Pediatric Primary Care 4th Edition Richardson Testbank/StudyGuide Chapter 1 Obtaining an Initial History MULTIPLE CHOICE 1. The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first? a. Introduce him- or herself. b.
Make the family comfortable.
c.
Give assurance of privacy.
d. Explain the purpose of the interview. ANS: A The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. Clarification of the purpose of the interview and the nurses role is the second thing that should be done. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. The interview also should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality. 2. Which is considered a block to effective communication? a. Using silence b.
Using clichs
c.
Directing the focus
d. Defining the problem ANS: B Using stereotyped comments or clichs can block effective communication. After the nurse uses such trite phrases, parents often do not respond. Silence can be an effective interviewing tool. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. To be effective, the nurse must be able to direct the focus of the interview while allowing maximum freedom of expression. By using open-ended questions and guiding questions, the nurse can obtain the necessary information and maintain a relationship with the family. The nurse and parent must collaborate and define the problem that will be the focus of the nursing intervention. 3. Which is the single most important factor to consider when communicating with children? a. Presence of the childs parent b.
Childs physical condition
c.
Childs developmental level
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d. Childs nonverbal behaviors ANS: C The nurse must be aware of the childs developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Nonverbal behaviors vary in importance based on the childs developmental level and physical condition. Although the childs physical condition is a consideration, developmental level is much more important. The presence of parents is important when communicating with young children but may be detrimental when speaking with adolescents. 4. Because children younger than 5 years are egocentric, the nurse should do which when communicating with them? a. Focus communication on the child. b.
Use easy analogies when possible.
c.
Explain experiences of others to the child.
d. Assure the child that communication is private. ANS: A Because children of this age are able to see things only in terms of themselves, the best approach is to focus communication directly on them. Children should be provided with information about what they can do and how they will feel. With children who are egocentric, analogies, experiences, and assurances that communication is private will not be effective because the child is not capable of understanding. 5. The nurses approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle? a. The child may think the equipment is alive. b.
Explaining the equipment will only increase the childs fear.
c.
One brief explanation will be enough to reduce the childs fear.
d. The child is too young to understand what the equipment does. ANS: A Young children attribute human characteristics to inanimate objects. They often fear that the objects may jump, bite, cut, or pinch all by themselves without human direction. Equipment should be kept out of sight until needed. Simple, concrete explanations about what the equipment does and how it will feel will help alleviate the childs fear. Preschoolers need repeated explanations as reassurance. 6. When the nurse interviews an adolescent, which is especially important? a. Focus the discussion on the peer group. b.
Allow an opportunity to express feelings.
c.
Use the same type of language as the adolescent.
d. Emphasize that confidentiality will always be maintained. ANS: B Adolescents, like all children, need opportunities to express their feelings. Often they interject feelings into their words. The nurse must be alert to the words and feelings expressed. The nurse
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should maintain a professional relationship with adolescents. To avoid misunderstanding or misinterpretation of words and phrases used, the nurse should clarify the terms used, what information will be shared with other members of the health care team, and any limits to confidentiality. Although the peer group is important to this age group, the interview should focus on the adolescent. 7. The nurse is preparing to assess a 10-month-old infant. He is sitting on his fathers lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate? a. Initiate a game of peek-a-boo. b.
Ask the infants father to place the infant on the examination table.
c.
Talk softly to the infant while taking him from his father.
d. Undress the infant while he is still sitting on his fathers lap. ANS: A Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done with the child on the fathers lap. The nurse should have the father undress the child as needed during the examination. 8. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which? a. Ask her why she wants to know. b.
Determine why she is so anxious.
c.
Explain in simple terms how it works.
d. Tell her she will see how it works as it is used. ANS: C School-age children require explanations and reasons for everything. They are interested in the functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child so that the child can then observe during the procedure. The nurse should respond positively for requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child. The child is not exhibiting anxiety in asking how the blood pressure apparatus works, just requesting clarification of what will occur. 9. The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which technique should be most helpful? a. Recommend that the child keep a diary. b.
Provide supplies for the child to draw a picture.
c.
Suggest that the parent read fairy tales to the child.
d. Ask the parent if the child is always uncommunicative. ANS: B Drawing is one of the most valuable forms of communication. Childrens drawings tell a great deal about them because they are projections of the childrens inner self. A diary should be difficult for a 6-year-old child, who is most likely learning to read. The parent reading fairy tales to the child is a passive activity involving the parent and child; it should not facilitate
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communication with the nurse. The child is in a stressful situation and is probably uncomfortable with strangers, not always uncommunicative. 10. Which data should be included in a health history? a. Review of systems b.
Physical assessment
c.
Growth measurements
d. Record of vital signs ANS: A A review of systems is done to elicit information concerning any potential health problems. This further guides the interview process. Physical assessment, growth measurements, and a record of vital signs are components of the physical examination. 11. The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined? a. Request a detailed listing of symptoms. b.
Ask the adolescent, Why did you come here today?
c.
Interview the parent away from the adolescent to determine the chief complaint.
d. Use what the adolescent says to determine, in correct medical terminology, what the problem is. ANS: B The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. Requesting a detailed list of symptoms makes it difficult to determine the chief complaint. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help. 12. The nurse is interviewing the mother of an infant. The mother reports, I had a difficult delivery, and my baby was born prematurely. This information should be recorded under which heading? a. History b.
Present illness
c.
Chief complaint
d. Review of systems ANS: A The history refers to information that relates to previous aspects of the childs health, not to the current problem. The difficult delivery and prematurity are important parts of the infants history. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of the present illness. The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. It should not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth but might include sequelae such as pulmonary dysfunction. 13. Where in the health history does a record of immunizations belong?
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a.
History
b.
Present illness
c.
Review of systems
d. Physical assessment ANS: A The history contains information relating to all previous aspects of the childs health status. The immunizations are appropriately included in the history. The present illness, review of systems, and physical assessment are not appropriate places to record the immunization status. 14. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active? a. Ask her, Are you sexually active? b.
Ask her, Are you having sex with anyone?
c.
Ask her, Are you having sex with a boyfriend?
d. Ask both the girl and her parent if she is sexually active. ANS: B Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information for the nurse to provide necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend. Using gender-neutral terms is inclusive and conveys acceptance to the adolescent. Questioning about sexual activity should occur when the adolescent is alone. 15. When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which? a. Lacking in protein b.
Indicating they live in poverty
c.
Providing sufficient amino acids
d. Needing enrichment with meat and milk ANS: C A diet that contains vegetables, legumes, and starches may provide sufficient essential amino acids even though the actual amount of meat or dairy protein is low. Combinations of foods contain the essential amino acids necessary for growth. Many cultures use diets that contain this combination of foods. It is not indicative of poverty. A dietary assessment should be done, but many vegetarian diets are sufficient for growth. 16. Which parameter correlates best with measurements of total muscle mass? a. Height b.
Weight
c.
Skinfold thickness
d. Upper arm circumference ANS: D
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Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the bodys major protein reserve and is considered an index of the bodys protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skinfold thickness is a measurement of the bodys fat content. 17. The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which? a. Appropriate because of childs age b.
Appropriate, but the mother may be uncomfortable
c.
Inappropriate because of childs age
d. Inappropriate because child is same sex as mother ANS: A It is appropriate to give older school-age children the option of having the parent present or not. During the examination, the nurse should respect the childs need for privacy. Children who are 10 years old are minors, and parents are responsible for health care decisions. The mother of a 10-year-old child would not be uncomfortable. The child should help determine who is present during the examination. 18. With the National Center for Health Statistics criteria, which body mass index (BMI)for-age percentiles should indicate the patient is at risk for being overweight? a. 10th percentile b.
75th percentile
c.
85th percentile
d. 95th percentile ANS: C Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children who are greater than or equal to the 95th percentile are considered overweight. Children whose BMI is between the 10th and 75th percentiles are within normal limits. 19. Rectal temperatures are indicated in which situation? a. In the newborn period b.
Whenever accuracy is essential
c.
Rectal temperatures are never indicated
d. When rapid temperature changes are occurring ANS: B Rectal temperatures are recommended when definitive measurements are necessary in infants older than age 1 month. Rectal temperatures are not done in the newborn period to avoid trauma to the rectal mucosa. Rectal temperature is an intrusive procedure that should be avoided whenever possible. 20. What is the earliest age at which a satisfactory radial pulse can be taken in children? a. 1 year b.
2 years
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c.
3 years
d. 6 years ANS: B Satisfactory radial pulses can be taken in children older than 2 years. In infants and young children, the apical pulse is more reliable. 21. The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which? a. Use the small cuff. b.
Use the large cuff.
c.
Use either cuff using the palpation method.
d. Wait to take the blood pressure until a proper cuff can be located. ANS: B If blood pressure measurement is indicated and the appropriate size cuff is not available, the next larger size is used. The nurse recognizes that this may be a falsely low blood pressure. Using the small cuff will give an incorrectly high reading. The palpation method will not improve the inaccuracy inherent in the cuff. 22. Where is the best place to observe for the presence of petechiae in dark-skinned individuals? a. Face b.
Buttocks
c.
Oral mucosa
d. Palms and soles ANS: C Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark-skinned individuals unless they are in the mouth or conjunctiva. 23. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action? a. Recheck head control at next visit. b.
Teach the parents appropriate exercises.
c.
Schedule the child for further evaluation.
d. Refer the child for further evaluation if the anterior fontanel is still open. ANS: C Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Head control is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated. 24. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the childs head (opisthotonos) with pain on flexion. Which is the most appropriate action? a. Ask the parent when the neck was injured. b.
Refer for immediate medical evaluation.
c.
Continue assessment to determine the cause of the neck pain.
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d. Record head lag on the assessment record and continue the assessment of the child. ANS: B Hyperextension of the childs head with pain on flexion is indicative of meningeal irritation and needs immediate evaluation. No indication of injury is present. This situation is not descriptive of head lag. 25. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which? a. A normal finding b.
A sign of a possible visual defect and a need for vision screening
c.
An abnormal finding requiring referral to an ophthalmologist
d. A sign of small hemorrhages, which usually resolve spontaneously ANS: A A brilliant, uniform red reflex is an important normal finding. It rules out many serious defects of the cornea, aqueous chamber, lens, and vitreous chamber. 26. Which explains the importance of detecting strabismus in young children? a. Color vision deficit may result. b.
Amblyopia, a type of blindness, may result.
c.
Epicanthal folds may develop in the affected eye.
d. Corneal light reflexes may fall symmetrically within each pupil. ANS: B By the age of 3 to 4 months, infants are able to fixate on one visual field with both eyes simultaneously. In strabismus, or cross-eye, one eye deviates from the point of fixation. If misalignment is constant, the weak eye becomes lazy, and the brain eventually suppresses the image produced from that eye. If strabismus is not detected and corrected by age 4 to 6 years, blindness from disuse, known as amblyopia, may occur. Color vision is not the only concern. Epicanthal folds are not related to amblyopia. In children with strabismus, the corneal light reflex will not be symmetric for each eye. 27. Which is the most frequently used test for measuring visual acuity? a. Snellen letter chart b.
Ishihara vision test
c.
Allen picture card test
d. Denver eye screening test ANS: A The Snellen letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity. The Ishihara Vision Test is used for color vision. The Allen picture card test and Denver eye screening test involve single cards for children ages 2 years and older who are unable to use the Snellen letter chart. 28. The nurse is testing an infants visual acuity. By which age should the infant be able to fix on and follow a target? a. 1 month
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b.
1 to 2 months
c.
3 to 4 months
d. 6 months ANS: C Visual fixation and ability to follow a target should be present by ages 3 to 4 months. One to 2 months is too young for this developmental milestone. If an infant is not able to fix and follow by 6 months, further ophthalmologic evaluation is needed. 29. During an otoscopic examination on an infant, in which direction is the pinna pulled? a. Up and back b.
Up and forward
c.
Down and back
d. Down and forward ANS: C In infants and toddlers, the ear canal is curved upward. To visualize the ear canal, it is necessary to pull the pinna down and back to the 6 to 9 oclock range to straighten the canal. In children older than age 3 years and adults, the canal curves downward and forward. The pinna is pulled up and back to the 10 oclock position. Up and forward and down and forward are positions that do not facilitate visualization of the ear canal.
Chapter 2 Obtaining an Interval History 1. What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?
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a.
Rinne test
b.
Weber test
c.
Pure tone audiometry
d. Eliciting the startle reflex ANS: C Pure tone audiometry uses an audiometer that produces sounds at different volumes and pitches in the childs ears. The child is asked to respond in some way when the tone is heard in the earphone. The Rinne and Weber tests measure bone conduction of sound. Eliciting the startle reflex may be useful in infants. 2. What is the appropriate placement of a tongue blade for assessment of the mouth and throat? a. On the lower jaw b.
Side of the tongue
c.
Against the soft palate
d. Center back area of the tongue ANS: B The side of the tongue is the correct position. It avoids the gag reflex yet allows visualization. On the lower jaw and against the soft palate are not appropriate places for the tongue blade. Placement in the center back area of the tongue elicits the gag reflex. 3. When assessing a preschoolers chest, what should the nurse expect? a. Respiratory movements to be chiefly thoracic b.
Anteroposterior diameter to be equal to the transverse diameter
c.
Retraction of the muscles between the ribs on respiratory movement
d. Movement of the chest wall to be symmetric bilaterally and coordinated with breathing ANS: D Movement of the chest wall should be symmetric bilaterally and coordinated with breathing. In children younger than 6 or 7 years, respiratory movement is principally abdominal or diaphragmatic. The anteroposterior diameter is equal to the transverse diameter during infancy. As the child grows, the chest increases in the transverse direction, so that the anteroposterior diameter is less than the lateral diameter. Retractions of the muscles between the ribs on respiratory movement are indicative of respiratory distress. 4. When auscultating an infants lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as? a. Suggestive of chronic pulmonary disease b.
Suggestive of impending respiratory failure
c.
An abnormal finding warranting investigation
d. A normal finding in infants younger than 1 year of age ANS: C Absent or diminished breath sounds are always an abnormal finding. Fluid, air, or solid masses in the pleural space all interfere with the conduction of breath sounds. Further data are necessary for diagnosis of chronic pulmonary disease or impending respiratory failure. Diminished breath
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sounds in certain segments of the lungs can alert the nurse to pulmonary areas that may benefit from chest physiotherapy. Further evaluation is needed in all age groups. 5. Which type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium? a. Vesicular b.
Bronchial
c.
Adventitious
d. Bronchovesicular ANS: A This is the definition of vesicular breath sounds. They are heard over the entire surface of the lungs, with the exception of the upper intrascapular area and the area beneath the manubrium. Bronchial breath sounds are heard only over the trachea near the suprasternal notch. Adventitious breath sounds are not usually heard over the chest. These sounds occur in addition to normal or abnormal breath sounds. Bronchovesicular breath sounds are heard over the manubrium and in the upper intrascapular regions, where the trachea and bronchi bifurcate. 6. The nurse is assessing a childs capillary refill time. This can be accomplished by doing what? a. Inspect the chest. b.
Auscultate the heart.
c.
Palpate the apical pulse.
d. Palpate the nail bed with pressure to produce a slight blanching. ANS: D Capillary refill time is assessed by pressing lightly on the skin to produce blanching and then noting the amount of time it takes for the blanched area to refill. Inspecting the chest, auscultating the heart, and palpating the apical pulse will not provide an assessment of capillary refill time. 7. Which heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood? a. S1 and S2 b.
S3 and S4
c.
Murmur
d. Physiologic splitting ANS: C Murmurs are the sounds that are produced in the heart chambers or major arteries from the backand-forth flow of blood. S1 and S2 are normal heart sounds. S1 is the closure of the tricuspid and mitral valves, and S2 is the closure of the pulmonic and aortic valves. S3 is a normal heart sound sometimes heard in children. S4 is rarely heard as a normal heart sound. If it is heard, medical evaluation is required. Physiologic splitting is the distinction of the two sounds in S2, which widens on inspiration. It is a significant normal finding. 8. Examination of the abdomen is performed correctly by the nurse in which order? a. Inspection, palpation, percussion, and auscultation
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b.
Inspection, percussion, auscultation, and palpation
c.
Palpation, percussion, auscultation, and inspection
d. Inspection, auscultation, percussion, and palpation ANS: D The correct order of abdominal examination is inspection, auscultation, percussion, and palpation. Palpation is always performed last because it may distort the normal abdominal sounds. Auscultation is performed before percussion. The act of percussion can influence the findings on auscultation. 9. Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation? a. Palpate another area simultaneously. b.
Ask the child not to laugh or move if it tickles.
c.
Begin with deeper palpation and gradually progress to superficial palpation.
d. Have the child help with palpation by placing his or her hand over the palpating hand. ANS: D Having the child help with palpation by placing his or her hand over the palpating hand will help minimize the feeling of tickling and enlist the childs cooperation. Palpating another area simultaneously will create the sensation of tickling in the other area also. Asking the child not to laugh or move will bring attention to the tickling and make it more difficult for the child. Superficial palpation is done before deep palpation. 10. During examination of a toddlers extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is which? a. Abnormal and requires further investigation b.
Abnormal unless it occurs in conjunction with knock-knee
c.
Normal if the condition is unilateral or asymmetric
d. Normal because the lower back and leg muscles are not yet well developed ANS: D Lateral bowing of the tibia (bowlegged) is an expected finding in toddlers when they begin to walk. It usually persists until all of their lower back and leg muscles are well developed. Further evaluation is needed if it persists beyond ages 2 to 3 years, especially in African American children. 11. The nurse is caring for a nonEnglish-speaking child and family. Which should the nurse consider when using an interpreter? a. Pose several questions at a time. b.
Use medical jargon when possible.
c.
Communicate directly with family members when asking questions.
d. Carry on some communication in English with the interpreter about the familys needs. ANS: C
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When using an interpreter, the nurse should communicate directly with family members when asking questions to reinforce interest in them and to observe nonverbal expressions. Questions should be posed one at a time to elicit only one answer at a time. Medical jargon should be avoided whenever possible. The nurse should avoid discussing the familys needs with the interpreter in English because some family members may understand some English. 12. Which action should the nurse implement when taking an axillary temperature? a. Take the temperature through one layer of clothing. b.
Add a degree to the result when recording the temperature.
c.
Place the tip of the thermometer under the arm in the center of the axilla.
d. Hold the childs arm away from the body while taking the temperature. ANS: C The thermometer tip should be placed under the arm in the center of the axilla and kept close to the skin, not clothing. The temperature should not be taken through any clothing. The childs arm should be pressed firmly against the side, not held away from the body. The temperature should be recorded without a degree added and designated as being taken by the axillary method. 13. The nurse is aware that skin turgor best estimates what? a. Perfusion b.
Adequate hydration
c.
Amount of body fat
d. Amount of anemia ANS: B Skin turgor is one of the best estimates of adequate hydration and nutrition. It does not indicate amount of body fat and is not a test for anemia. 14. The Asian parent of a child being seen in the clinic avoids eye contact with the nurse. What is the best explanation for this considering cultural differences? a. The parent feels inferior to the nurse. b.
The parent is showing respect for the nurse.
c.
The parent is embarrassed to seek health care.
d. The parent feels responsible for her childs illness. ANS: B In some ethnic groups, eye contact is avoided. In the Vietnamese culture, an individual may not look directly into the nurses eyes as a sign of respect. The nurse providing culturally competent care would recognize that the other answers listed are not why the parent avoids eye contact with the nurse. 15. The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect?(Select all that apply.) a. Ashen gray areas b.
A well-defined light reflex
c.
A small, round, concave spot near the center of the drum
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d.
The tympanic membrane is a nontransparent grayish color
e. A whitish line extending from the umbo upward to the margin of the membrane ANS: B, C, E Normal findings include the light reflex and bony landmarks. The light reflex is a fairly welldefined, cone-shaped reflection that normally points away from the face. The bony landmarks of the eardrum are formed by the umbo, or tip of the malleus. It appears as a small, round, opaque, concave spot near the center of the eardrum. The manubrium (long process or handle) of the malleus appears to be a whitish line extending from the umbo upward to the margin of the membrane. The tympanic membrane should be light pearly pink or gray and translucent, not nontransparent. Ashen gray areas indicate signs of scarring from a previous perforation. 16. The nurse is assessing breath sounds on a child. Which are expected auscultated breath sounds? (Select all that apply.) a. Wheezes b.
Crackles
c.
Vesicular
d.
Bronchial
e. Bronchovesicular ANS: C, D, E Normal breath sounds are classified as vesicular, bronchovesicular, or bronchial. Wheezes or crackles are abnormal or adventitious sounds. 17. The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.) a. Lightly brush the palate with a cotton swab. b.
Perform the examination in front of a mirror.
c.
Let the child examine someone elses mouth first.
d.
Have the child breathe deeply and hold his or her breath.
e. Use a tongue blade to help the child open his or her mouth. ANS: A, B, C, D To encourage a child to open the mouth for examination, the nurse can lightly brush the palate with a cotton swab, perform the examination in front of a mirror, let the child examine someone elses mouth first, and have the child breathe deeply and hold his or her breath. A tongue blade may elicit the gag reflex and should not be used. 18. Which are effective auscultation techniques? (Select all that apply.) a. Ask the child to breathe shallowly. b.
Apply light pressure on the chest piece.
c.
Use a symmetric and orderly approach.
d.
Place the stethoscope over one layer of clothing.
e. Warm the stethoscope before placing it on the skin. ANS: C, E
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Effective auscultation techniques include using a symmetric approach and warming the stethoscope before placing it on the skin. Breath sounds are best heard if the child inspires deeply, not shallowly. Firm, not light, pressure should be used on the chest piece. The stethoscope should be placed on the skin, not over clothing. 19. The nurse is assessing heart sounds on a school-age child. Which should the nurse document as abnormal findings if found on the assessment? (Select all that apply.) a. S4 heart sound b.
S3 heart sound
c.
Grade II murmur
d.
S1 louder at the apex of the heart
e. S2 louder than S1 in the aortic area ANS: A, C, E S4 is rarely heard as a normal heart sound; it usually indicates the need for further cardiac evaluation. A grade II murmur is not normal; it is slightly louder than grade I and is audible in all positions. S3 is normally heard in some children. Normally, S1 is louder at the apex of the heart in the mitral and tricuspid area, and S2 is louder near the base of the heart in the pulmonic and aortic area. 20. The nurse understands that blocks to therapeutic communication include what? (Select all that apply.) a. Socializing b.
Use of silence
c.
Using clichs
d.
Defending a situation
e. Using open-ended questions ANS: A, C, D Blocks to communication include socializing, using clichs, and defending a situation. Use of silence and using open-ended questions are therapeutic communication techniques.
Chapter 3 Performing a Physical Examination Question 1 Type: MCSA
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The nurse is taking a health history from a family of a 3-year-old child. Which statement by the nurse would most likely establish rapport and elicit an accurate response from the family? 1. Does any member of your family have a history of asthma, heart disease, or diabetes? 2. Hello, I would like to talk with you and get some information on you and your child. 3. Tell me about the concerns that brought you to the clinic today. 4. You will need to fill out these forms; make sure that the information is as complete as possible. Correct Answer: 3 Global Rationale: Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parents perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview. Question 2 Type: MCSA When assessing the cognitive development, which technique would be appropriate to test the remote memory of a 5-year-old? 1. Say the name of an object and after 5 minutes ask the child to tell you what you said the object was. 2. Ask the child to repeat his address. 3. Ask the child to say a poem and listen to the childs speech articulation. 4. Have the child point to various parts of the body as you name them. Correct Answer: 2 Global Rationale: Repeating the name of an object after 510 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills. Question 3 Type: SEQ Place the nursing assessments of a toddler in the best order. Standard Text: Click and drag the options below to move them up or down. Choice 1. Examination of eyes, ears, and throat Choice 2. Auscultation of chest Choice 3. Palpation of abdomen Choice 4. Developmental assessment Correct Answer: 4,2,3,1 Global Rationale: In examining a toddler, it is usually best to go from least invasive to most invasive examination in order to build her trust and cooperation. Developmental assessment involves visual inspection and activities that the toddler may view as games and will likely cooperate with. Auscultation is usually less threatening to the toddler than palpation, especially if
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the nurse were to use the stethoscope on a parent or a toy. The most uncomfortable, invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat, so that should be performed last. Question 4 Type: MCSA While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system should the nurse further evaluate to determine an ongoing disease process? 1. Cardiac 2. Respiratory 3. Gastrointestinal 4. Genitourinary Correct Answer: 3 Global Rationale: This infants sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system. Question 5 Type: MCSA A nurse caring for a school-age client notices some swelling in the childs ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure and notices a markedly slow disappearance of the indentation. Which priority nursing assessment is appropriate? 1. Skin integrity, especially in the lower extremities 2. Urine output 3. Level of consciousness 4. Range of motion and ankle mobility Correct Answer: 2 Global Rationale: Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important. Question 6 Type: MCSA A new mother is worried about a soft spot on the top of her newborn infants head. The nurse informs her that this is a normal physical finding called the anterior fontanel. At what age will the nurse educate the mother that the soft spot will close? 1. 2 to 3 months of age 2. 6 to 9 months of age 3. 12 to 18 months of age
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4. Approximately 2 years of age Correct Answer: 3 Global Rationale: The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age. Question 7 Type: MCSA While inspecting a 5-year-old childs ears, the nurse notes that the right pinna protrudes outward and that there is a mass behind the right ear. In light of these findings, which vital-sign parameter would the nurse assess on priority? 1. Temperature 2. Heart rate 3. Respirations 4. Blood pressure Correct Answer: 1 Global Rationale: Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vitalsign parameters, but they would not be specific for the presence of infection. Question 8 Type: MCMA A 7-year-old child presents to the clinic with an exacerbation of asthma symptoms. On physical examination, the nurse would expect which assessment findings? Standard Text: Select all that apply. 1. Wheezing 2. Increased tactile fremitus 3. Decreased vocal resonance 4. Decreased tactile fremitus 5. Bronchophony Correct Answer: 1,3,4 Global Rationale: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance. Question 9 Type: MCSA The nurse is caring for a newly-admitted infant diagnosed with failure to thrive. The nurse begins to implement the healthcare provider prescribed orders by taking blood pressures in all four extremities. Which congenital cardiac defect does the nurse anticipate based on the prescribed order? 1. Tetralogy of Fallot 2. Pulmonary atresia
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3. Coarctation of the aorta 4. Ventricular septal defect Correct Answer: 3 Rationale 1: Normally, blood pressures in the lower extremities are the same as or higher Global Rationale: Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect. Question 10 Type: MCSA During an examination, a nurse asks a 5-year-old child to repeat his address. What is the nurse evaluating with this action? 1. Recent memory 2. Language development 3. Remote memory 4. Social-skill development Correct Answer: 3 Global Rationale: Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the childs language development, and assessing how he interacts with others evaluates social-skill development. Question 11 Type: MCSA During the newborn examination, the nurse assesses the infant for signs of developmental dysplasia of the hip. A finding that would strongly indicate this disorder would be: 1. soles are flat with prominent fat pads. 2. positive Babinski reflex. 3. metatarsus varus. 4. asymmetric thigh and gluteal folds. Correct Answer: 4 Rationale 1: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound. Rationale 2: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound.
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Rationale 3: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound. Rationale 4: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound. Question 12 Type: MCSA The nurse must assess each of the 2-year-olds listed below. Which one should be evaluated first? 1. A child with a temperature of 101 degrees F 2. A child who has stridor 3. A child who has absent Babinski sign 4. A child who has a pot belly appearance Correct Answer: 2 Global Rationale: A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinski sign and the pot-bellied child are normal. Question 13 Type: MCSA The nurse notes a history of a grade III heart murmur in a small infant. When assessing the heart, the nurse would expect to: 1. hear a quiet but easily heard murmur. 2. hear a moderately loud murmur without a palpable thrill. 3. hear a very loud murmur with easily palpable thrill. 4. listen without a stethoscope and hear a murmur at chest wall. Correct Answer: 2 Global Rationale: A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI. Question 14 Type: MCSA The nurse is measuring an abdominal girth on a child with abdominal distension. Identify the area on the childs abdomen where the tape measure should be placed for an accurate abdominal girth. 1. Just above the umbilicus, around the largest circumference of the abdomen 2. Below the umbilicus 3. Just below the sternum 4. Just above the pubic bone Correct Answer: 1
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Global Rationale: An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth. Question 15 Type: MCMA The nurse is preparing to assessment a toddler client. Which activities would gain cooperation from the toddler? Standard Text: Select all that apply. 1. Asking the parents to wait outside 2. Allowing the client to sit in the parents lap 3. Administering vaccinations prior to the assessment 4. Handing the client a stethoscope while taking the health history 5. Making a game out of the assessment process Correct Answer: 2,4 Global Rationale: Allowing the client to stay on the parents lap and allowing the client to play with instruments that will be used in the assessment process are activities the nurse can implement to gain the toddlers cooperation during the assessment process. Asking the parents to wait outside may cause the toddler to become fearful. Vaccinations should be administered at the end of the visit. While making a game out of the assessment process may be appropriate for older children, this is not an appropriate strategy for a toddler client. Question 16 Type: MCMA The nurse is assessing an infant client during a health supervision visit. Which assessment findings are considered normal variations for this client? Standard Text: Select all that apply. 1. Sucking pads in the mouth 2. A rounded chest 3. Hearing breath sounds over the entire chest 4. Pubertal development 5. Knock-knees Correct Answer: 1,2,3 Global Rationale: Normal variations for the infant client include sucking pads in the mouth, a rounded chest, and hearing breath sounds over the entire chest. Pubertal development and knockknees are not normal variations for the infant client. Question 17 Type: MCMA The nurse is conducting a health surveillance visit with a 6-month-old infant. Which methods are appropriate to monitor the infants growth pattern since birth? Standard Text: Select all that apply. 1. Weight the infant twice and average together 2. Measure the infants height
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3. Measure the infants head circumference 4. Determine the infants body mass index 5. Plot the infants growth on appropriate chart Correct Answer: 1,3,5 Global Rationale: In order to determine the infants growth pattern the nurse will obtain two weights and average them together, measure the infants head circumference, and obtain the infants length, not height. After the measurements have been obtained the nurse will plot the measurements on the appropriate growth chart and monitor the infants growth pattern. Body mass index is not determined during infancy. 18. A 5-year-old child is in the clinic for a checkup. The nurse would expect him to: a. Need to be held on his mothers lap. b.
Be able to sit on the examination table.
c.
Be able to stand on the floor for the examination.
d. Be able to remain alone in the examination room. ANS: B At 4 or 5 years old, a child usually feels comfortable on the examination table. Older infants and young children aged 6 months to 2 or 3 years should be positioned in the parents lap. 19. Which statement is true regarding the recording of data from the history and physical examination? a. Use long, descriptive sentences to document findings. b.
Record the data as soon as possible after the interview and physical examination.
c.
If the information is not documented, then it can be assumed that it was done as a standard of care.
The examiner should avoid taking any notes during the history and examination d. because of the possibility of decreasing the rapport with the patient. ANS: B The data from the history and physical examination should be recorded as soon after the event as possible. From a legal perspective, if it is not documented, then it was not done. Brief notes should be taken during the examination. When documenting, the nurse should use short, clear phrases and avoid redundant phrases and descriptions. 20. When assessing the neonate, the nurse should test for hip stability with which method? a. Eliciting the Moro reflex b.
Performing the Romberg test
c.
Checking for the Ortolani sign
d. Assessing the stepping reflex ANS: C The nurse should test for hip stability in the neonate by testing for the Ortolani sign. The other tests are not appropriate for testing hip stability. 21. A female patient tells the nurse that she has four children and has had three pregnancies. How should the nurse document this?
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a.
Gravida 3, para 4
b.
Gravida 4, para 3
c.
This information cannot be documented using the terms gravida and para.
d. The patient seems to be confused about how many times she has been pregnant. ANS: A Gravida refers to the number of pregnancies, and para refers to the number of children. One pregnancy was with twins. 22. The nurse is documenting the assessment of an infant. During the abdominal assessment, the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side. This finding would indicate: a. Epigastric hernia. b.
Pyloric obstruction.
c.
Hypoactive bowel sounds.
d. Hyperactive bowel sounds. ANS: D A succussion splash, which is unrelated to peristalsis, is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach as observed with pyloric obstruction or large hiatus hernia 23. Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup? a. Testing for Ortolani sign b.
Assessment for stereognosis
c.
Blood pressure measurement
d. Assessment for the presence of the startle reflex ANS: A Until the age of 12 months, the infant should be assessed for Ortolani sign. If Ortolani sign is present, then it could indicate the presence of a dislocated hip. The other tests are not appropriate for a 9-month-old child.
Chapter 4 Making Newborn Rounds MULTIPLE CHOICE 1. What is a function of brown adipose tissue (BAT) in newborns? a. Generates heat for distribution to other parts of body b.
Provides ready source of calories in the newborn period
c.
Protects newborns from injury during the birth process
d.
Insulates the body against lowered environmental temperature
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ANS: A Brown fat is a unique source of heat for newborns. It has a larger content of mitochondrial cytochromes and a greater capacity for heat production through intensified metabolic activity than does ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of the body by the blood. It is effective only in heat production. Brown fat is located in superficial areas such as between the scapulae, around the neck, in the axillae, and behind the sternum. These areas should not protect the newborn from injury during the birth process. The newborn has a thin layer of subcutaneous fat, which does not provide for conservation of heat. 2. Which characteristic is representative of a full-term newborns gastrointestinal tract? a. Transit time is diminished. b.
Peristaltic waves are relatively slow.
c.
Pancreatic amylase is overproduced.
d. Stomach capacity is very limited. ANS: D Newborns require frequent small feedings because their stomach capacity is very limited. A newborns colon has a relatively small volume and resulting increased bowel movements. Peristaltic waves are rapid. A deficiency of pancreatic lipase limits the absorption of fats. 3. Which term is used to describe a newborns first stool? a. Milia b.
Milk stool
c.
Meconium
d. Transitional ANS: C Meconium is composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood. It is a newborns first stool. Milia involves distended sweat glands that appear as minute vesicles, primarily on the face. Milk stool usually occurs by the fourth day. The appearance varies depending on whether the newborn is breast or formula fed. Transitional stools usually appear by the third day after the beginning of feeding. They are usually greenish brown to yellowish brown, thin, and less sticky than meconium. 4. In term newborns, the first meconium stool should occur no later than within how many hours after birth? a. 6 b.
8
c.
12
d. 24 ANS: D The first meconium stool should occur within the first 24 hours. It may be delayed up to 7 days in very lowbirth-weight newborns. 5. Which is true regarding an infants kidney function? a. Conservation of fluid and electrolytes occurs. b.
Urine has color and odor similar to the urine of adults.
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c.
The ability to concentrate urine is less than that of adults.
d. Normally, urination does not occur until 24 hours after delivery. ANS: C At birth, all structural components are present in the renal system, but there is a functional deficiency in the kidneys ability to concentrate urine and to cope with conditions of fluid and electrolyte stress such as dehydration or a concentrated solute load. Infants urine is colorless and odorless. The first voiding usually occurs within 24 hours of delivery. Newborns void when the bladder is stretched to 15 ml, resulting in about 20 voidings per day. 6. The Apgar score of an infant 5 minutes after birth is 8. Which is the nurses best interpretation of this? a. Resuscitation is likely to be needed. b.
Adjustment to extrauterine life is adequate.
c.
Additional scoring in 5 more minutes is needed.
d. Maternal sedation or analgesia contributed to the low score. ANS: B The Apgar reflects an infants status in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 8 to 10 indicates an absence of difficulty adjusting to extrauterine life. Scores of 0 to 3 indicate severe distress, and scores of 4 to 7 indicate moderate difficulty. All infants are rescored at 5 minutes of life, and a score of 8 is not indicative of distress; the newborn does not have a low score. The Apgar score is not used to determine the infants need for resuscitation at birth. 7. Which statement best represents the first stage or the first period of reactivity in the infant? a. Begins when the newborn awakes from a deep sleep b.
Is an excellent time to acquaint the parents with the newborn
c.
Ends when the amounts of respiratory mucus have decreased
d. Provides time for the mother to recover from the childbirth process ANS: B During the first period of reactivity, the infant is alert, cries vigorously, may suck his or her fist greedily, and appears interested in the environment. The infants eyes are usually wide open, suggesting that this is an excellent opportunity for mother, father, and infant to see each other. The second period of reactivity begins when the infant awakes from a deep sleep and ends when the amounts of respiratory mucus have decreased. The mother should sleep and recover during the second stage, when the infant is sleeping. 8. Which statement reflects accurate information about patterns of sleep and wakefulness in the newborn? a. States of sleep are independent of environmental stimuli. b.
The quiet alert stage is the best stage for newborn stimulation.
c.
Cycles of sleep states are uniform in newborns of the same age.
d. Muscle twitches and irregular breathing are common during deep sleep. ANS: B
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During the quiet alert stage, the newborns eyes are wide open and bright. The newborn responds to the environment by active body movement and staring at close-range objects. Newborns ability to control their own cycles depend on their neurobehavioral development. Each newborn has an individual cycle. Muscle twitches and irregular breathing are common during light sleep. 9. The nurse observes that a new mother avoids making eye contact with her infant. What should the nurse do? a. Ask the mother why she wont look at the infant. b.
Examine the infants eyes for the ability to focus.
c.
Assess the mother for other attachment behaviors.
d. Recognize this as a common reaction in new mothers. ANS: C Attachment behaviors are thought to indicate the formation of emotional bonds between the newborn and mother. A mothers failure to make eye contact with her infant may indicate difficulties with the formation of emotional bonds. The nurse should perform a more thorough assessment. Asking the mother why she will not look at the infant is a confrontational response that might put the mother in a defensive position. Infants do not have binocularity and cannot focus. Avoiding eye contact is an uncommon reaction in new mothers. 10. Which should the nurse use when assessing the physical maturity of a newborn? a. Length b.
Apgar score
c.
Posture at rest
d. Chest circumference ANS: C With the newborn quiet and in a supine position, the degree of flexion in the arms and legs can be used for determination of gestational age. Length and chest circumference reflect the newborns size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. The Apgar score is an indication of the newborns adjustment to extrauterine life. 11. What is the grayish white, cheeselike substance that covers the newborns skin? a. Milia b.
Meconium
c.
Amniotic fluid
d. Vernix caseosa ANS: D The vernix caseosa is the grayish white, cheeselike substance that covers a newborns skin. 12. What is most descriptive of the shape of the anterior fontanel in a newborn? a. Circle b.
Square
c.
Triangle
d.
Diamond
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ANS: D The anterior fontanel is diamond shaped and measures from barely palpable to 4 to 5 cm. The shape of the posterior fontanel is a triangle. Neither of the fontanels is a circle or a square. 13. Which term describes irregular areas of deep blue pigmentation seen predominantly in infants of African, Asian, Native American, or Hispanic descent? a. Acrocyanosis b.
Mongolian spots
c.
Erythema toxicum
d. Harlequin color change ANS: B Mongolian spots are irregular areas of deep blue pigmentation, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet; this is a usual finding in infants. Erythema toxicum is a pink papular rash with vesicles that may appear in 24 to 48 hours and resolve after several days. Harlequin color changes are clearly outlined areas of color change. As the infant lies on a side, the lower half of the body becomes pink, and the upper half is pale. 14. The nurse should expect the apical heart rate of a stabilized newborn to be in which range? a. 60 to 80 beats/min b.
80 to 100 beats/min
c.
120 to 140 beats/min
d. 160 to 180 beats/min ANS: C The pulse rate of the newborn varies with periods of reactivity. Usually the pulse rate is between 120 and 140 beats/min. Sixty to 100 beats/min is too slow for a newborn, and 160 to 180 beats/min is too fast for a newborn. 15. Which finding in the newborn is considered abnormal? a. Nystagmus b.
Profuse drooling
c.
Dark green or black stools
d. Slight vaginal reddish discharge ANS: B Profuse drooling and salivation are potential signs of a major abnormality. Newborns with esophageal atresia cannot swallow their oral secretions, resulting in excessive drooling. Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns. Meconium, the first stool of newborns, is dark green or black. A pseudomenstruation may be present in normal newborns. This is a blood-tinged or mucoid vaginal discharge. 16. When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous, and pendulous. What should this be interpreted as? a. A hydrocele b.
An inguinal hernia
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c.
A normal finding
d. An absence of testes ANS: C A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a breech position, is a normal finding. A hydrocele is fluid in the scrotum, usually unilateral, which usually resolves within a few months. An inguinal hernia may or may not be present at birth. It is more easily detected when the child is crying. The presence or absence of testes should be determined on palpation of the scrotum and inguinal canal. Absence of testes may be an indication of ambiguous genitalia. 17. Why are rectal temperatures not recommended in newborns? a. They are inaccurate. b.
They do not reflect core body temperature.
c.
They can cause perforation of rectal mucosa.
d. They take too long to obtain an accurate reading. ANS: C Rectal temperatures are avoided in newborns. If done incorrectly, the insertion of a thermometer into the rectum can cause perforation of the mucosa. The time it takes to determine body temperature is related to the equipment used, not only the route. 18. Which is the name of the suture separating the parietal bones at the top of a newborns head? a. Frontal b.
Sagittal
c.
Coronal
d. Occipital ANS: B The sagittal suture separates the parietal bones at the top of the newborns head. The frontal suture separates the frontal bones. The coronal suture is said to crown the head. The lambdoid suture is at the margin of the parietal and occipital. 19. The nurse observes flaring of nares in a newborn. What should this be interpreted as? a. Nasal occlusion b.
Sign of respiratory distress
c.
Snuffles of congenital syphilis
d. Appropriate newborn breathing ANS: B Nasal flaring is an indication of respiratory distress. A nasal occlusion should prevent the child from breathing through the nose. Because newborns are obligatory nose breathers, this should require immediate referral. Snuffles are indicated by a thick, bloody nasal discharge without sneezing. Sneezing and thin, white mucus drainage are common in newborns and are not related to nasal flaring. 20. The nurse is assessing the reflexes of a newborn. Stroking the outer sole of the foot assesses which reflex?
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a.
Grasp
b.
Perez
c.
Babinski
d. Dance or step ANS: C This is a description of the Babinski reflex. Stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toes to dorsiflex and the other toes to hyperextend. This reflex persists until approximately age 1 year or when the newborn begins to walk. The grasp reflex is elicited by touching the palms or soles at the base of the digits. The digits will flex or grasp. The Perez reflex involves stroking the newborns back when prone; the child flexes the extremities, elevating the head and pelvis. This disappears at ages 4 to 6 months. When the newborn is held so that the sole of the foot touches a hard surface, there is a reciprocal flexion and extension of the leg, simulating walking. This reflex disappears by ages 3 to 4 weeks. 21. Which is most important in the immediate care of the newborn? a. Maintain a patent airway. b.
Administer prophylactic eye care.
c.
Maintain a stable body temperature.
d. Establish identification of the mother and baby. ANS: A Maintaining a patent airway is the primary objective in the care of the newborn. First, the pharynx is cleared with a bulb syringe followed by the nasal passages. Administering prophylactic eye care and establishing identification of the mother and baby are important functions, but physiologic stability is the first priority in the immediate care of the newborn. Conserving the newborns body heat and maintaining a stable body temperature are important, but a patent airway must be established first. 22. What should nursing interventions to maintain a patent airway in a newborn include? a. Positioning the newborn supine after feedings. b.
Wrapping the newborn as snugly as possible.
c.
Placing the newborn to sleep in the prone (on abdomen) position.
d. Using a bulb syringe to suction as needed, suctioning the nose first and then the pharynx. ANS: A Positioning the newborn supine after feedings is recommended by the American Academy of Pediatrics to prevent sudden newborn death syndrome. The child can be wrapped snugly but should be placed on the side or back. Placing a newborn to sleep in the prone (on abdomen) position is not advised because of the possible link between sleeping in the prone position and sudden newborn death syndrome. A bulb syringe should be kept by the bedside if necessary, but the pharynx should be suctioned before the nose. 23. The nurse quickly dries the newborn after delivery. This is to conserve the newborns body heat by preventing heat loss through which method? a. Radiation b.
Conduction
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c.
Convection
d. Evaporation ANS: D Evaporation is the loss of heat through moisture. The newborn should be quickly dried of the amniotic fluid. Radiation is the loss of heat to a cooler solid object. The cold air from either the window or the air conditioner will cool the walls of the incubator and subsequently the body of the newborn. Conduction involves the loss of heat from the body because of direct contact of the skin with a cooler object. Convection is similar to conduction but is the loss of heat aided by air currents. 24. An infant is being discharged at 48 hours of age. The parents ask how the infant should be bathed this first week home. Which is the best recommendation by the nurse? a. Bathe the infant daily with mild soap. b.
Bathe the infant daily with an alkaline soap.
c.
Bathe the infant two or three times this week with mild soap.
d. Bathe the infant two or three times this week with plain water. ANS: D A newborn infants skin has a pH of approximately 5. This acidic pH has a bacteriostatic effect. The parents should be taught to use only plain warm water for the bath and to bathe the infant no more than two or three times the first 2 weeks. Soaps are alkaline. They will alter the acid mantle of the infants skin, providing a medium for bacterial growth. 25. The stump of the umbilical cord usually drops off in how many days? a. 3 to 6 b.
10 to 14
c.
16 to 21
d. 24 to 28 ANS: B The average umbilical cord separates in 10 to 14 days. Three to 6 days is too soon, and 16 to 28 days is too late. 26. The parents of an infant plan to have him circumcised. They ask the nurse about pain associated with this procedure. The nurses response should be based on which? a. That infants experience pain with circumcision b.
That infants are too young for anesthesia or analgesia
c.
That infants do not experience pain with circumcision
d. That infants quickly forget about the pain of circumcision ANS: A Circumcision is a surgical procedure. The American Academy of Pediatrics has recommended that procedural analgesia be provided when circumcision is performed. The pain infants experience with surgical procedures can be alleviated with analgesia. Infants who undergo circumcision without anesthetic agents react more intensely to immunization injections at 4 to 6 months of age compared with infants who had an anesthetic.
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27. The nurse is teaching a class on breastfeeding to expectant parents. Which is a contraindication for breastfeeding? a. Mastitis b.
Twin births
c.
Inverted nipples
d. Maternal cancer therapy ANS: D Mothers receiving chemotherapy with antimetabolites and certain antineoplastic drugs should not breastfeed. The drugs are passed to the newborn through the breast milk. Mastitis, twin births, and inverted nipples are not contraindications. 28. Successful breastfeeding is most dependent on which? a. Birth weight of newborn b.
Size of mothers breasts
c.
Mothers desire to breastfeed
d. Familys socioeconomic level ANS: C The factors that contribute to successful breastfeeding are the mothers desire to breastfeed, satisfaction with breastfeeding, and available support systems. Very lowbirth-weight infants may be unable to breastfeed. The mother can express milk, and it can be used for the infant. The size of mothers breasts does not affect the success of breastfeeding. The familys socioeconomic level may affect the mothers need to return to work and available support systems, but with support, the mother can be successful. 29. A mother who breastfeeds her 6-week-old infant every 4 hours tells the nurse that he seems hungry all the time. The nurse should recommend which? a. Newborn cereal b.
Supplemental formula
c.
More frequent feedings
d. No change in feedings ANS: C Infants who are breastfed tend to be hungry every 2 to 3 hours. They should be fed frequently. Six weeks is too early to introduce newborn cereal. Supplemental formula is not indicated. Giving additional formula or water to a breastfed infant may satiate the infant and create problems with breastfeeding. The infant requires additional feedings. Four hours is too long between feedings for a breastfed infant. 30. What should a nursing intervention to promote parentinfant attachment include? a. Encouraging parents to hold the infant frequently unless the infant is fussy b.
Explaining individual differences among infants to the parents
c.
Delaying parentinfant interactions until the second period of reactivity
d. Alleviating stress for parents by decreasing their participation in the infants care ANS: B
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Nurses can positively influence the attachment of parent and infant by recognizing and explaining individual differences to the parents. The nurse should emphasize the normalcy of these variations and demonstrate the uniqueness of each infant. The parents should be encouraged to hold the infant when he or she is fussy and learn how best to soothe their infant. The nurse should facilitate parentinfant interaction during the first period of reactivity. Decreasing the parents participation in care interferes with parentinfant attachment. 31. A new mother wants to be discharged with her infant as soon as possible. Before discharge, what should the nurse be certain of? a. The infant has voided at least once. b.
The infant does not spit up after feeding.
c.
Jaundice, if present, appeared before 24 hours.
d. A follow-up appointment with the practitioner is made within 48 hours. ANS: D The American Academy of Pediatrics recommends that newborns discharged early receive follow-up care within 48 hours in either a primary practitioners office or the home. The child should void every 4 to 6 hours. Spitting up small amounts after feeding is normal in newborns; it should not delay discharge. Jaundice within the first 24 hours of life must be evaluated. 32. The nurse is teaching new parents about the benefits of breastfeeding their infant. Which statement by the parent should indicate a correct understanding of the teaching? a. I should breastfeed my baby so that she will grow at a faster rate than a bottle-fed newborn. b.
One of the advantages of breastfeeding is that the baby will have fewer stools per day.
c.
I should breastfeed my baby because breastfed babies adapt more easily to a regular schedule of feeding
Some of the advantages of breastfeeding are that breast milk is economical and readily available for my d. baby. ANS: D Some advantages of breastfeeding a newborn are that breast milk is more economical, is readily available, and is sanitary. Breastfed newborns usually grow at a satisfactory, slower rate than bottle-fed newborns, which research indicates aids in decreased obesity in children. Breastfed babies have an increased number of stools throughout a 24-hour period, and neither breastfed nor bottle-fed newborns should be placed on a regular schedule; they should be fed on demand. 33. The nurse is caring for a patient who has chosen to breastfeed her infant. Which statement should the nurse include when teaching the mother about breastfeeding problems that may occur? If you experience painful nipples, cleanse your nipples with soap two times per day and keep your nipp a. covered as much as possible. b.
If you experience plugged ducts, continue to breastfeed every 2 to 3 hours and alternate feeding positio
c.
If mastitis occurs, discontinue breastfeeding while taking prescribed antibiotics and apply warm compresses.
d. If engorgement occurs, use cold compresses before a feeding and wear a well-fitting bra at night. ANS: B If a woman experiences plugged ducts, the best interventions are to continue breastfeeding every 2 to 3 hours and alternate feeding positions while pointing the infants chin toward the obstructed
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area. Other interventions include massaging breasts and applying warm compresses before feeding or pumping. If painful nipples occur, the woman should avoid soaps, oils, and lotions and air the nipples as much as possible. If mastitis occurs, the woman should continue breastfeeding to keep the breast well drained. If engorgement occurs, the woman should use a warm compress before feedings and wear a well-fitting bra 24 hours a day. MULTIPLE RESPONSE 1. The nurse is completing a physical and gestational age assessment on an infant who is 12 hours old. Which components are included in the gestational age assessment? (Select all that apply.) a. Arm recoil b.
Popliteal angle
c.
Motor performance
d.
Primitive reflexes
e.
Square window
f. Scarf sign ANS: A, B, E, F The components of the typical gestational age assessment include posture, square window, arm recoil, popliteal angle, scarf sign, and heel to ear. Motor performance and reflexes are parts of the behaviors in the Brazelton Neonatal Behavioral Assessment Scale. 2. The nurse is teaching parents about the visual ability of their newborn. Which should the nurse include in the teaching session? (Select all that apply.) a. Visual acuity is between 20/100 and 20/400. b.
Tear glands do not begin to function until 8 to 12 weeks of age.
c.
Infants can momentarily fixate on a bright object that is within 8 inches.
d.
The infant demonstrates visual preferences of black-and-white contrasting patterns.
e. The infant prefers bright colors (red, orange, blue) over medium colors (yellow, green, pink). ANS: A, C, D Visual acuity is reported to be between 20/100 and 20/400, depending on the vision measurement techniques. The infant has the ability to momentarily fixate on a bright or moving object that is within 20 cm (8 inches) and in the midline of the visual field. The infant demonstrates visual preferences of black-and-white contrasting patterns. The visual preference is for medium colors (yellow, green, pink) over dim or bright colors (red, orange, blue). Tear glands begin to function until 2 to 4 weeks of age. 3. Which assessments are included in the Apgar scoring system? (Select all that apply.) a. Heart rate b.
Muscle tone
c.
Blood pressure
d.
Blood glucose
e. Reflex irritability ANS: A, B, E
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The Apgar score is based on observation of heart rate, respiratory effort, muscle tone, reflex irritability, and color. Blood pressure and blood glucose are not part of the Apgar scoring system. 4. The nurse is completing a respiratory assessment on a newborn. What are normal findings of the assessment the nurse should document? (Select all that apply.) a. Periodic breathing b.
Respiratory rate of 40 breaths/min
c.
Wheezes on auscultation
d.
Apnea lasting 25 seconds
e. Slight intercostal retractions ANS: A, B, E Periodic breathing is common in full-term newborns and consists of rapid, nonlabored respirations followed by pauses of less than 20 seconds. The newborns respiratory rate is between 30 and 60 breaths/min. The ribs are flexible, and slight intercostal retractions are normal on inspiration. Periods of apnea lasting more than 20 seconds are abnormal, and wheezes should be reported. 5. The nurse is instructing a new mother on safety measures for newborn abduction. Which should the nurse include in the instructions? (Select all that apply.) a. Publish the birth announcement in your local newspaper. b.
Dont relinquish the newborn to anyone without identification.
c.
Keep your door open if the newborn is in the room while you shower.
d.
Use a password system with the staff when the newborn is taken from the room.
e. When you use the restroom, ring for a nurse to stay in the room with your newborn. ANS: B, D, E Safety measures to be taught to new mothers should include (1) not leaving the newborn alone in the crib while taking a shower or using the bathroom; rather, they should ask to have the newborn observed by a health care worker if a family member is not present in the room; (2) not relinquishing the newborn to anyone without identification; and (3) using a password system with the staff when the newborn is taken from the room as a routine security measure. The newborn should not be left alone while the mother is showering, even if the door is left open. It is recommended to not publish the birth announcement in the newspaper. 6. The nurse is conducting discharge teaching to parents regarding care of the umbilical cord. Which should the nurse include in the instructions? (Select all that apply.) a. Cover the umbilical cord with the diaper. b.
The cord will fall off in 5 to 15 days.
c.
Clean around the umbilical cord stump with water.
d.
Watch for redness and drainage around the umbilical cord stump.
e. A tub bath can be done every other day. ANS: B, C, D The umbilical cord is cleansed initially with sterile water or a neutral pH cleanser and then subsequently with water. The stump deteriorates through the process of dry gangrene, with an
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average separation time of 5 to 15 days. The umbilical cord area should be watched for redness or drainage, which could indicate infection. The diaper is placed below the cord to avoid irritation and wetness on the site, and tub bathing is not allowed until the umbilical cord falls off. COMPLETION 1. A health care provider prescribes vitamin K intramuscular 1 mg one time within 1 hour of birth. The medication label states: Vitamin K 2 mg/1 ml. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place. ________________ ANS: 0.5 Follow the formula for dosage calculation. Desired Volume = ml per dose Available 1 mg 1 ml = 0.5 ml 2 mg
Chapter 5 Guidelines for Breastfeeding MULTIPLE CHOICE 1. The breastfeeding client should be taught a safe method to remove her breast from the babys mouth. Which suggestion by the nurse is most appropriate? a. Break the suction by inserting your finger into the corner of the infants mouth. b.
A popping sound occurs when the breast is correctly removed from the infants mouth.
c.
Slowly remove the breast from the babys mouth when the infant has fallen asleep and the jaws are relaxed.
d.
Elicit the Moro reflex in the baby to wake the baby up, and remove the breast when the baby cries.
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ANS: A Inserting a finger into the corner of the babys mouth between the gums to break the suction avoids trauma to the breast. A popping sound indicates improper removal of the breast from the babys mouth and may cause cracks or fissures in the breast. The infant who is sleeping may lose grasp on the nipple and areola, resulting in chewing on the nipple, making it sore. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended. 2. Which woman is most likely to continue breastfeeding beyond 6 months? a. A woman who avoids using bottles b.
A woman who uses formula for every other feeding
c.
A woman who offers water or formula after breastfeeding
d. A woman whose infant is satisfied for 4 hours after the feeding ANS: A Women who avoid using bottles and formula are more likely to continue breastfeeding. Use of formula decreases breastfeeding time and decreases the production of prolactin and, ultimately, the milk supply. Overfeeding after breastfeeding causes a sense of fullness in the infant, so the infant will not be hungry in 2 to 3 hours. Formula takes longer to digest. The new breastfeeding mother needs to nurse often to stimulate milk production. 3. In which condition is breastfeeding contraindicated? a. Triplet birth b.
Flat or inverted nipples
c.
Human immunodeficiency virus infection
d. Inactive, previously treated tuberculosis ANS: C Human immunodeficiency virus is a serious illness that can be transmitted to the infant via body fluids. Because the amount of milk being produced depends on the amount of suckling of the breasts, providing enough milk should not be a problem. Nipple abnormality can begin to be treated during pregnancy but may begin after birth. Many methods help flat or inverted nipples to become more erect. Only active tuberculosis patients would be cautioned not to breastfeed. 4. Which type of formula should not be diluted before being administered to an infant? a. Powdered b.
Concentrated
c.
Ready to use
d. Modified cows milk ANS: C Ready to use formula can be poured directly from the can into the babys bottle and is good (but expensive) when a proper water supply is not available. Formula should be well mixed to dissolve the powder and make it uniform. Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. Cows milk is more difficult for the infant to digest and is not recommended, even if it is diluted. 5. How many kilocalories per kilogram (kcal/kg) of body weight does a full-term formula-fed infant need each day?
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a.
50 to 75
b.
100 to 110
c.
120 to 140
d. 150 to 200 ANS: B The term newborn being fed with formula requires 100 to 110 kcal/kg to meet nutritional needs each day. 50 to 75 kcal/kg is too little and 120 to 140 kcal/kg and 150 to 200 kcal/kg are too much. 6. How many milliliters per kilogram (mL/kg) of fluids does a newborn need daily for the first 3 to 5 days of life? a. 20 to 30 b.
40 to 60
c.
60 to 100
d. 120 to 150 ANS: C The newborn needs 60 to 100 mL/kg of fluids daily for the first 3 to 5 days of life. 20 to 30 mL/kg and 40 to 60 mL/kg are too small an amount for the newborn. 120 to 150 mL/kg is too large an amount for the newborn. 7. Which is the hormone necessary for milk production? a. Estrogen b.
Prolactin
c.
Progesterone
d. Lactogen ANS: B Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce milk. Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Progesterone decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Human placental lactogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. 8. Which recommendation should the nurse make to a client to initiate the milk ejection reflex? a. Wear a well-fitting firm bra. b.
Drink plenty of fluids.
c.
Place the infant to the breast.
d. Apply cool packs to the breast. ANS: C Oxytocin, which causes the milk let-down reflex, increases in response to nipple stimulation. A firm bra is important to support the breast but will not initiate the let-down reflex. Drinking plenty of fluids is necessary for adequate milk production but will not initiate the let-down reflex. Cool packs to the breast will decrease the let-down reflex. 9. Which is the first step in assisting the breastfeeding mother?
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a.
Assess the womans knowledge of breastfeeding.
b.
Provide instruction on the composition of breast milk.
c.
Discuss the hormonal changes that trigger the milk ejection reflex.
d. Help her obtain a comfortable position and place the infant to the breast. ANS: A The nurse should first assess the womans knowledge and skill in breastfeeding to determine her teaching needs. Assessment should occur before instruction. Discussing the hormonal changes and helping her obtain a comfortable position may be part of the instructional plan, but assessment should occur first to determine what instruction is needed. 10. Which is an important consideration in positioning a newborn for breastfeeding? a. Placing the infant at nipple level facing the breast b.
Keeping the infants head slightly lower than the body
c.
Using the forefinger and middle finger to support the breast
d. Limiting the amount of areola the infant takes into the mouth ANS: A Positioning the infant at nipple level will prevent downward pulling of the nipple and subsequent nipple trauma. Keeping the infants head slightly lower will pull the nipple down and cause trauma. The forefinger and middle finger can be used to support the breast, but this is not an important consideration in positioning the newborn. The infant should take in as much areola as possible to prevent trauma to the nipples. 11. The client should be taught that when her infant falls asleep after feeding for only a few minutes, she should do which of the following? a. Unwrap and gently arouse the infant. b.
Wait an hour and attempt to feed again.
c.
Try offering a bottle at the next feeding.
d. Put the infant in the crib and try again later. ANS: A The infant who falls asleep during feeding may not have fed adequately and should be gently aroused to continue the feeding. Breastfeeding should continue. By offering a bottle, breast milk production will decrease. The infant should be aroused and feeding continued. 12. To prevent breast engorgement, what should the new breastfeeding mother be instructed to do? a. Feed her infant no more than every 4 hours. b.
Limit her intake of fluids for the first few days.
c.
Apply cold packs to the breast prior to feeding.
d. Breast-feed frequently and for adequate lengths of time. ANS: D Engorgement occurs when the breasts are not adequately emptied at each feeding or if feedings are not frequent enough. Breast milk moves through the stomach within 1.5 to 2 hours, so waiting 4 hours to feed is too long. Frequent feedings are important to empty the breast and
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establish lactation. Fluid intake should not be limited with a breastfeeding mother; that would decrease the amount of breast milk produced. Warm packs should be applied to the breast before feedings. 13. What is the difference between the aseptic and terminal methods of sterilization? a. The aseptic method requires a longer preparation time. b.
The aseptic method does not require boiling of the bottles.
c.
The terminal method requires boiling water to be added to the formula.
d. The terminal method sterilizes the prepared formula at the same time it sterilizes the equipment. ANS: D In the terminal sterilization method, the formula is prepared in the bottles, which are loosely capped, and then the bottles are placed in the sterilizer, where they are boiled for 25 minutes. The terminal method takes 25 minutes to boil; the aseptic method takes 5 minutes to boil. With the aseptic method, the bottles are boiled separate from the formula. With the terminal method, the formula is prepared, placed in bottles, and everything is boiled at one time. 14. How many ounces will an infant who is on a 4-hour feeding schedule need to consume at each feeding to meet daily caloric needs? a. 1 b.
1.5
c.
3.5
d. 5 ANS: C The newborn requires approximately 12 to 24 oz of formula each day (6 feedings/24-hour period). 1 and 1.5 ounces are too small to meet calorie needs; 5 ounces with every feeding would be overfeeding the infant. 15. A new mother is concerned because her 1-day-old newborn is taking only 1 oz at each feeding. What should the nurse explain? a. The infant is probably having difficulty adjusting to the formula. b.
An infant does not require as much formula in the first few days of life.
c.
The infants stomach capacity is small at birth but will expand within a few days.
d. The infant tires easily during the first few days but will gradually take more formula. ANS: C The infants stomach capacity at birth is 10 to 20 mL and increases to 30 to 90 mL by the end of the first week. There are other symptoms if there is a formula intolerance. The infants requirements are the same, but the stomach capacity needs to increase before taking in adequate amounts. The infants sleep patterns do change, but the infant should be awake enough to feed. 16. As the nurse assists a new mother with breastfeeding, the mother asks, If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better? The nurses best response is that it contains: a. more calcium.
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b.
more calories.
c.
essential amino acids.
d. important immunoglobulins. ANS: D Breast milk contains immunoglobulins that protect the newborn against infection. Calcium levels are higher in formula than breast milk. This higher level can cause an excessively high renal solute load if the formula is not diluted properly. The calorie counts of formula and breast milk are about the same. All the essential amino acids are in formula and breast milk. The concentrations may differ. 17. What should the nurse explain when responding to the question, Will I produce enough milk for my baby as she grows and needs more milk at each feeding? a. Early addition of baby food will meet the infants needs. b.
The breast milk will gradually become richer to supply additional calories.
c.
As the infant requires more milk, feedings can be supplemented with cows milk.
d. The mothers milk supply will increase as the infant demands more at each feeding. ANS: D The amount of milk produced depends on the amount of stimulation of the breast. Increased demand with more frequent and longer breastfeeding sessions results in more milk available for the infant. Solids should not be added until about 4 to 6 months, when the infants immune system is more mature. This will decrease the chance of allergy formations. Mature breast milk will stay the same. The amounts will increase as the infant feeds for longer times. Supplementation will decrease the amount of stimulation of the breast and decrease the milk production. 18. Which should the nurse recommend to the postpartum client to prevent nipple trauma? a. Assess the nipples before each feeding. b.
Limit the feeding time to less than 5 minutes.
c.
Wash the nipples daily with mild soap and water.
d. Position the infant so the nipple is far back in the mouth. ANS: D If the infants mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, causing trauma to the area. Assessing the nipples for trauma is important, but it will not prevent sore nipples. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need. Soap can be drying to the nipples and should be avoided during breastfeeding. 19. A breastfeeding client who was discharged yesterday calls to ask about a tender hard area on her right breast. What should be the nurses first response? a. This is a normal response in breastfeeding mothers. b.
Notify your doctor so he can start you on antibiotics.
c.
Stop breastfeeding because you probably have an infection.
d.
Try massaging the area and apply heat; it is probably a plugged duct.
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ANS: D A plugged lactiferous duct results in localized edema, tenderness, and a palpable hard area. Massage of the area followed by heat will cause the duct to open. This is a normal deviation but requires intervention to prevent further complications. Tender hard areas are not the signs of an infection, so antibiotics are not indicated. Fatigue, aching muscles, fever, chills, malaise, and headache are signs of mastitis. She may have a localized area of redness and inflammation. 20. Which is an important consideration about the storage of breast milk? a. Can be thawed and refrozen b.
Can be frozen for up to 2 months
c.
Should be stored only in glass bottles
d. Can be kept refrigerated for 48 hours ANS: D If used within 48 hours after being refrigerated, breast milk will maintain its full nutritional value. It should not be refrozen. Frozen milk should be kept for 1 month only. Antibodies in the milk will adhere to glass bottles. Only rigid polypropylene plastic containers should be used. 21. What is the most serious consequence of propping an infants bottle? a. Colic b.
Aspiration
c.
Dental caries
d. Ear infections ANS: B Propping the bottle increases the likelihood of choking and aspiration if regurgitation occurs. Colic can occur but is not the most serious consequence. Dental caries becomes a problem when milk stays on the gums for a long period of time. This may cause a buildup of bacteria that will alter the growing teeth buds. However, this is not the most serious consequence. Ear infections can occur when the warm formula runs into the ear and bacterial growth occurs. However, this is not the most serious consequence. 22. A new mother asks why she has to open a new bottle of formula for each feeding. What is the nurses best response? a. Formula may turn sour after it is opened. b.
Bacteria can grow rapidly in warm milk.
c.
Formula loses some nutritional value once it is opened.
d. This makes it easier to keep track of how much the baby is taking. ANS: B Formula should not be saved from one feeding to the next because of the danger of rapid growth of bacteria in warm milk. Formula will have bacterial growth before turning sour. This will cause problems in a newborn with an immature immune system. The loss of some nutritional value after the formula is opened is not the reason for using fresh bottles with each feeding. The danger of bacterial growth is the main concern. 23. A new mother asks whether she should feed her newborn colostrum because it is not real milk. The nurses best answer includes which information?
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a.
Colostrum is unnecessary for newborns.
b.
Colostrum is high in antibodies, protein, vitamins, and minerals.
c.
Colostrum is lower in calories than milk and should be supplemented by formula.
Giving colostrum is important in helping the mother learn how to breast-feed before d. she goes home. ANS: B Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Colostrum provides immunity and enzymes necessary to clean the gastrointestinal system, among other things. Supplementation is not necessary. It will decrease stimulation to the breast and decrease the production of milk. It is important for the mother to feel comfortable in this role before discharge, but the importance of the colostrum to the infant is top priority. 24. A newborn infant weighs 7 pounds, 2 ounces, on the fifth day of life. How much water should be given to the newborn based on required fluid needs? a. Fluid replacement should be based on weight and calculated in the range of 60 to 100 mL/kg. b.
Offer additional water to tolerance in between infant feedings to maintain hydration.
c.
Give 12 ounces of fluid per feeding.
d. No water is needed because formula and breast milk are adequate to maintain hydration. ANS: A There is an expected weight loss of up to 10% postdelivery, so fluid replacement should be calculated to improve health outcomes and maintain adequate hydration.12 ounces of fluid per feeding is excessive and may cause overdistention. Offering water between feedings to tolerance may not provide enough fluid replacement. Newborn 25. A mother is breastfeeding her newborn infant but is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The best nursing response would be to: a. tell the client to wear a bra at all times to provide more support to breast tissue. b.
have the client put the infant to her breast more frequently.
c.
place ice packs on breast tissue after infant feeding. explain that this is a normal finding and will resolve as her breast tissue becomes more used to nursing.
d. ANS: B The client may be experiencing signs of engorgement. Intervention methods such as placing the infant to feed more frequently may help prevent physical complaints of tenderness to milk accumulation. Wearing a bra at all times will not help resolve engorgement issues but can provide comfort. Ice packs provide symptomatic relief but do not resolve engorgement issues. Warm water compresses are more likely to provide comfort. Engorgement is not a normal finding but is a common presentation in nursing mothers. These symptoms will not dissipate with continuation of breastfeeding. 26. A mother is attempting to breastfeed her infant in the hospital setting. The infant is sleepy and displays some audible swallowing, the maternal nipples are flat, and the breasts are soft. The nurse has attempted to teach the mother positioning on one side, and now the mother wants to
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place the infant to the breast on the other side. Based on LATCH scores, the nurse would designate a score of: a. 10 and document findings in the chart. b.
6 and further teach and assist the mother in feeding activities.
c.
5 and tell the mother to discontinue feeding attempts at this time because the infant is too sleepy.
d. 8 and no further assistance is needed for feeding. ANS: B The LATCH assessment tool is used to identify whether mothers need additional instruction in the area of breastfeeding. The LATCH categories are latch, audible communication/swallowing, type of nipple, comfort of breasts, and holding position of infant. The assessment data reveal a score of 6 (0 + 2 + 1 + 2 + 1) so the mother needs additional assistance during breastfeeding at this time. 27. A mother conveys concern over the fact that she is not sure if her newborn child is getting enough nutrients from breastfeeding. This is the babys first clinic visit after birth. What information can you provide that will help alleviate her fears about nutrient status for her newborn? Monitor the infants output; as long as at least six or more diapers are changed in a 24-hour period, that a. should be sufficient. b.
Tell the mother that if a baby is satisfied with feeding, she or he will be content and not fussy.
c.
Tell the mother that breast milk contains everything required for the infant and not to worry about nutrition.
Provide nutrition information in the form of pamphlets for the mother to take home d. with her so that she uses them as a point of reference. ANS: A The presence of wet diapers confirms that the infant is receiving enough milk. Recording weight and seeing an increase in weight is also an objective finding that can be used to note nutritional status. Newborns may be fussy and still be receiving adequate nutrition. Although breast milk is potentially the perfect food for the newborn, not everyones breast milk has nutrient quality, so recording of weight gain and output measurements (wet diapers and stool production) confirm nutritional status. Providing the mother with educational pamphlets may be advisable but does not address the immediate problem. 28. A breastfeeding mother asks the postpartum nurse if any supplementation is necessary once her breast milk comes in. What is the nurses best response? a. Are you concerned about your ability to adequately nurse your baby? b.
Do you eat a well-balanced diet, high in protein and carbohydrates?
c.
Breast milk is low in vitamin D and supplementation with 400 IU is recommended.
d. Your breast milk has all the vitamins and will adequately meet your babys needs. ANS: C Generally, nutrients provided in breast milk are present in amounts and proportions needed by the infant. However, recent studies have shown that the vitamin D content of breast milk is low, and daily supplementation with 400 IU of vitamin D is recommended within the first few days of
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life. Breastfeeding infants who are not exposed to the sun and those with dark skin are particularly at risk for insufficient vitamin D. Formula-fed infants who drink less than 1 quart of vitamin Dfortified milk per day should also be supplemented. Although the fatty acid content of breast milk is influenced by the mothers diet, malnourished mothers milk has about the same proportions of total fat, protein, carbohydrates, and most minerals as milk from those who are well nourished. Levels of water-soluble vitamins in breast milk are affected by the mothers intake and stores. It is important for breastfeeding women to eat a well-balanced diet to maintain their own health and energy levels. 29. A new mother is preparing for discharge. She plans on bottle feeding her baby. Which statement indicates to the nurse that the mom needs more information about bottle feeding? a. I should encourage my baby to consume the entire amount of formula prepared for each feeding. b.
I can make up a 24-hour supply of formula and refrigerate the bottles so I am ready to feed my baby.
c.
I will hold my baby in a cradle hold and alternate sides from left to right when I feed my baby.
d. I will generally feed my baby every 3 to 4 hours or more as signs of hunger are displayed. ANS: A Infants will stop suckling when they are full. Encouraging them to overeat may lead to problems with regurgitation and possible aspiration. The mother can prepare a single bottle or a 24-hour supply if adequate refrigeration is available. Show the parents how to position the infant in a semiupright position, such as the cradle hold. This allows them to hold the infant close in a faceto-face position. The bottle is held with the nipple kept full of formula to prevent excessive swallowing of air. Placing the infant in the opposite arm for each feeding provides varied visual stimulation during feedings. Feed the infant every 3 to 4 hours but avoid rigid scheduling and take cues from the infant. 30. A client who is receiving a pitocin (Oxytocin) infusion for the augmentation of labor is experiencing a contraction pattern of more than eight contractions in a 10-minute period. Which intervention would be a priority? a. Increase the rate of pitocin infusion to help spread out the contraction pattern. b.
Place oxygen on the client at 8 to 10 L/min via face mask and turn the client to her left side.
c.
Stop the pitocin infusion.
d. Call the physician to obtain an order for the initiation of magnesium sulfate. ANS: C The client is exhibiting uterine tachysystole (uterine tetany). The priority intervention is to stop the infusion. The next course of action is to place oxygen on the client and reposition and increase the flow rate of the primary infusion. If the condition does not improve, the physician may be contacted for additional orders. 31. The nurse is teaching a postpartum client different holds for breastfeeding. Which of the following figures depicts the football hold frequently used for clients who have had a cesarean birth? a. b. c.
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d. ANS: C For the football or clutch hold, the mother supports the infants head and neck in her hand, with the infants body resting on pillows next to her hip. This method allows the mother to see the position of the infants mouth on the breast, helps her control the infants head, and is especially helpful for mothers with heavy breasts. This hold also avoids pressure against an abdominal incision. For the cradle hold, the mother positions the infants head at or near the antecubital space and level with her nipple, with her arm supporting the infants body. Her other hand is free to hold the breast. The cross-cradle or modified cradle hold is helpful for infants who are preterm or have a fractured clavicle. The mother holds the infants head with the hand opposite the side on which the infant will feed and supports the infants body across her lap with her arm. The other hand holds the breast. The side-lying position avoids pressure on the episiotomy or abdominal incision and allows the mother to rest while feeding. MULTIPLE RESPONSE 32. Late in pregnancy, the clients breasts should be assessed by the nurse to identify any potential concerns related to breastfeeding. Which of the following nipple conditions make it necessary to intervene before birth. (Select all that apply.) a. Flat nipples b.
Cracked nipples
c.
Everted nipples
d.
Inverted nipples
e. Nipples that contract when compressed ANS: A, D, E Flat nipples appear soft, like the areola, and do not stand erect unless stimulated by rolling them between the fingers. Inverted nipples are retracted into the breast tissue. These nipples appear normal; however, they will draw inward when the areola is compressed by the infants mouth. Dome-shaped devices known as breast shells can be worn during the last weeks of pregnancy and between feedings after birth. The shells are placed inside the bra, with the opening over the nipple. The shells exert slight pressure against the areola to help the nipples protrude. The helpfulness of breast shells has been debated. A breast pump can be used to draw the nipples out before feedings after birth. Everted nipples protrude and are normal. No intervention will be required. Cracked, blistered, and bleeding nipples occur after breastfeeding has been initiated and are the result of improper latching on. The infant should be repositioned during feeding. The application of colostrum and breast milk after feedings will aid in healing. 33. Which interventions may relieve symptoms of colic in the infant? (Select all that apply.) a. Increased stimulation of infant to provide distraction b.
Burping infant frequently during feedings
c.
Feeding infant placed in an upright position
d.
Providing chamomile tea to infant
e. Feeding infant on an on demand schedule ANS: B, C, D
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The presence of colic is a self-limiting temporary condition seen in infants during the first few months of life. Although there are many theories about its cause, none has been determined to show direct causation. Providing a quiet environment and a consistent feeding schedule, positioning the infant in an upright position during feeding, burping the infant frequently, and using supplements or medications that have antispasmodic properties may be recommended. Chamomile tea is reported to have antispasmodic effects. Feeding the infant on an on demand schedule may exacerbate the condition as a result of overfeeding. 34. For which infant should the nurse anticipate the use of soy formula? (Select all that apply.) a. Preterm infant b.
Infant with galactosemia
c.
Infant with phenylketonuria
d.
Infant with lactase deficiency
e. Infant with a malabsorption disorder ANS: B, D, E Soy formula may be given to infants with galactosemia or lactase deficiency or those whose families are vegetarians. Soy milk is derived from the protein of soybeans and supplemented with amino acids. The formulas are also used for infants with malabsorption disorders. The preterm infant may require a more concentrated formula, with more calories in less liquid. Modifications of other nutrients are also made. Human milk fortifiers can be added to breast milk to adapt it for preterm infants. Low-phenylalanine formulas are needed for infants with phenylketonuria, a deficiency in the enzyme to digest phenylalanine found in standard formulas. 35. A new mother asks the nurse, How will I know early signs of hunger in my baby? The nurses best response is which of the following? (Select all that apply.) a. Crying b.
Rooting
c.
Lip smacking
d.
Decrease in activity
e. Sucking on the hands ANS: B, C, E Early signs of hunger in a baby are rooting, lip smacking, and sucking on the hands. Crying is a late sign, and the babys activity will increase, not decrease.
36. The mother of a 7-month-old states, The baby is eating food now. Should I give him regular milk, too? What is the nurses best response? a. You should give the baby low-fat milk. b. Try the milk. See if he has any digestive problems. c. Continue breast milk or iron-fortified formula until 1 year of age. d. At this age, infants can tolerate lactose-free or soy-based milk. ANS: C
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Whole milk should not be introduced before 1 year of age. Low-fat milk should not be introduced before 2 years of age. 37. The nurse observes that a 2-year-old is able to use a spoon steadily at mealtime. What does self-feeding help to develop in the toddler? a. Good nutrition b. A sense of independence c. Adequate height and weight d. Healthy teeth ANS: B By the end of the second year, toddlers can feed themselves. This helps them to develop a sense of independence. 38. The breastfeeding client whose recommended prepregnancy caloric intake was 2000 calories per day would need how many calories per day to meet her current needs? a. 2300 b.
2500
c.
2750
d. 3000 ANS: B The increase for a breastfeeding client is 500 calories above her recommended prepregnancy caloric intake. 2300 calories is not enough to meet her needs. 2750 calories may be too many calories and may lead to weight gain. 3000 calories is too many for this client and will lead to weight gain. 39. Which client would require additional calories and nutrients? a. A 36-year-old female gravida 2, para 1, in her first trimester of pregnancy b.
An 18-year-old female who delivered a 7-lb baby and is bottle feeding
c.
A 23-year-old female who had a cesarean section birth and is bottle feeding
d. A 20-year-old female who had a vaginal birth 5 months ago and is breastfeeding ANS: D A client who is breastfeeding will require more calories and nutrients than individuals who are pregnant, delivered regardless of the type of birth, and whether they are bottle feeding. 40. Which client has correctly increased her caloric intake from her recommended pregnancy intake to the amount necessary to sustain breastfeeding in the first 6 postpartum months? a. From 1800 to 2200 calories per day b.
From 2000 to 2500 calories per day
c.
From 2200 to 2530 calories per day
d. From 2500 to 2730 calories per day ANS: C The increased calories necessary for breastfeeding are 500, with 330 calories coming from increased caloric intake and 170 calories from maternal stores. An increase of 230 calories is
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insufficient for breastfeeding. An increase of 400 and 500 calories is above the recommended amount. 41. The nurse is teaching a breastfeeding client about substances to avoid while she is breastfeeding. Which substances should the nurse include in the teaching session? (Select all that apply.) a. Caffeine b.
Alcohol
c.
Omega-6 fatty acids
d.
Appetite suppressants
e. Polyunsaturated omega-3 fatty acids ANS: A, B, D Foods high in caffeine should be limited. Infants of mothers who drink more than two or three cups of caffeinated coffee or the equivalent each day may be irritable or have trouble sleeping. Although the relaxing effect of alcohol was once thought to be helpful to the nursing mother, the deleterious effects of alcohol are too important to consider this suggestion appropriate today. An occasional single glass of an alcoholic beverage may not be harmful, but larger amounts may interfere with the milk ejection reflex and may be harmful to the infant. Nursing mothers should avoid appetite suppressants, which may pass into the milk and harm the infant. The long-chain polyunsaturated omega-3 and omega-6 fatty acids are present in human milk. Therefore, they should be included in the mothers diet during lactation.
Chapter 6 Common Genetic Disorders MULTIPLE CHOICE 1. Obstruction within the ventricles of the brain or inadequate reabsorption of cerebrospinal fluid may be responsible for the occurrence of: a. Meningitis b.
Meningocele
c.
Spina bifida occulta
d. Hydrocephalus ANS: D Hydrocephalus is characterized by an increase in cerebrospinal fluid in the ventricles of the brain. 2. The nurse caring for an infant with hydrocephalus would take special precaution to:
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a.
Align the limbs
b.
Support the head
c.
Keep the head lower than the hips
d. Check intake and output ANS: B The child with hydrocephalus has a heavy head on a small body with poor muscle tone; the head must be supported when feeding and moving the child to prevent injury to the neck. 3. The nurse observes that the infants anterior fontanelle is bulging after placement of a ventriculoperitoneal shunt. The nurse positions this infant: a. Prone, with the head of the bed elevated b.
Supine, with the head flat
c.
Side-lying on the operative side
d. In the semi-Fowlers position ANS: D If the fontanels are bulging, the child would be positioned in a semi-Fowlers position to promote drainage from the ventricles through the shunt. 4. After feeding a baby with hydrocephalus, the nurse will take special care to: a. Sit the baby upright in an infant seat b.
Place the baby over the shoulder to burp
c.
Leave the baby in a side-lying position
d. Stimulate the baby by rubbing its feet ANS: C Because children with hydrocephalus are prone to vomiting, the child is fed and then positioned in the side-lying position in a quiet atmosphere to reduce the incidence of vomiting. 5. A newborn was just admitted to the NICU with a meningomyelocele. The priority for preoperative nursing care of this newborn is to protect the sac by: a. Keeping the sac dry b.
Diapering snugly
c.
Positioning prone in an incubator
d. Moving from side to side every hour ANS: C The infant is placed prone in a humidified incubator, and the sac is covered with dressings of sterile saline. The babys hips are kept lower than the lesion, and the baby is usually not in diapers. 6. The nurse caring for the child who has had a ventriculoperitoneal shunt for hydrocephalus observes an increasing abdominal girth. The most appropriate response would be to: a. Elevate the childs head b.
Check bowel sounds
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c.
Record retention of feeding
d. Notify charge nurse of possible malabsorption ANS: D An increasing abdominal girth in a child with a VP shunt may be indicative of malabsorption of the CSF that is being shunted to the peritoneum. 7. The nurse counsels the parents of a child with a cleft palate that they should be alert for signs of: a. Facial paralysis b.
Ear infections
c.
Increasing ICP
d. Drooling ANS: B Children with cleft palate are at risk of ear infections and dental disorders. 8. Postoperative nursing care of the infant following surgical repair of a cleft lip would include: a. Feeding the infant with a spoon to avoid sucking b.
Positioning the infant on the abdomen to facilitate drainage
c.
Applying elbow restraints to protect the surgical area
d. Providing minimal stimulation to prevent injury to the incision ANS: C Elbow restraints are used postoperatively to prevent the infant from damaging the operative area. 9. The statement that indicates parents understand how to feed their infant who had surgical repair of a cleft lip is: a. We are feeding the baby with a dropper for two weeks. b.
We resumed bottle feeding after discharge.
c.
We started the baby on solid food yesterday.
d. The baby is drinking well from a straw. ANS: A The infant is fed with a dropper until the incision is completely healed, about 1 to 2 weeks after surgery. 10. An 18-month-old child who has had a surgical repair of a cleft palate is now allowed to eat a regular diet. The adjustment the nurse would make in feeding is: a. Feed solid foods with the spoon at the side of the mouth. b.
Puree foods and offer them through a straw.
c.
Place small bites of food in the mouth with a tongue blade.
d. Offer small, frequent meals of finger foods. ANS: A The primary concern with feeding is to protect the operative site. The child can be fed with a spoon, but only the side of the spoon is placed into the mouth at the side of the mouth. The spoon must not touch the roof of the mouth.
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11. The nurse bathing an infant would recognize a sign of developmental hip dysplasia, which is: a. Hypotonicity of the leg muscles b.
One leg is shorter than the other
c.
Broadening and flattening of the buttocks
d. Two skin folds on the back of each thigh ANS: B When developmental hip dysplasia is present, the leg on the affected side will appear shorter than the leg on the unaffected side. 12. A 3-month-old infant is diagnosed with developmental hip dysplasia. The nurse explains that the usual treatment for this infant would be: a. A Pavlik harness b.
A body spica cast
c.
Traction
d. Triple-diapering ANS: A In infants more than 2 months of age, longer-term immobilization with a Pavlik harness is required. 13. Following delivery, a mother asks the nurse about newborn screening tests. The nurse explains that the optimal time for testing for phenylketonuria is: a. In the first 24 hours of life b.
After 2 to 3 days
c.
At 4 to 6 weeks of age
d. At 2 months of age ANS: B Blood tests for phenylketonuria should be obtained 48 to 72 hours after birth. The newborn will have had enough time to ingest protein through feedings and the chance of false-negative results will be reduced. 14. The nurse advising parents about feeding their infant who has phenylketonuria, would include the information to: a. Provide a life-long high-protein diet. b.
Use a formula that is low in the amino acid leucine.
c.
Feed the baby a soy-based formula.
d. Substitute Lofenalac for some protein foods. ANS: D A synthetic food providing enough protein for growth and tissue repair, but little phenylalanine, is substituted for natural protein foods. 16. The nurse instructing parents about positioning their toddler who has just had a body spica cast applied would include to: a. Prop the child upright with pillows for meals.
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b.
Use the bar between the legs to turn the child.
c.
Put the child on her abdomen to sleep.
d. Change the childs position frequently. ANS: D The childs position must be changed frequently to relieve pressure on body points and promote circulation. 17. The nurse explains that the Rh-negative mother who should receive RhoGAM is the mother who: a. Has had one Rh-negative child and is pregnant with an Rh-negative child b.
Had an Rh-positive baby and is pregnant with an Rh-positive baby
c.
Has had an O-negative child and is pregnant with a B-negative child
d. Is a primipara with an O-negative child ANS: B The only woman with antibodies against the Rh-positive baby is the Rh-negative woman who has had one Rh-positive child and is now pregnant with another. 18. When the parents ask what the light does for their jaundiced baby, the nurse responds that the light: a. Increases the babys metabolism b.
Stimulates liver function
c.
Dilates blood vessels
d. Breaks down bilirubin ANS: D Severe jaundice can cause kernicterus, an accumulation of bilirubin in the brain tissue, which can lead to serious brain damage. The light breaks down excess bilirubin so that it can be excreted. 19. Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired. The nurse explains that a child with a cleft lip usually undergoes surgical repair: a. Immediately after birth b.
By 3 months of age
c.
After 12 months of age
d. Varies in every case ANS: B A cleft lip is repaired by 3 months of age when weight gain is established and the infant is free of infection. 20. Phototherapy is instituted for an infant with jaundice. An appropriate nursing action for the infant with jaundice is to: a. Cover the infants head with a hat. b.
Dress the infant lightly in a T-shirt.
c.
Keep the infants eyes covered.
d.
Reposition at least every 4 to 8 hours.
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ANS: C The infants eyes are protected with patches to prevent damage from the high-intensity lights. 21. The nurse is caring for a newborn whose mother has diabetes. The nurse would assess the neonate for: a. Hypoglycemia b.
Erythroblastosis fetalis
c.
Intracranial hemorrhage
d. Pancreatic failure ANS: A The newborn of a mother with diabetes is prone to hypoglycemia. MULTIPLE RESPONSE 1. The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of a crack-addicted mother, which would be manifested by: Select all that apply. a. Body tremors b.
Excessive sneezing
c.
Hyperirritability
d.
Drowsiness
e. Excessive appetite ANS: A, B, C The neonate with abstinence syndrome will be hyperirritable and wakeful, have excessive sneezing or yawning, and have no appetite. 2. The nurse assesses the hydrocephalic child for increasing ICP, which would be manifested by: Select all that apply. a. High-pitched cry b.
Inequality of pupils
c.
Bulging fontanelles
d.
Diarrhea
e. Strabismus ANS: A, B, C Increased ICP is manifested by high-pitched cry, inequality of pupils, and bulging fontanelles. COMPLETION 1. The nurse uses a diagram to show that when the CSF is obstructed in the subarachnoid space rather than in the ventricles, the resulting hydrocephalus is diagnosed as ____________________ hydrocephalus. ANS: communicating NOT: Rationale: Communicating hydrocephalus occurs when the CFS is obstructed in the subarachnoid space rather than in the ventricles. 2. The nurse clarifies to the parents of a child with spina bifida that their child has a portion of the spinal cord in the sac, in addition to the meninges, which makes this defect a ____________________.
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ANS: meningomyelocele NOT: Rationale: A spina bifida that includes a portion of the cord in the sac in addition to the meninges is classified as a meningomyelocele. 3. The nurse demonstrates how to flush the ventriculoperitoneal shunt by the use of the ____________________ that is in place behind the babys ear. ANS: pump NOT: Rationale: A small pump is part of the VP shunt. The pump is in place behind the childs ear. The shunt can be pumped according to the physicians instructions in order to maintain flow from the ventricles to the peritoneum.
Chapter 7 Two-Week Visit 1. 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. 2. A nurse is providing discharge teaching to parents of a newborn. The baby had no medical problems and is healthy other than having failed an automated auditory brainstem response
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(AABR) hearing test conducted in the nursery. What information does the nurse provide? A. AABR tests are conclusive and the baby is deaf. B. Background noise may have interfered with the test. C. The babys hearing should be retested within 1 month. D. The baby should have another hearing test next week. ANS: C Babies who fail a hearing screening test at birth should have a follow-up test within a month. The AARB test can be conducted in the presence of background noise. The results are not conclusive (it is a screening device), which is why the babys hearing needs to be retested. 3. The perinatal nurse teaches new parents that the best sleeping position for infants is which of the following? A. Prone B. Side-lying C. Side-lying with a blanket roll behind the infants back D. Supine ANS: D The nurse should teach the parents that all newborns should be placed on their backs (supine) for sleep by every caregiver for the first year of life. 4. The nursery nurse notes the presence of diffuse edema on a newborn babys head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. What action by the nurse is best? A. Document the findings in the infants chart. B. Measure head circumference every 12 hours. C. Prepare to administer IV osmotic diuretics. D. Transfer the baby to the NICU for monitoring . ANS: A Caput succedaneum is diffuse edema that crosses the cranial suture lines and disappears without treatment during the first few days of life. It often is the result of a traumatic or difficult birth. The nurse should document the findings. No other action is needed.
5. The nurse completes an initial newborn examination. The nurses findings include the following: heart rate, 136 beats/minute; respiratory rate, 64 breaths/minute; temperature, 98.2F (36.8C). The nurse also documents a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which finding requires immediate consultation with the health-care provider? A. Absent bowel sounds B. Heart murmur C. Respiratory rate D. Temperature ANS: A Bowel obstruction in the neonate is often first identified by an absence of bowel sounds in a
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small, distinct section of the intestines; therefore, this finding should be reported. The other findings are normal (it is not uncommon to hear murmurs in infants less than 24 hours old). 6. The nurse is assessing the neonates skin and notes the presence of small irregular red patches on the cheeks that turn into single yellow pimples on the babys chest. What treatment and care does the nurse recommend to the parents to help resolve this rash? A. Apply aloe vera lotion to lesions and skin. B. Apply hormonal skin cream twice a day. C. None; it will disappear within about a month. D. Vigorously wash and cleanse the babys skin. ANS: C Erythema toxicum is a newborn rash that consists of small, irregular flat red patches on the cheeks that develop into singular, small yellow pimples appearing on the chest, abdomen, and extremities. The etiology is unknown and it may persist for up to a month before resolving on its own. 7.The mother of an infant born prematurely at 32 weeks expresses the desire to breastfeed her child. The nurse correctly responds with which statement when the mother asks how long she should breastfeed her baby? 1. Until the child begins solid foods. 2. Many breastfeed for 2 years. 3. It is recommended that mothers of preterm infants breastfeed at least a month. 4. Breast milk should be the only food for the first 6 months. Correct Answer: 4 Rationale 1: Breast milk should be the only food for the first 6 months, and should continue until 12 months even after solid foods are introduced. Rationale 2: Breast milk should be the only food for the first 6 months, and should continue until 12 months even after solid foods are introduced. Rationale 3: Breast milk should be the only food for the first 6 months, and should continue until 12 months even after solid foods are introduced. Rationale 4: Breast milk should be the only food for the first 6 months, and should continue until 12 months even after solid foods are introduced. Global Rationale: Breast milk should be the only food for the first 6 months, and should continue until 12 months even after solid foods are introduced. 8. The nurse is instructing a parent of a newborn on the foods that are to be started based on age. The nurse instructs the parent that the first food given to a newborn is rice cereal. What statement by the parent suggests appropriate understanding of the next food that can be introduced? 1. Chicken can be given next. 2. Eggs can be given next. 3. Fruits should be given next. 4. Whole milk should be started. Correct Answer: 3
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Rationale 1: Chicken is not given until 810 months, eggs are not given until 12 months, and whole milk is given at 12 months. Fruits are given after rice cereal. Rationale 2: Chicken is not given until 8-10 months, eggs are not given until 12 months, whole milk is given at 12 months. Fruits are given after rice cereal. Rationale 3: Chicken is not given until 8-10 months, eggs are not given until 12 months, whole milk is given at 12 months. Fruits are given after rice cereal. Rationale 4: Chicken is not given until 8-10 months, eggs are not given until 12 months, whole milk is given at 12 months. Fruits are given after rice cereal. Global Rationale: Chicken is not given until 8-10 months, eggs are not given until 12 months, whole milk is given at 12 months. Fruits are given after rice cereal. 9. A follow-up visit for a newborn client is scheduled with the pediatric nurse practitioner 3 days after discharge. What will the nurse include in the assessment during the scheduled visit for this newborn? Standard Text: Select all that apply. 1. Feeding pattern 2. Jaundice 3. Length 4. Vision screen 5. Sleep pattern Correct Answer: 1,2,5 Global Rationale: Feeding pattern, sleep pattern, and jaundice assessment would be appropriate 3 days after discharge. It would not be necessary to do a length or vision screen at this age. 10. A nursery nurse is planning care for the newborns currently in the newborn nursery. Which activities does the nurse plan for the first 48 hours of life? Standard Text: Select all that apply. 1. Monitor feeding behaviors. 2. Perform a hearing screening. 3. Perform a heel stick to obtain blood for the newborn screen. 4. Monitor the mother as she performs the first newborn bath to remove blood and amniotic fluids. 5. Administer folic-acid injection to the infant to prevent bleeding. Correct Answer: 1,2,3 Global Rationale: The nurse should assess feeding behaviors of the infant whether the infant is breast-fed or bottle-fed. A hearing screening is performed on all newborn infants prior to discharge. The newborn screen is performed prior to infant discharge from the newborn unit. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. Vitamin K is administered, not folic acid. 11. A nurse is discharging parents and their new infant. When assisting the family to place the infant in a car seat, which observation leads the nurse to reinforce teaching? A. The baby is wearing a sack-type sleeper. B. The baby is wearing a single layer of clothes.
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C. The parent checks the temperature of the car seat. D. A rear-facing car seat is in the back seat. ANS: A Sack-type sleepers are not recommended for wearing in a child safety seat because the straps may not fit properly. The other observations are appropriate.
Chapter 8 One-Month Visit 1.New parents wish to include their extended family in welcoming their new baby. What suggestion does the nurse offer this couple? A. Avoid visitors for a month to prevent illness. B. Do not permit other individuals to feed the baby. C. Encourage visiting when the baby is sleeping. D. Welcome family in small groups for short visits. ANS: D Nurses can foster attachment in several ways, including encouraging parents to invite siblings and other family members to visit for short periods of time to avoid tiring the mother and overstimulating the baby. Of course sick people should not visit. Others can be recruited to feed the baby, and often relatives and close friends desire to do so. If all the visiting takes place when the baby is sleeping, the baby and the visitors cannot get to know each other. 2. Prior to giving a newborn the first bath, what action by the nurse is most appropriate? A. Assess the infants temperature.
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B. Ensure the tub water is not too hot. C. Obtain all of the needed supplies. D. Take the babys blood pressure. ANS: A Preventing temperature instability is a critical nursing action when bathing an infant in the hospital. If the infants temperature is within normal limits, the baby can be given a sponge bath. After the umbilical cord stump falls off, the infant can be bathed in a tub of water. Obtaining needed supplies is always important prior to performing any procedure, but this is not as important as maintaining safety. Taking the blood pressure is not needed. 3. A nurse notes that an infant has a drooping tongue, which causes difficulty with feeding. What cranial nerve should the nurse assess further? A. Facial B. Olfactory C. Trigeminal D. Vagus ANS: A Birth-related damage to the 7th cranial nerve (facial) can lead to drooping tongue or mouth, unequal movement of the cheek muscles, or inappropriate eyelid movement. 4. A nursing student is measuring a newborn babys head circumference. Which action by the student demonstrates good understanding of this procedure? A. Measures three times, records the average B. Places tape measure at the hair line C. Records the largest of three measurements D. Uses two finger-breadths to estimate size ANS: C The student should measure the infants head three times and record the largest of the three measurements. The other actions are incorrect; the student should not use the average, the tape measure is placed above the eyebrows and pinna of the ear, and a tape measure is used, not the fingers. 5.A nurse takes a newborns initial set of vital signs and records the following: Temperature: 97.9F (36.6C), pulse: 198 beats/minute, respirations: 78 breaths/minute, blood pressure: 64/44 mm Hg. What does the nurse conclude about this infant? A. Hypotensive: needs IV fluid administration B. Hypothermic: needs to be put in an incubator C. Tachycardic: take pulse again when baby is not crying D. Tachypneic: suction if needed, administer oxygen per protocol ANS: D A normal respiratory rate for an infant is 3060 breaths/minute. This respiratory rate is too rapid, and the nurse needs to suction the infant if needed and provide oxygen per protocol. The blood pressure and temperature are normal. The heart rate is too fast, even for a crying baby.
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6. A nurse is beginning a newborns physical assessment and notes that the infant is jumpy and seems irritable when being handled and when the nurse or parents speak. What action by the nurse is best? A. Ask the mother to attempt to breastfeed the infant. B. Conduct the assessment quickly then swaddle the baby. C. Increase the heat in the room so the baby wont get chilled. D. Postpone the assessment until the infant has calmed. ANS: D An infant who seems irritable and overreacts to voices, touch, or movement is displaying disorganized behavior. The nurse should postpone the physical examination until the infant has been calmed. To continue the assessment would risk increasing the babys behavioral disorganization and would be disruptive for the infant. The other actions are not appropriate in this situation, although swaddling can help calm the baby, as can cuddling, rocking, and gentle holding. 7.A student nurse is verbalizing disappointment in a new mothers seeming lack of interest in her newborn baby. The student complains to the registered nurse that the mother just wants to sleep and have someone else care for the infant. What response by the registered nurse is best? A. Assess closely; we may need to call social work. B. Dont judge other people until you have had a baby. C. The mother may be completely exhausted from the childbirth experience. D. We have to accept that everyones experience is different. ANS: C Each option has an element of an appropriate response to the student. A definitive lack of bonding may call for a social work consult. Nurses should not judge other peoples responses. Every mothers experience is different. However, the best response is the one that gives the student definitive information that can clarify the situation. After a long and possibly difficult birth, the mother may be too exhausted and too overwhelmed to assume an active role in parenting at this point. The student should show acceptance, reinforce previously taught information, allow the mother rest, and assist with bonding as opportunities present themselves, praising the mother for her efforts. 8.While teaching the parents of a newborn about infant care and feeding, which instruction by the nurse is the most appropriate? 1. Delay supplemental foods until the infant is 4 to 6 months old. 2. Delay supplemental foods until the infant reaches 15 pounds or greater. 3. Begin diluted fruit juice at 2 months of age, but wait three to five days before trying a new food. 4. Add rice cereal to the nighttime feeding if the infant is having difficulty sleeping after 2 months of age. Correct Answer: 1 Global Rationale: Four to six months is the optimal age to begin supplemental feedings because earlier feeding of nonformula foods is not needed by the infant and does not promote sleep. Earlier feeding of nonformula foods, regardless of the infants weight, is more likely to cause the development of food allergies. Also, early feeding is not well tolerated by infants because the
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necessary tongue control is not well developed and they lack the digestive enzymes to take in and metabolize many food products.
Chapter 9 Two-Month Visit 1. At a 2-month well-child visit, parents ask the nurse about the red area on the babys neck. They tell the nurse that the mark appeared a few weeks after birth. The nurse recognizes this skin lesion as a(n): a. Port wine nevus b.
Strawberry nevus
c.
Exanthum
d. Intertrigo ANS: B The strawberry nevus is a common hemangioma consisting of dilated capillaries in the dermal space, which may not become apparent for a few weeks after birth. 2. Parents of a 2-month-old Down syndrome infant should be instructed, because of the generalized hypotonicity of the child, that special attention should be given to:
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a.
Careful feeding
b.
Respiratory care
c.
Range of motion
d. Incontinent care ANS: B The child with Down syndrome has generalized hypotonicity, which caused mucus accumulation and respiratory problems 3. The nurse is careful to apply only the prescribed amount of ointment to the skin of a 2-monthold because the infants skin, compared to the adults, has: a. Less perfusion b.
Greater moisture
c.
More perspiration
d. Greater absorption ANS: D The childs skin has a dramatically greater ability to absorb than does that of the adult.
4. The nurse is watching new parents suction their newborn. The baby begins gagging. What action should the nurse demonstrate to the parents? A. Pick the baby up and comfort her. B. Place the baby on her back. C. Turn the babys head to the side. D. Wipe secretions out with a cloth. ANS: C If the baby begins gagging or vomiting, the parents (or nurse) should position the infants head to the side or downward to prevent aspiration. The other actions are not appropriate.
5.The nurse is assessing an infant client and parents during a routine health supervision visit at 2 months of age. Which items will the nurse assess to determine if the infants mental health needs are being addressed? Standard Text: Select all that apply. 1. Immunization record 2. Newborn screen results 3. Temperament during the visit 4. Feeding schedule 5. Sleep-wake patterns Correct Answer: 3,4,5 Global Rationale: When addressing mental health issues, the nurse would assess the infants temperament during the visit, feeding schedule, and sleep-wake patterns. The infants mental
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health is related to early experiences, inborn characteristics such as temperament and resilience, and relationships with caregivers. The first year of life provides many opportunities for the infant to develop positive mental health; interventions during this important period can enhance the childs future mental status. The immunization record and the newborn screen results will not provide the needed information for the nurse in terms of whether the infants mental health needs are being addressed. 6.When assessing a newborn baby, which action should the nurse perform first? A. Auscultate the babys heart and lungs. B. Don clean gloves before taking the baby. C. Record the parents choice of name. D. Suction the nares and then the mouth. ANS: B The nurse should observe standard precautions when handling a neonate until all blood and amniotic fluid has been removed to avoid possible infection. Then the nurse can take the baby and suction the babys mouth, and then the nares if needed. Auscultating the babys heart and lungs will occur later. The parents may not name the baby immediately, but even if they have, recording the name would not take priority over using standard precautions to prevent the spread of disease.
Chapter 10 Four-Month Visit 1. The nurse is teaching the parents of a 4-month-old infant about good feeding habits. The nurse emphasizes the importance of holding the baby during feeding and not letting the infant go to sleep with the bottle. Which disorder is associated with propped feedings and going to sleep with the bottle? 1. Otitis media 2. Aspiration 3. Malocclusion problems 4. Sleeping disorders Correct Answer: 1 Global Rationale: It has been shown in numerous studies that allowing an infant to fall asleep with a bottle in his or her mouth causes pooling of the formula in the mouth, which increases the risk of both dental caries and otitis media. There has been limited data to date showing a positive correlation between bottle propping and increased risk of aspiration, malocclusions, and sleeping disorders.
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2.During a 4-month-olds well-child check, the nurse discusses introduction of solid foods into the infants diet and concerns for foods commonly associated with food allergies. Due to allergies, which foods will the nurse instruction the parents to avoid until after 1 year of age? 1. Strawberries, eggs, and wheat 2. Peas, tomatoes, and spinach 3. Carrots, beets, and spinach 4. Squash, pork, and tomatoes Correct Answer: 1 Global Rationale: Strawberries, eggs, and wheat, along with corn, fish, and nut products, are all foods that have commonly been associated with food allergies. Carrots, beets, and spinach contain nitrates and should not be given before the age of 4 months. Squash, peas, and tomatoes are acceptable to try after an infant is 4 to 6 months old but should be given one at a time and three to five days after starting a new food. Pork can be tried after the infant is 8 to 10 months old, as meats are harder to digest and have a high protein load. 3. A nurse asks the mother of a 4-month-old infant to undress the infant. The nurse observes the mother taking off several layers of clothing and knows that the outdoor temperature is 70 degrees Fahrenheit. Which statement by the nurse is most appropriate in this situation? 1. My, you are dressing your infant warmly today. 2. Did you think it was cold when you left your home this morning? 3. I see that you have many layers of clothing on your baby. This may cause your babys temperature to rise. 4. When you leave the office, only put one layer of clothing on your baby. Correct Answer: 3 Rationale 1: In this scenario, the mother has overdressed the infant. The nurse needs to \ Global Rationale: In this scenario, the mother has overdressed the infant. The nurse needs to gently inform the mother of this problem and to provide information to the mother on why it is a problem. Just making a statement on how warmly the child is dressed will not accomplish this goal or just telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time, so this statement also is not helpful to the mother.
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Chapter 11 Six-Month Visit 1. A mother asks which developmental milestones she can expect when her baby is 6 months old. Which response by the nurse is the most appropriate? 1. Lifts head momentarily when prone 2. Has well-developed pincer grasp 3. Transfers objects from one hand to the other 4. Rolls from front to back Correct Answer: 3 Global Rationale: Lifting head when prone is a milestone at 1 month. A well-developed pincer grasp is a milestone at 12 months. Transferring objects from one hand to the other is a milestone at 6 months. Rolling from front to back is a milestone at 4 months. 2. The nurse is counseling the parents of a 6-1/2-month-old infant. Which age-appropriate toy is most appropriate for the nurse to suggest to these parents? 1. Soft, fluid-filled ring that can be chilled in the refrigerator 2. Colorful rattle
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3. Jack-in-the-box toy 4. Push-and-pull toy Correct Answer: 1 Global Rationale: Teething toys would be appropriate for this age. The rattle might be better enjoyed by a 3- to 6-month-old infant, and the jack-in-the-box and push-and-pull toys are better suited for a 9- to 12-month-old child.
Chapter 12 Nine-Month Visit 1. While assessing the development of a 9-month-old infant, the nurse asks the mother if the child actively looks for toys when they are placed out of sight. Which developmental task is the nurse assessing this infant for? 1. Object permanence 2. Centration 3. Transductive reasoning 4. Conservation Correct Answer: 1 Global Rationale: A child who has developed object permanence has the ability to understand that even though something is out of sight, it still exists. In centration, a child focuses only on a particular aspect of a situation. Transductive reasoning happens when a child connects two events in a cause-effect relationship because they have occurred at the same time. Conservation describes when a child knows that matter is not changed when its form is altered. 2. A nurse is assessing an 11-month-old infant and notes that the infants height and weight are at the 5th percentile on the growth chart. Family history reveals that the infants two siblings are at the 50th percentile for height and at the 75th percentile for weight. Psychosocial history reveals that the parents are separated and are planning to divorce. Which of these nursing diagnoses takes priority?
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1. Alteration in Growth Pattern Related to Parental Anxiety 2. Alteration in Growth Pattern Secondary to Familial Short Stature 3. Nutritional Intake: Excessive Secondary to Maternal Feeding Patterns 4. At Risk for Constitutional Growth Delay Related to Decreased Appetite Correct Answer: 1 Global Rationale: The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is alteration in growth patterns related to parental anxiety. There is no data that indicates familial short stature. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. This infant is not at risk for constitutional growth delay.
Chapter 13 Twelve-Month Visit 1.While in the pediatricians office for their childs 12-month well-child exam, the parents ask the nurse for advice on age-appropriate toys for their child. Based on the childs developmental level, which types of toys would the nurse suggest? Standard Text: Select all that apply. 1. Soft toys that can be manipulated 2. Small toys that can pop apart and go back together 3. Jack-in-the-box toys 4. Toys with black and white patterns 5. Push-and-pull toys Correct Answer: 1,3,5 Global Rationale: Both gross and fine motor skills are becoming more developed, and children at this age enjoy toys that can help them refine these skills. They tend to enjoy more colorful toys at this age and are more mobile and thus have less interest in placing toys in their mouths and more interest in toys that can be manipulated. 2. A mother calls the pediatricians office because her infant is colicky. The helpful measure the nurse would suggest to the parent is:
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a.
Sing songs to the infant in a soft voice.
b.
Place the infant in a well-lit room.
c.
Walk around and massage the infants back.
d. Rock the fussy infant slowly and gently. ANS: D One technique the nurse can offer parents of a fussy infant is to rock the infant gently and slowly while being careful to avoid sudden movements. 3. The nurse is aware that the age at which the posterior fontanelle closes is: a. 2 to 3 months b.
3 to 6 months
c.
6 to 9 months
d. 9 to 12 months ANS: A The posterior fontanel closes between 2 and 3 months of age. 4. The nurse knows that an infants birthweight should be tripled by: a. 9 months b.
1 year
c.
18 months
d. 2 years ANS: B 5. The nurse is aware that the age at which an infant is able to sit steadily alone is: a. 4 months b.
5 months
c.
8 months
d. 15 months ANS: C The infant can sit alone without support at about 8 months of age. 6. The infant should be able to walk independently by the age of: a. 8-10 months b.
12-15 months
c.
15-18 months
d. 18-21 months ANS: B For the majority of children, the milestone of walking alone is achieved between 12 and 15 months. 7. The parent of a 3-month-old infant asks the nurse, At what age do infants usually begin drinking from a cup? The nurse would reply: a. 5 months
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b.
9 months
c.
1 year
d. 2 years ANS: A The infant can usually drink from a cup when it is offered at about 5 months. 8. The nurse would expect a 4-month-old to be able to: a. Hold a cup b.
Stand with assistance
c.
Lift head and shoulders
d. Sit with back straight ANS: C Because development is cephalocaudal, of these choices, sitting is the one that the infant learns to do first. The infant can usually sit with support at about 5 months of age and can sit alone at about 8 months. 9. The abnormal finding in an evaluation of growth and development for a 6-month-old infant would be: a. Weight gain of 4-7 ounces per week b.
Length increase of 1 inch in 2 months
c.
Head lag present
d. Can sit alone for a few seconds ANS: C The infant should be holding the head up well by 5 months of age. If head lag is present at 6 months, the child should undergo further evaluation. 10. A parent brings a 6-month-old infant to the pediatric clinic for her well-child examination. Her birthweight was 8 pounds, 2 ounces. The nurse weighing the infant today would expect her weight to be at least: a. 12 pounds b.
16 pounds
c.
20 pounds
d. 24 pounds ANS: B Birth weight is usually doubled by 6 months of age. 11. The nurse would advise a parent when introducing solid foods to: a. Begin with one tablespoon of the food. b.
Mix foods together.
c.
Eliminate a refused food from the diet.
d. Introduce each new food 4 to 7 days apart. ANS: D Only one new food is offered in a 4- to 7-day period to determine tolerance.
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12. When talking with a parent about tooth eruption, the nurse explains that the first deciduous teeth to erupt are the: a. Lower central incisors b.
Upper central incisors
c.
Lower lateral incisors
d. Upper lateral incisors ANS: A The first teeth to erupt, usually at about 7 months, are the lower central incisors. 13. When assessing development in a 9-month-old infant, the nurse would expect to observe the infant: a. Sitting if supported b.
Grasping objects with the palm
c.
Imitating sounds such as da-da
d. Beginning to use a spoon rather sloppily ANS: C The 9-month-old tries to imitate sounds such as da-da or ba-ba. 14. The statement made by a parent that indicates correct understanding of infant feeding is: a. Ive been mixing rice cereal and formula in the babys bottle. b.
I switched the baby to low-fat milk at 9 months.
c.
The baby really likes little pieces of chocolate.
d. I give the baby any new foods before he takes his bottle. ANS: D New solid foods should be introduced before formula or breast milk to encourage the infant to try new foods. 15. The nurse would advise a mother who is concerned because her 10-month-old is lethargic, to: a. Keep the babys room well-lit. b.
Rub the babys soles vigorously.
c.
Offer the baby a pacifier.
d. Handle the infant slowly and gently. ANS: D Some infants respond to stimulating environments by shutting down. Move and handle infants slowly and gently. 16. The nurse discusses safety-proofing the home with the mother of a 9-month-old. The statement made by the mother that indicates an unsafe behavior is: a. I put covers on all of the electrical outlets. b.
In the car, she rides in a front-facing car seat.
c.
There are locks on all of the cabinets in the house.
d.
I have a gate at the top and bottom of the stairs.
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ANS: B A rear-facing infant car seat should be used for infants under 1 year of age. 17. The nurse observes a 10-month-old infant using her index finger and thumb to pick up Cheerios. This behavior is evidence that the infant has developed the: a. Pincer grasp b.
Grasp reflex
c.
Prehension ability
d. Parachute reflex ANS: A By 1 year, the pincer-grasp coordination of index finger and thumb is well established. 18. A parent is concerned because her infant has a diaper rash. The nurse would advise the parent to: a. Use commercial diaper wipes to clean the area. b.
Apply a protective ointment on the area.
c.
Change the babys diaper less frequently.
d. Keep the diaper area covered all of the time. ANS: B A protective ointment can be applied when the skin in the diaper area appears pink and irritated. 19. The mother of an infant born prematurely tells the nurse, The baby is irritable. He cries during diaper changes and feedings. Can you make some suggestions about what I should do to soothe him? The most appropriate recommendation to help this parent would be: a. Play the radio or TV while you feed the baby. b.
Put the baby in a room with sunlight.
c.
Cover the baby snugly when you hold him.
d. Change the babys position quickly. ANS: C A strategy that may be helpful is to swaddle the infant snugly in a light blanket with extremities flexed and hands near the face. 20. The most appropriate activity to recommend to parents to promote sensorimotor stimulation for a 1-year-old would be: a. Ride a tricycle. b.
Spend time in an infant swing.
c.
Play with push-pull toys.
d. Read large picture books. ANS: C Push-pull toys are appropriate to promote sensorimotor stimulation for a 1-year-old child. 21. The statement that indicates the mother of an 8-month-old understands infant sleep patterns is: a. I put the baby in my bed until she falls asleep, then I put her in her crib.
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b.
I let the baby skip an afternoon nap so she will fall asleep earlier.
c.
I put the pacifier in the crib so she can find it when she wakes up.
d. I rock the baby back to sleep if she wakes up at night. ANS: C The parent should assist the infant to develop self-soothing behaviors so the infant can get back to sleep on her own. MULTIPLE RESPONSE 22. The nurse is aware that the 7-month-old can signal feeding readiness by: Select all that apply. a. Pulling spoon toward mouth b.
Biting at spoon with upper and lower incisors
c.
Pointing to food bowl
d.
Bouncing up and down with excitement at sight of food
e. Manipulating finger foods ANS: A, E The 7-month-old pulls the spoon toward its mouth, and can manipulate finger foods. The 7month-old does not have upper incisors and has not developed adequately to recognize the food container or exhibit excitement related to the sight of food. COMPLETION 2. The nurse reminds the parents that the first DPT, oral polio, and flu immunizations should be given when the child is ____________________ months old. ANS: 2 of Disease NOT: Rationale: The first DPT, polio, and flu immunizations are given at the age of 2 months. 24. The nurse explains the second process of self-mobility a baby learns is seen at the age of 9 months, when the baby begins to ____________________. ANS: creep NOT: Rationale: At 7 months the baby begins to crawl, using arms and dragging trunk and legs. At 9 months the baby begins to creep, holding its trunk above the floor. The next self-mobility activity is cruising, where the child walks from one piece of furniture to the next before it begins to walk independently. 25. The nurse cautions parents to place their baby in the ____________________ or ____________________ positions, rather than on its stomach, to reduce the risk of sudden infant death syndrome (SIDS). ANS: supine or side-lying NOT: Rationale: The supine or side-lying position has been found to reduce possible 26. The nurse explains that a babys prehensile development is progressive and logical. Arrange the development in the order from the simplest to the most complex. a. Hands held open most of the time b. Grasps with thumb on one side and three fingers on the other c. Picks up toy with squeeze action d. Thumb and forefinger hold object e. Hands held closed most of the time
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ANS: E, A, C, B, D The development advances from the newborns closed hands to the open star hands of the older infant, to the squeeze action, to a grasp with thumb and fingers, to the pincher movement of thumb and forefinger.
Chapter 14 - Fifteen- to Eighteen-Month Visit 1.During a clinic visit, the parents of a 15-month-old ask what disease and injury prevention topics would be appropriate to discuss at this age. Which response by the nurse is the most appropriate? 1. Its never too early to teach a child to wear a helmet when riding a bicycle. 2. Teaching simple handwashing is a good topic at this age. 3. Tell the child over and over to stay away from water unless you are with him. 4. Tell him firmly no when he tries to cross the street. Correct Answer: 2 Global Rationale: Disease and injury prevention are ongoing topics at all ages. Simple handwashing is appropriate for a 15-month-old child. A 15-month-old is too young for bicycle riding, so this can be delayed. A 15-month-old is too young to understand water safety and crossing the street, and should never be left unattended in these situations. 2.A mother of an 18-month old asks the nurse whether she can begin to introduce low-fat milk like the rest of the family drinks. The nurse answers the mother based on the knowledge that low-fat milk can safely be introduced at what age? 1. 18 months 2. 24 months
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3. 3 years 4. 4 years Correct Answer: 1 Global Rationale: Health promotion for the toddler includes whole milk until age 2. Age 1 is too early for low-fat milk, and it can safely be introduced before ages 3 and 4. 3.A nurse is preparing to perform a physical assessment on a toddler. Which action is most appropriate for the nurse to take? 1. Perform the assessment from head to toe. 2. Leave intrusive procedures such as ear and eye examinations until the end. 3. Explain each part of the examination to the child before performing it. 4. Ask the mother to tell the child not to be afraid. Correct Answer: 2 Global Rationale: Intrusive procedures such as examination of the ears, throat, eye, and genital areas should be done last to decrease the anxiety of the child during the initial phases of the examination, which includes the heart and lungs.
Chapter 15 Two-Year Visit 1. A 27-month-old toddler who is in the pediatric office for a well-child visit begins to cry the moment he is placed on the examination table. The parent attempts to comfort the toddler; however, nothing is effective. Which of these actions by the nurse takes priority? 1. Instruct the father to hold the toddler down tightly to complete the examination. 2. Allow the toddler to sit on the parents lap and begin the assessment. 3. Allow the toddler to stand on the floor until he stops crying. 4. Ask another nurse in the office to hold the toddler, since the parent is not able to control the toddlers behavior. Correct Answer: 2 Global Rationale: Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the examination of the throat and ears to prevent injury from movement.
2. Which statement by the nurse is most appropriate prior to giving an intramuscular injection to a 2-1/2-year-old child? 1. We will give you your shot when your mommy comes back.
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2. This is medicine that will make you better. First we will hold your leg, then I will wipe it off with this magic cloth that kills the germs on your leg right here, then I will hold the needle like this and say one, two, three . . . go and give you your shot. Are you ready? 3. It is all right to cry, I know that this hurts. After we are done you can go to the box and pick out your favorite sticker. 4. This is a magic sword that will give you your medicine and make you all better. Correct Answer: 3 Global Rationale: The most appropriate response would be to acknowledge the childs feelings and give her something to look forward to (picking out a sticker). Waiting for the mother to come back would be inappropriate because toddlers do not have an understanding of time. Giving elaborate descriptions and using colorful language are inappropriate. The instructions should not end with a are you ready statement because the toddler will say no. You also dont want to frighten and/or confuse the child by using statements such as use of a magic sword.
Chapter 16 Three-Year Visit (Preschool) MULTIPLE CHOICE 1. Which of the following statements best describes the 3-year-old child? a. Boisterous, tattles on others b.
Aggressive, shows off
c.
Helpful, wants to assist with chores
d. Talkative, inquisitive about the environment ANS: C Three-year-old children are helpful and can assist in simple household chores. 2. 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
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Masturbation at this age is common and indicates that the preschooler has a normal curiosity about sexuality. 3. A preschool-age child is asked, Why do trees have leaves? Which of the following responses would be an example of animism? a. So I can have shade over my sandbox. b.
Because God made them that way.
c.
To hide behind when they are scared.
d. For the squirrels to play in. ANS: C Animism describes the tendency of preschool children to attribute human characteristics to nonhuman objects. 4. The tasks that would be appropriate to expect of a 5-year-old would be: a. Setting the table with paper plates b.
Washing the dirty knives
c.
Carrying glasses from the table to the sink
d. Scrubbing out the sink with cleanser ANS: A Parents must consider developmental level and safety when asking the 5-year-old child to help with chores. 5. A 3-year-old child, while playing with her favorite toy in the playroom of the pediatric unit, is approached by another child who also wants to play with the same toy. The nurse anticipates that the 3-year-old will: a. Play well with the other child b.
Give the toy up and then not play any more
c.
Become angry and a physical response might ensue
d. Ignore the toy and go on to something else ANS: C The 3-year-old child is egocentric and likely will become angry when others attempt to take his or her possessions. 6. A parent is concerned about her childrens reaction should their grandmother die. In planning a response, the nurse is guided by the understanding that: a. Children are unlikely to notice their grandmothers absence if no one reminds them. b.
Young children often understand that other people die, but do not equate it with themselves.
c.
The childrens response will depend entirely on whether they have been acquainted with death before th
d. Children can understand the concept of a higher being much like adults can. ANS: B Between 3 and 4 years of age, the child becomes curious about death and dying. They may realize that others die, but they do not relate death to themselves. 7. The intervention that is most effective in dealing with occasional aggression in a 4-year-old child is:
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a.
Have the child take a time-out in the corner for 4 minutes.
b.
Spank the child at the time of the incident.
c.
Take away television privileges for the day.
d. Send the child to his room for 30 minutes. ANS: A Time-out periods, usually lasting 1 minute per year of age, with the child sitting in a chair or corner, are considered an effective disciplinary technique. 8. A parent is concerned about how to make his preschool-age child stop sucking his thumb and asks the nurse for suggestions. The nurses most helpful response would be: a. Most children will stop thumb-sucking naturally by school age. b.
Over-the-counter treatments that give a bad taste can be placed on the thumb to discourage the practice
c.
Consistently touching the childs fingers whenever he sucks his thumb is most effective.
d. Thumb-sucking is detrimental to the eruption of the childs teeth and must be stopped as soon as possibl ANS: A Most children give up the habit of thumb-sucking by the time they reach school. 9. The nurse characterizes the play of 5-year-old children as: a. Rough and tumble play b.
Well-organized games
c.
Following rules
d. Prefer inside activities ANS: C The 5-year-old wants to play by the rules but cannot accept losing. The rules may be very strict or change as the game progresses. 10. When discussing preschoolers sexual curiosity with the parent, the nurse determines that the parent understands the information when she states she would: a. Make up funny words for body parts. b.
Distract my child with a toy if she asks about sex.
c.
Answer her questions when she asks.
d. Tell her to ask me again when she is 6 years old. ANS: C Parents should provide sex education at the time the child asks about sex. 11. In planning care for a moderately retarded child, the type of play most appropriate is: a. Play should exercise leg and arm muscles. b.
Play should be educationally oriented to make up for lost time.
c.
Play should be adjusted to her mental age rather than her chronological age.
d. Play is not a necessary component of the care of a mentally retarded child. ANS: C
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The nurse must consider the childs mental age rather than her chronological age when selecting toys for play. 12. The nurses best advice to a parent about a preschoolers imaginary friend would be that: a. Imaginary friends is a sign that the child has a low self-esteem. b.
It is common for preschoolers to have imaginary friends.
c.
The preschooler invents an imaginary friend when he feels overwhelmed.
d. The best approach to dealing with an imaginary friend is to ignore them. ANS: B Imaginary friends are common and normal during the preschool period and serve many purposes, such as relief from loneliness, mastery of feats, and scapegoat. 13. The nurse suggests measures that might be helpful for the child with enuresis, such as: a. Apply an electric pad that gently shocks the child. b.
Wake the child several times during the night to urinate.
c.
Decrease fluid intake after the evening meal.
d. Increase dietary fiber intake. ANS: C If a child is experiencing enuresis, liquids after dinner should be limited and the child should routinely void before going to bed. 14. The nurse suggests that the most appropriate toy choice for a 3-year-old would be: a. A board game b.
A small pet, such as a goldfish
c.
A large construction set
d. Push-pull toys ANS: C Large construction sets are suitable toys for the preschool-age child. 15. The parent of a 3-year-old child tells the nurse, My daughter points whenever she wants me to get something for her but she understands me when I ask her to do something. Based on the parents comment, the nurse recognizes that: a. The childs language development is age-appropriate. b.
The child may have expressive language delay.
c.
The child has a receptive language delay.
d. The child should have her hearing tested. ANS: B An expressive language delay is suspected when the child understands spoken language but is not talking. 16. The parent of a 4-year-old child tells the nurse, Bedtime is difficult. I cant get my child to bed at night. The nurse and the childs mother discuss options and decide that the best choice would be to: a. Allow the child to put himself to bed when he is tired.
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b.
Let the child read in his room until he falls asleep.
c.
Establish a bedtime routine and use it consistently.
d. Tire him out with physical activity before bedtime. ANS: C Parents should engage the child in quiet activities before bedtime and establish a ritual that signals readiness for bedtime. 17. The nurse understands that a fear unique to the preschool period is: a. Fear of water b.
Fear of animals
c.
Fear of bodily harm
d. Fear of death ANS: C The fear of bodily harm, particularly the loss of body parts, is unique to this stage. 18. A 4-year-old child tells the nurse that he will not eat peas because they are green. This is an example of: a. Egocentrism b.
Artificialism
c.
Animism
d. Centering ANS: D The tendency to concentrate on a single outstanding characteristic of an object while excluding other features is known as centering. 19. A 4-year-old child insists that he has more money with a nickel than his father has with a dime. The nurse is aware that this perception is described in Piagets theory as: a. Egocentrism b.
Artificialism
c.
Animism
d. Centering ANS: D The intuitive stage, as described by Piaget, is prelogical thinking that is based on the outside appearance of objects. A nickel is larger than a dime, and therefore more valuable MULTIPLE RESPONSE 1. The nurse suggests that bedtime preparation be preceded by rituals, such as: Select all that apply. a. Telling a story b.
Placing a favorite toy in bed
c.
Placing a glass of water at the bedside
d.
Turning on a night light
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e. Playing energetically ANS: A, B, C, D All options are soothing and bedtime suggestive rituals except energetic playing, which would be stimulating and counterproductive to sleep. 2. The nurse planning a seminar on safety for the preschooler will focus on: Select all that apply. a. Poison b.
Burns
c.
Falls
d.
Abduction
e. Car-pedestrian ANS: A, B, C, D, E All of the options are significant safety threats to the preschooler because of their developmental characteristics of playing boisterously, imitating their parents using matches, and drinking from bottles or taking pills. Their egocentrism does not make them suspicious of strangers. 3. The nurse points out that among the advantages of a nursery school experience are: Select all that apply. a. Increasing self-confidence b.
Fostering group cooperation
c.
Detecting adjustment problems
d.
Enhancing social skills
e. Playing experiences with other children ANS: A, B, C, D, E Nursery school increases self-confidence, group cooperation, social skills, and cooperative play. Objective observations by a nursery school instructor can detect early adjustment problems. 1. When planning an activity for a 3-year-old, the nurse bases the plan on the average attention span of ____________________ minutes. ANS: 15
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Chapter 17 Six-Year Visit (School Readiness) 1.The school nurse performs screenings on all students in the middle school. In addition, the nurse will perform selected screenings on individual school-age children. When planning the screenings for the year, which screenings will the nurse include for all school-age children? Standard Text: Select all that apply. 1. Hearing 2. Height and weight 3. Blood-pressure measurement 4. Hepatitis B profile serology 5. Chest x-ray Correct Answer: 1,2,3 Global Rationale: Routine screening for school-age children include hearing, checking for height and weight, and blood-pressure measurements. The hepatitis B profile is only needed once, prior to administration of hepatitis B vaccine; however, this is not a required screening for all schoolage children. A chest x-ray is not a routine screening test for school-age children. 2.An school-age client who recently moved to a new school in a different town presents to an ambulatory care center and describes the following: I have no friends in my new school, and I no
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longer want to go to play soccer. I know I will be lonely there, too. Which of these takes priority when speaking with the school-age client? 1. Helping the school-age client realize the value of soccer 2. Promoting healthy mental-health outcomes 3. Acknowledging the fact that it takes several months to make new friends at a new school 4. Stressing the importance of remaining in a close parentchild relationship during these stressful times Correct Answer: 2 Global Rationale: The school-age client is obviously lonely with the move to the new school. The nurse should focus on appropriate coping skills, which will enhance good mental-health outcomes for the child. It would not be appropriate to discuss the importance of soccer at this time, since the school-age client must deal with the loss of friends and developing new friendships first. The parentchild relationship should not be used as a substitute for the development of new peer relationships. 3. The nurse is aware that, in general, the school-age child will: a. Grow 3 to 6 inches/year b.
Gain 5 to 7 pounds/year
c.
Increase head circumference by 1 inch/year
d. Reach a visual acuity of 20/20 by 9 years of age ANS: B During the school-age period, the average weight gain per year is generally 5.5 to 7 pounds. 4. The nurse, planning to teach a class on nutrition to fourth-grade students, would keep in mind that school-age children: a. Can concentrate on only one aspect of a situation b.
Can think abstractly
c.
Are egocentric in their thinking
d. Think logically and concretely ANS: D Piaget refers to the thought process of this period as concrete operations, which involves logical thinking and an understanding of cause and effect. 5. The nurse explains that the preferred social interaction for the school-age child is based on relationships that are: a. Heterosexual interest groups b.
Association with one best friend
c.
Organized groups like Boy Scouts
d. Same-sex peer groups ANS: D The preferred social interaction of the school-age child is in same-sex peer groups or cliques. 6. The nurse advises the parents of a 10-year-old boy that, according to Eriksons theory, the most developmentally supportive experience for him would be:
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a.
Constant variety of activities
b.
Successful performance in Little League
c.
Feeling healthy and strong
d. Having a girl friend ANS: B The child who is successful in activities will feel positively about himself or herself. 7. The parents of an 8-year-old tell the nurse the child wakes the household crying out during his frequent nightmares. The nurses most helpful response is to explain that nightmares are: a. A normal extension of the childs fear of mutilation b.
An abnormal response to repressed feelings
c.
A common result of latent sexuality
d. A side effect of overactivity and stimulation ANS: A The nightmares experienced by an 8-year-old are an extension of their characteristic fear of mutilation. 8. The nurse suggests an appropriate toy for a hospitalized 6-year-old boy would be a: a. Game Boy game b.
Compact disc player
c.
Adventure book
d. Jigsaw puzzle ANS: A The 6-year-old child can perform numerous feats that require muscle coordination. At this age, the Gameboy toy will offer nonaggressive competition. 9. The nurse discusses preparation for school with the parents of a 6-year-old girl who will soon be starting first grade. The nurse determines that the parents understood the information when the girls father states: a. We should put a stop to her thumb-sucking. b.
Well have a talk about what school is like.
c.
We will let her walk to the bus stop by herself.
d. Well have her meet some children who will be in her class. ANS: D To prepare a child for school, parents can arrange for the child to meet other children who will be entering school with her. 10. A 9-year-old boy is often cranky and irritable and his school performance has declined. All the options are true about the child. The possible factor causing this behavior is that he: a. Sleeps only 6 to 7 hours a night b.
Eats eggs every day
c.
Has a new dog
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d. Plays about 1 to 3 hours each evening ANS: A The 9-year-old child requires about 10 hours of sleep per night. 11. A parent asked the nurse, At what age are children capable of assuming more responsibility for personal belongings? Based on a knowledge of growth and development, the nurse would respond: a. 6 years b.
7 years
c.
9 years
d. 12 years ANS: C The 9-year-old is dependable and assumes more responsibility for personal belongings. 12. The school nurse who is preserving a tooth that was knocked out on the school yard will be especially careful to: a. Wrap the tooth loosely in a clean cloth. b.
Rinse the tooth with alcohol.
c.
Handle the tooth only by the crown.
d. Place the tooth in a warm environment. ANS: C When a permanent tooth is avulsed, the tooth should be picked up by the crown to prevent any further damage to the root and placed in milk until the child can be examined by a dentist. 13. A parent states, My 7-year-old really wants a dog. His 10-year-old brother has allergies to animal dander. I dont know what to do. The nurse could advise this parent to: a. Choose a small breed of dog because the large dogs produce more allergens. b.
An older unneutered dog produces fewer allergens than a younger one.
c.
A cat may be a good choice since it requires less care and is less allergenic.
d. Poodles do not shed, making this dog a good choice for people with allergies. ANS: D The poodle breed of dog does not have a shed cycle and so it may be the least offensive pet for the allergic child. 14. When asked about her activities, a 10-year-old girl responded, I like school. I play the flute in the school band and I take tennis lessons. The nurse knows these activities will help this child develop a sense of: a. Initiative b.
Industry
c.
Identity
d. Intimacy ANS: B The school-age period is referred to by Erikson as the stage of industry. Successful participation in activities facilitates the childs sense of industry.
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15. A mother reports that she has a new job and her 12-year-old child is home alone for a time after school. The statement made by the parent, indicating a potentially unsafe situation for this child, is: a. I told him that he could invite a few friends after school. b.
I put a list of emergency numbers next to the telephone.
c.
Last week we made a first aid kit together.
d. There is a neighbor available in case of an emergency. ANS: A Latchkey children are subject to a higher rate of accidents. Permitting school-age children and their friends to be home alone in an unsupervised environment is an unsafe situation. 16. A mother is concerned because her 9-year-old has developed the habit of twitching his eyes and flipping his hair while communicating with anyone. The best nursing response to this parent is: a. This may indicate that he needs eyeglasses. b.
Children sometimes do these things for attention.
c.
This behavior suggests low self-esteem.
d. Tics appear when a child is under stress. ANS: D The child cannot help such actions and should not be scolded for them because they are mainly a result of tension. 17. A seventh-grade girl tells the school nurse that her art teacher, also a female, is her hero. The most appropriate interpretation of the girls comment is: a. The student may be exploring her career options. b.
The comment is cause for concern about sexual abuse.
c.
The child may have difficulty interacting with her peers.
d. Hero worship is a normal phenomenon. ANS: D School-age children tend to admire their teachers and adult companions. For the 11- to 12-yearold, hero worship is a normal phenomenon. 18. According to Piaget, a 9-year-old child is in which stage of cognitive development? a. Formal operations b.
Preoperational
c.
Concrete operations
d. Sensorimotor ANS: C School-age children are in the concrete operations stage of cognitive development. 19. The nurse assesses that the 11-year-old has moved from the mind set of egocentrism when he says: a. I am a member of the best Cub Scout group in the world.
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b.
I must do my homework before I can play.
c.
My dad can do anything!
d. Im sorry. I bet that hurt your feelings. ANS: D The ability to see anothers point of view indicates moving away from egocentrism into a more altruistic mind set. 20. When the school-age child becomes frustrated with a school assignment and says, I cant do this!, the parent should: a. Ask, What is it that is so difficult? b.
Allow the child to quit the effort.
c.
Call in older siblings to help.
d. Finish the project for him. ANS: A Helping the child focus on the problem that is keeping him from mastery can limit frustration. Quitting or having someone else finish is detrimental to the development of industry. MULTIPLE RESPONSE 21. The nurse, in attempting to help a 7-year-old girl express her feelings about being in a new school, would prompt the child with basic feeling words, such as: Select all that apply. a. Mad b.
Glad
c.
Sad
d.
Scared
e. Jealous ANS: A, B, C, D The words mad, glad, sad, and scared are basic feeling words that can prompt a young child to better express his or her feelings. 22. The nurse advises the parents of a 6-year-old to try and ensure at least ____________________ hours of sleep daily. ANS: 11 NOT: Rationale: The 6-year-old school-age child needs at least 11 hours of sleep. 23. The nurse reminds the parents who are trying to select a dog for their allergic child that the best selection would be a female dog that is ____________________ and ____________________. ANS: young, neutered NOT: Rationale: Young, neutered female dogs produced less allergens. 24. When the fifth-grade class collected geckos in a special aquarium in the classroom, the school nurse cautioned the teacher to be alert for symptoms of ____________________ that can be carried by the reptiles. ANS: Salmonella of Disease NOT: Rationale: Geckos can infect humans with Salmonella.
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25. The pediatric nurse assesses the child who has been diagnosed with diabetes to ensure that he does to come to believe that his disease is a form of ____________________. ANS: punishment NOT: Rationale: School-age children may come to believe their illness is a form of punishment for bad behavior or bad thoughts.
Chapter 18 Seven- to Ten-Year Visit (School Age) 1. A nurse obtains a nutritional health history from a 10-year-old child. Which of these food selections, if consumed on a regular basis, should lead the nurse to become concerned about the need for improving oral hygiene? 1. Peanuts and crackers 2. Sorbet and yogurt 3. Gummy bears and licorice 4. Fluoridated water Correct Answer: 3 Global Rationale: Food items that stick to the teeth lead to dental caries. Items such as gummy bears and licorice all stick to the teeth and lead to dental caries. Foods such as peanut butter, crackers, sorbet, and yogurt do not stick to the teeth and are not considered foods that increase dental caries. Fluoridated water has been shown to decrease the incidence of dental caries. 2. When examining a 7-year-old, which action by the nurse would be most appropriate? 1. Allow the child to participate in the exam.
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2. Ask the parent what kind of food the child likes to eat. 3. Ask the child whether he plays outside for at least 30 minutes a day. 4. Allow the child to decide whether he is ready for his next immunization. Correct Answer: 1 Global Rationale: At this age, children have logical thought, and are learning about their bodies. Participating in the physical exam is appropriate for this age. The child can answer the question about food intake himself. Asking whether he plays outside for 30 minutes is fine, but children at this age need at least 60 minutes of activity, so the question will not gather appropriate information. It is not the childs decision whether he is ready for immunization, so do not ask this question.
Chapter 19 Eleven- to Thirteen-Year Visit (Preadolescent) 1. The nurse working in the clinic includes an adolescent history in every client intake interview. Which issue should the nurse address when the parents are not present? 1. Possible domestic violence 2. Teen job responsibilities 3. Activities that are done as a family 4. The adolescents role in the family Correct Answer: 1 Rationale 1: If domestic violence is suspected, it would only be appropriate to ask these questions when the teenager is alone with the nurse or healthcare provider. Rationale 2: If domestic violence is suspected, it would only be appropriate to ask these questions when the teenager is alone with the nurse or healthcare provider. Rationale 3: If domestic violence is suspected, it would only be appropriate to ask these questions when the teenager is alone with the nurse or healthcare provider. Rationale 4: If domestic violence is suspected, it would only be appropriate to ask these questions when the teenager is alone with the nurse or healthcare provider. Global Rationale: If domestic violence is suspected, it would only be appropriate to ask these questions when the teenager is alone with the nurse or healthcare provider.
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2. An adolescent female presents at a nurse practitioners office and requests a signature for working papers. The nurse reviews her chart and notes that the last physical examination was two years ago. In addition to providing the signature for the working papers, what else should the nurse use this visit? 1. An opportunity to discuss birth-control measures 2. A time to discuss exercise and sports participation 3. A health-supervision opportunity 4. A chance to discuss the importance of pursuing post secondary education Correct Answer: 3 Global Rationale: All visits should be used as health-promotion and health-supervision visits. While discussing birth control, exercise, and future plans is important, these can be included in the overall health-supervision protocols. 3. The preadolescent child reports issues during assessment. While the mother is in the room, the nurse should avoid which questions? Standard Text: Select all that apply. 1. Sexual activity 2. Cigarette smoking 3. School performance 4. Use of alcohol 5. Car seatbelt use Correct Answer: 1,2,4 Global Rationale: The nurse must maintain the nurseclient relationship, which is between the nurse and the adolescent, and the nurse must maintain confidentiality. Therefore, the nurse cannot ask any personal questions while the mother is in the room, such as those related to sexual activity, drug and alcohol use, and smoking cigarettes. The nurse can ask general questions about seatbelt use and academic performance without breaching confidentiality. 4. The school nurse performs screenings on all students in the middle school. In addition, the nurse will perform selected screenings on individual school-age children. When planning the screenings for the year, which screenings will the nurse include for all school-age children? Standard Text: Select all that apply. 1. Hearing 2. Height and weight 3. Blood-pressure measurement 4. Hepatitis B profile serology 5. Chest x-ray Correct Answer: 1,2,3 Global Rationale: Routine screening for school-age children include hearing, checking for height and weight, and blood-pressure measurements. The hepatitis B profile is only needed once, prior to administration of hepatitis B vaccine; however, this is not a required screening for all schoolage children. A chest x-ray is not a routine screening test for school-age children. 5. A school nurse is performing annual height and weight screening. The nurse notes that three females who are close friends each lost 15 pounds over the past year. What is the priority nursing action in this situation?
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1. Call the respective parents to discuss the eating patterns of each adolescent. 2. Speak with the girls in a group to discuss the problems associated with anorexia nervosa. 3. Refer these adolescents to the school psychologist. 4. Obtain a nutritional history for each of these adolescents. Correct Answer: 4 Global Rationale: The school nurse must evaluate why these three friends have all lost 15 pounds in one year. The best way to begin this assessment is to obtain a nutritional history for each client. Speaking with the parents would not be appropriate at this time. Discussing anorexia nervosa is too extreme, as is referring the adolescents to a school psychologist without performing a complete nursing assessment.
Chapter 20 Fourteen- to Eighteen-Year Visit (Adolescent) MULTIPLE CHOICE 1. When assessing a 13-year-old boy, the nurse would keep in mind physical changes in the pubertal male, beginning with: a. Development of axillary and facial hair b.
Enlargement of pectoral muscles
c.
Enlargement of testicles
d. Voice changes ANS: C In boys, pubertal changes begin with enlargement of the testicles and internal structures. 2. A 13-year-old boy states, The girls in my class tower over me. The nurses most informative response would be: a. It may seem that way because girls have a growth spurt 2 years earlier than boys. b.
Perhaps your parents are not exceptionally tall.
c.
Boys usually experience a growth spurt 1 year earlier than girls.
d. You may feel short, but you are actually average height for your age. ANS: A
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Although the age for growth spurts during puberty varies, growth spurts occur 2 years earlier for girls than for boys. 3. A parent comments that her adolescent daughter seems to be daydreaming a lot these days. The nurse understands that this behavior indicates she is: a. Bored b.
Not getting enough rest
c.
Trying to block out stress and anxiety
d. Mentally preparing for real situations ANS: D Daydreaming allows adolescents to act out in their imaginations what will be said or done in certain situations. This helps them to prepare for and cope with interactions with others. 4. The nurse planning a safety program for high school students should understand that most accidental deaths in adolescence are related to: a. Firearms b.
Automobiles
c.
Drowning
d. Diving injuries ANS: B The chief safety hazard for the adolescent is automobiles. 5. A 16-year-old excitedly tells his parents that he was offered a part-time job. Which response represents an effective problem-solving approach for his parents? a. Your studies are too important for you to have a part-time job. b.
When we went to high school, academics were the teenagers priority.
c.
We want you to put your earnings in a savings account.
d. How do you think you will manage your school work and a job? ANS: D An effective approach to help adolescents learn to solve problems is for parents to guide them in exploring alternatives. 6. One psychosocial task of adolescence on which the nurse must focus when planning care, is the development of a sense of: a. Initiative b.
Industry
c.
Identity
d. Involvement ANS: C Psychosocial milestones that must be accomplished during adolescence include the five Isimage of self, identity, independence, interpersonal relationships, and intellectual maturity. 7. A 13-year-old female tells the school nurse that she is getting fat, especially in her hips and legs. The understanding by the nurse that would best guide the response is:
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a.
Many teenagers are unaware of proper nutrition.
b.
Teenagers of this age become less active and should eat fewer calories.
c.
Puberty is often preceded by fat deposits in these areas.
d. As soon as menarche occurs, she will lose this excess weight. ANS: C Secondary sexual characteristics become apparent before menarche. Fat is deposited in the hips, thighs, and breasts, causing them to enlarge. 8. The school nurse is planning a program for girls about the physical changes of puberty; this program should be directed to girls of the age: a. 16 years b.
14 years
c.
12 years
d. 10 years ANS: D Because puberty can occur in girls as early as age 10 years, instruction must be given by that age. 9. The statement made by a parent indicating understanding about helping a 13-year-old manage allowance money is: a. I set amounts he can earn for particular chores. b.
I give him a certain amount of money for each day.
c.
I put money into his bank account each month.
d. I told him to ask me when he needs money. ANS: A If money is simply handed out as requested, it is difficult to develop responsibility for finances and money management. The older adolescent is able to get a job. The younger teen can earn money by doing particular chores. 10. The nurse suggests a good dietary source of zinc for an adolescent who is a vegetarian would be: a. Green, leafy vegetables b.
Citrus fruits
c.
Nuts
d. Enriched breads ANS: C Zinc is essential for growth and sexual maturation in adolescence. Good vegetable sources include nuts, legumes, and wheat germ. 11. An adolescents parent comments, My son seems so preoccupied with his appearance these days. Is this normal? The nurses best response would be: a. It is his attempt to express his individualism. b.
His preoccupation with his looks is quite normal.
c.
He is probably troubled with his physical changes.
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d. This shows that he has a positive self-image. ANS: B Preoccupation with self-image is normal and accounts for the constant primping of teenagers. 12. Foods that would be a healthy choice for an adolescent who just finished playing in a strenuous game would be: a. Cheeseburger and soda b.
Hot fudge sundae
c.
Two Egg McMuffins and orange juice
d. Bagel and skim milk ANS: D A bagel provides a rapid supply of carbohydrates to the muscles, and skim milk provides a slow release of carbohydrates to the muscles. 13. When planning to answer a 16-year-old girls questions about menstruation, the nurse must consider cognitive development. According to Piaget, the cognitive aspect that is developed during adolescence is the ability to: a. View a situation from multiple perspectives b.
Focus more on the past than present situations
c.
Exercise concrete reasoning
d. Consider hypothetical situations ANS: D According to Piaget, in the formal operations stage adolescents have the ability to think abstractly. 14. A girl tells the nurse that she and her best friend belong to the popular clique. She states, I love Britney Spears and I want to be a singer. The nurse recognizes the girls statement as characteristic of peer relationships in: a. Early adolescence b.
Middle adolescence
c.
Late adolescence
d. Entire adolescent period ANS: A Cliques of unisex friends, having a best friend, and hero worship are characteristics of the early adolescent. 15. The nurse is leading a discussion group with parents of adolescents. One parent comments, My son cant do anything without checking with his friends first. My opinion doesnt count anymore. The nurse would formulate a response on the knowledge that this behavior is: a. Unusual for adolescent boys b.
Often more apparent in boys than girls
c.
A normal phenomenon during adolescence
d.
Suggestive of feelings of low self-worth
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ANS: A Parents may need help understanding that the teenagers exaggerated conformity is necessary for moving away from dependence and obtaining approval from persons outside the nuclear family. 16. The nurse points out to a group of parents that the most positive developmental significance of a peer group to the adolescent is that the group serves as: a. A social outlet b.
An association to blur personal identity
c.
A platform for group think
d. An initial separation from family ANS: D Being a member of a peer group and communicating with and seeking approval from this group are the first separation from the family. 17. The nurse understands that the adolescents avid sexual orientation to be based on Freuds theory, which describes adolescence as the _____ stage. a. Conceptual b.
Genital
c.
Glandular
d. Pubertal ANS: B Freud describes the adolescent period as genital. 18. The nurse using the PACE interview guide for persons at risk for substance abuse arrives at a score of 2 for an adolescent patient. The nurse should assess this score as: a. Nonindicative of potential substance abuse b.
Normal experimentation of the adolescent
c.
Need to schedule another PACE interview in 3 months
d. Indication for referral for counseling ANS: D The PACE guide recommends that a score of 2 or higher would suggest the need for a referral for counseling about substance abuse. MULTIPLE RESPONSE 1. The nurse explains that the restlessness seen in the adolescent is, in part, attributable to: Select all that apply. a. Drive to be accepted by society as an individual b.
Surge for independence
c.
Establishment of a personal identity
d.
Intense libido
e. Rapid body changes ANS: A, B, C, D, E All the options listed are sources of stress to the adolescent and are stimulants to restlessness. 2. The nurse teaching a seminar on teen pregnancy tells the parents that they should be alert for indications of a child concealing a pregnancy with such behaviors as:
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Select all that apply. a. Wearing baggy clothes b.
Wearing excessive makeup
c.
Dieting to lose weight
d.
Seeking privacy
e. Ostentatiously purchasing tampons ANS: A, C, E Wearing of concealing clothing, dieting to lose weight, and conspicuous advertising of a menstrual period are indicators of a hidden pregnancy. Wearing of excessive makeup and seeking privacy are normal adolescent behaviors. 3. The nurse considers the rites of passage that are valued by the adolescent in American society, which are: Select all that apply. a. Attaining legal drinking age b.
Selection of a career
c.
Religious affiliation
d.
Obtaining a drivers license
e. High school graduation ANS: A, D, E Rites of passage are socially recognized milestones that signify adulthood. Legal drinking age, drivers license, and matriculation through high school are such signals. Religious affiliation and selection of a career path do not necessarily signal adulthood. Chapter 21 Dermatological Problems MULTIPLE CHOICE 1. The nurse is amused, but understands that as adolescents strive for individuality, the strongest need of any adolescent in society is that of ____________________. ANS: conformity 2. The nurse takes into consideration that children who have been diagnosed with infantile eczema have an increased risk of: a. Pneumonia b.
Acne
c.
Sun sensitivity
d. Asthma ANS: D Some children with eczema also develop asthma and hay fevertype allergies. 3. The appropriate technique for the application of a topical treatment for a child with eczema is: a. Apply skin lotions in a circular motion. b.
Apply prescribed ointments with a gloved hand.
c.
Apply as much and as frequently as relieves the symptoms.
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d. Choose lanolin-based ointments. ANS: B The prescribed amount of ointment is usually applied to the skin by a gloved hand in long, smooth strokes. Lanolin-based preparations should be avoided because of a possible allergy to wool. 4. When the 2-day-old infant is noted to have small pustules on her skin, the nurse should: a. Report it immediately because it may be a staphylococcus infection. b.
Keep the affected area dry and clean.
c.
Teach the parents how to care for seborrheic dermatitis.
d. Chart the finding as it may be the beginning of a strawberry nevus. ANS: A A staphylococcal infection can spread readily from one infant to another. Small pustules on the newborn must be reported immediately. 5. The home health nurse discovers a family infected with pediculosis and helps the mother understand ways to start eradication of the lice, such as: a. Covering the hair with Vaseline b.
Applying a soda-vinegar solution to the hair
c.
Combing through the hair with a vinegar-water solution
d. Shampooing the hair with dish detergent ANS: C Combing a vinegar/water solution through the hair with a fine-tooth comb and then shampooing is an initial step toward eradication. 6. A group of football players is taking oral griseofulvin for tinea pedis. The school nurse cautions that while they are taking this medication they should avoid: a. Changing socks often b.
Eating shellfish
c.
Alcohol consumption
d. Taking corticosteroids ANS: C Consumption of alcohol while taking griseofulvin will cause severe tachycardia. 7. Before the 17-year-old boy starts a protocol of Accutane for his acne, the nurse should instruct him to: a. Get a prescription for oral contraceptives. b.
Increase the dose if his acne worsens.
c.
Limit intake of chocolate, cola, and peanuts.
d. Increase exposure to sunlight. ANS: A Oral contraceptives are prescribed to young males to reduce androgens, which make the skin greasy. 8. The nurse assesses a major burn as:
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a.
Partial-thickness burn involving 25% of the body surface
b.
Partial-thickness burn involving 12% of the body surface
c.
Full-thickness burn involving 20% of the body surface
d. Full-thickness burn involving 5% of the body surface ANS: C A full-thickness burn involving 10% or more of the body surface is considered a major burn. 9. A child had a burn evidenced by pink skin and blistering. The child complains of pain and is crying. The nurse documents the burn as: a. First-degree b.
Second-degree superficial
c.
Second-degree deep dermal
d. Third-degree ANS: B A second-degree superficial burn appears blistered, moist, and pink or red. The pain associated with this burn indicates tissue viability. 10. The best first action to take when a child sustains a second-degree deep thermal burn to the hand is to: a. Immerse the burned area in cold water. b.
Apply ice to the burned area.
c.
Break any blisters that are present.
d. Apply petroleum jelly to the burned skin. ANS: A First-aid treatment of a second-degree deep thermal burn is immersion of the burned area in water to halt the burning process. 11. An allergy to which of the following would contraindicate the use of Silvadene as a topical agent for burns? a. Penicillin b.
Iodine
c.
Tetanus immunizations
d. Sulfa ANS: D The use of Silvadene cream on burns is contraindicated if the patient has a sulfa allergy. 12. Which of the following would help the child with a serious burn meet nutritional needs during the subacute phase of recovery? a. Decrease calories because the child will be on bed rest and will not need as many. b.
Increase calories and protein to compensate for the healing process.
c.
Increase fat to replace the layer of fat next to the burned skin.
d.
Decrease carbohydrates and starches because the pancreas is strained by the healing process.
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ANS: B Frequent meals and snacks high in calories, protein, and iron are needed to meet the increased metabolic needs of the child with burns. 13. The statement made by a parent indicating an understanding of the topical application of medications for a skin condition is: a. I apply the medication after I give my child a bath. b.
I rub the ointment in a circular motion over the rash.
c.
I increased the amount of cream because the rash was not improving.
d. I use powder and cornstarch to keep the skin dry. ANS: A Absorption of topical medications is best when preparations are applied after a warm bath. 14. On the first day postburn the bodys fluid reserves have left the circulating volume and entered the interstitial space, causing massive edema. The nurse monitors the burn victim very closely for: a. Increasing intracranial pressure b.
Reduced urine output
c.
Eschar formation
d. Fluid overload ANS: B With the fluid shift associated with severe burns, the nurse must be observant for the reduction of urine, an indication of altered renal function. 16. A mother is concerned about what might have caused a heat rash on her infant. The nurse observes tiny pinhead-sized reddened papules on the infants neck and axilla. The nurse explains the cause of this rash is most likely: a. Sun exposure b.
Allergic reaction
c.
Infection
d. Heat and moisture ANS: D Miliaria, or prickly heat rash, is caused by excess body heat and moisture. 17. What is the correct nursing response to a mother who asks, How can I get rid of the babys cradle cap? a. Rub baby oil on the infants head at night and shampoo the hair the next morning. b.
Use a brush with firm bristles to loosen the scales on the babys head several times a day.
c.
Wash the babys head every night with a dandruff-control shampoo.
d. Lubricate the babys head every morning with a small amount of olive oil. ANS: A Scales may be softened by applying baby oil to the head the evening before, and shampooing the hair in the morning.
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18. The statement made by a parent, indicating the need for further teaching about strategies to control itching for the infant with eczema, is: a. Wool is the best fabric for the babys clothing. b.
I should avoid laundry detergents with fragrances.
c.
I put cotton gloves on the babys hands.
d. The babys fingernails are kept short. ANS: A Clothing should be made of cotton. Wool is avoided because of its allergy potential. 19. When teaching about general skin care measures that could help prevent acne, the nurse would include: a. Eliminate chocolate, peanuts, and cola from the diet. b.
Wash the face with a cleansing product frequently.
c.
Plan indoor activities to avoid sun exposure.
d. Eat a balanced diet, and get sufficient rest. ANS: D General hygienic measures of cleanliness, rest, and avoidance of emotional stress may help prevent exacerbations. 20. When the nurse caring for a patient with severe frostbite observes a purple flush on the hands and feet, the nurse should: a. Report this sign immediately b.
Place a warm towel over the extremities
c.
Gently sponge with cool water
d. Medicate for pain ANS: D A purple flush indicates the return of sensation and causes extreme pain. 21. A child is brought to the emergency department with burns on the face and chest. The nurses first priority is: a. Assessing respiratory status b.
Administering pain medication
c.
Removing clothing
d. Inserting a Foley catheter ANS: A Airway assessment and establishing an airway are the initial priorities. 22. The adolescent girl whose acne is being treated with an antibiotic in addition to topical applications is cautioned by the nurse to expect: a. Lessened effectiveness of oral contraceptives b.
Urinary burning and frequency
c.
Breast engorgement
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d. Vaginitis ANS: D Antibiotic therapy can cause a monilial vaginitis. 23. When the nurse observes a tarry stool from a 16-year-old burn victim who has been in the ICU for 2 weeks, the nurse documents and reports the probable complication of: a. Diverticulitis b.
Stress diarrhea
c.
Curlings ulcer
d. Perforated bowel ANS: C Curlings ulcer is a complication of burn victims resulting from the stress of their trauma. 24. A child is brought to the emergency department with severe frostbite. The body parts that should be warmed first are: a. Hands and arms b.
Feet and legs
c.
Fingers and toes
d. Head and torso ANS: D In extreme cases of exposure to freezing temperatures, the head and torso should be warmed before the extremities. 25. An adolescent is at the pediatricians office because he has been experiencing intense itching, particularly in the axilla and between the fingers. The itching is worse during the night and he has not been sleeping well. This symptom is associated with: a. Scabies b.
Pediculosis capitis
c.
Tinea corporis
d. Eczema ANS: A Intense itching, especially at night, is characteristic of scabies. 1. To avoid diaper rash, the nurse would offer instruction to the parents to: Select all that apply. a. Use emollients. b.
Expose perineum to light and air periodically.
c.
Use disposable diapers frequently.
d.
Avoid plastic pants.
e. Change diaper frequently. ANS: A, B, C, D, E Keeping the skin dry and protected with emollients, changing the diaper frequently, and avoiding plastic pants will prevent diaper rash.
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2. The nurse, speaking to a group of junior high school students, informs them that acne can be exacerbated by such drugs as: Select all that apply. a. Steroids b.
Dilantin
c.
Phenobarbital
d.
Aspirin
e. Oral contraceptives ANS: A, B, C Long-term use of steroids, Dilantin, phenobarbital, lithium, and vitamin B12 can cause acne. COMPLETION 1. The nurse recognizes the blisters and erythema of the hands of a person recovering from frostbite as the skin disorder called ____________________. ANS: chilblain NOT: Rationale: After exposure to cold, blisters appear on the hands and feet that are similar to a burn. These are called chilblains. 2. The nurse differentiates a type of topical medication that is an oil-based emulsion to be used on dry skin as a(n) ____________________.ANS: ointment 3. A 5-year-old boy is brought to the emergency department with a second-degree burn of his entire right arm and hand, anterior trunk and genital area, and front of right thigh. The nurse assesses the BSA percentage burn as ____________________. ANS: 26% Chapter 22 Eye Disorders MULTIPLE CHOICE 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.
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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 eye is stimulated.
The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in d. 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.
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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 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
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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. A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should: a. Examine the retina to determine the number of floaters. b.
Presume the patient has glaucoma and refer him for further testing.
c.
Consider these to be abnormal findings, and refer him to an ophthalmologist.
d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers. ANS: D Floaters are a common sensation with myopia or after middle age and are attributable to condensed vitreous fibers. Floaters or spots are not usually significant, but the acute onset of floaters may occur with retinal detachment. 13. 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. 14. 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
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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. 15. 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. 16. 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. 17. 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. 18. 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
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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. 19. During an assessment of the sclera of a black patient, 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. 20. A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? a. Perform the confrontation test. b.
Assess the individuals near vision.
c.
Observe the distance between the palpebral fissures.
d. Perform the corneal light test, and look for symmetry of the light reflex. ANS: C Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision. Measuring near vision or the corneal light test does not check for ptosis. 21. 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. 22. 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
Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately d. 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.
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23. 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. 24. 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. 25. 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. 27. 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.
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28. 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. 29. The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? a. Decrease in tear production b.
Unequal pupillary constriction in response to light
c.
Presence of arcus senilis observed around the cornea
d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles ANS: B Pupils are small in the older adult, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons. 30. The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: a. Check for the presence of exophthalmos. b.
Suspect that the patient has hyperthyroidism.
c.
Ask the patient if he or she has a history of heart failure.
d. Assess for blepharitis, which is often associated with periorbital edema. ANS: C Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis. 31. When a light is directed across the iris of a patients eye from the temporal side, the nurse is assessing for: a. Drainage from dacryocystitis. b.
Presence of conjunctivitis over the iris.
c.
Presence of shadows, which may indicate glaucoma.
d. Scattered light reflex, which may be indicative of cataracts. ANS: C The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This method is not correct for the assessment of dacryocystitis, conjunctivitis, or cataracts. 32. In a patient who has anisocoria, the nurse would expect to observe:
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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. 33. A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he cant see well from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: a. Loss of central vision. b.
Shadow or diminished vision in one quadrant or one half of the visual field.
c.
Loss of peripheral vision.
d. Sudden loss of pupillary constriction and accommodation. ANS: B With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment. 34. A patient 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 35. A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have: a. Macular degeneration. b.
Vision that is normal for someone her age.
c.
The beginning stages of cataract formation.
d. Increased intraocular pressure or glaucoma. ANS: A Macular degeneration is the most common cause of blindness. It is characterized by the loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the
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most common type of glaucoma, involves a gradual loss of peripheral vision. These findings are not consistent with vision that is considered normal at any age. 36. A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion? a. Smooth and clear corneas b.
Opacity of the lens behind the cornea
c.
Bleeding from the areas across the cornea
d. Shattered look to the light rays reflecting off the cornea ANS: D A corneal abrasion causes irregular ridges in reflected light, which produce a shattered appearance to light rays. No opacities should be observed in the cornea. The other responses are not correct. 37. An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: a. Retinal detachment. b.
Diabetic retinopathy.
c.
Acute-angle glaucoma.
d. Increased intracranial pressure. ANS: D Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses. 38. 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. 39. During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling dry and itchy. Which action by the nurse is correct? a. Assessing the eye for a possible foreign body b.
Documenting the finding as ptosis
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c.
Assessing for other signs of ectropion
d. Contacting the prescriber; these are signs of basal cell carcinoma ANS: C The condition described is known as ectropion, and it occurs in older adults and is attributable to atrophy of the elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot effectively siphon tears; excessive tearing results. Ptosis is a drooping of the upper eyelid. These signs do not suggest the presence of a foreign body in the eye or basal cell carcinoma. MULTIPLE RESPONSE 1. During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma?Select all that apply. a. Patient may experience sensitivity to light, nausea, and halos around lights. b.
Patient experiences tunnel vision in the late stages.
c.
Immediate treatment is needed.
d.
Vision loss begins with peripheral vision.
e.
Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision.
f. Virtually no symptoms are exhibited. ANS: B, D, F Open-angle glaucoma is the most common type of glaucoma; virtually no symptoms are exhibited. Chapter 23 Ear Disorders MULTIPLE CHOICE 1. The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the: a. Auricle. b.
Concha.
c.
Outer meatus.
d. Mastoid process. ANS: A The external ear is called the auricle or pinna and consists of movable cartilage and skin. 2. The nurse is examining a patients ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? a. Sticky honey-colored cerumen is a sign of infection. b.
The presence of cerumen is indicative of poor hygiene.
c.
The purpose of cerumen is to protect and lubricate the ear.
d. Cerumen is necessary for transmitting sound through the auditory canal. ANS: C The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates and protects the ear. 3. When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:
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a.
Light pink with a slight bulge.
b.
Pearly gray and slightly concave.
c.
Pulled in at the base of the cone of light.
d. Whitish with a small fleck of light in the superior portion. ANS: B The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles. 4. The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true? a. The eustachian tube is responsible for the production of cerumen. b.
It remains open except when swallowing or yawning.
c.
The eustachian tube allows passage of air between the middle and outer ear.
d. It helps equalize air pressure on both sides of the tympanic membrane. ANS: D The eustachian tube allows an equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture during, for example, altitude changes in an airplane. The tube is normally closed, but it opens with swallowing or yawning. 5. A patient with a middle ear infection asks the nurse, What does the middle ear do? The nurse responds by telling the patient that the middle ear functions to: a. Maintain balance. b.
Interpret sounds as they enter the ear.
c.
Conduct vibrations of sounds to the inner ear.
d. Increase amplitude of sound for the inner ear to function. ANS: C Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle ear. 6. The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti? a. I b.
III
c.
VIII
d. XI ANS: C The nerve impulses are conducted by the auditory portion of CN VIII to the brain. 7. The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?
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a.
Air conduction is the normal pathway for hearing.
b.
Vibrations of the bones in the skull cause air conduction.
c.
Amplitude of sound determines the pitch that is heard.
d. Loss of air conduction is called a conductive hearing loss. ANS: A The normal pathway of hearing is air conduction, which starts when sound waves produce vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear. The other statements are not true concerning air conduction. 8. A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: a. Speak loudly so the patient can hear the questions. b.
Assess for middle ear infection as a possible cause.
c.
Ask the patient what medications he is currently taking.
d. Look for the source of the obstruction in the external ear. ANS: C A simple increase in amplitude may not enable the person to understand spoken words. Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea. 9. During an interview, the patient states he has the sensation that everything around him is spinning. The nurse recognizes that the portion of the ear responsible for this sensation is the: a. Cochlea. b.
CN VIII.
c.
Organ of Corti.
d. Labyrinth. ANS: D If the labyrinth ever becomes inflamed, then it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo. 10. A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correctregarding the significance of this in relation to the infants hearing? a. Rubella may affect the mothers hearing but not the infants. b.
Rubella can damage the infants organ of Corti, which will impair hearing.
c.
Rubella is only dangerous to the infant in the second trimester of pregnancy.
d. Rubella can impair the development of CN VIII and thus affect hearing. ANS: B If maternal rubella infection occurs during the first trimester, then it can damage the organ of Corti and impair hearing. 11. 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? a. It is unusual for a small child to have frequent ear infections unless something else is
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wrong. b.
We need to check the immune system of your son to determine why he is having so many ear infections.
c.
Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear.
Your sons eustachian tube is shorter and wider than yours because of his age, which d. allows for infections to develop more easily. ANS: D 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. 12. A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is: a. Otosclerosis. b.
Presbycusis.
c.
Trauma to the bones.
d. Frequent ear infections. ANS: A Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years. Presbycusis is a type of hearing loss that occurs with aging. Trauma and frequent ear infections are not a likely cause of his hearing loss. 13. A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he cant always tell where the sound is coming from and the words often sound mixed up. What might the nurse suspect as the cause for this change? a. Atrophy of the apocrine glands b.
Cilia becoming coarse and stiff
c.
Nerve degeneration in the inner ear
d. Scarring of the tympanic membrane ANS: C Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even in those living in a quiet environment. This sensorineural loss is gradual and caused by nerve degeneration in the inner ear. Words sound garbled, and the ability to localize sound is also impaired. This communication dysfunction is accentuated when background noise is present. 14. During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding: a. Is probably the result of lesions from eczema in his ear. b.
Represents poor hygiene.
c.
Is a normal finding, and no further follow-up is necessary.
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d. Could be indicative of change in cilia; the nurse should assess for hearing loss. ANS: C Asians and Native Americans are more likely to have dry cerumen, whereas Blacks and Whites usually have wet cerumen. 15. The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? a. Do you ever notice ringing or crackling in your ears? b.
When was the last time you had your hearing checked?
c.
Have you ever been told that you have any type of hearing loss?
d. Is there any relationship between the ear pain and the discharge you mentioned? ANS: D Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs. 16. A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding: a. Is normal for people of his age. b.
Is a characteristic of recruitment.
c.
May indicate a middle ear infection.
d. Indicates that the patient has a cerumen impaction. ANS: B Recruitment is significant hearing loss occurring when speech is at low intensity, but sound actually becomes painful when the speaker repeats at a louder volume. The other responses are not correct. 17. 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. 18. The nurse is performing an otoscopic examination on an adult. Which of these actions is correct? a. Tilting the persons head forward during the examination b.
Once the speculum is in the ear, releasing the traction
c.
Pulling the pinna up and back before inserting the speculum
d. Using the smallest speculum to decrease the amount of discomfort ANS: C
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The pinna is pulled up and back on an adult or older child, which helps straighten the S-shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed. 19. The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal? a. If the drum has ruptured, then purulent drainage will result. b.
Bloody or clear watery drainage can indicate a basal skull fracture.
c.
The auditory canal many be occluded from increased cerumen.
d. Foreign bodies from the accident may cause occlusion of the canal. ANS: B Frank blood or clear watery drainage (cerebrospinal leak) after a trauma suggests a basal skull fracture and warrants immediate referral. Purulent drainage indicates otitis externa or otitis media. 20. In performing a voice test to assess hearing, which of these actions would the nurse perform? a. Shield the lips so that the sound is muffled. b.
Whisper a set of random numbers and letters, and then ask the patient to repeat them.
c.
Ask the patient to place his finger in his ear to occlude outside noise.
d. Stand approximately 4 feet away to ensure that the patient can really hear at this distance. ANS: B With the head 30 to 60 cm (1 to 2 feet) from the patients ear, the examiner exhales and slowly whispers a set of random numbers and letters, such as 5, B, 6. Normally, the patient is asked to repeat each number and letter correctly after hearing the examiner say them. 21. 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. 22. The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination? a. Immobility of the drum is a normal finding. b.
An injected membrane would indicate an infection.
c.
The normal membrane may appear thick and opaque.
d. The appearance of the membrane is identical to that of an adult. ANS: C
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During the first few days after the birth, the tympanic membrane of a newborn often appears thickened and opaque. It may look injected and have a mild redness from increased vascularity. The other statements are not correct. 23. The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant: a. Turns his or her head to localize the sound. b.
Shows no obvious response to the noise.
c.
Shows a startle and acoustic blink reflex.
d. Stops any movement, and appears to listen for the sound. ANS: A With a loud sudden noise, the nurse should notice the infant turning his or her head to localize the sound and to respond to his or her own name. A startle reflex and acoustic blink reflex is expected in newborns; at age 3 to 4 months, the infant stops any movement and appears to listen. 24. The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal? a. High-tone frequency loss b.
Increased elasticity of the pinna
c.
Thin, translucent membrane
d. Shiny, pink tympanic membrane ANS: A A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller in the older person than in the younger adult. 25. An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these? a. Any change in the ability to hear b.
Any recent drainage from the ear
c.
Recent history of trauma to the ear
d. Any prolonged exposure to extreme cold ANS: D Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness. 26. 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): a. Fungal infection. b.
Acute otitis media.
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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. 27. 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. 28. In an individual with otitis externa, which of these signs would the nurse expect to find on assessment? a. Rhinorrhea b.
Periorbital edema
c.
Pain over the maxillary sinuses
d. Enlarged superficial cervical nodes ANS: D The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness. Rhinorrhea, periorbital edema, and pain over the maxillary sinuses do not occur with otitis externa. 29. 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.
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30. The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this: a. Is most likely a benign sebaceous cyst. b.
Is most likely a keloid.
c.
Could be a potential carcinoma, and the patient should be referred for a biopsy.
d. Is a tophus, which is common in the older adult and is a sign of gout. ANS: C An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and intermittently bleed. Individuals with such symptoms should be referred for a biopsy The other responses are not correct. 31. The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane? a. Red and bulging b.
Hypomobility
c.
Retraction with landmarks clearly visible
d. Flat, slightly pulled in at the center, and moves with insufflation ANS: B An early sign of otitis media is hypomobility of the tympanic membrane. As pressure increases, the tympanic membrane begins to bulge. 32. The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 oclock and landmarks visible. The nurse should: a. Refer the patient for the possibility of a fungal infection. b.
Know that these are scars caused from frequent ear infections.
c.
Consider that these findings may represent the presence of blood in the middle ear.
d. Be concerned about the ability to hear because of this abnormality on the tympanic membrane. ANS: B Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing. 33. The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correctprocedure? 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
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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. 34. 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. 35. During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest? a. Malignancy b.
Viral infection
c.
Blood in the middle ear
d. Yeast or fungal infection ANS: D A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis). 36. A 17-year-old student is a swimmer on her high schools swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to: a. Use a cotton-tipped swab to dry the ear canals thoroughly after each swim. b.
Use rubbing alcohol or 2% acetic acid eardrops after every swim.
c.
Irrigate the ears with warm water and a bulb syringe after each swim.
d. Rinse the ears with a warmed solution of mineral oil and hydrogen peroxide. ANS: B With otitis externa (swimmers ear), swimming causes the external canal to become waterlogged and swell; skinfolds are set up for infection. Otitis externa can be prevented by using rubbing alcohol or 2% acetic acid eardrops after every swim. 37. During an examination, the patient states he is hearing a buzzing sound and says that it is driving me crazy! The nurse recognizes that this symptom indicates: a. Vertigo. b.
Pruritus.
c.
Tinnitus.
d. Cholesteatoma. ANS: C Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.
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38. During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, It feels like the room is spinning! The nurse notices that the patient is experiencing: a. Objective vertigo. b.
Subjective vertigo.
c.
Tinnitus.
d. Dizziness. ANS: AWith objective vertigo, the patient feels like the room spins; with subjective vertigo, the person feels like he or she is spinning. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Dizziness is not the same as true vertigo; the person who is dizzy may feel unsteady and lightheaded. 39. A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, I dont know what the matter is. All of a sudden, I cant hear you out of my left ear! What should the nurse do next? a. Make note of this finding for the report to the next shift. b.
Prepare to remove cerumen from the patients ear.
c.
Notify the patients health care provider.
d. Irrigate the ear with rubbing alcohol. ANS: CAny sudden loss of hearing in one or both ears that is not associated with an upper respiratory infection needs to be reported at once to the patients health care provider. Hearing loss associated with trauma is often sudden. Irrigating the ear or removing cerumen is not appropriate at this time. 1. The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? Select all that apply. a. Hearing loss related to aging begins in the mid 40s. b.
Progression of hearing loss is slow.
c.
The aging person has low-frequency tone loss.
d.
The aging person may find it harder to hear consonants than vowels.
e.
Sounds may be garbled and difficult to localize.
f. Hearing loss reflects nerve degeneration of the middle ear. ANS: B, D, EPresbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after the age of 50 years. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels, which makes words sound garbled. The ability to localize sound is also impaired.
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Chapter 24 Sinus, Mouth, Throat, and Neck Disorders MULTIPLE CHOICE 1. The primary purpose of the ciliated mucous membrane in the nose is to: a. Warm the inhaled air. b.
Filter out dust and bacteria.
c.
Filter coarse particles from inhaled air.
d. Facilitate the movement of air through the nares. ANS: B The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air. 2. The projections in the nasal cavity that increase the surface area are called the: a. Meatus. b.
Septum.
c.
Turbinates.
d. Kiesselbach plexus. ANS: C The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. These increase the surface area, making more blood vessels and mucous membrane available to warm, humidify, and filter the inhaled air. 3. The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? a. Sphenoid sinuses are full size at birth. b.
Maxillary sinuses reach full size after puberty.
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c.
Frontal sinuses are fairly well developed at birth.
d. Maxillary and ethmoid sinuses are the only sinuses present at birth. ANS: D Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty. 4. The tissue that connects the tongue to the floor of the mouth is the: a. Uvula. b.
Palate.
c.
Papillae.
d. Frenulum. ANS: D The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongues dorsal surface. 5. The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland. a. Parotid b.
Stensens
c.
Sublingual
d. Submandibular ANS: A The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw. The Stensens duct (not gland) drains the parotid gland onto the buccal mucosa opposite the second molar. The sublingual gland is located within the floor of the mouth under the tongue. The submandibular gland lies beneath the mandible at the angle of the jaw. 6. 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. 7. The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, I think she is getting her first tooth because she has started drooling a lot. The nurses best response would be:
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a.
Youre right, drooling is usually a sign of the first tooth.
b.
It would be unusual for a 3 month old to be getting her first tooth.
c.
This could be the sign of a problem with the salivary glands.
d. She is just starting to salivate and hasnt learned to swallow the saliva. ANS: D In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does. 8. The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? a. Hypertrophy of the gums b.
Increased production of saliva
c.
Decreased ability to identify odors
d. Finer and less prominent nasal hair ANS: C The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers. Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva production decreases. 9. The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is: a. Leukoedema and is common in dark-pigmented persons. b.
The result of hyperpigmentation and is normal.
c.
Torus palatinus and would normally be found only in smokers.
d. Indicative of cancer and should be immediately tested. ANS: A Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is most often observed in Blacks. 10. While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurses best response? a. While sitting up, place a cold compress over your nose. b.
Sit up with your head tilted forward and pinch your nose.
c.
Just allow the bleeding to stop on its own, but dont blow your nose.
d. Lie on your back with your head tilted back and pinch your nose. ANS: B With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes. 11. A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? a. Epistaxis
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b.
Rhinorrhea
c.
Dysphagia
d. Xerostomia ANS: C Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is a dry mouth. 12. 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.
d. Prolonged use of a bottle can increase the risk for tooth decay and ear infections. ANS: D Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections. 13. A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be: a. Do you use a fluoride supplement? b.
Have you had tonsillitis in the last year?
c.
At what age did you get your first tooth?
d. Have you noticed any dryness in your mouth? ANS: D Xerostomia (dry mouth) is a side effect of many drugs taken by older people, including antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, and bronchodilators. 14. The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a. Inserting the speculum at least 3 cm into the vestibule b.
Avoiding touching the nasal septum with the speculum
c.
Gently displacing the nose to the side that is being examined
d. Keeping the speculum tip medial to avoid touching the floor of the nares ANS: B The correct technique for using an otoscope is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum. 15. The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?
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a.
Are you aware of having any allergies?
b.
Do you have an elevated temperature?
c.
Have you had any symptoms of a cold?
d. Have you been having frequent nosebleeds? ANS: A With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated body temperature, colds, and nosebleeds do not cause these mucosal changes. 16. The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? a. No sensation b.
Firm pressure
c.
Pain during palpation
d. Pain sensation behind eyes ANS: B The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection (sinusitis). 17. During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? a. Check the patients hemoglobin for anemia. b.
Assess for other signs of insufficient oxygen supply.
c.
Proceed with the assessment, knowing that this appearance is a normal finding.
d. Ask if he has been exposed to an excessive amount of carbon monoxide. ANS: C Some Blacks may have bluish lips and a dark line on the gingival margin; this appearance is a normal finding. 18. During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: a. Dehydration. b.
Irritation by gastric juices.
c.
A normal oral assessment.
d. Side effects from nausea medication. ANS: A Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures. 19. A 32-year-old woman is at the clinic for little white bumps in my mouth. During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? a. These spots indicate an infection such as strep throat.
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b.
These bumps could be indicative of a serious lesion, so I will refer you to a specialist.
c.
This condition is called leukoplakia and can be caused by chronic irritation such as with smoking.
d. These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition. ANS: D Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky, white raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots. 20. A 10 year old is at the clinic for a sore throat that has lasted 6 days. Which of these findings would be consistent with an acute infection? a. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa b.
Tonsils 2+/1-4+ with small plugs of white debris
c.
Tonsils 3+/1-4+ with large white spots
d. Tonsils 3+/1-4+ with pale coloring ANS: C With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection. 21. Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? a. Attempt to suction again with a bulb syringe. b.
Wait a few minutes, and try again once the infant stops crying.
c.
Recognize that this situation requires immediate intervention. Contact the physician to schedule an appointment for the infant at his or her next hospital visit.
d. ANS: C Determining the patency of the nares in the immediate newborn period is essential because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned with a bulb syringe. If obstruction is suspected, then a small lumen (5 to 10 Fr) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which requires immediate intervention. 22. 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
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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. 23. 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. 24. During an assessment of a 26 year old at the clinic for a spot on my lip I think is cancer, the nurse notices a group of clear vesicles with an erythematous base around them located at the lipskin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse? a. Tell the patient she needs to see a skin specialist. b.
Discuss the benefits of having a biopsy performed on any unusual lesion.
c.
Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days.
d. Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrit ANS: C Cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. Recurrent herpes infections may be precipitated by sunlight, fever, colds, or allergy. that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess? a. Nutritional status b.
When the patient first noticed the lesion
c.
Whether the patient has had a recent cold
d. Whether the patient has had any recent exposure to sick animals ANS: B With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred. 26. A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse? a. Your condition is probably due to a vitamin C deficiency. b.
Im not sure what causes swollen and bleeding gums, but let me know if its not better in a
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few weeks. c.
You need to make an appointment with your dentist as soon as possible to have this checked. Swollen and bleeding gums can be caused by the change in hormonal balance in your system during pregnancy.
d. ANS: D Gum margins are red and swollen and easily bleed with gingivitis. A changing hormonal balance may cause this condition to occur in pregnancy and puberty. 27. A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: a. Aphthous ulcers. b.
Candidiasis.
c.
Leukoplakia.
d. Koplik spots. ANS: B Candidiasis is a white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that easily bleeds. It also occurs after the use of antibiotics or corticosteroids and in persons who are immunosuppressed. 28. The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? a. We will need to get a biopsy to determine the cause. b.
This is an overgrowth of hair and will go away in a few days.
c.
Black, hairy tongue is a fungal infection caused by all the antibiotics you have received.
d. This is probably caused by the same bacteria you had in your lungs. ANS: C A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus. 29. The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of: a. Acquired immunodeficiency syndrome (AIDS). b.
Measles.
c.
Leukemia.
d. Carcinoma. ANS: A
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Oral Kaposis sarcoma is a bruiselike, dark red or violet, confluent macule that usually occurs on the hard palate. It may appear on the soft palate or gingival margin. Oral lesions may be among the earliest lesions to develop with AIDS. 30. A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother? a. This area of irritation is caused from teething and is nothing to worry about. b.
This finding is abnormal and should be evaluated by another health care provider.
c.
This area of irritation is the result of chronic drooling and should resolve within the next month or two.
This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and i d. normal. ANS: D A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breastfeeding or bottle-feeding. This condition is not caused by irritation, teething, or excessive drooling, and evaluation by another health care provider is not warranted. 31. 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. 32. When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? a. Teeth appearing shorter b.
Tongue that looks smoother in appearance
c.
Buccal mucosa that is beefy red in appearance
d. Small, painless lump on the dorsum of the tongue ANS: B In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of the recession of gingival margins. 33. When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause?
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a.
Nasal polyps
b.
Acute sinusitis
c.
Allergic rhinitis
d. Acute rhinitis ANS: C Rhinorrhea, itching of the nose and eyes, and sneezing are present with allergic rhinitis. On physical examination, serous edema is noted, and the turbinates usually appear pale with a smooth, glistening surface. 34. When assessing the tongue of an adult, the nurse knows that an abnormal finding would be: a. Smooth glossy dorsal surface. b.
Thin white coating over the tongue.
c.
Raised papillae on the dorsal surface.
d. Visible venous patterns on the ventral surface. ANS: A The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present. The ventral surface may show veins. Smooth, glossy areas may indicate atrophic glossitis 35. The nurse is performing an assessment. Which of these findings would cause the greatest concern? a. Painful vesicle inside the cheek for 2 days b.
Presence of moist, nontender Stensens ducts
c.
Stippled gingival margins that snugly adhere to the teeth
d. Ulceration on the side of the tongue with rolled edges ANS: D Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. The risk of early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous. The other responses are normal findings. 36. A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur? a. Rubella b.
Leukoplakia
c.
Rheumatic fever
d. Scarlet fever ANS: C Untreated strep throat may lead to rheumatic fever. When performing a health history, the patient should be asked whether his or her sore throat has been documented as streptococcal. 37. During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be:
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a.
You should never use over-the-counter nasal sprays because of the risk of addiction.
b.
You should try switching to another brand of medication to prevent this problem.
c.
Continuing to use this spray is important to keep your allergies under control.
Using these nasal medications irritates the lining of the nose and may cause rebound d. swelling. ANS: D The misuse of over-the-counter nasal medications irritates the mucosa, causing rebound swelling, which is a common problem. 38. 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. 39. A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has: a. Posterior epistaxis. b.
Frontal sinusitis.
c.
Maxillary sinusitis.
d. Nasal polyps. ANS: C Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge. 40. A woman who is in the second trimester of pregnancy mentions that she has had more nosebleeds than ever since she became pregnant. The nurse recognizes that this is a result of: a. A problem with the patients coagulation system. b.
Increased vascularity in the upper respiratory tract as a result of the pregnancy.
c.
Increased susceptibility to colds and nasal irritation.
d. Inappropriate use of nasal sprays. ANS: B Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract.
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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. a. One pinch of SLT in the mouth for 30 minutes delivers the equivalent of one 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. 2. During an assessment, a patient mentions that I just cant smell like I used to. I can barely smell the roses in my garden. Why is that? For which possible causes of changes in the sense of smell will the nurse assess? Select all that apply. a. Chronic alcohol use b.
Cigarette smoking
c.
Frequent episodes of strep throat
d.
Chronic allergies
e.
Aging
f. Herpes simplex virus I ANS: B, D, E The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell.
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Chapter 25 Respiratory Disorders MULTIPLE CHOICE 1. The nurse tells the parents of a child who has a positive throat culture for group A hemolytic streptococcus that the treatment most likely will be: a. Acetaminophen and plenty of fluids b.
Oral penicillin for 10 days
c.
Penicillin until his sore throat is gone
d. Streptococcus immunization ANS: B When a throat culture is positive for group A beta-hemolytic streptococcus, penicillin is administered for 10 days even if symptoms are alleviated before the medication is finished. 2. The initial intervention that the nurse would suggest to the parents of a child experiencing laryngeal spasm is to: a. Take the child outside in the cool air. b.
Bring the child directly to the emergency department.
c.
Put the child in the bathroom with a hot shower running.
d. Have the child drink plenty of fluids. ANS: C The child experiencing laryngeal spasm should be placed in a high-humidity environment such as the bathroom with a hot shower running. The humidity liquefies secretions and reduces spasm. 3. The nurse would observe a child for frequent swallowing following a tonsillectomy and adenoidectomy (T & A) because this is indicative of: a. Bleeding from the surgical site b.
Pain at the incision area
c.
Sore throat from postnasal drip
d.
Potential vomiting
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ANS: A Hemorrhage is the most common postoperative complication. Blood trickling down the back of the childs throat could cause frequent swallowing. 4. The best choice for fluid replacement that the nurse can offer a child who has just had a tonsillectomy is: a. Popsicle b.
Chocolate milk
c.
Orange juice
d. Cola drink ANS: A Small amounts of clear liquids can be offered to the child. Synthetic fruit juices are not as irritating as natural juices. A popsicle is usually well-tolerated. 5. The 4-month-old child in the emergency department shows extreme dyspnea, a croaking inspiration, and excessive drooling. Based on these observations alone, the nurses initial intervention would be to: a. Sit the child upright and notify the physician. b.
Start oxygen by mask and keep the child flat.
c.
Apply a cold compress to the throat.
d. Assess the back of the throat for obstruction. ANS: A These are the classic signs of epiglottitis. If epiglottitis is suspected, the nurse should not examine the back of the throat because laryngospasm may occur followed by respiratory arrest. The child should be made as comfortable as possible and the physician should be summoned. Epiglottitis is a medical emergency. 6. The nurse, auscultating the breath sounds of a child hospitalized for an acute asthma attack, would expect to find: a. Fine crackles b.
Coarse rhonchi
c.
Expiratory wheezing
d. Decreased breath sounds at lung bases ANS: C The child experiencing an acute asthma attack will wheeze as air moves in and out of the narrowed airways. The expiratory wheeze is most pronounced. 7. The nurse caring for a child experiencing an acute asthma attack would include: a. Offering plenty of fluids, particularly carbonated beverages b.
Placing the child in a humidified cool mist tent with oxygen
c.
Administering sedatives as ordered to decrease anxiety
d. Positioning the child with arms resting on the overbed table ANS: D
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This position is comfortable and allows maximum use of the accessory muscles for breathing. Sedatives would mask symptoms of increasing air hunger. Carbonated beverages are contraindicated in persons with dyspnea. 8. The nurse explains to the parent of a child with exercise-induced asthma that Cromolyn, an antiinflammatory drug, should be inhaled: a. Before exercise to prevent attacks b.
At the initial onset of the attack
c.
During the attack to relieve symptoms
d. As often as 4 times a day ANS: A Antiinflammatory inhalants are taken before exercise to prevent attacks. These drugs can do nothing for the attack in progress. They are meant to be used as prophylactic therapies. 9. The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got this disease, because no one in their families has CF. The nurses response is based on the understanding that with CF: a. Only one parent carries the CF gene. b.
Both parents are carriers of the CF gene.
c.
The inheritance pattern is multifactorial.
d. The result is probably a genetic mutation. ANS: B Cystic fibrosis is an inherited disease. Both parents must be carriers of the CF gene for the child to have the disease. 10. The statement indicating that the childs parents understand how to perform respiratory therapy is: a. We do her postural drainage before the aerosol therapy. b.
We give her respiratory treatments when she is coughing a lot.
c.
We give the aerosol followed by postural drainage before meals.
d. She needs respiratory therapy everyday when she has an infection. ANS: C Postural drainage for the child with CF is done following nebulization. Therapy is best scheduled before meals or at least 1 hour after eating to prevent vomiting. 11. To facilitate digestion and absorption of nutrients, the nurse teaches the child with cystic fibrosis that she needs to take: a. Pancreatic enzymes b.
Water-soluble minerals
c.
Fat-soluble vitamins
d. Salt supplements ANS: A An oral pancreatic enzyme is given to the child with every meal and with snacks to replace the pancreatic enzymes that the childs body cannot produce.
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12. The nurse would advise a mother to clear the nostrils when her infant has a cold by: a. Clearing the nasal passages after the infant has a feeding b.
Using over-the-counter nose drops to clear passages
c.
Removing nasal secretions with a bulb syringe
d. Instilling saline nose drops after clearing away secretions ANS: C The nasal passages can be cleared by instilling a few drops of saline into the nose and then suctioning the secretions with a bulb syringe. 13. The nurse offers a variety of fluids to compensate for the fluid loss through dyspnea. Appropriate fluids would be: a. Room temperature water b.
Carbonated beverages
c.
Iced fruit juice
d. Cold milk ANS: A Room temperature fluids are the best. Carbonated and iced beverages increase spasm Milk stimulates mucus production. 14. The asthmatic child who has been taking theophylline complains of stomach ache and tachycardia and is sweating profusely. The nurse recognizes these symptoms as: a. Severe asthma attack b.
Allergic response to theophylline
c.
Onset of bronchitis
d. Drug toxicity ANS: D The symptoms described are the signs of theophylline toxicity. 15. The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). Significant information would be to: a. Wrap the infant snugly for rest periods. b.
Position the infant prone for sleep.
c.
Sit the baby up in an infant seat.
d. Place infants on their back or side for sleep. ANS: D The American Academy of Pediatrics recommends that all healthy infants be placed in the supine or side-lying position on a firm mattress to prevent SIDS. 16. An infant is hospitalized with RSV bronchiolitis. The priority nursing diagnosis is: a. Fatigue related to increased work of breathing b.
Ineffective breathing pattern related to airway inflammation and increased secretions
c.
Risk for fluid volume deficit related to tachypnea and decreased oral intake
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d. Fear/anxiety related to dyspnea and hospitalization ANS: B An ineffective breathing pattern is the priority nursing diagnosis for an infant hospitalized with RSV infection. 20. The nurse is caring for a toddler with acute laryngotracheobronchitis. The assessment finding that would indicate the child is experiencing increased respiratory obstruction is: a. Restlessness b.
Tachycardia
c.
Brassy cough
d. Expiratory wheezing ANS: C Restlessness is a primary sign of increased respiratory obstruction. 1. The nurse describes the allergic salute as a cluster of signs related to chronic allergy, which are: Select all that apply. a. Mouth breathing b.
Transverse nasal crease
c.
Dark circles under the eyes
d.
Productive cough
e. Reddened conjunctiva ANS: A, B, C, E The allergic salute does not include a productive cough. 2. The nurse would suggest to the parents of an asthmatic child to encourage participation in such activities as: Select all that apply. a. Swimming b.
Gymnastics
c.
Baseball
d.
Basketball
e. Tennis ANS: A, B, C Sports that require bursts of energy rather than long-term output of energy are suitable pursuits for asthmatics. Swimming, gymnastics, and baseball fit this criterion. COMPLETION 1. The nurse explains that the ____________________ can sense the oxygen concentration in the blood and can signal the brainstem to increase respiration. ANS: chemoreceptors 2. After the 3-month-old child with respiratory syncytial virus is given a protocol of antiviral medications, the nurse explains that routine immunizations will need to be delayed for ____________________ months.
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ANS: 9 3. The nurse reviews for the client drugs such Accolate and Zyflo, which are _______________ _______________; they are capable of blocking the inflammatory response as well as providing bronchodilation. ANS: leukotriene modifiers
Chapter 26 Cardiovascular Disorders 1. An infant with congestive heart failure is receiving Lanoxin. The nurse recognizes signs of digoxin toxicity, which are: a. Restlessness b.
Decreased respiratory rate
c.
Increased urinary output
d. Vomiting ANS: D Symptoms of digoxin toxicity include the following: nausea, vomiting, anorexia, irregularity in pulse rate and rhythm, and a sudden change in pulse. 2. The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, Why do my childs fingertips look like that? The nurse bases a response on the understanding that clubbing occurs as a result of: a. Untreated congestive heart failure b.
A left-to-right shunting of blood
c.
Decreased cardiac output
d. Chronic hypoxia ANS: D Clubbing of the fingers develops in response to chronic hypoxia. 3. When a father asks why his child with tetralogy of Fallot seems to favor a squatting position, the nurse would explain that squatting: a. Increases the return of venous blood back to the heart b.
Decreases arterial blood flow away from the heart
c.
Is a common resting position when a child is tachycardic
d. Increases the workload of the heart ANS: A The squatting position allows the child to breathe more easily because systemic venous return is increased.
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4. An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). The nurse understands dyspnea occurs because: a. Blood is circulated through the lungs again, causing pulmonary circulatory congestion. b.
Blood is shunted past the pulmonary circulation, causing pulmonary hypoxia.
c.
Blood is shunted past cardiac arteries, causing myocardial hypoxia.
Blood is circulated through the ductus from the pulmonary artery to the aorta, d. bypassing the left side of the heart. ANS: A When PDA is present, oxygenated blood recycles through the lungs, overburdening the pulmonary circulation. 5. An appropriate nursing action related to the administration of Lanoxin to an infant would be: a. Counting the apical rate for 30 seconds before administering the medication b.
Withholding a dose if the apical heart rate is less than 100 beats/min
c.
Repeating a dose if the child vomits within 30 minutes of the previous dose
d. Checking respiratory rate and blood pressure before each dose ANS: B As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and the physician is notified. 6. A child develops carditis from rheumatic fever. The nurse knows that the areas of the heart affected by carditis are: a. The coronary arteries b.
The heart muscle and the mitral valve
c.
The aortic and pulmonic valves
d. The contractility of the ventricles ANS: B The tissues that cover the heart and heart valves are affected. The heart muscle may be involved and the mitral valve is frequently involved. 7. The comment made by a parent of a 1-month-old that would alert the nurse about the presence of a congenital heart defect is: a. He is always hungry. b.
He tires out during feedings.
c.
He is fussy for several hours every day.
d. He sleeps all the time. ANS: B Fatigue during feeding or activity is common to most infants with congenital cardiac problems. 8. The nurse is caring for a child with a diagnosis of Kawasaki disease. The childs parent asks the nurse, How does Kawasaki disease affect my childs heart and blood vessels? The nurses response is based on the understanding that: a. Inflammation weakens blood vessels, leading to aneurism. b.
Increased lipid levels lead to the development of atherosclerosis.
c.
Untreated disease causes mitral valve stenosis.
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d. Altered blood flow increases cardiac workload with resulting heart failure. ANS: A Inflammation of vessels weakens the walls of the vessels and often results in aneurysm. 9. A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever? a. Subcutaneous nodules and fever b.
Painful, tender joints and carditis
c.
Erythema marginatum and arthralgia
d. Chorea and elevated sedimentation rate ANS: B The presence of two major Jones criteria would indicate a high probability of rheumatic fever. 10. The nurse explains that a ventricular septal defect will: a. Allow blood to shunt left to right, causing increased pulmonary flow and no cyanosis b.
Allow right-to-left shunt, causing decreased pulmonary flow and cyanosis
c.
Allow no shunting because of high pressure in the left ventricle
Allow increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating d. volume ANS: A Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis. 11. The assessment that would lead the nurse to suspect that a newborn infant has a ventricular septal defect, is: a. A loud, harsh murmur with a systolic tremor b.
Cyanosis when crying
c.
Blood pressure higher in the arms than in the legs
d. A machinery-like murmur ANS: A A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal defect. 12. The finding the nurse would expect when measuring blood pressure on all four extremities of a child with coarctation of the aorta is: a. Blood pressure is higher on the right side. b.
Blood pressure is higher on the left side.
c.
Blood pressure is lower in the arms than in the legs.
d. Blood pressure is lower in the legs than in the arms. ANS: D The characteristic symptoms of coarctation of the aorta are a marked difference in blood pressure and pulses between the upper and lower extremities. Pressure is increased proximal to the defect and decreased distal to the coarctation.
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Chapter 27 Gastrointestinal Disorders MULTIPLE CHOICE 1. The finding in a newborn assessment suggestive of tracheoesophageal fistula is: a. Failure to pass meconium in 24 hours b.
Choking on the first feeding
c.
Palpable mass in the sternal area
d. Visible peristalsis across abdomen ANS: B After birth, a newborn with tracheoesophageal fistula will vomit and choke when the first feeding is introduced. 2. A child is brought to the pediatric clinic because he has been vomiting for the past 2 days. An acid-base imbalance that the nurse would expect to occur from this persistent vomiting is: a. Hyperkalemia b.
Hypernatremia
c.
Acidosis
d. Alkalosis ANS: D Hydrochloric acid and sodium chloride from the stomach are lost from persistent vomiting. This results in alkalosis. 3. On the second day of hospitalization for a 3-month-old brought in for treatment for gastroenteritis, the nurse makes all of the assessments listed below. The assessment that indicates that the treatment is not effective is: a. Weight loss of 4 ounces b.
Dry mucous membranes
c.
Decreased skin turgor
d. Depressed fontanelle ANS: A Weight loss is the most significant indicator of dehydration.
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4. The nurse is aware that rapid respirations are a possible cause of dehydration because they: a. Prevent the child from drinking b.
Increase circulation, thus increasing urine production
c.
Cause evaporation of fluid on the mucous membranes
d. Often lead to vomiting ANS: C Rapid respirations cause increased insensible fluid loss. 5. An appropriate intervention for a 3-month-old infant who has gastroesophageal reflux is to: a. Position the infant in the crib on its abdomen, with the head elevated. b.
Administer medication as ordered to stimulate the pyloric sphincter.
c.
Give thin rice cereal with formula before feeding solid foods.
d. Place the infant in an infant seat after feedings. ANS: A After feedings, the infant is placed in a prone position to avoid increased intraabdominal pressure. 6. The nurse interviewing parents of an infant with pyloric stenosis would expect the parents to report the infant has had: a. Diarrhea b.
Projectile vomiting
c.
Poor appetite
d. Constipation ANS: B Vomiting is the outstanding symptom of pyloric stenosis. Food is ejected with considerable force, which is described as projectile vomiting. 7. A parent reports that her child has been scratching the anal area and complaining of itching. Based on this information, the nurse might suspect this child has: a. Pinworms b.
Giardiasis
c.
Ringworm
d. Roundworm ANS: A With pinworms, the nurse or parent may notice that the child scratches the anal area and complains of itchiness. The other choices do not cause this reaction. 8. The nurse that is teaching a parent about pyrvinium (Povan) would include the information that the drug will cause: a. Diarrhea b.
Skin rash
c.
Red stool
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d. Metallic taste ANS: B The nurse should advise parents that Povan stains and turns stools red. 9. The instruction the nurse would give to parents about preventing the spread and reinfection of pinworms is: a. Keep childrens nails short b.
Dress child in loose-fitting underwear
c.
Clean the bathroom with bleach solution
d. Wash bed linens in cold water ANS: A One intervention to prevent the further spread of pinworms is to keep the childs fingernails short. Pinworms are not spread from person to person. 10. A parent reports that her 2-year-old child experiences constipation frequently. The nurse would recommend to the mother to include in the childs diet: a. Cooked vegetables b.
Pretzels
c.
Whole-grain cereal
d. Yogurt ANS: C Dietary modifications for constipation include eating more high-roughage foods such as wholegrain breads and cereals. 11. Intussusception would be suspected when parents describe the childs stools as: a. Currant jelly b.
Black and tarry
c.
Green liquid
d. Greasy and foul-smelling ANS: A Bowel movements of blood and mucus that contain no feces (currant jelly stools) are common about 12 hours after the onset of the obstruction. 12. The nurse explains that the treatment of choice for a child with intussusception is: a. A barium enema b.
Immediate surgery
c.
IV fluids until the spasms subside
d. Gastric lavage ANS: A A barium enema is the treatment of choice for intussusception because the passage of the barium frequently un-telescopes the bowel. Surgery is scheduled only if reduction is not achieved. 13. Parents ask the nurse how their infant developed a Meckels diverticulum. The nurses response is based on the knowledge that this condition occurs when:
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a.
The yolk sac remains connected to the intestine.
b.
There is inflammation of the ileocecal valve.
c.
A pouch forms when the vitelline duct fails to disappear.
d. There is a weakness in the abdominal wall. ANS: C If the vitelline duct fails to disappear completely after birth, a blind pouch may form. 14. An infant is admitted to the hospital with severe isotonic dehydration. In planning the infants care, the nurse is aware the infant is at risk for: a. Metabolic alkalosis b.
Hypocalcemia
c.
Sepsis
d. Shock ANS: D Shock is the greatest threat to life in isotonic dehydration. 15. A child is brought to the emergency department because he ingested an unknown quantity of Tylenol. After gastric lavage is completed, the nurse might expect this child to receive: a. Activated charcoal b.
N-Acetylcysteine
c.
Vitamin K
d. Syrup of ipecac ANS: B Gastric lavage is followed by N-acetylcysteine (Mucomyst), the antidote for acetaminophen. 16. The nurse, planning a parent education program about lead poisoning prevention, would include the information that the sources of lead in the community are most likely: a. Increased lead content of air b.
Use of aluminum cookware
c.
Deteriorating paint in older buildings
d. Inhaling smog ANS: C The primary source of lead is paint from old, deteriorating buildings. 17. A frightened mother calls a neighbor because her child swallowed dishwashing detergent. The most appropriate action that the neighbor can advise is: a. Induce vomiting by giving the child syrup of ipecac. b.
Take the child to the local emergency department.
c.
Give the child activated charcoal mixed with juice.
d. Give the child milk to soothe affected mucous membranes. ANS: B
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Inducing vomiting is no longer recommended because it may pose additional problems. The child should be taken immediately to the nearest emergency department. 18. A child has been diagnosed with ascariasis (roundworm). The statement made by her mother that may suggest a cause for her condition is: a. Ive been airing out the house on these nice breezy days. b.
My child often goes out to the garden and pulls up a carrot to eat.
c.
She runs barefoot so much I have to wash her feet at least twice a day.
d. We just remodeled our bathroom at home. ANS: B The child can ingest roundworm eggs from contaminated soil. 19. The nurse would expect the stools of a child with celiac disease to have which appearance? a. Ribbonlike b.
Hard, constipated
c.
Bulky, frothy
d. Loose, foul-smelling ANS: C Celiac disease causes malabsorption. Stools that are large, bulky, and frothy may indicate malabsorption. 20. After reviewing dietary restrictions for celiac disease, the nurse determines that a parent understands the information when she states that a grain that can be eaten by a child with celiac disease is: a. Wheat b.
Oats
c.
Barley
d. Rice ANS: D Rice is a gluten-free grain that can be eaten by children afflicted with celiac disease. 21. A 7-month-old infant is admitted to the hospital with a diagnosis of acute gastroenteritis. The priority goal of the infants care is to prevent: a. Fluid and electrolyte imbalance b.
Nutritional deficiency
c.
Skin breakdown
d. Malabsorption ANS: A The priority goal of care in gastroenteritis is preventing fluid and electrolyte imbalance. 22. The nurse, speaking to the parent of a 3-year-old child who has mild diarrhea, would advise the dietary modification of: a. Soft diet with rice, bananas, toast, and applesauce b.
Small amounts of clear fluids such as gelatin
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c.
An oral rehydrating solution such as Pedialyte
d. Chicken soup because it is high in sodium ANS: C An oral rehydrating solution is recommended to replace fluids and electrolytes lost from frequent bowel movements. 23. The nurse would expect a child admitted to the hospital for nonorganic failure to thrive to: a. Cry to be picked up b.
Be limp like a rag doll
c.
Be responsive to cuddling
d. Weigh in the 10th percentile for age ANS: B Some children with failure to thrive have rag-doll limpness (hypotonia) and appear wary of their caregivers. 24. Nursing interventions for the mother of a 10-month-old infant with nonorganic failure to thrive would include: a. Pointing out errors that the nurse observes when the mother is caring for the infant b.
Discussing negative characteristics of the infant with the mother
c.
Having the nurse provide as much of the infants care as possible
d. Teaching the mother about the developmental milestones to expect in the next few months ANS: D The nurse can increase parents knowledge of growth and development by providing anticipatory guidance about normal developmental milestones. 25. The statement by a mother that may indicate a cause of her sons vitamin C deficiency is: a. We get our fruits from homemade preserves. b.
We use milk from our own goats.
c.
We raise all our own vegetables.
d. Were not big meat eaters. ANS: A Vitamin C is destroyed by heat. 26. The nurse instructing a mother how to administer oral nystatin suspension, prescribed to treat thrush, would teach to: a. Pour the prescribed amount into a nipple and have the infant suck the medication. b.
Squirt the prescribed dose into the back of the mouth and have the infant swallow.
c.
Give the medication mixed with a small amount of juice in a bottle.
d. Use a sterile applicator to swab the medication on the oral mucosa. ANS: D An appropriate way to administer nystatin is to moisten a sterile applicator with the medication and then swab it on the inside of the mouth.
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27. One reason that infants are more vulnerable to fluid and electrolyte imbalances than adults is that: a. They have a smaller surface area than adults in proportion to body weight. b.
Water needs and losses per kilogram are lower than those for adults.
c.
A greater percentage of body water in infants is extracellular.
d. Infants have a lower metabolic turnover of water. ANS: C A greater percentage of body water is contained in the extracellular compartment of children under 2 years of age. 28. An infant is admitted to the hospital with severe dehydration. Laboratory results show pH 7.32, PaCO2 40, HCO321. The nurse interprets these values as: a. Metabolic acidosis b.
Metabolic alkalosis
c.
Respiratory acidosis
d. Respiratory alkalosis ANS: A A pH lower than 7.35 indicates acidosis. If the childs pH falls in the same line as the HCO3-, the problem is metabolic (see Table 27-4). MULTIPLE RESPONSE 1. When feeding a child with pyloric stenosis, the nurse will: Select all that apply. a. Give a formula thinned with water. b.
Burp the baby before and during feeding.
c.
Give the feeding slowly.
d.
Refeed if the baby vomits.
e. Position baby on left side after feeding. ANS: B, C, D Children with pyloric stenosis are given formula thickened with cereal; the baby is burped before and during feeding to get rid of any gas in the stomach; the baby is fed slowly and refed if vomiting occurs. The baby is positioned on the right side to allow the weight of the feeding to stay in the stomach against the pyloric valve. COMPLETION 1. The nurse, assessing an elevated erythrocyte sedimentation rate (ESR) for a baby with gastroenteritis, recognizes that this confirms the ____________________ process that is part of this disease. ANS: inflammatory 2. The nurse explains that because ____________________ drinks cause diuresis, they are not good choices for fluid replacement in a child who is dehydrated. ANS: cola caffeinated
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3. The nurse explains that rickets, a deficiency disease that causes bony deformities, is caused by the inadequate supply of vitamin ____________________. ANS: D 4. The nurse reminds parents of a child allergic to cows milk that they should avoid foods that list ____________________ as part of their contents. ANS: casein Rationale: Food labels that list casein contain cows milk.
Chapter 28 Genitourinary Disorders. MULTIPLE CHOICE 1. The nurse discussed strategies with a parent to prevent a recurrence of urinary tract infection in the child. The statement made by the parent indicating a need for further teaching is: a. My daughter should wash and wipe the perineal area from front to back. b.
I am only going to have my daughter wear cotton underwear.
c.
It is acceptable to take frequent bubble baths.
d. She needs to drink lots of fluids and void frequently. ANS: C Oils in bubble bath and similar products are known to irritate the urethra. 2. When asked about correcting the hypospadias of their newborn, the nurse explains that with this condition: a. No intervention is necessary as the defect will correct itself over time. b.
Surgical repair of the hypospadias is done before 18 months of age.
c.
Corrective surgery is usually delayed until the preschool period.
d. Repairing the defect will increase the risk of testicular cancer. ANS: B Treatment of hypospadias consists of surgical repair and is usually performed before 18 months of age. 3. The initial sign of nephrosis that the nurse might note in the child would be: a. Raspberry-like rash b.
Periorbital edema
c.
Temperature elevation
d. Abdominal pain ANS: B The edema of nephrotic syndrome is generalized, and not readily noticed, even by the parents, but an early sign that can be assessed is periorbital edema.
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4. While a child is receiving prednisone to treat nephrotic syndrome, it is important for the nurse to assess the child for: a. Infection b.
Urinary retention
c.
Easy bruising
d. Hypoglycemia ANS: A Prednisone depresses the immune response and increases susceptibility to infection. Because steroids mask signs of infection, the child must be assessed for more subtle symptoms of illness. 5. 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. 6. A 7-year-old child with acute glomerulonephritis has gross hematuria and has been confined to bed. An appropriate nursing intervention for this child would be: a. Providing activities for the child on restricted activity b.
Feeding the child a protein-restricted diet
c.
Carefully handling edematous extremities
d. Observing the child for evidence of hypotension ANS: A Although children may feel well, activity is limited until hematuria resolves. 7. The nurse clarifies that the urinary diversion procedure that would be least damaging to the body image of the adolescent would be: a. Urostomy b.
Ileal conduit
c.
Nephrostomy
d. Suprapubic placement ANS: B The ileal conduit diverts urine to the colon, and the urine is excreted with the feces. There is no external appliance as is needed with the other diversion methods. 8. The mother of a 5-year-old child taking prednisone for nephrotic syndrome tells the nurse he needs to get immunizations to enter kindergarten. The nurse clarifies that while on prednisone, immunizations: a. Can interfere with the treatment for nephrosis
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b.
Require that the child have antibiotic coverage
c.
Can be given in smaller, divided doses
d. Should be delayed ANS: D No vaccinations or immunizations should be administered while the disease is active and during immunosuppressive therapy. 9. When diuresis has not occurred after a month on corticosteroids, the nurse explains to the parents of a child with nephrotic syndrome that diuresis can be brought about by a protocol of: a. Ibuprofen, an antiinflammatory agent b.
Lasix, a diuretic
c.
Cipro, an antibiotic
d. Cytoxan, an antisuppressant ANS: D A potent antisuppressant such as Cytoxan can bring about diuresis when corticosteroids have proven ineffective. 10. Because of the hyperkalemia associated with acute glomerulonephritis, the nurse recommends that the child avoid such foods as: a. Dairy products b.
Whole-grain cereals
c.
Organ meats
d. Bananas ANS: D Bananas are very high in potassium and should be avoided. 11. The physical assessment that the nurse would omit in caring for a 2-year-old who has a Wilms tumor is: a. Performing ROM on lower extremities b.
Palpating the abdomen
c.
Assessing for bowel sounds
d. Percussing ankle and knee reflexes ANS: B Palpation of the abdomen could disturb the tumor and cause spread of the malignancy. 12. Parents are speaking with the urologist about their sons undescended testicle. The nurse determines the childs father understands the information presented when he states: a. An undescended testicle can reduce fertility. b.
The testicle usually descends spontaneously during the first month of life.
c.
Surgical correction reduces the risk for testicular tumors.
d. The optimal time to surgically correct the condition is at diagnosis. ANS: A
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Although orchiopexy improves the condition, the fertility rate among patients may be reduced even when only one testis is undescended. 13. A parent tells the nurse her child is scheduled for an x-ray of the bladder and urethra that is done while the child is urinating. The nurse recognizes this description as a(n): a. Cystometrogram b.
Cystoscopy
c.
Voiding cystourethrogram
d. Intravenous pyelogram ANS: C An x-ray examination of the bladder and urethra before and during micturition is called a voiding cystourethrogram. ] 14. A 6-year-old child with daytime enuresis complains of dysuria and urgency; the nurse recognizes these as signs and symptoms of: a. Urinary tract infection b.
Nephrotic syndrome
c.
Acute glomerulonephritis
d. Vesicoureteral reflux ANS: A Urinary frequency and pain during micturition are symptoms of acute urinary tract infection. 15. An appropriate intervention for the child with minimal change nephrotic syndrome who is edematous would be to: a. Teach the child to minimize body movements. b.
Change the childs position frequently.
c.
Keep the head of the childs bed flat.
d. Keep edematous areas moist and covered. ANS: A The child should be turned frequently to prevent respiratory tract infection and to prevent pressure on delicate skin. 16. The statement made by a parent of a child with nephrotic syndrome indicating an understanding of discharge teaching is: a. I will make sure he gets his measles vaccine as soon as he gets home. b.
He can stop taking his medication next week.
c.
I should check his urine for protein when he goes to the bathroom.
d. He should eat a low-protein diet for the next few weeks. ANS: C The parents should be instructed to keep a daily record of the childs urinary proteins. 17. A 5-year-old boy is admitted to the hospital with acute glomerulonephritis. In taking the childs history, the nurse recognizes the probable cause of this condition as: a. Recovered from German measles 2 months ago
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b.
Dysuria since the previous night
c.
A history of allergy
d. A sore throat 2 weeks ago ANS: D Acute glomerulonephritis develops from 1 to 3 weeks after a streptococcal infection, which causes an allergic-type response that alters the effectiveness of the glomeruli. 18. The nurse is explaining to a 17-year-old female the actions to prevent urinary tract infection. The nurse determines the adolescent understands the information when she says a good drink to keep urine acidic is: a. Milk b.
Grape juice
c.
Apple juice
d. Orange juice ANS: C Juices such as apple or cranberry help maintain acidity of urine. 19. The 6-year-old scheduled for an orchiopexy shyly asks the nurse, What are they going to do to me down there? The nurses best response would be: a. They are going to fix you up down there b.
They will move your testicle from your abdomen to your scrotum.
c.
What do you think your doctor is going to do?
d. You shouldnt worry. Your doctor knows exactly what to do. ANS: C Encourage the patient to talk about what he knows and what feelings he has about the surgery. School-age children have a fear of bodily harm. MULTIPLE RESPONSE 1. The nurse caring for a newborn with exstrophy of the bladder will include in the care: Select all that apply. a. Diaper infant tightly. b.
Protect skin around bladder.
c.
Position infant on back.
d.
Prepare for surgical closure.
e. Cover exposed bladder with shield. ANS: B, C, D, E The infant is kept on his back or side with special attention to the skin around the exposed bladder, which is constantly bathed with urine. These infants are diapered loosely, if at all. Surgical closure is done as quickly as possible. 2. The nurse caring for a child with nephrotic syndrome is alert to the classic symptoms of this disorder, which are: Select all that apply. a. Proteinuria
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b.
Grossly bloody urine
c.
Hyperalbuminemia
d.
Fatigue
e. Generalized edema ANS: A, B, D, E All options listed are those of nephrotic syndrome with the exception of hyperalbuminemia. The nephrotic child has hypoalbuminemia, as most of the protein has been spilled in the urine. COMPLETION 1. The nurse explains that the test that measures the pressure and volume of the urine stream is called the ____________________. ANS: uroflowmeter 2. The nurse uses a diagram to show how the ____________________, the working unit of the kidney, filters and regulates fluids. ANS: nephron NOT: Rationale: The nephron is the working unit of the kidney that filters and regulates fluids in the body. There are roughly 1 million nephrons in each kidney. 3. When a childs ureter becomes completely obstructed from scarring, the nurse explains that urinary diversion may be necessary to prevent the reflux back into the renal pelvis from causing ____________________. ANS: hydronephrosis NOT: Rationale: Hydronephrosis occurs when the urine is unable to pass through the ureter into the bladder; the urine refluxes back into the renal pelvis, causing dilation and swelling of the kidney.
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Chapter 29 Gynecologic Disorders MULTIPLE CHOICE 1. Following an amniotomy, the nursing assessment that should be reported immediately is: a. Fetal heart rate is regular at 154 beats/min b.
Amniotic fluid is clear with flecks of vernix
c.
Amniotic fluid is watery and pale green
d. Maternal temperature is 37.8C ANS: C Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise. 2. A woman 2 weeks past her expected delivery date who is receiving an oxytocin infusion to induce labor begins to have contractions every 90 seconds. The nurses initial action should be to: a. Stop the oxytocin infusion b.
Continue the infusion and report the findings to the physician
c.
Turn her on her left side and reassess the contractions
d. Administer oxygen by mask ANS: A Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur. 3. The nursing care of a woman with a third-degree laceration immediately after delivery would include: a. Warm compresses to the perineum b.
Cold pack to the perineum
c.
Warm sitz bath
d. Elevation of hips to prevent edema ANS: B Ice is applied to the perineum to reduce bruising and edema. 4. After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm dilated but contractions are becoming shorter and less frequent. The nurse knows that this labor pattern is described as:
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a.
Normal
b.
Hypotonic
c.
Hypertonic
d. False ANS: B The woman with hypotonic labor dysfunction begins labor normally, but contractions diminish after the active phase. 5. When a hypotonic labor dysfunction occurs in a patient who is dilated to 5 cm with membranes intact, the nurse informs the patient that the physician most likely will: a. Perform an amniotomy b.
Initiate tocolytic drugs
c.
Order a sedative for the patient
d. Plan to do an emergency cesarean section ANS: A Medical treatment for hypotonic labor dysfunction includes an amniotomy if the membranes are intact as the first remedy. 6. The nurse would assess an infant delivered with the use of forceps for: a. Loss of hair from contact with forceps b.
Sacral hematoma
c.
Facial asymmetry
d. Shoulder dislocation ANS: C Pressure from forceps may injure the infants facial nerve, which is evidenced by facial asymmetry. 7. The new mother is distressed and tearful about the elevated dome over her babys posterior fontanelle. The nurses best response is, This condition will resolve itself in a few days. It is caused by: a. Prolonged pressure against the partially dilated cervix. b.
Small leak of fluid through the posterior fontanel.
c.
Pressure of the forceps during delivery.
d. The effect of the vacuum extractor. ANS: D The chignon is due to the effect of the vacuum extractor and will disappear in a few days. 8. The frustrated patient in hypotonic labor complains My doctor wont induce my labor because of some silly Bishop score. He said I was a 4. What kind of magic number do I need? The nurse explains that prior to induction the patient should be a Bishop score of at least: a. 6 b.
8
c.
10
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d. 12 ANS: A The Bishop Score evaluated the suitability of the patient for a vaginal delivery. A minimum score of 6 is recommended by the ACOG. 9. A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). To encourage fetal rotation and pain relief the nurse would position the patient: a. Prone with legs supported and give her a back massage b.
Supine with legs bent at the knee
c.
Standing with support
d. Sitting up and leaning forward on the over-bed table ANS: D A position that favors fetal rotation and descent and that is helpful for the woman with back labor is to sit or kneel leaning forward on a support. 10. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman asks the nurse, Please give me something. The most appropriate pain relief intervention for a woman in precipitate labor is to: a. Get an order for an intravenous narcotic b.
Notify the anesthesiologist for an epidural block
c.
Stay and breathe with her during contractions
d. Tell her to bear with it because she is close to delivery ANS: C The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractions to help the woman focus and cope with each contraction. 11. A woman who is 33 weeks pregnant is admitted to the obstetrical unit because her membranes ruptured spontaneously. She must be closely observed for signs of: a. Chorioamnionitis b.
Hemorrhage
c.
Hypotension
d. Amniotic fluid embolism ANS: A Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken. 12. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The nurse would assess for which adverse effect? a. Maternal tachycardia b.
Maternal hypertension
c.
Fetal bradycardia
d. Fetal hypokalemia ANS: A
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Maternal tachycardia is the common negative side effect of terbutaline which should be corrected with a dose of propranolol. 13. The statement that indicates a woman understands activity limitations for the management of preterm labor is: a. After my shower in the morning, I do the laundry and straighten up the house, then I rest. b.
I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.
c.
I have a 2-year-old to care for, but I try to rest as much as I can.
d. I get really bored at home, so I go to the shopping mall for just a little while. ANS: B Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman identify ways to organize necessary activities and maximize rest. 14. A student nurse questions the instructor as to what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. The best response is that the fundus of a patient with a cesarean section is: a. Not assessed until the second postoperative day b.
Gently assessed as usual
c.
Assessed only if large clots appear in lochia
d. Only once every shift ANS: B Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage. 15. A pulsating structure is felt during a vaginal examination of a woman in labor. To prevent compression of a prolapsed cord, the nurse would position the woman: a. On her hands and knees b.
On her left side with a pillow placed between her legs
c.
On her back with her head lower than the rest of her body
d. Supine with her legs elevated and bent at the knee ANS: C The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord. 16. Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency Csection. The most appropriate nursing diagnosis is: a. Anxiety related to the development of postpartum complications b.
Ineffective individual coping related to unfamiliarity with procedures
c.
Risk for ineffective parenting related to emergency cesarean section
d. Grieving related to loss of expected birth experience ANS: D Women who have cesarean birth usually need greater support than those having vaginal births. They may feel grief, guilt, or anger because the expected course of birth did not occur.
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17. A pregnant womans membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. The nurse planning discharge instructions would teach the woman to: a. Report any increase in fetal activity b.
Notify her obstetrician for a temperature above 37.8C
c.
Massage her breasts to promote uterine relaxation
d. Rest in a side-lying Trendelenburg position with hips elevated ANS: B For the woman with PROM who is not having labor induced right away, teaching combines information about infection and preterm labor. The woman should monitor her temperature and report a temperature greater than 37.8C. 18. A woman who is 24 weeks pregnant is placed on an IV infusion of magnesium sulfate. The nurse should inform the patient that she might experience the side effect of this drug which is: a. Nausea and vomiting b.
Headache
c.
Warm flush
d. Urinary frequency ANS: C Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug. 19. When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, anxious about the welfare of her baby, anxious about how quickly she will recoverin short, anxious about everything. The nurse is aware that anxiety can affect labor by: a. Decreasing a womans pain sensitivity b.
Reducing blood flow to the uterus
c.
Increasing the ability to tolerate pain
d. Enhancing maternal pushing through greater muscle tension ANS: B Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions. 20. During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae which seems to occur with every breath she takes. The nurse should: a. Give the pain remedy b.
Notify the charge nurse immediately
c.
Turn patient to her back and flex her knees
d. Suggest that the coach give her a back rub ANS: B Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. This should be immediately reported.
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MULTIPLE RESPONSE 1. The nurse reviews for the childbirth preparation class the rationales for labor induction, which are: Select all that apply. a. Placenta previa b.
Prolapse of cord
c.
High station of fetus
d.
Maternal diabetes
e. Placental insufficiency ANS: D, E Maternal diabetes and placental insufficiency are rationales for induction. Options a, b, and c are contraindications for labor induction. 2. After an amniotomy, the nurse is alert for signs of infection which would include: Select all that apply. a. Oral temperature of 99.8F b.
Increase in FHR to 172 beats/min
c.
Flecks of vernix in the amniotic fluid
d.
Low back pain
e. Edematous labia ANS: B Increase in the FHR indicates fetal distress. All the other options are normal findings for late pregnancy. 3. The client has been declared to be in hypotonic labor. Among the interventions a nurse could apply to help the labor progress are: Select all that apply. a. Encouraging the client to sit upright b.
Assisting client to ambulate
c.
Stimulating the nipples
d.
Offering emotional support
e. Allowing client to vent frustration ANS: A, B, C Sitting upright, ambulating, and stimulation of the nipples may encourage progression of labor. Offering emotional support and allowing patient to vent frustration are supportive to the patient, but do not stimulate more effective labor. COMPLETION 1. Following an amniotomy, the umbilical cord becomes depressed. The nurse prepares the client for an installation of a bolus of warm sterile saline into the uterus, which is called ____________________. ANS: amnioinfusion
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NOT: Rationale: A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord. 2. The nurse explains to a client that a minimum score of ____________________ on the Bishop scale is predictive of successful labor induction. ANS: 6
Chapter 30 Endocrine Disorders MULTIPLE CHOICE 1. The nurse planning to teach a family about Tay-Sachs disease understands the pattern of inheritance for inborn errors of metabolism is usually: a. Autosomal recessive b.
Autosomal dominant
c.
X-linked recessive
d. Multifactorial ANS: A The pattern of inheritance is generally autosomal recessive. 2. The nurse explains that because of an inadequate secretion of insulin: a. Protein synthesis is increased. b.
Increased fat breakdown leads to ketonemia.
c.
Serum glucose levels are markedly decreased.
d. More rapid conversion and storage of carbohydrates to glucose occurs. ANS: B When insulin is deficient, the body cannot metabolize carbohydrates for energy. The body is also unable to store and use fat properly. Incomplete fat metabolism produces ketone bodies that accumulate in the blood. 3. The nurse caring for a child with a new diagnosis of type 1 diabetes mellitus plans the care based on the understanding that: a. There is an absolute deficiency of insulin. b.
Insufficient quantities of insulin are produced by the pancreas.
c.
Oral hypoglycemic agents can control it.
d. Insulin deficiency is caused by another disease affecting the pancreas. ANS: A Type 1 insulin-dependent diabetes mellitus is characterized by an absolute or complete deficiency of insulin. 4. A child receives a combination of regular and NPH insulin at 8:00 AM. At 8:45 AM, when the breakfast trays have not yet arrived from the kitchen, the nurse should:
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a.
Notify the charge nurse.
b.
Give the patient a snack of graham crackers and milk.
c.
Ambulate the patient in the hall for a short time.
d. Give the patient more insulin according to the sliding scale. ANS: B A child who receives regular insulin before meals may have an insulin reaction if food is not eaten within 20 minutes. A snack of graham crackers and milk will prevent an episode of hypoglycemia. 5. Although the type 1 diabetic child had her prescribed insulin at 7:30 AM, the child is complaining of hunger and thirst and is drowsy at noon. The nurse should: a. Administer glucagon immediately and test her blood with a glucometer in 10 minutes. b.
Have her eat some peanut butter crackers.
c.
Give her a cup of orange juice.
d. Test her blood with a glucometer and give insulin according to the sliding scale. ANS: D The immediate treatment for hyperglycemia is to give the patient more insulin. Giving more sugar will increase the blood sugar in a hyperglycemic child. Walking exercise will use up even more glucose. 6. The comment made by a school-age child, indicating that he needs more teaching about diabetes mellitus and exercise, is: a. I carry a piece of hard candy with me in case I start to feel shaky. b.
I make sure I have emergency money when I have soccer practice or a game.
c.
Sometimes I skip my breakfast when I have a game in the morning.
d. I play in soccer games that are scheduled after dinner. ANS: C Blood sugar is high after meals. The child with type 1 diabetes mellitus who skips a meal before exercise is at risk for hypoglycemia. 7. The statement made by a 7-year-old child with diabetes mellitus that indicates a need for more teaching is: a. My pancreas is sick and needs insulin until it gets better. b.
I will need to take my insulin every day.
c.
I need to keep a piece of candy in my pocket in case I start to feel shaky.
d. My mom has to give me insulin shots twice a day. ANS: A The child with type 1 diabetes mellitus has a complete insulin deficiency and will require lifelong management of this disease. Insulin does not cure the pancreas. 8. The general dietary measure the nurse will include in a teaching plan for the child with type 1 diabetes mellitus is: a. Control intake of carbohydrates and consume fewer calories.
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b.
Restrict concentrated carbohydrates and eat foods high in fiber.
c.
Calories must come from proteins and fats.
d. Eat a diet low in fat and low in complex carbohydrates. ANS: B The nutritional needs of a child with diabetes mellitus are essentially the same as those of the nondiabetic child, with the exception of the elimination of concentrated carbohydrates such as sugar. Fiber has been shown to reduce blood sugar levels. 9. A child with diabetes is brought to the emergency department; he is flushed, his skin is dry, and he is drowsy. His father states that the child has been feeling progressively worse since the morning. This child is most likely experiencing: a. Somogyi syndrome b.
Insulin shock
c.
Ketoacidosis
d. Water intoxication ANS: C In ketoacidosis the childs skin is dry and the face is flushed. Patients appear dehydrated. They may perspire and be restless. The breath has a fruity odor, and there is no rest period between inspiration and expiration. 10. A mother reports that her 4-month-old infant is lethargic, is sleeping 18 hours a day, and is snoring. The nurse recognizes that these signs are characteristic of: a. Hypothyroidism b.
Hyperthyroidism
c.
Type 1 diabetes mellitus
d. Tay-Sachs disease ANS: A The infant with hypothyroidism will appear sluggish, and the tongue will be enlarged, causing noisy respiration. 11. An important consideration for the school-age child taking DDAVP for diabetes insipidus would be: a. Observing for signs of water deprivation b.
Restricting his physical education program
c.
Permitting the child to use the bathroom when needed
d. Limiting fluid intake other than during the lunch period ANS: C The child with diabetes insipidus needs liberal access to bathrooms and water fountains. 12. The laboratory data indicating good metabolic control for a child with type 1 diabetes mellitus are: a. Glycosylated hemoglobin value of 8% b.
Fasting blood glucose level less than 140 mg/dl
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c.
Glucose tolerance test result of 190 mg/dl
d. No glucose or ketones present in the urine ANS: A Glycosylated hemoglobin reflects glycemic levels over a period of months. Levels of 6% to 9% represent good metabolic control. 13. The condition the nurse suspects when a child with type 1 diabetes mellitus has hyperglycemia, diaphoresis, and headaches in the morning is: a. Dawn phenomenon b.
Somogyi phenomenon
c.
Honeymoon effect
d. Ketoacidosis ANS: B The Somogyi phenomenon (rebound hyperglycemia) occurs when the blood glucose level is lowered to the point at which the bodys counter-regulatory hormones are released, producing the symptoms described. 14. What would be the most appropriate nursing response to a woman who says, My sister had a child with Tay-Sachs disease. I want to know if I could have a child with this condition. a. The disease is rare. It is unlikely that you would have a child with Tay-Sachs disease. b.
A screening test can be done to determine if you are a carrier of the gene.
c.
The gene for Tay-Sachs disease is transmitted by the father.
d. The cause of Tay-Sachs disease is thought to be an autoimmune response to a virus. ANS: B Carriers can be identified by screening tests. Tay-Sachs disease has an autosomal recessive pattern of transmission. 15. The nurse determines a parent is administering Synthroid correctly when she states: a. I stopped giving the medication because my daughter was losing her hair. b.
I am using a different brand now because it costs less money.
c.
I dont give the medication on the weekends.
d. I give the medication at 8:00 AM everyday. ANS: D Synthroid should be given at the same time each day, preferably in the morning. 16. Following a closed head injury, the unconscious 10-year-old child begins to excrete copious amounts of pale urine with an attendant drop in blood pressure. Based on these symptoms, the nurse suspects the development of: a. Diabetes insipidus b.
Diabetes mellitus
c.
Hypothyroidism
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d. Hyperthyroidism ANS: A Diabetes insipidus can be acquired as the result of a head injury or tumor, and suppression of the posterior pituitary causes copious urine output with an attendant drop in BP. The child can become dehydrated very quickly if some remedy is not applied. 17. The nurse teaching parents of a child with diabetes insipidus about water intoxication would tell the parents to be alert for: a. Polyuria b.
Cough
c.
Weight loss
d. Lethargy ANS: D Signs of water intoxication include edema, lethargy, nausea, and CNS signs. MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 18. The parents of a child newly diagnosed with diabetes mellitus tell the nurse, Our sons body is resistant to insulin. The nurse recognizes this description as consistent with: a. Type 1, insulin-dependent diabetes mellitus b.
Type 2, noninsulin-dependent diabetes mellitus
c.
Maturity-onset diabetes of youth
d. Drug-induced diabetes ANS: B Type 2, noninsulin-dependent, diabetes mellitus is caused by insulin resistance or failure of the body to use the insulin. 19. When teaching a 12-year-old how to administer insulin, the nurse includes the following instruction: a. Make sure injection sites are 6 inches apart. b.
Select an injection site that was recently exercised.
c.
Inject the needle at a 90-degree angle.
d. The injection is given deep into the muscle. ANS: C It is easier for the child to learn to inject the needle at a 90-degree angle. 20. The nurse discussed treatment of hypoglycemia with an adolescent. The nurse determined the adolescent understood the instructions when she verbalized that if her blood sugar is low or if she begins to feel hungry and weak, she will: a. Eat six LifeSavers b.
Give herself Lispro insulin
c.
Have a slice of cheese
d. Drink a diet soda ANS: A
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The immediate treatment of hypoglycemia consists of administering sugar in some form such as orange juice, hard candy, or a commercial product. MULTIPLE RESPONSE 1. The nurse explains that the endocrine system is primarily responsible for controlling the processes of: Select all that apply. a. Maturation b.
Reproduction
c.
Sexual identity
d.
Stress response
e. Growth ANS: A, B, D, E The endocrine system governs maturation, reproduction, stress response, and sexual maturity. Sexual identity is a psychosocial response. 2. The home health nurse monitoring an 8-month-old hypothyroid child taking Synthroid, recognizes signs of overdose when the assessment reveals: Select all that apply. a. Tachycardia b.
Irritability
c.
Vomiting
d.
Weight loss
e. Diaphoresis ANS: A, B, D, E All the options with the exception of vomiting are indications of overdose of Synthroid. 3. The nurse warns that keeping diabetes in control in an adolescent is made difficult because of: Select all that apply. a. Hormonal changes b.
Developmental conflict of independence vs. dependence
c.
Addiction to fast food
d.
Growth spurt
e. Denial of disease ANS: A, B, C, D, E The adolescent who is in a growth spurt and filled with raging hormones resents and denies the need to be dependent on a medication. Medication schedules and diet restrictions do not correlate well with the adolescents lifestyle of eating fast foods. COMPLETION 1. The nurse explains that the diagnosis of diabetes is made when the fasting blood glucose level is ____________________ mg/dl on two separate occasions, and the history is positive for indication of the disease.
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ANS: 126 NOT: Rationale: An elevated blood glucose level of 126 mg/dl on two separate occasions is grounds for the diagnosis of DM when the history is positive for the disease. 2. The nurse assessing a glycosylated hemoglobin (HbA1c) test is aware that this test can evaluate average glucose levels over a period of ____________________ to ____________________ months. ANS: 3, 4
Chapter 31 Musculoskeletal Disorders MULTIPLE CHOICE 1. In planning teaching to parents of a child with Legg-Calv-Perthes disease about the long-term effects of this disease, the nurse would include that: a. There are no long-term effects. b.
The disease is self-limiting, resolving itself in a year.
c.
Degenerative arthritis may develop later in life.
d. There is risk of osteogenic sarcoma in adulthood. ANS: C Marked distortion of the head of the femur may lead to an imperfect joint or to degenerative arthritis of the hip later in life. 2. The nurse caring for a child in Bucks skin traction will keep the: a. Child in high-Fowlers position b.
Child pulled up in bed
c.
Childs heel on the bed surface
d. Childs feet against the foot of the bed ANS: B Bucks traction is a type of skin traction that relies on the childs weight as counter-balance The child must be kept with head elevated no more than 20 degrees, pulled up in bed, and the feet should not touch the bed surface or the foot of the bed. 3. When caring for a child in Bucks extension, the nurse would include: a. Positioning the child with hips flexed 90 at all times b.
Keeping the weights in contact with the floor
c.
Checking for skin irritation from traction equipment
d. Releasing the weights on a schedule ANS: C The skin exposed to frequent friction may break down. 4. The nurse reviewing the characteristics of Ewings sarcoma would point out that with Ewings sarcoma: a. Amputation is the accepted treatment.
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b.
The disease is sensitive to radiation and chemotherapy.
c.
Metastasis is rare.
d. The disease is more prevalent in toddlers and preschoolers. ANS: B Ewings sarcoma is sensitive to radiation therapy and chemotherapy. Amputation of the affected extremity is not recommended. This cancer occurs in school-age children and does metastasize. 5. The nurse caring for a child with Duchennes muscular dystrophy notes a characteristic manifestation, which is that the child: a.
Ambulates by holding onto furniture
b.
Exhibits atrophy of the calf muscles
c.
Falls frequently and is clumsy
d. Has delayed fine-motor development ANS: C Frequent falling and clumsiness are clinical manifestations of Duchennes muscular dystrophy. 6. The nurse assessing a child with juvenile rheumatoid arthritis notes the childs right knee and ankle are swollen, warm, and tender. This finding is suggestive of the _____ type of juvenile rheumatoid arthritis. a. Pauciarticular b.
Polyarticular
c.
Systemic
d. Acute febrile ANS: A The pauciarticular form of juvenile rheumatoid arthritis is limited to four joints or fewer. 7. The nurse is providing instructions about how to treat a sprained ankle. The nurse will recognize the need for additional teaching when the mother states: a. Apply warm compresses to the ankle for the first 24 hours. b.
Put an ice pack on the ankle, alternating 30 minutes on with 30 minutes off.
c.
Wrap the ankle in an Ace bandage for support.
d. Keep the leg elevated when sitting. ANS: A Heat is not a treatment for soft tissue injuries. The principles of managing soft tissue injuries are rest, ice, compression, and elevation. 8. The nurse explains that Russell traction is a type of skin traction that: a. Subluxates the tibia b.
Does not interfere with range of motion
c.
Prevents the knee from flexing
d. Supplies continuous pull in two directions ANS: D
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Russell traction is skin traction, similar to Bucks traction, with a sling positioned under the knee, which prevents subluxation of the tibia. Although the traction interferes with full ROM, the patient can change position without disrupting the continuous pull in two directions. 9. The nurse who is checking for capillary refill on a child in Bryants traction will record adequate perfusion if the toe regains color in _____ seconds a. 3 b.
4
c.
5
d. 6 ANS: A Capillary refill in 3 seconds or less is determined to be indicative of adequate perfusion. 10. The parent of a child with osteomyelitis asks why his child is in so much pain. The nurses response will be based on the understanding that the pain of osteomyelitis is caused by: a. The pressure of inelastic bone b.
Purulent drainage in the bone marrow
c.
The cast applied on the extremity
d. Circulatory congestion of the skin ANS: B Osteomyelitis is an infection of the bone. Inflammation produces an exudate that collects under the marrow and cortex of the bone. The vessels are compressed and thrombosis occurs, producing ischemia and pain. 11. A child hospitalized for treatment of osteomyelitis complains that he is tired of being sick and wants to know when the antibiotic protocol will end. The nurse responds that antibiotic therapy will probably last for: a. 2 weeks b.
6 weeks
c.
2 months
d. 3 months ANS: B Because osteomyelitis is an infection in the bone, antibiotics are given intravenously for 4 to 6 weeks. 12. The nurse, assessing the neurovascular status of a child in Russell traction, should report immediately the finding of: a. Skin warm to the touch b.
Capillary refill less than 3 seconds
c.
Ability to wiggle toes
d. Bluish coloration of skin ANS: D Cyanosis or pallor noted in an extremity is an indication of circulatory impairment.
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-old girl is diagnosed with functional scoliosis, the nurse would explain the spinal curvature defect is usually caused by: a. Juvenile rheumatoid arthritis b.
Poor posture
c.
Heredity
d. Myelomeningocele ANS: B Functional scoliosis usually is caused by poor posture, and it is not a spinal disease. 14. A nurse assessing a preadolescent child for scoliosis would: a. Ask the child to bend forward at the waist, and would observe the childs back for asymmetry b.
Observe the gait while the child is walking forward heel to toe
c.
Have the child flex the knees and look for uneven knee height
d. Look at the childs shoulders and hips while fully clothed ANS: A The nurse looks at the back, as the child bends forward, for general body alignment and asymmetry. 15. The nurse caring for a child in Bryants traction knows that the risk of serious complications will be reduced by ensuring that: a. Neurovascular checks are done frequently b.
Ace bandages are wrapped tightly
c.
The baby is restrained from rolling over
d. The childs buttocks are resting on the bed ANS: A The nurse caring for a child in traction must be alert for Volkmanns ischemia, which occurs when circulation is obstructed. 16. The interventions that would be helpful in relieving morning discomfort associated with juvenile rheumatoid arthritis would be: a. Wearing splints at night to prevent extension contractures b.
Applying moist heat packs upon awakening
c.
Taking a warm tub bath the evening before
d. Sleeping with two pillows under the head ANS: B Application of moist heat, with a compress or by tub bath upon awakening, will help to lessen stiffness. 17. The nurse providing instructions to an adolescent who has been fitted with a Milwaukee brace would teach the patient to: a. Wear the brace directly against the skin. b.
Wear the brace over regular clothing.
c.
Wear the brace over a T-shirt 23 hours a day.
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d. Remove the brace before sleeping. ANS: C A Milwaukee brace is worn approximately 23 hours a day over a T-shirt that protects the skin. 18. The observation that may cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs is: a. The child has red, green, and yellow bruises on his body. b.
The childs bruises are dispersed on his head, arms, and legs.
c.
The child had a broken arm last year and is described as accident prone.
d. The childs mother is very anxious for her son to get medical attention. ANS: A As bruises heal, they change color in stages. Different colors of bruises indicate that injuries have not all occurred at the same time. The nurse must consider whether the bruises match the caretakers explanation of what happened. 19. A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain when she raises herself onto the bedpan. The nursing diagnosis that takes highest priority for this child is: a. Pain resulting from tissue trauma b.
High risk for impaired skin integrity resulting from immobility
c.
Altered growth and development related to separation from family
d. Altered urinary elimination related to immobility and traction ANS: A Although all of these nursing diagnoses are relevant to the child in traction, pain resulting from muscle spasm and tissue trauma is the highest priority. 20. The nurse notes as an abnormal finding on a musculoskeletal assessment of a 4-year-old that the child: a. Has inward-turned knees while standing b.
Walks on his toes
c.
Appears to have flat feet
d. Swings his arms when walking ANS: B Toe walking after 3 years of age may indicate a muscle problem. 21. The nurse understands a difference in the childs skeletal system as compared to an adults is: a. The childs bone is less porous than adult bone. b.
Bone growth is not affected by fractures.
c.
Bone overgrowth in healing fractures is uncommon.
d. Callus formation in healing fractures occurs more rapidly. ANS: B Callus forms more rapidly in the child than the adult. MULTIPLE RESPONSE 1. The nurse demonstrates how all traction devices:
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Select all that apply. a. Pull the limb into extension b.
Decrease muscle spasm
c.
Reduce pain
d.
Align two bone fragments
e. Immobilize the limb ANS: A, B, D, E Tractions are designed to immobilize and pull limbs into extension. Traction can also align broken bones and decrease muscle spasm. Although some tractions may relieve pain, many tractions may actually cause pain. 2. The nurse performing a neurovascular check on a limb in traction will assess: Select all that apply. a. Pulse quality b.
Degree of sensation
c.
Color quality
d.
Capillary refill
e. Degree of movement ANS: A, B, C, D, E All options listed are integral components of the neurovascular assessment that is done to ensure adequate perfusion to a limb in traction. COMPLETION 1. The nurse explains that Bryants traction is reserved for children who weigh less than ____________________ pounds. ANS: 40 2. The nurse reminds the adolescent boy with Ewings sarcoma that he is prohibited from vigorous weight-bearing during treatment with radiation to reduce the risk of a ____________________ fracture. ANS: pathological 3. The child with Duchennes muscular dystrophy must push on his legs and walk up the leg in order to rise to a standing position. The nurse recognizes this characteristic behavior as ____________________ maneuver. ANS: Gowers 4. The nurse recognizes the signs of ____________________ syndrome in a child in a 90-90 traction when the toes are pale and edematous and have a very slow capillary refill. ANS: compartment
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Chapter 32 Neurologic Disorders MULTIPLE CHOICE 1. The American Association on Intellectual and Developmental Disabilities (AAIDD), formerly the American Association on Cognitive Impairment, classifies cognitive impairment based on what parameter? a. Age of onset b.
Subaverage intelligence
c.
Adaptive skill domains
d. Causative factors for cognitive impairment ANS: C The AAIDD has categorized cognitive impairment into adaptive skill domains. The child must demonstrate functional impairment in at least two of the following adaptive skill domains: communication, self-care, home living, social skills, use of community resources, self-direction, health and safety, functional academics, leisure, and work. Age of onset before 18 years is part of the former criteria. Low intelligence quotient (IQ) alone is not the sole criterion for cognitive impairment. Etiology is not part of the classification. 2. Secondary prevention for cognitive impairment includes what activity? a. Genetic counseling b.
Avoidance of prenatal rubella infection
c.
Preschool education and counseling services
d. Newborn screening for treatable inborn errors of metabolism ANS: D Secondary prevention involves activities that are designed to identify the condition early and initiate treatment to avert cerebral damage. Inborn errors of metabolism such as hypothyroidism, phenylketonuria, and galactosemia can cause cognitive impairment. Genetic counseling and avoidance of prenatal rubella infections are examples of primary prevention strategies to preclude the occurrence of disorders that can cause cognitive impairment. Preschool education and counseling services are examples of tertiary prevention. These are designed to include early identification of conditions and provision of appropriate therapies and rehabilitation services. 3. What is a primary goal in caring for a child with cognitive impairment? a. Developing vocational skills b.
Promoting optimum development
c.
Finding appropriate out-of-home care
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d. Helping child and family adjust to future care ANS: B The goal for children with cognitive impairment is the promotion of optimum social, physical, cognitive, and adaptive development as individuals within a family and community. Vocational skills are only one part of that goal. The focus must also be on the family and other aspects of development. Out-of-home care is considered part of the childs development. Optimum development includes adjustment for both the family and child. 4. One of the techniques that has been especially useful for learners having cognitive impairment is called fading. What description best explains this technique? a. Positive reinforcement when tasks or behaviors are mastered b.
Repeated verbal explanations until tasks are faded into the childs development
c.
Negative reinforcement for specific tasks or behaviors that need to be faded out
d. Gradually reduces the assistance given to the child so the child becomes more independent ANS: D Fading is physically taking the child through each sequence of the desired activity and gradually fading out the physical assistance so the child becomes more independent. Positive reinforcement when tasks or behaviors are mastered is part of behavior modification. An essential component is ignoring undesirable behaviors. Verbal explanations are not as effective as demonstration and physical guidance. Consistent negative reinforcement is helpful, but positive reinforcement that focuses on skill attainment should be incorporated. 5. The parents of a child with cognitive impairment ask the nurse for guidance with discipline. What should the nurses recommendation be based on? a. Discipline is ineffective with cognitively impaired children. b.
Cognitively impaired children do not require discipline.
c.
Behavior modification is an excellent form of discipline.
d. Physical punishment is the most appropriate form of discipline. ANS: C Discipline must begin early. Limit-setting measures must be clear, simple, consistent, and appropriate for the childs mental age. Behavior modification, especially reinforcement of desired behavior and use of time-out procedures, is an appropriate form of behavior control. Aversive strategies should be avoided in disciplining the child. 6. What intervention is most appropriate to facilitate social development of a child with a cognitive impairment? a. Provide age-appropriate toys and play activities. b.
Avoid exposure to strangers who may not understand cognitive development.
c.
Provide peer experiences, such as infant stimulation and preschool programs.
Emphasize mastery of physical skills because they are delayed more often than d. verbal skills. ANS: C The acquisition of social skills is a complex task. Initially, an infant stimulation program should be used. Children of all ages need peer relationships. Parents should enroll the child in preschool.
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When older, they should have peer experiences similar to those of other children such as group outings, Boy and Girl Scouts, and Special Olympics. Providing age-appropriate toys and play activities is important, but peer interactions facilitate social development. Parents should expose the child to individuals who do not know the child. This enables the child to practice social skills. Verbal skills are delayed more often than physical skills. 7. The nurse is discussing sexuality with the parents of an adolescent girl who has a moderate cognitive impairment. What factor should the nurse consider when dealing with this issue? a. Sterilization is recommended for any adolescent with cognitive impairment. b.
Sexual drive and interest are very limited in individuals with cognitive impairment.
c.
Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct. Sexual intercourse rarely occurs unless the individual with cognitive impairment is sexually abused.
d. ANS: C Adolescents with moderate cognitive impairment may be easily persuaded and lack judgment. A well-defined, concrete code of conduct with specific instructions for handling certain situations should be defined for the adolescent. Permanent contraception by sterilization presents moral and ethical issues and may have psychologic effects on the adolescent. It may be prohibited in some states. The adolescent needs to have practical sexual information regarding physical development and contraception. Cognitively impaired individuals may desire to marry and have families. The adolescent needs to be protected from individuals who may make intimate advances. 8. The mother of a young child with cognitive impairment asks for suggestions about how to teach her child to use a spoon for eating. The nurse should make which recommendation? a. Do a task analysis first. b.
Do not expect this task to be learned.
c.
Continue to spoon feed the child until the child tries to do it alone.
d. Offer only finger foods so spoon feeding is unnecessary. ANS: A Successful teaching begins with a task analysis. The endpoint (self-feeding, toilet training, and so on) is broken down into the component steps. The child is then guided to master the individual steps in sequence. Depending on the childs functional level, using a spoon for eating should be an achievable goal. The child requires demonstration and then guided training for each component of the self-feeding. Feeding finger foods so spoon feeding is unnecessary eliminates some of the intermediate steps that are necessary to using a fork and spoon. For socialization purposes, it is desirable that a child use feeding implements. 9. A newborn assessment shows a separated sagittal suture, oblique palpebral fissures, a depressed nasal bridge, a protruding tongue, and transverse palmar creases. These findings are most suggestive of which condition? a. Microcephaly b.
Cerebral palsy
c.
Down syndrome
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d. Fragile X syndrome ANS: C These are characteristics associated with Down syndrome. An infant with microcephaly has a small head. Cerebral palsy is a diagnosis not usually made at birth; no characteristic physical signs are present. The infant with fragile X syndrome has increased head circumference; long, wide, or protruding ears; a long, narrow face with a prominent jaw; hypotonia; and a high-arched palate. 10. A 2-week-old infant with Down syndrome is being seen in the clinic. His mother tells the nurse that he is difficult to hold, that hes like a rag doll. He doesnt cuddle up to me like my other babies did. What is the nurses best interpretation of this lack of clinging or molding? a. Sign of detachment and rejection b.
Indicative of maternal deprivation
c.
A physical characteristic of Down syndrome
d. Suggestive of autism associated with Down syndrome ANS: C Infants with Down syndrome have hypotonicity of muscles and hyperextensibility of joints, which complicate positioning. The limp, flaccid extremities resemble the posture of a rag doll. Holding the infant is difficult and cumbersome, and parents may feel that they are inadequate. A lack of clinging or molding is characteristic of Down syndrome, not detachment. There is no evidence of maternal deprivation. Autism is not associated with Down syndrome, and it would not be evident at 2 weeks of age. 11. Many of the clinical features of Down syndrome present challenges to caregivers. Based on these features, what intervention should be included in the childs care? a. Delay feeding solid foods until the tongue thrust has stopped. b.
Modify the diet as necessary to minimize the diarrhea that often occurs.
c.
Provide calories appropriate to the childs mental age.
d. Use a cool-mist vaporizer to keep the mucous membranes moist and secretions liquefied. ANS: D The constant stuffy nose forces the child to breathe by mouth, drying the mucous membranes and increasing the susceptibility to upper respiratory tract infections. A cool-mist vaporizer will keep the mucous membranes moist and liquefy secretions. Respiratory tract infections combined with cardiac anomalies are the primary cause of death in the first years. The child has a protruding tongue, which makes feeding difficult. The parents must persist with feeding while the child continues the physiologic response of the tongue thrust. The child is predisposed to constipation. Calories should be appropriate to the childs weight and growth needs, not mental age. 12. What description applies to fragile X syndrome? a. Chromosomal defect affecting only females b.
Second most common genetic cause of cognitive impairment
c.
Most common cause of uninherited cognitive impairment
d. Chromosomal defect that follows the pattern of X-linked recessive disorders ANS: B
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Fragile X syndrome is the most common inherited cause of cognitive impairment and the second most common genetic cause of cognitive impairment after Down syndrome. Fragile X primarily affects males and follows the pattern of X-linked dominant inheritance with reduced penetrance. 13. The nurse should suspect a hearing impairment in an infant who fails to demonstrate which behavior? a. Babbling by age 12 months b.
Eye contact when being spoken to
c.
Startle or blink reflex to sound
d. Gesturing to indicate wants after age 15 months ANS: A The absence of babbling or inflections in voice by at least age 7 months is an indication of hearing difficulties. Lack of eye contact is not indicative of a hearing loss. An infant with a hearing impairment might react to a loud noise but not respond to the spoken word. The child with hearing impairment uses gestures rather than vocalizations to express desires at this age. 14. The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing aid is making an annoying whistling sound that the child cannot hear. What intervention is the most appropriate nursing action? a. Ignore the sound. b.
Suggest he reinsert the hearing aid.
c.
Ask him to reverse the hearing aids in his ears.
d. Suggest he raise the volume of the hearing aid. ANS: B The whistling sound is acoustic feedback. The nurse should have the child remove the hearing aid and reinsert it, making sure no hair is caught between the ear mold and the ear canal. Ignoring the sound or suggesting he raise the volume of the hearing aid would be annoying to others. The hearing aids are molded specifically for each ear. 15. What technique facilitates lip reading by a hearing-impaired child? a. Speak at an even rate. b.
Avoid using facial expressions.
c.
Exaggerate pronunciation of words.
d. Repeat in exactly the same way if child does not understand. ANS: A Help the child learn and understand how to read lips by speaking at an even rate. Avoiding using facial expressions, exaggerating pronunciation of words, and repeating in exactly the same way if the child does not understand interfere with the childs understanding of the spoken word. 16. What condition is defined as reduced visual acuity in one eye despite appropriate optical correction? a. Myopia b.
Hyperopia
c.
Amblyopia
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d. Astigmatism ANS: C Amblyopia, or lazy eye, is reduced visual acuity in one eye. Amblyopia is usually caused by one eye not receiving sufficient stimulation. The resulting poor vision in the affected eye can be avoided with the treatment of the primary visual defect such as strabismus. Myopia, or nearsightedness, refers to the ability to see objects clearly at close range but not a distance. Hyperopia, or farsightedness, is the ability to see objects at a distance but not at close range. Astigmatism is unequal curvatures in refractive apparatus. 17. The school nurse is caring for a child with a penetrating eye injury. Emergency treatment includes what intervention? a. Place a cool compress on eye during transport to the emergency department. b.
Irrigate the eye copiously with a sterile saline solution.
c.
Remove the object with a lightly moistened gauze pad.
d. Apply a Fox shield to the affected eye and any type of patch to the other eye. ANS: D The nurses role in a penetrating eye injury is to prevent further injury to the eye. A Fox shield (if available) should be applied to the injured eye and a regular eye patch to the other eye to prevent bilateral movement. Placing cool compress on the eye during transport to emergency department, irrigating eye copiously with a sterile saline solution, or removing object with a lightly moistened gauze pad may cause more damage to the eye. 18. A father calls the emergency department nurse saying that his daughters eyes burn after getting some dishwasher detergent in them. The nurse recommends that the child be seen in the emergency department or by an ophthalmologist. The nurse also should recommend which action before the child is transported? a. Keep the eyes closed. b.
Apply cold compresses.
c.
Irrigate the eyes copiously with tap water for 20 minutes.
d. Prepare a normal saline solution (salt and water) and irrigate the eyes for 20 minutes. ANS: C The first action is to flush the eyes with clean tap water. This will rinse the detergent from the eyes. Keeping the eyes closed and applying cold compresses may allow the detergent to do further harm to the eyes during transport. Normal saline is not necessary. The delay can allow the detergent to cause continued injury to the eyes. 19. A 5-year-old child has bilateral eye patches in place after surgery yesterday morning. Today he can be out of bed. What nursing intervention is most important at this time? a. Speak to him when entering the room. b.
Allow him to assist in feeding himself.
c.
Orient him to his immediate surroundings.
d. Reassure him and allow his parents to stay with him. ANS: C
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Safety is the priority concern. Because he can now be out of bed, it is imperative that he knows about his physical surroundings. Speaking to the child is a component of nursing care that is expected with all clients unless contraindicated. Unless additional impairments are present, his meal tray should be set up, and he should be able to feed himself. Reassuring him and allowing his parents to stay with him are essential parts of nursing care for all children. 20. Autism is a complex developmental disorder. The diagnostic criteria for autism include delayed or abnormal functioning in which area with onset before age 3 years? a. Parallel play b.
Gross motor development
c.
Ability to maintain eye contact
d. Growth below the fifth percentile ANS: C One hallmark of autism spectrum disorders is the childs inability to maintain eye contact with another person. Parallel play is play typical of toddlers and is usually not affected. Social, not gross motor, development is affected by autism. Physical growth and development are not usually affected. 21. What intervention should be included in the nursing care of a child with autism spectrum disorder (ASD)? a. Assign multiple staff to care for the child. b.
Communicate with the child at his or her developmental level.
c.
Provide a wide variety of foods for the child to try.
d. Place the child in a semiprivate room with a roommate of a similar age. ANS: B Children with ASD require individualized care. The nurse needs to communicate with the child at the childs developmental level. Consistent caregivers are essential for children with ASD. The same staff members should care for the child as much as possible. Children with ASD do not adapt to changing situations. The same foods should be provided to allow the child to adjust. A private room is desirable for children with ASD. Stimulation is minimized. 22. What suggestion by the nurse for parents regarding stuttering in children is most helpful? a. Offer rewards for proper speech. b.
Encourage the child to take it easy and go slow when stuttering.
c.
Help the child by supplying words when he or she is experiencing a block.
d. Give the child plenty of time and the impression that you are not in a hurry. ANS: D Hesitancy and dysfluency should be considered a normal part of speech development. An important approach is to allow the child plenty of time to speak. Promising rewards for proper speech places additional pressure on the child. Encouraging the child to take it easy and go slow when stuttering draws attention to the dysfluency. The child needs to complete a sentence and thought without being interrupted. 23. What observation in a child should indicate the need for a referral to a specialist regarding a communication impairment?
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a.
At 2 years of age, the child fails to respond consistently to sounds.
b.
At 3 years of age, the child fails to use sentences of more than five words.
c.
At 4 years of age, the child has impaired sentence structure.
d. At 5 years of age, the child has poor voice quality. ANS: A If a 2-year-old child fails to respond consistently to sounds, it is an indication for referral to a specialist regarding communication impairment. At age 3 years, the child failing to use sentences of three words would be an indication for referral; impaired sentence structure would be seen in a 5-year-old child and poor voice quality in an older child who has a communication impairment. 24. The nurse is performing a physical assessment on a 3-year-old child. The parents state that the child excessively rubs the eyes and often tilts the head to one side. What visual impairment should the nurse suspect? a. Strabismus b.
Astigmatism
c.
Hyperopia, or farsightedness
d. Myopia, or nearsightedness ANS: D Clinical manifestations of myopia include excessive eye rubbing, head tilting, difficulty reading, headaches, and dizziness. Strabismus, astigmatism, and hyperopia have other clinical manifestations. 25. The community nurse is planning prevention measures designed to avoid conditions that can cause cognitive impairment. Taking folic acid supplements during pregnancy to prevent neural tube defects is which type of prevention strategy? a. Primary b.
Secondary
c.
Tertiary
d. Rehabilitative ANS: A Primary prevention strategies are those designed to avoid conditions that cause cognitive impairment. Use of folic acid supplements during pregnancy to prevent neural tube defects is a primary prevention strategy. Secondary prevention activities are those designed to identify the condition early and initiate treatment to avert cerebral damage. Tertiary prevention strategies are those concerned with treatment to minimize long-term consequences. Rehabilitation services is an example of tertiary prevention. 26. The nurse is teaching a preschool child with a cognitive impairment how to throw a ball overhand. What teaching strategy should the nurse use for this child? a. Demonstrate how to throw a ball overhand. b.
Explain the reason for throwing a ball overhand.
c.
Show pictures of children throwing balls overhand.
d.
Explain to the child how to throw the ball overhand.
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ANS: A Children with cognitive impairment have a deficit in discrimination, which means that concrete ideas are much easier to learn effectively than abstract ideas. Therefore, demonstration is preferable to verbal explanation, and the nurse should direct learning toward mastering a skill rather than understanding the scientific principles underlying a procedure. Demonstrating how to throw the ball is the best teaching strategy. 27. The camp nurse is choosing a toy for a child with cognitive impairment to play with during swimming time. What toy should the nurse choose to encourage improvement of developmental skills? a. Dive rings b.
An inner tube
c.
Floating ducks
d. A large beach ball ANS: D Toys are selected for their recreational and educational value. For example, a large inflatable beach ball is a good water toy; encourages interactive play; and can be used to learn motor skills such as balance, rocking, kicking, and throwing. Dive rings, an inner tube, and floating ducks are not interactive toys. 28. The nurse is teaching feeding strategies to a parent of a 12-month-old infant with Down syndrome. What statement made by the parent indicates a need for further teaching? a. If the food is thrust out, I will reefed it. b.
I will use a small, long, straight-handled spoon.
c.
I will place the food on the top of the tongue.
d. I know the tongue thrust doesnt indicate a refusal of the food. ANS: C Parents of a child with Down syndrome need to know that the tongue thrust does not indicate refusal to feed but is a physiologic response. Parents are advised to use a small but long, straighthandled spoon to push the food toward the back and side of the mouth. If food is thrust out, it should be refed. If the parent indicates placing the food on the tongue, further teaching is needed. 29. The nurse is counseling a pregnant 35-year-old woman about estimated risk of Down syndrome. What is the estimated risk for a woman who is 35 years of age? a. One in 1200 b.
One in 900
c.
One in 350
d. One in 100 ANS: C The estimated risk of Down syndrome for a 35-year-old woman is one in 350. One in 1200 is the risk for a 25-year-old woman, one in 900 is the risk for a 30-yearold woman, and one in 100 is the risk for a 40-year-old woman. 30. The nurse is teaching parents of a child with cataracts about the upcoming treatment. The nurse should give the parents what information about the treatment of cataracts?
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a.
The treatment may require more than one surgery.
b.
It is corrected with biconcave lenses that focus rays on the retina.
c.
Cataracts require surgery to remove the cloudy lens and replace it.
d. Treatment is with a corrective lenses; no surgery is necessary. ANS: C Treatment for cataracts requires surgery to remove the cloudy lens and replace it (with an intraocular lens implant, removable contact lens, or prescription glasses). Treatment for glaucoma may require more than one surgery. Anisometropia is treated with corrective lenses. Myopia is corrected with biconcave lenses that focus rays on the retina. 31. What action should the school nurse take for a child who has a hematoma (black eye) with no hemorrhage into the anterior chamber? a. Apply a warm moist pack. b.
Have the child keep the eyes open.
c.
Apply ice for the first 24 hours.
d. Refer to an ophthalmologist immediately. ANS: C The care for a hematoma eye injury with no hemorrhage into the anterior chamber is to apply ice for the first 24 hours. A warm moist pack should not be applied, and the child should keep the eyes closed. Referral to an ophthalmologist is recommended if hyphema (hemorrhage into the anterior chamber) is present. MULTIPLE RESPONSE 1. The nurse is preparing an education program on hearing impairment for a group of new staff nurses. What concepts should be included? (Select all that apply.) a. A child with a slight hearing loss is usually unaware of a hearing difficulty. b.
A clinical manifestation of a hearing impairment in children is avoidance of social interaction.
c.
A child with a severe hearing loss may hear a loud voice if nearby.
d.
Children with sensorineural hearing loss can benefit from the use of a hearing aid.
e.
A clinical manifestation of hearing impairment in an infant is lack of the startle reflex.
Identification of a hearing loss after the first year is essential to facilitate language development in f. children. ANS: A, B, C, E When discussing hearing impairment in children, the nurse should include information about differences in hearing losses, such as with a slight hearing loss, the child is usually unaware of a hearing difficulty, and with a severe loss, the child may hear a loud noise if it is nearby. An infant with a hearing loss may lack the startle response, and a hearing impaired child may avoid social interaction. Children with a sensorineural hearing loss would not benefit from a hearing aid. Identification of a hearing loss is imperative in the first 3 to 6 months to facilitate language and educational development for children. 2. The nurse understands that which gestational disorders can cause a cognitive impairment in the newborn? (Select all that apply.)
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a.
Prematurity
b.
Postmaturity
c.
Low birth weight
d.
Physiological jaundice
e. Large for gestational age ANS: A, B, C Prematurity, postmaturity, and low birth weight can be causes of cognitive impairment in newborns. Physiological jaundice and large for gestational age are not associated causes of cognitive impairment in newborns. 3. The clinic nurse is assessing an infant. What are early signs of cognitive impairment the nurse should discuss with the health care provider? (Select all that apply.) a. Head lag at 11 months of age b.
No pincer grasp at 4 months of age
c.
Colicky incidents at 3 months of age
d.
Unable to speak two to three words at 24 months of age
e. Unresponsiveness to the environment at 12 months of age ANS: A, D, E Early signs of cognitive impairment include gross motor delay (head lag should be established by 6 months, and head lag still present at 11 months is a delay), language delay (normal language development is speaking two to three words by age 12 months; if unable to speak two to three words at 24 months, that is a delay), and unresponsiveness to the environment at 12 months. No pincer grasp at 4 months of age is normal (palmar grasp is the expected finding), and colicky incidents at 3 months of age is a normal finding. 4. The nurse is teaching parents of a child with a cognitive impairment signs that indicate the child is developmentally ready for dressing training. What signs should the nurse include that indicate the child is developmentally ready for dressing training? (Select all that apply.) a. Can follow verbal commands b.
Can sit quietly for 1 to 2 minutes
c.
Can master every task of dressing
d.
Can follow physical gestures or cues
e. Can relate clothing to the appropriate body part ANS: A, D, E Children are considered developmentally ready for dressing training if they can sit quietly for 3 to 5 minutes (not 1 to 2) while working on a task; can follow physical gestures or cues; can follow verbal commands; and can relate clothing to the appropriate body part, such as socks to feet. As with other self-help skills, the child may not be able to master every task but should be evaluated for evidence of willingness to participate at his or her level of readiness. 5. The nurse is assessing a child with Down syndrome. The nurse recognizes that which are possible comorbidities that can occur with Down syndrome? (Select all that apply.) a. Diabetes mellitus
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b.
Hodgkins disease
c.
Congenital heart defects
d.
Respiratory tract infections
e. Acute megakaryoblastic leukemia ANS: C, D, E Children with Down syndrome often have multiple comorbidities, contributing to numerous other conditions. Respiratory tract infections are prevalent; when combined with cardiac anomalies, they are the chief cause of death, particularly during the first year. The incidence of leukemia is several times more frequent than expected in the general population, and in about half of the cases, the type is acute megakaryoblastic leukemia. 6. A child has a slight (2640 dB) degree of hearing loss. The nurse recognizes this amount of hearing loss can have what effect? (Select all that apply.) a. No speech defects b.
Difficulty hearing faint speech
c.
Usually is unaware of the hearing difficulty
d.
Can distinguish vowels but not consonants
e. Unable to understand conversational speech ANS: A, B, C A child with a slight degree of hearing loss has no speech defects, may have difficulty hearing faint speech, and is usually unaware of the hearing difficulty. The ability to distinguish vowels but not consonants is an effect of severe hearing loss and being unable to understand conversational speech is an effect of moderately severe hearing loss. 7. What risk factors can cause a sensorineural hearing impairment in an infant? (Select all that apply.) a. Cat scratch disease b.
Bacterial meningitis
c.
Childhood case of measles
d.
Childhood case of chicken pox
e. Administration of aminoglycosides for more than 5 days ANS: B, C, E Risk criteria for sensorineural hearing impairment in infants include bacterial meningitis; a case of measles; and administration of ototoxic medications (e.g., gentamicin, tobramycin, kanamycin, streptomycin), including but not limited to the aminoglycosides, for more than 5 days. Cat scratch disease and a childhood case of chicken pox are not risk factors that can cause a sensorineural hearing impairment. 8. The nurse is teaching parents the signs of a hearing impairment in infants. What should the nurse include as signs?(Select all that apply.) a. Lack of a fencing reflex b.
Lack of a startle reflex to a loud sound
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c.
Awakened by loud environmental noises
d.
Failure to localize a sound by 6 months of age
e. Response to loud noises as opposed to the voice ANS: B, D, E The fencing reflex is elicited when the infant is placed on his or her back; it does not indicate a hearing impairment. Awakening by a loud environmental noise is a normal response. 9. The nurse is teaching parents the signs of a hearing impairment in a child. What should the nurse include as signs?(Select all that apply.) a. Outgoing behavior b.
Yelling to express pleasure
c.
Asking to have statements repeated
d.
Foot stamping for vibratory sensation
e. Failure to develop intelligible speech by age 24 months ANS: B, C, D, E Signs of a hearing impairment in a child include yelling to express pleasure, asking to have statements repeated, foot stamping for vibratory sensation, and failure to develop intelligible speech by age 24 months. The childs behavior is shy, not outgoing. 10. The nurse should plan which actions to assist the stuttering child? (Select all that apply.) a. Ask the child to stop and start over. b.
Promise a reward for proper speech.
c.
Set a good example by speaking clearly.
d.
Give the child plenty of time to finish sentences.
e. Look directly at the child while he or she is speaking. ANS: C, D, E Actions to be encouraged to help the stuttering child include setting a good example by speaking clearly, giving the child plenty of time to finish sentences, and looking directly at the child while he or she is speaking. Asking the child to stop and start over and promising a reward for proper speech are actions to be avoided with stuttering children. 11. The nurse should plan which actions to facilitate lipreading for a child with a hearing impairment? (Select all that apply.) a. Face the child directly. b.
Speak at eye level.
c.
Keep sentences short.
d.
Speak at a fast, even-paced rate.
e. Establish eye contact and show interest. ANS: A, B, C, E To facilitate lipreading, the nurse should plan to face the child directly, speak at eye level, keep sentences short, and establish eye contact and show interest. The nurse should plan to speak at a slow rate, not a fast one.
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12. What are indications for a referral regarding a communication impairment in a school-age child? (Select all that apply.) a. Barely audible voice quality b.
Vocal pitch inappropriate for age
c.
Intonation noted during speaking
d.
Maintains a rhythm while speaking
e. Distortion of sounds after age 7 years ANS: A, B, E Barely audible voice quality, vocal pitch inappropriate for age, and distortion of sounds after age 7 years are indications for a referral regarding a communication impairment. Intonation noted while speaking and maintaining a rhythm while speaking are normal characteristics of speech. MATCHING Match the type of visual impairment to its definition. a. Myopia b.
Hyperopia
c.
Astigmatism
d.
Anisometropia
e. Amblyopia 1. Different refractive strength in each eye 2. Ability to see objects clearly at close range but not at a distance 3. Reduced visual acuity in one eye 4. Unequal curvatures in refractive apparatus 5. Ability to see objects at a distance but not at a close range
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Chapter 33 Hematologic Disorders MULTIPLE CHOICE 1. When teaching the mother of a young child about iron deficiency anemia, the nurse would tell her that a rich source of iron is: a. Egg whites b.
Cream of wheat
c.
Bananas
d. Carrots ANS: B Good nutritional sources of iron include boiled egg yolk, liver, green leafy vegetables, cream of wheat, dried fruits, beans, nuts, and whole-grain breads. 2. The statement by a mother that may indicate a cause for her 9-month-old having iron deficiency anemia is: a. Formula is so expensive. We switched to regular milk right away. b.
She almost never drinks water.
c.
She doesnt really like peaches or pears, so we stick to bananas for fruit.
d. I give her a piece of bread now and then. She likes to chew on it. ANS: A Because cows milk contains very little iron, infants should drink iron-fortified formula for the first year of life. 3. The nurse would instruct the parent to give ferrous sulfate drops to the child: a. With milk b.
With orange juice
c.
With water
d. On a full stomach ANS: B Vitamin C aids in the absorption of iron, whereas food and milk interfere with the absorption of iron. 4. The nurse would ask the patient with hemophilia A to reconsider a vacation he has planned to: a. The Caribbean for a cruise b.
Denver for skiing
c.
Canada for a rail tour
d. New England for a bus tour ANS: B Hemophiliacs are discouraged from exercising in high altitudes and exposure to cold as this depletes their already low oxygen concentration.
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5. A 2-year-old child has been diagnosed with hemophilia A. The information the nurse would include in a teaching plan about home care would be: a. If bleeding occurs, apply pressure, ice, elevate, and rest the extremity. b.
Childrens aspirin in lowered doses may be given for joint discomfort.
c.
A firm, dry toothbrush should be used to clean teeth at least twice a day.
d. Do not permit interactive play with other children. ANS: A When bleeding occurs, the traditional approach is to follow RICErest, ice, compression, and elevation. 6. The nurse would teach the parents of a child with a low platelet count to avoid: a. Ibuprofen b.
Aspirin
c.
Caffeine
d. Prednisone ANS: B Aspirin interferes with platelet function and should be avoided to prevent the risk of prolonged bleeding. 7. A child who is receiving a transfusion should be closely assessed for: a. Fever b.
Lethargy
c.
Jaundice
d. Bradycardia ANS: A The child receiving a blood transfusion is observed for signs of a transfusion reaction including chills, itching, fever, rash, headache, and back pain. 8. On admission, a child with leukemia has widespread purpura and a platelet count of 19,000/mm3. The priority nursing intervention is: a. Assessing neurological status b.
Inserting an intravenous line
c.
Monitoring vital signs during platelet transfusions
d. Providing family education about how to prevent bleeding ANS: A When platelets are low, the greatest danger is spontaneous intracranial bleeding. Neurological assessments are therefore a priority of care. 9. An adolescent is diagnosed with Hodgkins disease. Lymph nodes on both sides of her diaphragm have been found to be involved, including cervical and inguinal nodes. The disease is in: a. Stage I b.
Stage II
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c.
Stage III
d. Stage IV ANS: C Lymph node regions on both sides of the diaphragm are consistent with a diagnosis of stage III Hodgkins disease. 10. A 3-year-old child with sickle cell disease is admitted to the hospital in sickle cell crisis for severe abdominal pain. The nurse recognizes that the type of crisis the child is most likely experiencing is: a. Aplastic b.
Hyperhemolytic
c.
Vaso-occlusive
d. Splenic sequestration ANS: C Vaso-occlusive crises or painful crises are caused by obstruction of blood flow by sickle cells, infarctions, and some degrees of vasospasm. 11. The statement made by a parent indicating understanding of health maintenance of a child with sickle cell anemia is: a. I should give my child a daily iron supplement. b.
It is important for my child to drink plenty of fluids.
c.
He needs to wear protective equipment if he plays contact sports.
d. He shouldnt receive any immunizations until he is older. ANS: B Prevention of dehydration, which can trigger the sickling process, is a priority goal in the care of a child with sickle cell disease. 12. A newly married couple is seeking genetic counseling because they are both carriers of the sickle cell trait. How can the nurse best explain their childrens risk of inheriting this disease? a. Every fourth child will have the disease; two others will be carriers. b.
All of their children will be carriers, just as they are.
c.
Each child has a one-in-four chance of having the disease and a two-in-four chance of being a carrier.
d. The risk levels of their children cannot be determined by this information. ANS: C The sickle cell gene is inherited from both parents; therefore each offspring has a one-in-four chance of inheriting the disease. 13. A child with thalassemia major receives blood transfusions frequently. The nurse is aware that a complication of repeated blood transfusions is: a. Hemarthrosis b.
Hematuria
c.
Hemoptysis
d.
Hemosiderosis
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ANS: D As a result of repeated blood transfusions, excessive deposits of iron (hemosiderosis) are stored in tissues. 14. A child has just been diagnosed with acute lymphoblastic leukemia. The nurse is aware that the result of an overproduction of immature white blood cells in the bone marrow is: a. Decreased T-cell production b.
Decreased hemoglobin
c.
Increased blood clotting
d. Increased susceptibility to infection ANS: D An overproduction of immature white blood cells increases the childs susceptibility to infection. 15. When the child receiving a transfusion complains of back pain and itching, the nurses initial action would be to: a. Notify the charge nurse b.
Disconnect IV lines immediately
c.
Give Benadryl
d. Clamp off blood and keep line open with NS ANS: D If a blood transfusion reaction occurs, the first action is to stop the blood infusion, keep the line open with normal saline, and notify the charge nurse. 16. The nurse would include in a teaching plan about mouth care of a child receiving chemotherapy to: a. Use commercial mouthwash b.
Clean teeth with a soft toothbrush
c.
Avoid use of a Waterpik
d. Inspect the mouth weekly for ulcerations ANS: B A soft toothbrush reduces capillary damage and mucous membrane breakdown, and prevents bleeding and infection. Commercial mouthwashes may kill oral flora that combat infection. Waterpiks are useful for toughening gums. 17. A 6-year-old with leukemia asks, Who will take care of me in heaven? The best response for the nurse to make is: a. Who do you think will take care of you? b.
Your grandparents and God will take care of you.
c.
Your mom will know more about that than I do.
d. Why are you asking me that? ANS: A
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This response gives the child an opportunity to verbalize his or her feelings and concerns, whereas the closed response in option 2 shuts off communication. The asking of a why question is not therapeutic as it calls for justification. 18. When dealing with a preschool-age child with a life-threatening illness, the nurse should remember that at this age the childs concept of death includes: a. That it is final b.
Only a fear of separation from her parents
c.
That a person becomes alive again soon after death
d. An understanding based on simple logic ANS: C The preschooler views death as reversible and temporary. 19. The nurse notes that a 4-year-old childs gums bleed easily and he has bruising and petechiae on his extremities. The lab value that would be consistent with these symptoms is: a. Platelet count of 25,000/mm3 b.
Hemoglobin level of 8 g/dl
c.
Hematocrit level of 36%
d. Leukocyte count of 14,000/mm3 ANS: A The normal platelet count is 150,000 to 400,000/mm3. This finding is very low, indicating an increased bleeding potential. 20. The nurse, caring for a child receiving chemotherapy, notes that the childs abdomen is firm and slightly distended. Also, there is no record of a bowel movement for the last 2 days. These assessment findings suggest the possibility of: a. Peripheral neuropathy b.
Stomatitis
c.
Myelosuppression
d. Hemorrhage ANS: A Peripheral neuropathy may be signaled by severe constipation resulting from decreased nerve sensations in the bowel. 21. The nurse finds an adolescent with Hodgkins disease crying. The adolescent says, I am so scared. The most appropriate nursing response to this comment is: a. I understand how you must feel. b.
You shouldnt feel that way.
c.
Is this the strongest feeling youve had today?
d. Tell me whats got you scared. ANS: D The nurse should encourage the adolescent to express her feelings and concerns. 22. The most recent blood count for a child who received chemotherapy last week shows neutropenia. The priority nursing diagnosis for this child is:
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a.
Risk for infection
b.
Risk for hemorrhage
c.
Altered skin integrity
d. Disturbance in body image ANS: A The child with neutropenia is at risk for infection. 23. The nurse takes into consideration an important focus of nursing care for the dying child and his/her family, which is: a. Nursing care should be organized to minimize contact with the child. b.
Adequate oral intake is crucial to the dying child.
c.
Families should be made aware that hearing is the last sense to stop functioning before death.
d. It is best for the family if the nursing staff provides all of the childs care. ANS: C Hearing is intact even when there is a loss of consciousness. MULTIPLE RESPONSE 1. The nursing care of a 12-year-old child receiving radiation therapy for Hodgkins disease, should include: Select all that apply. a. Application of sunblock to the skin to prevent burning b.
Appetite stimulation
c.
Conservation of energy
d.
Provision for expressions of anger
e. Preparation for delay in sexual development ANS: A, B, C, D, E Sun block should be applied to skin after radiation to prevent burning. Low energy levels produce anorexia and anger in many young patients. Radiation delays the development of secondary sex characteristics and menses. 2. The nurse reviews the classic symptoms of thalassemia major (Cooleys anemia), such as: Select all that apply. a. Hepatomegaly b.
Jaundice
c.
Protruding teeth
d.
Pathological fractures
e. Cardiac failure ANS: A, B, C, D, E All of the options are classic signs of thalassemia major. 3. The nurse reviews for a family how the development of synthetic recombinant antihemophilic factor has improved the management of hemophilia, because this drug:
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Select all that apply. a. Eliminates the need for frequent transfusions b.
Can be administered by family at home
c.
Prevents hemorrhage
d.
Reduces cost of care of the hemophiliac
e. Reduces risk of HIV and hepatitis A and B transmission ANS: A, B, D, E The drug can be given at home by the family. Because it supplies the missing factor, transfusions are not necessary and consequently the exposure to HIV and hepatitis A and B is reduced. Cost of care is greatly reduced because hospitalizations and transfusions are not as frequently required. The drug does not prevent hemorrhage; it makes hemorrhage manageable. 4. The family of a child receiving chemotherapy for leukemia should be taught to focus on the childs care in regard to the need to: Select all that apply. a. Use a support group b.
Stimulate appetite
c.
Maintain adequate hydration
d.
Delay immunizations
e. Report exposure to infectious diseases ANS: A, B, C, D, E The child on chemotherapy is anorexic and has no appetite. Maintenance of hydration is essential for the adequate therapeutic effect of the drugs. Because the drugs suppress the bone marrow, children are at risk for infection, and the suppression will not allow the antibody response needed for immunization. Support groups are helpful for emotional support and realistic tips on care. COMPLETION 1. The nurse shows slides of red blood cells from a child with sickle cell anemia, noting that in addition to their sickle shape, the cells contain the abnormal element of ________ ______. ANS: hemoglobin S
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Chapter 34 Pediatric Obesity and Comorbidities Question 1 Type: MCSA A school-age client, recently diagnosed with asthma, also has a peanut allergy. The nurse instructs the family to not only avoid peanuts but also to carefully check food label ingredients for peanut products and to make sure dishes and utensils are adequately washed prior to food preparation. The mother asks why this is specific for her child. Based on the clients history, the nurse knows that this client is at an increased risk for which complication? 1. Urticaria 2. Diarrhea 3. Anaphylaxis 4. Headache Correct Answer: 3 Global Rationale: Children with food allergies may experience all of the above reactions to a particular food, but the child who also has asthma is most at risk for death secondary to anaphylaxis caused by a food allergy. Question 2 Type: MCSA While teaching the parents of a newborn about infant care and feeding, which instruction by the nurse is the most appropriate? 1. Delay supplemental foods until the infant is 4 to 6 months old. 2. Delay supplemental foods until the infant reaches 15 pounds or greater. 3. Begin diluted fruit juice at 2 months of age, but wait three to five days before trying a new food. 4. Add rice cereal to the nighttime feeding if the infant is having difficulty sleeping after 2 months of age. Correct Answer: 1 Global Rationale: Four to six months is the optimal age to begin supplemental feedings because earlier feeding of nonformula foods is not needed by the infant and does not promote sleep. Earlier feeding of nonformula foods, regardless of the infants weight, is more likely to cause the development of food allergies. Also, early feeding is not well tolerated by infants because the necessary tongue control is not well developed and they lack the digestive enzymes to take in and metabolize many food products. Question 3 Type: MCSA During a 4-month-olds well-child check, the nurse discusses introduction of solid foods into the infants diet and concerns for foods commonly associated with food allergies. Due to allergies, which foods will the nurse instruction the parents to avoid until after 1 year of age? 1. Strawberries, eggs, and wheat
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2. Peas, tomatoes, and spinach 3. Carrots, beets, and spinach 4. Squash, pork, and tomatoes Correct Answer: 1 Global Rationale: Strawberries, eggs, and wheat, along with corn, fish, and nut products, are all foods that have commonly been associated with food allergies. Carrots, beets, and spinach contain nitrates and should not be given before the age of 4 months. Squash, peas, and tomatoes are acceptable to try after an infant is 4 to 6 months old but should be given one at a time and three to five days after starting a new food. Pork can be tried after the infant is 8 to 10 months old, as meats are harder to digest and have a high protein load. Question 4 Type: MCSA The mother of a toddler is concerned because her child does not seem interested in eating. The child is drinking five to six cups of whole milk per day and one cup of fruit juice. When the weight-to-height percentile is calculated, the child is in the 90th to 95th percentile. What is the best advice the nurse can provide to the mother? 1. Eliminate the fruit juice from the childs diet. 2. Offer healthy snacks, presented in a creative manner, and let the child choose what he wants to eat without pressure from the parents. 3. Change from whole milk to 2 percent milk and decrease milk consumption to three to four cups per day and the fruit juice to a half cup per day, offering water if the child is still thirsty in between. 4. Make sure that the child is getting adequate opportunities for exercise, as this will increase his appetite and help lower the childs weight-to-height percentile. Correct Answer: 3 Global Rationale: Toddlers require a maximum of about one liter of milk per day. This toddler is consuming most of his or her calories from the milk and thus is not hungry. The high fat content of the milk and the high sugar content of the fruit juice are also contributing to the childs higher weight-to-height percentile. Decreasing the amount and fat content of the milk and decreasing the intake of fruit juice will decrease calories and thus make the child hungry for other foods. The other advice is also appropriate but did not address the problem of excessive milk consumption. Question 5 Type: MCSA A nurse is talking to the mother of an exclusively breast-fed African American 3-month-old infant who was born in late fall. Which supplement will the nurse recommend for this infant? 1. Iron 2. Vitamin D 3. Fluoride 4. Calcium Correct Answer: 2 Global Rationale: An infants iron stores are usually adequate until about 4 to 6 months of age. The infant should be receiving sufficient amounts of calcium from breast milk, and fluoride
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supplementation, if needed, does not begin until the child is approximately 6 months old. This infant will have limited exposure to sunlight and thus vitamin D because of the infants dark skin and decreased sun exposure in the fall and winter months. Question 6 Type: MCSA The nurse is teaching the parents of a 4-month-old infant about good feeding habits. The nurse emphasizes the importance of holding the baby during feeding and not letting the infant go to sleep with the bottle. Which disorder is associated with propped feedings and going to sleep with the bottle? 1. Otitis media 2. Aspiration 3. Malocclusion problems 4. Sleeping disorders Correct Answer: 1 Global Rationale: It has been shown in numerous studies that allowing an infant to fall asleep with a bottle in his or her mouth causes pooling of the formula in the mouth, which increases the risk of both dental caries and otitis media. There has been limited data to date showing a positive correlation between bottle propping and increased risk of aspiration, malocclusions, and sleeping disorders. Question 7 Type: MCMA The parents of a toddler are concerned about their childs finicky eating habits. While counseling the parents, which statements by the nurse are the most appropriate? Standard Text: Select all that apply. 1. The child is experiencing physiologic anorexia, which is normal for this age group. 2. A general guideline for food quantity at a meal is one-quarter cup of each food per year of age. 3. It is more appropriate to assess a toddlers nutritional demands over a 1-week period rather than a 24-hour one. 4. Nutritious foods should be made available at all times of the day so that she is able to graze whenever she is hungry. 5. The toddler should drink 16 to 24 ounces of milk daily. Correct Answer: 1,3,5 Global Rationale: Physiologic anorexia is caused when the extremely high metabolic demands of infancy slow to keep pace with the slower growth of toddlerhood, and it is a very normal finding at this age. It is not unusual for toddlers to have food jags during which they only want one or two food items for that day. So it is more helpful to look at what their intake has been over a week instead of a day. Two to three cups of milk per day are sufficient for a toddler, and more than that can decrease the childs desire for other foods and lead to dietary deficiencies. The correct general guideline for food quantity is one tablespoon of each food per year of age. Food should only be offered at meal and snack times, and children should sit at the table while eating to encourage their socialization skills. Question 8 Type: MCSA
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The nurse is providing nutritional guidance to the parents of a toddler. Which comment by the parent would prompt the nurse to provide additional education? 1. I should not give my child raw oysters. 2. It is safe to leave my meat red in the center as long as there are no juices running. 3. We always wash our hands well before any food preparation. 4. We use separate utensils for preparing raw meat and preparing fruits, vegetables, and other foods. Correct Answer: 2 Global Rationale: Meats should be cooked thoroughly before eating. Meat that is red in the center, with or without running juices, is insufficiently cooked and increases the risk of foodborne illness. Washing hands and using separate utensils help to prevent infection with foodborne pathogens. Raw oysters should be avoided. Question 9 Type: MCSA During a well-child physical, an adolescent female has a normal history and physical except for an excessive amount of tooth enamel erosion, a greater-than-normal number of filled cavities, and calluses on the back of her hand. Her body mass index is in the 50th to 75th percentile for her age. Which disorder is the nurse concerned about based on the assessment findings? 1. Anorexia nervosa 2. Kwashiorkor 3. Bulimia nervosa 4. Marasmus. Correct Answer: 3 Global Rationale: The erosion of tooth enamel, dental caries, and calluses on the back of her hand all most likely are due to frequent vomiting of gastric acids, which is common with bulimia nervosa as part of a bingepurge cycle. Anorexia nervosa is an eating disorder where adolescents literally starve themselves to prevent weight gain; they also exercise excessively and use laxatives and diuretics to lose weight. Anorexia usually manifests as extreme weight loss and an obsession with food. Kwashiorkor is a protein deficiency, usually from malnutrition, that manifests as generalized edema. Marasmus is a lack of energy-producing calories that can be seen in anorexia, and this causes emaciation, decreased energy levels, and retarded development. Question 10 Type: MCSA The nurse is instructing a parent of a newborn on the foods that are to be started based on age. The nurse instructs the parent that the first food given to a newborn is rice cereal. What statement by the parent suggests appropriate understanding of the next food that can be introduced? 1. Chicken can be given next. 2. Eggs can be given next. 3. Fruits should be given next. 4. Whole milk should be started. Correct Answer: 3
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Global Rationale: Chicken is not given until 8-10 months, eggs are not given until 12 months, whole milk is given at 12 months. Fruits are given after rice cereal. Question 11 The mother of an infant born prematurely at 32 weeks expresses the desire to breastfeed her child. The nurse correctly responds with which statement when the mother asks how long she should breastfeed her baby? 1. Until the child begins solid foods. 2. Many breastfeed for 2 years. 3. It is recommended that mothers of preterm infants breastfeed at least a month. 4. Breast milk should be the only food for the first 6 months. Correct Answer: 4 Global Rationale: Breast milk should be the only food for the first 6 months, and should continue until 12 months even after solid foods are introduced. Question 12 Celiac disease presents many challenges for a family. What should the nurse emphasize when educating the parents of a newly diagnosed child? 1. Ice cream is a safe dessert on a gluten-free diet. 2. The childs weight and height should reach normal levels in about 1 year. 3. Processed foods are usually gluten-free. 4. Insurance pays only a small amount of the cost of celiac diets. Correct Answer: 2 Global Rationale: Ice cream and many processed foods contain gluten. Payment by insurance is dependent on the plan the family has. Once on a gluten-free diet, the childs height and weight will reach normal range in about 1 year. Question 13 While teaching a health promotion class to a group of parents of children in a Head Start class, which information should the nurse include to help decrease the risk of dental caries? 1. Delay introducing cows milk until at least 1 year of age. 2. Offer drinking cups only at meal and snack times. 3. Encourage use of homemade baby food without preservatives. 4. Offer juices diluted 50% with water. Correct Answer: 2 Global Rationale: Offering drinking cups only at meal and snack times encourages drinking when thirsty rather than carrying a cup around. This reduces the risk of dental caries. Delaying the introduction of cows milk, making homemade baby food, or diluting juice does not decrease dental caries. Question 14 The nurse is planning a class for school-age children on prevention of obesity through exercise. It is important to encourage the children to exercise a minimum of how many minutes a day to meet current recommendations? 1. 20 minutes 2. 30 minutes 3. 60 minutes 4. 90 minutes Correct Answer: 3 Global Rationale: The current recommendation is 60 minutes of exercise daily.
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Question 15 Parents of a child who will begin enteral feedings ask the nurse what advantage this type of feeding has over other methods. Which responses by the nurse are the most appropriate? Standard Text: Select all that apply. 1. Enteral feeding is the closest to natural feeding methods. 2. The child must be able to absorb nutrients. 3. Enteral feeding is complex to administer. 4. Enteral feeding requires a central venous catheter. 5. Enteral feeding has a high success rate. Correct Answer: 1,2,5 Global Rationale: Enteral feedings are the closest to natural feeding methods. The child must be able to absorb nutrients. Enteral feeding has a high success rate. It is not complex to administer, and does not require a central venous catheter. Question 16 The nurse is providing care to a pediatric client recently diagnosed with celiac disease. Which food choice indicates appropriate understanding of the material presented? 1. Pizza with milk 2. Spaghetti and meat sauce with juice 3. Hot dog on a bun with a shake 4. Fruit plate with Gatorade Correct Answer: 4 Global Rationale: A child with celiac disease needs a gluten-free diet. Included on the list are fruits, meats, rice, and vegetables, including corn. Excluded are bread, cake, doughnuts, cookies, crackers, and many processed foods that may contain hidden gluten. Therefore, the child would be allowed to have the fruit plate with Gatorade. Question 17 The nurse is conducting a nutritional assessment for a toddler client who is diagnosed with failure to thrive (FTT). Which parameters will the nurse include in the assessment process for this toddler and family? Standard Text: Select all that apply. 1. Height 2. Weight 3. Hemoglobin and hematocrit 4. Twenty four hour food diary 5. Maternal dietary intake during pregnancy Correct Answer: 1,2,3,4 Global Rationale: In order to adequately assess the toddler clients FTT, the nurse would plan to measure height and weight; obtain a hemoglobin and hematocrit; and ask the family for a twenty-four hour food diary. Information regarding maternal dietary intake during pregnancy is not information that is necessary to assess for a toddler diagnosed with FTT.
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Chapter 35 Behavioral Disorders MULTIPLE CHOICE 1. When a parent asks the nurse to describe what is meant by a learning disability, the nurses most helpful response would be: a. A child may have difficulty with perception, language, comprehension, or memory. b.
It is characterized by inattention, impulsiveness, and hyperactivity.
c.
The childs intellectual ability limits his learning.
d. The child has difficulty learning because of brain damage. ANS: A Learning disability is an educational term. Children with learning disabilities may have average to above-average intelligence, but they may experience difficulties in perception, language, comprehension, and conceptualization. 2. What would be the appropriate response to an adolescent who states, This has been the worst day of my life? a. You should focus your mind on positive thoughts. b.
Everybody has a bad day now and then.
c.
Youre young. What could be so terrible?
d. Tell me about the worst day in your life. ANS: D The nurse establishes a rapport with the adolescent by acknowledging his or her feelings and giving the adolescent full attention. 3. The nurse asks, Do your parents drink every day? The adolescent suddenly shouts, Im not going to talk about that! Its none of your business, anyway! Leave me alone! The nurse recognizes that the outburst was stimulated by the fact that the adolescent is: a. Acting out and needs to be brought under control so the conference can continue b.
Trying to shift the focus of the conference away from himself, and the nurse needs to refocus
c.
Demonstrating that this problem requires the assistance of a psychiatrist
Responding to the discrediting of his parents, which causes anxiety in the child; thus reassurance is nee that blame will not be directed at anyone
d. ANS: D Discrediting parents threatens the childs security and creates anxiety. 4. The nurse answering phone calls at a local suicide prevention hotline would recognize the statement indicating the greatest risk of suicide is: a. I just needed to talk to someone to keep myself from thinking silly thoughts about killing myself. b.
My parents arent home and wont be back for 4 hours. That should be enough time for the pills to work. Ive got a hundred of them.
c.
My dad will be home first, so hell find me. So I think Ill use his gun. I hope he didnt lock the cabinet.
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d. My girlfriend is here with me. She told me to call because I was talking crazy about killing myself. ANS: B The risk of death increases when there is a definite plan of action, the means are readily available, and the person has few resources for help and support. 5. The nurse assesses an early sign of depression in a 15- year-old boy who previously was active in a band, and had saved his money to buy a special guitar when he: a. Gives up the band to spend time with his girlfriend b.
Spends all of his time at the library studying in order to qualify for the honor society
c.
Gives his guitar away and spends his time listening to music in his room
d. Withdraws all of his money out of the bank to buy an expensive leather jacket ANS: C A major depression is characterized by a prolonged behavioral change from baseline that interferes with school, family life, and age-specific activities, frequently signaled by giving prized possessions away. 6. A mother is concerned because her teenage son is always in trouble for fighting at school and always seems to be angry. She mentions that her husband drinks a bit. The understanding guiding the nurses response is: a. The boy is displaying antisocial behavior and should be evaluated for mental illness. b.
He is displaying one of the typical defense patterns of children of alcoholics and should receive immed treatment.
c.
The mother is displaying her own anger with her husbands drinking, and she needs immediate intervention. This boy is only one member of the family affected by alcoholism, and all members should receive immediate intervention.
d. ANS: D Early recognition of and intervention for children of alcoholics are paramount. This adolescent is using the coping pattern of acting-out behaviors to deal with the family situation. 7. The school nurse suggests to the classroom teacher that the most appropriate classroom intervention for a child with attention deficit hyperactivity disorder would be: a. Seat the child in the back of the room to prevent distractions for other children. b.
Pair the child with a student buddy to offer reminders to pay attention.
c.
Divide work assignments into shorter periods with breaks in between.
d. Separate the child from others to increase his focus on schoolwork. ANS: C The child with attention deficit hyperactivity disorder needs breaks between periods of work and study. 8. The nurse explains that the person who is bulimic: a. Is severely underweight b.
Alternates binge eating with purging
c.
Is an introverted perfectionist
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d. Has extremely close family relationships ANS: B Bulimia is characterized by alternating binge eating and purge behavior. tease her because she washes her hands many times during the school day. The nurse is aware that this disorder puts the adolescent at greater risk for: a. Anorexia nervosa b.
Suicidal behavior
c.
Attention deficit hyperactivity disorder
d. Learning disability ANS: B OCD is related to depression and other psychiatric disorders. Suicidal behavior is a high risk for adolescents with OCD. 10. The statement made by a parent of an adolescent with anorexia nervosa indicating an understanding of this condition is: a. There really isnt anything to worry about. Dont they say you can never be too thin? b.
My daughter just doesnt have much of an appetite.
c.
She is just trying to punish me for divorcing her father.
d. She seems to see herself as fat, even though her weight is below normal. ANS: D Individuals with anorexia nervosa have a disturbed body image, which this parent correctly recognizes. 11. An appropriate nursing intervention for a hospitalized child who is autistic would be to: a. Place the child in a location where she can watch all of the activity on the unit. b.
Use the childs chronological age as a guide for communication.
c.
Keep the childs room free of toys or objects that she might want to take home with her.
d. Organize care to provide as few disruptions to the routine as possible. ANS: D During hospitalization, the nurse should provide a highly structured environment with few distractions for a child who is autistic. 12. A nurse planning to speak with a parent support group about childhood autism would include the information: a. Significant signs of the disorder manifest by 1 year of age. b.
The earliest signs of autism are impulsivity and overactivity.
c.
Autism is usually diagnosed when the child goes to elementary school.
d. Medications can cure childhood autism. ANS: A Failure to use eye contact and look at others, poor attention span, and poor orienting to ones name are significant signs of dysfunction by 1 year of age. 13. An adolescent is brought to the emergency department after an automobile accident. When the nurse approaches the adolescent, he becomes combative. The nurse notes his speech is slurred and his gait is ataxic. The nurse suspects the adolescent has used:
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a.
Alcohol
b.
Cocaine
c.
Amphetamines
d. PCP ANS: A Behavioral signs of alcohol ingestion include slurred speech, short attention span, drowsiness, combativeness, and violence. 14. When the nurse is collecting a nursing history, an adolescent states that she has tried speed. The nurse recognizes this as the street name for: a. Barbiturates b.
Cocaine
c.
Methamphetamine
d. Marijuana ANS: C Speed is the street name for methamphetamine. 15. The nurse explains that the member of the child guidance team who is a medical doctor with special training in psychoanalytic theory is the: a. Psychiatrist b.
Psychoanalyst
c.
Psychologist
d. Counselor ANS: A The psychiatrist is a medical doctor; the psychoanalyst may be a medical doctor or a psychologist. The psychologist is not a medical doctor, and neither is the counselor. 16. Because young children cannot express themselves well, the nurse uses the therapeutic intervention that allows children to act out their feelings, which is: a. Art therapy b.
Play therapy
c.
Music therapy
d. Bibliotherapy ANS: B Play therapy allows a young child to act out with dolls or figures concerns that the child may be unable to adequately express verbally. 17. The nurse explains that use of stimulants will decrease hyperactivity in the autistic child, but has the negative aspect of: a. Sedating the child b.
Impairing cognition
c.
Causing hypotension
d.
Creating fluid retention
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ANS: B Stimulants that decrease the hyperactivity in the autistic child also impair cognition and may increase the potential of self-injuring behavior. 18. A 9-year-old has been admitted to the hospital after huffing lighter fluid. The nurse should assess for: a. Depressed respirations b.
Severe vomiting
c.
Frightening hallucinations
d. Elevation of temperature ANS: A Inhaling hydrocarbons depresses the central nervous system, including respiratory rate and general sensorium. 19. As the pediatric nurse listens to a 9-year-old child read to his 6-year-old roommate, the nurse assesses possible dyslexia when the child: a. Becomes hyperactive and ceases to read b.
Reads the word GOD as DOG
c.
Makes up a story rather than reading the text
d. Stutters as he reads ANS: B Dyslexics often transpose a word as they read; for example, the word is GOD, but it appears to the dyslexic child as the word DOG. 1. The nurse describes the members of a mental health team for child guidance as including a: Select all that apply. a. Psychiatrist b.
Pediatrician
c.
Psychologist
d.
Dietitian
e. Social worker ANS: A, B, C, E The traditional members of the child guidance team are the psychiatrist, pediatrician, psychologist, and social worker. The dietitian is not usually on the treatment team.
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Chapter 36 Mental Health Disorders Question 1 Type: MCSA A nurse is caring for four pediatric clients in the hospital. Which client should the nurse refer for play therapy? 1. An adolescent with asthma 2. A preschool-age child with a fractured femur 3. A school-age child having an appendectomy 4. An infant with sepsis Correct Answer: 2 Global Rationale: Play therapy is often used with preschool and school-age children who are experiencing anxiety, stress, and other specific nonpsychotic mental disorders. In this case, the child who experiences a condition that requires longer hospitalization and recovery, such as a fracture of the femur, should be referred for play therapy. The adolescent with asthma, the school-age child having an appendectomy, and the infant with sepsis do not have as high a need for play therapy as the preschool child with a broken bone. Question 2 Type: MCSA A school-age client diagnosed with autism is admitted to the hospital because of recent vomiting and diarrhea. Which intervention by the nurse is most appropriate upon admission? 1. Take the child on a quick tour of the whole unit. 2. Take the child to the playroom immediately for arts and crafts. 3. Orient the child to the hospital room with minimal distractions. 4. Admit the child to a four-bed unit with small children. Correct Answer: 3 Global Rationale: Autistic children interpret and respond to the environment differently from other individuals. The child needs to be oriented to new settings and adjusts best to a quiet, controlled environment. A hospital room with only one other child is best. . Question 3 Type: MCSA A nurse is planning preoperative teaching for a school-age client scheduled to have a tonsillectomy. The client has a history of attention deficit hyperactivity disorder (ADHD). Which intervention will the nurse include in the plan of care? 1. Give instructions verbally and use a picture pamphlet, repeating points more than once. 2. Ask other children who have had this procedure to talk to the child. 3. Allow the child to lead the session to gain a sense of control. 4. Play a television show in the background. Correct Answer: 1 Global Rationale: A teaching session for a child with ADHD should foster attention. Giving instructions verbally and in written form, repeating points, will improve learning for a child with
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ADHD. The environment needs to be quiet, with minimal distractions. A child who has difficulty concentrating should not lead the session even though the child needs to feel in control. Talking to other children who have had this procedure may not foster understanding, because this child has ADHD. Distractions such as noise from a television should be minimized. Question 4 Type: MCSA A school-age client is prescribed Adderall (amphetamine mixed salts) for attention deficit hyperactivity disorder (ADHD). At which time is it most appropriate for the nurse to teach the parents to administer this medication? 1. At bedtime 2. Before lunch 3. With the evening meal 4. Early in the morning Correct Answer: 4 Global Rationale: A side effect of Adderall can be insomnia. Administering the medication early in the day can help alleviate the effect of insomnia. Question 5 Type: MCSA An adolescent client diagnosed with attention deficit hyperactivity disorder (ADHD) is interested in playing the drums in the school band. Which action by the nurse is the most appropriate? 1. Recommend the child take private lessons and not join the band. 2. Encourage the child to join the band. 3. Consult with the healthcare provider about allowing participation in band activities. 4. Discourage the child from playing in the band. Correct Answer: 2 Global Rationale: A child with ADHD may lack connectedness with other children. Participation in a school activity where the rules of working with others can be learned should be encouraged. Question 6 Type: MCSA A school-age client is evaluated for depression. Which assessment tool does the nurse anticipate will be used by the psychologist? 1. Denver Developmental Screening tool 2. Revised Childrens Manifest Anxiety Scale 3. Parent Developmental Questionnaire 4. Disruptive Behavior Disorder Scale Correct Answer: 2 Global Rationale: The Revised Childrens Manifest Anxiety Scale is a tool used to assess for depression. The Denver Developmental Screening tool and the Parent Developmental Questionnaire are tools used to assess development. The Disruptive Behavior Disorder Scale is used to assess for autism. Question 7 Type: FIB
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A nurse is calculating the maximum recommended dose that a school-age client diagnosed with depression can receive for sertraline (Zoloft). The recommended pediatric dose for sertraline (Zoloft) is 1.5 to 3 mg/kg/day. If the child weighs 31 kg, the maximum recommended dose for this child would be ____ mg. Standard Text: Round answer to the nearest whole number. Correct Answer: 93 Global Rationale: The maximum recommended dose for sertraline (Zoloft) is 3 mg/kg/day. If the child weighs 31 kg, it would be 3 31 = 93 mg a day. Question 8 Type: MCSA The nurse is planning care for a school-age client, who is diagnosed with bipolar disorder and is having suicidal ideations. Which nursing diagnosis is the priority for this client? 1. Powerlessness Related to Mood Instability 2. Social Isolation Related to Disorder 3. Risk for Injury Related to Suicidal Ideas 4. Impaired Social Interaction Correct Answer: 3 Global Rationale: The priority for a child with bipolar disorder and suicidal ideas is safety. Risk for Injury would be the nursing diagnosis that would address safety for the child. The other diagnoses have a lower priority. Question 9 Type: MCSA An adolescent client diagnosed with panic disorder is prescribed paroxetine (Paxil), a selective serotonin reuptake inhibitor (SSRI). The client tells the nurse she often takes diet pills because she is trying to lose weight. Which response by the nurse is the most appropriate? 1. You can continue with the paroxetine (Paxil) and the diet pills. 2. It is important to stop both the paroxetine (Paxil) and the diet pills. 3. Discontinue using the diet pills while taking the paroxetine (Paxil). 4. You should discuss the safety of these two medications pills with a pharmacist. Correct Answer: 3 Global Rationale: Serotonin syndrome, the serious and life-threatening side effect of SSRIs, can develop when the drug is taken with diet pills, St. Johns wort, other antidepressants, alcohol, or LSD. In this case, the diet pills should be discontinued in order to avoid serotonin syndrome. The Paxil should not be discontinued, and waiting to discuss the use of diet pills with a pharmacist would not be an appropriate option. Question 10 Type: MCSA The nurse is conducting a health history for a school-age client. The parents of the client tell the nurse that their child has the following behaviors: excessive handwashing, counting objects, and hoarding substances. Based on these assessment findings, which diagnosis does the nurse anticipate for this client? 1. Depression
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2. Separation anxiety disorder 3. Obsessive-compulsive disorder 4. Bipolar disorder Correct Answer: 3 Global Rationale: Common behaviors of obsessive-compulsive disorder (OCD) are excessive handwashing, counting objects, and hoarding substances. These practices may take up one or more hours each day. Question 11 Type: MCSA A nurse is concerned about the safety of a suicidal adolescent client and wants to be prepared for the use of physical restraints, if necessary. Which action by the nurse is the most appropriate in this situation? 1. Obtain a healthcare providers order, and follow the institutions policy for use of restraints. 2. Apply the restraints, and then obtain a healthcare providers order later. 3. Apply the restraints if parental permission is obtained. 4. Ask for the childs permission before applying the restraints. Correct Answer: 1 Global Rationale: Restraints are used only when ordered by the physician and interdisciplinary team caring for the child. Physical restraint is only a short-term approach to provide immediate safety if necessary. It would not be appropriate to apply the restraints, and then obtain a healthcare providers order. Even if permission is given by the parent and/or child, a healthcare providers order still needs to be obtained. Question 12 Type: MCMA A nurse is conducting developmental assessments on several children in the day-care setting. Which child(ren) does the nurse identify as having development delays? Standard Text: Select all that apply. 1. An 18-month-old toddler who is unable to phrase sentences 2. A 5-year-old who is unable to button his shirt 3. A 6-year-old who is unable to sit still for a short story 4. A 2-year-old who is unable to cut with scissors 5. A 2-year-old who cannot recite her phone number Correct Answer: 2,3 Global Rationale: A developmental milestone that can indicate learning disability is a kindergarteners being unable to button his shirt. Inability to phrase sentences is considered a delay if not done by 2-1/2 years, inability to sit still for a short story is considered a delay if the child is 3 to 5 years old, and being unable to cut with scissors indicates a delay if not done by kindergarten age. Reciting the phone number is not appropriate for a 2-year-old. Question 13 Type: MCSA The parents of a client recently diagnosed with Down syndrome relate to the nurse that they feel guilty about causing the condition. Which response by the nurse is the most appropriate? 1. Down syndrome is a condition caused by an extra chromosome; the cause of it is unknown.
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2. Down syndrome is a condition that is genetically transmitted from both the father and the mother. 3. Down syndrome is a condition that is carried on the X chromosome, so it came from the mother. 4. Down syndrome is caused by birth trauma, not by genetics. Correct Answer: 1 Global Rationale: The therapeutic and accurate response is that Down syndrome is a condition caused by an extra chromosome, but we dont know why it occurs. The other responses are nontherapeutic or inaccurate. Question 14 Type: MCSA A child with a profound intellectual disability is admitted to the hospital for an appendectomy. Which IQ does the nurse anticipate to see documented when reviewing this childs medical record? 1. Between 50 and 70 2. Below 20 3. Between 35 and 50 4. Between 20 and 35 Correct Answer: 2 Global Rationale: Profound intellectual disability is described as an intelligence quotient (IQ) below 20. Mild intellectual disability is described as an IQ between 50 and 70, moderate intellectual disability is an IQ between 35 and 50, and severe intellectual disability is an IQ between 20 and 35. Question 15 Type: MCSA The family of a preschool-age client diagnosed with an intellectual disability is expressing difficulty with managing the care needs of the child. Which nursing diagnosis is most appropriate for this situation? 1. Hopelessness Related to Terminal Condition of the Child 2. Compromised Family Coping Related to the Childs Developmental Variations 3. Family Processes That are Dysfunctional Related to a Child with Intellectual Disability 4. Impaired Parenting Related to Poor Parenting Skills Correct Answer: 2 Global Rationale: The family is compromised but not dysfunctional. Hopelessness and impaired parenting are not appropriate in the given situation. Question 16 Type: MCMA The nurse is planning care for an adolescent client with a newly diagnosed intellectual disability following a traumatic brain injury. Which expected outcomes are appropriate for this client? Standard Text: Select all that apply. 1. The family understands the adolescents diagnosis. 2. The family understands the specific physical and developmental needs of the adolescent. 3. The adolescent develops self-care skills appropriate to his or her developmental level.
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4. The adolescents family is able to access the necessary community and educational resources. 5. The familys ability to cope with changing needs of the adolescent. Correct Answer: 1,2,3,4 Global Rationale: All statements are appropriate outcomes for the adolescent and the family except the statement regarding the familys ability to cope with the changing needs of the adolescent. This is an evaluation statement.
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