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PEDS T3 (Ch. 22-27)

Terms in this set (184)

What is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease?

a. Teaching how to irrigate the colostomy
b. Protecting the skin around the colostomy
c. Discussing the implications of a colostomy during puberty
d. Using simple, straightforward language to prepare the child
ANS: B

Protection of the peristomal skin is a major priority. Well-fitting appliances and skin protectants are used. Teaching how to irrigate a colostomy is not necessary because colostomies are not irrigated in infants. The colostomy is usually reversed within 6 months to 1 year. The parents, not the infant, need to be prepared for the surgery.
What disease processes require contact isolation? (Select all that apply.)

a. Rotavirus
b. Hepatitis A
c. Streptococcal pharyngitis
d. Mycoplasmal pneumonia
e. Respiratory syncytial virus
ANS: A, B, E

In addition to Standard Precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patients environment. Examples of such illnesses include rotavirus, hepatitis A, and respiratory syncytial virus. Streptococcal pharyngitis and mycoplasmal pneumonia require droplet precautions.
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. How should the nurse instruct the mother?

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.
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.
A child with congestive heart failure is placed on a maintenance dosage of digoxin (Lanoxin). The dosage is 0.07 mg/kg/day, and the child's weight is 7.2 kg. The physician prescribes the digoxin to be given once a day by mouth. Each dose will be _____ milligrams. (Record your answer below using one decimal place.)
ANS: 0.5

0.07 mg/day x 7.2 kg = 0.5 mg/day
What factor predisposes an infant to fluid imbalances?

a. Decreased surface area
b. Lower metabolic rate
c. Immature kidney functioning
d. Decreased daily exchange of extracellular fluid
ANS: C

The infants kidneys are functionally immature at birth and are inefficient in excreting waste products of metabolism. Infants have a relatively high body surface area (BSA) compared with adults. This allows a higher
loss of fluid to the environment. A higher metabolic rate is present as a result of the higher BSA in relation to active metabolic tissue. The higher metabolic rate increases heat production, which results in greater insensible
water loss. Infants have a greater exchange of extracellular fluid, leaving them with a reduced fluid reserve in conditions of dehydration.
What is the required number of milliliters of fluid needed per day for a 14-kg child?

a. 800
b. 1000
c. 1200
d. 1400
ANS: C

For the first 10 kg of body weight, a child requires 100 ml/kg. For each additional kilogram of body weight, an extra 50 ml is needed.
An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation?

a. Water excess
b. Sodium excess
c. Water depletion
d. Potassium excess
ANS: C

These clinical manifestations indicate water depletion or dehydration. Edema and weight gain occur with water excess or overhydration. Sodium or potassium excess would not cause these symptoms.
What amount of fluid loss occurs with moderate dehydration?

a. <50 ml/kg
b. 50 to 90 ml/kg
c. <5% total body weight
d. >15% total body weight
ANS: B

Moderate dehydration is defined as a fluid loss of between 50 and 90 ml/kg. Mild dehydration is defined as a fluid loss of less than 50 ml/kg. Weight loss up to 5% is considered mild dehydration. Weight loss over 15% is severe dehydration.
Physiologically, the child compensates for fluid volume losses by which mechanism?

a. Inhibition of aldosterone secretion
b. Hemoconcentration to reduce cardiac workload
c. Fluid shift from interstitial space to intravascular space
d. Vasodilation of peripheral arterioles to increase perfusion
ANS: C

Compensatory mechanisms attempt to maintain fluid volume. Initially, interstitial fluid moves into the intravascular compartment to maintain blood volume. Aldosterone is released to promote sodium retention and
conserve water in the kidneys. Hemoconcentration results from the fluid volume loss. With less circulating
volume, tachycardia results. Vasoconstriction of peripheral arterioles occurs to help maintain blood pressure.
Ongoing fluid losses can overwhelm the childs ability to compensate, resulting in shock. What early clinical sign precedes shock?

a. Tachycardia
b. Slow respirations
c. Warm, flushed skin
d. Decreased blood pressure
ANS: A

Shock is preceded by tachycardia and signs of poor tissue perfusion and decreased pulse oximetry values. Respirations are increased as the child attempts to compensate. As a result of the poor peripheral circulation, the child has skin that is cool and mottled with decreased capillary refilling after blanching. In children,
lowered blood pressure is a late sign and may accompany the onset of cardiovascular collapse.
The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant?

a. Weight loss and decreased heart rate
b. Capillary refill of less than 2 seconds and no tears
c. Increased skin elasticity and sunken anterior fontanel
d. Dry mucous membranes and generally ill appearance
ANS: D

A good predictor of a fluid deficit of at least 5% is any two four factors: capillary refill of more than 2 seconds, absent tears, dry mucous membranes, and ill general appearance. Weight loss is associated with fluid deficit,
but the degree needs to be quantified. Heart rate is usually elevated. Skin elasticity is decreased, not increased. The anterior fontanel is depressed.
The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is
suggestive of water intoxication?

a. Oliguria
b. Weight loss
c. Irritability and seizures
d. Muscle weakness and cardiac dysrhythmias
ANS: C

Irritability, somnolence, headache, vomiting, diarrhea, and generalized seizures are manifestations of water
intoxication. Urinary output is increased as the child attempts to maintain fluid balance. Weight gain is usually associated with water intoxication. Muscle weakness and cardiac dysrhythmias are not associated with water
intoxication.
What type of diarrhea is associated with an inflammation of the mucosa and submucosa in the ileum and colon caused by infectious agents?

a. Osmotic
b. Secretory
c. Cytotoxic
d. Dysenteric
ANS: D

Dysenteric diarrhea is associated with an inflammation of the mucosa and submucosa in the ileum and colon caused by infectious agents such as Campylobacter, Salmonella, or Shigella organisms. Edema, mucosal bleeding, and leukocyte infiltration occur. Osmotic diarrhea occurs when the intestine cannot absorb nutrients or electrolytes. It is commonly seen in malabsorption syndromes such as lactose intolerance. Secretory diarrhea is usually a result of bacterial enterotoxins that stimulate fluid and electrolyte secretion from the mucosal crypt cells, the principal secretory cells of the small intestine. Cytotoxic diarrhea is characterized by the viral destruction of the villi of the small intestine. This results in a smaller intestinal surface area, with a decreased capacity for fluid and electrolyte absorption.
What is the most frequent cause of hypovolemic shock in children?

a. Sepsis
b. Blood loss
c. Anaphylaxis
d. Heart failure
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. Heart failure contributes to hypervolemia, not hypovolemia.
What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?

a. Neurogenic shock
b. Cardiogenic shock
c. Hypovolemic shock
d. Anaphylactic shock
ANS: D

Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission after a spinal cord injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure.
In what condition should the nurse be alert for altered fluid requirements in children? (Select all that apply.)

a. Oliguric renal failure
b. Increased intracranial pressure
c. Mechanical ventilation
d. Compensated hypotension
e. Tetralogy of Fallot
f. Type 1 diabetes mellitus
ANS: A, B, C

The nurse should recognize that conditions such as oliguric renal failure, increased intracranial pressure, and mechanical ventilation can cause an increase or a decrease in fluid requirements. Conditions such as hypotension, tetralogy of Fallot, and diabetes mellitus (type 1) do not cause an alteration in fluid requirements.
What clinical manifestations should be observed in a 2-year-old child with hypotonic dehydration? (Select
all that apply.)

a. Thick, doughy feel to the skin
b. Slightly moist mucous membranes
c. Absent tears
d. Very rapid pulse
e. Hyperirritability
ANS: B, C, D

Clinical manifestations of hypotonic dehydration include slightly moist mucous membranes, absent tears, and a very rapid pulse. A thick, doughy feel to the skin and hyperirritability are signs of hypertonic dehydration.
The nurse is caring for a child with hypokalemia. The nurse evaluates the child for which signs and symptoms of hypokalemia? (Select all that apply.)

a. Twitching
b. Hypotension
c. Hyperreflexia
d. Muscle weakness
e. Cardiac arrhythmias
ANS: B, D, E

Signs and symptoms of hypokalemia are hypotension, muscle weakness, and cardiac arrhythmias. Twitching and hyperreflexia are signs of hyperkalemia.
Daily Maintenance Fluid Requirements
1. Calculate the child's weight in kilograms
2. Allow 100 mL/kg for the first 10 kg of body weight
3. Allow 50 mL/kg for the second 10 kg of body weight
4. Allow 20 mL/kg for the remaining kilograms of body weight
A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. What
nursing goal is appropriate for this child?

a. Stimulate appetite.
b. Detect evidence of edema.
c. Minimize risk of infection.
d. Promote adherence to the antibiotic regimen.
ANS: C

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.
What condition is the most common cause of acute renal failure in children?

a. Pyelonephritis
b. Tubular destruction
c. Severe dehydration
d. Upper tract obstruction
ANS: C

The most common cause of acute renal failure in children is dehydration or other causes of poor perfusion that may respond to restoration of fluid volume. Pyelonephritis and tubular destruction are not common causes of
acute renal failure. Obstructive uropathy may cause acute renal failure, but it is not the most common cause.
A child is admitted in acute renal failure (ARF). Therapeutic management to rapidly provoke a flow of urine includes the administration of what medication?

a. Propranolol (Inderal)
b. Calcium gluconate
c. Mannitol (Osmitrol) or furosemide (Lasix) (or both)
d. Sodium, chloride, and potassium
ANS: C

In ARF, if hydration is adequate, mannitol or furosemide (or both) is administered to provoke a flow of urine. If glomerular function is intact, an osmotic diuresis will occur. Propranolol is a beta-blocker; it will not
produce a rapid flow of urine in ARF. Calcium gluconate is administered for its protective cardiac effect when hyperkalemia exists. It does not affect diuresis. Electrolyte measurements must be done before administration of sodium, chloride, or potassium. These substances are not given unless there are other large, ongoing losses.
In the absence of urine production, potassium levels may be elevated, and additional potassium can cause cardiac dysrhythmias.
What major complication is associated with a child with chronic renal failure?

a. Hypokalemia
b. Metabolic alkalosis
c. Water and sodium retention
d. Excessive excretion of blood urea nitrogen
ANS: C

Chronic renal failure leads to water and sodium retention, which contributes to edema and vascular congestion. Hyperkalemia, metabolic acidosis, and retention of blood urea nitrogen are complications of chronic renal failure.
What diet is most appropriate for the child with chronic renal failure (CRF)?

a. Low in protein
b. Low in vitamin D
c. Low in phosphorus
d. Supplemented with vitamins A, E, and K
ANS: C

Dietary phosphorus may need to be restricted by limiting protein and milk intake. Substances that bind phosphorus are given with meals to prevent its absorption, which enables a more liberal intake of phosphoruscontaining protein. Protein is limited to the recommended daily allowance for the childs age. Further restriction
is thought to negatively affect growth and neurodevelopment. Vitamin D therapy is administered in children with CRF to increase calcium absorption. Supplementation of vitamins A, E, and K, beyond normal dietary
intake, is not advised in children with CRF. These fat-soluble vitamins can accumulate.
What nursing consideration is most important when caring for a child with end-stage renal disease
(ESRD)?

a. Children with ESRD usually adapt well to minor inconveniences of treatment.
b. Children with ESRD require extensive support until they outgrow the condition.
c. Multiple stresses are placed on children with ESRD and their families until the illness is cured.
d. Multiple stresses are placed on children with ESRD and their families because childrens lives are
maintained by drugs and artificial means.
ANS: D

Stressors on the family are often overwhelming because of the progressive deterioration. The child progresses from renal insufficiency to uremia to dialysis and transplantation, each of which requires intensive therapy and
supportive care. The treatment of ESRD is intense and requires multiple examinations, dietary restrictions, and medications. Adherence to the regimen is often difficult for children and families because of the progressive nature of the renal failure. ESRD has an unrelenting course that has no known cure. Children do not outgrow the renal failure.
The nurse is caring for an adolescent who has just started dialysis. The child always seems angry, hostile, or depressed. The nurse should recognize that this is most likely related to what underlying cause?

a. Physiologic manifestations of renal disease
b. The fact that adolescents have few coping mechanisms
c. Neurologic manifestations that occur with dialysis
d. Resentment of the control and enforced dependence imposed by dialysis
ANS: D

Older children and adolescents need to feel in control. Dialysis forces the adolescent into a dependent relationship, which results in these behaviors. Being angry, hostile, or depressed are functions of the age of the child, not neurologic or physiologic manifestations of the dialysis.
What statement is an advantage of peritoneal dialysis compared with hemodialysis?

a. Protein loss is less extensive.
b. Dietary limitations are not necessary.
c. It is easy to learn and safe to perform.
d. It is needed less frequently than hemodialysis.
ANS: C

Peritoneal dialysis is the preferred form of dialysis for parents, infants, and children who wish to remain independent. Parents and older children can perform the treatments themselves. Protein loss is not significantly different. The dietary limitations are necessary, but they are not as stringent as those for hemodialysis. Treatments are needed more frequently but can be done at home.
The nurse is caring for a child with acute renal failure. What laboratory findings should the nurse expect to find? (Select all that apply.)

a. Hyponatremia
b. Hyperkalemia
c. Metabolic alkalosis
d. Elevated blood urea nitrogen level
e. Decreased plasma creatinine level
ANS: A, B, D

A child with acute renal failure would have hyponatremia, hyperkalemia, and elevated blood urea nitrogen levels. The child would have metabolic acidosis, not alkalosis, and the plasma creatinine levels would be increased, not decreased.
What dietary instructions should the nurse give to parents of a child undergoing chronic hemodialysis? (Select all that apply.)

a. High protein
b. Fluid restriction
d. Sodium restriction
e. Potassium restriction
ANS: B, D, E

Dietary limitations are necessary in patients undergoing chronic dialysis to avoid biochemical complications. Fluid and sodium are restricted to prevent fluid overload and its associated symptoms of hypertension, cerebral manifestations, and congestive heart failure. Potassium is restricted to prevent complications related to hyperkalemia; phosphorus restriction helps prevent parathyroid hyperactivity and its attendant risk of abnormal calcification in soft tissues. Adequate protein, not high intake, is necessary to maximize growth potential. Fluid limitations are determined by residual urinary output and the need to limit intradialytic weight gain.
A child is hospitalized in acute renal failure and has a serum potassium greater than 7 mEq/L. What temporary measures that will produce a rapid but transient effect to reduce the potassium should the nurse expect to be prescribed? (Select all that apply.)

a. Dialysis
b. Calcium gluconate
c. Sodium bicarbonate
d. Glucose 50% and insulin
e. Sodium polystyrene sulfonate (Kayexalate)
ANS: B, C, D

Several measures are available to reduce the serum potassium concentration, and the priority of implementation is usually based on the rapidity with which the measures are effective. Temporary measures that produce a rapid but transient effect are calcium gluconate, sodium bicarbonate, and glucose 50%, and insulin. Definitive but slower-acting measures are then implemented which include administration of a cation exchange resin such as sodium polystyrene sulfonate (Kayexalate), 1 g/kg, administered orally or rectally, and/or dialysis.
Parents of a child who will need hemodialysis ask the nurse, What are the advantages of a fistula over a graft or external access device for hemodialysis? What response should the nurse give? (Select all that apply.)

a. It is ready to be used immediately.
b. There are fewer complications with a fistula.
c. There is less restriction of activity with a fistula.
d. It produces dilation and thickening of the superficial vessels.
e. The fistula does not require a needle insertion at each dialysis.
ANS: B, C, D

The creation of a subcutaneous (internal) arteriovenous fistula by anastomosing a segment of the radial artery and brachiocephalic vein produces dilation and thickening of the superficial vessels of the forearm to provide easy access for repeated venipuncture. Fewer complications and less restriction of activity are observed with
the use of a fistula. Both the graft and the fistula require needle insertion at each dialysis. The fistula cannot be used immediately.
Calculate the 24-hour maintenance fluid requirement for a child weighing 25 kg. Fill in the blank with ml/day. Record your answer in a whole number.
ANS: 1600

First 10 kg: 100 ml/kg/day 10 kg = 1000 ml/day
Second 10 kg: 50 ml/kg/day 10 kg = 500 ml/day
Each additional 1 kg: 20 ml/kg/day 5 kg = 100 ml/day
Calculate the 24-hour maintenance fluid requirement for a child weighing 12 kg. Fill in the blank with ml/day. Record your answer in a whole number.
ANS: 1100

First 10 kg: 100 ml/kg/day 10 kg = 1000 ml/day
Second 10 kg: 50 ml/kg/day 2 kg = 100 ml/day
Which is the most common cause of acute renal failure in children?

a. Pyelonephritis
b. Tubular destruction
c. Urinary tract obstruction
d. Inadequate perfusion
ANS: D

The most common cause of acute renal failure in children is poor perfusion that may respond
to restoration of fluid volume. Pyelonephritis and tubular destruction are not common causes of acute renal failure. Obstructive uropathy may cause acute renal failure, but it is not the most common cause.
The nurse is conducting an admission assessment on a school-age child with acute renal failure. Which are the primary clinical manifestations the nurse expects to find with this condition?

a. Oliguria and hypertension
b. Hematuria and pallor
c. Proteinuria and muscle cramps
d. Bacteriuria and facial edema
ANS: A

The principal feature of acute renal failure is oliguria; hypertension is a nonspecific clinical
manifestation. Hematuria and pallor, proteinuria and muscle cramps, and bacteriuria and facial edema are not principal features of acute renal failure.
The nurse is caring for a child with acute renal failure. Which clinical manifestation should the nurse recognize as a sign of hyperkalemia?

a. Dyspnea
b. Seizure
c. Oliguria
d. Cardiac arrhythmia
ANS: D

Hyperkalemia is the most common threat to the life of the child. Signs of hyperkalemia
include electrocardiograph anomalies such as prolonged QRS complex, depressed ST
segments, peaked T waves, bradycardia, or heart block. Dyspnea, seizure, and oliguria are not manifestations of hyperkalemia.
When a child has chronic renal failure, the progressive deterioration produces a variety of clinical and biochemical disturbances that eventually are manifested in the clinical syndrome known as:

a. uremia.
b. oliguria.
c. proteinuria.
d. pyelonephritis.
ANS: A

Uremia is the retention of nitrogenous products, producing toxic symptoms. Oliguria is diminished urinary output. Proteinuria is the presence of protein, usually albumin, in the urine. Pyelonephritis is an inflammation of the kidney and renal pelvis.
Which clinical manifestation would be seen in a child with chronic renal failure?

a. Hypotension
b. Massive hematuria
c. Hypokalemia
d. Unpleasant "uremic" breath odor
ANS: D

Children with chronic renal failure have a characteristic breath odor resulting from the
retention of waste products. Hypertension may be a complication of chronic renal failure.
With chronic renal failure, little or no urinary output occurs. Hyperkalemia is a concern in
chronic renal failure.
One of the clinical manifestations of chronic renal failure is uremic frost. Which best describes this term?

a. Deposits of urea crystals in urine
b. Deposits of urea crystals on skin
c. Overexcretion of blood urea nitrogen
d. Inability of body to tolerate cold temperatures
ANS: B

Uremic frost is the deposition of urea crystals on the skin. The urea crystals are present on the
skin, not in the urine. The kidneys are unable to excrete blood urea nitrogen, leading to
elevated levels. There is no relation between cold temperatures and uremic frost.
Calcium carbonate is given with meals to a child with chronic renal disease. What is the purpose of administering calcium carbonate?

a. Prevent vomiting
b. Bind phosphorus
c. Stimulate appetite
d. Increase absorption of fat-soluble vitamins
ANS: B

Oral calcium carbonate preparations combine with phosphorus to decrease gastrointestinal
absorption and the serum levels of phosphate. Serum calcium levels are increased by the
calcium carbonate, and vitamin D administration is necessary to increase calcium absorption. Calcium carbonate does not prevent vomiting, stimulate appetite, or increase the absorption of fat-soluble vitamins.
Which should the nurse recommend for the diet of a child with chronic renal failure?

a. High in protein
b. Low in vitamin D
c. Low in phosphorus
d. Supplemented with vitamins A, E, and K
ANS: C

Dietary phosphorus is controlled by the reduction of protein and milk intake to prevent or control the calcium-phosphorus imbalance. Protein should be limited in chronic renal failure to decrease intake of phosphorus. Vitamin D therapy is administered in chronic renal failure to increase calcium absorption. Supplementation of vitamins A, E, and K is not part of dietary management in chronic renal disease.
What is an advantage of peritoneal dialysis?

a. Treatments are done in hospitals.
b. Protein loss is less extensive.
c. Dietary limitations are not necessary.
d. Parents and older children can perform treatments.
ANS: D

Peritoneal dialysis is the preferred form of dialysis for parents, infants, and children who wish to remain independent. Parents and older children can perform the treatments themselves. Treatments can be done at home. Protein loss is not significantly different. The dietary limitations are necessary, but they are not as stringent as those for hemodialysis.
The nurse is teaching parents of a child with chronic renal failure (CRF) about the use of recombinant human erythropoietin (rHuEPO) subcutaneous injections. Which statement indicates the parents have understood the teaching?

a. "These injections will help with the hypertension."
b. "We're glad the injections only need to be given once a month."
c. "The red blood cell count should begin to improve with these injections."
d. "Urine output should begin to improve with these injections."
ANS: C

Anemia in children with CRF is related to decreased production of erythropoietin.
Recombinant human erythropoietin (rHuEPO) is being offered to these children as
thrice-weekly or weekly subcutaneous injections and is replacing the need for frequent blood transfusions. The parents understand the teaching if they say that the red blood cell count will begin to improve with these injections.
A school-age child with chronic renal failure is admitted to the hospital with a serum potassium level of 5.2 mEq/L. Which prescribed medication should the nurse plan to
administer?

a. Spironolactone (Aldactone)
b. Sodium polystyrene sulfonate (Kayexalate)
c. Lactulose (Cephulac)
d. Calcium carbonate (Calcitab)
ANS: B

Normal serum potassium levels in a school-age child are 3.5 to 5 mEq/L. Sodium polystyrene
sulfonate is administered to reduce serum potassium levels. Spironolactone is a potassium-sparing diuretic and should not be used if the serum potassium is elevated.
Lactulose is administered to reduce ammonia levels in patients with liver disease. Calcium
carbonate may be prescribed as a calcium supplement, but it will not reduce serum potassium levels.
What statement best describes Hirschsprung disease?

a. The colon has an aganglionic segment.
b. It results in frequent evacuation of solids, liquid, and gas.
c. The neonate passes excessive amounts of meconium.
d. It results in excessive peristaltic movements within the gastrointestinal tract.
ANS: A

Mechanical obstruction in the colon results from a lack of innervation. In most cases, the aganglionic segment includes the rectum and some portion of the distal colon. There is decreased evacuation of the large intestine
secondary to the aganglionic segment. Liquid stool may ooze around the blockage. The obstruction does not affect meconium production. The infant may not be able to pass the meconium stool. There is decreased movement in the colon.
A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. How should the nurse prepare this child?

a. It is unnecessary because of childs age.
b. It is essential because it will be an adjustment.
c. Preparation is not needed because the colostomy is temporary.
d. Preparation is important because the child needs to deal with negative body image.
ANS: B

The childs age dictates the type and extent of psychologic preparation. When a colostomy is performed, it is necessary to prepare the child who is at least preschool age by telling him or her about the procedure and what to expect in concrete terms, with the use of visual aids. The preschooler is not yet concerned with body image.
A child has a nasogastric (NG) tube after surgery for Hirschsprung disease. What is the purpose of the NG
tube?

a. Prevent spread of infection.
b. Monitor electrolyte balance.
c. Prevent abdominal distention.
d. Maintain accurate record of output.
ANS: C

The NG tube is placed to suction out gastrointestinal secretions and prevent abdominal distention. The NG tube would not affect infection. Electrolyte content of the NG drainage can be monitored. Without the NG tube, there would be no drainage. After the NG tube is placed, it is important to maintain an accurate record of intake and output. This is not the reason for placement of the tube.
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
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.
Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease. What enema solution should be used?

a. Tap water
b. Normal saline
c. Oil retention
d. Phosphate preparation
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.
A parent of an infant with gastroesophageal reflux asks how to decrease the number and total volume of emesis. What recommendation should the nurse include in teaching this parent?

a. Surgical therapy is indicated.
b. Place in prone position for sleep after feeding.
c. Thicken feedings and enlarge the nipple hole.
d. Reduce the frequency of feeding by encouraging larger volumes of formula.
ANS: C

Thickened feedings decrease the childs crying and increase the caloric density of the feeding. Although it does not decrease the pH, the number and volume of emesis are reduced. Surgical therapy is reserved for children
who have failed to respond to medical therapy or who have an anatomic abnormality. The prone position is not recommended because of the risk of sudden infant death syndrome. Smaller, more frequent feedings are more effective than less frequent, larger volumes of formula.
A 4-month-old infant has gastroesophageal reflux (GER) but is thriving without other complications. Which should the nurse suggest to minimize reflux?

a. Place in Trendelenburg position after eating.
b. Thicken formula with rice cereal.
c. Give continuous nasogastric tube feedings.
d. Give larger, less frequent feedings.
ANS: B

Small, frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal
per ounce of formula have been recommended. Milk-thickening agents have been shown to decrease the number of episodes of vomiting and to increase the caloric density of the formula. This may benefit infants who are underweight as a result of GER disease. Placing the child in a Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive.
After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to perform at this time?

a. Notify the practitioner.
b. Insert the NG tube so feedings can be given.
c. Replace the NG tube to maintain gastric decompression.
d. Leave the NG tube out because it has probably been in long enough.
ANS: A

When surgery is performed on the upper gastrointestinal tract, usually the surgical team replaces the NG tube because of potential injury to the operative site. The decision to replace the tube or leave it out is made by the
surgical team. Replacing the tube is also usually done by the practitioner because of the surgical site.
An adolescent with irritable bowel syndrome comes to see the school nurse. What information should the nurse share with the adolescent?

a. A low-fiber diet is required.
b. Stress management may be helpful.
c. Milk products are a contributing factor.
d. Pantoprazole (a proton pump inhibitor) is effective in treatment.
ANS: B

Irritable bowel syndrome is believed to involve motor, autonomic, and psychologic factors. Stress management, environmental modification, and psychosocial intervention may reduce stress and gastrointestinal
symptoms. A high-fiber diet with psyllium supplement is often beneficial. Milk products can exacerbate bowel problems caused by lactose intolerance. Antispasmodic drugs, antidiarrheal drugs, and simethicone are beneficial for some individuals. Proton pump inhibitors have no effect.
One of the major differences in clinical presentation between Crohn disease (CD) and ulcerative colitis
(UC) is that UC is more likely to cause which clinical manifestation?

a. Pain
b. Rectal bleeding
c. Perianal lesions
d. Growth retardation
ANS: B

Rectal bleeding is more common in UC than CD. Pain, perianal lesions, and growth retardation are common manifestations of CD.
Nutritional management of the child with Crohn disease includes a diet that has which component?

a. High fiber
b. Increased protein
c. Reduced calories
d. Herbal supplements
ANS: B

The child with Crohn disease often has growth failure. Nutritional support is planned to reduce ongoing losses and provide adequate energy and protein for healing. Fiber is mechanically hard to digest. Foods containing
seeds may contribute to obstruction. A high-calorie diet is necessary to minimize growth failure. Herbal supplements should not be used unless discussed with the practitioner. Vitamin supplementation with folic acid, iron, and multivitamins is recommended.
What information should the nurse include when teaching an adolescent with Crohn disease (CD)?

a. How to cope with stress and adjust to chronic illness
b. Preparation for surgical treatment and cure of CD
c. Nutritional guidance and prevention of constipation
d. Prevention of spread of illness to others and principles of high-fiber diet
ANS: A

CD is a chronic illness with a variable course and many potential complications. Guidance about living with chronic illness is essential for adolescents. Stress management techniques can help with exacerbations and possible limitations caused by the illness. At this time, there is no cure for CD. Surgical intervention may be indicated for complications that cannot be controlled by medical and nutritional therapy. Nutritional guidance is an essential part of management. Constipation is not usually an issue with CD. CD is not infectious, so transmission is not a concern. A low-fiber diet is indicated.
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 disease the inflammatory process involves the whole GI tract."
b. "There is no difference between the two diseases."
c. "The inflammation with Crohn disease is limited to the colon and rectum."
d. "Ulcerative colitis is characterized by skip lesions."
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.
Which is used to treat moderate to severe inflammatory bowel disease?

a. Antacids
b. Antibiotics
c. Corticosteroids
d. Antidiarrheal medications
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.
A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication?

a. Hyperkalemia
b. Hyperchloremia
c. Metabolic acidosis
d. Metabolic alkalosis
ANS: D

Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Potassium and chloride ions are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.
What signs or symptoms are most commonly associated with the prodromal phase of acute viral hepatitis?

a. Bruising and lethargy
b. Anorexia and malaise
c. Fatigability and jaundice
d. Dark urine and pale stools
ANS: B

The signs and symptoms most common in the prodromal phase are anorexia, malaise, lethargy, and easy fatigability. Bruising would not be an issue unless liver damage has occurred. Jaundice is a late sign and often
does not occur in children. Dark urine and pale stools would occur during the onset of jaundice (icteric phase) if it occurs.
The nurse is discussing home care with a mother whose 6-year-old child has hepatitis A. What information
should the nurse include?

a. Advise bed rest until 1 week after the icteric phase.
b. Teach infection control measures to family members.
c. Inform the mother that the child cannot return to school until 3 weeks after onset of jaundice.
d. Reassure the mother that hepatitis A cannot be transmitted to other family members.
ANS: B

Hand washing is the single most effective measure in preventing and controlling hepatitis. Hepatitis A can be transmitted through the fecal-oral route. Family members must be taught preventive measures. Rest and quiet activities are essential and adjusted to the childs condition, but bed rest is not necessary. The child is not infectious 1 week after the onset of jaundice and may return to school as activity level allows.
Which statement best characterizes hepatitis A?

a. Incubation period is 6 weeks to 6 months.
b. Principal mode of transmission is through the parenteral route.
c. Onset is usually rapid and acute.
d. There is a persistent carrier state.
ANS: C

Hepatitis A is the most common form of acute hepatitis in most parts of the world. It is
characterized by a rapid and acute onset. The incubation period is approximately 3 weeks for
hepatitis A, and the principal mode of transmission for it is the fecal-oral route. Hepatitis A does not have a carrier state.
The nurse observes that a newborn is having problems after birth. What should indicate a tracheoesophageal fistula?

a. Jitteriness
b. Meconium ileus
c. Excessive frothy saliva
d. Increased need for sleep
ANS: C

Excessive frothy saliva is indicative of a tracheoesophageal fistula. The child is unable to swallow the secretions, so there are excessive amounts of saliva in the mouth. Jitteriness is associated with several disorders, including electrolyte imbalances. Meconium ileus is associated with cystic fibrosis. Increased need for sleep is not associated with a tracheoesophageal fistula.
The nurse is caring for a neonate with a suspected tracheoesophageal fistula. What should nursing care
include?

a. Feed glucose water only.
b. Elevate the patients head for feedings.
c. Raise the patients head and give nothing by mouth.
d. Avoid suctioning unless the infant is cyanotic.
ANS: C

When a newborn is suspected of having a tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that any source of aspiration be
removed at once; oral feedings are withheld. The oral pharynx should be kept clear of secretions by oral suctioning. This is to prevent the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.
The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include?

a. Keep the tube clamped.
b. Suction the tube as needed.
c. Leave the tube open to gravity drainage.
d. Lower the tube to a point below the level of the stomach.
ANS: C

In the immediate postoperative period, the gastrostomy tube is open to gravity drainage. This usually is continued until the infant is able to tolerate feedings. The tube is unclamped in the postoperative period to allow for the drainage of secretions and air. Gastrostomy tubes are not suctioned on an as-needed basis. They may be connected to low suction to facilitate drainage of secretions. Lowering the tube to a point below the level of the stomach would create too much pressure.
A nurse is planning preoperative care for a newborn with tracheoesophageal fistula (TEF). Which interventions should the nurse plan to implement? (Select all that apply.)

a. Positioning with head elevated on a 30-degree plane
b. Feedings through a gastrostomy tube
c. Nasogastric tube to continuous low wall suction
d. Suctioning with a Replogle tube passed orally to the end of the pouch
e. Gastrostomy tube to gravity drainage
ANS: A, D, E

The most desirable position for a newborn who has TEF is supine (or sometimes prone) with
the head elevated on an inclined plane of at least 30 degrees. This positioning minimizes the
reflux of gastric secretions at the distal esophagus into the trachea and bronchi, especially when intra-abdominal pressure is elevated. It is imperative to immediately remove any secretions that can be aspirated. Until surgery, the blind pouch is kept empty by intermittent or continuous suction through an indwelling double-lumen or Replogle catheter passed orally or nasally to the end of the pouch. In some cases, a percutaneous gastrostomy tube is inserted and left open so that any air entering the stomach through the fistula can escape, thus minimizing the danger of gastric contents being regurgitated into the trachea. The gastrostomy tube is emptied by gravity drainage. Feedings through the gastrostomy tube and irrigations with fluid are contraindicated before surgery in an infant with a distal TEF. A nasogastric tube to low intermittent suctioning could not be accomplished because the esophagus ends in a blind pouch in TEF.
A 3-day-old infant presents with abdominal distention, is vomiting, and has not passed any meconium stools. What disease should the nurse suspect?

a. Pyloric stenosis
b. Intussusception
c. Hirschsprung disease
d. Celiac disease
ANS: C

The clinical manifestations of Hirschsprung disease in a 3-day-old infant include abdominal distention, vomiting, and failure to pass meconium stools. Pyloric stenosis would present with vomiting but not distention
or failure to pass meconium stools. Intussusception presents with abdominal cramping and celiac disease presents with malabsorption.
A school-age child with celiac disease asks for guidance about snacks that will not exacerbate the disease.
What snack should the nurse suggest?

a. Pizza
b. Pretzels
c. Popcorn
d. Oatmeal cookies
ANS: C

Celiac disease symptoms result from ingestion of gluten. Corn and rice do not contain gluten. Popcorn or corn chips will not exacerbate the intestinal symptoms. Pizza and pretzels are usually made from wheat flour that contains gluten. Also, in the early stages of celiac disease, the child may be lactose intolerant. Oatmeal contains gluten.
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.
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.
A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy. What should
postoperative teaching to the parents include?

a. Dilating the stoma
b. Assessing bowel function
c. Limitation of physical activities
d. Measures to prevent prolapse of the rectum
ANS: B

In the postoperative period, the nurse involves the parents in the care of the child with a temporary colostomy, allowing them to help with feedings and observe for signs of wound infection or irregular passage of stool
(constipation or true incontinence). Some children will require daily anal dilatations in the postoperative period to avoid anastomotic strictures but not stoma dilatations. Physical activities should be encouraged. There is not a risk of prolapse of the rectum in Hirschsprung disease, just strictures.
What is the purpose in using cimetidine (Tagamet) for gastroesophageal reflux?

a. The medication reduces gastric acid secretion.
b. The medication neutralizes the acid in the stomach.
c. The medication increases the rate of gastric emptying time.
d. The medication coats the lining of the stomach and esophagus.
ANS: A

Pharmacologic therapy may be used to treat infants and children with gastroesophageal reflux disease. Both H2-receptor antagonists (cimetidine [Tagamet], ranitidine [Zantac], or famotidine [Pepcid]) and proton pump
inhibitors (esomeprazole [Nexium], lansoprazole [Prevacid], omeprazole [Prilosec], pantoprazole [Protonix], and rabeprazole [Aciphex]) reduce gastric hydrochloric acid secretion.
A histamine-receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is ordered for an infant with GER. What is the purpose of this medication?

a. Prevent reflux
b. Prevent hematemesis
c. Reduce gastric acid production
d. Increase gastric acid production
ANS: C

The mechanism of action of histamine-receptor antagonists is to reduce the amount of acid
present in gastric contents and perhaps prevent esophagitis. Preventing reflux or hematemesis and increasing gastric acid production are not the modes of action of histamine-receptor antagonists.
A child is being admitted to the hospital with acute gastroenteritis. The health care provider prescribes an
antiemetic. What antiemetic does the nurse anticipate being prescribed?

a. Ondansetron (Zofran)
b. Promethazine (Phenergan)
c. Metoclopramide (Reglan)
d. Dimenhydrinate (Dramamine)
ANS: A

Ondansetron reduces the duration of vomiting in children with acute gastroenteritis. This would be the expected prescribed antiemetic. Adverse effects with earlier generation antiemetics (e.g., promethazine and
metoclopramide) include somnolence, nervousness, irritability, and dystonic reactions and should not be routinely administered to children. For children who are prone to motion sickness, it is often helpful to administer an appropriate dose of dimenhydrinate (Dramamine) before a trip, but it would not be ordered as an antiemetic.
The nurse should instruct parents to administer a daily proton pump inhibitor to their child with
gastroesophageal reflux at which time?

a. Bedtime
b. With a meal
c. Midmorning
d. 30 minutes before breakfast
ANS: D

Proton pump inhibitors are most effective when administered 30 minutes before breakfast so that the peak plasma concentrations occur with mealtime. If they are given twice a day, the second best time for administration is 30 minutes before the evening meal.
The nurse is teaching a parent of a 6-month-old infant with gastroesophageal reflux (GER) before discharge. What instructions should the nurse include? (Select all that apply.)

a. Elevate the head of the bed in the crib to a 90-degree angle while the infant is sleeping.
b. Hold the infant in the prone position after a feeding.
c. Discontinue breastfeeding so that a formula and rice cereal mixture can be used.
d. The infant will require the Nissen fundoplication after 1 year of age.
e. Prescribed cimetidine (Tagamet) should be given 30 minutes before feedings.
ANS: B, E

Discharge instructions for an infant with GER should include the prone position (up on the shoulder or across the lap) after a feeding. Use of the prone position while the infant is sleeping is still controversial. The American Academy of Pediatrics recommends the supine position to decrease the risk of sudden infant death syndrome even in infants with GER. Prescribed cimetidine or another proton pump inhibitor should be given 30 minutes before the morning and evening feeding so that peak plasma concentrations occur with mealtime.
The head of the bed in the crib does not need to be elevated. The mother may continue to breastfeed or express breast milk to add rice cereal if recommended by the health care provider; thickening breast milk or formula
with cereal is not recommended by all practitioners. The Nissen fundoplication is only done on infants with GER in severe cases with complications.
The nurse is teaching parents of a child with gastroesophageal reflux (GER) disease foods that can
exacerbate acid reflux. What foods should be included in the teaching session? (Select all that apply.)

a. Citrus
b. Bananas
c. Spicy foods
d. Peppermint
e. Whole wheat bread
ANS: A, C, D

Avoidance of certain foods that exacerbate acid reflux (e.g., caffeine, citrus, tomatoes, alcohol, peppermint, spicy or fried foods) can improve mild GER symptoms. Bananas and whole wheat bread will not exacerbate acid reflux.
The nurse is preparing to admit a 6-year-old child with irritable bowel syndrome (IBS). What clinical manifestations should the nurse expect to observe? (Select all that apply.)

a. Flatulence
b. Constipation
c. No urge to defecate
d. Absence of abdominal pain
e. Feeling of incomplete evacuation of the bowel
ANS: A, B, E

Children with IBS often have alternating diarrhea and constipation, flatulence, bloating or a feeling of abdominal distention, lower abdominal pain, a feeling of urgency when needing to defecate, and a feeling of incomplete evacuation of the bowel.
The nurse is caring for a child with celiac disease. The nurse understands that what may precipitate a celiac
crisis? (Select all that apply.)

a. Exercise
b. Infections
c. Fluid overload
d. Electrolyte depletion
e. Emotional disturbance
ANS: B, D, E

A celiac crisis can be precipitated by infections, electrolyte depletion, and emotional disturbance. Exercise or fluid overload does not precipitate a crisis.
The nurse is assisting a child with celiac disease to select foods from a menu. What foods should the nurse
suggest?

a. Hamburger on a bun
b. Spaghetti with meat sauce
c. Corn on the cob with butter
d. Peanut butter and crackers
ANS: C

Treatment of celiac disease consists primarily of dietary management. Although a gluten-free diet is prescribed, it is difficult to remove every source of this protein. Some patients are able to tolerate restricted amounts of gluten. Because gluten occurs mainly in the grains of wheat and rye but also in smaller quantities in
barley and oats, these foods are eliminated. Corn, rice, and millet are substitute grain foods. Corn on the cob with butter would be gluten free.
The nurse is preparing to admit a 6-year-old child with celiac disease. What clinical manifestations should
the nurse expect to observe? (Select all that apply.)

a. Steatorrhea
b. Polycythemia
c. Malnutrition
d. Melena stools
e. Foul-smelling stools
ANS: A, C, E

Clinical manifestations of celiac disease include impaired fat absorption (steatorrhea and foul-smelling stools) and impaired nutrient absorption (malnutrition). Anemia, not polycythemia, is a manifestation, and melena stools do not occur.
The nurse is preparing to admit a 2-month-old child with hypertrophic pyloric stenosis. What clinical manifestations should the nurse expect to observe? (Select all that apply.)

a. Weight loss
b. Bilious vomiting
c. Abdominal pain
d. Projectile vomiting
e. The infant is hungry after vomiting
ANS: A, D, E

Clinical manifestations of hypertrophic pyloric stenosis include weight loss, projectile vomiting, and hunger after vomiting. The vomitus is nonbilious, and there is no evidence of pain or discomfort, just chronic hung
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
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.
What are the results of excessive vomiting in an infant with pyloric stenosis?

a. Hyperchloremia
b. Hypernatremia
c. Metabolic acidosis
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.
What is the best description of pyloric stenosis?

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
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.
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
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.
The nurse is preparing to admit a 6-month-old child with gastroesophageal reflux disease. What clinical manifestations should the nurse expect to observe? (Select all that apply.)

a. Spitting up
b. Bilious vomiting
c. Failure to thrive
d. Excessive crying
e. Respiratory problems
ANS: A, C, D, E

Clinical manifestations of gastroesophageal reflux disease include spitting up, failure to thrive, excessive crying, and respiratory problems. Hematemesis, not bilious vomiting, is a manifestation.
The nurse is preparing to admit a 5-year-old child with hepatitis A. What clinical features of hepatitis A should the nurse recognize? (Select all that apply.)

a. The onset is rapid.
b. Fever occurs early.
c. There is usually a pruritic rash.
d. Nausea and vomiting are common.
e. The mode of transmission is primarily by the parenteral route.
ANS: A, B, D

Clinical features of hepatitis A include a rapid onset, fever occurring early, and nausea and vomiting. A rash is rare, and the mode of transmission is by the fecaloral route, rarely by the parenteral route.
The nurse is preparing to admit a 7-year-old child with hepatitis B. What clinical features of hepatitis B should the nurse recognize? (Select all that apply.)

a. The onset is rapid.
b. Rash is common.
c. Jaundice is present
d. No carrier state exists.
e. The mode of transmission is principally by the parenteral route.
ANS: B, C, E

Clinical features of hepatitis B include a rash, jaundice, and the mode of transmission principally by the parenteral route. The onset is insidious, not rapid, and a carrier state does exist.
Which is true concerning hepatitis B? (Select all that apply.)

a. Hepatitis B cannot exist in carrier state.
b. Hepatitis B can be prevented by HBV vaccine.
c. Hepatitis B can be transferred to an infant of a breastfeeding mother.
d. Onset of hepatitis B is insidious.
e. Principal mode of transmission for hepatitis B is fecal-oral route.
f. Immunity to hepatitis B occurs after one attack.
ANS: B, C, D, F

The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is
protective against hepatitis B. Hepatitis B can be transferred to an infant of a breastfeeding
mother, especially if the mother's nipples are cracked. The onset of hepatitis B is insidious.
Immunity develops after one exposure to hepatitis B. Hepatitis B has a carrier state. The
fecal-oral route is the principal mode of transmission for hepatitis A. Hepatitis B is
transmitted through the parenteral route.
The nurse is preparing to admit a 7-year-old child with Crohn disease. What clinical manifestations should
the nurse expect to observe? (Select all that apply.)

a. Pain is common.
b. Weight loss is severe.
c. Rectal bleeding is common.
d. Diarrhea is moderate to severe.
e. Anal and perianal lesions are rare.
ANS: A, B, D

Clinical manifestations of Crohn disease include pain, severe weight loss, and moderate to severe diarrhea. Rectal bleeding is rare, but anal and perianal lesions are common.
The health care provider has prescribed ondansetron (Zofran) 0.1 mg/kg as needed for nausea for a child
admitted for vomiting. The child weighs 55 lb. Calculate the correct dose of Zofran in milligrams. Record your
answer using one decimal place.
ANS: 2.5

55 lb/2.2 kg = 25 kg
Dose of Zofran is 0.1 mg/kg
0.1 mg 25 = 2.5 mg
It is important that a child with acute streptococcal pharyngitis be treated with antibiotics to prevent which condition?

a. Otitis media
b. Diabetes insipidus (DI)
c. Nephrotic syndrome
d. Acute rheumatic fever
ANS: D

Group A hemolytic streptococcal infection is a brief illness with varying symptoms. It is essential that pharyngitis caused by this organism be treated with appropriate antibiotics to avoid the sequelae of acute rheumatic fever and acute glomerulonephritis. The cause of otitis media is either viral or other bacterial organisms. DI is a disorder of the posterior pituitary. Infections such as meningitis or encephalitis, not streptococcal pharyngitis, can cause DI. Glomerulonephritis, not nephrotic syndrome, can result from acute
streptococcal pharyngitis.
A 4-year-old girl is brought to the emergency department. She has a froglike croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should intervene in which manner?

a. Make her lie down and rest quietly.
b. Examine her oral pharynx and report to the physician.
c. Auscultate her lungs and prepare for placement in a mist tent.
d. Notify the physician immediately and be prepared to assist with a tracheostomy or intubation.
ANS: D

This child is exhibiting signs of respiratory distress and possible epiglottitis. Epiglottitis is always a medical emergency requiring antibiotics and airway support for treatment. Sitting up is the position that facilitates breathing in respiratory disease. The oral pharynx should not be visualized. If the epiglottis is inflamed, there is
the potential for complete obstruction if it is irritated further. Although lung auscultation provides useful assessment information, a mist tent would not be beneficial for this child. Immediate medical evaluation and intervention are indicated.
The nurse is assessing a child with croup in the emergency department. The child has a sore throat and is drooling. Examining the childs throat using a tongue depressor might precipitate what condition?

a. Sore throat
b. Inspiratory stridor
c. Complete obstruction
d. Respiratory tract infection
ANS: C

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. Sore throat and pain on swallowing are early signs of epiglottitis. Stridor is aggravated when a child with epiglottitis is supine. Epiglottitis is caused by
Haemophilus influenzae in the respiratory tract.
The mother of a 20-month-old boy tells the nurse that he has a barking cough at night. His temperature is 37 C (98.6 F). The nurse suspects mild croup and should recommend which intervention?

a. Admit to the hospital and observe for impending epiglottitis.
b. Provide fluids that the child likes and use comfort measures.
c. Control fever with acetaminophen and call if cough gets worse tonight.
d. Try over-the-counter cough medicine and come to the clinic tomorrow if no improvement.
ANS: B

In mild croup, therapeutic interventions include adequate hydration (as long as the child can easily drink) and comfort measures to minimize distress. The child is not exhibiting signs of epiglottitis. A temperature of 37 C is within normal limits. Although a return to the clinic may be indicated, the mother is instructed to return if
the child develops noisy respirations or drooling.
An infant with bronchiolitis is hospitalized. The causative organism is respiratory syncytial virus (RSV). The nurse knows that a child infected with this virus requires what type of isolation?

a. Reverse isolation
b. Airborne isolation
c. Contact Precautions
d. Standard Precautions
ANS: C

RSV is transmitted through droplets. In addition to Standard Precautions and hand washing, Contact Precautions are required. Caregivers must use gloves and gowns when entering the room. Care is taken not to touch their own eyes or mucous membranes with a contaminated gloved hand. Children are placed in a private
room or in a room with other children with RSV infections. Reverse isolation focuses on keeping bacteria away from the infant. With RSV, other children need to be protected from exposure to the virus. The virus is not airborne.
An infant has been diagnosed with staphylococcal pneumonia. Nursing care of the child with pneumonia
includes which intervention?

a. Administration of antibiotics
b. Frequent complete assessment of the infant
c. Round-the-clock administration of antitussive agents
d. Strict monitoring of intake and output to avoid congestive heart failure
ANS: A

Antibiotics are indicated for bacterial pneumonia. Often the child has decreased pulmonary reserve, and clustering of care is essential. The childs respiratory rate and status and general disposition are monitored closely, but frequent complete physical assessments are not indicated. 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.
What statement is the most descriptive of asthma?

a. It is inherited.
b. There is heightened airway reactivity.
c. There is decreased resistance in the airway.
d. The single cause of asthma is an allergic hypersensitivity.
ANS: B

In asthma, spasm of the smooth muscle of the bronchi and bronchioles causes constriction, producing impaired respiratory function. Atopy, or development of an immunoglobulin E (IgE)mediated response, is inherited but
is not the only cause of asthma. Asthma is characterized by increased resistance in the airway. Asthma has multiple causes, including allergens, irritants, exercise, cold air, infections, medications, medical conditions, and endocrine factors.
What condition is the leading cause of chronic illness in children?

a. Asthma
b. Pertussis
c. Tuberculosis
d. Cystic fibrosis
ANS: A

Asthma is the most common chronic disease of childhood, the primary cause of school absences, and the third leading cause of hospitalization in children younger than the age of 15 years. Pertussis is not a chronic illness.
Tuberculosis is not a significant factor in childhood chronic illness. Cystic fibrosis is the most common lethal genetic illness among white children.
A child has a chronic cough and diffuse wheezing during the expiratory phase of respiration. This suggests
what condition?

a. Asthma
b. Pneumonia
c. Bronchiolitis
d. Foreign body in trachea
ANS: A

Asthma may have these chronic signs and symptoms. Pneumonia appears with an acute onset, fever, and general malaise. Bronchiolitis is an acute condition caused by respiratory syncytial virus. Foreign body in the trachea occurs with acute respiratory distress or failure and maybe stridor.
A child with asthma is having pulmonary function tests. What rationale explains the purpose of the peak
expiratory flow rate?

a. To assess severity of asthma
b. To determine cause of asthma
c. To identify triggers of asthma
d. To confirm diagnosis of asthma
ANS: A

Peak expiratory flow rate monitoring is used to monitor the childs current pulmonary function. It can be used to manage exacerbations and for daily long-term management. The cause of asthma is known. Asthma is caused by a complex interaction among inflammatory cells, mediators, and the cells and tissues present in the
airways. The triggers of asthma are determined through history taking and immunologic and other testing. The diagnosis of asthma is made through clinical manifestations, history, physical examination, and laboratory testing.
One of the goals for children with asthma is to maintain the childs normal functioning. What principle of
treatment helps to accomplish this goal?

a. Limit participation in sports.
b. Reduce underlying inflammation.
c. Minimize use of pharmacologic agents.
d. Have yearly evaluations by a health care provider.
ANS: B

Children with asthma are often excluded from exercise. This practice interferes with peer interaction and physical health. Most children with asthma can participate provided their asthma is under control. Inflammation is the underlying cause of the symptoms of asthma. By decreasing inflammation and reducing the symptomatic airway narrowing, health care providers can minimize exacerbations. Pharmacologic agents are used to prevent and control asthma symptoms, reduce the frequency and severity of asthma exacerbations,
and reverse airflow obstruction. It is recommended that children with asthma be evaluated every 6 months.
What 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 b2-agonists
ANS: D

Short-acting b2-agonists are the first treatment in an acute asthma exacerbation. Ephedrine and aminophylline are not helpful in acute asthma exacerbations. Theophylline is unnecessary for treating asthma exacerbations.
Cystic fibrosis (CF) may affect single or multiple systems of the body. What is the primary factor responsible for possible multiple clinical manifestations in CF?

a. Hyperactivity of sweat glands
b. Hypoactivity of autonomic nervous system
c. Atrophic changes in mucosal wall of intestines
d. Mechanical obstruction caused by increased viscosity of mucous gland secretions
ANS: D

The mucous glands produce a thick mucoprotein that accumulates and results in dilation. Small passages in organs such as the pancreas and bronchioles become obstructed as secretions form concretions in the glands and ducts. The exocrine glands, not sweat glands, are dysfunctional. Although abnormalities in the autonomic nervous system are present, it is not hypoactive. Intestinal involvement in CF results from the thick intestinal secretions, which can lead to blockage and rectal prolapse.
What is the earliest recognizable clinical manifestation(s) of cystic fibrosis (CF)?

a. Meconium ileus
b. History of poor intestinal absorption
c. Foul-smelling, frothy, greasy stools
d. Recurrent pneumonia and lung infections
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. Foulsmelling stools and recurrent respiratory infections are later manifestations of CF.
What tests aid in the diagnosis of cystic fibrosis (CF)?

a. Sweat test, stool for fat, chest radiography
b. Sweat test, bronchoscopy, duodenal fluid analysis
c. Sweat test, stool for trypsin, biopsy of intestinal mucosa
d. Stool for fat, gastric contents for hydrochloride, radiography
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 manifestation of CF, and a chest radiograph showing patchy atelectasis and obstructive emphysema indicates CF. Bronchoscopy, duodenal fluid analysis, stool tests for trypsin, and intestinal biopsy are not helpful in diagnosing CF. Gastric contents normally contain hydrochloride; it is not diagnostic.
A child with cystic fibrosis (CF) receives aerosolized bronchodilator medication. When should this
medication be administered?

a. After chest physiotherapy (CPT)
b. Before chest physiotherapy (CPT)
c. After receiving 100% oxygen
d. Before receiving 100% oxygen
ANS: B

Bronchodilators should be given before CPT to open bronchi and make expectoration easier. These medications are not helpful when used after CPT. Oxygen is administered only in acute episodes, with caution, because of chronic carbon dioxide retention.
A child with cystic fibrosis is receiving recombinant human deoxyribonuclease (DNase). What statement about DNase is true?

a. Given subcutaneously
b. May cause voice alterations
c. May cause mucus to thicken
d. Not indicated for children younger than age 12 years
ANS: B

One of the only adverse effects of DNase is voice alterations and laryngitis. DNase is given in an aerosolized form, decreases the viscosity of mucus, and is safe for children younger than 12 years.
The parent of a child with cystic fibrosis (CF) calls the clinic nurse to report that the child has developed tachypnea, tachycardia, dyspnea, pallor, and cyanosis. The nurse should tell the parent to bring the child to the clinic because these signs and symptoms are suggestive of what condition?

a. Pneumothorax
b. Bronchodilation
c. Carbon dioxide retention
d. Increased viscosity of sputum
ANS: A

Usually the signs of pneumothorax are nonspecific. Tachypnea, tachycardia, dyspnea, pallor, and cyanosis are significant signs and symptoms and are indicative of respiratory distress caused by pneumothorax. If the
bronchial tubes were dilated, the child would have decreased work of breathing and would most likely be asymptomatic. Carbon dioxide retention is a result of the chronic alveolar hypoventilation in CF. Hypoxia replaces carbon dioxide as the drive for respiration progresses. Increased viscosity would result in more difficulty clearing secretions.
Pancreatic enzymes are administered to the child with cystic fibrosis. What nursing consideration should be included in the plan of care?

a. Give pancreatic enzymes between meals if at all possible.
b. Do not administer pancreatic enzymes if the child is receiving antibiotics.
c. Decrease the dose of pancreatic enzymes if the child is having frequent, bulky stools.
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. Enzymes should be given just before meals and snacks. Pancreatic enzymes are not a contraindication for antibiotics. The dose of enzymes should be increased if child is having frequent, bulky stools.
What do the initial signs of respiratory syncytial virus (RSV) infection in an infant include?

a. Rhinorrhea, wheezing, and fever
b. Tachypnea, cyanosis, and apnea
c. Retractions, fever, and listlessness
d. Poor breath sounds and air hunger
ANS: A

Symptoms such as rhinorrhea and a low-grade fever often appear first. OM and conjunctivitis may also be present. In time, a cough may develop. Wheezing is an initial sign as well. Progression of illness brings on the symptoms of tachypnea, retractions, poor breath sounds, cyanosis, air hunger, and apnea.
The nurse is caring for a 1-month-old infant with respiratory syncytial virus (RSV) who is receiving 23% oxygen via a plastic hood. The childs SaO2 saturation is 88%, respiratory rate is 45 breaths/min, and pulse is 140 beats/min. Based on these assessments, what action should the nurse take?

a. Withhold feedings.
b. Notify the health care provider.
c. Put the infant in an infant seat.
d. Keep the infant in the plastic hood.
ANS: B

The American Academy of Pediatrics practice parameter (2006) recommends the use of supplemental oxygen if the infant fails to maintain a consistent oxygen saturation of at least 90%. The health care provider should be
notified of the saturation reading of 88%. Withholding the feedings or placing the infant in an infant seat would not increase the saturation reading. The infant should be kept in the hood, but because the saturation reading is 88%, the health care provider should be notified to obtain orders to increase the oxygen concentration.
A 5-year-old child is admitted with bacterial pneumonia. What signs and symptoms should the nurse expect to assess with this disease process?

a. Fever, cough, and chest pain
b. Stridor, wheezing, and ear infection
c. Nasal discharge, headache, and cough
d. Pharyngitis, intermittent fever, and eye infection
ANS: A

Children with bacterial pneumonia usually appear ill. Symptoms include fever, malaise, rapid and shallow respirations, cough, and chest pain. Ear infection, nasal discharge, and eye infection are not symptoms of bacterial pneumonia.
An infant with a congenital heart defect is to receive a dose of palivizumab (Synagis). What is the purpose of this?

a. Prevent RSV infection.
b. Prevent secondary bacterial infection.
c. Decrease toxicity of antiviral agents.
d. Make isolation of infant with RSV unnecessary.
ANS: A

The only product available in the United States for prevention of RSV is palivizumab, a humanized mouse monoclonal antibody, which is given once every 30 days (15 mg/kg) between November and March. It is given to high-risk infants, which includes an infant with a congenital heart defect.
A 3-year-old is brought to the emergency department with symptoms of stridor, fever, restlessness, and drooling. No coughing is observed. Based on these findings, the nurse should be prepared to assist with what action?

a. Throat culture
b. Nasal pharynx washing
c. Administration of corticosteroids
d. Emergency intubation
ANS: D

Three clinical observations that are predictive of epiglottitis are absence of spontaneous cough, presence of drooling, and agitation. Nasotracheal intubation or tracheostomy is usually considered for a child with epiglottitis with severe respiratory distress. The throat should not be inspected because airway obstruction can occur, and steroids would not be done first when the child is in severe respiratory distress.
A 3-year-old child woke up in the middle of the night with a croupy cough and inspiratory stridor. The parents bring the child to the emergency department, but by the time they arrive, the cough is gone, and the stridor has resolved. What can the nurse teach the parents with regard to this type of croup?

a. A bath in tepid water can help resolve this type of croup.
b. Tylenol can help to relieve the cough and stridor.
c. A cool mist vaporizer at the bedside can help prevent this type of croup.
d. Antibiotics need to be given to reduce the inflammation.
ANS: C

Acute spasmodic laryngitis (spasmodic croup, midnight croup, or twilight croup) is distinct from laryngitis and LTB and characterized by paroxysmal attacks of laryngeal obstruction that occur chiefly at night. The child goes to bed well or with some mild respiratory symptoms but awakens suddenly with characteristic barking; a
metallic cough; hoarseness; noisy inspirations; and restlessness. However, there is no fever, and the episode subsides in a few hours. Children with spasmodic croup are managed at home. Cool mist is recommended for the childs room. A tepid water bath will not help, but steam provided by hot water may relieve the laryngeal
spasm. The child will not need Tylenol, and antibiotics are not given for this type of croup.
A child is in the hospital for cystic fibrosis. What health care providers prescription should the nurse clarify before implementing?

a. Dornase alfa (Pulmozyme) nebulizer treatment bid
b. Pancreatic enzymes every 6 hours
c. Vitamin A, D, E, and K supplements daily
d. Proventil (albuterol) nebulizer treatments tid
ANS: B

The principal treatment for pancreatic insufficiency that occurs in cystic fibrosis is replacement of pancreatic enzymes, which are administered with meals and snacks to ensure that digestive enzymes are mixed with food
in the duodenum. The enzymes should not be given every 6 hours, so this should be clarified before implementing this prescription. Dornase alfa (Pulmozyme) is given by nebulizer to decrease the viscosity of secretions, vitamin supplements are given daily, and Proventil nebulizer treatments are given to open the
bronchi for easier expectoration.
A 6-year-old child is in the hospital for status asthmaticus. Nursing care during this acute period includes
which prescribed interventions?

a. Prednisolone (Pediapred) PO every day, IV fluids, cromolyn (Intal) inhaler bid
b. Salmeterol (Serevent) PO bid, vital signs every 4 hours, spot check pulse oximetry
c. Triamcinolone (Azmacort) inhaler bid, continuous pulse oximetry, vital signs once a shift
d. Methylprednisolone (Solumedrol) IV every 12 hours, continuous pulse oximetry, albuterol
nebulizer treatments every 4 hours and prn
ANS: D

The child in status asthmaticus should be placed on continuous cardiorespiratory (including blood pressure) and pulse oximetry monitoring. A systemic corticosteroid (oral, IV, or IM) may also be given to decrease the effects of inflammation. Inhaled aerosolized short-acting b2-agonists are recommended for all patients. Therefore, Solumedrol per IV, continuous pulse oximetry, and albuterol nebulizer treatments are the expected prescribed treatments. Oral medications would not be used during the acute stage of status asthmaticus. Vital signs once a shift and spot pulse oximetry checks would not be often enough.
In providing nourishment for a child with cystic fibrosis (CF), what factors should the nurse keep in mind?

a. Fats and proteins must be greatly curtailed.
b. Most fruits and vegetables are not well tolerated.
c. Diet should be high in calories, proteins, and unrestricted fats.
d. Diet should be low fat but high in calories and proteins.
ANS: C

Children with CF require a well-balanced, high-protein, high-caloric diet, with unrestricted fat (because of the impaired intestinal absorption).
A quantitative sweat chloride test has been done on an 8-month-old child. What value should be indicative
of cystic fibrosis (CF)?

a. Less than 18 mEq/L
b. 18 to 40 mEq/L
c. 40 to 60 mEq/L
d. Greater than 60 mEq/L
ANS: D

Normally sweat chloride content is less than 40 mEq/L, with a mean of 18 mEq/L. A chloride concentration greater than 60 mEq/L is diagnostic of CF; in infants younger than 3 months, a sweat chloride concentration greater than 40 mEq/L is highly suggestive of CF.
A preschool child has asthma, and a goal is to extend expiratory time and increase expiratory effectiveness.
What action should the nurse implement to meet this goal?

a. Encourage increased fluid intake.
b. Recommend increased use of a budesonide (Pulmicort) inhaler.
c. Administer an antitussive to suppress coughing.
d. Encourage the child to blow a pinwheel every 6 hours while awake.
ANS: D

Play techniques that can be used for younger children to extend their expiratory time and increase expiratory pressure include blowing cotton balls or a ping-pong ball on a table, blowing a pinwheel, blowing bubbles, or
preventing a tissue from falling by blowing it against the wall. Increased fluids, increased use of a Pulmicort inhaler, or suppressing a cough will not increase expiratory effectiveness.
A school-age child has asthma. The nurse should teach the child that if a peak expiratory flow rate is in the yellow zone, this means that the asthma control is what?

a. 80% of a personal best, and the routine treatment plan can be followed.
b. 50% to 79% of a personal best and needs an increase in the usual therapy.
c. 50 % of a personal best and needs immediate emergency bronchodilators.
d. Less than 50% of a personal best and needs immediate hospitalization.
ANS: B

The interpretation of a peak expiratory flow rate that is yellow (50%79% of personal best) signals caution. Asthma is not well controlled. An acute exacerbation may be present. Maintenance therapy may need to be increased. Call the practitioner if the child stays in this zone.
A family requires home care teaching with regard to preventative measures to use at home to avoid an
asthmatic episode. What strategy should the nurse teach?

a. Use a humidifier in the childs room.
b. Launder bedding daily in cold water.
c. Replace wood flooring with carpet.
d. Use an indoor air purifier with HEPA filter.
ANS: D

Allergen control includes use of an indoor air purifier with HEPA filter. Humidity should be kept low, bedding laundered in hot water once a week, and carpet replaced with wood floors.
A school-age child with cystic fibrosis takes four enzyme capsules with meals. The child is having four or
five bowel movements per day. The nurses action in regard to the pancreatic enzymes is based on the knowledge that the dosage is what?

a. Adequate
b. Adequate but should be taken between meals
c. Needs to be increased to increase the number of bowel movements per day
d. Needs to be increased to decrease the number of bowel movements per day
ANS: D

The amount of enzyme is adjusted to achieve normal growth and a decrease in the number of stools to one or two per day.
The nurse is preparing a staff education program about pediatric asthma. What concepts should the nurse
include when discussing the asthma severity classification system? (Select all that apply.)

a. Children with mild persistent asthma have nighttime signs or symptoms less than two times a month.
b. Children with moderate persistent asthma use a short-acting b-agonist more than two times per week.
c. Children with severe persistent asthma have a peak expiratory flow (PEF) of 60% to 80% of predicted value.
d. Children with mild persistent asthma have signs or symptoms more than two times per week.
e. Children with moderate persistent asthma have some limitations with normal activity.
f. Children with severe persistent asthma have frequent nighttime signs or symptoms.
ANS: D, E, F

Children with mild persistent asthma have signs or symptoms more than two times per week and nighttime signs or symptoms three or four times per month. Children with moderate persistent asthma have some limitations with normal activity and need to use a short-acting b-agonist for sign or symptom control daily. Children with severe persistent asthma have frequent nighttime signs or symptoms and have a PEF of less than 60%
The nurse is preparing to admit a 3-year-old child with acute spasmodic laryngitis. What clinical features of hepatitis B should the nurse recognize? (Select all that apply.)

a. High fever
b. Croupy cough
c. Tendency to recur
d. Purulent secretions
e. Occurs sudden, often at night
ANS: B, C, E

Clinical features of acute spasmodic laryngitis include a croupy cough, a tendency to recur, and occurring sudden, often at night. High fever is a feature of acute epiglottitis and purulent secretions are seen with acute tracheitis.
Which type of croup is always considered a medical emergency?

a. Laryngitis
b. Epiglottitis
c. Spasmodic croup
d. Laryngotracheobronchitis (LTB)
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.
A nurse is admitting an infant with asthma. What usually triggers asthma in infants?

a. Medications
b. A viral infection
c. Exposure to cold air
d. Allergy to dust or dust mites
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.
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.
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.
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
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.
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
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.
Beta-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
ANS: B

Beta-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.
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
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.
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.
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.
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
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.
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.
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.
A nurse is teaching an adolescent how to use the peak expiratory flowmeter. The adolescent has understood the teaching if which statement is made?

a. "I will record the average of the readings."
b. "I should be sitting comfortably when I perform the readings."
c. "I will record the readings at the same time every day."
d. "I will repeat the routine two times."
ANS: C

Instructions for use of a peak flowmeter include standing up straight before performing the
reading, recording the highest of the three readings (not the average), measuring the peak
expiratory flow rate (PEFR) close to the same time each day, and repeating the entire routine
three times, waiting 30 seconds between each routine.
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
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.
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
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.
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 the child 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.
A nurse is caring for a school-age child with left unilateral pneumonia and pleural effusion. A chest tube has been inserted to promote continuous closed chest drainage. Which interventions should the nurse implement when caring for this child? (Select all that apply.)

a. Positioning child on the right side
b. Assessing the chest tube and drainage device for correct settings
c. Administering prescribed doses of analgesia
d. Clamping the chest tube when child ambulates
e. Monitoring for need of supplemental oxygen
ANS: B, C, E

Nursing care of the child with a chest tube requires close attention to respiratory status; the
chest tube and drainage device used are monitored for proper function (i.e., drainage is not impeded, vacuum setting is correct, tubing is free of kinks, dressing covering chest tube
insertion site is intact, water seal is maintained, and chest tube remains in place). Movement
in bed and ambulation with a chest tube are encouraged according to the child's respiratory
status, but children require frequent doses of analgesia. Supplemental oxygen may be required in the acute phase of the illness and may be administered by nasal cannula, face mask, flow-by, or face tent. The child should be positioned on the left side, not the right. Lying on
the affected side if the pneumonia is unilateral ("good lung up") splints the chest on that side
and reduces the pleural rubbing that often causes discomfort. The chest tube should never be clamped; this can cause a pneumothorax. The chest tube should be maintained to the underwater seal at all times.
A nurse is interpreting the results of a child's peak expiratory flow rate. Which percentage, either at this number or less than this number, is considered to be a red zone? (Record your answer in a whole number.)
ANS: 50

A peak expiratory flow rate of red (<50% of personal best) signals a medical alert. Severe
airway narrowing may be occurring. A short-acting bronchodilator should be administered.
Notify the practitioner if the peak expiratory flow rate does not return immediately and stay in
yellow or green zones.
What statement best identifies the cause of heart failure (HF)?

a. Disease related to cardiac defects
b. Consequence of an underlying cardiac defect
c. Inherited disorder associated with a variety of defects
d. Result of diminished workload imposed on an abnormal myocardium
ANS: B

HF is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the bodys metabolic demands. HF is not a disease but rather a result of the inability of
the heart to pump efficiently. HF is not inherited. HF occurs most frequently secondary to congenital heart defects in which structural abnormalities result in increased volume load or increased pressures on the ventricles.
What drug is an angiotensin-converting enzyme (ACE) inhibitor?

a. Furosemide (Lasix)
b. Captopril (Capoten)
c. Chlorothiazide (Diuril)
d. Spironolactone (Aldactone)
ANS: B

Captopril is an ACE inhibitor. Furosemide is a loop diuretic. Chlorothiazide works on the distal tubules. Spironolactone blocks the action of aldosterone and is a potassium-sparing diuretic.
A 2-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which rate?

a. 60 beats/min
b. 90 beats/min
c. 100 beats/min
d. 120 beats/min
ANS: B

If a 1-minute apical pulse is less than 90 beats/min for an infant or young child, the digoxin is withheld. Sixty beats/min is the cut-off for holding the digoxin dose in an adult. One hundred to 120 beats/min is an acceptable
pulse rate for the administration of digoxin.
What clinical manifestation is a common sign of digoxin toxicity?

a. Seizures
b. Vomiting
c. Bradypnea
d. Tachycardia
ANS: B

Vomiting is a common sign of digoxin toxicity and is often unrelated to feedings. Seizures are not associated with digoxin toxicity. The child will have a slower (not faster) heart rate but not a slower respiratory rate.
The parents of a young child with heart failure (HF) tell the nurse that they are nervous about giving digoxin. The nurses response should be based on which knowledge?

a. It is a safe, frequently used drug.
b. Parents lack the expertise necessary to administer digoxin.
c. It is difficult to either overmedicate or undermedicate with digoxin.
d. Parents need to learn specific, important guidelines for administration of digoxin.
ANS: D

Digoxin has a narrow therapeutic range. The margin of safety between therapeutic, toxic, and lethal doses is very small. Specific guidelines are available for parents to learn how to administer the drug safely and to monitor for side effects. Parents may lack the expertise to administer the drug at first, but with discharge preparation, they should be prepared to administer the drug safely
What nutritional component should be altered in the infant with heart failure (HF)?

a. Decrease in fats
b. Increase in fluids
c. Decrease in protein
d. Increase in calories
ANS: D

Infants with HF have a greater metabolic rate because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of average infants, yet their ability to take in calories is diminished by their fatigue. The diet should include increased protein and increased fat to facilitate the childs intake of sufficient calories. Fluids must be carefully monitored because of the HF.
Decreasing the demands on the heart is a priority in care for the infant with heart failure (HF). In evaluating the infants status, which finding is indicative of achieving this goal?

a. Irritability when awake
b. Capillary refill of more than 5 seconds
c. Appropriate weight gain for age
d. Positioned in high Fowler position to maintain oxygen saturation at 90%
ANS: C

Appropriate weight gain for an infant is indicative of successful feeding and a reduction in caloric loss secondary to the HF. Irritability is a symptom of HF. The child also uses additional energy when irritable. Capillary refill should be brisk and within 2 to 3 seconds. The child needs to be positioned upright to maintain oxygen saturation at 90%. Positioning is helping to decrease respiratory effort, but the infant is still having difficulty with oxygenation.
A cardiac defect that allows blood to shunt from the (high pressure) left side of the heart to the (lower pressure) right side can result in which condition?

a. Cyanosis
b. Heart failure
c. Decreased pulmonary blood flow
d. Bounding pulses in upper extremities
ANS: B

As blood is shunted into the right side of the heart, there is increased pulmonary blood flow and the child is at high risk for heart failure. Cyanosis usually occurs in defects with decreased pulmonary blood flow. Bounding
upper extremity pulses are a manifestation of coarctation of the aorta.
What structural defects constitute tetralogy of Fallot?

a. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
c. Aortic stenosis, ventricular septal defect, overriding aorta, left ventricular hypertrophy
d. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
ANS: A

Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy.
What primary nursing intervention should be implemented to prevent bacterial endocarditis?

a. Counsel parents of high-risk children.
b. Institute measures to prevent dental procedures.
c. Encourage restricted mobility in susceptible children.
d. Observe children for complications, such as embolism and heart failure.
ANS: A

The objective of nursing care is to counsel the parents of high-risk children about the need for both prophylactic antibiotics for dental procedures and maintaining excellent oral health. The childs dentist should be aware of the childs cardiac condition. Dental procedures should be done to maintain a high level of oral health. Restricted mobility in susceptible children is not indicated. Parents are taught to observe for
unexplained fever, weight loss, or change in behavior.
What sign/symptom is a major clinical manifestation of rheumatic fever (RF)?

a. Fever
b. Polyarthritis
c. Osler nodes
d. Janeway spots
ANS: B

Polyarthritis, which is swollen, hot, red, and painful joints, is a major clinical manifestation. The affected joints will change every 1 or 2 days. The large joints are primarily affected. Fever is considered a minor manifestation of RF. Osler nodes and Janeway spots are characteristic of bacterial endocarditis.
What action by the school nurse is important in the prevention of rheumatic fever (RF)?

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.
ANS: C

Nurses have a role in prevention, primarily in screening school-age children for sore throats caused by group A streptococci. They can actively participate in throat culture screening or refer children with possible streptococcal sore throats for testing. Routine cholesterol screenings and blood pressure screenings do not facilitate the recognition and treatment of group A hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses.
What type of drug reduces hypertension by interfering with the production of angiotensin II?

a. Diuretics
b. Vasodilators
c. Beta-blockers
d. Angiotensin-converting enzyme (ACE) inhibitors
ANS: D

ACE inhibitors act by interfering with the production of angiotensin II, which is a potent vasoconstrictor. Diuretics lower blood pressure by increasing fluid output. Vasodilators act on the vascular smooth muscle. By causing arterial dilation, blood pressure is lowered. Beta-blockers interfere with beta stimulation and depress renin output.
A child with heart failure is on Lanoxin (digoxin). The laboratory value a nurse must closely monitor is which?

a. Serum sodium
b. Serum potassium
c. Serum glucose
d. Serum chloride
ANS: B

A fall in the serum potassium level enhances the effects of digoxin, increasing the risk of digoxin toxicity. Increased serum potassium levels diminish digoxins effect. Therefore, serum potassium levels (normal range, 3.55.5 mmol/L) must be carefully monitored.
An infant has tetralogy of Fallot. In reviewing the record, what laboratory result should the nurse expect to be documented?

a. Leukopenia
b. Polycythemia
c. Anemia
d. Increased platelet level
ANS: B

Persistent hypoxemia that occurs with tetralogy of Fallot stimulates erythropoiesis, which results in polycythemia, an increased number of red blood cells.
What child has a cyanotic congenital heart defect?

a. An infant with patent ductus arteriosus
b. A 1-year-old infant with atrial septal defect
c. A 2-month-old infant with tetralogy of Fallot
d. A 6-month-old infant with repaired ventricular septal defect
ANS: C

Tetralogy of Fallot is a cyanotic congenital heart defect. Patent ductus arteriosus, atrial septal defect, and ventricular septal defect are acyanotic congenital heart defects.
The nurse is teaching parents about administering digoxin (Lanoxin). What instructions should the nurse tell the parents?

a. If the child vomits, give another dose.
b. Give the medication at regular intervals.
c. If a dose is missed, give a give an extra dose.
d. Give the medication mixed with the childs formula.
ANS: B

The family should be taught to administer digoxin at regular intervals. If a dose is missed, an extra dose should not be given; the same schedule should be maintained. If the child vomits, do not give a second dose. The drug should not be mixed with foods or other fluids because refusal to consume these would result in inaccurate intake of the drug
Heart failure (HF) is a problem after the child has had a congenital heart defect repaired. The nurse knows
a sign of HF is what?

a. Wheezing
b. Increased blood pressure
c. Increased urine output
d. Decreased heart rate
ANS: A

A clinical manifestation of heart failure is wheezing from pulmonary congestion. The blood pressure decreases, urine output decreases, and heart rate increases.
A 1-year-old has been admitted for complete repair of a tetralogy of Fallot. What assessment finding should the nurse expect to be documented?

a. Weight gain
b. Pale skin color
c. Increasing cyanosis
d. Decrease in hemoglobin and hematocrit
ANS: C

Elective repair of tetralogy of Fallot is usually performed in the first year of life. Indications for repair include increasing cyanosis and the development of hypercyanotic spells. The child would not have a weight gain, pale skin color, or decrease in hemocrit.
What medication used to treat heart failure (HF) is a diuretic?

a. Captopril (Capten)
b. Digoxin (Lanoxin)
c. Hydrochlorothiazide (Diuril)
d. Carvedilol (Coreg)
ANS: C

Hydrochlorothiazide is a diuretic. Captopril is an ACE inhibitor, digoxin is a digital glycoside, and carvedilol is a beta-blocker.
The nurse is preparing to give digoxin (Lanoxin) to a 9-month-old infant. The nurse checks the dose and draws up 4 ml of the drug. The most appropriate nursing action is which?

a. Mix the dose with juice to disguise its taste.
b. Do not give the dose; suspect a dosage error.
c. Check the heart rate; administer digoxin if the rate is greater than 100 beats/min.
d. Check the heart rate; administer digoxin if the rate is greater than 80 beats/min.
ANS: B

Infants rarely receive more than 1 ml (50 mcg, or 0.05 mg) of digoxin in one dose; a higher dose is an immediate warning of a dosage error. To ensure safety, compare the calculation with that of another staff member before giving digoxin.
A 12-year-old child with Down syndrome is admitted to the hospital for surgical correction of a heart defect. The boys mental age is that of a 3-year-old child. The nurse should prepare the child and family for surgery by what method?

a. Extend preoperative teaching over several days.
b. Explain the surgery to the child and the parents in detail.
c. Exclude the child from preoperative teaching; teach only the parents.
d. Provide teaching to the parents, keeping the information to the child simple
ANS: D

Important factors to consider in planning preparation strategies before cardiac surgery are the childs cognitive developmental level, previous hospital experiences, temperament and coping style, the timing of the preparation, and the involvement of the parents. The teaching should be provided to the parents, keeping the
information simple to the child with a mental age of 3 years old.
Bacterial infective endocarditis (IE) should be treated with which protocol?

a. Oral antibiotics for 6 months
b. Oral antibiotics (penicillin) for 10 full days
c. IV antibiotics, diuretics, and digoxin
d. IV antibiotics (penicillin type) for 2 to 8 weeks
ANS: D

Treatment for IE includes the administration of high-dose antibiotics given intravenously for 2 to 8 weeks to completely eradicate the infecting microorganism.
An adolescent is being placed on an ACE inhibitor. What should the nurse inform the adolescent with regard
to this medication? (Select all that apply.)

a. Stay well hydrated.
b. Increase intake of potassium.
c. Avoid rapid position changes.
d. Take the medication with meals.
e. Side effects may include a cough.
ANS: A, C, E

The adolescent should be instructed to stay well hydrated and avoid rapid position changes and that side effects may include a cough when on ACE inhibitors. ACE inhibitors do not deplete potassium, and they should be taken 1 hour before meals to increase absorption.
An adolescent is being placed on a beta-blocker. What should the nurse inform the adolescent with regard to
this medication? (Select all that apply.)

a. Medication may cause fatigue.
b. Side effects may include impotence.
c. Side effects may include bradycardia.
d. Take the medication 1 hour before meals.
e. Side effects may include peripheral edema.
ANS: A, B, C

The adolescent should be instructed that the medication may cause fatigue, impotence, and bradycardia. The medications should be taken with meals and side effects do not include peripheral edema.
An adolescent is being placed on a calcium channel blocker. What should the nurse inform the adolescent with regard to this medication? (Select all that apply.)

a. The medication may cause fatigue.
b. The medication may increase heart rate.
c. The medication may cause constipation.
d. The medication may cause cold extremities.
e. The medication may cause peripheral edema.
ANS: B, C, E

Calcium channel blockers may cause an increase in heart rate, constipation, and peripheral edema. Betablockers can cause fatigue and cold extremities, but calcium channel blockers do not cause these potential side effects.
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
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.
Which is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures?

a. Pulmonary congestion
b. Congenital heart defect
c. Heart failure
d. Systemic venous congestion
ANS: C

The definition of heart failure is the inability of the heart to pump an adequate amount of
blood to the systemic circulation at normal filling pressures to meet the body's metabolic
demands. Pulmonary congestion is an excessive accumulation of fluid in the lungs. Congenital heart defect is a malformation of the heart present at birth. Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature.
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
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.
The nurse is preparing to administer a dose of digoxin (Lanoxin) to a child in heart failure (HF). Which is a beneficial effect of administering digoxin (Lanoxin)?

a. It decreases edema.
b. It decreases cardiac output.
c. It increases heart size.
d. It increases venous pressure.
ANS: A

Digoxin has a rapid onset and is useful for increasing cardiac output, decreasing venous
pressure, and, as a result, decreasing edema. Cardiac output is increased by digoxin. Heart size and venous pressure are decreased by digoxin.
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
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.
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
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. Sixty 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.
The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which
statement about feeding the child is correct?

a. "You may need to increase the caloric density of your infant's formula."
b. "You should feed your baby every 2 hours."
c. "You may need to increase the amount of formula your infant eats with each
feeding."
d. "You should place a nasal oxygen cannula on your infant during and after each
feeding."
ANS: A

The metabolic rate of infants with heart failure is greater because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of the average infants, yet their ability to take in the calories is diminished by their fatigue. Infants with heart failure should be fed every 3 hours; a 2-hour schedule does not allow for enough rest, and a 4-hour schedule is too long. Fluids must be carefully monitored because of the heart failure. Infants do not require supplemental oxygen with feedings.
As part of the treatment for heart failure, the child takes the diuretic furosemide (Lasix). As
part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in which nutrient?

a. Chlorides
b. Potassium
c. Sodium
d. Vitamins
ANS: B

Diuretics that work on the proximal and distal renal tubules contribute to increased losses of potassium. The child's diet should be supplemented with this electrolyte. With this type of diuretic, potassium must be monitored and supplemented as needed.
Which is the most common causative agent of bacterial endocarditis?

a. Staphylococcus albus
b. Streptococcus hemolyticus
c. Staphylococcus albicans
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.
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
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.
What is the primary nursing intervention to prevent bacterial endocarditis?

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.
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.
Which is a common, serious complication of rheumatic fever?

a. Seizures
b. Cardiac arrhythmias
c. Pulmonary hypertension
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.
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
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.
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.
ANS: C

Nurses have a role in prevention—primarily in screening school-age children for sore throats caused by group A beta-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 beta-hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses.
The nurse is caring for an infant with congestive heart disease (CHD). The nurse should plan which intervention to decrease cardiac demands?

a. Organize nursing activities to allow for uninterrupted sleep.
b. Allow the infant to sleep through feedings during the night.
c. Wait for the infant to cry to show definite signs of hunger.
d. Discourage parents from rocking the infant
ANS: A

The infant requires rest and conservation of energy for feeding. Every effort is made to organize nursing activities to allow for uninterrupted periods of sleep. Whenever possible, parents are encouraged to stay with their infant to provide the holding, rocking, and cuddling that help children sleep more soundly. To minimize disturbing the infant, changing bed linens
and complete bathing are done only when necessary. Feeding is planned to accommodate the infant's sleep and wake patterns. The child is fed at the first sign of hunger, such as when sucking on fists, rather than waiting until he or she cries for a bottle because the stress of crying exhausts the limited energy supply. Because infants with CHD tire easily and may sleep through feedings, smaller feedings every 3 hours may be helpful.
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
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.
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