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Peds Exam 2

STUDY
PLAY
1. A 2-year-old child has been returned to the nursing unit after an inguinal hernia repair. Which pain assessment tool should the nurse use to assess this child for the presence of pain?
a.
FACES pain rating tool
b.
Numeric scale
c.
Oucher scale
d.
FLACC tool
d.
FLACC tool


ANS: D
A behavioral pain tool should be used when the child is preverbal or doesn't have the language skills to express pain. The FLACC (face, legs, activity, cry, consolability) tool should be used with a 2-year-old child. The FACES, numeric, and Oucher scales are all self-report pain rating tools. Self-report measures are not sufficiently valid for children younger than 3 years of age because many are not able to accurately self-report their pain.
2. The nurse is caring for a 6-year-old girl who had surgery 12 hours ago. The child tells the nurse that she does not have pain, but a few minutes later she tells her parents that she does. Which should the nurse consider when interpreting this?
a.
Truthful reporting of pain should occur by this age.
b.
Inconsistency in pain reporting suggests that pain is not present.
c.
Children use pain experiences to manipulate their parents.
d.
Children may be experiencing pain even though they deny it to the nurse.
d.
Children may be experiencing pain even though they deny it to the nurse.


ANS: D
Children may deny pain to the nurse because they fear receiving an injectable analgesic or because they believe they deserve to suffer as a punishment for a misdeed. They may refuse to admit pain to a stranger but readily tell a parent. Truthfully reporting pain and inconsistency in pain reporting suggesting that pain is not present are common fallacies about children and pain. Pain is whatever the experiencing person says it is, whenever the person says it exists. Pain would not be questioned in an adult 12 hours after surgery.
3. A nurse is gathering a history on a school-age child admitted for a migraine headache. The child states, "I have been getting a migraine every 2 or 3 months for the last year." The nurse documents this as which type of pain?
a.
Acute
b.
Chronic
c.
Recurrent
d.
Subacute
c.
Recurrent

ANS: C
Pain that is episodic and reoccurs is defined as recurrent pain. The time frame within which episodes of pain recur is at least 3 months. Recurrent pain in children includes migraine headache, episodic sickle cell pain, recurrent abdominal pain (RAP), and recurrent limb pain. Acute pain is pain that lasts for less than 3 months. Chronic pain is pain that lasts, on a daily basis, for more than 3 months. Subacute is not a term for documenting type of pain.
4. Physiologic measurements in children's pain assessment are:
a.
the best indicator of pain in children of all ages.
b.
essential to determine whether a child is telling the truth about pain.
c.
of most value when children also report having pain.
d.
of limited value as sole indicator of pain.
d.
of limited value as sole indicator of pain.

ANS: D
Physiologic manifestations of pain may vary considerably, not providing a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize. Physiologic measurements are of limited value and must be viewed in the context of a pain-rating scale, behavioral assessment, and parental report. When the child states that pain exists, it does. That is the truth.
7. A lumbar puncture is needed on a school-age child. The most appropriate action to provide analgesia during this procedure is to apply _____ before the procedure.
a.
TAC (tetracaine-adrenaline-cocaine) 15 minutes
b.
transdermal fentanyl (Duragesic) patch immediately
c.
EMLA (eutectic mixture of local anesthetics) 1 hour
d.
EMLA (eutectic mixture of local anesthetics) 30 minutes
c.
EMLA (eutectic mixture of local anesthetics) 1 hour

ANS: C
EMLA is an effective analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. TAC provides skin anesthesia about 15 minutes after application to nonintact skin. The gel can be placed on the wound for suturing. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control. For maximal effectiveness, EMLA must be applied approximately 60 minutes in advance.
8. The nurse is caring for a child receiving intravenous (IV) morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to:
a.
administer naloxone (Narcan).
b.
discontinue IV infusion.
c.
discontinue morphine until child is fully awake.
d.
stimulate child by calling name, shaking gently, and asking to breathe deeply.
a.
administer naloxone (Narcan).

ANS: A
The management of opioid-induced respiratory depression includes lowering the rate of infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be aroused, then IV naloxone should be administered. The child will be in pain because of the reversal of the morphine. The morphine should be discontinued, but naloxone is indicated if the child is unresponsive. The child is unresponsive, therefore naloxone is indicated.
2. A nurse is monitoring a patient for side effects associated with opioid analgesics. Which side effects should the nurse expect to monitor for? (Select all that apply.)
a.
Diarrhea
b.
Respiratory depression
c.
Hypertension
d.
Pruritus
e.
Sweating
b.
Respiratory depression
d.
Pruritus
e.
Sweating

ANS: B, D, E
Side effects of opioids include respiratory depression, pruritus, and sweating. Constipation may occur, not diarrhea, and orthostatic hypotension may occur but not hypertension.
3. Which dietary recommendations should a nurse make to an adolescent patient to manage constipation related to opioid analgesic administration? (Select all that apply.)
a.
Bran cereal
b.
Decrease fluid intake
c.
Prune juice
d.
Cheese
e.
Vegetables
a.
Bran cereal
d.
Cheese
e.
Vegetables

ANS: A, D, E
To manage the side effect of constipation caused by opioids, fluids should be increased, and bran cereal and vegetables are recommended to increase fiber. Prune juice can act as a nonpharmacologic laxative. Fluids should be increased, not decreased, and cheese can cause constipation so it should not be recommended.
1. A nurse is assessing a 12-month-old infant. Which statement best describes the infant's physical development a nurse should expect to find?
a.
Anterior fontanel closes by age 6 to 10 months.
b.
Binocularity is well established by age 8 months.
c.
Birth weight doubles by age 5 months and triples by age 1 year.
d.
Maternal iron stores persist during the first 12 months of life.
c.
Birth weight doubles by age 5 months and triples by age 1 year.

ANS: C
Growth is very rapid during the first year of life. The birth weight has approximately doubled by age 5 to 6 months and triples by age 1 year. The anterior fontanel closes at age 12 to 18 months. Binocularity is not established until age 15 months. Maternal iron stores are usually depleted by age 6 months.
2. The nurse is assessing a 6-month-old healthy infant who weighed 7 pounds at birth. The nurse should expect the infant to now weigh approximately how many pounds?
a.
10
b.
15
c.
20
d.
25
b.
15

ANS: B
Birth weight doubles at about age 5 to 6 months. At 6 months, a child who weighed 7 pounds at birth would weigh approximately 15 pounds; 10 pounds is too little. The infant would have gone from the 50th percentile at birth to below the 5th percentile; 20 to 25 pounds is too much. The infant would have tripled the birth weight at 6 months.
3. The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. The nurse should interpret this as a(n):
a.
normal finding.
b.
finding requiring a referral.
c.
abnormal finding.
d.
normal finding, but requires rechecking in 1 month.
a.
normal finding.

ANS: A
This is a normal finding. The anterior fontanel closes between ages 12 and 18 months. No further intervention is required.
33. A parent asks the nurse whether her infant is susceptible to pertussis. The nurse's response should be based on which statement concerning susceptibility to pertussis?
a.
Neonates will be immune the first few months.
b.
If the mother has had the disease, the infant will receive passive immunity.
c.
Children younger than 1 year seldom contract this disease.
d.
Most children are highly susceptible from birth.
d.
Most children are highly susceptible from birth.

ANS: D
The acellular pertussis vaccine is recommended by the American Academy of Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. The vaccine is not given after age 7 years, when the risks of the vaccine become greater than those of pertussis. The infant is highly susceptible to pertussis, which can be a life-threatening illness in this age group.
34. A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. The nurse should explain that:
a.
this cannot be prevented.
b.
infants do not feel pain as adults do.
c.
this is not a good reason for refusing immunizations.
d.
a topical anesthetic, EMLA, can be applied before injections are given.
d.
a topical anesthetic, EMLA, can be applied before injections are given.

ANS: D
Several topical anesthetic agents can be used to minimize the discomfort associated with immunization injections. These include EMLA (eutectic mixture of local anesthetic) and vapor coolant sprays. Pain associated with many procedures can be prevented and minimized by using the principles of atraumatic care. With preparation, the injection site can be properly anesthetized to decrease the amount of pain felt by the infant. Infants have the neural pathways to feel pain. Numerous research studies have indicated that infants perceive and react to pain in the same manner as do children and adults. The mother should be allowed to discuss her concerns and the alternatives available. This is part of the informed consent process.
4. A nurse is preparing to administer routine immunizations to a 4-month-old infant. The infant is currently up to date on all previously recommended immunizations. Which immunizations will the nurse prepare to administer? (Select all that apply.)
a.
Measles, mumps, and rubella (MMR)
b.
Rotavirus (RV)
c.
Diphtheria, tetanus, pertussis (DTaP)
d.
Varicella
e.
Haemophilus influenzae type b (HIB)
f.
Inactivated poliovirus (IPV)
b.
Rotavirus (RV)
c.
Diphtheria, tetanus, pertussis (DTaP)
e.
Haemophilus influenzae type b (HIB)
f.
Inactivated poliovirus (IPV)

ANS: B, C, E, F
Recommended immunization schedule for a 4-month-old, up to date on immunizations, would be to administer the rotavirus (RV), diphtheria, tetanus, pertussis (DTaP), Haemophilus influenza type b (HIB), and inactivated poliovirus (IPV) vaccinations. The measles, mumps, and rubella (MMR) and varicella would not be administered until the child is at least 1 year of age.
5. A nurse is preparing to administer immunizations to a 6-month-old infant. Which interventions should the nurse implement to minimize local reaction and reduce pain? (Select all that apply.)
a.
Select a needle of adequate length (1 inch).
b.
Inject into the deltoid muscle.
c.
Apply a vapocoolant spray directly to the skin, 15 seconds before administration.
d.
Apply a topical anesthetic LMX4 (4% lidocaine) 10 minutes before administration.
a.
Select a needle of adequate length (1 inch).
c.
Apply a vapocoolant spray directly to the skin, 15 seconds before administration.
d.
Apply a topical anesthetic LMX4 (4% lidocaine) 10 minutes before administration.

ANS: A, C, D
To minimize local reaction and reduce pain when administering an immunization, select a needle of adequate length (25 mm [1 inch] in infants) to deposit the antigen deep in the muscle mass. Apply a vapocoolant spray (e.g., ethyl chloride or Fluori-Methane) directly to the skin or to a cotton ball, which is placed on the skin for 15 seconds immediately before the injection. Inject into the vastus lateralis or ventrogluteal muscle; the deltoid may be used in children 18 months of age and older. Apply the topical anesthetic LMX4 (4% lidocaine) to the injection site 30 minutes before the injection. Ten minutes does not allow the anesthetic to be effective.
1. Which is described as the time interval between infection or exposure to disease and appearance of initial symptoms?
a.
Incubation period
b.
Prodromal period
c.
Desquamation period
d.
Period of communicability
a.
Incubation period

ANS: A
The incubation period is the interval between infection or exposure and appearance of symptoms. The prodromal period is the interval between the time when early manifestations of disease appear and the overt clinical syndrome is evident. Desquamation refers to the shedding of skin. The period of communicability is the time or times during which an infectious agent may be transferred directly or indirectly from an infected person to another person.
2. Airborne isolation is required for a child who is hospitalized with:
a.
mumps.
b.
chickenpox.
c.
exanthema subitum (roseola).
d.
erythema infectiosum (fifth disease).
b.
chickenpox.

ANS: B
Chickenpox is communicable through direct contact, droplet spread, and contaminated objects. Mumps is transmitted from direct contact with saliva of infected person and is most communicable before onset of swelling. The transmission and source of the viral infection exanthema subitum (roseola) is unknown. Erythema infectiosum (fifth disease) is communicable before onset of symptoms.
3. Acyclovir (Zovirax) is given to children with chickenpox to:
a.
minimize scarring.
b.
decrease the number of lesions.
c.
prevent aplastic anemia.
d.
prevent spread of the disease.
b.
decrease the number of lesions.

ANS: B
Acyclovir decreases the number of lesions; shortens duration of fever; and decreases itching, lethargy, and anorexia. Treating pruritus and discouraging itching minimizes scarring. Aplastic anemia is not a complication of chickenpox. Strict isolation until vesicles are dried prevents spread of disease.
4. The single parent of a 3-year-old child who has just been diagnosed with chickenpox tells the nurse that she cannot afford to stay home with the child and miss work. The parent asks the nurse if some medication will shorten the course of the illness. Which is the most appropriate nursing intervention?
a.
Reassure the parent that it is not necessary to stay home with the child.
b.
Explain that no medication will shorten the course of the illness.
c.
Explain the advantages of the medication acyclovir (Zovirax) to treat chickenpox.
d.
Explain the advantages of the medication VCZ immune globulin (VariZIG) to treat chickenpox.
c.
Explain the advantages of the medication acyclovir (Zovirax) to treat chickenpox.

ANS: C
Acyclovir is effective in treating the number of lesions; shortening the duration of fever; and decreasing itching, lethargy, and anorexia. It is important the parent stay with the child to monitor fever. Acyclovir lessens the severity of chickenpox. VariZIG is given only to high-risk children.
5. Which may be given to high-risk children after exposure to chickenpox to prevent varicella?
a.
Acyclovir (Zovirax)
b.
Varicella globulin
c.
Diphenhydramine hydrochloride (Benadryl)
d.
VCZ immune globulin (VariZIG)
d.
VCZ immune globulin (VariZIG)

ANS: D
VariZIG is given to high-risk children to prevent the development of chickenpox. Acyclovir decreases the severity, not the development, of chickenpox. Varicella globulin is not effective because it is not the immune globulin. Diphenhydramine may help pruritus but not the actual chickenpox.
6. Vitamin A supplementation may be recommended for the young child who has which disease?
a.
Mumps
b.
Rubella
c.
Measles (rubeola)
d.
Erythema infectiosum
c.
Measles (rubeola)

ANS: C
Evidence shows vitamin A decreases morbidity and mortality in measles. Mumps is treated with analgesics for pain and antipyretics for fever. Rubella is treated similarly to mumps. Erythema infectiosum is treated similarly to mumps and rubella.
7. A nurse is teaching parents about caring for their child with chickenpox. The nurse should let the parents know that the child is considered to be no longer contagious when which occurs?
a.
When fever is absent
b.
When lesions are crusted
c.
24 hours after lesions erupt
d.
8 days after onset of illness
b.
When lesions are crusted

ANS: B
When the lesions are crusted, the chickenpox is no longer contagious. This may be a week after onset of disease. Chickenpox is still contagious when child has fever. Children are contagious after lesions erupt. If lesions are crusted at 8 days, the child is no longer contagious.
8. A nurse is assessing a child and notes Koplik spots. In which of these communicable diseases are Koplik spots present?
a.
Rubella
b.
Measles (rubeola)
c.
Chickenpox (varicella)
d.
Exanthema subitum (roseola)
b.
Measles (rubeola)

ANS: B
Koplik spots are small irregular red spots with a minute, bluish white center found on the buccal mucosa 2 days before systemic rash. Rubella occurs with rash on the face, which rapidly spreads downward. Varicella appears with highly pruritic macules, followed by papules and vesicles. Roseola is seen with rose-pink macules on the trunk, spreading to face and extremities.
9. Which is a common childhood communicable disease that may cause severe defects in the fetus when it occurs in its congenital form?
a.
Erythema infectiosum
b.
Roseola
c.
Rubeola
d.
Rubella
d.
Rubella

ANS: D
Rubella causes teratogenic effects on the fetus. There is a low risk of fetal death to those in contact with children affected with fifth disease. Roseola and rubeola are not dangerous to the fetus.
10. Which is the causative agent of scarlet fever?
a.
Enteroviruses
b.
Corynebacterium organisms
c.
Scarlet fever virus
d.
Group A β-hemolytic streptococci (GABHS)
d.
Group A β-hemolytic streptococci (GABHS)

ANS: D
GABHS infection causes scarlet fever. Enteroviruses do not cause the same complications. Corynebacterium organisms cause diphtheria. Scarlet fever is not caused by a virus.
11. A parent reports to the nurse that her child has inflamed conjunctivae of both eyes with purulent drainage and crusting of the eyelids, especially on awakening. These manifestations suggest:
a.
viral conjunctivitis.
b.
allergic conjunctivitis.
c.
bacterial conjunctivitis.
d.
conjunctivitis caused by foreign body.
c.
bacterial conjunctivitis.

ANS: C
Bacterial conjunctivitis has these symptoms. Viral or allergic conjunctivitis has watery drainage. Foreign body causes tearing and pain, and usually only one eye is affected.
14. The nurse suspects that a child has ingested some type of poison. Which clinical manifestation would be most suggestive that the poison was a corrosive product?
a.
Tinnitus
b.
Disorientation
c.
Stupor, lethargy, coma
d.
Edema of lips, tongue, pharynx
d.
Edema of lips, tongue, pharynx

ANS: D
Edema of lips, tongue, and pharynx indicates a corrosive ingestion. Tinnitus is indicative of aspirin ingestion. Corrosives do not act on the central nervous system (CNS).
15. A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The nurse taking the call should know that the primary danger is which result?
a.
Hepatic dysfunction
b.
Dehydration secondary to vomiting
c.
Esophageal stricture and shock
d.
Bronchitis and chemical pneumonia
d.
Bronchitis and chemical pneumonia

ANS: D
Lighter fluid is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose, not hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger. Esophageal stricture is a late or chronic issue of hydrocarbon ingestion.
16. Which is a clinical manifestation of acetaminophen poisoning?
a.
Hyperpyrexia
b.
Hepatic involvement
c.
Severe burning pain in stomach
d.
Drooling and inability to clear secretions
b.
Hepatic involvement

ANS: B
Hepatic involvement is the third stage of acetaminophen poisoning. Hyperpyrexia is a severe elevation in body temperature and is not related to acetaminophen poisoning. Acetaminophen does not cause burning pain in stomach or pose an airway threat.
18. A young child has just arrived at the emergency department after ingestion of aspirin at home. The practitioner has ordered activated charcoal. The nurse administers charcoal in which way?
a.
Administer through a nasogastric tube because the child will not drink it because of the taste.
b.
Serve in a clear plastic cup so the child can see how much has been drunk.
c.
Give half of the solution, and then give the other half in 1 hour.
d.
Serve in an opaque container with a straw.
d.
Serve in an opaque container with a straw.

ANS: D
Although the activated charcoal can be mixed with a flavorful beverage, it will be black and resemble mud. When it is served in an opaque container, the child does not have any preconceived ideas about its being distasteful. The nasogastric tube should be used only in children without a gag reflex. The ability to see the charcoal solution may affect the child's desire to drink it. The child should be encouraged to drink the solution all at once.
19. Which is the most frequent source of acute childhood lead poisoning?
a.
Folk remedies
b.
Unglazed pottery
c.
Lead-based paint
d.
Cigarette butts and ashes
c.
Lead-based paint

ANS: C
Lead-based paint in houses built before 1978 is the most frequent source of lead poisoning. Some folk remedies and unglazed pottery may contain lead, but they are not the most frequent source. Cigarette butts and ashes do not contain lead.
20. Chelation therapy for lead poisoning is initiated when a child's blood level is _____ g/dl.
a.
10 to 14
b.
15 to 19
c.
20 to 44
d.
>45
d.
>45

ANS: D
Chelation therapy is initiated if the child's blood level is greater than 45 g/dl. At 10 to 14 g/dl, the family should have lead-poisoning education and follow-up level. At 15 to 19 g/dl, the family should have lead-poisoning education and follow-up level but if it persists, initiate environmental investigation. At 20 to 44 g/dl environmental investigation and lead hazard control are necessary.
23. A 3-month-old infant dies shortly after arrival to the emergency department. The infant has subdural and retinal hemorrhages but no external signs of trauma. The nurse should suspect:
a.
unintentional injury.
b.
shaken-baby syndrome.
c.
sudden infant death syndrome (SIDS).
d.
congenital neurologic problem.
b.
shaken-baby syndrome.

ANS: B
Shaken-baby syndrome causes internal bleeding but may have no external signs. Unintentional injury would not cause these injuries. SIDS and congenital neurologic problems would not appear this way.
26. A nurse is beginning chelation therapy on a child for lead poisoning. Which intervention should the nurse implement during the time the child is receiving chelation therapy?
a.
Calorie counts
b.
Strict intake and output
c.
Telemetry monitoring
d.
Contact isolation
b.
Strict intake and output

ANS: B
Because calcium disodium edetate (EDTA) and lead are toxic to the kidneys, a nurse should keep strict records of intake and output to monitor renal functioning. Adequate hydration is essential during therapy because the chelates are excreted via the kidneys. Calorie counts, telemetry, or contact isolation would not be nursing interventions appropriate for a child undergoing chelation therapy.
27. A child has been admitted to the emergency department with an acetaminophen (Tylenol) poisoning. An antidote is being prescribed by the health care provider. Which antidote should the nurse prepare to administer?
a.
Naloxone (Narcan)
b.
N-acetylcysteine (Mucomyst)
c.
Flumazenil (Romazicon)
d.
Digoxin immune Fab (Digibind)
b.
N-acetylcysteine (Mucomyst)

ANS: B
Antidotes available to treat toxin ingestion include N-acetylcysteine for acetaminophen poisoning, naloxone for opioid overdose, flumazenil (Romazicon) for benzodiazepines (diazepam [Valium], midazolam [Versed]) overdose, and digoxin immune Fab (Digibind) for digoxin toxicity.
28. A clinic nurse is assessing a child with erythema infectiosum (fifth disease). Which figure depicts the rash the nurse should expect to assess?
ANS: A
Erythema infectiosum rash appears in three stages: erythema on face, chiefly on cheeks ("slapped face" appearance); disappears by 1-4 days. Chicken pox rash begins as macule, rapidly progresses to papule and then vesicle (surrounded by erythematous base; becomes umbilicated and cloudy; breaks easily and forms crusts); all three stages (papule, vesicle, crust) present in varying degrees at one time. Roseola rash is discrete rose-pink macules or maculopapules appearing first on trunk and then spreading to neck, face, and extremities; nonpruritic; fades on pressure; lasts 1-2 days. Rubeola rash—appears 3-4 days after onset of prodromal stage; begins as erythematous maculopapular eruption on face and gradually spreads downward; more severe in earlier sites (appears confluent) and less intense in later sites (appears discrete); after 3-4 days, assumes brownish appearance, and fine desquamation occurs over area of extensive involvement.
1. A nurse is teaching parents methods to reduce lead levels in their home. Which should the nurse include in the teaching? (Select all that apply.)
a.
Plant bushes around the outside of the house.
b.
Ensure your child eats frequent meals.
c.
Use hot water from the tap when boiling vegetables.
d.
Food can be stored in ceramic in the refrigerator.
e.
Ensure that your child's diet contains sufficient iron and calcium.
a.
Plant bushes around the outside of the house.
b.
Ensure your child eats frequent meals.
e.
Ensure that your child's diet contains sufficient iron and calcium.

ANS: A, B, E
Methods to reduce lead levels in homes include: planting bushes around the outside of the house, if soil is contaminated with lead, so children cannot play there; ensuring that children eat regular meals because more lead is absorbed on an empty stomach; and ensuring that children's diets contain sufficient iron and calcium. Cold water should only be used for drinking, cooking, and reconstituting powder infant formula. Hot water dissolves lead more quickly than cold water and thus contains higher levels of lead. Do not use pottery or ceramic ware that was inadequately fired or is meant for decorative use for food storage or service.
1. Place in order the correct sequence for emergency treatment of poisoning in a child. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d).
a. Locate the poison.
b. Assess the child.
c. Prevent absorption of poison.
d. Terminate exposure to the toxic substance.
b. Assess the child.
d. Terminate exposure to the toxic substance.
a. Locate the poison.
c. Prevent absorption of poison.

ANS:
b, d, a, c
The initial step in treating poisonings is to assess the child, treat immediate life-threatening conditions, and initiate cardiopulmonary resuscitation (CPR) if indicated. Terminating the exposure to the toxic substance is the second step. Locating the poison for identification is the third step. Preventing absorption of poison is the fourth step.
21. Which describes a child who is abused by the parent(s)?
a.
Unintentionally contributes to the abusing situation
b.
Belongs to a low socioeconomic population
c.
Is healthier than the nonabused siblings
d.
Abuses siblings in the same way as child is abused by the parent(s)
a.
Unintentionally contributes to the abusing situation

ANS: A
Child's temperament, position in the family, additional physical needs, activity level, or degree of sensitivity to parental needs unintentionally contribute to the abusing situation. Abuse occurs among all socioeconomic levels. Children who are ill or have additional physical needs are more likely to be abused. The abused child may not abuse siblings.
22. Which is a common characteristic of those who sexually abuse children?
a.
Pressure victim into secrecy
b.
Are usually unemployed and unmarried
c.
Are unknown to victims and victims' families
d.
Have many victims that are each abused once only
a.
Pressure victim into secrecy

ANS: A
Sex offenders may pressure the victim into secrecy regarding the activity as a "secret between us" that other people may take away if they find out. The offender may be anyone, including family members and persons from any level of society. Sex offenders are usually trusted acquaintances of the victims and victims' families. Many victims are abused many times over a long period.
24. Which is probably the most important criterion on which to base the decision to report suspected child abuse?
a.
Inappropriate parental concern for the degree of injury
b.
Absence of parents for questioning about child's injuries
c.
Inappropriate response of child
d.
Incompatibility between the history and injury observed
d.
Incompatibility between the history and injury observed

ANS: D
Conflicting stories about the "accident" are the most indicative red flags of abuse. Inappropriate response of caregiver or child may be present, but is subjective. Parents should be questioned at some point during the investigation.
3. A child has been diagnosed with enuresis. TCA imipramine (Tofranil) has been prescribed for the child. The nurse understands that this medication is in which category?
a.
Antidepressant
b.
Antidiuretic
c.
Antispasmodic
d.
Analgesic
c.
Antispasmodic

ANS: C
Drug therapy is increasingly being prescribed to treat enuresis. Three types of drugs are used: tricyclic antidepressants (TCAs), antidiuretics, and antispasmodics. The selection depends on the interpretation of the cause. The drug used most frequently is the TCA imipramine (Tofranil), which exerts an anticholinergic action in the bladder to inhibit urination. Tofranil is in the antispasmodic category. Analgesics are not used to treat enuresis.
5. Which syndrome involves a common sex chromosome defect?
a.
Down
b.
Turner
c.
Marfan
d.
Hemophilia
b.
Turner

ANS: B
Turner syndrome is caused by an absence of one of the X chromosomes. Down syndrome is caused by trisomy 21, three copies rather than two copies of chromosome 21. Marfan syndrome is a connective tissue disorder inherited in an autosomal dominant pattern. Hemophilia is a disorder of blood coagulation inherited in an X-linked recessive pattern.
6. Turner syndrome is suspected in an adolescent girl with short stature. This is caused by:
a.
absence of one of the X chromosomes.
b.
presence of an incomplete Y chromosome.
c.
precocious puberty in an otherwise healthy child.
d.
excess production of both androgens and estrogens.
a.
absence of one of the X chromosomes.

ANS: A
Turner syndrome is caused by an absence of one of the X chromosomes. Most girls who have this disorder have one X chromosome missing from all cells. No Y chromosome is present in individuals with Turner syndrome. This young woman has 45 rather than 46 chromosomes.
17. A nurse is conducting a class for adolescent girls about pelvic inflammatory disease (PID). Why should the nurse emphasize the importance of preventing pelvic inflammatory disease (PID)?
a.
PID can be sexually transmitted.
b.
PID cannot be treated.
c.
PID can have devastating effects on the reproductive tract.
d.
PID can cause serious defects in future children of affected adolescents.
c.
PID can have devastating effects on the reproductive tract.

ANS: C
PID is a major concern because of its devastating effects on the reproductive tract. Short-term complications include abscess formation in the fallopian tubes, whereas long-term complications include ectopic pregnancy, infertility, and dyspareunia. PID is an infection of the upper female genital tract, most commonly caused by sexually transmitted infections but it is not sexually transmitted to another person. PID can be treated by treating the underlying cause. There is a possibility of ectopic pregnancy but not birth defects in children.
18. Which statement is correct about childhood obesity?
a.
Heredity is an important factor in the development of obesity.
b.
Childhood obesity in the United States is decreasing.
c.
Childhood obesity is the result of inactivity.
d.
Childhood obesity can be attributed to an underlying disease in most cases.
a.
Heredity is an important factor in the development of obesity.

ANS: A
Heredity is an important fact that contributes to obesity. Identical twins reared apart tend to resemble their biologic parents to a greater extent than their adoptive parents. It is difficult to distinguish between hereditary and environmental factors. The number of overweight children is increasing in the United States. Inactivity is related to childhood obesity, but it is not the only component. Underlying diseases such as hypothyroidism and hyperinsulinism account for only a small number of cases of childhood obesity.
19. The psychological effects of being obese during adolescence include:
a.
sexual promiscuity.
b.
poor body image.
c.
feelings of contempt for thin peers.
d.
accurate body image but self-deprecating attitude.
b.
poor body image.

ANS: B
Common emotional consequences of obesity include poor body image, low self-esteem, social isolation, and feelings of depression and isolation. Sexual promiscuity, feelings of contempt for thin peers, and accurate body image but self-deprecating attitude are not usually associated with obesity.
26. Which is descriptive of attention deficit hyperactivity disorder (ADHD)?
a.
Manifestations exhibited are so bizarre that the diagnosis is fairly easy.
b.
Manifestations affect every aspect of the child's life but are most obvious in the classroom.
c.
Learning disabilities associated with ADHD eventually disappear when adulthood is reached.
d.
Diagnosis of ADHD requires that all manifestations of the disorder be present.
b.
Manifestations affect every aspect of the child's life but are most obvious in the classroom.

ANS: B
ADHD affects every aspect of the child's life, but the disruption is most obvious in the classroom. The behaviors exhibited by the child with ADHD are not unusual aspects of behavior. The difference lies in the quality of motor activity and developmentally inappropriate inattention, impulsivity, and hyperactivity that the child displays. Some children experience decreased symptoms during late adolescence and adulthood, but a significant number carry their symptoms into adulthood. Any given child will not have every symptom of the condition. The manifestations may be numerous or few, mild or severe, and will vary with the child's developmental level.
27. The nurse is teaching the parents of a child recently diagnosed with ADHD who has been prescribed methylphenidate (Ritalin). Which should the nurse include in teaching about the side effects of methylphenidate?
a.
"Your child may experience a sense of nervousness."
b.
"You may see an increase in your child's appetite."
c.
"Your child may experience daytime sleepiness."
d.
"You may see a decrease in your child's blood pressure."
a.
"Your child may experience a sense of nervousness."

ANS: A
Nervousness is one of the common side effects of Ritalin. Decreased appetite with subsequent weight loss, insomnia, and increased blood pressure are other common side effects.
1. A nurse is recommending strategies to a group of school-age children for prevention of obesity. Which should the nurse include? (Select all that apply.)
a.
Eat breakfast daily.
b.
Limit fruits and vegetables.
c.
Have frequent family meals with parents present.
d.
Eat frequently at restaurants.
e.
Limit television viewing to 2 hours a day.
a.
Eat breakfast daily.
c.
Have frequent family meals with parents present.
e.
Limit television viewing to 2 hours a day.

ANS: A, C, E
The nurse should counsel school-age children to eat breakfast daily, have mealtimes with family, and limit television viewing to 2 hours a day to prevent obesity. Fruits and vegetables should be consumed in the recommended quantities, and eating at restaurants should be limited.
2. Which strategies should the school nurse recommend implementing in the classroom for a child with attention deficit hyperactive disorder (ADHD)? (Select all that apply.)
a.
Schedule heavier subjects to be taught in the afternoon.
b.
Accompany verbal instructions by written format.
c.
Limit number of breaks taken during instructional periods.
d.
Allow more time for testing.
e.
Reduce homework and classroom assignments.
b.
Accompany verbal instructions by written format.
d.
Allow more time for testing.
e.
Reduce homework and classroom assignments.


ANS: B, D, E
Children with ADHD need an orderly, predictable, and consistent classroom environment with clear and consistent rules. Homework and classroom assignments may need to be reduced, and more time may need to be allotted for tests to allow the child to complete the task. Verbal instructions should be accompanied by visual references such as written instructions on the blackboard. Schedules may need to be arranged so that academic subjects are taught in the morning when the child is experiencing the effects of the morning dose of medication. Regular and frequent breaks in activity are helpful because sitting in one place for an extended time may be difficult.
4. Approach behaviors are those coping mechanisms that result in a family's movement toward adjustment and resolution of the crisis of having a child with a chronic illness or disability. Which is considered an approach behavior?
a.
Is unable to adjust to a progression of the disease or condition
b.
Anticipates future problems and seeks guidance and answers
c.
Looks for new cures without a perspective toward possible benefit
d.
Fails to recognize seriousness of child's condition despite physical evidence
b.
Anticipates future problems and seeks guidance and answers

ANS: B
The parents who anticipate future problems and seek guidance and answers are demonstrating approach behaviors. They are demonstrating positive actions in caring for their child. Being unable to adjust to a progression of the disease or condition, looking for new cures without a perspective toward possible benefit, and failing to recognize seriousness of child's condition despite physical evidence are avoidance behaviors. The parents are moving away from adjustment (and toward maladaptation) in the crisis of a child with chronic illness or disability.
6. Which nursing intervention is especially helpful in assessing parental guilt when a disability or chronic illness is diagnosed?
a.
Ask the parents if they feel guilty.
b.
Discuss guilt only after the parents mention it.
c.
Discuss the meaning of the parents' religious and cultural background.
d.
Observe for signs of overprotectiveness.
c.
Discuss the meaning of the parents' religious and cultural background.

ANS: C
Guilt may be associated with cultural or religious beliefs. Some parents are convinced that they are being punished for some previous misdeed. Others may see the disorder as a sacrifice sent by God to test their religious beliefs. The nurse can help the parents explore their religious beliefs. The parents may not be able to identify the feelings of guilt. It would be appropriate for the nurse to explore their adjustment responses. Overprotectiveness is a parental response during the adjustment phase. The parents fear letting the child achieve any new skill and avoid all discipline.
7. The nurse observes that a seriously ill child passively accepts all painful procedures. The nurse should recognize that this is most likely an indication that the child is experiencing a:
a.
sense of hopefulness.
b.
sense of chronic sorrow.
c.
belief that procedures are a deserved punishment.
d.
belief that procedures are an important part of care.
c.
belief that procedures are a deserved punishment.

ANS: C
The nurse should be particularly alert to the child who passively accepts all painful procedures. This child may believe that such acts are inflicted as deserved punishment. The child who is hopeful is mobilized into goal-directed actions. This child would actively participate in care. Chronic sorrow is the feeling of sorrow and loss that recurs in waves over time. It is usually evident in the parents, not in the child. A child who believes that procedures are an important part of care would actively participate in care. Nursing interventions should be used to minimize the pain.
8. The nurse comes into the room of a child who was just diagnosed with a chronic disability. The child's parents begin to yell at the nurse about a variety of concerns. Which is the nurse's best response?
a.
"What is really wrong?"
b.
"Being angry is only natural."
c.
"Yelling at me will not change things."
d.
"I will come back when you settle down."
b.
"Being angry is only natural."

ANS: B
Parental anger after the diagnosis of a child with a chronic disability is a common response. One of the most common targets for parental anger is members of the staff. The nurse should recognize the common response of anger to the diagnosis and allow the family to ventilate. "What is really wrong?"/"Yelling at me will not change things"/"I will come back when you settle down" will place the parents on the defensive and not facilitate communication.
16. Which is the most appropriate nursing intervention to promote normalization in a school-age child with a chronic illness?
a.
Give child as much control as possible.
b.
Ask child's peer to make child feel normal.
c.
Convince child that nothing is wrong with him or her.
d.
Explain to parents that family rules for the child do not need to be the same as for healthy siblings.
a.
Give child as much control as possible.

ANS: A
The school-age child who is ill may be forced into a period of dependency. To foster normalcy, the child should be given as much control as possible. It is unrealistic to expect one individual to make the child feel normal. The child has a chronic illness. It would be unacceptable to convince the child that nothing is wrong. The family rules should be similar for each of the children in a family. Resentment and hostility can arise if different standards are applied to each child.
18. The parents of a child born with disabilities ask the nurse for advice about discipline. The nurse's response should be based on knowledge that discipline is:
a.
essential for the child.
b.
too difficult to implement with a special-needs child.
c.
not needed unless child becomes problematic.
d.
best achieved with punishment for misbehavior.
a.
essential for the child.

ANS: A
Discipline is essential for the child. It provides boundaries on which to test out their behavior and teaches them socially acceptable behaviors. The nurse should teach the parents ways to manage the child's behavior before it becomes problematic. Punishment is not effective in managing behavior.
20. A 16-year-old boy with a chronic illness has recently become rebellious and is taking risks such as missing doses of his medication. The nurse should explain to his parents that:
a.
he needs more discipline.
b.
he needs more socialization with peers.
c.
this is part of normal adolescence.
d.
this is how he is asking for more parental control.
c.
this is part of normal adolescence.

ANS: C
Risk taking, rebelliousness, and lack of cooperation are normal parts of adolescence.
21. Which term best describes a multidisciplinary approach to the management of a terminal illness that focuses on symptom control and support?
a.
Dying care
b.
Curative care
c.
Restorative care
d.
Palliative care
d.
Palliative care

ANS: D
This is one of the definitions of palliative care. The goal of palliative care is the achievement of the highest possible quality of life for patients and their families.
27. A school-age child is diagnosed with a life-threatening illness. The parents want to protect their child from knowing the seriousness of the illness. The nurse should explain that:
a.
this will help the child cope effectively by denial.
b.
this attitude is helpful to give parents time to cope.
c.
terminally ill children know when they are seriously ill.
d.
terminally ill children usually choose not to discuss the seriousness of their illness.
c.
terminally ill children know when they are seriously ill.

ANS: C
The child needs honest and accurate information about the illness, treatments, and prognosis. Children, even at a young age, realize that something is seriously wrong and that it involves them. The nurse should help the parents understand the importance of honesty.
28. A cure is no longer possible for a young child with cancer. The nursing staff recognizes that the goal of treatment must shift from cure to palliation. Which is an important consideration at this time?
a.
The family is included in the decision to shift the goals of treatment.
b.
The decision must be made by the health professionals involved in the child's care.
c.
The family needs to understand that palliative care takes place in the home.
d.
The decision should not be communicated to the family because it will encourage a sense of hopelessness.
a.
The family is included in the decision to shift the goals of treatment.

ANS: A
When the child reaches the terminal stage, the nurse and physician should explore the family's wishes. The family should help decide what interventions will occur as they plan for their child's death.
29. The nurse is caring for a child who has just died. The parents ask to be left alone so that they can rock their child one more time. The nurse's most appropriate response is to:
a.
grant their request.
b.
assess why they feel this is necessary.
c.
discourage this because it will only prolong their grief.
d.
kindly explain that they need to say good-bye to their child now and leave.
a.
grant their request.

ANS: A
The parents should be allowed to remain with their child after the death. The nurse can remove all the tubes and equipment and offer the parents the option of preparing the body.
30. The nurse is talking with the parents of a child who died 6 months ago. They sometimes still "hear" the child's voice and have trouble sleeping. They describe feeling "empty" and depressed. The nurse should recognize that:
a.
these are normal grief responses.
b.
the pain of the loss is usually less by this time.
c.
these grief responses are more typical of the early stages of grief.
d.
this grieving is essential until the pain is gone and the child is gradually forgotten.
a.
these are normal grief responses.

ANS: A
These are normal grief responses. The process of grief work is lengthy.
32. Which is an appropriate nursing intervention when providing comfort and support for a child when death is imminent?
a.
Limit care to essentials.
b.
Avoid playing music near child.
c.
Explain to child need for constant measurement of vital signs.
d.
Whisper to child instead of using normal voice.
a.
Limit care to essentials.

ANS: A
When death is imminent, care should be limited to interventions for palliative care
33. The nurse is providing support to a family who is experiencing anticipatory grief related to their child's imminent death. Which of the following is an appropriate nursing intervention?
a.
Be available to family.
b.
Attempt to "lighten the mood."
c.
Suggest activities to cheer up the family.
d.
Discourage crying until actual time of death.
a.
Be available to family.

ANS: A
One of the most important nursing interventions of death is the availability of the nurse for the family.
34. The nurse and a new nurse are caring for a child who will require palliative care. Which statement made by the new nurse would indicate a correct understanding of palliative care?
a.
"Palliative care serves to hasten death and make the process easier for the family."
b.
"Palliative care provides pain and symptom management for the child."
c.
"The goal of palliative care is to place the child in a hospice setting at the end of life."
d.
"The goal of palliative care is to act as the liaison between the family, child, and other health care professionals."
b.
"Palliative care provides pain and symptom management for the child."

ANS: B
One of the goals of palliative care is to provide pain and symptom management.
36. A nurse is planning palliative care for a child with severe pain. Which should the nurse expect to be prescribed for pain relief?
a.
Opioids as needed
b.
Opioids on a regular schedule
c.
Distraction and relaxation techniques
d.
Nonsteroidal anti-inflammatory drugs
b.
Opioids on a regular schedule

ANS: B
Pain medications, for children in palliative care, should be given on a regular schedule, and extra doses for breakthrough pain should be available to maintain comfort. Opioid drugs such as morphine should be given for severe pain, and the dose should be increased as necessary to maintain optimal pain relief. Techniques such as distraction, relaxation techniques, and guided imagery should be combined with drug therapy to provide the child and family strategies to control pain. Nonsteroidal anti-inflammatory drugs are not sufficient to manage severe pain for children in palliative care.
4. A nurse is caring for a child who is near death. Which physical signs indicate the child is approaching death? (Select all that apply.)
a.
Body feels warm
b.
Tactile sensation decreasing
c.
Speech becomes rapid
d.
Change in respiratory pattern
e.
Difficulty swallowing
b.
Tactile sensation decreasing
d.
Change in respiratory pattern
e.
Difficulty swallowing

ANS: B, D, E
Physical signs of approaching death include: tactile sensation beginning to decrease, a change in respiratory pattern, and difficulty swallowing. Even though there is a sensation of heat the body feels cool, not warm, and speech becomes slurred, not rapid.
2. When a child with mild cognitive impairment reaches the end of adolescence, which characteristic should be expected?
a.
Achieves a mental age of 5 to 6 years
b.
Achieves a mental age of 8 to 12 years
c.
Unable to progress in functional reading or arithmetic
d.
Acquires practical skills and useful reading and arithmetic to an eighth-grade level
b.
Achieves a mental age of 8 to 12 years

ANS: B
By the end of adolescence, the child with mild cognitive impairment can acquire practical skills and useful reading and arithmetic to a third- to sixth-grade level. A mental age of 8 to 12 years is obtainable, and the child can be guided toward social conformity. The achievement of a mental age of 5 to 6 years and being unable to progress in functional reading or arithmetic are characteristics of children with moderate cognitive impairment. Acquiring practical skills and useful reading and arithmetic to an eighth-grade level is not descriptive of cognitive impairment.
4. Which should be the major consideration when selecting toys for a child who is cognitively impaired?
a.
Safety
b.
Age appropriateness
c.
Ability to provide exercise
d.
Ability to teach useful skills
a.
Safety

ANS: A
Safety is the primary concern in selecting recreational and exercise activities for all children. This is especially true for children who are cognitively impaired. Age appropriateness, the ability to provide exercise, and the ability to teach useful skills should all be considered in the selection of toys, but safety is of paramount importance.
5. Appropriate interventions to facilitate socialization of the cognitively impaired child include:
a.
providing age-appropriate toys and play activities.
b.
providing peer experiences, such as scouting, when older.
c.
avoiding exposure to strangers who may not understand cognitive development.
d.
emphasizing mastery of physical skills because they are delayed more often than verbal skills.
b.
providing peer experiences, such as scouting, when older.

ANS: B
The acquisition of social skills is a complex task. Children of all ages need peer relationships. Parents should enroll the child in preschool. When older, they should have peer experiences similar to those of other children such as group outings, Boy and Girl Scouts, and Special Olympics. It is important to provide age-appropriate toys and play activities, but peer interactions will facilitate social development. Parents should expose the child to strangers so that the child can practice social skills. Verbal skills are delayed more than physical skills.
7. When caring for a newborn with Down syndrome, the nurse should be aware that the most common congenital anomaly associated with Down syndrome is:
a.
hypospadias.
b.
pyloric stenosis.
c.
congenital heart disease.
d.
congenital hip dysplasia.
c.
congenital heart disease.

ANS: C
Congenital heart malformations, primarily septal defects, are the most common congenital anomaly in Down syndrome. Hypospadias, pyloric stenosis, and congenital hip dysplasia are not frequent congenital anomalies associated with Down syndrome.
8. Mark, a 9-year-old with Down syndrome, is mainstreamed into a regular third-grade class for part of the school day. His mother asks the school nurse about programs, such as Cub Scouts, that he might join. The nurse's recommendation should be based on which statement?
a.
Programs like Cub Scouts are inappropriate for children who are mentally retarded.
b.
Children with Down syndrome have the same need for socialization as other children.
c.
Children with Down syndrome socialize better with children who have similar disabilities.
d.
Parents of children with Down syndrome encourage programs, such as scouting, because they deny that their children have disabilities.
b.
Children with Down syndrome have the same need for socialization as other children.

ANS: B
Children of all ages need peer relationships. Children with Down syndrome should have peer experiences similar to those of other children, such as group outings, Cub Scouts, and Special Olympics. Programs such as Cub Scouts can help children with cognitive impairment develop socialization skills. Although all children should have an opportunity to form a close relationship with someone of the same developmental level, it is appropriate for children with disabilities to develop relationships with children who do not have disabilities. The parents are acting as advocates for their child.
9. What is one of the major physical characteristics of the child with Down syndrome?
a.
Excessive height
b.
Spots on the palms
c.
Inflexibility of the joints
d.
Hypotonic musculature
d.
Hypotonic musculature

ANS: D
Hypotonic musculature is one of the major characteristics. Children with Down syndrome have short stature and a transverse palmar crease. Hyperflexibility is a characteristic of Down syndrome.
10. A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed nasal bridge, protruding tongue, and transverse palmar creases. These findings are most suggestive of:
a.
microcephaly.
b.
Down syndrome.
c.
cerebral palsy.
d.
fragile X syndrome.
b.
Down syndrome.

ANS: B
These are characteristics associated with Down syndrome. The 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, and/or protruding ears; long, narrow face with prominent jaw; hypotonia; and high arched palate.
11. The child with Down syndrome should be evaluated for which condition before participating in some sports?
a.
Hyperflexibility
b.
Cutis marmorata
c.
Atlantoaxial instability
d.
Speckling of iris (Brushfield spots)
c.
Atlantoaxial instability

ANS: C
Children with Down syndrome are at risk for atlantoaxial instability. Before participating in sports that put stress on the head and neck, a radiologic examination should be done. Hyperflexibility, cutis marmorata, and speckling of iris (Brushfield spots) are characteristic of Down syndrome, but they do not affect the child's ability to participate in sports.
12. Many of the physical characteristics of Down syndrome present nursing problems. Care of the child should include which intervention?
a.
Delay feeding solid foods until the tongue thrust has stopped.
b.
Modify diet as necessary to minimize the diarrhea that often occurs.
c.
Provide calories appropriate to child's age.
d.
Use a cool-mist vaporizer to keep mucous membranes moist.
d.
Use a cool-mist vaporizer to keep mucous membranes moist.

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. 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 child's weight and growth needs, not age.
13. A child has just been diagnosed with fragile X syndrome. The nurse recognizes that fragile X syndrome is:
a.
a chromosomal defect affecting females only.
b.
a chromosomal defect that follows the pattern of X-linked recessive disorders.
c.
the second most common genetic cause of mental retardation.
d.
the most common cause of noninherited mental retardation.
c.
the second most common genetic cause of mental retardation.

ANS: C
Fragile X syndrome is the second most common cause of mental retardation after Down syndrome. Fragile X primarily affects males, follows the inheritance pattern of X-linked dominant with reduced penetrance. This is in distinct contrast to the classic X-linked recessive pattern in which all carrier females are normal, all affected males have symptoms of the disorder, and no males are carriers.
31. The nurse is talking to the parent of a 13-month-old child. The mother states, "My child does not make noises like 'da' or 'na' like my sister's baby, who is only 9 months old." Which statement by the nurse would be most appropriate to make?
a.
"I am going to request a referral to a hearing specialist."
b.
"You should not compare your child to your sister's child."
c.
"I think your child is fine, but we will check again in 3 months."
d.
"You should ask other parents what noises their children made at this age."
a.
"I am going to request a referral to a hearing specialist."

ANS: A
By 11 months of age a child should be making well-formed syllables such as "da" or "na" and should be referred to a specialist if not. You should not compare your child to your sister's child, I think your child is fine, but we will check again in 3 months, and You should ask other parents what noises their children made at this age are not appropriate statements to make to the parent.
33. Parents of a child with Down syndrome ask the nurse about techniques for introducing solid food to their 8-month-old child's diet. The nurse should give the parents which priority instruction?
a.
It is too early to add solids; the parents should wait for 2 to 3 months.
b.
A small but long, straight-handled spoon should be used to push the food toward the back and side of the mouth.
c.
If the child thrusts the food out, the feeding should be stopped.
d.
Solids should be offered only three times a day.
b.
A small but long, straight-handled spoon should be used to push the food toward the back and side of the mouth.

ANS: B
Down syndrome children have a protruding tongue which can interfere with feeding, especially of solid foods. Parents need to know that the tongue thrust is not an indication of refusal to feed but a physiologic response. Parents are advised to use a small but long, straight-handled spoon to push the food toward the back and side of the mouth. If food is thrust out, it should be re-fed. Six months is the time to introduce solid foods to a child, so waiting 2 to 3 months is inappropriate. Small frequent feedings should be initiated to prevent the child from tiring. Three times a day is too infrequent.
34. A child with autism spectrum disorder (ASD) is admitted to the hospital with pneumonia. The nurse should plan which priority intervention when caring for the child?
a.
Maintain a structured routine and keep stimulation to a minimum.
b.
Place child in a room with a roommate of the same age.
c.
Maintain frequent touch and eye contact with the child.
d.
Take the child frequently to the playroom to play with other children.
a.
Maintain a structured routine and keep stimulation to a minimum.

ANS: A
Providing a structured routine for the child to follow is a key in the management of ASD. Decreasing stimulation by using a private room, avoiding extraneous auditory and visual distractions, and encouraging the parents to bring in possessions the child is attached to may lessen the disruptiveness of hospitalization. Because physical contact often upsets these children, minimum holding and eye contact may be necessary to avoid behavioral outbursts. Children with ASD need to be introduced slowly to new situations, with visits with staff caregivers kept short whenever possible. The playroom would be too overwhelming with new people and situations and should not be a priority of care.
1. Autism is a complex developmental disorder. The diagnostic criteria for autism include delayed or abnormal functioning in which areas with onset before age 3 years? (Select all that apply.)
a.
Language as used in social communication
b.
Parallel play
c.
Gross motor development
d.
Growth below the 5th percentile for height and weight
e.
Symbolic or imaginative play
f.
Social interaction
a.
Language as used in social communication
e.
Symbolic or imaginative play
f.
Social interaction

ANS: A, E, F
These are three of the areas in which autistic children may show delayed or abnormal functioning: language as used in social communication, symbolic or imaginative play, and social interaction. Parallel play is typical play of toddlers and is usually not affected. Gross motor development and growth below the 5th percentile for height and weight are usually not characteristic of autism.
2. Which assessment findings indicate to the nurse a child has Down syndrome? (Select all that apply.)
a.
High arched narrow palate
b.
Protruding tongue
c.
Long, slender fingers
d.
Transverse palmar crease
e.
Hypertonic muscle tone
a.
High arched narrow palate
b.
Protruding tongue
d.
Transverse palmar crease


ANS: A, B, D
The assessment findings of Down syndrome include high arched narrow palate, protruding tongue, and transverse palmar creases. The fingers are stubby and the muscle tone is hypotonic not hypertonic.
4. Using knowledge of child development, which is the best approach when preparing a toddler for a procedure?
a.
Avoid asking the child to make choices.
b.
Demonstrate the procedure on a doll.
c.
Plan for teaching session to last about 20 minutes.
d.
Show necessary equipment without allowing child to handle it.
b.
Demonstrate the procedure on a doll.

ANS: B
Prepare toddlers for procedures by using play. Demonstrate on a doll, but avoid the child's favorite doll because the toddler may think the doll is really "feeling" the procedure. In preparing a toddler for a procedure, allow the child to participate in care and help whenever possible. Teaching sessions for toddlers should be about 5 to 10 minutes. Use a small replica of the equipment, and allow the child to handle it.
6. The emergency department nurse is cleaning multiple facial abrasions on a 9-year-old child whose mother is present. The child is crying and screaming loudly. The nurse's action should be to:
a.
ask the child to be quieter.
b.
have the child's mother give instructions about relaxation.
c.
tell the child it is okay to cry and scream.
d.
remove the mother from the room.
c.
tell the child it is okay to cry and scream.

ANS: C
The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion. The child needs to know it is all right to cry. There is no reason for the child to be quieter and feelings need to be able to be expressed. The mother should stay in the room to provide comfort to the child.
10. A 6-year-old child is hospitalized for intravenous (IV) antibiotic therapy. He eats little on his "regular diet" trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. Which is the best nursing action?
a.
Request these favorite foods for him.
b.
Identify healthier food choices that he likes.
c.
Explain that he needs fruits and vegetables.
d.
Reward him with ice cream at end of every meal that he eats.
a.
Request these favorite foods for him.

ANS: A
Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate nutrition, favorite foods should be requested for the child. These foods provide nutrition and can be supplemented with additional fruits and vegetables. Ice cream and other desserts should not be used as rewards or punishment.
11. A 3-year-old child has a fever associated with a viral illness. Her mother calls the nurse, reporting a fever of 102° F even though she had acetaminophen 2 hours ago. The nurse's action should be based on which statement?
a.
Fevers such as this are common with viral illnesses.
b.
Seizures are common in children when antipyretics are ineffective.
c.
Fever over 102° F indicates greater severity of illness.
d.
Fever over 102° F indicates a probable bacterial infection.
a.
Fevers such as this are common with viral illnesses.

ANS: A
Most fevers are of brief duration, with limited consequences, and are viral. Little evidence supports the use of antipyretic drugs to prevent febrile seizures. Neither the increase in temperature nor its response to antipyretics indicates the severity or etiology of infection.
12. A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen (Tylenol). The nurse should explain that antipyretics:
a.
may cause malignant hyperthermia.
b.
may cause febrile seizures.
c.
are of no value in treating hyperthermia.
d.
are of limited value in treating hyperthermia.
c.
are of no value in treating hyperthermia.

ANS: C
Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already normal. Cooling measures are used instead. Malignant hyperthermia is a genetic myopathy that is triggered by anesthetic agents. Antipyretic agents do not have this effect. Antipyretics do not cause seizures and are of no value in hyperthermia.
17. A mother calls the outpatient clinic requesting information on appropriate dosing for over-the-counter medications for her 13-month-old who has symptoms of an upper respiratory tract infection and fever. The box of acetaminophen says to give 120 mg q4h when needed. At his 12-month visit, the nurse practitioner prescribed 150 mg. The nurse's best response is:
a.
"The doses are close enough; it doesn't really matter which one is given."
b.
"It is not appropriate to use dosages based on age because children have a wide range of weights at different ages."
c.
"From your description, medications are not necessary. They should be avoided in children at this age."
d.
"The nurse practitioner ordered the drug based on weight, which is a more accurate way of determining a therapeutic dose."
d.
"The nurse practitioner ordered the drug based on weight, which is a more accurate way of determining a therapeutic dose."

ANS: D
The method most often used to determine children's dosage is based on a specific dose per kilogram of body weight. The mother should be given correct information. For a therapeutic effect, the dosage should be based on weight, not age. Acetaminophen can be used to relieve discomfort in children at this age group.
18. An 8-month-old infant is restrained to prevent interference with the IV infusion. The nurse's action is to:
a.
remove the restraints once a day to allow movement.
b.
keep the restraints on constantly.
c.
keep the restraints secure so infant remains supine.
d.
remove restraints whenever possible.
d.
remove restraints whenever possible.

ANS: D
The nurse should remove the restraints whenever possible. When parents or staff are present, the restraints can be removed and the IV site protected. Restraints must be checked and documented every 1 to 2 hours. They should be removed for range of motion on a periodic basis. The child should not be securely restrained in the supine position because of risks of aspiration.
20. A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, the nurse's best action is to:
a.
prepare child for conscious sedation during the test.
b.
set up a tray with equipment the same size as for adults.
c.
reassure the parents that the test is simple, painless, and risk free.
d.
apply EMLA to puncture site 15 minutes before procedure.
a.
prepare child for conscious sedation during the test.

ANS: A
Because of the urgency of the child's condition, conscious sedation should be used for the procedure. Pediatric spinal trays have smaller needles than do adult trays. Reassuring the parents that the test is simple, painless, and risk free is incorrect information. A spinal tap does have associated risks, and analgesia will be given for the pain. EMLA (a eutectic mixture of anesthetics) should be applied approximately 60 minutes before the procedure. The emergency nature of the spinal tap precludes its use.
21. Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant. Which is the most appropriate way to collect small amounts of urine for these tests?
a.
Apply a urine-collection bag to perineal area.
b.
Tape a small medicine cup to inside of diaper.
c.
Aspirate urine from cotton balls inside diaper with a syringe.
d.
Aspirate urine from superabsorbent disposable diaper with a syringe.
c.
Aspirate urine from cotton balls inside diaper with a syringe.

ANS: C
To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. If diapers with absorbent material are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine, and aspirate the urine with a syringe. For frequent urine sampling, the collection bag would be too irritating to the child's skin. It is not feasible to tape a small medicine cup to inside of diaper; the urine will spill from the cup. Diapers with superabsorbent gels absorb the urine, so there is nothing to aspirate.
23. The Allen test is performed as a precautionary measure before which procedure?
a.
Heel stick
b.
Venipuncture
c.
Arterial puncture
d.
Lumbar puncture
c.
Arterial puncture

ANS: C
The Allen test assesses the circulation of the radial, ulnar, or brachial arteries before arterial puncture. The Allen test is used before arterial punctures, not heel sticks, venipunctures, or lumbar punctures.
28. When liquid medication is given to a crying 10-month-old infant, which approach minimizes the possibility of aspiration?
a.
Administer the medication with a syringe (without needle) placed along the side of the infant's tongue.
b.
Administer the medication as rapidly as possible with the infant securely restrained.
c.
Mix the medication with the infant's regular formula or juice and administer by bottle.
d.
Keep the child upright with the nasal passages blocked for a minute after administration.
a.
Administer the medication with a syringe (without needle) placed along the side of the infant's tongue.

ANS: A
Administer the medication with a syringe without needle placed along the side of the infant's tongue. The contents are administered slowly in small amounts, allowing the child to swallow between deposits. Medications should be given slowly to avoid aspiration. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking or eating, it is difficult to determine how much medication was consumed. Essential foods also should not be used. Holding the child's nasal passages will increase the risk of aspiration
29. Which is the preferred site for intramuscular injections in infants?
a.
Deltoid
b.
Dorsogluteal
c.
Rectus femoris
d.
Vastus lateralis
d.
Vastus lateralis

ANS: D
The preferred site for infants is the vastus lateralis. The deltoid and dorsogluteal sites are used for older children and adults. The rectus femoris is not a recommended site.
30. Guidelines for intramuscular administration of medication in school-age children include which action?
a.
Inject medication as rapidly as possible.
b.
Insert needle quickly, using a dartlike motion.
c.
Penetrate skin immediately after cleansing site, before skin has dried.
d.
Have child stand, if possible, and if child is cooperative.
b.
Insert needle quickly, using a dartlike motion.

ANS: B
The needle should be inserted quickly in a dartlike motion at a 90-degree angle unless contraindicated. Inject medications slowly. Allow skin preparation to dry completely before skin is penetrated. Place child in lying or sitting position.
31. Several types of long-term central venous access devices are used. Which is considered an advantage of a Hickman-Broviac catheter?
a.
No need to keep exit site dry
b.
Easy to use for self-administered infusions
c.
Heparinized only monthly and after each infusion
d.
No limitations on regular physical activity, including swimming
b.
Easy to use for self-administered infusions

ANS: B
The Hickman-Broviac catheter has several benefits, including that it is easy to use for self-administered infusions. The exit site must be kept dry to decrease risk of infection. The Hickman-Broviac catheter requires daily heparin flushes. Water sports may be restricted because of risk of infection.
32. When teaching a mother how to administer eye drops, where should the nurse tell her to place them?
a.
In the conjunctival sac that is formed when the lower lid is pulled down
b.
Carefully under the eye lid while it is gently pulled upward
c.
On the sclera while the child looks to the side
d.
Anywhere as long as drops contact the eye's surface
a.
In the conjunctival sac that is formed when the lower lid is pulled down

ANS: A
The lower lid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area. The medication should not be administered directly on the eyeball.
33. A 2-year-old child comes to the emergency department with dehydration and hypovolemic shock. Which best explains why an intraosseous infusion is started?
a.
It is less painful for small children.
b.
Rapid venous access is not possible.
c.
Antibiotics must be started immediately.
d.
Long-term central venous access is not possible.
b.
Rapid venous access is not possible.

ANS: B
In situations in which rapid establishment of systemic access is vital and venous access is hampered, such as peripheral circulatory collapse and hypovolemic shock, intraosseous infusion provides a rapid, safe, lifesaving alternative. The procedure is painful, and local anesthetics and systemic analgesics are given. Antibiotics could be given when vascular access is obtained. Long-term central venous access is time-consuming, and intraosseous infusion is used in an emergency situation.
37. The nurse is teaching a mother how to perform chest physical therapy and postural drainage on her 3-year-old child, who has cystic fibrosis. To perform percussion, the nurse should instruct her to:
a.
cover the skin with a shirt or gown before percussing.
b.
strike the chest wall with a flat-hand position.
c.
percuss over the entire trunk anteriorly and posteriorly.
d.
percuss before positioning for postural drainage.
a.
cover the skin with a shirt or gown before percussing.

ANS: A
For postural drainage and percussion, the child should be dressed in a light shirt to protect the skin and placed in the appropriate postural drainage positions. The chest wall is struck with a cupped-hand, not a flat-hand position. The procedure should be done over the rib cage only. Positioning precedes the percussion.
40. A child is receiving total parenteral nutrition (TPN; hyperalimentation). At the end of 8 hours, the nurse observes the solution and notes that 200 ml/8 hr is being infused rather than the ordered amount of 300 ml/8 hr. The nurse should adjust the rate so that how much will infuse during the next 8 hours?
a.
200 ml
b.
300 ml
c.
350 ml
d.
400 ml
b.
300 ml

ANS: B
The TPN infusion rate should not be increased or decreased without the practitioner being informed because alterations in rate can cause hyperglycemia or hypoglycemia. Any changes from the prescribed flow rate may lead to hyperglycemia or hypoglycemia.
1. The nurse is teaching nursing students about normal physiologic changes in the respiratory system of toddlers. Which best describes why toddlers have fewer respiratory tract infections as they grow older?
a.
The amount of lymphoid tissue decreases.
b.
Repeated exposure to organisms causes increased immunity.
c.
Viral organisms are less prevalent in the population.
d.
Secondary infections rarely occur after viral illnesses.
b.
Repeated exposure to organisms causes increased immunity.

ANS: B
Children have increased immunity after exposure to a virus. The amount of lymphoid tissue increases as children grow older. Viral organisms are not less prevalent, but older children have the ability to resist invading organisms. Secondary infections after viral illnesses include Mycoplasma pneumoniae and group A β-hemolytic streptococcal infections.
2. A nurse is charting that a hospitalized child has labored breathing. Which describes labored breathing?
a.
Dyspnea
b.
Tachypnea
c.
Hypopnea
d.
Orthopnea
a.
Dyspnea

ANS: A
Dyspnea is labored breathing. Tachypnea is rapid breathing. Hypopnea is breathing that is too shallow. Orthopnea is difficulty breathing except in upright position.
3. Which explains why cool-mist vaporizers rather than steam vaporizers are recommended in home treatment of childhood respiratory tract infections?
a.
They are safer.
b.
They are less expensive.
c.
Respiratory secretions are dried.
d.
A more comfortable environment is produced.
a.
They are safer.

ANS: A
Cool-mist vaporizers are safer than steam vaporizers, and little evidence exists to show any advantages to steam. The cost of cool-mist and steam vaporizers is comparable. Steam loosens secretions, not dries them. Both may promote a more comfortable environment, but cool-mist vaporizers present decreased risk for burns and growth of organisms.
4. Decongestant nose drops are recommended for a 10-month-old infant with an upper respiratory tract infection. Instructions for nose drops should include which action?
a.
Avoid using for more than 3 days.
b.
Keep drops to use again for nasal congestion.
c.
Administer drops until nasal congestion subsides.
d.
Administer drops after feedings and at bedtime.
a.
Avoid using for more than 3 days.

ANS: A
Vasoconstrictive nose drops such as phenylephrine (Neo-Synephrine) should not be used for more than 3 days to avoid rebound congestion. Drops should be discarded after one illness because they may become contaminated with bacteria. Vasoconstrictive nose drops can have a rebound effect after 3 days of use. Drops administered before feedings are more helpful.
5. Which is an appropriate nursing intervention when caring for an infant with an upper respiratory tract infection and elevated temperature?
a.
Give tepid water baths to reduce fever.
b.
Encourage food intake to maintain caloric needs.
c.
Have child wear heavy clothing to prevent chilling.
d.
Give small amounts of favorite fluids frequently to prevent dehydration.
d.
Give small amounts of favorite fluids frequently to prevent dehydration.

ANS: D
Preventing dehydration by small frequent feedings is an important intervention in the febrile child. Tepid water baths may induce shivering, which raises temperature. Food should not be forced; it may result in the child vomiting. The febrile child should be dressed in light, loose clothing.
6. The parent of an infant with nasopharyngitis should be instructed to notify the health professional if the infant displays which clinical manifestation?
a.
Fussiness
b.
Coughing
c.
A fever over 99° F
d.
Signs of an earache
d.
Signs of an earache

ANS: D
If an infant with nasopharyngitis shows signs of an earache, it may mean a secondary bacterial infection is present and the infant should be referred to a practitioner for evaluation. Irritability is common in an infant with a viral illness. Cough can be a sign of nasopharyngitis. Fever is common in viral illnesses.
7. It is generally recommended that a child with acute streptococcal pharyngitis can return to school:
a.
when sore throat is better.
b.
if no complications develop.
c.
after taking antibiotics for 24 hours.
d.
after taking antibiotics for 3 days.
c.
after taking antibiotics for 24 hours.

ANS: C
After children have taken antibiotics for 24 hours, they are no longer contagious to other children. Sore throat may persist longer than 24 hours after beginning antibiotic therapy, but the child is no longer considered contagious. Complications may take days to weeks to develop.
8. A child is diagnosed with influenza, probably type A disease. Management includes which recommendation?
a.
Clear liquid diet for hydration
b.
Aspirin to control fever
c.
Amantadine hydrochloride (Symmetrel) to reduce symptoms
d.
Antibiotics to prevent bacterial infection
c.
Amantadine hydrochloride (Symmetrel) to reduce symptoms

ANS: C
Amantadine hydrochloride may reduce symptoms related to influenza A if administered within 24 to 48 hours of onset. It is ineffective against type B or C. A clear liquid diet is not necessary for influenza, but maintaining hydration is important. Aspirin is not recommended in children because of increased risk of Reye syndrome. Acetaminophen or ibuprofen is a better choice. Preventive antibiotics are not indicated for influenza unless there is evidence of a secondary bacterial infection.
9. Chronic otitis media with effusion (OME) is differentiated from acute otitis media (AOM) because it is usually characterized by:
a.
a fever as high as 40° C (104° F).
b.
severe pain in the ear.
c.
nausea and vomiting.
d.
a feeling of fullness in the ear.
d.
a feeling of fullness in the ear.

ANS: D
OME is characterized by feeling of fullness in the ear or other nonspecific complaints. Fever is a sign of AOM. OME does not cause severe pain. This may be a sign of AOM. Nausea and vomiting are associated with otitis media.
10. Parents have understood teaching about prevention of childhood otitis media if they make which statement?
a.
"We will only prop the bottle during the daytime feedings."
b.
"Breastfeeding will be discontinued after 4 months of age."
c.
"We will place the child flat right after feedings."
d.
"We will be sure to keep immunizations up to date."
d.
"We will be sure to keep immunizations up to date."

ANS: D
Parents have understood the teaching about preventing childhood otitis media if they respond they will keep childhood immunizations up to date. The child should be maintained upright during feedings and after. Otitis media can be prevented by exclusively breastfeeding until at least 6 months of age. Propping bottles is discouraged to avoid pooling of milk while the child is in the supine position.
11. An 18-month-old child is seen in the clinic with AOM. Trimethoprim-sulfamethoxazole (Bactrim) is prescribed. Which statement made by the parent indicates a correct understanding of the instructions?
a.
"I should administer all the prescribed medication."
b.
"I should continue medication until the symptoms subside."
c.
"I will immediately stop giving medication if I notice a change in hearing."
d.
"I will stop giving medication if fever is still present in 24 hours."
a.
"I should administer all the prescribed medication."

ANS: A
Antibiotics should be given for their full course to prevent recurrence of infection with resistant bacteria. Symptoms may subside before the full course is given. Hearing loss is a complication of AOM. Antibiotics should continue to be given. Medication may take 24 to 48 hours to make symptoms subside. It should be continued.
12. An infant's parents ask the nurse about preventing OM. Which should be recommended?
a.
Avoid tobacco smoke.
b.
Use nasal decongestant.
c.
Avoid children with OM.
d.
Bottle-feed or breastfeed in supine position.
a.
Avoid tobacco smoke.

ANS: A
Eliminating tobacco smoke from the child's environment is essential for preventing OM and other common childhood illnesses. Nasal decongestants are not useful in preventing OM. Children with uncomplicated OM are not contagious unless they show other upper respiratory tract infection (URI) symptoms. Children should be fed in an upright position to prevent OM.
13. The nurse is assessing a child with acute epiglottitis. Examining the child's throat by using a tongue depressor might precipitate which symptom or condition?
a.
Inspiratory stridor
b.
Complete obstruction
c.
Sore throat
d.
Respiratory tract infection
b.
Complete obstruction

ANS: B
If a child has acute epiglottitis, examination of the throat may cause complete obstruction and should be performed only when immediate intubation can take place. Stridor is aggravated when a child with epiglottitis is supine. Sore throat and pain on swallowing are early signs of epiglottitis. Epiglottitis is caused by H. influenzae in the respiratory tract.
14. Which type of croup is always considered a medical emergency?
a.
Laryngitis
b.
Epiglottitis
c.
Spasmodic croup
d.
Laryngotracheobronchitis (LTB)
b.
Epiglottitis

ANS: B
Epiglottitis is always a medical emergency needing antibiotics and airway support for treatment. Laryngitis is a common viral illness in older children and adolescents, with hoarseness and URI symptoms. Spasmodic croup is treated with humidity. LTB may progress to a medical emergency in some children.
15. The nurse encourages the mother of a toddler with acute laryngotracheobronchitis (LTB) to stay at the bedside as much as possible. The nurse's rationale for this action is described primarily in which statement?
a.
Mothers of hospitalized toddlers often experience guilt.
b.
The mother's presence will reduce anxiety and ease child's respiratory efforts.
c.
Separation from mother is a major developmental threat at this age.
d.
The mother can provide constant observations of the child's respiratory efforts.
b.
The mother's presence will reduce anxiety and ease child's respiratory efforts.

ANS: B
The family's presence will decrease the child's distress. It is true that mothers of hospitalized toddlers often experience guilt but this is not the best answer. The main reason to keep parents at the child's bedside is to ease anxiety and therefore respiratory effort. The child should have constant monitoring by cardiorespiratory monitor and noninvasive oxygen saturation monitoring, but the parent should not play this role in the hospital.
16. A school-age child had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. The cough has become productive in the past 24 hours. This is most suggestive of which diagnosis?
a.
Bronchitis
b.
Bronchiolitis
c.
Viral-induced asthma
d.
Acute spasmodic laryngitis
a.
Bronchitis

ANS: A
Bronchitis is characterized by these symptoms and occurs in children older than 6 years. Bronchiolitis is rare in children older than 2 years. Asthma is a chronic inflammation of the airways that may be exacerbated by a virus. Acute spasmodic laryngitis occurs in children between 3 months and 3 years.
17. Which frequency is recommended for childhood skin testing for tuberculosis (TB) using the Mantoux test?
a.
Every year for all children older than 2 years
b.
Every year for all children older than 10 years
c.
Every 2 years for all children starting at age 1 year
d.
Periodically for children who reside in high-prevalence regions
d.
Periodically for children who reside in high-prevalence regions

ANS: D
Children who reside in high-prevalence regions for TB should be tested every 2 to 3 years. Annual testing is not necessary. Testing is not necessary unless exposure is likely or an underlying medical risk factor is present.
18. Which consideration is the most important in managing tuberculosis (TB) in children?
a.
Skin testing annually
b.
Pharmacotherapy
c.
Adequate nutrition
d.
Adequate hydration
b.
Pharmacotherapy

ANS: B
Drug therapy for TB includes isoniazid, rifampin, and pyrazinamide daily for 2 months and two or three times a week for the remaining 4 months. Pharmacotherapy is the most important intervention for TB.
19. The mother of a toddler yells to the nurse, "Help! He is choking to death on his food." The nurse determines that lifesaving measures are necessary based on which symptom?
a.
Gagging
b.
Coughing
c.
Pulse over 100 beats/min
d.
Inability to speak
d.
Inability to speak

ANS: D
The inability to speak is indicative of a foreign-body airway obstruction of the larynx. Abdominal thrusts are needed for treatment of the choking child. Gagging indicates irritation at the back of the throat, not obstruction. Coughing does not indicate a complete airway obstruction. Tachycardia may be present for many reasons.
20. The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. Nursing actions should include:
a.
forcing fluids.
b.
monitoring pulse oximetry.
c.
instituting seizure precautions.
d.
encouraging a high-protein diet.
b.
monitoring pulse oximetry.

ANS: B
Monitoring cardiopulmonary status is an important evaluation tool in the care of the child with ARDS. Maintenance of vascular volume and hydration is important and should be done parenterally. Seizures are not a side effect of ARDS. Adequate nutrition is necessary, but a high-protein diet is not helpful.
21. The nurse is caring for a child with carbon monoxide poisoning associated with smoke inhalation. Which is essential in this child's care?
a.
Monitor pulse oximetry.
b.
Monitor arterial blood gases.
c.
Administer oxygen if respiratory distress develops.
d.
Administer oxygen if child's lips become bright, cherry red.
b.
Monitor arterial blood gases.

ANS: B
Arterial blood gases are the best way to monitor carbon monoxide poisoning. Pulse oximetry is contraindicated in the case of carbon monoxide poisoning because the PaO2 may be normal. The child should receive 100% oxygen as quickly as possible, not only if respiratory distress or other symptoms develop.
22. A nurse is admitting an infant with asthma. The nurse understands that asthma in infants is usually triggered by:
a.
medications.
b.
a viral infection.
c.
exposure to cold air.
d.
allergy to dust or dust mites.
b.
a viral infection.

ANS: B
Viral illnesses cause inflammation that causes increased airway reactivity in asthma. Medications such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and antibiotics may aggravate asthma, but not frequently in infants. Exposure to cold air may exacerbate already existing asthma. Allergy is associated with asthma, but 20% to 40% of children with asthma have no evidence of allergic disease.
23. A nurse is conducting an in-service on asthma. Which statement is the most descriptive of bronchial asthma?
a.
There is heightened airway reactivity.
b.
There is decreased resistance in the airway.
c.
The single cause of asthma is an allergic hypersensitivity.
d.
It is inherited.
a.
There is heightened airway reactivity.

ANS: A
In bronchial asthma, spasm of the smooth muscle of the bronchi and bronchioles causes constriction, producing impaired respiratory function. In bronchial asthma, there is increased resistance in the airway. There are multiple causes of asthma, including allergens, irritants, exercise, cold air, infections, medications, medical conditions, and endocrine factors. Atopy or development of an immunoglobulin E (IgE)-mediated response is inherited but is not the only cause of asthma.
24. A child is admitted to the hospital with asthma. Which assessment findings support this diagnosis?
a.
Nonproductive cough, wheezing
b.
Fever, general malaise
c.
Productive cough, rales
d.
Stridor, substernal retractions
a.
Nonproductive cough, wheezing

ANS: A
Asthma presents with a nonproductive cough and wheezing. Pneumonia appears with an acute onset, fever, and general malaise. A productive cough and rales would be indicative of pneumonia. Stridor and substernal retractions are indicative of croup.
25. It is now recommended that children with asthma who are taking long-term inhaled steroids should be assessed frequently because which disease or assessment findings may develop?
a.
Cough
b.
Osteoporosis
c.
Slowed growth
d.
Cushing syndrome
c.
Slowed growth

ANS: C
The growth of children on long-term inhaled steroids should be assessed frequently to assess for systemic effects of these drugs. Cough is prevented by inhaled steroids. No evidence exists that inhaled steroids cause osteoporosis. Cushing syndrome is caused by long-term systemic steroids.
26. β-Adrenergic agonists and methylxanthines are often prescribed for a child with an asthma attack. Which describes their action?
a.
Liquefy secretions.
b.
Dilate the bronchioles.
c.
Reduce inflammation of the lungs.
d.
Reduce infection.
b.
Dilate the bronchioles.

ANS: B
β-Adrenergic agonists and methylxanthines work to dilate the bronchioles in acute exacerbations. These medications do not liquefy secretions or reduce infection. Corticosteroids and mast cell stabilizers reduce inflammation in the lungs.
27. Parents of two school-age children with asthma ask the nurse, "What sports can our children participate in?" The nurse should recommend which sport?
a.
Soccer
b.
Running
c.
Swimming
d.
Basketball
c.
Swimming

ANS: C
Swimming is well tolerated in children with asthma because they are breathing air fully saturated with moisture and because of the type of breathing required in swimming. Exercise-induced bronchospasm is more common in sports that involve endurance, such as soccer. Prophylaxis with medications may be necessary.
28. Which drug is usually given first in the emergency treatment of an acute, severe asthma episode in a young child?
a.
Ephedrine
b.
Theophylline
c.
Aminophylline
d.
Short-acting β2 agonists
d.
Short-acting β2 agonists

ANS: D
Short-acting β2 agonists are the first treatment in an acute asthma exacerbation. Ephedrine is not helpful in acute asthma exacerbations. Theophylline is unnecessary for treating asthma exacerbations. Aminophylline is not helpful for acute asthma exacerbation.
29. Parents of a child with cystic fibrosis ask the nurse about genetic implications of the disorder. Which statement, made by the nurse, expresses accurately the genetic implications?
a.
If it is present in a child, both parents are carriers of this defective gene.
b.
It is inherited as an autosomal dominant trait.
c.
It is a genetic defect found primarily in non-Caucasian population groups.
d.
There is a 50% chance that siblings of an affected child also will be affected.
a.
If it is present in a child, both parents are carriers of this defective gene.

ANS: A
CF is an autosomal recessive gene inherited from both parents and is inherited as an autosomal recessive, not autosomal dominant, trait. CF is found primarily in Caucasian populations. An autosomal recessive inheritance pattern means that there is a 25% chance a sibling will be infected but a 50% chance a sibling will be a carrier.
30. A nurse is teaching nursing students about clinical manifestations of cystic fibrosis (CF). Which is/are the earliest recognizable clinical manifestation(s) of CF?
a.
Meconium ileus
b.
History of poor intestinal absorption
c.
Foul-smelling, frothy, greasy stools
d.
Recurrent pneumonia and lung infections
a.
Meconium ileus

ANS: A
The earliest clinical manifestation of CF is a meconium ileus, which is found in about 10% of children with CF. Clinical manifestations include abdominal distention, vomiting, failure to pass stools, and rapid development of dehydration. History of malabsorption is a later sign that manifests as failure to thrive. Foul-smelling stools are a later manifestation of CF. Recurrent respiratory tract infections are a later sign of CF.
31. A child is being admitted to the hospital to be tested for cystic fibrosis (CF). Which tests should the nurse expect?
a.
Sweat chloride test, stool for fat, chest radiograph films
b.
Stool test for fat, gastric contents for hydrochloride, chest radiograph films
c.
Sweat chloride test, bronchoscopy, duodenal fluid analysis
d.
Sweat chloride test, stool for trypsin, biopsy of intestinal mucosa
a.
Sweat chloride test, stool for fat, chest radiograph films

ANS: A
A sweat test result of greater than 60 mEq/L is diagnostic of CF, a high level of fecal fat is a gastrointestinal (GI) manifestation of CF, and a chest radiograph showing patchy atelectasis and obstructive emphysema indicates CF. Gastric contents contain hydrochloride normally; it is not diagnostic. Bronchoscopy and duodenal fluid are not diagnostic. Stool test for trypsin and intestinal biopsy are not helpful in diagnosing CF.
32. Cystic fibrosis (CF) is suspected in a toddler. Which test is essential in establishing this diagnosis?
a.
Bronchoscopy
b.
Serum calcium
c.
Urine creatinine
d.
Sweat chloride test
d.
Sweat chloride test

ANS: D
A sweat chloride test result greater than 60 mEq/L is diagnostic of CF. Bronchoscopy, although helpful for identifying bacterial infection in children with CF, is not diagnostic. Serum calcium is normal in children with CF. Urine creatinine is not diagnostic of CF.
33. A child with cystic fibrosis (CF) receives aerosolized bronchodilator medication. When should this medication be administered?
a.
Before chest physiotherapy (CPT)
b.
After CPT
c.
Before receiving 100% oxygen
d.
After receiving 100% oxygen
a.
Before chest physiotherapy (CPT)

ANS: A
Bronchodilators should be given before CPT to open bronchi and make expectoration easier. Aerosolized bronchodilator medications are not helpful when used after CPT. Oxygen administration is necessary only in acute episodes with caution because of chronic carbon dioxide retention.
34. A child with cystic fibrosis (CF) is receiving recombinant human deoxyribonuclease (DNase). Which is an adverse effect of this medication?
a.
Mucus thickens
b.
Voice alters
c.
Tachycardia
d.
Jitteriness
b.
Voice alters

ANS: B
One of the only adverse effects of DNase is voice alterations and laryngitis. DNase decreases viscosity of mucus, is given in an aerosolized form, and is safe for children younger than 12 years. β2 agonists can cause tachycardia and jitteriness.
35. Pancreatic enzymes are administered to the child with cystic fibrosis (CF). Nursing considerations should include to:
a.
not administer pancreatic enzymes if child is receiving antibiotics.
b.
decrease dose of pancreatic enzymes if child is having frequent, bulky stools.
c.
administer pancreatic enzymes between meals if at all possible.
d.
pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.
d.
pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.

ANS: D
Enzymes may be administered in a small amount of cereal or fruit at the beginning of a meal or swallowed whole. Pancreatic enzymes are not a contraindication for antibiotics. The dosage of enzymes should be increased if child is having frequent, bulky stools. Enzymes should be given just before meals and snacks.
36. In providing nourishment for a child with cystic fibrosis (CF), which factor should the nurse keep in mind?
a.
Diet should be high in carbohydrates and protein.
b.
Diet should be high in easily digested carbohydrates and fats.
c.
Most fruits and vegetables are not well tolerated.
d.
Fats and proteins must be greatly curtailed.
a.
Diet should be high in carbohydrates and protein.

ANS: A
Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired intestinal absorption. Enzyme supplementation helps digest foods; other modifications are not necessary. A well-balanced diet containing fruits and vegetables is important. Fats and proteins are a necessary part of a well-balanced diet.
40. The Heimlich maneuver is recommended for airway obstruction in children older than _____ year(s).
a.
1
b.
4
c.
8
d.
12
a.
1

ANS: A
The Heimlich maneuver is recommended for airway obstruction in children older than 1 year. Younger than 1 year, back blows and chest thrusts are administered. The Heimlich maneuver can be used in children older than 1 year.
41. A nurse is caring for a child in acute respiratory failure. Which blood gas analysis indicates the child is still in respiratory acidosis?
a.
pH 7.50, CO2 48
b.
pH 7.30, CO2 30
c.
pH 7.32, CO2 50
d.
pH 7.48, CO2 33
c.
pH 7.32, CO2 50

ANS: C
Respiratory failure is a process that involves pulmonary dysfunction generally resulting in impaired alveolar gas exchange, which can lead to hypoxemia or hypercapnia. Acidosis indicates the pH is less than 7.35 and the CO2 is greater than 45. If the pH is less than 7.35 but the CO2 is low, it is metabolic acidosis. Alkalosis is when the pH is greater than 7.45. If the pH is high and the CO2 is high, it is metabolic alkalosis. When the pH is high and the CO2 is low, it is respiratory alkalosis.
43. A school-age child has been admitted with an acute asthma episode. The child is receiving oxygen by nasal prongs at 2 liters. How often should the nurse plan to monitor the child's pulse oximetry status?
a.
Continuous
b.
Every 30 minutes
c.
Every hour
d.
Every 2 hours
a.
Continuous

ANS: A
The child on supplemental oxygen requires intermittent or continuous oxygenation monitoring, depending on severity of respiratory compromise and initial oxygenation status. The child in status asthmaticus should be placed on continuous cardiorespiratory (including blood pressure) and pulse oximetry monitoring.
44. A nurse is interpreting the results of a tuberculin skin test (TST) on an adolescent who is HIV positive. Which induration size indicates a positive result for this child 48-72 hours after the test?
a.
5 mm
b.
10 mm
c.
15 mm
d.
20 mm
a.
5 mm

ANS: A
Clinical evidence of a positive TST in children receiving immunosuppressive therapy, including immunosuppressive doses of steroids or who have immunosuppressive conditions, including HIV infection is an induration of 5 mm. Children younger than 4 years of age with: (a) other medical risk conditions, including Hodgkin disease, lymphoma, diabetes mellitus, chronic renal failure, or malnutrition; (b) born or whose parents were born in high-prevalence (TB) regions of the world; (c) frequently exposed to adults who are HIV infected, homeless, users of illicit drugs, residents of nursing homes, incarcerated or institutionalized, or migrant farm workers; and (d) who travel to high-prevalence (TB) regions of the world are positive when the induration is 10 mm. Children 4 years of age or older without any risk factors are positive when the induration is 20 mm.
1. An infant has developed staphylococcal pneumonia. Nursing care of the child with pneumonia includes which interventions? (Select all that apply.)
a.
Cluster care to conserve energy
b.
Round-the-clock administration of antitussive agents
c.
Strict intake and output to avoid congestive heart failure
d.
Administration of antibiotics
a.
Cluster care to conserve energy
d.
Administration of antibiotics

ANS: A, D
Antibiotics are indicated for a bacterial pneumonia. Often the child will have decreased pulmonary reserve, and the clustering of care is essential. Antitussive agents are used sparingly. It is desirable for the child to cough up some of the secretions. Fluids are essential to kept secretions as liquefied as possible.
2. The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which intervention should be included in the child's care? (Select all that apply.)
a.
Place in a mist tent.
b.
Administer antibiotics.
c.
Administer cough syrup.
d.
Encourage to drink 8 ounces of formula every 4 hours.
e.
Cluster care to encourage adequate rest.
f.
Place on noninvasive oxygen monitoring.
d.
Encourage to drink 8 ounces of formula every 4 hours.
e.
Cluster care to encourage adequate rest.
f.
Place on noninvasive oxygen monitoring.

ANS: D, E, F
Hydration is important in children with RSV bronchiolitis to loosen secretions and prevent shock. Clustering of care promotes periods of rest. The use of noninvasive oxygen monitoring is recommended. Mist tents are no longer used. Antibiotics do not treat illnesses with viral causes. Cough syrup suppresses clearing of respiratory secretions and is not indicated for young children.
1. Which condition in a child should alert a nurse for increased fluid requirements?
a.
Fever
b.
Mechanical ventilation
c.
Congestive heart failure
d.
Increased intracranial pressure (ICP)
a.
Fever

ANS: A
Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid overload in children. Increased ICP does not lead to increased fluid requirements in children.
3. Which type of dehydration is defined as "dehydration that occurs in conditions in which electrolyte and water deficits are present in approximately balanced proportion"?
a.
Isotonic dehydration
b.
Hypotonic dehydration
c.
Hypertonic dehydration
d.
All types of dehydration in infants and small children
a.
Isotonic dehydration

ANS: A
Isotonic dehydration is the correct term for this definition and is the most frequent form of dehydration in children. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. Hypertonic dehydration results from water loss in excess of electrolyte loss and is usually caused by a proportionately larger loss of water or a larger intake of electrolytes. This definition is specific to isotonic dehydration.
4. A nurse is admitting an infant with dehydration caused from water loss in excess of electrolyte loss. Which type of dehydration is this infant experiencing?
a.
Isotonic
b.
Isosmotic
c.
Hypotonic
d.
Hypertonic
d.
Hypertonic

ANS: D
Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion and is another term for isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic.
5. An infant is brought to the emergency department with dehydration. Which physical assessment finding does the nurse expect?
a.
Weight gain
b.
Bradycardia
c.
Poor skin turgor
d.
Brisk capillary refill
c.
Poor skin turgor

ANS: C
Clinical manifestations of dehydration include poor skin turgor, weight loss, lethargy, and tachycardia. The infant would have prolonged capillary refill, not brisk.
6. Parents call the clinic and report that their toddler has had acute diarrhea for 24 hours. The nurse should further ask the parents if the toddler has which associated factor that is causing the acute diarrhea?
a.
Celiac disease
b.
Antibiotic therapy
c.
Immunodeficiency
d.
Protein malnutrition
b.
Antibiotic therapy

ANS: B
Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy. Celiac disease is a problem with gluten intolerance and may cause chronic diarrhea if not identified and managed appropriately. Immunodeficiency would occur with chronic diarrhea. Protein malnutrition or kwashiorkor causes chronic diarrhea from lowered resistance to infection.
7. Which pathogen is the viral pathogen that frequently causes acute diarrhea in young children?
a.
Giardia organisms
b.
Shigella organisms
c.
Rotavirus
d.
Salmonella organisms
c.
Rotavirus

ANS: C
Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia (parasite) and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial pathogen that is uncommon in the United States.
8. Which is a parasite that causes acute diarrhea?
a.
Shigella organisms
b.
Salmonella organisms
c.
Giardia lamblia
d.
Escherichia coli
c.
Giardia lamblia

ANS: C
G. lamblia is a parasite that represents 10% of non-dysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens.
10. Which therapeutic management should the nurse prepare to initiate first for a child with acute diarrhea and moderate dehydration?
a.
Clear liquids
b.
Adsorbents, such as kaolin and pectin
c.
Oral rehydration solution (ORS)
d.
Antidiarrheal medications such as paregoric
c.
Oral rehydration solution (ORS)

ANS: C
ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended. Antidiarrheals are not recommended because they do not get rid of pathogens.
11. A school-age child with diarrhea has been rehydrated. The nurse is discussing the child's diet with the family. Which statement by the parent would indicate a correct understanding of the teaching?
a.
"I will keep my child on a clear liquid diet for the next 24 hours."
b.
"I should encourage my child to drink carbonated drinks but avoid food for the next 24 hours."
c.
"I will offer my child bananas, rice, applesauce, and toast for the next 48 hours."
d.
"I should have my child eat a normal diet with easily digested foods for the next 48 hours."
d.
"I should have my child eat a normal diet with easily digested foods for the next 48 hours."

ANS: D
Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness. Clear liquids and carbonated drinks have high carbohydrate content and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. The BRAT diet has little nutritional value and is high in carbohydrates.
12. A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child should begin with:
a.
intravenous (IV) fluids.
b.
ORS.
c.
clear liquids, 1 to 2 ounces at a time.
d.
administration of antidiarrheal medication.
a.
intravenous (IV) fluids.

ANS: A
In children with severe dehydration, IV fluids are initiated. ORS is acceptable therapy if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth. These fluids have a high carbohydrate content, low electrolyte content, and high osmolality. Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea.
15. Which is a high-fiber food that the nurse should recommend for a child with chronic constipation?
a.
Popcorn
b.
Pancakes
c.
Muffins
d.
Ripe bananas
a.
Popcorn

ANS: A
Popcorn is a high-fiber food. Pancakes and muffins do not have significant fiber unless made with fruit or bran. Raw fruits, especially those with skins and seeds, other than ripe bananas, have high fiber.
16. Which therapeutic management treatment is implemented for children with Hirschsprung disease?
a.
Daily enemas
b.
Low-fiber diet
c.
Permanent colostomy
d.
Surgical removal of affected section of bowel
d.
Surgical removal of affected section of bowel

ANS: D
Most children with Hirschsprung disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery. The colostomy that is created in Hirschsprung disease is usually temporary.
17. Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease. The enema solution should be:
a.
tap water.
b.
normal saline.
c.
oil retention.
d.
phosphate preparation.
b.
normal saline.

ANS: B
Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid overload. Oil-retention enemas will not achieve the "until clear" result. Phosphate enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the phosphate enema can result in diarrhea, which can lead to metabolic acidosis.
18. A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child psychologically is:
a.
not necessary because of child's age.
b.
not necessary because colostomy is temporary.
c.
necessary because it will be an adjustment.
d.
necessary because the child must deal with a negative body image.
c.
necessary because it will be an adjustment.

ANS: C
The child's age dictates the type and extent of psychological preparation. When a colostomy is performed, the child who is at least preschool age is told about the procedure and what to expect in concrete terms, with the use of visual aids. It is necessary to prepare a 3-year-old child for procedures. The preschooler is not yet concerned with body image.
19. The nurse is explaining to a parent how to care for a school-age child with vomiting associated with a viral illness. Which action should the nurse include?
a.
Avoid carbohydrate-containing liquids.
b.
Give nothing by mouth for 24 hours.
c.
Brush teeth or rinse mouth after vomiting.
d.
Give plain water until vomiting ceases for at least 24 hours.
c.
Brush teeth or rinse mouth after vomiting.

ANS: C
It is important to emphasize the need for the child to brush the teeth or rinse the mouth after vomiting to dilute the hydrochloric acid that comes in contact with the teeth. Ad libitum administration of glucose-electrolyte solution to an alert child will help restore water and electrolytes satisfactorily. It is important to include carbohydrate to spare body protein and avoid ketosis.
22. Which clinical manifestation would be the most suggestive of acute appendicitis?
a.
Rebound tenderness
b.
Bright red or dark red rectal bleeding
c.
Abdominal pain that is relieved by eating
d.
Abdominal pain that is most intense at McBurney point
d.
Abdominal pain that is most intense at McBurney point

ANS: D
Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain localizes to the right lower quadrant at McBurney point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Bright red or dark red rectal bleeding and abdominal pain that is relieved by eating are not signs of acute appendicitis.
23. When caring for a child with probable appendicitis, the nurse should be alert to recognize that which condition or symptom is a sign of perforation?
a.
Bradycardia
b.
Anorexia
c.
Sudden relief from pain
d.
Decreased abdominal distention
c.
Sudden relief from pain

ANS: C
Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical manifestation of appendicitis. Abdominal distention usually increases.
24. The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. Which is appropriate to relieve the abdominal discomfort?
a.
Place in Trendelenburg position.
b.
Allow to assume position of comfort.
c.
Apply moist heat to the abdomen.
d.
Administer a saline enema to cleanse bowel.
b.
Allow to assume position of comfort.

ANS: B
The child should be allowed to take a position of comfort, usually with the legs flexed. The Trendelenburg position will not help with the discomfort. In any instance in which appendicitis is a possibility, there is a danger in administering a laxative or enemas or applying heat to the area. Such measures stimulate bowel motility and increase the risk of perforation.
26. A nurse is admitting a child with Crohn disease. Parents ask the nurse, "How is this disease different from ulcerative colitis?" Which statement should the nurse make when answering this question?
a.
"With Crohn's the inflammatory process involves the whole GI tract."
b.
"There is no difference between the two diseases."
c.
"The inflammation with Crohn's is limited to the colon and rectum."
d.
"Ulcerative colitis is characterized by skip lesions."
a.
"With Crohn's the inflammatory process involves the whole GI tract."

ANS: A
The chronic inflammatory process of Crohn disease involves any part of the GI tract from the mouth to the anus but most often affects the terminal ileum. Crohn disease involves all layers of the bowel wall in a discontinuous fashion, meaning that between areas of intact mucosa, there are areas of affected mucosa (skip lesions). The inflammation found with ulcerative colitis is limited to the colon and rectum, with the distal colon and rectum the most severely affected. Inflammation affects the mucosa and submucosa and involves continuous segments along the length of the bowel with varying degrees of ulceration, bleeding, and edema.
27. Which is used to treat moderate to severe inflammatory bowel disease?
a.
Antacids
b.
Antibiotics
c.
Corticosteroids
d.
Antidiarrheal medications
c.
Corticosteroids

ANS: C
Corticosteroids, such as prednisone and prednisolone, are used in short bursts to suppress the inflammatory response in inflammatory bowel disease. Antacids and antidiarrheal medications are not drugs of choice in the treatment of inflammatory bowel disease. Antibiotics may be used as an adjunctive therapy to treat complications.
28. Bismuth subsalicylate, clarithromycin, and metronidazole are prescribed for a child with a peptic ulcer to:
a.
eradicate Helicobacter pylori.
b.
coat gastric mucosa.
c.
treat epigastric pain.
d.
reduce gastric acid production.
a.
eradicate Helicobacter pylori.

ANS: A
The drug therapy combination of bismuth subsalicylate, clarithromycin, and metronidazole is effective in the treatment of H. pylori and is prescribed to eradicate it.
30. Which vaccine is now recommended for the immunization of all newborns?
a.
Hepatitis A vaccine
b.
Hepatitis B vaccine
c.
Hepatitis C vaccine
d.
Hepatitis A, B, and C vaccines
b.
Hepatitis B vaccine

ANS: B
Universal vaccination for hepatitis B is now recommended for all newborns. A vaccine is available for hepatitis A, but it is not yet universally recommended. No vaccine is currently available for hepatitis C. Only hepatitis B vaccine is recommended for newborns.
33. A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. Initial therapeutic approach to the mother should be:
a.
restating what the physician has told her about plastic surgery.
b.
encouraging her to express her feelings.
c.
emphasizing the normalcy of her baby and the baby's need for mothering.
d.
recognizing that negative feelings toward the child continue throughout childhood.
b.
encouraging her to express her feelings.

ANS: B
For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must place emphasize not only the infant's physical needs but also the parents' emotional needs. The mother needs to be able to express her feelings before she can accept her child. Although the nurse will restate what the physician has told the mother about plastic surgery, it is not part of the initial therapeutic approach. As the mother expresses her feelings, the nurse's actions should convey to the parents that the infant is a precious human being. The nurse emphasizes the child's normalcy and helps the mother recognize the child's uniqueness. Maternal-infant attachment was not negatively affected at age 1 year.
34. Caring for the newborn with a cleft lip and palate before surgical repair includes:
a.
gastrostomy feedings.
b.
keeping infant in near-horizontal position during feedings.
c.
allowing little or no sucking.
d.
providing satisfaction of sucking needs.
d.
providing satisfaction of sucking needs.

ANS: D
Using special or modified nipples for feeding techniques helps meet the infant's sucking needs. Gastrostomy feedings are usually not indicated. Feeding is best accomplished with the infant's head in an upright position. The child requires both nutritive and nonnutritive sucking.
35. A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing interventions should include:
a.
giving medication to suppress lactation.
b.
encouraging and helping mother to breastfeed.
c.
teaching mother to feed breast milk by gavage.
d.
recommending use of a breast pump to maintain lactation until infant can suck.
b.
encouraging and helping mother to breastfeed.

ANS: B
The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infant's oral cavity so that the tongue action facilitates milk expression. Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation. Because breastfeeding can usually be accomplished, gavage feedings are not indicated. The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex.
36. The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infant's postoperative care include:
a.
arm restraints, postural drainage, mouth irrigations.
b.
cleansing the suture line, supine and side-lying positions, arm restraints.
c.
mouth irrigations, prone position, cleansing suture line.
d.
supine and side-lying positions, postural drainage, arm restraints.
b.
cleansing the suture line, supine and side-lying positions, arm restraints.

ANS: B
The suture line should be cleansed gently after feeding. The child should be positioned on the back, on the side, or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. There is no reason to perform mouth irrigations, and the child should not be placed in the prone position where injury to the suture site can occur.
37. During the first few days after surgery for cleft lip, which intervention should the nurse do?
a.
Leave infant in crib at all times to prevent suture strain.
b.
Keep infant heavily sedated to prevent suture strain.
c.
Remove restraints periodically to cuddle infant.
d.
Alternate position from prone to side-lying to supine.
c.
Remove restraints periodically to cuddle infant.

ANS: C
Remove restraints periodically, while supervising the infant, to allow him or her to exercise arms and to provide cuddling and tactile stimulation. The infant should not be left in the crib, but should be removed for appropriate holding and stimulation. Analgesia and sedation are administered for pain. Heavy sedation is not indicated. The child should not be placed in the prone position.
39. Which type of hernia has an impaired blood supply to the herniated organ?
a.
Hiatal hernia
b.
Incarcerated hernia
c.
Omphalocele
d.
Strangulated hernia
d.
Strangulated hernia

ANS: D
A strangulated hernia is one in which the blood supply to the herniated organ is impaired. Hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus. Incarcerated hernia is a hernia that cannot be reduced easily. Omphalocele is the protrusion of intra-abdominal viscera into the base of the umbilical cord. The sac is covered with peritoneum, not skin.
40. Pyloric stenosis can best be described as:
a.
dilation of the pylorus.
b.
hypertrophy of the pyloric muscle.
c.
hypotonicity of the pyloric muscle.
d.
reduction of tone in the pyloric muscle.
b.
hypertrophy of the pyloric muscle.

ANS: B
Hypertrophic pyloric stenosis occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel. Dilation of the pylorus, hypotonicity of the pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.
41. Which observation made of the exposed abdomen is most indicative of pyloric stenosis?
a.
Abdominal rigidity
b.
Substernal retraction
c.
Palpable olive-like mass
d.
Marked distention of lower abdomen
c.
Palpable olive-like mass

ANS: C
The diagnosis of pyloric stenosis is often made after the history and physical examination. The olive-like mass is easily palpated when the stomach is empty, the infant is quiet, and the abdominal muscles are relaxed. Abdominal rigidity and substernal retraction are usually not present. The upper abdomen, not lower abdomen, is distended.
42. The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?
a.
Abdominal rigidity and pain on palpation
b.
Rounded abdomen and hypoactive bowel sounds
c.
Visible peristalsis and weight loss
d.
Distention of lower abdomen and constipation
c.
Visible peristalsis and weight loss

ANS: C
Visible gastric peristaltic waves that move from left to right across the epigastrium and weight loss are observed in pyloric stenosis. Abdominal rigidity and pain on palpation or a rounded abdomen and hypoactive bowel sounds are usually not present. The upper abdomen, not lower abdomen, is distended.
43. An infant with pyloric stenosis experiences excessive vomiting that can result in:
a.
hyperchloremia.
b.
hypernatremia.
c.
metabolic acidosis.
d.
metabolic alkalosis.
d.
metabolic alkalosis.

ANS: D
Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Chloride ions and sodium are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.
44. Invagination of one segment of bowel within another is called:
a.
atresia.
b.
stenosis.
c.
herniation.
d.
intussusception.
d.
intussusception.

ANS: D
Intussusception occurs when a proximal section of the bowel telescopes into a more distal segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction. Invagination of one segment of bowel within another is the definition of intussusception, not atresia, stenosis, or herniation.
45. The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. Which nursing action is the most appropriate?
a.
Notify practitioner.
b.
Measure abdominal girth.
c.
Auscultate for bowel sounds.
d.
Take vital signs, including blood pressure.
a.
Notify practitioner.

ANS: A
Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic-therapeutic care plan. The first action would be to report the normal stool to the practitioner.
46. Which is an important nursing consideration in the care of a child with celiac disease?
a.
Refer to a nutritionist for detailed dietary instructions and education.
b.
Help child and family understand that diet restrictions are usually only temporary.
c.
Teach proper hand washing and standard precautions to prevent disease transmission.
d.
Suggest ways to cope more effectively with stress to minimize symptoms.
a.
Refer to a nutritionist for detailed dietary instructions and education.

ANS: A
The main consideration is helping the child adhere to dietary management. Considerable time is spent explaining to the child and parents about the disease process, the specific role of gluten in aggravating the condition, and foods that must be restricted. Referral to a nutritionist would help in this process. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible or stress related.
2. The nurse is assessing a child after a cardiac catheterization. Which complication should the nurse be assessing for?
a.
Cardiac arrhythmia
b.
Hypostatic pneumonia
c.
Heart failure
d.
Rapidly increasing blood pressure
a.
Cardiac arrhythmia

ANS: A
Because a catheter is introduced into the heart, a risk exists of catheter-induced dysrhythmias occurring during the procedure. These are usually transient. Hypostatic pneumonia, heart failure, and rapidly increasing blood pressure are not risks usually associated with cardiac catheterization.
4. Which explanation regarding cardiac catheterization is appropriate for a preschool child?
a.
Postural drainage will be performed every 4 to 6 hours after the test.
b.
It is necessary to be completely "asleep" during the test.
c.
The test is short, usually taking less than 1 hour.
d.
When the procedure is done, you will have to keep your leg straight for at least 4 hours.
d.
When the procedure is done, you will have to keep your leg straight for at least 4 hours.

ANS: D
The child's leg will have to be maintained in a straight position for approximately 4 hours. Younger children can be held in the parent's lap with the leg maintained in the correct position. Postural drainage will not be performed unless the child has corresponding pulmonary problems. The child should be sedated to lie still, but being completely asleep is not necessary. The test will vary in length of time from start to finish.
6. The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the adolescent would indicate a need for further teaching?
a.
"I should avoid tub baths but may shower."
b.
"I have to stay on strict bed rest for 3 days."
c.
"I should remove the pressure dressing the day after the procedure."
d.
"I may attend school but should avoid exercise for several days."
b.
"I have to stay on strict bed rest for 3 days."

ANS: B
The child does not need to be on strict bed rest for 3 days. Showers are recommended; children should avoid a tub bath. The pressure dressing is removed the day after the catheterization and replaced by an adhesive bandage to keep the area clean. Strenuous activity must be avoided for several days, but the child can return to school.
9. The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes tetralogy of Fallot?
a.
Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
b.
Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
c.
Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
d.
Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
a.
Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy

ANS: A
Tetralogy of Fallot has these four characteristics: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not atrial stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular hypertrophy, is present in tetralogy of Fallot. Tetralogy of Fallot has right ventricular hypertrophy, not left ventricular hypertrophy, and an atrial septal defect, not aortic hypertrophy.
10. A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow?
a.
Atrial septal defect
b.
Tetralogy of Fallot
c.
Ventricular septal defect
d.
Patent ductus arteriosus
b.
Tetralogy of Fallot

ANS: B
Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis increases the pressure in the right ventricle, causing the blood to go from right to left across the ventricular septal defect. Atrial and ventricular septal defects and patent ductus arteriosus result in increased pulmonary blood flow.
12. Which is a clinical manifestation of the systemic venous congestion that can occur with heart failure?
a.
Tachypnea
b.
Tachycardia
c.
Peripheral edema
d.
Pale, cool extremities
c.
Peripheral edema

ANS: C
Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous congestion. Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale, cool extremities are clinical manifestations of impaired myocardial function.
15. An 8-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than _____ beats/min.
a.
60
b.
70
c.
90
d.
100
b.
70

ANS: B
If a 1-minute apical pulse is less than 70 beats/min for an older child, the digoxin is withheld; 60 beats/min is the cut-off for holding the digoxin dose in an adult. A pulse below 90 to 110 beats/min is the determination for not giving a digoxin dose to infants and young children.
16. A 6-month-old infant is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than _____ beats/min.
a.
60
b.
70
c.
90 to 110
d.
110 to 120
c.
90 to 110

ANS: C
If the 1-minute apical pulse is below 90 to 110 beats/min, the digoxin should not be given to a 6-month-old. 60 beats/min is the cut-off for holding the digoxin dose in an adult. 70 beats/min is the determining heart rate to hold a dose of digoxin for an older child. 110 to 120 beats/min is an acceptable heart rate to administer digoxin to a 6-month-old.
17. The nurse is teaching parents about signs of digoxin (Lanoxin) toxicity. Which is a common sign of digoxin toxicity?
a.
Seizures
b.
Vomiting
c.
Bradypnea
d.
Tachycardia
b.
Vomiting

ANS: B
Vomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin toxicity. The child will have a slower heart rate, not respiratory rate. The heart rate will be slower, not faster.
29. Which is the most common causative agent of bacterial endocarditis?
a.
Staphylococcus albus
b.
Streptococcus hemolyticus
c.
Staphylococcus albicans
d.
Streptococcus viridans
d.
Streptococcus viridans

ANS: D
S. viridans is the most common causative agent in bacterial (infective) endocarditis. Staphylococcus albus, Streptococcus hemolyticus, and Staphylococcus albicans are not common causative agents.
30. Which painful, tender, pea-sized nodules may appear on the pads of the fingers or toes in bacterial endocarditis?
a.
Osler nodes
b.
Janeway lesions
c.
Subcutaneous nodules
d.
Aschoff nodes
a.
Osler nodes

ANS: A
Osler nodes are red, painful, intradermal nodes found on pads of the phalanges in bacterial endocarditis. Janeway lesions are painless hemorrhagic areas on palms and soles in bacterial endocarditis. Subcutaneous nodules are nontender swellings, located over bony prominences, commonly found in rheumatic fever. Aschoff nodules are small nodules composed of cells and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis.
31. The primary nursing intervention to prevent bacterial endocarditis is to:
a.
institute measures to prevent dental procedures.
b.
counsel parents of high-risk children about prophylactic antibiotics.
c.
observe children for complications, such as embolism and heart failure.
d.
encourage restricted mobility in susceptible children.
b.
counsel parents of high-risk children about prophylactic antibiotics.

ANS: B
The objective of nursing care is to counsel the parents of high-risk children about both the need for prophylactic antibiotics for dental procedures and the necessity of maintaining excellent oral health. The child's dentist should be aware of the child's cardiac condition. Dental procedures should be done to maintain a high level of oral health. Prophylactic antibiotics are necessary. Children should be observed for complications such as embolism and heart failure and restricted mobility should be encouraged in susceptible children, but maintaining good oral health and prophylactic antibiotics is important.
32. Which is a common, serious complication of rheumatic fever?
a.
Seizures
b.
Cardiac arrhythmias
c.
Pulmonary hypertension
d.
Cardiac valve damage
d.
Cardiac valve damage

ANS: D
Cardiac valve damage is the most significant complication of rheumatic fever. Seizures, cardiac arrhythmias, and pulmonary hypertension are not common complications of rheumatic fever.
33. The nurse is conducting a staff in-service on childhood-acquired heart diseases. Which is a major clinical manifestation of rheumatic fever?
a.
Polyarthritis
b.
Osler nodes
c.
Janeway spots
d.
Splinter hemorrhages of distal third of nails
a.
Polyarthritis

ANS: A
Polyarthritis, which is swollen, hot, red, and painful joints, is a major clinical manifestation of rheumatic fever. The affected joints will change every 1 to 2 days. Primarily the large joints are affected. Osler nodes, Janeway spots, and splinter hemorrhages are characteristic of infective endocarditis.
34. The nurse is admitting a child with rheumatic fever. Which therapeutic management should the nurse expect to implement?
a.
Administering penicillin
b.
Avoiding salicylates (aspirin)
c.
Imposing strict bed rest for 4 to 6 weeks
d.
Administering corticosteroids if chorea develops
a.
Administering penicillin

ANS: A
The goal of medical management is the eradication of the hemolytic streptococci. Penicillin is the drug of choice. Salicylates can be used to control the inflammatory process, especially in the joints, and reduce the fever and discomfort. Bed rest is recommended for the acute febrile stage, but it does not need to be strict. The chorea is transient and will resolve without treatment.
35. Which action by the school nurse is important in the prevention of rheumatic fever?
a.
Encourage routine cholesterol screenings.
b.
Conduct routine blood pressure screenings.
c.
Refer children with sore throats for throat cultures.
d.
Recommend salicylates instead of acetaminophen for minor discomforts.
c.
Refer children with sore throats for throat cultures.

ANS: C
Nurses have a role in prevention—primarily in screening school-age children for sore throats caused by group A β-hemolytic streptococci. They can achieve this by actively participating in throat culture screening or by referring children with possible streptococcal sore throats for testing. Cholesterol and blood pressure screenings do not facilitate the recognition and treatment of group A β-hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses.
39. The nurse is teaching nursing students about shock that occurs in children. One of the most frequent causes of hypovolemic shock in children is:
a.
sepsis.
b.
blood loss.
c.
anaphylaxis.
d.
congenital heart disease.
b.
blood loss.

ANS: B
Blood loss is the most frequent cause of hypovolemic shock in children. Sepsis causes septic shock, which is overwhelming sepsis and circulating bacterial toxins. Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Congenital heart disease contributes to hypervolemia, not hypovolemia.
41. Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock?
a.
Thirst
b.
Irritability
c.
Apprehension
d.
Confusion and somnolence
d.
Confusion and somnolence

ANS: D
Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock.
42. Which occurs in septic shock?
a.
Hypothermia
b.
Increased cardiac output
c.
Vasoconstriction
d.
Angioneurotic edema
b.
Increased cardiac output

ANS: B
Increased cardiac output, which results in warm, flushed skin, is one of the manifestations of septic shock. Fever and chills are characteristic of septic shock. Vasodilation is more common than vasoconstriction. Angioneurotic edema occurs as a manifestation in anaphylactic shock.
43. A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, the nurse should prepare which medication for immediate administration?
a.
Diphenhydramine (Benadryl)
b.
Dobutamine (Dobutarex)
c.
Epinephrine (Adrenalin)
d.
Calcium chloride (calcium chloride)
c.
Epinephrine (Adrenalin)

ANS: C
After the first priority of establishing an airway, administration of epinephrine is the drug of choice. Diphenhydramine, an antihistamine, is usually not used for severe reactions. Dobutamine and calcium chloride are not appropriate drugs for this type of reaction.
44. Clinical manifestations of toxic shock syndrome include:
a.
severe hypertension.
b.
subnormal temperature.
c.
erythematous macular rash.
d.
papular rash over extremities.
c.
erythematous macular rash.

ANS: C
One of the diagnostic criteria for toxic shock syndrome is a diffuse macular erythroderma. Hypotension is one of the manifestations. Fever of 38.9° C or higher is a characteristic. Desquamation of the palms and soles of the feet occurs in about 1 to 2 weeks.
2. Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock? (Select all that apply.)
a.
Thirst and diminished urinary output
b.
Irritability and apprehension
c.
Cool extremities and decreased skin turgor
d.
Confusion and somnolence
e.
Normal blood pressure and narrowing pulse pressure
f.
Tachypnea and poor capillary refill time
c.
Cool extremities and decreased skin turgor
d.
Confusion and somnolence
f.
Tachypnea and poor capillary refill time

ANS: C, D, F
Cool extremities, decreased skin turgor, confusion, somnolence, tachypnea, and poor capillary refill time are beginning signs of decompensated shock. Thirst, diminished urinary output, irritability, apprehension, normal blood pressure, and narrowing pulse pressure are signs of compensated shock.
3. The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include? (Select all that apply.)
a.
Warm flushed extremities
b.
Weight loss
c.
Decreased urinary output
d.
Sweating (inappropriate)
e.
Fatigue
c.
Decreased urinary output
d.
Sweating (inappropriate)
e.
Fatigue

ANS: C, D, E
The signs and symptoms of heart failure include decreased urinary output, sweating, and fatigue. Other signs include pale, cool extremities, not warm and flushed, and weight gain, not weight loss.
1. Which child should the nurse document as being anemic?
a.
7-year-old child with a hemoglobin of 11.5 g/dl
b.
3-year-old child with a hemoglobin of 12 g/dl
c.
14-year-old child with a hemoglobin of 10 g/dl
d.
1-year-old child with a hemoglobin of 13 g/dl
d.
1-year-old child with a hemoglobin of 13 g/dl

ANS: D
Anemia is a condition in which the number of red blood cells, or hemoglobin concentration, is reduced below the normal values for age. Anemia is defined as a hemoglobin level below 10 or 11 g/dl. The child with a hemoglobin of 10 g/dl would be considered anemic. The normal hemoglobin for a child after 2 years of age is 11.5 to 15.5 g/dl.
2. Several blood tests are ordered for a preschool child with severe anemia. The child is crying and upset because of memories of the venipuncture done at the clinic 2 days ago. The nurse should explain:
a.
venipuncture discomfort is very brief.
b.
only one venipuncture will be needed.
c.
topical application of local anesthetic can eliminate venipuncture pain.
d.
most blood tests on children require only a finger puncture because a small amount of blood is needed.
c.
topical application of local anesthetic can eliminate venipuncture pain.

ANS: C
Preschool children are concerned with both pain and the loss of blood. When preparing the child for venipuncture, the nurse will use a topical anesthetic to eliminate any pain. This is a traumatic experience for preschool children. They are concerned about their bodily integrity. A local anesthetic should be used, and a bandage should be applied to maintain bodily integrity. The nurse should not promise one attempt in case multiple attempts are required. Both finger punctures and venipunctures are traumatic for children. Both require preparation.
4. The nurse is teaching parents about the importance of iron in a toddler's diet. Which explains why iron deficiency anemia is common during toddlerhood?
a.
Milk is a poor source of iron.
b.
Iron cannot be stored during fetal development.
c.
Fetal iron stores are depleted by age 1 month.
d.
Dietary iron cannot be started until age 12 months.
a.
Milk is a poor source of iron.

ANS: A
Children between the ages of 12 and 36 months are at risk for anemia because cow's milk is a major component of their diet and it is a poor source of iron. Iron is stored during fetal development, but the amount stored depends on maternal iron stores. Fetal iron stores are usually depleted by age 5 to 6 months. Dietary iron can be introduced by breastfeeding, iron-fortified formula, and cereals during the first 12 months of life.
5. The nurse is teaching parents of an infant about the causes of iron deficiency anemia. Which statement best describes iron deficiency anemia in infants?
a.
It is caused by depression of the hematopoietic system.
b.
It is easily diagnosed because of an infant's emaciated appearance.
c.
Clinical manifestations are similar regardless of the cause of the anemia.
d.
Clinical manifestations result from a decreased intake of milk and the premature addition of solid foods.
c.
Clinical manifestations are similar regardless of the cause of the anemia.

ANS: C
In iron deficiency anemia, the child's clinical appearance is a result of the anemia, not the underlying cause. Usually the hematopoietic system is not depressed in iron deficiency anemia. The bone marrow produces red cells that are smaller and contain less hemoglobin than normal red cells. Children who are iron deficient from drinking excessive quantities of milk are usually pale and overweight. They are receiving sufficient calories, but are deficient in essential nutrients. The clinical manifestations result from decreased intake of iron-fortified solid foods and an excessive intake of milk.
7. Iron dextran is ordered for a young child with severe iron deficiency anemia. Nursing considerations include to:
a.
administer with meals.
b.
administer between meals.
c.
inject deeply into a large muscle.
d.
massage injection site for 5 minutes after administration of drug.
c.
inject deeply into a large muscle.

ANS: C
Iron dextran is a parenteral form of iron. When administered intramuscularly, it must be injected into a large muscle. Iron dextran is for intramuscular or intravenous (IV) administration. The site should not be massaged to prevent leakage, potential irritation, and staining of the skin.
8. The nurse is recommending how to prevent iron deficiency anemia in a healthy, term, breast-fed infant. Which should be suggested?
a.
Iron (ferrous sulfate) drops after age 1 month
b.
Iron-fortified commercial formula by age 4 to 6 months
c.
Iron-fortified infant cereal by age 2 months
d.
Iron-fortified infant cereal by age 4 to 6 months
d.
Iron-fortified infant cereal by age 4 to 6 months

ANS: D
Breast milk supplies inadequate iron for growth and development after age 5 months. Supplementation is necessary at this time. The mother can supplement the breastfeeding with iron-fortified infant cereal. Iron supplementation or the introduction of solid foods in a breast-fed baby is not indicated. Providing iron-fortified commercial formula by age 4 to 6 months should be done only if the mother is choosing to discontinue breastfeeding.
9. Parents of a child with sickle cell anemia ask the nurse, "What happens to the hemoglobin in sickle cell anemia?" Which statement by the nurse explains the disease process?"
a.
Normal adult hemoglobin is replaced by abnormal hemoglobin.
b.
There is a lack of cellular hemoglobin being produced.
c.
There is a deficiency in the production of globulin chains.
d.
The size and depth of the hemoglobin are affected.
a.
Normal adult hemoglobin is replaced by abnormal hemoglobin.

ANS: A
Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being produced. Thalassemia major refers to a variety of inherited disorders characterized by deficiencies in production of certain globulin chains. Iron deficiency anemia affects the size and depth of the color.
11. The nurse is conducting a staff in-service on sickle cell anemia. Which describes the pathologic changes of sickle cell anemia?
a.
Sickle-shaped cells carry excess oxygen.
b.
Sickle-shaped cells decrease blood viscosity.
c.
Increased red blood cell destruction occurs.
d.
Decreased adhesion of sickle-shaped cells occurs.
c.
Increased red blood cell destruction occurs.

ANS: C
The clinical features of sickle cell anemia are primarily the result of increased red blood cell destruction and obstruction caused by the sickle-shaped red blood cells. Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low oxygen tension. When the sickle cells change shape, they increase the viscosity in the area where they are involved in the microcirculation. Increased adhesion and entanglement of cells occurs.
12. Which clinical manifestation should the nurse expect when a child with sickle cell anemia experiences an acute vasoocclusive crisis?
a.
Circulatory collapse
b.
Cardiomegaly, systolic murmurs
c.
Hepatomegaly, intrahepatic cholestasis
d.
Painful swelling of hands and feet; painful joints
d.
Painful swelling of hands and feet; painful joints

ANS: D
A vasoocclusive crisis is characterized by severe pain in the area of involvement. If in the extremities, painful swelling of the hands and feet is seen; if in the abdomen, severe pain resembles that of acute surgical abdomen; and if in the head, stroke and visual disturbances occur. Circulatory collapse results from sequestration crises. Cardiomegaly, systolic murmurs, hepatomegaly, and intrahepatic cholestasis result from chronic vasoocclusive phenomena.
13. Meperidine (Demerol) is not recommended for children in sickle cell crisis because it:
a.
may induce seizures.
b.
is easily addictive.
c.
is not adequate for pain relief.
d.
is given by intramuscular injection.
a.
may induce seizures.

ANS: A
A metabolite of meperidine, normeperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Patients with sickle cell disease are particularly at risk for normeperidine-induced seizures. Meperidine is no more addictive than other narcotic agents. Meperidine is adequate for pain relief. It is available for IV infusion.
14. A school-age child is admitted in vasoocclusive sickle cell crisis. The child's care should include:
a.
correction of acidosis.
b.
adequate hydration and pain management.
c.
pain management and administration of heparin.
d.
adequate oxygenation and replacement of factor VIII.
b.
adequate hydration and pain management.

ANS: B
The management of crises includes adequate hydration, minimization of energy expenditures, pain management, electrolyte replacement, and blood component therapy if indicated. Hydration and pain control are two of the major goals of therapy. The acidosis will be corrected as the crisis is treated. Heparin and factor VIII is not indicated in the treatment of vasoocclusive sickle cell crisis. Oxygen may prevent further sickling, but it is not effective in reversing sickling because it cannot reach the clogged blood vessels.
28. Which immunization should not be given to a child receiving chemotherapy for cancer?
a.
Tetanus vaccine
b.
Inactivated poliovirus vaccine
c.
Diphtheria, pertussis, tetanus (DPT)
d.
Measles, rubella, mumps
d.
Measles, rubella, mumps

ANS: D
The vaccine used for measles, mumps, and rubella is a live virus and can result in an overwhelming infection. Tetanus vaccine, inactivated poliovirus vaccine, and diphtheria, pertussis, tetanus (DPT) are not live virus vaccines.
4. The nurse is teaching parents about prevention of urinary tract infections in children. Which factor predisposes the urinary tract to infection?
a.
Increased fluid intake
b.
Short urethra in young girls
c.
Prostatic secretions in males
d.
Frequent emptying of the bladder
b.
Short urethra in young girls

ANS: B
The short urethra in females provides a ready pathway for invasion of organisms. Increased fluid intake and frequent emptying of the bladder offer protective measures against urinary tract infections. Prostatic secretions have antibacterial properties that inhibit bacteria.
5. Which should the nurse recommend to prevent urinary tract infections in young girls?
a.
Wear cotton underpants.
b.
Limit bathing as much as possible.
c.
Increase fluids; decrease salt intake.
d.
Cleanse perineum with water after voiding.
a.
Wear cotton underpants.

ANS: A
Cotton underpants are preferable to nylon underpants. No evidence exists that limiting bathing, increasing fluids/decreasing salt intake, or cleansing the perineum with water after voiding decrease urinary tract infections in young girls.
8. Which is an objective of care for a 10-year-old child with minimal change nephrotic syndrome?
a.
Reduce blood pressure.
b.
Reduce excretion of urinary protein.
c.
Increase excretion of urinary protein.
d.
Increase ability of tissues to retain fluid.
b.
Reduce excretion of urinary protein.

ANS: B
The objectives of therapy for the child with minimal change nephrotic syndrome include reduction of the excretion of urinary protein, reduction of fluid retention, prevention of infection, and minimization of complications associated with therapy. Blood pressure is usually not elevated in minimal change nephrotic syndrome. Excretion of urinary protein and fluid retention are part of the disease process and must be reversed.
9. Which is instituted for the therapeutic management of minimal change nephrotic syndrome?
a.
Corticosteroids
b.
Antihypertensive agents
c.
Long-term diuretics
d.
Increased fluids to promote diuresis
a.
Corticosteroids

ANS: A
Corticosteroids are the first line of therapy for minimal change nephrotic syndrome. Response is usually seen within 7 to 21 days. Antihypertensive agents and long-term diuretic therapy are usually not necessary. A diet that has fluid and salt restrictions may be indicated.
10. Which is a common side effect of short-term corticosteroid therapy?
a.
Fever
b.
Hypertension
c.
Weight loss
d.
Increased appetite
d.
Increased appetite

ANS: D
Side effects of short-term corticosteroid therapy include an increased appetite. Fever is not a side effect of therapy. It may be an indication of infection. Hypertension is not usually associated with initial corticosteroid therapy. Weight gain, not weight loss, is associated with corticosteroid therapy.
11. The nurse closely monitors the temperature of a child with minimal change nephrotic syndrome. The purpose of this assessment is to detect an early sign of which possible complication?
a.
Infection
b.
Hypertension
c.
Encephalopathy
d.
Edema
a.
Infection

ANS: A
Infection is a constant source of danger to edematous children and those receiving corticosteroid therapy. An increased temperature could be an indication of an infection. Temperature is not an indication of hypertension or edema. Encephalopathy is not a complication usually associated with minimal change nephrotic syndrome. The child will most likely have neurologic signs and symptoms.
12. A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. Which is an appropriate nursing goal related to this?
a.
Prevent infection.
b.
Stimulate appetite.
c.
Detect evidence of edema.
d.
Ensure compliance with prophylactic antibiotic therapy.
a.
Prevent infection.

ANS: A
High-dose steroid therapy has an immunosuppressant effect. These children are particularly vulnerable to upper respiratory tract infections. A priority nursing goal is to minimize the risk of infection by protecting the child from contact with infectious individuals. Appetite is increased with prednisone therapy. The amount of edema should be monitored as part of the disease process, not necessarily related to the administration of prednisone. Antibiotics would not be used as prophylaxis.
13. Which is included in the diet of a child with minimal change nephrotic syndrome?
a.
High protein
b.
Salt restriction
c.
Low fat
d.
High carbohydrate
b.
Salt restriction

ANS: B
Salt is usually restricted (but not eliminated) during the edema phase. The child has little appetite during the acute phase. Favorite foods are provided (with the exception of high-salt ones) in an attempt to provide nutritionally complete meals.
14. Which best describes acute glomerulonephritis?
a.
Occurs after a urinary tract infection
b.
Occurs after a streptococcal infection
c.
Associated with renal vascular disorders
d.
Associated with structural anomalies of genitourinary tract
b.
Occurs after a streptococcal infection

ANS: B
Acute glomerulonephritis is an immune-complex disease that occurs after a streptococcal infection with certain strains of the group A â-hemolytic streptococcus. Acute glomerulonephritis usually follows streptococcal pharyngitis and is not associated with renal vascular disorders or genitourinary tract structural anomalies.
15. A child is admitted with acute glomerulonephritis. The nurse should expect the urinalysis during this acute phase to show:
a.
bacteriuria, hematuria.
b.
hematuria, proteinuria.
c.
bacteriuria, increased specific gravity.
d.
proteinuria, decreased specific gravity.
b.
hematuria, proteinuria.

ANS: B
Urinalysis during the acute phase characteristically shows hematuria and proteinuria. Bacteriuria and changes in specific gravity are not usually present during the acute phase.
16. A mother asks the nurse what would be the first indication that acute glomerulonephritis is improving. The nurse's best response should be that the:
a.
blood pressure will stabilize.
b.
the child will have more energy.
c.
urine will be free of protein.
d.
urinary output will increase.
d.
urinary output will increase.

ANS: D
An increase in urinary output may signal resolution of the acute glomerulonephritis. If blood pressure is elevated, stabilization usually occurs with the improvement in renal function. The child having more energy and the urine being free of protein are related to the improvement in urinary output.
17. The nurse notes that a child has lost 8 pounds after 4 days of hospitalization for acute glomerulonephritis. This is most likely the result of:
a.
poor appetite.
b.
increased potassium intake.
c.
reduction of edema.
d.
restriction to bed rest.
c.
reduction of edema.

ANS: C
This amount of weight loss in this period is a result of the improvement of renal function and mobilization of edema fluid. Poor appetite and bed rest would not result in a weight loss of 8 pounds in 4 days. Foods with substantial amounts of potassium are avoided until renal function is normalized.
18. The nurse is teaching the parent about the diet of a child experiencing severe edema associated with acute glomerulonephritis. Which information should the nurse include in the teaching?
a.
"You will need to decrease the number of calories in your child's diet."
b.
"Your child's diet will need an increased amount of protein."
c.
"You will need to avoid adding salt to your child's food."
d.
"Your child's diet will consist of low-fat, low-carbohydrate foods."
c.
"You will need to avoid adding salt to your child's food."

ANS: C
For most children, a regular diet is allowed, but it should contain no added salt. The child should be offered a regular diet with favorite foods. Severe sodium restrictions are not indicated.
19. Which is the most appropriate nursing diagnosis for the child with acute glomerulonephritis?
a.
Risk for Injury related to malignant process and treatment
b.
Fluid Volume Deficit related to excessive losses
c.
Fluid Volume Excess related to decreased plasma filtration
d.
Fluid Volume Excess related to fluid accumulation in tissues and third spaces
c.
Fluid Volume Excess related to decreased plasma filtration

ANS: C
Glomerulonephritis has a decreased filtration of plasma, which results in an excessive accumulation of water and sodium that expands plasma and interstitial fluid volumes, leading to circulatory congestion and edema. No malignant process is involved in acute glomerulonephritis. A fluid volume excess is found. The fluid accumulation is secondary to the decreased plasma filtration.
33. A preschool child is being admitted to the hospital with dehydration and a urinary tract infection (UTI). Which urinalysis result should the nurse expect with these conditions?
a.
WBC <1; specific gravity 1.008
b.
WBC <2; specific gravity 1.025
c.
WBC >2; specific gravity 1.016
d.
WBC >2; specific gravity 1.030
d.
WBC >2; specific gravity 1.030

ANS: D
WBC count in a routine urinalysis should be <1 or 2. Over that amount indicates a urinary tract inflammatory process. The urinalysis specific gravity for children with normal fluid intake is 1.016 to 1.022. When the specific gravity is high, dehydration is indicated. A low specific gravity is seen with excessive fluid intake, distal tubular dysfunction, or insufficient antidiuretic hormone secretion.
1. The nurse is caring for an infant with a suspected urinary tract infection. Which clinical manifestations should be expected? (Select all that apply.)
a.
Vomiting
b.
Jaundice
c.
Failure to gain weight
d.
Swelling of the face
e.
Back pain
f.
Persistent diaper rash
a.
Vomiting
c.
Failure to gain weight
f.
Persistent diaper rash

ANS: A, C, F
Vomiting, failure to gain weight, and persistent diaper rash are clinical manifestations observed in an infant with a UTI.
2. A school-age child is admitted to the hospital with acute glomerulonephritis and oliguria. Which dietary menu items should be allowed for this child? (Select all that apply.)
a.
Apples
b.
Bananas
c.
Cheese
d.
Carrot sticks
e.
Strawberries
a.
Apples
d.
Carrot sticks
e.
Strawberries

ANS: A, D, E
Moderate sodium restriction and even fluid restriction may be instituted for children with acute glomerulonephritis. Foods with substantial amounts of potassium are generally restricted during the period of oliguria. Apples, carrot sticks, and strawberries would be items low in sodium and allowed. Bananas are high in potassium and cheese is high in sodium. Those items would be restricted.
3. A school-age child has been admitted to the hospital with an exacerbation of nephrotic syndrome. Which clinical manifestations should the nurse expect to assess? (Select all that apply.)
a.
Weight loss
b.
Facial edema
c.
Cloudy smoky brown-colored urine
d.
Fatigue
e.
Frothy-appearing urine
b.
Facial edema
d.
Fatigue
e.
Frothy-appearing urine

ANS: B, D, E
A child with nephrotic syndrome will present with facial edema, fatigue, and frothy-appearing urine (proteinuria). Weight gain, not loss, is expected because of the fluid retention. Cloudy smoky brown-colored urine is seen with acute glomerulonephritis but not with nephrotic syndrome because there is no gross hematuria associated with nephrotic syndrome.
1. The nurse has documented that a child's level of consciousness is obtunded. Which describes this level of consciousness?
a.
Slow response to vigorous and repeated stimulation
b.
Impaired decision making
c.
Arousable with stimulation
d.
Confusion regarding time and place
c.
Arousable with stimulation

ANS: C
Obtunded describes a level of consciousness in which the child is arousable with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion regarding time and place.
2. The nurse has received report on four children. Which child should the nurse assess first?
a.
A school-age child in a coma with stable vital signs
b.
A preschool child with a head injury and decreasing level of consciousness
c.
An adolescent admitted after a motor vehicle accident is oriented to person and place
d.
A toddler in a persistent vegetative state with a low-grade fever
b.
A preschool child with a head injury and decreasing level of consciousness

ANS: B
The nurse should assess the child with a head injury and decreasing level of consciousness first (LOC). Assessment of LOC remains the earliest indicator of improvement or deterioration in neurologic status. The next child the nurse should assess is a toddler in a persistent vegetative state with a low-grade fever. The school-age child in a coma with stable vital signs and the adolescent admitted to the hospital who is oriented to his surroundings would be of least worry to the nurse.
4. The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as:
a.
eye trauma.
b.
neurosurgical emergency.
c.
severe brainstem damage.
d.
indication of brain death.
b.
neurosurgical emergency.

ANS: B
The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or bilateral fixed pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain. One fixed and dilated pupil is not suggestive of brain death.
6. The nurse is taking care of a child who is alert but showing signs of increased intracranial pressure. Which test is contraindicated in this case?
a.
Oculovestibular response
b.
Doll's head maneuver
c.
Funduscopic examination for papilledema
d.
Assessment of pyramidal tract lesions
a.
Oculovestibular response

ANS: A
The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a comatose child. The caloric test is painful and is never performed on an awake child or one who has a ruptured tympanic membrane. Doll's head maneuver, funduscopic examination for papilledema, and assessment of pyramidal tract lesions can be performed on awake children.
7. The nurse is preparing a school-age child for computed tomography (CT scan) to assess cerebral function. The nurse should include which statement in preparing the child?
a.
"Pain medication will be given."
b.
"The scan will not hurt."
c.
"You will be able to move once the equipment is in place."
d.
"Unfortunately, no one can remain in the room with you during the test."
b.
"The scan will not hurt."

ANS: B
For CT scans, the child must be immobilized. It is important to emphasize to the child that at no time is the procedure painful. Pain medication is not required; however, sedation is sometimes necessary. Someone is able to remain with the child during the procedure.
9. Which is the priority nursing intervention for an unconscious child after a fall?
a.
Establish adequate airway.
b.
Perform neurologic assessment.
c.
Monitor intracranial pressure.
d.
Determine whether a neck injury is present.
a.
Establish adequate airway.

ANS: A
Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishment of an adequate airway is always the first priority. A neurologic assessment and determination of whether a neck injury is present will be performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after airway, breathing, and circulation are maintained.
10. Which drug should the nurse expect to administer to a preschool child who has increased intracranial pressure (ICP) resulting from cerebral edema?
a.
Mannitol (Osmitrol)
b.
Epinephrine hydrochloride (Adrenalin)
c.
Atropine sulfate (Atropine)
d.
Sodium bicarbonate (Sodium bicarbonate)
a.
Mannitol (Osmitrol)

ANS: A
For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used most frequently for rapid reduction. Epinephrine hydrochloride, atropine sulfate, and sodium bicarbonate are not used to decrease ICP.
13. The nurse is teaching nursing students about childhood fractures. Which describes a compound skull fracture?
a.
Involves the basilar portion of the occipital bone
b.
Bone is exposed through the skin
c.
Traumatic separations of the cranial sutures
d.
Bone is pushed inward, causing pressure on the brain
b.
Bone is exposed through the skin

ANS: B
A compound fracture has the bone exposed through the skin. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. Diastatic skull fractures are traumatic separations of the cranial sutures. A depressed fracture has the bone pushed inward, causing pressure on the brain.
14. Which statement best describes a subdural hematoma?
a.
Bleeding occurs between the dura and the skull.
b.
Bleeding occurs between the dura and the cerebrum.
c.
Bleeding is generally arterial, and brain compression occurs rapidly.
d.
The hematoma commonly occurs in the parietotemporal region.
b.
Bleeding occurs between the dura and the cerebrum.

ANS: B
A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.
15. The nurse should recommend medical attention if a child with a slight head injury experiences:
a.
sleepiness.
b.
vomiting, even once.
c.
headache, even if slight.
d.
confusion or abnormal behavior.
d.
confusion or abnormal behavior.

ANS: D
Medical attention should be sought if the child exhibits confusion or abnormal behavior, loses consciousness, has amnesia, has fluid leaking from the nose or ears, complains of blurred vision, or has an unsteady gait. Sleepiness alone does not require evaluation. If the child is difficult to arouse from sleep, medical attention should be obtained. Vomiting more than three times requires medical attention. Severe or worsening headache or one that interferes with sleep should be evaluated.
27. The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like her oldest son did when he was an infant. The nurse should base her response on which statement?
a.
Meningitis rarely occurs during infancy.
b.
Often a genetic predisposition to meningitis is found.
c.
Vaccination to prevent all types of meningitis is now available.
d.
Vaccination to prevent Haemophilus influenzae type B meningitis has decreased the frequency of this disease in children.
d.
Vaccination to prevent Haemophilus influenzae type B meningitis has decreased the frequency of this disease in children.

ANS: D
H. influenzae type B meningitis has been virtually eradicated in areas of the world where the vaccine is administered routinely. Bacterial meningitis remains a serious illness in children. It is significant because of the residual damage caused by undiagnosed and untreated or inadequately treated cases. The leading causes of neonatal meningitis are the group B streptococci and Escherichia coli organisms. Meningitis is an extension of a variety of bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of the potential causative organisms.
28. The vector reservoir for agents causing viral encephalitis in the United States is:
a.
tarantula spiders.
b.
mosquitoes.
c.
carnivorous wild animals.
d.
domestic and wild animals.
b.
mosquitoes.

ANS: B
Viral encephalitis, not attributable to a childhood viral disease, is usually transmitted by mosquitoes. The vector reservoir for most agents pathogenic for humans and detected in the United States are mosquitoes and ticks; therefore, most cases of encephalitis appear during the hot summer months. Tarantula spiders, carnivorous wild animals, and domestic and wild animals are not reservoirs for the agents that cause viral encephalitis.
33. A child is brought to the emergency department after experiencing a seizure at school. There is no previous history of seizures. The father tells the nurse that he cannot believe the child has epilepsy. The nurse's best response is:
a.
"Epilepsy is easily treated."
b.
"Very few children have actual epilepsy."
c.
"The seizure may or may not mean that your child has epilepsy."
d.
"Your child has had only one convulsion; it probably won't happen again."
c.
"The seizure may or may not mean that your child has epilepsy."

ANS: C
Seizures are the indispensable characteristic of epilepsy; however, not every seizure is epileptic. Epilepsy is a chronic seizure disorder with recurrent and unprovoked seizures. The treatment of epilepsy involves a thorough assessment to determine the type of seizure the child is having and the cause, followed by individualized therapy to allow the child to have as normal a life as possible. The nurse should not make generalized comments regarding the incidence of epilepsy until further assessment is made.
34. Which type of seizure involves both hemispheres of the brain?
a.
Focal
b.
Partial
c.
Generalized
d.
Acquired
c.
Generalized

ANS: C
Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. Partial seizures are caused by abnormal electric discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure.
35. Which is the initial clinical manifestation of generalized seizures?
a.
Being confused
b.
Feeling frightened
c.
Losing consciousness
d.
Seeing flashing lights
c.
Losing consciousness

ANS: C
Loss of consciousness is a frequent occurrence in generalized seizures and is the initial clinical manifestation. Being confused, feeling frightened, and seeing flashing lights are clinical manifestations of a complex partial seizure.
37. An important nursing intervention when caring for a child who is experiencing a seizure would be to:
a.
describe and record the seizure activity observed.
b.
restrain the child when seizure occurs to prevent bodily harm.
c.
place a tongue blade between the teeth if they become clenched.
d.
suction the child during a seizure to prevent aspiration.
a.
describe and record the seizure activity observed.

ANS: A
When a child is having a seizure, the priority nursing care is observation of the child and seizure. The nurse then describes and records the seizure activity. The child should not be restrained, and nothing should be placed in the child's mouth. This may cause injury. To prevent aspiration, if possible, the child should be placed on the side, facilitating drainage.
38. A 10-year-old child, without a history of previous seizures, experiences a tonic-clonic seizure at school. Breathing is not impaired, but some postictal confusion occurs. The most appropriate initial action by the school nurse is to:
a.
stay with child and have someone call emergency medical service (EMS).
b.
notify parent and regular practitioner.
c.
notify parent that child should go home.
d.
stay with child, offering calm reassurance.
a.
stay with child and have someone call emergency medical service (EMS).

ANS: A
The EMS should be called to transport the child because this is the child's first seizure. Because this is the first seizure, evaluation should be performed as soon as possible. The nurse should stay with the child while someone else notifies the EMS.
39. A child has been seizure-free for 2 years. A father asks the nurse how much longer the child will need to take the antiseizure medications. The nurse includes which intervention in the response?
a.
Medications can be discontinued at this time.
b.
The child will need to take the drugs for 5 years after the last seizure.
c.
A step-wise approach will be used to reduce the dosage gradually.
d.
Seizure disorders are a lifelong problem. Medications cannot be discontinued.
c.
A step-wise approach will be used to reduce the dosage gradually.

ANS: C
A predesigned protocol is used to wean a child gradually off antiseizure medications, usually when the child is seizure-free for 2 years and has a normal electroencephalogram (EEG). Medications must be gradually reduced to minimize the recurrence of seizures. Seizure medications can be safely discontinued. The risk of recurrence is greatest within the first year.
40. Children taking phenobarbital (phenobarbital sodium) and/or phenytoin (Dilantin) may experience a deficiency of:
a.
calcium.
b.
vitamin C.
c.
fat-soluble vitamins.
d.
vitamin D and folic acid.
d.
vitamin D and folic acid.

ANS: D
Deficiencies of vitamin D and folic acid have been reported in children taking phenobarbital and phenytoin. Calcium, vitamin C, and fat-soluble vitamin deficiencies are not associated with phenobarbital or phenytoin.
41. Which clinical manifestations would suggest hydrocephalus in a neonate?
a.
Bulging fontanel and dilated scalp veins
b.
Closed fontanel and high-pitched cry
c.
Constant low-pitched cry and restlessness
d.
Depressed fontanel and decreased blood pressure
a.
Bulging fontanel and dilated scalp veins

ANS: A
Bulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. Closed fontanel and high-pitched cry, constant low-pitched cry and restlessness, and depressed fontanel and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation.
2. The nurse is caring for a preschool child immobilized by a spica cast. Which effect on metabolism should the nurse monitor on this child related to the immobilized status?
a.
Hypocalcemia
b.
Decreased metabolic rate
c.
Positive nitrogen balance
d.
Increased production of stress hormones
b.
Decreased metabolic rate

ANS: B
Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased food intake. Immobilization leads to hypercalcemia and causes a negative nitrogen balance secondary to muscle atrophy. A decreased production of stress hormones occurs with decreased physical and emotional coping capacity.
3. The nurse should monitor for which effect on the cardiovascular system when a child is immobilized?
a.
Venous stasis
b.
Increased vasopressor mechanism
c.
Normal distribution of blood volume
d.
Increased efficiency of orthostatic neurovascular reflexes
a.
Venous stasis

ANS: A
The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. A decreased vasopressor mechanism results in orthostatic hypotension, syncope, hypotension, decreased cerebral blood flow, and tachycardia. An altered distribution of blood volume is found with decreased cardiac workload and exercise tolerance. Immobilization causes a decreased efficiency of orthostatic neurovascular reflexes with an inability to adapt readily to the upright position and with pooling of blood in the extremities in the upright position.
4. Which can result from the bone demineralization associated with immobility?
a.
Osteoporosis
b.
Urinary retention
c.
Pooling of blood
d.
Susceptibility to infection
a.
Osteoporosis

ANS: A
Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi. Urinary retention is secondary to the effect of immobilization on the urinary tract. Pooling of blood is a result of the cardiovascular effects of immobilization. Susceptibility to infection can result from the effects of immobilization on the respiratory and renal systems.
6. Which term is used to describe a type of fracture that does not produce a break in the skin?
a.
Simple
b.
Compound
c.
Complicated
d.
Comminuted
a.
Simple

ANS: A
If a fracture does not produce a break in the skin, it is called a simple, or closed, fracture. A compound, or open, fracture is one with an open wound through which the bone protrudes. A complicated fracture is one in which the bone fragments damage other organs or tissues. A comminuted fracture occurs when small fragments of bone are broken from the fractured shaft and lie in the surrounding tissue. These are rare in children.
18. The nurse is teaching a family how to care for their infant in a Pavlik harness to treat developmental dysplasia of the hip. Which should be included?
a.
Apply lotion or powder to minimize skin irritation.
b.
Remove harness several times a day to prevent contractures.
c.
Return to clinic every 1 to 2 weeks.
d.
Place diaper over harness, preferably using a superabsorbent disposable diaper that is relatively thin.
c.
Return to clinic every 1 to 2 weeks.

ANS: C
Infants have a rapid growth pattern. The child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness. The harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.
19. A neonate is born with bilateral mild talipes equinovarus (clubfoot). When the parents ask the nurse how this will be corrected, the nurse should give which explanation?
a.
Traction is tried first.
b.
Surgical intervention is needed.
c.
Frequent, serial casting is tried first.
d.
Children outgrow this condition when they learn to walk.
c.
Frequent, serial casting is tried first.

ANS: C
Serial casting is begun shortly after birth before discharge from nursery. Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy. Serial casting is the preferred treatment. Surgical intervention is done only if serial casting is not successful. Children do not improve without intervention.
22. A school nurse is conducting a staff in-service to other school nurses on idiopathic scoliosis. During which period of child development does idiopathic scoliosis become most noticeable?
a.
Newborn period
b.
When child starts to walk
c.
Preadolescent growth spurt
d.
Adolescence
c.
Preadolescent growth spurt

ANS: C
Idiopathic scoliosis is most noticeable during the preadolescent growth spurt. Idiopathic scoliosis is seldom apparent before age 10 years. Diagnosis usually occurs during the preadolescent growth spurt.
1. The nurse is caring for an infant with developmental dysplasia of the hip. Which clinical manifestations should the nurse expect to observe? (Select all that apply.)
a.
Positive Ortolani click
b.
Unequal gluteal folds
c.
Negative Babinski sign
d.
Trendelenburg sign
e.
Telescoping of the affected limb
f.
Lordosis
a.
Positive Ortolani click
b.
Unequal gluteal folds

ANS: A, B
A positive Ortolani test and unequal gluteal folds are clinical manifestations of developmental dysplasia of the hip seen from birth to 2 to 3 months. Unequal gluteal folds, negative Babinski sign, and Trendelenburg sign are signs that appear in older infants and children. Telescoping of the affected limb and lordosis are not clinical manifestations of developmental dysplasia of the hip.
1. The nurse is planning a staff in-service on childhood spastic cerebral palsy. Spastic cerebral palsy is characterized by:
a.
hypertonicity and poor control of posture, balance, and coordinated motion.
b.
athetosis and dystonic movements.
c.
wide-based gait and poor performance of rapid, repetitive movements.
d.
tremors and lack of active movement.
a.
hypertonicity and poor control of posture, balance, and coordinated motion.

ANS: A
Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic cerebral palsy. Athetosis and dystonic movements are part of the classification of dyskinetic (athetoid) cerebral palsy. Wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic cerebral palsy. Tremors and lack of active movement may indicate other neurologic disorders.
2. The parents of a child with cerebral palsy ask the nurse whether any drugs can decrease their child's spasticity. The nurse's response should be based on which statement?
a.
Anticonvulsant medications are sometimes useful for controlling spasticity.
b.
Medications that would be useful in reducing spasticity are too toxic for use with children.
c.
Many different medications can be highly effective in controlling spasticity.
d.
Implantation of a pump to deliver medication into the intrathecal space to decrease spasticity has recently become available.
d.
Implantation of a pump to deliver medication into the intrathecal space to decrease spasticity has recently become available.

ANS: D
Baclofen, given intrathecally, is best suited for children with severe spasticity that interferes with activities of daily living and ambulation. Anticonvulsant medications are used when seizures occur in children with cerebral palsy. The intrathecal route decreases the side effects of the drugs that reduce spasticity. Few medications are currently available for the control of spasticity.
3. The nurse is preparing to admit a newborn with myelomeningocele to the neonatal intensive care nursery. Which describes this newborn's defect?
a.
Fissure in the spinal column that leaves the meninges and the spinal cord exposed
b.
Herniation of the brain and meninges through a defect in the skull
c.
Hernial protrusion of a saclike cyst of meninges with spinal fluid but no neural elements
d.
Visible defect with an external saclike protrusion containing meninges, spinal fluid, and nerves
d.
Visible defect with an external saclike protrusion containing meninges, spinal fluid, and nerves

ANS: D
A myelomeningocele is a visible defect with an external saclike protrusion, containing meninges, spinal fluid, and nerves. Rachischisis is a fissure in the spinal column that leaves the meninges and the spinal cord exposed. Encephalocele is a herniation of brain and meninges through a defect in the skull, producing a fluid-filled sac. Meningocele is a hernial protrusion of a saclike cyst of meninges with spinal fluid, but no neural elements.
4. The nurse is conducting a staff in-service on common problems associated with myelomeningocele. Which common problem is associated with this defect?
a.
Hydrocephalus
b.
Craniosynostosis
c.
Biliary atresia
d.
Esophageal atresia
a.
Hydrocephalus

ANS: A
Hydrocephalus is a frequently associated anomaly in 80% to 90% of children. Craniosynostosis is the premature closing of the cranial sutures and is not associated with myelomeningocele. Biliary and esophageal atresia is not associated with myelomeningocele.
5. The nurse is teaching a group of nursing students about newborns born with the congenital defect of myelomeningocele. Which common problem is associated with this defect?
a.
Neurogenic bladder
b.
Mental retardation
c.
Respiratory compromise
d.
Cranioschisis
a.
Neurogenic bladder

ANS: A
Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder dysfunction among children. Risk of mental retardation is minimized through early intervention and management of hydrocephalus. Respiratory compromise is not a common problem in myelomeningocele. Cranioschisis is a skull defect through which various tissues protrude. It is not associated with myelomeningocele.
6. The nurse is reviewing prenatal vitamin supplements with an expectant client. Which supplement should be included in the teaching?
a.
Vitamin A throughout pregnancy
b.
Multivitamin preparations as soon as pregnancy is suspected
c.
Folic acid for all women of childbearing age
d.
Folic acid during the first and second trimesters of pregnancy
c.
Folic acid for all women of childbearing age

ANS: C
The widespread use of folic acid among women of childbearing age has decreased the incidence of spina bifida significantly. Vitamin A is not related to the prevention of spina bifida. Folic acid supplementation is recommended for the preconception period and during the pregnancy. Only 42% of women actually follow these guidelines.
10. Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which action?
a.
Avoid using any latex product.
b.
Use only nonallergenic latex products.
c.
Administer medication for long-term desensitization.
d.
Teach family about long-term management of asthma.
a.
Avoid using any latex product.

ANS: A
Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment. There are no nonallergenic latex products. At this time, desensitization is not an option. The child does not have asthma. The parents must be taught about allergy and the risk of anaphylaxis.
15. The nurse is conducting reflex testing on infants at a well-child clinic. Which reflex finding should be reported as abnormal and considered as a possible sign of cerebral palsy?
a.
Tonic neck reflex at 5 months of age
b.
Absent Moro reflex at 8 months of age
c.
Moro reflex at 3 months of age
d.
Extensor reflex at 7 months of age
d.
Extensor reflex at 7 months of age

ANS: D
Establishing a diagnosis of cerebral palsy (CP) may be confirmed with the persistence of primitive reflexes: (1) either the asymmetric tonic neck reflex or persistent Moro reflex (beyond 4 months of age) and (2) the crossed extensor reflex. The tonic neck reflex normally disappears between 4 and 6 months of age. The crossed extensor reflex, which normally disappears by 4 months, is elicited by applying a noxious stimulus to the sole of one foot with the knee extended. Normally, the contralateral foot responds with extensor, abduction, and then adduction movements. The possibility of CP is suggested if these reflexes occur after 4 months.
5. The nurse in the neonatal intensive care unit is caring for an infant with myelomeningocele scheduled for surgical repair in the morning. Which early signs of infection should the nurse monitor on this infant? (Select all that apply.)
a.
Temperature instability
b.
Irritability
c.
Lethargy
d.
Bradycardia
e.
Hypertension
a.
Temperature instability
b.
Irritability
c.
Lethargy

ANS: A, B, C
The nurse should observe an infant with unrepaired myelomeningocele for early signs of infection, such as temperature instability (axillary), irritability, and lethargy. Bradycardia and hypertension are not early signs of infection in infants.
4. Surgery has informed a nurse that the patient returning to the floor after spinal surgery has an opioid epidural catheter for pain management. The nurse should prepare to monitor the patient for which side effects of an opioid epidural catheter? (Select all that apply.)
a.
Urinary frequency
b.
Nausea
c.
Itching
d.
Respiratory depression
b.
Nausea
c.
Itching
d.
Respiratory depression

ANS: B, C, D
Respiratory depression, nausea, itching, and urinary retention are dose-related side effects from an epidural opioid. Urinary retention, not urinary frequency, would be seen.
4. A nurse is assessing a 6-month-old infant. The nurse recognizes the posterior fontanel usually closes at which age?
a.
6 to 8 weeks
b.
10 to 12 weeks
c.
4 to 6 months
d.
8 to 10 months
a.
6 to 8 weeks

ANS: A
The bones surrounding the posterior fontanel fuse and close by age 6 to 8 weeks; 10 to 12 weeks, 4 to 6 months, and 8 to 10 months are too late. The posterior fontanel is usually closed by age 8 weeks.
38. When caring for the child with Kawasaki disease, the nurse should know which information?
a.
A child's fever is usually responsive to antibiotics within 48 hours.
b.
The principal area of involvement is the joints.
c.
Aspirin is contraindicated.
d.
Therapeutic management includes administration of gamma globulin and aspirin.
d.
Therapeutic management includes administration of gamma globulin and aspirin.

ANS: D
High-dose IV gamma globulin and aspirin therapy is indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. The fever of Kawasaki disease is unresponsive to antibiotics and antipyretics. Mucous membranes, conjunctiva, changes in the extremities, and cardiac involvement are seen. Aspirin is part of the therapy.