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PCN 103 Test 3 - Ch 30: Basic Pediatric Nursing Care, Ch 31: Care of the Child with a Physical Disorder

Terms in this set (96)

1. Dr. Abraham Jacobi focused attention on health problems in children and made a major stride toward their welfare by initiating:
a. pediatric wards in hospitals.
b. free inoculations against smallpox.
c. milk stations in the city of New York.
d. serving nutritious foods in orphanages.
ANS: C
Dr. Abraham Jacobi, referred to as the father of pediatrics, initiated the establishment of milk stations in New York showing how to sanitize milk for children.

REF: Page 942 TOP: Abraham Jacobi
2. Lillian Wald, a social reformer at the turn of the 20th century, founded the:
a. National Commission on Children.
b. Henry Street Settlement.
c. White House Conference.
d. U.S. Children's Bureau.
ANS: B
Lillian Wald, regarded as the founder of public health, founded Henry Street Settlement, which provided nursing services and social assistance.

REF: Page 942
TOP: Lillian Wald
3. When the pediatric nurse is attempting to establish a trusting relationship with a child, the most important and lasting thing to be done is to:
a. convey respect.
b. talk with the child.
c. be honest.
d. talk with family.
ANS: C
To establish a trusting relationship, the most important thing is to be honest.

REF: Page 943 TOP: Pediatric nurse
4. The nurse recognizes that children who have congenital abnormalities, malignancies, gastrointestinal (GI) diseases, or central nervous system (CNS) anomalies are grouped into a special category called:
a. very dependent children.
b. children requiring special education.
c. children with special needs.
d. children requiring long-term care.
ANS: C
The definition of children with special needs includes congenital abnormalities, malignancies, GI diseases, and CNS anomalies.

REF: Page 944 TOP: Children
5. The mother of a child with diabetes asks the nurse in charge of the family-centered pediatric unit if she might see her child's laboratory reports. The nurse should reply:
a. "Although the actual reports are not shared, I can tell you her blood sugar is 200 mg."
b. "I'll write them down for you and bring them to your room."
c. "Come to the conference room where we can have privacy while you look at them."
d. "I'll notify the physician that you wish to see the reports."
ANS: C
With a family-centered care approach, hospitals welcome parents, and parents have access to information 24 hours a day.

REF: Pages 944-945 TOP: Family-centered care
6. The pediatric nurse who uses the developmental approach in her practice will focus on:
a. stimulation of the child to reach expected norms.
b. age-centered care plans.
c. strengths of the child.
d. characteristics for the particular age.
ANS: C
A developmental approach emphasizes the child's abilities and considers individuality.

REF: Page 946 TOP: Developmental approach
7. When using anticipatory guidance to prepare a 5-year-old for an IM injection, the nurse should state:
a. "Ethan, I'm going to give you a shot."
b. "Ethan, the doctor wants you to have some medicine, and it will hurt."
c. "Ethan, some medicine can only be given with a needle."
d. "Ethan, I am going to give you some medicine that will sting, but only for a little while."
ANS: D
Anticipatory guidance is the psychological preparation of a patient for a stressful event by explaining what will happen and the probable outcome.

REF: Page 947 TOP: Anticipatory guidance
8. When measuring the head circumference of an infant, the nurse should place the tape measure:
a. across the eyebrows and around the occipital lobe.
b. over the zygomatic arches and around the parietal areas.
c. around forehead and around the crown of the head.
d. above the eyebrows and pinnas and around the occipital lobe.
ANS: D
Head circumference is measured in children up to 36 months above the eyebrows and pinnas and around the occipital lobe.

REF: Page 948 TOP: Head circumference
9. The nurse delays assessing the temperature in an infant because of the false elevation of temperature caused by the child:
a. having a bowel movement.
b. crying vigorously.

c. having just eaten.
d. having been in a cold room.
ANS: B
Crying increases the temperature; eating and bowel movements do not. A cold room would lower the temperature.

REF: Page 949 TOP: Vital signs
10. To ensure accuracy of measurements, the nurse performs vital signs assessment in which order?
a. Respiration, temperature, pulse
b. Pulse, respiration, temperature
c. Temperature, pulse, respiration
d. Respiration, pulse, temperature
ANS: D
The respiration is taken first on an infant before the child is disturbed, pulses are assessed next, and last the temperature is obtained.

REF: Page 949 TOP: Vital signs
11. Obtaining the respirations of an infant requires a modified approach from that of an adult because:
a. infants breathe through their noses.
b. infants have very rapid respirations.
c. infants' respirations are thoracic in nature.
d. infants' respiratory movements are abdominal.
ANS: D
In children under 6 or 7 years of age, respiratory movements are abdominal.

REF: Page 950 TOP: Vital signs
12. An 8-year-old child asks how a blood pressure is taken. The nurse should reply:
a. "This small machine will measure your systolic and diastolic pressure."
b. "The armband will hug your arm and tell me how well your blood is going through your arm."
c. "The armband will cut off your circulation for a while and then we can hear when it comes back."

d. "When you are ill we need to know if your blood is still moving in your body."
ANS: B
Because children are upset by unfamiliar procedures, it is best to explain each step in simple terms. It is best not to mention anything that may increase anxiety.

REF: Pages 957-958
TOP: Vital signs
13. The nurse compresses the nailbed of a child who has just received an arm cast to assess:
a. loss of sensation.
b. impending edema.
c. perception of pain.
d. peripheral circulation.
ANS: D
The blanch test is done by pressing down on the free edge of the nail and comparing the return of blood flow to assess for peripheral circulation.

REF: Page 951 TOP: Circulation
14. When assessing jaundice in an African-American child with sickle cell anemia, the nurse should:
a. examine the sclera.
b. press the edge of the pinna.
c. apply pressure to the gum.
d. compare the color on the soles of the feet.
ANS: C
The gums in individuals with dark complexions can be used to assess jaundice by pressing the gums about the teeth.

REF: Page 951 TOP: Jaundice
15. When discussing growth and development with the parents of a child, the nurse explains that nutrition is the single most important influence on:
a. cognitive development.
b. secondary sexual characteristics.
c. production of blood cells.

d. growth of bones and muscle.
ANS: D
Nutrition is probably the single most important influence on growth.

REF: Page 954 TOP: Nutrition Step: Planning
16. When the mother of a 3-year-old expresses concern about her daughter's slowed growth rate, the nurse's most informative response would be:
a. "Three-year-olds have finished a growth spurt and now their coordination can catch up."
b. "Children's growth is hereditary. She may be of small stature like you."
c. "The growth of a 3-year-old is associated with their nutrition. How is she eating?"
d. "Your daughter is healthy and happy. Don't worry about her growth right now."
ANS: A
Three-year-olds slow down in their growth in a natural cycle.

REF: Page 946 TOP: Growth
17. The nurse explains to the anxious parents that the administration of an opioid analgesic to their 3-year-old is:
a. likely to cause significant respiratory depression.
b. done with the knowledge that addiction may occur.
c. effective as a pain control method.
d. given only in cases of severe pain.
ANS: C
When administered to children, opioid analgesics do not have any greater respiratory depression than when given to an adult, and the risk of addiction is virtually nonexistent in children. It is an effective type of analgesia.

REF: Page 962 TOP: Opioid analgesia
18. When assessing a neonate, the pediatric nurse should alert the head nurse or physician about which assessment finding?
a. Crossed eyes
b. A tuft of hair on the sacrum
c. Purposeless movement of the arms

d. Blue tint to the soles of the feet
ANS: B
The tuft of hair along the spine is an indicator for spina bifida occulta. All other options are normal in the newborn.

REF: Page 951
TOP: Newborn assessment
19. When communicating with a 5-year-old child, the nurse should:
a. use two-word sentences and colored pictures.
b. rely on short three-word sentences.
c. use descriptive words with hand gestures.
d. speak in no more than six-word sentences.
ANS: D
When conversing with children, the nurse should use sentences with the number of words being equal to their age plus 1. A 5-year-old can follow a six-word sentence.

REF: Page 957
TOP: Development
20. The parents ask about preparation of their toddler for hospital admission. The nurse suggests the child be told:
a. a week prior.
b. 2 weeks prior.
c. the day of admission.
d. only two or three days before.
ANS: D
The nurse should suggest the toddler be told only days before.

REF: Page 959 TOP: Hospitalization
21. When the newly admitted 2-year-old who was potty-trained before admission begins to wet the bed, the mother is frightened. The nurse can allay anxiety by saying:
a. "Don't be concerned. Accidents happen."
b. "Let's put a diaper on your child until this gets better."
c. "The stress of hospitalization makes children regress a little."
d. "Your child will relearn 'potty-training' if you are patient."
ANS: C
It is not unusual for children to regress when hospitalized.

REF: Page 960 TOP: Hospitalization regression
22. When initiating a care plan for a child with special needs, the nurse recognizes the probability that the child will be:
a. accustomed to the hospital milieu.
b. unable to adapt to the hospital setting.
c. withdrawn and uncooperative.
d. hospitalized for a longer period of time.
ANS: D
Children with special needs who are hospitalized are more vulnerable to the emotional and developmental consequences of hospitalization and will have longer and more traumatic hospital stays.

REF: Page 960 TOP: Hospitalization of child with special needs
23. When attempting to provide information to the parents of a child undergoing surgery, the nurse notes that the parents appear confused and do not seem to remember what they are being told. This may be because of the:
a. noisy environment.
b. serious nature of surgery.
c. increased level of parents' anxiety.
d. developmental age of the child.
ANS: C
Anxiety of the parents may result in confusion and forgetfulness.

REF: Page 963 TOP: Hospitalization
24. The best time to bathe an infant is:
a. at bedtime.
b. early in the morning.
c. after a feeding.
d. before a feeding.
ANS: D
Bathing is usually done before a feeding to reduce the possibility of vomiting, regurgitation, or aspiration.

REF: Page 965 TOP: Feeding Step: Planning
25. After feeding, the nurse should position the infant on the:
a. stomach.
b. right side.
c. left side.
d. back.
ANS: B
After feeding, the infant is positioned on the right side to direct the food into the stomach.

REF: Page 966 TOP: Feeding
26. When a safety reminder device (SRD) is used to protect a child, a responsibility of the nurse is to:
a. apply it loosely.
b. remove it every 2 hours.
c. place it over clothing.
d. apply only one type.
ANS: B
Any SRD should be removed every 2 hours.

REF: Page 967 TOP: Safety
27. Before performing a gavage feeding, the nurse should:
a. hold the feeding tube under water to check for bubbling.
b. check for gastric distention.
c. aspirate stomach contents.
d. ensure sterility of feeding equipment.
ANS: C
Aspirating stomach contents to confirm tube placement is the most effective test.

REF: Page 967 TOP: Tube feedings
28. When a child with respiratory difficulties is placed in a mist tent, the nurse explains that the purpose of the tent is to:
a. provide a constant oxygen supply.
b. liquefy respiratory secretions.
c. provide moisture to the mucous membranes.
d. improve the infant's hydration.
ANS: B
The purpose of the mist tent is to liquefy respiratory secretions.

REF: Page 971 TOP: Mist tent
29. When suctioning to remove secretions from an artificial airway, the nurse should limit the suction time to:
a. 1 minute.
b. 5 seconds.
c. 10 seconds.
d. 15 seconds.
ANS: B
The nurse should limit suctioning to no more than 5 seconds.

REF: Page 972 TOP: Tracheal suction
30. The toddler is receiving oxygen in a mist tent. One of the disadvantages of the tent is that it requires the nurse to:
a. remove the restless child.
b. change wet bedding and clothing as needed.
c. open the mist tent at least once an hour.
d. keep all objects outside of the tent.
ANS: B
Frequent linen and clothing changes may be necessary because of the heavy humidity in the tent.

REF: Page 971

TOP: Mist tent
31. The nurse recognizes that getting the hospitalized child to eat adequate amounts of food can be a challenge. One way to enhance nutrition is to:
a. reward with sweets for eating meals.
b. discourage participation in noneating activities.
c. administer large amounts of nutritious fluids.
d. leave nutritious finger foods out for the child to eat.
ANS: C
Using nutritious liquids may satisfy the nutritional needs when a toddler is "too busy" to eat. Toddlers should not be left to eat unsupervised because of the danger of aspiration.

REF: Page 966 TOP: Nutrition
32. The pediatric nurse warns student nurses about medicating newborns and young children because these children are:
a. less susceptible to medication effects than adults.
b. more susceptible to medication effects than adults.
c. equally susceptible to medication effects as adults.
d. less susceptible to all medications.
ANS: B
Newborns and young children are more susceptible to the toxic effects of some medications than adults.

REF: Page 972 TOP: Medication
33. The nurse preparing to administer an IM injection to a 2-year-old recognizes the preferred injection site for a child of this age is the:
a. deltoid muscle.
b. upper thigh.
c. mid-thigh.
d. gluteus.
ANS: C
The primary site for an IM injection for a 2-year-old is the vastus lateralis.

REF: Page 976, Box 30-10 TOP: IM medication
34. The nurse explains that for stability of the IV insertion site in an infant younger than 9 months of age, the insertion site is the:
a. radial vein.
b. scalp vein.
c. femoral vein.
d. brachial vein.
ANS: B
A superficial scalp vein is the injection site for administering IV medication to infants younger than 9 months of age.

REF: Page 975 TOP: IV medication
35. Following a lumbar puncture of a 2-year-old, the nurse:
a. keeps the child flat for several hours.
b. allows the child to play at will.
c. holds the child in a flexed position for 5 minutes.
d. stands the child upright immediately.
ANS: B
Children younger than 3 years of age are usually not affected by post-lumbar headache. These children are allowed to play at will following a lumbar puncture.

REF: Page 970 TOP: Lumbar puncture
36. The nurse can minimize an unpleasant-tasting drug by:
a. pouring the drug over ice.
b. squirting the drug in the mouth with a syringe.
c. administering the drug through a straw.
d. enlisting the parent's assistance.
ANS: C
Administering the drug through a straw will diminish an unpleasant taste. Having the child hold the nose is helpful, as bad taste is associated with the smell of the drug.

REF: Page 974 TOP: Medication
37. The pediatric nurse recognizes the significant developmental impact that a disfiguring facial wound could have on a:
a. 4-year-old.
b. 6-year-old.
c. 10-year-old.
d. 14-year-old.
ANS: D
The adolescent fears a change in body image associated with surgery.

REF: Page 963, Table 30-8
TOP: Surgery
38. When the nurse is inserting a feeding tube in an 8-month-old, the most efficient safety reminder device (SRD) the nurse would use is a(n):
a. mummy.
b. clove hitch.
c. jacket device.
d. elbow device.
ANS: A
The mummy restraint controls the arms and the body of the infant.

REF: Page 967
TOP: Safety reminder devices (SRDs) Step: Planning
39. The nurse welcomes the presence of the family in a pediatric unit because it reduces the stressors of hospitalization. Which are common stressors for the hospitalized child? (Select all that apply.)
a. Separation
b. Lack of love
c. Fear of pain
d. Unfamiliar food
e. Loss of control
ANS: A, C, E
Parents lend stability and comfort for the child and restore his or her sense of control.

REF: Page 944 TOP: Parents on the pediatric unit
40. The pediatric nurse, along with the primary caregiver(s), has a special duty to
the child and the family.
ANS:
teach
The pediatric nurse is in a position to assess, instruct, and support children and their families about developmental progress, nutrition, and possible undiagnosed anomalies.

REF: Page 943 TOP: Teaching
41. The nurse recognizes that % of hospitalized children have special needs.
ANS:
35
thirty-five
Children with special needs comprise 35% of the pediatric hospitalization admissions.

REF: Page 944 TOP: Special needs children
42. The nurse is aware that visual acuity evaluation in a child is best assessed after the age of years.
ANS:
6
six
A child's refraction does not reach 20/20 until about the age of 6.

REF: Page 952
TOP: Visual acuity
43. The nurse clarifies that the family-centered care approach terminates which policies? (Select all that apply.)
a. Rigid visiting hours
b. Age restrictions on visitors
c. Exclusion of family during procedures
d. Discouraging family to stay overnight
e. Restricting parents from reading the chart
ANS: A, B, C, D, E

Family-centered care terminates all the restrictive policies of traditional hospitals.

REF: Pages 944-945 TOP: Family-centered care
1. The nurse uses a diagram to show that tetralogy of Fallot involves a combination of which four congenital defects?
a. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
b. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
c. Aortic stenosis, atrial septal defect, overriding aorta, right ventricular hypertrophy
d. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
ANS: B
Tetralogy of Fallot involves a combination of four congenital defects: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy.

REF: Page 990 TOP: Heart defect
2. When caring for a child with coarctation of the aorta, the nurse assesses for the most common clinical manifestation, which is:
a. clubbing of the digits.
b. upper extremity hypertension.
c. pedal edema and portal congestion.
d. loud systolic ejection murmur.
ANS: B
Coarctation of the aorta results in hypertension in the upper extremities.

REF: Page 991 TOP: Heart defect
3. Parents of a 6-month-old child who has just been diagnosed with iron deficiency anemia ask why it was not diagnosed earlier. The nurse's best response is:
a. "Are you sure your child has iron deficiency anemia?"
b. "This happens when the maternal stores of iron are depleted at about 6 months."
c. "This anemia is caused by blood loss."
d. "The child may not have had it for a long time."
ANS: B
Iron deficiency anemia becomes apparent at about 6 months of age in a full-term infant, when maternal stores of iron are depleted.

REF: Page 992 TOP: Anemia
4. Therapeutic management of iron deficiency anemia includes administration of what?
a. Multivitamins
b. Calcium
c. Ferrous sulfate
d. Iodine
ANS: C
Therapeutic management of iron deficiency anemia is iron supplementation.

REF: Pages 992-993
TOP: Anemia
5. The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. The nurse explains that the child's pain is caused by:
a. inflammation of the vessels.
b. obstructed blood flow.
c. overhydration.
d. stress-related headaches.
ANS: B
The signs and symptoms of sickle cell anemia include the sickle-shaped cells clumping and obstructing blood flow, which causes pain.

REF: Page 993 TOP: Blood disorders
6. The parents of a child diagnosed with sickle cell anemia ask what to do to avoid a sickle cell crisis. The nurse explains that the medical management of sickle cell crisis includes:
a. information for the parents including home care.
b. providing adequate hydration and pain management.
c. pain management and administration of iron supplements.
d. adequate oxygenation and factor VIII.
ANS: B
Medical management of sickle cell crisis includes palliative analgesics, hydration, and oxygen.

REF: Page 994 TOP: Blood disorders
7. When reviewing laboratory results for a child with hemophilia, the nurse anticipates finding an abnormal:
a. prothrombin time.
b. bleeding time.
c. platelet count.
d. partial thromboplastin time.
ANS: D
Expected laboratory findings for a child with hemophilia include a prolonged partial thromboplastin time.

REF: Page 995
TOP: Blood disorders
8. The parents of a child with acute lymphoblastic leukemia ask about the best approach for maintaining remission of the disease. The nurse informs them that the most effective therapy would be:
a. surgery to remove enlarged lymph nodes.
b. long-term chemotherapy.
c. nutritional supplements to enhance blood cell production.
d. blood transfusions to replace ineffective red cells.
ANS: B
The drug of choice is methotrexate, a chemotherapeutic agent, to produce remission.

REF: Page 998 TOP: Blood disorders
9. The nurse teaches parents that the severity of infant respiratory distress syndrome (RDS) is most influenced by:
a. poor cough and gag reflex.
b. the gestational age at birth.
c. administering high concentrations of oxygen.
d. the sex of the infant.
ANS: B
RDS is caused by a deficiency of surfactant and occurs almost exclusively in preterm, low-birth-weight infants.

REF: Page 1003 TOP: Respiratory distress syndrome (RDS)
10. A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. The nurse should:
a. restrain the child in the tent and notify the physician.
b. increase the oxygen concentration in the tent.
c. take the child out of the tent and into the playroom.
d. ask the mother for help in comforting the child.
ANS: B
The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation.

REF: Page 1009 TOP: Laryngotracheobronchitis (LTB)
11. The mother of a child with acute laryngotracheobronchitis (LTB) asks why her child must be kept NPO. The nurse explains that:
a. the epinephrine given causes nausea and vomiting.
b. the child is being hydrated with IV fluids.
c. swollen respiratory passages make eating difficult.
d. the child's rapid respirations pose a risk for aspiration.
ANS: D
Rapid respirations predispose to aspiration.

REF: Page 1009 TOP: Laryngotracheobronchitis (LTB)
12. The nurse teaches the parents of a child with acute epiglottitis that the child could suddenly suffer:
a. increased carbon dioxide levels.
b. airway obstruction.

c. inability to swallow.
d. bronchial collapse.
ANS: B
Immediate treatment of acute epiglottitis includes an artificial airway.

REF: Page 1009 TOP: Epiglottis
13. The mother of a child who has pneumonia is asking what could have been done to prevent the infection. The nurse teaches the mother that children older than 2 years:
a. are still protected by antibodies from the mother.
b. can be inoculated against pneumococcal pneumonia.
c. may have nutritional deficits that make them vulnerable.
d. are frequently sedentary, which makes them susceptible to infections.
ANS: B
The new recommendations for inoculations include protection against pneumonia.

REF: Page 1042 TOP: Pneumonia
14. When conducting a class for parents about sudden infant death syndrome (SIDS), the nurse instructs the class that new information suggests not placing the infant in which position?
a. Right side-lying
b. Left side-lying
c. Prone
d. Supine
ANS: C
The American Academy of Pediatrics recommends placing the infant supine or side- lying rather than prone as a defense against SIDS.

REF: Page 1006 TOP: Sudden infant death syndrome (SIDS)
15. When interacting with the parents of a SIDS infant, one of the things the nurse attempts to assist with is:
a. referring the parents to a psychologist.
b. encouraging the parents to remain stoic.

c. allaying feelings of guilt and blame.
d. learning how the event could have been prevented.
ANS: C
As parents try to cope, they have feelings of guilt and blame.

REF: Page 1007 TOP: Sudden infant death syndrome (SIDS)
16. The nurse educates the family of a newly admitted child with cystic fibrosis that the therapy will be centered on:
a. chest physiotherapy.
b. mucus-drying agents.
c. prevention of diarrhea.
d. insulin therapy.
ANS: A
Chest physiotherapy and aerosol medications are the center of treatment for cystic fibrosis.

REF: Page 1012 TOP: Cystic fibrosis
17. When reviewing the pathophysiology of cystic fibrosis, the nurse recognizes that it is characterized by:
a. multiple upper respiratory infections.
b. an underproduction of exocrine glands.
c. excessive, thick mucus.
d. an overproduction of thin mucus.
ANS: C
The pathophysiology of cystic fibrosis includes excessive, thick mucus.

REF: Page 1011
TOP: Cystic fibrosis
18. The nurse selects which time as the best to administer the pancreatic enzyme replacement?
a. Before meals and snacks
b. Before bedtime
c. Early in the morning

d. After meals and snacks
ANS: A
Pancreatic enzymes are administered before meals and snacks.

REF: Page 1012 TOP: Cystic fibrosis
19. Following surgical repair of a cleft palate, when soft food is introduced, the nurse modifies the care plan to include feeding safety based on the knowledge that to avoid injury to the suture line, it is best to avoid the use of a:
a. feeding dropper.
b. spoon.
c. syringe.
d. cup.
ANS: B
When feeding a child with a repaired cleft palate, the nurse should avoid utensils.

REF: Page 1017
TOP: Cleft lip and palate Step: Planning
20. The nurse is assisting the parents of a child born with a cleft lip and palate to deal with the deformity. An appropriate nursing diagnosis for the parents is:
a. parental role conflict.
b. risk for delayed growth and development.
c. risk for impaired attachment.
d. anticipatory grieving.
ANS: C
A goal is to promote bonding between parents and infant.

REF: Page 1017
TOP: Cleft lip and palate
21. When discussing long-term complications of a child with cleft lip and palate, the nurse tells the parents that one of the complications is:
a. cognitive impairment.
b. altered growth and development.
c. faulty dentition.
d. physical abilities.
ANS: C
The older child with cleft lip and palate may experience psychologic difficulties because of the cosmetic appearance of the defect, problems with impaired speech, and faulty dentition.

REF: Page 1016 TOP: Cleft lip and palate
22. The nurse measures intake and output for an infant with dehydration by:
a. attaching a urine collecting bag.
b. wringing out the diaper.
c. weighing the diaper.
d. inserting a catheter.
ANS: C
Wet diapers can be weighed to assess the amount of output.

REF: Page 1018 TOP: Dehydration
23. A school-age child has been rehydrated following a bout of diarrhea. The nurse offers foods that are nonirritating to the bowel, including:
a. apricots and peaches.
b. chocolate milk.
c. applesauce and milk.
d. bananas and rice.
ANS: D
When rehydration has been completed, the nurse should offer bananas and rice, which are nonirritating.

REF: Page 1019 TOP: Nutrition
24. The nurse explains that gastroesophageal reflux (GER) usually begins within the first week of life in infants and is usually treated by:
a. making the infant NPO.
b. thickening the food with cereal.
c. placing the infant in an upright position.
d. feeding the infant in a car seat.
ANS: B

GER is treated with small feedings thickened with cereal.

REF: Page 1021 TOP: Nutrition
25. The nurse assessing an infant who has been diagnosed with hypertrophic pyloric stenosis anticipates:
a. a history of diarrhea following each feeding.
b. gastric pain evidenced by vigorous crying.
c. poor appetite due to a poor sucking reflex.
d. an olive-shaped mass at the midline.
ANS: D
Examination of the abdomen may assist in the diagnosis and reveal key signs of hypertrophic pyloric stenosis. Visible peristaltic waves that move from left to right across the epigastric region may be evident, and palpation may reveal an olive-shaped mass in this area to the right of the midline.

REF: Page 1022
TOP: Pyloric stenosis
26. When assessing a child admitted with intussusception, the nurse discovers the hallmark sign of intussusception, which is:
a. mucus-like stools.
b. currant jelly-like stools.
c. tarry, black stools.
d. green, soft stools.
ANS: B
The hallmark sign of intussusception is currant jelly stools.

REF: Page 1023
TOP: Gastrointestinal disorders
27. When a 2-year-old child is admitted with a diagnosis of Hirschsprung's disease, the nurse explains that the causative factor of this disease is:
a. frequent evacuation of solids, liquid, and gases.
b. excessive peristaltic movement.
c. the absence of parasympathetic ganglion cells in a portion of the colon.
d. one portion of the bowel telescoping into another.
ANS: C

The causative factor in Hirschsprung's disease is the absence of parasympathetic ganglion cells in a portion of the colon.

REF: Page 1024 TOP: Gastrointestinal disorders
28. The nurse caring for a 6-year-old child with acute glomerulonephritis anticipates that the most difficult part of the care will be implementing:
a. forced fluids.
b. increased feedings.
c. bed rest.
d. frequent position changes.
ANS: C
During the acute phase of glomerulonephritis, bed rest is usually recommended. A diet of restricted fluid, sodium, potassium, and phosphate is initially required.

REF: Page 1028 TOP: Genitourinary disorders
29. When selecting nursing diagnoses for the 4-year-old child with nephrosis, the nurse places priority on risk for:
a. impaired body image.
b. skin impairment.
c. nutritional deficit.
d. injury.
ANS: B
Nephrosis is a clinical state characterized by gross edema, which makes skin care a priority.

REF: Page 1027
TOP: Genitourinary disorders
30. When caring for a 7-week-old infant with hypothyroidism, the nurse explains that the administration of oral thyroid replacement therapy is critical for this child to prevent:
a. excessive growth.
b. cognitive impairment.
c. damage to the nervous system.
d. damage to the urinary system.
ANS: B
The treatment of choice for congenital and acquired hypothyroidism is oral thyroid hormone replacement therapy. Prompt treatment is especially critical in the infant with congenital hypothyroidism to avoid permanent cognitive impairment.

REF: Page 1030 TOP: Hypothyroidism
31. The nurse explains to the parents of a child with developmental hip dysplasia that the application of a Pavlik harness will hold the child's femurs in:
a. abduction.
b. adduction.
c. flexion.
d. extension.
ANS: A
The use of the Pavlik harness maintains abduction for 4 to 6 months.

REF: Page 1035 TOP: Pavlik
32. A teenage girl has been placed in a body cast for the treatment of scoliosis, the most common skeletal deformity of adolescence. When the family asks what they can do to be more supportive, the nurse suggests:
a. enrolling her in a health club.
b. taking her to the mall in a wheelchair.
c. purchasing clothes to disguise the cast.
d. spending a majority of their time with her.
ANS: C
The adolescent is trying to fit in with peers and has concerns about body image.

REF: Pages 1036-1038 TOP: Scoliosis
33. A newborn has talipes and has been casted. The nurse explains that the casts must be changed:
a. daily.
b. weekly.
c. bi-weekly.

d. monthly.
ANS: B
Treatment of talipes consists of manipulation and the application of a series of short leg casts. The foot is gently manipulated into a more normal position and then casted to maintain the correction. Casts are changed weekly to allow for further manipulation and to accommodate the rapidly growing infant.

REF: Pages 1038-1039 TOP: Club foot
34. A child with Duchenne's muscular dystrophy rises from the floor by walking up the thighs with the hands. The nurse records this observation as:
a. hand-assistance.
b. leg crawling.
c. Gowers' sign.
d. Bright's sign.
ANS: C
Using the hands to walk up the thighs is known as Gowers' sign.

REF: Page 1039 TOP: Duchenne's muscular dystrophy (DMD)
35. When assessing a child for classical signs of meningeal irritation, the nurse records:
a. positive Kernig's sign, diarrhea, and headache.
b. negative Brudzinski's sign, positive Kernig's sign, and irritability.
c. positive Brudzinski's and Kernig's signs and photophobia.
d. negative Kernig's sign, vomiting, and fever.
ANS: C
Manifestations of meningitis include photophobia and positive Kernig's and Brudzinski's signs.

REF: Page 1041 TOP: Meningitis
36. The physician is treating a child with meningitis with a course of antibiotic therapy. The nurse assures the parents that the child will be out of isolation when:
a. the course of antibiotics is complete.
b. a negative CNS culture is obtained.

c. the antibiotics have been initiated for 24 hours.
d. the child has no symptoms of the disease.
ANS: C
The child with bacterial meningitis is isolated until antibiotic therapy has been administered for at least 24 hours.

REF: Page 1041 TOP: Meningitis
37. The nurse caring for a 4-year-old child with cerebral palsy recognizes that the priority nursing interventions are designed to:
a. assist with referral to specialized education.
b. support the child with independent toileting.
c. assist the child to develop effective communication.
d. encourage the child to ambulate independently.
ANS: D
A clinical manifestation of cerebral palsy is usually the need of support with communication, locomotion, and self-help.

REF: Page 1045
TOP: Cerebral palsy Step: Planning
38. The nurse is caring for a newborn with a myelomeningocele. Before surgery, the nursing interventions should include:
a. leaving the lesion uncovered and placing the infant supine.
b. covering the lesion with a sterile, saline-soaked gauze.
c. applying lotion to the lesion to keep it moist.
d. covering the lesion with a dry, sterile gauze.
ANS: B
Nursing interventions for an infant with myelomeningocele include covering the lesion with a sterile, saline-soaked gauze.

DIF: Cognitive Level: ApplicationREF: Page 1047, Box 31-10 OBJ: 13 TOP: Spina bifida
39. Which additional congenital malformation is expected in 80% of infants with a myelomeningocele?
a. Cerebral palsy
b. Hydrocephalus

c. Meningitis
d. Neuroblastoma
ANS: B
Hydrocephalus is present in 80% of infants affected by a myelomeningocele.

REF: Page 1047 TOP: Spina bifida
40. When speaking to young parents, the nurse states that lead poisoning is one of the most common preventable health problems affecting children. When lead levels exceed the amount that can be absorbed by the bones, it leads to:
a. malnutrition.
b. anemia.
c. bone pain.
d. diarrhea.
ANS: B
When the amount of lead ingested exceeds the amount that can be absorbed by the bone, it leads to anemia.

REF: Page 1049
TOP: Lead poisoning
41. An infant has been diagnosed with cradle cap. The nurse recognizes that the intervention to treat the scaly patches on the scalp is to apply:
a. alcohol.
b. mineral oil.
c. calamine.
d. A&D ointment.
ANS: B
Crusty patches can be removed with the application of mineral oil.

REF: Page 1053 TOP: Skin disorders
42. An adolescent female asks the nurse about taking retinoic acid (Accutane). The nurse instructs that the medication:
a. should be used only for 10 weeks.
b. requires that sexually active females use contraception.
c. lowers hemoglobin very quickly.

d. has few side effects.
ANS: B
Accutane has many side effects and can produce birth defects. Effective contraception is necessary during treatment and 1 month after the 20 weeks it is to be taken.

REF: Page 1055 TOP: Acne
43. A new mother asks the clinic nurse if she must continue giving her baby nystatin for thrush since the white lesions on his tongue have disappeared. The nurse replies:
a. "No. When the lesions have gone you may stop the nystatin."
b. "Yes. You should continue it for the full 7 days."
c. "No. Thrush is a self-limiting disorder and nystatin is given for comfort only."
d. "Yes. The medication should be refilled for a second week of therapy."
ANS: B
Nystatin should be given for the full 7 days even if the lesions are no longer present.

REF: Page 1057 TOP: Skin disorders
44. The mother brings the child to the nurse because of exposure to varicella. The nurse explains that early signs of the disease are:
a. high fever over 101° F.
b. general malaise.
c. increased appetite.
d. crusty sores.
ANS: B
Early signs of varicella will develop during the prodromal period and are mainly low- grade fever, malaise, and anorexia. Lesions do not appear until later.

REF: Page 1059, Table 31-7 TOP: Skin disorders
45. The mother of a child who has been diagnosed with varicella asks the nurse when the child can return to school. The nurse states that the child is no longer contagious:
a. when the fever dissipates.

b. after the incubation period.
c. when the lesions have healed.
d. when the lesions are crusted over.
ANS: D
Varicella is no longer contagious when the lesions are dry.

REF: Page 1059, Table 31-7 TOP: Skin disorders
46. A child has developed a diaper rash, and the parents are using zinc oxide to treat it. The nurse is instructing the parents about removal of the ointment and suggests using:
a. mild soap and water.
b. a cotton ball.
c. mineral oil.
d. alcohol swabs.
ANS: C
To completely remove ointment, especially zinc oxide, mineral oil should be used.

DIF: Cognitive Level: ApplicationREF: Page 1052, Box 31-12 OBJ: 15 TOP: Diaper rash
47. The nurse instructs the parents of a child who has had a myringotomy to position the child:
a. supine.
b. on the affected side.
c. on the unaffected side.
d. in a Trendelenburg position.
ANS: B
Lying on the affected side facilitates drainage following a myringotomy.

REF: Page 1062 TOP: Myringotomy
48. The nurse instructs parents about the signs of otitis media, which include:
a. earache, wheezing, vomiting.
b. coughing, rhinorrhea, headache.

c. fever, irritability, pulling on ear.
d. wheezing, cough, drainage in ear canal.
ANS: C
Clinical manifestations of otitis media include fever, irritability, and pulling on the ear.

REF: Page 1058 TOP: Otitis media
49. The nurse instructs the mother of a child with a ventricular septal defect that she can expect the child to become cyanotic when the child does what?
a. Experiences an elevation in temperature
b. Sleeps on the left side
c. Cries vigorously
d. Is held upright
e. Eats
ANS: C
Crying vigorously will increase the pressure in the right ventricle, which will allow unoxygenated blood to enter the circulating volume.

REF: Page 990 TOP: Septal defects
50. When assessing the laboratory values of a child with nephrosis, the nurse anticipates which result(s)? (Select all that apply.)
a. High levels of protein in the urine
b. High serum lipid levels
c. Low serum protein levels
d. Low hemoglobin
e. High white blood cell count
ANS: A, B, C
A patient with nephrotic syndrome presents with high levels of serum lipids, low serum protein, and albumin in urine that is dark and frothy with a high specific gravity. The hemoglobin and WBC are usually normal.

REF: Pages 1026-1027
TOP: Nephrosis
51. When the mother of a child with gastroesophageal reflux calls the clinic nurse to report that her baby is vomiting small amounts of blood, the nurse explains that the esophagus has been irritated by .
ANS:
gastric acid
Gastric acid that has repeatedly come in contact with the esophageal mucosa will erode the mucosa, and bleeding will result.

REF: Page 1021 TOP: Gastroesophageal reflux (GER)
52. The nurse reassures the anxious mother of a child with pyloric stenosis who is to have surgery that the surgical procedure, called a , is quickly done and the child recovers almost immediately.
ANS:
pyloromyotomy
When the muscle is cut, the obstruction is immediately relieved and the child who is hungry will begin to eat and keep food down.

REF: Pages 1022-1023 TOP: Pyloromyotomy
53. The nurse anticipates that the cerebrospinal fluid (CSF) taken from a child with bacterial meningitis would have a low level.
ANS:
glucose
The glucose level in the CSF of a child with bacterial meningitis is low because the bacteria in the fluid have digested the glucose.

REF: Page 1041
TOP: Cerebrospinal fluid (CSF)
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