not indicative of breast cancer and may be a normal variation.

D This report is not indicative of breast cancer.

15. What technique does a nurse use when performing a breast examination on a patient who has

had a mastectomy? a. Excludes palpation of the axillary area where there was lymph node dissection b. Inspects and palpates both the operative and the nonoperative sides c. Avoids palpating the scar to prevent causing the patient any discomfort

d. Palpates only the muscle tissue on the affected side ANS: B

Feedback A Axilla is still palpated after node dissection.

B Women who have had a mastectomy require the same breast assessment as all other women.

C The scar tissue should not be tender and the technique of palpation on the operative side should be the same as the nonoperative side.

D Women who have had a mastectomy require the same breast assessment as all other women.

16. In a presentation on breast cancer risk factors, a nurse would be accurate in making which statement? a. Women who breastfeed their children are at increased risk of breast cancer. b. Women who are more than 30% overweight are at increased risk of breast cancer. c. African American women have the highest risk of breast cancer. d. Women who have children before age 30 are at increased risk of breast cancer.

ANS: B

Feedback A Breastfeeding is not a risk factor for breast cancer.

B Obesity especially after age 50 or increased weight gain as an adult increases breast cancer risk.

C White women have the highest incidence of breast cancer.

D First full-term pregnancy after age 30 increases risk.

17. A patient comes to the clinic because she found a mass in her left breast that is present during and after her menstrual periods. On palpation the nurse finds a mass in the left breast that is round, rubbery, mobile, and nontender. This finding is consistent with which breast disorder? a. Fibrocystic breast disease

b. Invasive breast cancer c. Mastitis

d. Fibroadenoma ANS: D

Feedback A Findings of this disorder affect both breasts and produce tenderness that subsides between menstrual periods.

B Masses of breast cancer are irregular, hard, and fixed.

C Mastitis is an inflammation of the entire breast that produces tissue that is red, edematous, tender, and warm to the touch.

D These findings are consistent with fibroadenoma.

18. A patient had a left radical mastectomy last year. The nurse assesses for painless and nonpitting swelling of the arm on that side. Which complication of a mastectomy is the nurse assessing for? a. Infection b. Lymphedema c. Inflammation d. Lymphoma ANS: B

Feedback A Localized signs of infection include redness, heat, and pain; there can also be edema, which, when associated with infection, is pitting.

B Lymphedema is a localized accumulation of lymph fluid in the interstitial spaces caused by removal of the lymph nodes.

C Localized signs of inflammation include redness, heat, and pain; there can also be edema, which, when associated with inflammation, is pitting.

D The sign of lymphoma is an enlarged lymph node rather than generalized swelling.

19. In assessing a patient with lymphedema after a mastectomy, the nurse expects which finding? a. Fragile, thin, pale skin covering the area of lymphedema b. Several brownish-red discolorations in the center of the affected arm

c. Unilateral nonpitting edema of the affected arm d. Pitting edema of affected arm ANS: C Feedback A This is an incorrect description of lymphedema.

B This is more consistent with a description of chronic venous insufficiency than lymphedema.

C Lymphedema is a localized accumulation of lymph fluid in the interstitial spaces caused by removal of the lymph nodes.

D The fluid accumulation in lymphedema usually is not enough to cause pitting.

20. A nurse is performing a breast examination of a patient who complains of pain in both breasts that occurs around the time of her menstrual period. The nurse expects which findings during the breast examination? a. Masses in the breasts that are round, soft, mobile, and well-delineated b. Masses in the breasts that are round, firm, mobile, and well-delineated c. Masses in the breasts that are irregular, hard, and fixed d. Breast tissue that is red, edematous, tender, and warm to the touch ANS: A

Feedback A This finding is consistent with fibrocystic breast disease. The findings are almost the same as fibroadenoma (except for consistency of the masses), but the nurse must correlate the history (occurs during the menses) with the findings for fibrocystic disease.

B These findings are consistent with fibroadenoma.

C These findings are consistent with breast cancer.

D These findings are consistent with mastitis.

21. The nurse notices dimpling of the skin surrounding a palpable mass in the right breast of a female patient. What is the most appropriate action for the nurse to take next? a. Record this as an expected finding.

b. Palpate the area of dimpling for pain. c. Palpate the borders of the area of dimpling for irregularity. d. Tell the patient that dimpling indicates the mass is benign.

ANS: C

Feedback A This finding is not normal.

B Malignant breast masses are not tender.

C Malignant breast masses are irregular and poorly delineated. As the mass grows, there may be breast asymmetry, discoloration (erythema or ecchymosis), unilateral vein prominence, peau dorange, ulceration, dimpling, puckering, or retraction of the skin.

D Dimpling may indicate a malignant mass rather than a benign mass.

22. A nurse becomes suspicious that a patient may have breast cancer based on which abnormal finding? a. An irregularly shaped hard mass in one breast b. Bilateral, small, nontender nodes close to the surface c. Multiple rubbery-feeling lumps with well-defined borders d. A mobile, firm lump located in the upper outer quadrant of the left breast ANS: A

Feedback A Malignant masses are solitary, irregularly-shaped, unilateral, nontender, and immobile.

B Malignant masses are unilateral.

C Malignant masses have irregular, poorly defined borders.

D Breast cancer often occurs in the upper outer quadrant, but is immobile.

23. The nurse would give immediate attention to the patient who presents with which complaint? a. Bilateral breast swelling b. Unilateral nipple discharge

c. A breast lump that changes during the menstrual cycle d. Unequal breast size ANS: B

Feedback A Bilateral breast swelling is frequently related to fibrocystic breast disease.

B A breast malignancy usually manifests in one breast, and a serosanguineous or clear nipple discharge may be present.

C A breast lump that changes during the menstrual cycle is frequently related to fibrocystic breast disease.

D Unequal breast size that does not include a mass in one breast is not an immediate concern.

MULTIPLE RESPONSE

1. Which life style behaviors do nurses ask about to identify patients with risk factors for breast cancer? Select all that apply. a. Obesity after age 18 b. Smoking more than one pack of cigarettes a day c. Never having given birth to a viable infant d. Drinking two to five alcoholic beverages a day e. Estrogen replacement therapy for more than 5 years f. High blood pressure for more than 3 years ANS: A, C, D, E Correct: Obesity after age 18, never having given birth to a viable infant (nulliparity), drinking two to five alcoholic beverages a day, and estrogen replacement therapy for more than 5 years are all risk factors for breast cancer.

Incorrect: Although smoking and high blood pressure are risk factors for many disorders, they are not risk factors for breast cancer.

Chapter 18. Female Genitalia 1. During the initial inspection of the female genitalia, the nurse recognizes which finding as normal? a. The labia minora are hair-covered and lying within the labia majora. b. The cervical os in the multiparous woman has the shape of a small circle. c. The vaginal vestibule lies between the labia minora and contains the urinary meatus. d. The openings of Skene and Bartholin glands are visible posteriorly.

ANS: C Feedback A The labia majora, rather than the labia minora, are covered with hair.

B The os of parous women is the shape of a slit.

C This description is of normal female anatomy.

D The opening of these glands is on either side of the vaginal vestibule.

2. On inspection of the internal structure of the vagina, the nurse notes a rounded protrusion on the posterior wall of the vagina. How does the nurse document this finding? a. Rectocele b. Cystocele c. Bartholin cyst d. Nabothian cyst ANS: A Feedback A Rectocele is a hernia type of protrusion of the rectum against the posterior wall of the vagina.

B Cystocele is a hernia type of protrusion of the bladder against the posterior wall of the vagina.

C The Bartholin glands are external structures.

D Nabothian cysts appear on the cervix.

3. During the examination of the internal genitalia with the speculum, the nurse records which finding as normal? a. A healed laceration of the cervix in a nulliparous patient b. A large amount of thick white drainage from the cervical os c. Deviation of the cervix toward the posterior vaginal wall d. Pink cervix with a small ring of reddened tissue near the os ANS: D Feedback

A This is an abnormal finding; a laceration is not expected in nulliparous women.

B This is an abnormal finding; this drainage may indicate a sexually transmitted disease.

C This is an abnormal finding.

D This is a normal finding.

4. The nurse recognizes that a Papanicolaou (Pap) test is indicated for which patient? a. A 12-year-old who has not yet reached menarche. b. A 30-year-old who had a normal Pap test 12 months ago. c. A 45-year-old who had a total hysterectomy for cervical cancer. d. A 55-year-old who had a total hysterectomy to treat endometriosis.

ANS: C Feedback A A Pap test is not indicated for this patient.

B A Pap test is not indicated for this patient.

C In women who have undergone a hysterectomy in which the cervix was removed, Pap testing is not required unless the hysterectomy was performed because of cervical cancer or its precursors.

D A Pap test is not indicated for this patient.

5. What technique does the nurse use to obtain a cervical tissue sample for a Papanicolaou (Pap) test? a. A Cervex-Brush is inserted into the cervix and rotated to obtain a sample of ectocervical and endocervical cells. b. A wooden spatula scrapes the cervix to obtain a sample of endocervical cells. c. A pipette is placed inside the cervical os and rotated to obtain a thick layer of endocervical and ectocervical cells. d. A cotton-tipped applicator is used on the outside of the cervix to obtain ectocervical cells.

ANS: A Feedback A This is the correct technique.

B A wooden spatula is not used and ectocervical cells are needed as well as endocervical cells.

C A pipette is not used and the cells are not contained in a thick layer.

D Using a brush as opposed to a cotton-tipped applicator has improved the quality of the sample of endocervical cells and ectocervical cells.

6. A nurse expects which normal findings when performing a bimanual palpation of the cervix and uterus? a. The uterus feels firm and slightly nodular. b. The cervix feels soft, smooth, and slightly rounded. c. The uterus of a nonpregnant patient cannot be felt with the internal fingers. d. The cervix is tender when moved laterally.

ANS: B Feedback A The uterus normally does not feel nodular.

B These are the normal findings from a bimanual examination of the cervix.

C The uterus of a nonpregnant woman can be palpated.

D The cervix normally is not tender; if it is, it may indicate a sexually transmitted disease.

13. A nurse expects which normal findings when palpating a patients ovaries? a. Nodular and nonmovable b. Smooth, fluid-filled, and nonmovable c. Smooth, firm, and about the size of a walnut d. Spongy, mobile, and about the size of a peanut ANS: C Feedback A Normally the ovaries do not feel nodular and nonmovable.

B Normally the ovaries do not feel fluid-filled and nonmovable.

C This is a correct description of a normal finding when palpating an ovary.

D Normally the ovaries do not feel spongy or mobile.

14. A patient complains of dysuria, yellow-green vaginal discharge, and vulvar itching. The nurse suspects which sexually transmitted disease? a. Syphilis b. Gonorrhea c. Genital warts d. Chlamydia ANS: B Feedback A Primary syphilis produces a single, firm, painless open sore or chancre with indurated borders at the site of entry on the genitals.

B Gonorrhea causes a yellow or green vaginal discharge, dysuria, pelvic or abdominal pain, and vaginal itching and burning.

C Genital warts appear as soft, papillary, pink to brown, elongated lesions that may occur singularly or in clusters on the internal genitalia, the external genitalia, and the anal-rectal region.

D Chlamydia infection is asymptomatic in up to 75% of women because it often does not cause enough inflammation to produce symptoms.

15. In assessing a patient with suspected Chlamydia, the nurses actions are guided by which characteristic of this disease? a. Chlamydia is frequently asymptomatic and requires screening. b. Chlamydia is associated with a yellow-green vaginal discharge. c. Chlamydia is accompanied by heavy bleeding and headache. d. Chlamydia is only seen in immunocompromised patients.

ANS: A Feedback A This answer is consistent with clinical findings of Chlamydia.

B This answer is consistent with clinical findings of gonorrhea.

C Chlamydia is not accompanied by heavy bleeding and headache.

D Chlamydia is seen in patients with healthy immune systems who are not immunocompromised.

16. A nurse examines a patient and finds a single, firm, painless open sore with indurated borders on the vulva. The nurse correlates this finding with which disorder? a. Human papillomavirus (HPV) infection b. Herpes infection c. Gonorrhea d. Syphilis ANS: D Feedback A HPV infection causes wartlike growths.

B Herpes infection forms vesicles rather than chancres.

C Gonorrhea produces a yellow or green vaginal discharge.

D The clinical finding is consistent with a chancre found in syphilis.

Chapter 19. Musculoskeletal System 1. Which is an accurate statement concerning a childs musculoskeletal system and how it may be different from adults? a. Growth occurs in children as a result of an increase in the number of muscle fibers. b. Infants are at greater risk for fractures because their epiphyseal plates are not fused. c. Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. d. Their bones have less blood flow.

ANS: C

Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. A childs growth occurs because of an increase in size rather than an increase in the number of the muscle fibers. Fractures in children younger than 1 year are unusual because a large amount of force is necessary to fracture their bones. A childs bones have greater blood flow than an adults bones.

2. When infants are seen for fractures, which nursing intervention is a priority?

a. No intervention is necessary. It is not uncommon for infants to fracture bones. b. Assess the familys safety practices. Fractures in infants usually result from falls. c. Assess for child abuse. Fractures in infants are often nonaccidental. d. Assess for genetic factors.

ANS: C Fractures in infants warrant further investigation to rule out child abuse. Fractures in children younger than 1 year are not common because of the cartilaginous quality of the skeleton; a large amount of force is necessary to fracture their bones. Infants should be cared for in a safe environment and should not be falling. Fractures in infancy are usually nonaccidental rather than

related to a genetic factor.

3. Which nursing assessment is appropriate for determining neurovascular competency?

a. Degree of motion and ability to position the extremity b. Length, diameter, and shape of the extremity c. Amount of swelling noted in the extremity and pain intensity d. Skin color, temperature, movement, sensation, and capillary refill of the extremity ANS: D A neurovascular evaluation includes assessing skin color and temperature, ability to move the affected extremity, degree of sensation experienced, and speed of capillary refill in the extremity.

The degree of motion in the affected extremity and the ability to position the extremity are incomplete assessments of neurovascular competency. The length, diameter, and shape of the extremity are not assessment criteria in a neurovascular evaluation. Although the amount of swelling is an important factor in assessing an extremity, it is not a criterion for a neurovascular assessment.

4. A mother whose 7-year-old child has been placed in a cast for a fractured right arm reports he will not stop crying even after taking Tylenol with codeine. He also will not straighten the fingers on his right arm. The nurse tells the mother to do which? a.

Take him to the emergency department.

b. Put ice on the injury. c. Avoid letting him get so tired. d. Wait another hour. If he is still crying, call back.

ANS: A Unrelieved pain and the childs inability to extend his fingers are signs of compartmental syndrome, which requires immediate attention. Placing ice on the extremity is an inappropriate action for the presenting symptoms. It is inappropriate for the nurse to tell the mother who is concerned about her child to avoid letting him get so tired. A child who has signs and symptoms of compartmental syndrome should be seen immediately. Waiting an hour could compromise the recovery of the child.

5. A 4-year-old child with a long leg cast complains of fire in his cast. The nurse should:

a.

notify the physician on his next rounds.

b.

chart the complaint in the nurses notes.

c. notify the physician immediately. d. report the complaint to the next nurse on duty.

ANS: C A burning sensation under the cast is an indication of tissue ischemia. It may be an early indication of serious neurovascular compromise, such as compartment syndrome, that requires immediate attention. The childs presenting symptom requires immediate attention. Notifying the physician on the next rounds is inappropriate. Charting the complaint in the nurses notes is an inappropriate action. Careful notation of symptoms is important, but the priority action is to contact the physician. Communication across shifts is important to the continuing assessment of the child; however, this symptom requires immediate evaluation, and the physician should be contacted.

6. Which statement is most correct with regard to childhood musculoskeletal injuries?

a. After the injury is iced, the swelling decreases, indicating the injury is not severe. b. The presence of localized tenderness indicates a more serious injury. c. The more swelling there is, the less severe the injury is. d. The less willing the child is to bear weight, the more serious the injury is.

ANS: D An inability to bear weight on the affected extremity is indicative of a more serious injury. With a fracture, general manifestations include pain or tenderness at the site, immobility or decreased range of motion, deformity of the extremity, edema, and inability to bear weight. A decrease in swelling after icing does not identify the degree of the injury. Localized tenderness along with limited joint mobility may indicate serious injury, but an inability to bear weight on the extremity is a more reliable sign. The degree of swelling does not indicate how serious the injury is.

7. A child with osteomyelitis asks the nurse, What is a sed rate? What is the best response for the nurse?

a. It tells us how you are responding to the treatment. b. It tells us what type of antibiotic you need. c. It tells us whether we need to immobilize your extremity. d. It tells us how your nerves and muscles are doing.

ANS: A The erythrocyte sedimentation rate (ESR) indicates the presence of inflammation and infectious process and is one of the best indicators of the childs response to treatment. Although the ESR indirectly identifies whether an antibiotic is needed, the organism involved dictates the type of antibiotic and the length of treatment. The ESR does not direct whether the extremity will be immobilized and will not evaluate neuromuscular status.

8. Which intervention is part of the discharge plan for a child with osteomyelitis?

a. Instructions for a low-calorie diet b. A referral to a home healthcare agency c. Instructions for a high-fat, low-protein diet d. Instructions for the parent to return the child to team sports immediately ANS: B Because the child with osteomyelitis often requires intravenous antibiotics at home, a home healthcare referral is appropriate. The child with osteomyelitis is on a high-calorie, high-protein diet. The child with osteomyelitis may need time for the bone to heal before returning to full activities.

9. During a 14-year-old adolescents physical examination, the nurse identifies that he plays soccer and football and is complaining of knee pain when he rises from a squatting position. The nurse should suspect:

a. Legg-Calv-Perthes disease. b. osteomyelitis. c. Duchenne muscular dystrophy. d. Osgood-Schlatter disease.

ANS: D

Knee pain and tenderness aggravated by activity that requires kneeling, running, climbing stairs, and rising from a squatting position are highly significant for Osgood-Schlatter disease. The etiology is believed to be related to repetitive stress from sports-related activities combined with overuse of immature muscles and tendons. Pain on activity that decreases with rest is indicative of Legg-Calv-Perthes disease. Preexisting pain, favoring the affected limb, erythema, and tenderness are associated with osteomyelitis. Duchenne muscular dystrophy presents with progressive generalized weakness and muscle wasting.

10. The nurse caring for a child with Osgood-Schlatter disease should evaluate the childs:

a. knowledge of activity restrictions. b. understanding of traction. c. acceptance of life-long limitations. d. knowledge of skin care.

ANS: A The major component of treatment for Osgood-Schlatter disease is activity restriction for 6 weeks or more. Traction is not used for Osgood-Schlatter disease. This is a self-limiting disorder, not a life-long disorder. The problem usually disappears once growth stops. Although activity is restricted, the degree of restriction should not result in skin care problems.

11. Which factor is important to include in the teaching plan for parents of a child with LeggCalv-Perthes disease? a. It is a chronic disease with long-term sequelae. b. It affects children in the toddler stage. c. There is a disturbance in the blood supply to the femoral epiphysis. d. It is caused by a virus.

ANS: C Legg-Calv-Perthes disease is a self-limiting disease that affects the blood supply to the femoral epiphysis. The most serious problem associated with it is the risk of permanent deformity. LeggCalv-Perthes disease is not a chronic disease. The disease process usually lasts between 1 and 2

years and is a disorder of growth. It is seen in children between 2 and 12 years of age. Most cases occur between 4 and 9 years of age. The etiology is unknown.

12. The major concern guiding treatment for the child with Legg-Calv-Perthes disease is to: a. avoid permanent deformity. b. minimize pain. c. maintain normal activities. d. encourage new hobbies.

ANS: A The major concern related to Legg-Calv-Perthes disease is to prevent an arthritic process resulting from the flattening of the femoral head of the femur when it protrudes outside the acetabulum. The pain associated with Legg-Calv-Perthes disease decreases with increased rest, making activity restriction an important factor for these children. The priority concern for treatment is to prevent deformity through decreased activity. Selected hobbies that do not require physical activity are encouraged.

13. What is a realistic outcome for the child with osteogenesis imperfecta?

a. The child will have a decreased number of fractures. b. The child will demonstrate normal growth patterns. c. The child will participate in contact sports. d. The child will have no fractures after infancy.

ANS: A

The biochemical defect associated with osteogenesis imperfecta causes a defect in the synthesis of collagen. The abnormal collagen results in incomplete bone development, placing the child at high risk for fracturing bones. Receiving safety education and wearing protective apparatus can decrease the number of fractures. Because of incomplete bone formation, children with osteogenesis imperfecta do not have normal growth patterns. The high risk of fractures and the abnormal growth patterns do not allow for active participation in contact sports. Osteogenesis imperfecta is a life-long disease process.

14. Discharge planning for the child with juvenile arthritis includes the need for: a. routine ophthalmological examinations to assess for visual problems. b. a low-calorie diet to decrease or control weight in the less mobile child. c. avoiding the use of aspirin to decrease gastric irritation. d. immobilizing the painful joints, which is the result of the inflammatory process.

ANS: A

The systemic effects of juvenile arthritis can result in visual problems, making routine eye examinations important. Children with juvenile arthritis do not have problems with increased weight and often are anorexic and in need of high-calorie diets. They are often treated with aspirin. Children with arthritis can immobilize their own joints. Range-of-motion exercises are important for maintaining joint flexibility and preventing restricted movement in the affected joints.

15. During painful episodes of juvenile arthritis, a plan of care should include which nursing intervention? a. A weight-control diet to decrease stress on the joints b. Proper positioning of the affected joints to prevent musculoskeletal complications c. Complete bed rest to decrease stress to joints d. High-resistance exercises to maintain muscular tone in the affected joints

ANS: B

Proper positioning is important to support and protect affected joints. Isometric exercises and passive range-of-motion exercises will prevent contractures and deformities. Children in pain often are anorexic and need high-calorie foods. Children with juvenile arthritis need a combination of rest and exercise and need to avoid high-resistance exercises. They also benefit from low-resistance exercises such as swimming.

16. When assessing a child for an upper extremity fracture, the nurse should know that these

fractures most often result from: a. automobile accidents. b. falls. c. physical abuse. d. sports injuries.

ANS: B

The major cause of childrens fractures is falls. Because of the protection reflexes, the outstretched arm often receives the full force of the fall. Automobile accidents, physical abuse, and sports injuries may result in fractures to any bone.

17. In caring for a child with a compound fracture, what should the nurse carefully assess for?

a. Infection b. Osteoarthritis c. Epiphyseal disruption d. Periosteum thickening

ANS: A

Because the skin has been broken, the child is at risk for organisms to enter the wound. The incidence of osteoarthritis and the chance of epiphyseal disruption are not increased with compound fracture. Periosteum thickening is part of the healing process and is not a complication.

18. A nurse is teaching parents the difference between pediatric fractures and adult fractures.

Which observation is true about pediatric fractures? a. They seldom are complete breaks. b. They are often compound fractures. c. They are often at the epiphyseal plate.

d. They are often the result of decreased mobility of the bones.

ANS: A Pediatric fractures seldom are complete breaks. Rather, childrens bones tend to bend or buckle.

Compound fractures are no more common than simple fractures in children. Epiphyseal plate fractures are no more common than any other type of fracture. Increased mobility of the bones prevents children from having complete fractures.

19. Patient and parent education for the child who has a synthetic cast should include which information? a. Apply a heating pad to the cast if the child has swelling in the affected extremity. b. Wrap the outer surface of the cast with an Ace bandage. c. Split the cast if the child complains of numbness or pain. d. Cover the cast with plastic and waterproof tape to keep it dry while bathing or showering.

ANS: D Damp skin is more susceptible to breakdown. The cast should be kept clean and dry. To prevent swelling, elevate the extremity and apply bagged ice to the casted area. Wrapping the outer surface with an Ace bandage is not indicated. If the child complains of numbness or pain, he should return immediately to the clinic or emergency department for an evaluation of neurovascular status.

20. A 6-year-old patient in skeletal traction for a femur fracture has pain and edema of the thigh and is febrile. The nurse should suspect which condition? a. Meningitis b. Crepitus c. Osteomyelitis d. Osteochondrosis ANS: C The most serious complication of skeletal traction is osteomyelitis. Clinical manifestations include complaints of localized pain, swelling, warmth, tenderness, or unusual odor. An elevated temperature may accompany the symptoms. The symptoms of meningitis include headache, photophobia, fever, nausea, and vomiting. Crepitus is the sandy or gravelly feeling noted when a broken bone is palpated. Osteochondrosis is a disorder of the epiphyses involving an interruption

of the blood supply.

21. A child who has fractured his forearm is unable to extend his fingers. The nurse knows that this: a. is normal following this type of injury. b. may indicate compartmental syndrome. c. may indicate fat embolism. d. may indicate damage to the epiphyseal plate.

ANS: B Swelling causes pressure to rise within the immobilizing device leading to compartmental syndrome. Signs include severe pain, often unrelieved by analgesics, and neurovascular impairment. It is not uncommon in the forearm, so the inability to extend the fingers may indicate compartmental syndrome. It is not normal that the child is unable to extend his fingers; this indicates neurovascular compromise of some type. Paresthesia or numbness or loss of feeling can indicate a neurovascular compromise and can result in paralysis. Fat embolism causes respiratory distress with hypoxia and respiratory acidosis. Paresthesia is not related to damage to the epiphyseal plate.

22. When teaching care for a child immobilized in a spica cast, which is the most appropriate intervention? a. Application of talcum powder to the skin twice daily b. Fluid restriction to prevent loose stools or diarrhea c. Assessment for a sluggish capillary refill d. Instructing that insertion of small objects into the cast for itching or discomfort is helpful ANS: C Capillary refill that is sluggish is indicative of impaired neurovascular function. The nurse should avoid applying talcum powder because it may become sticky or cake on the skin and cause irritation. The child needs appropriate fluid intake to prevent constipation or stool impaction.

This is especially important because activity is limited. The nurse should instruct caregivers that nothing should be put inside the cast. Keeping food, small toys, and sharp objects away from the cast will be important.

23. When assessing the child with osteogenesis imperfecta, the nurse should expect to make which observation?

a. Discolored teeth b. Below-normal intelligence c. Increased muscle tone d. Above-average stature ANS: A Children with osteogenesis imperfecta have incomplete development of bones, teeth, ligaments, and sclerae. Teeth are discolored because of abnormal enamel. Despite their appearance, the child with osteogenesis imperfecta has normal or above-normal intelligence. The child with osteogenesis imperfecta has weak muscles and decreased muscle tone. Because of compression fractures of the spine, the child appears short.

24. When teaching the parents of a child with osteogenesis imperfecta about nutrition, the nurse should emphasize a diet that is: a. high in protein. b. high in calories. c. low in fiber. d. high in calcium.

ANS: D Foods high in calcium, and calcium supplements if necessary, should be included in the diet.

Nutritional guidelines should support healthy growth and development. Protein intake should be based on the childs age-appropriate dietary needs. The diet should not be high in calories.

Excessive weight gain can place undue stress on the musculoskeletal system. High-fiber foods should be included in the diet.

25. A nurse understands that which type of exercise would be best for a child with juvenile arthritis? a. Jogging b. Tennis c. Gymnastics d. Swimming in a heated pool ANS: D The warmth of the water, coupled with mild resistance, makes swimming the perfect medium for

strengthening and range-of-motion exercises while protecting the joints. Jogging jars the hip, knee, and ankle joints and can cause joint damage. Tennis also jars the joints and can cause joint damage. Gymnastics does not protect the joints from injury.

26. Juvenile arthritis should be suspected in a child who exhibits which symptom? a. Frequent fractures b. Joint swelling and pain lasting longer than 6 weeks c. Increased joint mobility d. Lurching and abnormal gait, limited abduction ANS: B Intermittent joint pain lasting longer than 6 weeks is indicative of juvenile arthritis. Frequent fractures are indicative of osteogenesis imperfecta. Increased joint mobility is indicative of osteogenesis imperfecta. Lurching to the affected side causing an abnormal gait and limited abduction are associated with the developmental dysplasia of the hip (DDH).

27. When providing education for the parents of a child with Duchenne muscular dystrophy, the nurse plans to include: a. testing all female children for the disease. b. testing the father for the presence of the trait on the Y chromosome. c. genetic counseling for all female relatives. d. testing the parents to determine the carrier.

ANS: C Duchenne muscular dystrophy is a recessive sex-linked disease carried on the X chromosome so only males are affected with the disease. Because Duchenne muscular dystrophy is a recessive X-linked disorder, females can only be carriers and do not have the disease. The disease is an Xlinked recessive disorder and would not be found on the Y chromosome. The disease is a recessive X-linked disease and is always carried by the mother.

28. The nurse knows that treatment of Osgood-Schlatter disease includes which intervention? a. Limitation of knee bending or kneeling b. Increasing range of motion (ROM) of the knee c. Encouraging flexion of the hip d. Limitation of adduction of the hip

ANS: A Limitation of knee bending or kneeling provides pain control and allows the knees to heal.

Increasing ROM of the knee increases pain and exacerbates the disease. Encouraging flexion of the hip will have no effect on the process affecting the knees. Limitation of hip adduction will not help the child with Osgood-Schlatter disease.

29. What is the most appropriate intervention for an adolescent with a mild scoliosis? a. Long-term monitoring b. Surgical intervention c. Bracing d. No follow-up ANS: A The child with mild scoliosis requires long-term follow-up to determine whether the curve will progress or remain stable. Surgical intervention is not needed for mild scoliosis. Mild scoliosis is not braced if it is stable. Follow-up to monitor the curve is important until skeletal maturity has occurred.

30. Which statement made by the mother of an adolescent being discharged after spinal fusion for severe scoliosis indicates the need for further teaching? a. I am glad we chose surgery. Now it is all over and done. b. Ill see you in a month; well be back fairly regularly. c. I have to pick up some more T-shirts on the way home. d. Those exercises the physical therapist showed us were not too hard.

ANS: A Spinal fusion requires long-term follow-up to assess the stability of the spinal correction. It is not over and done at this point. Showing knowledge of follow-ups, clothing, and exercises indicates the mothers understanding and does not require further teaching.

31. Which factor should the nurse include when teaching a parent about the care of a child in a Pavlik harness for hip dysplasia? a. The harness may be removed with every diaper change. b. The harness is used to maintain the infants hips in flexion and abduction and external rotation. c. The harness is only the first step of treatment.

d. The harness is worn for only 2 weeks.

ANS: B The harness is used to maintain the infants hips in flexion and external rotation to allow the hips (femoral head and acetabulum) to mold and grow normally. The harness must be worn for 23 hours per day and should be removed only according to the physicians recommendation. Hips that remain unstable become progressively more deformed as maturity takes place. With early diagnosis and treatment, the Pavlik harness is often the only treatment necessary. The length of treatment is determined by radiographic documentation of the maturity of the hips.

32. Which nursing intervention is a priority when caring for a child in a Pavlik harness? a. Skin care b. Bowel function c. Feeding patterns d. Respiratory function ANS: A The child in a Pavlik harness needs special attention to skin care because the infants skin is sensitive and the harness may cause irritation. The harness should not affect normal bowel function, feeding patterns, or normal respiratory function in the infant.

33. When instructing parents about the care of an infant in a cast for a clubfoot, the nurse should include: a. reassurance that clubfoot usually resolves spontaneously. b. instructions on washing the cast daily to keep it clean. c. the importance of analogous blood donations for impending surgery. d. notifying the physician of any vascular problems, such as toe swelling.

ANS: D Toe swelling may be a sign of neurovascular compromise and the need for the cast to be readjusted. The physician should be notified immediately. Clubfoot does not resolve spontaneously. A clubfoot can recur and long-term follow-up is indicated. Casts are never washed. Parents should be instructed to keep the cast dry. Analogous blood donations are not a consideration for the child with a clubfoot.

34. During a well-child visit, the nurse identifies that an 18-month-old infant is bow legged. The

nurse is aware that this assessment is: a. common in children between the ages of 2 and 7 years. b. a common variation until 1 year after walking begins. c. a serious condition needing further evaluation. d. an indication of neurological impairment.

ANS: B Bow legs are a common occurrence in children until approximately 1 year after the child begins walking. They tend to correct as the child grows. Bow legs are not a common finding in children older than 30 months. Bow legs may need intervention but do not generally indicate serious abnormalities. Bow legs do not generally indicate a neurological impairment.

35. Which statement made by the parent of a 6-month-old infant undergoing serial casting for treatment of clubfoot indicates the parent is correctly following the treatment plan? a.

I am careful to leave him in his bed with his leg elevated as much as possible.

b.

I monitor the temperature of his foot often to make sure that the cast still fits.

c. Its okay that hes not trying to roll over; hell catch up later. d. Its okay if the cast gets wet during baths because it will be changed often.

ANS: B The temperature of the foot should be monitored often to assess for neurovascular compromise.

The child should be allowed to have developmental stimulation to achieve as normal a growth and development as possible. The child should be trying to roll over by this age; if the child is not, this indicates the need for further evaluation. The cast should be kept dry although it is being changed often.

36. The teaching plan for the child with structural disorders of the bones and joints, such as developmental dysphasia of the hip, should include which instruction? a. Importance of limiting physical activity to decrease the chance of injury b. Need for long-term hospitalization to ensure adequate treatment c. Importance of follow-up until the child reaches skeletal maturity d. Importance of avoiding child-resistant devices, as these can exacerbate the condition ANS: C Because recurrence is common, long-term follow-up is necessary until skeletal maturity is

reached. Physical activity will not necessarily reduce injury

Chapter 20. Neurological System 1. A nurse is explaining to parents how the central nervous system of a child differs from that of an adult. Which statement accurately describes these differences? a. The infant has 150 milliliters of cerebrospinal fluid compared with 50 milliliters in the adult. b. Papilledema is a common manifestation of increased intracranial pressure in the very young child. c. The brain of a term infant weighs less than half of the weight of the adult brain. d. Coordination and fine motor skills develop as myelinization of peripheral nerves progresses.

ANS: D Peripheral nerves are not completely myelinated at birth. As myelinization progresses, so does the childs coordination and fine muscle movements. An infant has about 50 milliliters of cerebrospinal fluid compared with 150 milliliters in an adult. Papilledema rarely occurs in infancy because open fontanels and sutures can expand in the presence of increased intracranial pressure. The brain of the term infant is two-thirds the weight of an adults brain.

2. A nurse is assessing a 1-year-old child for increased intracranial pressure (ICP). Which sign should the nurse assess for with this age of child? a. Headache b. Bulging fontanel c. Tachypnea d. Increase in head circumference ANS: A Headaches are a clinical manifestation of increased ICP in children. A change in the childs normal behavior pattern may be an important early sign of increased ICP. A bulging fontanel is a manifestation of increased ICP in infants. A 10-year-old child would have a closed fontanel. A change in respiratory pattern is a late sign of increased ICP. Cheyne-Stokes respiration may be evident. This refers to a pattern of increasing rate and depth of respirations followed by a decreasing rate and depth with a pause of variable length. By 10 years of age, cranial sutures have fused so that head circumference will not increase in the presence of increased ICP. 3. The nurse should give a child who is to have magnetic resonance imaging (MRI) of the brain which information?

a. Your head will be restrained. b. You will have to drink a special fluid before the test. c. You will have to lie flat after the test is finished. d. You will have electrodes placed on your head with glue.

ANS: A To reduce fear and enhance cooperation during the MRI, the child should be made aware that his head will be restricted to obtain accurate information. Drinking fluids is usually done for gastrointestinal procedures. A child would lie flat after a lumbar puncture, not during an MRI. Electrodes are attached to the head for an electroencephalogram.

4. A child with spina bifida is being admitted to the hospital for a shunt revision? The nurse admitting the child anticipates which type of precautions to be ordered for the child? a. Latex b. Bleeding c. Seizure d. Isolation ANS: A Children with spina bifida are at high risk for developing latex allergies because of frequent exposure to latex during catheterizations, shunt placements, and other operations. The child with spina bifida does not have a risk for bleeding. Not all children with spina bifida are at risk for seizures and isolation would not be indicated in a child being admitted for a shunt revision.

5. Nursing care of the infant who has had a myelomeningocele repair should include which intervention? a. Securely fastening the diaper b. Measurement of pupil size c. Measurement of head circumference d. Administration of seizure medications ANS: C Head circumference measurement is essential because hydrocephalus can develop in these infants. A diaper should be placed under the infant but not fastened. Keeping the diaper open facilitates frequent cleaning and decreases the risk for skin breakdown. Pupil size measurement is usually not necessary. Head circumference measurement is essential because hydrocephalus

can develop in these infants.

6. When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with an observable distended scalp vein, the nurse recognizes these signs as indicative of which condition? a. Hydrocephalus b. SIADH (syndrome of inappropriate antidiuretic hormone) c. Cerebral palsy d. Reyes syndrome ANS: A The combination of signs is strongly suggestive of hydrocephalus. SIADH would not present in this way. The child would have decreased urination, hypertension, weight gain, fluid retention, hyponatremia, and increased urine specific gravity. The manifestations of cerebral palsy vary but may include persistence of primitive reflexes, delayed gross motor development, and lack of progression through developmental milestones. Reyes syndrome is associated with an antecedent viral infection with symptoms of malaise, nausea, and vomiting. Progressive neurological deterioration occurs.

7. A child is admitted to the hospital with spastic cerebral palsy. The nurse will assess for which manifestations associated with this disorder? a. Tremulous movements at rest and with activity b. Sudden jerking movement caused by stimuli c. Writhing, uncontrolled, involuntary movements d. Clumsy, uncoordinated movements ANS: B Spastic cerebral palsy, the most common type of cerebral palsy, will manifest with hypertonicity and increased deep tendon reflexes. The childs muscles are very tight and any stimuli may cause a sudden jerking movement. Tremulous movements are characteristic of rigid/tremor/atonic cerebral palsy. Slow, writhing, uncontrolled, involuntary movements occur with athetoid or dyskinetic cerebral palsy. Clumsy movements and loss of coordination, equilibrium, and kinesthetic sense occur in ataxic cerebral palsy.

8. Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with a diagnosis of bacterial meningitis?

a. CSF appears cloudy. b. CSF pressure is decreased. c. Few leukocytes are present. d. Glucose level is increased compared with blood.

ANS: A In acute bacterial meningitis, the CSF is cloudy to milky or yellowish in color. The CSF pressure is usually increased in acute bacterial meningitis. Many polymorphonuclear cells are present in CSF with acute bacterial meningitis. The CSF glucose level is usually deceased compared with the serum glucose level.

9. Which would be an appropriate nursing intervention for the child with a tension headache? a. Assess for an aura. b. Maintain complete bed rest. c. Administer pharmacological headache relief measures. d. Assess for nausea and vomiting.

ANS: C Administration of pharmacological techniques is appropriate to assist in the management of a tension headache. An aura is associated with migraines but not with tension headaches.

Complete bed rest is not required. Nausea and vomiting are associated with a migraine but not with tension headaches.

10. How should the nurse explain positioning for a lumbar puncture to a 5-year-old child? a. You will be on your knees with your head down on the table. b. You will be able to sit up with your chin against your chest. c. You will be on your side with the head of your bed slightly raised. d. You will lie on your side and bend your knees so that they touch your chin.

ANS: D The child should lie on her side with knees bent and chin tucked into the knees. This position exposes the area of the back for the lumbar puncture. The knee-chest position is not appropriate for a lumbar puncture. An infant can be placed in a sitting position with the infant facing the nurse and the head steadied against the nurses body. A side-lying position with the head of the bed elevated is not appropriate for a lumbar puncture.

11. A mother reports that her child has episodes in which he appears to be staring into space.

This behavior is characteristic of which type of seizure? a. Absence b. Atonic c. Tonic-clonic d. Simple partial ANS: A Absence seizures are very brief episodes of altered awareness. The child has a blank expression.

Atonic seizures cause an abrupt loss of postural tone, loss of consciousness, confusion, lethargy, and sleep. Tonic-clonic seizures involve sustained generalized muscle contractions followed by alternating contraction and relaxation of major muscle groups. There is no change in level of consciousness with simple partial seizures. Simple partial seizures consist of motor, autonomic, or sensory symptoms.

12. What is the best response to a father who tells the nurse that his son daydreams at home and his teacher has observed this behavior at school? a. Your son must have an active imagination. b.

Can you tell me exactly how many times this occurs in one day?

c.

Tell me about your sons activity when you notice the daydreams.

d. He is probably getting tired and needs a rest.

ANS: C The daydream episodes are suggestive of absence seizures and data about activity associated with the daydreams should be obtained. Suggesting that the child has an active imagination does not address the childs symptoms or the fathers concern. The number of times the behavior occurs is consistent with absence seizures, which can occur one after the other several times a day.

Determining an exact number of absence seizures is not as useful as learning about behavior before the seizure that might have precipitated seizure activity. Blaming the seizures on rest ignores both the childs symptoms and the fathers concern about the daydreaming behavior.

13. The nurse teaches parents to alert their healthcare provider about which adverse effect when a child receives valproic acid (Depakene) to control generalized seizures? a. Weight loss b. Bruising c. Anorexia

d. Drowsiness ANS: B Thrombocytopenia is an adverse effect of valproic acid. Parents should be alert for any unusual bruising or bleeding. Weight gain, not loss or anorexia, is a side effect of valproic acid.

Drowsiness is not a side effect of valproic acid, although it is associated with other anticonvulsant medications.

14. A child with a head injury sleeps unless aroused, and when aroused responds briefly before falling back to sleep. Which term corresponds to this childs level of consciousness? a. Disoriented b. Obtunded c. Lethargic d. Stuporous ANS: B Obtunded describes an individual who sleeps unless aroused and once aroused has limited interaction with the environment. Disoriented refers to the lack of ability to recognize place or person. An individual is lethargic when he or she awakens easily but exhibits limited responsiveness. Stupor refers to requiring considerable stimulation to arouse the individual.

15. What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic-clonic seizure? a. Guide the child to the floor if he is standing and go for help. b. Turn the childs body on his side. c. Place a padded tongue blade between the teeth. d. Quickly slip soft restraints on the childs wrists.

ANS: B Positioning the child on his side will prevent aspiration. The child should be placed on a soft surface if he is not in bed; however, it would be inappropriate to leave the child during the seizure. Nothing should be inserted into the childs mouth during a seizure to prevent injury to the

mouth, gums, or teeth. Restraints could cause injury. Sharp objects and furniture should be moved out of the way to prevent injury.

16. After a tonic-clonic seizure, it would not be unusual for a child to display which symptom? a. Irritability and hunger b. Lethargy and confusion c. Nausea and vomiting d. Nervousness and excitability ANS: B In the period after a tonic-clonic seizure, the child may be confused and lethargic. Some children may sleep for a period of time. Neither irritability nor hunger is typical of the period after a tonic-clonic seizure. Nausea and vomiting are not expected reactions in the postictal period. The child will more likely be confused and lethargic after a tonic-clonic seizure.

17. What should the nurse teach parents when the child is taking phenytoin (Dilantin) to control seizures? a. The child should use a soft toothbrush and floss his teeth after every meal. b. The child will require monitoring of his liver function while taking this medication. c. Dilantin should be taken with food because it causes gastrointestinal distress. d. The medication can be stopped when the child has been seizure free for 1 month.

ANS: A A side effect of Dilantin is gingival hyperplasia. Good oral hygiene will minimize this adverse effect. The child receiving Depakene (valproic acid) should have liver function studies because this anticonvulsant may cause hepatic dysfunction. Dilantin has not been found to cause gastrointestinal upset. The medication can be taken without food. Anticonvulsants should never be stopped suddenly or without consulting the physician. Such action could result in seizure activity.

18. What is the most appropriate nursing response to the father of a newborn infant with myelomeningocele who asks about the cause of this condition? a. One of the parents carries a defective gene that causes myelomeningocele. b. A deficiency in folic acid in the father is the most likely cause. c. Offspring of parents who have a spinal abnormality are at greater risk for myelomeningocele. d. There may be no definitive cause identified.

ANS: D The etiology of most neural tube defects is unknown in most cases. There may be a genetic predisposition or a viral origin, and the disorder has been linked to maternal folic acid deficiency; however, the actual cause has not been determined. The exact cause of most cases of neural tube defects is unknown. There may be a genetic predisposition, but no pattern has been identified. Folic acid deficiency in the mother has been linked to neural tube defect. There is no evidence that children who have parents with spinal problems are at greater risk for neural tube defects.

19. Which assessment noted in an infant 1 day after placement of a ventriculoperitoneal shunt is indicative of surgical complications? a. Hypoactive bowel sounds b. Congestion in upper airways c. Increasing lethargy d. Mild incisional pain ANS: C A decreasing level of consciousness indicates a problem with shunt function and should be reported immediately to the neurosurgeon. Peristalsis is depressed during surgery. Hypoactive bowel sounds may be evident after surgery as peristalsis returns to its preoperative function.

Congestion in the upper airways may be evident after surgery. Mild incisional pain is a normal finding in the postoperative period.

20. Which change in vital signs should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury? a. Rapid, shallow breathing b. Irregular, rapid heart rate c. Increased diastolic pressure with narrowing pulse pressure d. Confusion and altered mental status ANS: D The child with a head injury may have confusion and altered mental status, a change in vital signs, retinal hemorrhage, hemiparesis, and papilledema. Respiratory changes occur with increased intracranial pressure. One pattern that may be evident is Cheyne-Stokes respiration.

This pattern of breathing is characterized by an increasing rate and depth, then a decreasing rate and depth, with a pause of variable length. Temperature elevation may occur in children with increased intracranial pressure. Changes in blood pressure occur, but the diastolic pressure does not increase, nor is there a narrowing of pulse pressure.

21. The nurse should expect a child who has frequent tension-type headaches to describe his headache pain with which statement? a. There is a rubber band squeezing my head. b. Its a throbbing pain over my left eye. c. My headaches are worse in the morning and get better later in the day. d. I have a stomachache and a headache at the same time.

ANS: A The child who has tension-type headaches may describe the pain as a band-like tightness or pressure, tight neck muscles, or soreness in the scalp. A common symptom of migraines is

throbbing headache pain, typically on one side of the eye. A headache that is worse in the morning and improves throughout the course of the day is typical of increased intracranial pressure. Abdominal pain may accompany headache pain in migraines.

22. A nurse is performing a Glasgow Coma Scale assessment. Which assessment should the nurse not include? a. Eye opening b. Verbal response c. Sensory response d. Motor response ANS: C Sensation is not a component of the Glasgow Coma Scale. The nurse would assess eye opening, verbal response, and motor response.

23. Which statement made by an adolescent indicates an understanding about factors that can trigger migraine headaches? a. I should avoid loud noises because this is a common migraine trigger. b. Exercise can cause a migraine. I guess I wont have to take gym anymore. c. I think Ill get a migraine if I go to bed at 9 PM on week nights. d. I am learning to relax because I get headaches when I am worried about stuff.

ANS: D Stress can trigger migraines. Relaxation therapy can help the adolescent control stress and headaches. Other precipitating factors in addition to stress include poor diet, food sensitivities, and flashing lights. Visual stimuli, not auditory stimuli, are known to be a common trigger for migraines. Exercise is not a trigger for migraines. The adolescent needs regular physical exercise. Altered sleep patterns and fatigue are common triggers for migraine headaches. Going to bed at 9 PM should allow an adolescent plenty of sleep to prevent fatigue.

24. What is the priority nursing intervention for the child with ascending paralysis as a result of Guillain-Barr syndrome (GBS)? a. Immunosuppressive medications b. Respiratory assessment c. Passive range-of-motion exercises d. Anticoagulant therapy ANS: B Special attention to respiratory status is needed because most deaths from GBS are attributed to respiratory failure. Respiratory support is necessary if the respiratory system becomes compromised and muscles weaken and become flaccid. Children with rapidly progressing paralysis are treated with intravenous immunoglobulins for several days. Administering this infusion is not the nursing priority. The child with GBS is at risk for complications of immobility. Performing passive range-of-motion exercises is an appropriate nursing intervention, but not the priority intervention. Anticoagulant therapy may be initiated because the risk of pulmonary embolus as a result of deep vein thrombosis is always a threat. This would not be the priority nursing intervention.

25. A child is brought to the emergency department in generalized tonic-clonic status epilepticus.

Which medication should the nurse expect to be given initially in this situation? a. Clorazepate dipotassium (Tranxene) b. Fosphenytoin (Cerebyx) c. Phenobarbital d. Lorazepam (Ativan) ANS: D Lorazepam or diazepam is given intravenously to control generalized tonic-clonic status epilepticus and may also be used for seizures lasting more than 5 minutes. Clorazepate

dipotassium (Tranxene) is indicated for cluster seizures. It can be given orally. Fosphenytoin and phenobarbital can be given intravenously as a second round of medication if seizures continue.

26. What should be the nurses first action when a child with a head injury complains of double vision and a headache and then vomits? a. Immobilize the childs neck. b. Report this information to the physician. c. Darken the room and put a cool cloth on the childs forehead. d. Restrict the childs oral fluid intake.

ANS: B Any indication of increased intracranial pressure should be promptly reported to the physician.

Stabilizing the childs neck does not address the childs symptoms. Darkening the room and putting a cool cloth on the childs forehead may facilitate the childs comfort. It would not be the nurses first action. The childs episode of vomiting does not necessitate a fluid restriction.

MULTIPLE RESPONSE 1. Which interventions should the nurse perform if a child is having a tonic-clonic seizure?

Select all that apply. a. Place a padded tongue blade in the childs mouth. b. Place the child in a supine position. c. Time the seizure. d.

Restrain the child. e.

Stay with the child. f.

Loosen the childs clothing.

ANS: C, E, F

As a seizure begins the nurse should look at his or her watch and time the seizure. The nurse should protect the child from injury by loosening clothing at the neck and turning the child gently onto the side, removing any obstacles in the childs environment. Do not restrain the child or insert any object into the childs mouth.