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PEDS T3 (Ch. 28-34)

Terms in this set (146)

An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough. These manifestations are most suggestive of what complication?

a. Air embolism
b. Allergic reaction
c. Hemolytic reaction
d. Circulatory overload

ANS: D

The signs of circulatory overload include distended neck veins, hypertension, crackles, a dry cough, cyanosis, and precordial pain. Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Urticaria, pruritus, flushing, asthmatic wheezing, and laryngeal edema are signs and symptoms of allergic reactions. Hemolytic reactions are characterized by chills, shaking, fever, pain at infusion site, nausea, vomiting, tightness in chest, flank pain, red or black urine, and progressive signs of shock and renal failure.

What condition occurs when the normal adult hemoglobin is partly or completely replaced by abnormal hemoglobin?

a. Aplastic anemia
b. Sickle cell anemia
c. Thalassemia major
d. Iron deficiency anemia

ANS: B

Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being produced. Thalassemia major refers to a variety of inherited disorders characterized by deficiencies in production of certain globulin chains. Iron-deficiency anemia affects red blood cell size and depth of color but does not involve abnormal hemoglobin

The parents of a child with sickle cell anemia (SCA) are concerned about subsequent children having the disease. What statement most accurately reflects inheritance of SCA?

a. SCA is not inherited.
b. All siblings will have SCA.
c. Each sibling has a 25% chance of having SCA.
d. There is a 50% chance of siblings having SCA.

ANS: C

SCA is inherited as an autosomal recessive disorder. In this inheritance pattern, each child born to these parents has a 25% chance of having the disorder, a 25% chance of having neither SCA nor the trait, and a 50% chance of being heterozygous for SCA (sickle cell trait). SCA is an inherited hemoglobinopathy.

The clinical manifestations of sickle cell anemia (SCA) are primarily the result of which physiologic alteration?

a. Decreased blood viscosity
b. Deficiency in coagulation
c. Increased red blood cell (RBC) destruction
d. Greater affinity for oxygen

ANS: C

The clinical features of SCA are primarily the result of increased RBC destruction and obstruction caused by the sickle-shaped RBCs. When the sickle cells change shape, they increase the viscosity in the area where they are involved in the microcirculation. SCA does not have a coagulation deficit. Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low oxygen tension.

A school-age child is admitted in vasoocclusive sickle cell crisis (pain episode). The childs care should include which therapeutic interventions?

a. Hydration and pain management
b. Oxygenation and factor VIII replacement
c. Electrolyte replacement and administration of heparin
d. Correction of alkalosis and reduction of energy expenditure

ANS: A

The management of crises includes adequate hydration, pain management, minimization of energy expenditures, electrolyte replacement, and blood component therapy if indicated. Factor VIII is not indicated in the treatment of vasoocclusive sickle cell crisis. Oxygen may prevent further sickling, but it is not effective in reversing sickling because it cannot reach the clogged blood vessels. Also, prolonged oxygen can reduce bone marrow activity. Heparin is not indicated in the treatment of vasoocclusive sickle cell crisis. Electrolyte replacement should accompany hydration. The acidosis will be corrected as the crisis is treated. Energy expenditure should be minimized to improve oxygen utilization. Acidosis, not alkalosis, results from hypoxia, which also promotes sickling.

A child with sickle cell anemia (SCA) develops severe chest and back pain, fever, a cough, and dyspnea. What should be the first action by the nurse?

a. Administer 100% oxygen to relieve hypoxia.
b. Notify the practitioner because chest syndrome is suspected.
c. Infuse intravenous antibiotics as soon as cultures are obtained.
d. Give ordered pain medication to relieve symptoms of pain episode.

ANS: B

These are the symptoms of chest syndrome, which is a medical emergency. Notifying the practitioner is the priority action. Oxygen may be indicated; however, it does not reverse the sickling that has occurred. Antibiotics are not indicated initially. Pain medications may be required, but evaluation by the practitioner is the priority.

In a child with sickle cell anemia (SCA), adequate hydration is essential to minimize sickling and delay the
vasoocclusion and hypoxiaischemia cycle. What information should the nurse share with parents in a teaching plan?

a. Encourage drinking.
b. Keep accurate records of output.
c. Check for moist mucous membranes.
d. Monitor the concentration of the childs urine.

ANS: C

Children with SCA have impaired kidney function and cannot concentrate urine. Parents are taught signs of dehydration and ways to minimize loss of fluid to the environment. Encouraging drinking is not specific enough for parents. The nurse should give the parents and child a target fluid amount for each 24-hour period. Accurate monitoring of output may not reflect the childs fluid needs. Without the ability to concentrate urine, the child needs additional intake to compensate. Dilute urine and specific gravity are not valid signs of hydration status in children with SCA.

What therapeutic intervention is most appropriate for a child with b-thalassemia major?

a. Oxygen therapy
b. Supplemental iron
c. Adequate hydration
d. Frequent blood transfusions

ANS: D

The goal of medical management is to maintain sufficient hemoglobin (>9.5 g/dl) to prevent bone marrow expansion. This is achieved through a long-term transfusion program. Oxygen therapy and adequate hydration are not beneficial in the overall management of thalassemia. The child does not require supplemental iron. Iron
overload is a problem because of frequent blood transfusions, decreased production of hemoglobin, and increased absorption from the gastrointestinal tract.

Iron overload is a side effect of chronic transfusion therapy. What treatment assists in minimizing this
complication?

a. Magnetic therapy
b. Infusion of deferoxamine
c. Hemoglobin electrophoresis
d. Washing red blood cells (RBCs) to reduce iron

ANS: B

Deferoxamine infusions in combination with vitamin C allow the iron to remain in a more chelatable form. The iron can then be excreted more easily. Use of magnets does not remove additional iron from the body. Hemoglobin electrophoresis is used to confirm the diagnosis of hemoglobinopathies; it does not affect iron overload. Washed RBCs remove white blood cells and other proteins from the unit of blood; they do not affect the iron concentration.

What statement is descriptive of most cases of hemophilia?

a. X-linked recessive deficiency of platelets causing prolonged bleeding
b. X-linked recessive inherited disorder in which a blood clotting factor is deficient
c. Autosomal dominant deficiency of a factor involved in the blood-clotting reaction
d. Y-linked recessive inherited disorder in which the red blood cells become moon shaped

ANS: B

The inheritance pattern in 80% of all the cases of hemophilia is X-linked recessive. The two most common forms of the disorder are factor VIII deficiency (hemophilia A, or classic hemophilia) and factor IX deficiency (hemophilia B, or Christmas disease). The disorder involves coagulation factors, not platelets. The disorder does not involve red blood cells or the Y chromosome.

The nurse is teaching the family of a child, age 8 years, with moderate hemophilia about home care. What
should the nurse tell the family to do to minimize joint injury?

a. Administer nonsteroidal anti-inflammatory drugs (NSAIDs).
b. Administer DDAVP (synthetic vasopressin).
c. Provide intravenous (IV) infusion of factor VIII concentrates.
d. Encourage elevation and application of ice to the involved joint.

ANS: C

Parents are taught home infusion of factor VIII concentrate. For moderate and severe hemophilia, prompt IV administration is essential to prevent joint injury. NSAIDs are effective for pain relief. They must be given with caution because they inhibit platelet aggregation. A factor VIII level of 30% is necessary to stop bleeding. DDAVP can raise the factor VIII level fourfold. Moderate hemophilia is defined by a factor VIII activity of 4.9. A fourfold increase would not meet the 30% level. Ice and elevation are important adjunctive therapy, but factor VIII is necessary.

What condition is an acquired hemorrhagic disorder that is characterized by excessive destruction of platelets?

a. Aplastic anemia
b. Thalassemia major
c. Idiopathic thrombocytopenic purpura
d. Disseminated intravascular coagulation

ANS: C

Idiopathic thrombocytopenic purpura is an acquired hemorrhagic disorder characterized by an excessive destruction of platelets, discolorations caused by petechiae beneath the skin, and normal bone marrow. Aplastic anemia refers to a bone marrow failure condition in which the formed elements of the blood are simultaneously depressed. Thalassemia major is a group of blood disorders characterized by deficiency in the production rate of specific hemoglobin chains. Disseminated intravascular coagulation is characterized by diffuse fibrin deposition in the microvasculature, consumption of coagulation factors, and endogenous generation of thrombin and plasma.

Care for the child with acute idiopathic thrombocytopenic purpura (ITP) includes which therapeutic intervention?

a. Splenectomy
b. Intravenous administration of anti-D antibody
c. Use of nonsteroidal anti-inflammatory drugs (NSAIDs)
d. Helping child participate in sports

ANS: B

Anti-D antibody causes an increase in platelet count approximately 48 hours after administration. Splenectomy is reserved for chronic severe ITP not responsive to pharmacologic management. NSAIDs are not used in ITP. Both NSAIDs and aspirin interfere with platelet aggregation. The nurse works with the child and parents to choose quiet activities while the platelet count is below 100,000/mm3.

A 5-year-old child is admitted to the hospital in a sickle cell crisis. The child has been alert and oriented but in severe pain. The nurse notes that the child is complaining of a headache and is having unilateral hemiplegia. What action should the nurse implement?

a. Notify the health care provider.
b. Place the child on bed rest.
c. Administer a dose of hydrocodone (Vicodin).
d. Start O2 per the hospitals protocol.

ANS: A

Any number of neurologic symptoms can indicate a minor cerebral insult, such as headache, aphasia, weakness, convulsions, visual disturbances, or unilateral hemiplegia. Loss of vision is usually the result of progressive retinopathy and retinal detachment. The nurse should notify the health care provider.

What pain medication is contraindicated in children with sickle cell disease (SCD)?

a. Meperidine (Demerol)
b. Hydrocodone (Vicodin)
c. Morphine sulfate
d. Ketorolac (Toradol)

ANS: A

Meperidine (pethidine [Demerol]) is not recommended. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Patients with SCD are particularly at risk for normeperidine-induced seizures.

In anticipation of the admission of a child with hereditary spherocytosis (HS) who is experiencing an aplastic crisis, what action should the nurse plan?

a. Secure an isolation room.
b. Prepare for a transfusion of packed red blood cells.
c. Anticipate preoperative preparation for a splenectomy.
d. Gather equipment and medication for treatment of shock.

ANS: B

In hereditary spherocytosis, aplastic crisis results in a sudden cessation of RBC production by the bone marrow. Hemoglobin and hematocrit values drop rapidly, which results in severe anemia. Transfusion support may be needed, and close monitoring of the childs cardiovascular status is necessary. The nurse should prepare for a transfusion of packed red blood cells initially. An isolation room is not needed, splenectomy would not be done at this time, and the child will not be in shock.

A child with hemophilia A will have which abnormal laboratory result?

a. PT (ProTime)
b. Platelet count
c. Fibrinogen level
d. PTT (partial thromboplastin time)

ANS: D

The basic defect of hemophilia A is a deficiency of factor VIII. The partial thromboplastin time measures abnormalities in the intrinsic pathway (abnormalities in factors I, II, V, VIII, IX, X, XII, HMK, and KAL). The prothrombin time measures abnormalities of the extrinsic pathway (abnormalities in factors I, II, V, VII, and X). Fibrinogen level is not dependent on the intrinsic pathway. Platelets are not affected with hemophilia A.

A child with hemophilia A is scheduled for surgery. What precautions should the nurse institute with this child?

a. Handle the child gently when transferring to a cart.
b. Caution the child not to brush his teeth before surgery.
c. Use tape sparingly on postoperative dressings.
d. Do not administer analgesics before surgery.

ANS: A

The goal of prevention of bleeding episodes is directed toward decreasing the risk of injury. The child should be handled carefully when transferring to a cart. Brushing teeth, use of tape, and giving analgesics will not risk a bleeding episode.

The nurse is caring for a child with hemophilia A. The childs activity is as tolerated. What activity is contraindicated for this child?

a. Ambulating to the cafeteria
b. Active range of motion
c. Ambulating to the playroom
d. Passive range of motion exercises

ANS: D

Passive range of motion exercises should never be part of an exercise regimen after an acute episode because the joint capsule could easily be stretched and bleeding could recur. Active range of motion exercises are best so that the patient can gauge his or her own pain tolerance. The child can ambulate to the playroom or the cafeteria.

The nurse is preparing to administer a unit of packed red blood cells to a hospitalized child. What is an appropriate action that applies to administering blood?

a. Take the vital signs every 15 minutes while blood is infusing.
b. Use blood within 1 hour of its arrival from the blood bank.
c. Administer the blood with 5% glucose in a piggyback setup.
d. Administer the first 50 ml of blood slowly and stay with the child.

ANS: D

The nurse should administer the first 50 ml of blood or initial 20% of volume (whichever is smaller) slowly and stay with the child. Vitals signs should be taken 15 minutes after initiation and then every hour, not every 15 minutes. Blood should be used within 30 minutes, not 1 hour. Normal saline, not 5% glucose, should be the IV solution.

A child with sickle cell disease is in a vasoocclusive crisis. What nonpharmacologic pain intervention should the nurse plan?

a. Exercise as a distraction
b. Heat to the affected area
c. Elevation of the extremity
d. Cold compresses to the affected area

ANS: B

Frequently, heat to the affected area is soothing. Cold compresses are not applied to the area because doing so enhances vasoconstriction and occlusion. Bed rest is usually well tolerated during a crisis, although the actual rest obtained depends a great deal on pain alleviation and the use of organized schedules of nursing care. Although the objective of bed rest is to minimize oxygen consumption, some activity, particularly passive range of motion exercises, is beneficial to promote circulation. Usually the best course is to let children determine their activity tolerance. Elevating the extremity will not help in sickle cell disease.

What activity should the school nurse recommend for a child with hemophilia A? (Select all that apply.)

a. Golf
b. Soccer
c. Rugby
d. Jogging
e. Swimming

ANS: A, D, E

Children and adolescents with severe hemophilia can participate in noncontact sports such as swimming, golf, walking, jogging, fishing, and bowling. Contact sports such as football, boxing, hockey, soccer, and rugby are strongly discouraged because the risk of injury outweighs the physical and psychosocial benefits of participating in these sports.

The nurse is administering a unit of blood to a child. What are signs and symptoms of a transfusion reaction? (Select all that apply.)

a. Chills
b. Shaking
c. Flank pain
d. Hypothermia
e. Sudden severe headache

ANS: A, B, C, E

Signs and symptoms of a transfusion reaction include chills, shaking, flank pain, and sudden severe headache. Hyperthermia, not hypothermia, occurs.

Parents of a child with sickle cell anemia ask the nurse, "What happens to the hemoglobin in sickle cell anemia?" Which statement by the nurse explains the disease process?

a. Normal adult hemoglobin is replaced by abnormal hemoglobin.
b. There is a lack of cellular hemoglobin being produced.
c. There is a deficiency in the production of globulin chains.
d. The size and depth of the hemoglobin are affected.

ANS: A

Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being produced. Thalassemia major refers to a variety of inherited disorders characterized by deficiencies in production of certain globulin chains.
Iron-deficiency anemia affects the size, depth, and color of hemoglobin.

When both parents have sickle cell trait, which is the chance their children will have sickle cell anemia?

a. 25%
b. 50%
c. 75%
d. 100%

ANS: A

Sickle cell anemia is inherited in an autosomal recessive pattern. If both parents have sickle cell trait (one copy of the sickle cell gene), then for each pregnancy, a 25% chance exists that their child will be affected with sickle cell disease. With each pregnancy, a 50% chance exists that the child will have sickle cell trait. Percentages of 75% and 100% are too high for the children of parents who have sickle cell trait.

The nurse is conducting a staff in-service on sickle cell anemia. Which describes the pathologic changes of sickle cell anemia?

a. Sickle-shaped cells carry excess oxygen.
b. Sickle-shaped cells decrease blood viscosity.
c. Increased red blood cell destruction occurs.
d. Decreased adhesion of sickle-shaped cells occurs.

ANS: C

The clinical features of sickle cell anemia are primarily the result of increased red blood cell destruction and obstruction caused by the sickle-shaped red blood cells. Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low
oxygen tension. When the sickle cells change shape, they increase the viscosity in the area where they are involved in the microcirculation. Increased adhesion and entanglement of cells occurs.

Which clinical manifestation should the nurse expect when a child with sickle cell anemia experiences an acute vasoocclusive crisis?

a. Circulatory collapse
b. Cardiomegaly, systolic murmurs
c. Hepatomegaly, intrahepatic cholestasis
d. Painful swelling of hands and feet; painful joints

ANS: D

A vasoocclusive crisis is characterized by severe pain in the area of involvement. If in the extremities, painful swelling of the hands and feet is seen; if in the abdomen, severe pain resembles that of acute surgical abdomen; and if in the head, stroke and visual disturbances occur. Circulatory collapse results from sequestration crises. Cardiomegaly, systolic murmurs, hepatomegaly, and intrahepatic cholestasis result from chronic vasoocclusive phenomena.

Why is meperidine (Demerol) not recommended for children in sickle cell crisis?

a. May induce seizures
b. Is easily addictive
c. Not adequate for pain relief
d. Given by intramuscular injection

ANS: A

A metabolite of meperidine, normeperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with
repetitive dosing. Patients with sickle cell disease are particularly at risk for normeperidine-induced seizures. Meperidine is no more addictive than other narcotic agents. Meperidine is adequate for pain relief. It is available for IV infusion.

A school-age child is admitted in vasoocclusive sickle cell crisis. What should be included in the child's care?

a. Correction of acidosis
b. Adequate hydration and pain management
c. Pain management and administration of heparin
d. Adequate oxygenation and replacement of factor VIII

ANS: B

The management of crises includes adequate hydration, minimization of energy expenditures, pain management, electrolyte replacement, and blood component therapy if indicated.
Hydration and pain control are two of the major goals of therapy. The acidosis will be corrected as the crisis is treated. Heparin and factor VIII are not indicated in the treatment of vasoocclusive sickle cell crisis. Oxygen may prevent further sickling, but it is not effective in reversing sickling because it cannot reach the clogged blood vessels.

The parents of a child hospitalized with sickle cell anemia tell the nurse that they are concerned about narcotic analgesics causing addiction. Which is appropriate for the nurse to explain about narcotic analgesics?

a. Are often ordered but not usually needed
b. Rarely cause addiction because they are medically indicated
c. Are given as a last resort because of the threat of addiction
d. Are used only if other measures, such as ice packs, are ineffective

ANS: B

The pain of sickle cell anemia is best treated by a multidisciplinary approach. Mild to moderate pain can be controlled by ibuprofen and acetaminophen. When narcotics are indicated, they are titrated to effect and are given around the clock. Patient-controlled analgesia reinforces the patient's role and responsibility in managing the pain and provides flexibility in dealing with pain. Few, if any, patients who receive opioids for severe pain become behaviorally addicted to the drug. Narcotics are often used because of the severe nature of the pain of vasoocclusive crisis. Ice is contraindicated because of its vasoconstrictive effects.

Parents of a hemophiliac child ask the nurse, "Can you describe hemophilia to us?" Which response by the nurse is descriptive of most cases of hemophilia?

a. Autosomal dominant disorder causing deficiency in a factor involved in the
blood-clotting reaction
b. X-linked recessive inherited disorder causing deficiency of platelets and prolonged
bleeding
c. X-linked recessive inherited disorder in which a blood-clotting factor is deficient
d. Y-linked recessive inherited disorder in which the red blood cells become
moon-shaped

ANS: C

The inheritance pattern in 80% of all of the cases of hemophilia is X-linked recessive. The two most common forms of the disorder are factor VIII deficiency, hemophilia A or classic hemophilia; and factor IX deficiency, hemophilia B or Christmas disease. The inheritance
pattern is X-linked recessive. The disorder involves coagulation factors, not platelets, and does not involve red cells or the Y chromosomes.

The nurse is conducting a staff in-service on childhood blood disorders. Which describes the pathology of idiopathic thrombocytopenic purpura?

a. Bone marrow failure in which all elements are suppressed
b. Deficiency in the production rate of globin chains
c. Diffuse fibrin deposition in the microvasculature
d. An excessive destruction of platelets

ANS: D

Idiopathic thrombocytopenic purpura is an acquired hemorrhagic disorder characterized by an excessive destruction of platelets, discolorations caused by petechiae beneath the skin, and a normal bone marrow. Aplastic anemia refers to a bone marrow-failure condition in which the formed elements of the blood are simultaneously depressed. Thalassemia major is a group of blood disorders characterized by deficiency in the production rate of specific hemoglobin globin chains. Disseminated intravascular coagulation is characterized by diffuse fibrin deposition in the microvasculature, consumption of coagulation factors, and endogenous generation of thrombin and plasma.

Several complications can occur when a child receives a blood transfusion. Which is an immediate sign or symptom of an air embolus?

a. Chills and shaking
b. Nausea and vomiting
c. Irregular heart rate
d. Sudden difficulty in breathing

ANS: D

Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Air emboli should be avoided by carefully flushing all tubing of air before connecting to patient. Chills, shaking, nausea, and vomiting are associated with hemolytic
reactions. Irregular heart rate is associated with electrolyte disturbances and hypothermia.

The nurse is planning care for a school-age child admitted to the hospital with hemophilia.
Which interventions should the nurse plan to implement for this child? (Select all that apply.)

a. Finger sticks for blood work instead of venipunctures
b. Avoidance of IM injections
c. Acetaminophen (Tylenol) for mild pain control
d. Soft tooth brush for dental hygiene
e. Administration of packed red blood cells

ANS: B, C, D

Nurses should take special precautions when caring for a child with hemophilia to prevent the use of procedures that may cause bleeding, such as IM injections. The subcutaneous route is substituted for IM injections whenever possible. Venipunctures for blood samples are usually preferred for these children. There is usually less bleeding after the venipuncture than after finger or heel punctures. Neither aspirin nor any aspirin-containing compound should be used. Acetaminophen is a suitable aspirin substitute, especially for controlling mild pain. A soft toothbrush is recommended for dental hygiene to prevent bleeding from the gums. Packed red blood cells are not administered. The primary therapy for hemophilia is replacement of the missing clotting factor. The products available are factor VIII concentrates.

Parents of a school-age child with hemophilia ask the nurse, "Which sports are recommended
for children with hemophilia?" Which sports should the nurse recommend? (Select all that
apply.)

a. Soccer
b. Swimming
c. Basketball
d. Golf
e. Bowling

ANS: B, D, E

Because almost all persons with hemophilia are boys, the physical limitations in regard to active sports may be a difficult adjustment, and activity restrictions must be tempered with
sensitivity to the child's emotional and physical needs. Use of protective equipment, such as padding and helmets, is particularly important, and noncontact sports, especially swimming, walking, jogging, tennis, golf, fishing, and bowling, are encouraged. Contact sports such as
soccer and basketball are not recommended.

Which should the nurse teach about prevention of sickle cell crises to parents of a preschool child with sickle cell disease? (Select all that apply.)

a. Limit fluids at bedtime.
b. Notify the health care provider if a fever of 38.5° C (101.3° F) or greater occurs.
c. Give penicillin as prescribed.
d. Use ice packs to decrease the discomfort of vasoocclusive pain in the legs.
e. Notify the health care provider if your child begins to develop symptoms of a cold.

ANS: B, C, E

The most important issues to teach the family of a child with sickle cell anemia are to (1) seek early intervention for problems, such as a fever of 38.5° C (101.3° F) or greater; (2) give penicillin as ordered; (3) recognize signs and symptoms of splenic sequestration, as well as respiratory problems that can lead to hypoxia; and (4) treat the child normally. The nurse emphasizes the importance of adequate hydration to prevent sickling and to delay the adhesion-stasis-thrombosis-ischemia cycle. It is not sufficient to advise parents to "force fluids" or "encourage drinking." They need specific instructions on how many daily glasses or bottles of fluid are required. Many foods are also a source of fluid, particularly soups, flavored ice pops, ice cream, sherbet, gelatin, and puddings. Increased fluids combined with impaired kidney function result in the problem of enuresis. Parents who are unaware of this fact frequently use the usual measures to discourage bedwetting, such as limiting fluids at night. Enuresis is treated as a complication of the disease, such as joint pain or some other symptom, to alleviate parental pressure on the child. Ice should not be used during a vasoocclusive pain crisis because it vasoconstricts and impairs circulation even more.

The nurse has initiated a blood transfusion on a preschool child. The child begins to exhibit
signs of a transfusion reaction. Place in order the interventions the nurse should implement
sequencing from the highest priority to the lowest. Provide the answer using lowercase letters
separated by commas (e.g., a, b, c, d).

a. Take the vital signs.
b. Stop the transfusion.
c. Notify the practitioner.
d. Maintain a patent IV line with normal saline.

ANS:

b, a, d, c
If a blood transfusion reaction of any type is suspected, stop the transfusion, take vital signs, maintain a patent IV line with normal saline and new tubing, notify the practitioner, and do not restart the transfusion until the child's condition has been medically evaluated.

The nurse is administering an intravenous chemotherapeutic agent to a child with leukemia. The child suddenly begins to wheeze and have severe urticaria. What nursing action is most appropriate to initiate?

a. Recheck the rate of drug infusion.
b. Stop the drug infusion immediately.
c. Observe the child closely for next 10 minutes.
d. Explain to the child that this is an expected side effect.

ANS: B

When an allergic reaction is suspected, the drug is immediately discontinued. Any drug in the line should be withdrawn, and a normal saline infusion begun to keep the line open. The intravenous infusion is stopped to minimize the amount of drug that infuses. The infusion rate can be confirmed at a later time. Observation of the child for 10 minutes is essential, but it is done after the infusion is stopped. These signs are indicative of an allergic reaction, not an expected response.

After chemotherapy is begun for a child with acute leukemia, prophylaxis to prevent acute tumor lysis syndrome includes which therapeutic intervention?

a. Hydration
b. Oxygenation
c. Corticosteroids
d. Pain management

ANS: A

Acute tumor lysis syndrome results from the release of intracellular metabolites during the initial treatment of leukemia. Hyperuricemia, hypocalcemia, hyperphosphatemia, and hyperkalemia can result. Hydration is used to reduce the metabolic consequences of the tumor lysis. Oxygenation is not helpful in preventing acute tumor lysis syndrome. Allopurinol, not corticosteroids, is indicated for pharmacologic management. Pain management may be indicated for supportive therapy of the child, but it does not prevent acute tumor lysis syndrome.

Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents should include which therapeutic intervention?

a. Restrict oral fluids.
b. Institute strict isolation.
c. Use good hand-washing technique.
d. Give immunizations appropriate for age.

ANS: C

Good hand washing minimizes the exposure to infectious organisms and decreases the chance of infection spread. Oral fluids are encouraged if the child is able to drink. If possible, the intravenous route is not used because of the increased risk of infection from parenteral fluid administration. Strict isolation is not indicated. When the child is immunocompromised, the vaccines are not effective. If necessary, the appropriate immunoglobulin is administered

A school-age child with leukemia experienced severe nausea and vomiting when receiving chemotherapy for the first time. What is the most appropriate nursing action to prevent or minimize these reactions with subsequent treatments?

a. Administer the chemotherapy between meals.
b. Give an antiemetic before chemotherapy begins.
c. Have the child bring favorite foods for snacks.
d. Keep the child NPO (nothing by mouth) until nausea and vomiting subside.

ANS: B

The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy is to administer a 5-hydroxytryptamine-3 receptor antagonist (e.g., ondansetron) before the chemotherapy is begun. The goal is to prevent anticipatory signs and symptoms. The child will experience nausea with chemotherapy whether or not food is present in the stomach. Because some children develop aversions to foods eaten during chemotherapy, refraining from offering favorite foods is advised. Keeping the child NPO until nausea and vomiting subside will help with this episode, but the child will have discomfort and be at risk for dehydration.

A child on chemotherapy has developed rectal ulcers. What interventions should the nurse teach to the child and parents to relieve the discomfort of rectal ulcers? (Select all that apply.)

a. Warm sitz baths
b. Use of stool softeners
c. Record bowel movements
d. Use of an opioid for discomfort
e. Occlusive ointment applied to the area

ANS: A, B, C, E

If rectal ulcers develop, meticulous toilet hygiene, warm sitz baths after each bowel movement, and an occlusive ointment applied to the ulcerated area promote healing; the use of stool softeners is necessary to prevent further discomfort. Parents should record bowel movements because the child may voluntarily avoid defecation to prevent discomfort. Opioids would cause increased constipation.

A health care provider prescribes ondansetron (Zofran) 0.15 mg/kg intravenously (IV) 30 minutes before chemotherapy for a child with acute lymphoblastic leukemia. The child weighs 22 kg. The medication label states: Ondansetron (Zofran) 2 mg/1 ml. The nurse prepares to administer the dose. How many milliliters will the nurse prepare to administer the dose? Fill in the blank. Round your answer to one decimal place.

ANS: 1.7

Myelosuppression, associated with chemotherapeutic agents or some malignancies such as leukemia, can cause bleeding tendencies because of a(n):

a. decrease in leukocytes.
b. increase in lymphocytes.
c. vitamin C deficiency.
d. decrease in blood platelets.

ANS: D

The decrease in blood platelets secondary to the myelosuppression of chemotherapy can cause an increase in bleeding. The child and family should be alerted to avoid risk of injury. Decrease in leukocytes, increase in lymphocytes, and vitamin C deficiency would not affect
bleeding tendencies.

The nurse is preparing to give oral care to a school-age child with mucositis secondary to chemotherapy administered to treat leukemia. Which preparations should the nurse use for oral care on this child? (Select all that apply.)

a. Chlorhexidine gluconate (Peridex)
b. Lemon glycerin swabs
c. Antifungal troches (lozenges)
d. Lip balm (Aquaphor)
e. Hydrogen peroxide

ANS: A, C, D

Preparations that may be used to prevent or treat mucositis include chlorhexidine gluconate (Peridex) because of its dual effectiveness against candidal and bacterial infections, antifungal troches (lozenges) or mouthwash, and lip balm (e.g., Aquaphor) to keep the lips moist. Agents that should not be used include lemon glycerin swabs (irritate eroded tissue and can decay teeth), hydrogen peroxide (delays healing by breaking down protein), and milk of magnesia (dries mucosa).

A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The childs level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. What is the most appropriate nursing action?

a. Explain that analgesia is contraindicated with a head injury.
b. Have the parents describe the childs previous experiences with pain.
c. Consult with a practitioner about what analgesia can be safely administered.
d. Teach the parents that analgesia is unnecessary when the child is not fully awake and alert.

ANS: C

A key nursing role is to provide sedation and analgesia for the child. Consultation with the appropriate practitioner is necessary to avoid conflict between the necessity to monitor the childs neurologic status and to promote comfort and relieve anxiety. Analgesia can be safely used in individuals who have sustained head injuries. The childs previous experiences with pain should be obtained as part of the assessment, but because of the severity of the injury, analgesia should be provided as soon as possible. Analgesia can decrease anxiety and resultant increased intracranial pressure.

The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What clinical manifestation is the most essential part of the nursing assessment to detect early signs of a worsening condition?

a. Posturing
b. Vital signs
c. Focal neurologic signs
d. Level of consciousness

ANS: D

The most important nursing observation is assessment of the childs level of consciousness. Alterations in consciousness appear earlier in the progression of an injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic damage.

The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like the childs younger brother had when he was an infant. The nurse should base a response on which information?

a. Meningitis rarely occurs during infancy.
b. Often a genetic predisposition to meningitis is found.
c. Vaccination to prevent all types of meningitis is now available.
d. Vaccinations to prevent pneumococcal and Haemophilus influenzae type B meningitis are
available.

ANS: D

H. influenzae type B meningitis has been virtually eradicated in areas of the world where the vaccine is administered routinely. Bacterial meningitis remains a serious illness in children. It is significant because of the residual damage caused by undiagnosed and untreated or inadequately treated cases. The leading causes of neonatal meningitis are the group B streptococci and Escherichia coli organisms. Meningitis is an extension of a variety of bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of the potential causative organisms.

A toddler is admitted to the pediatric unit with presumptive bacterial meningitis. The initial orders include isolation, intravenous access, cultures, and antimicrobial agents. The nurse knows that antibiotic therapy will begin when?

a. After the diagnosis is confirmed
b. When the medication is received from the pharmacy
c. After the childs fluid and electrolyte balance is stabilized
d. As soon as the practitioner is notified of the culture results

ANS: B

Antimicrobial therapy is begun as soon as a presumptive diagnosis is made. The choice of drug is based on the most likely infective agent. Drug choice may be adjusted when the culture results are obtained. Waiting for culture results to begin therapy increases the risk of neurologic damage. Although fluid and electrolyte balance is important, there is no indication that this child is unstable. Antibiotic therapy would be a priority
intervention.

The nurse is planning care for a school-age child with bacterial meningitis. What intervention should be included?

a. Keep environmental stimuli to a minimum.
b. Have the child move her head from side to side at least every 2 hours.
c. Avoid giving pain medications that could dull sensorium.
d. Measure head circumference to assess developing complications.

ANS: A

The room is kept as quiet as possible and environmental stimuli are kept to a minimum. Most children with meningitis are sensitive to noise, bright lights, and other external stimuli. The nuchal rigidity associated with meningitis would make moving the head from side to side a painful intervention. If pain is present, the child should be treated appropriately. Failure to treat can cause increased intracranial pressure. In this age group, the head circumference does not change. Signs of increased intracranial pressure would need to be assessed.

What intervention should be beneficial in reducing the risk of Reye syndrome?

a. Immunization against the disease
b. Medical attention for all head injuries
c. Prompt treatment of bacterial meningitis
d. Avoidance of aspirin for children with varicella or those suspected of having influenza

ANS: D

Although the etiology of Reye syndrome is obscure, most cases follow a common viral illness, either varicella or influenza. A potential association exists between aspirin therapy and the development of Reye syndrome, so use of aspirin is avoided. No immunization currently exists for Reye syndrome. Reye syndrome is not
correlated with head injuries or bacterial meningitis.

The nurse is caring for a 10-year-old child who has an acute head injury, has a pediatric Glasgow Coma
Scale score of 9, and is unconscious. What intervention should the nurse include in the childs care plan?

a. Elevate the head of the bed 15 to 30 degrees with the head maintained in midline.
b. Maintain an active, stimulating environment.
c. Perform chest percussion and suctioning every 1 to 2 hours.
d. Perform active range of motion and nontherapeutic touch every 8 hours.

ANS: A

Nursing activities for children with head trauma and increased intracranial pressure (ICP) include elevating the head of the bed 15 to 30 degrees and maintaining the head in a midline position. The nurse should try to maintain a quiet, nonstimulating environment for a child with increased ICP. Chest percussion and suctioning should be performed judiciously because they can elevate ICP. Range of motion should be passive and nontherapeutic touch should be avoided because both of these activities can increase ICP.

A child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. What is a common reason for elective revision of this shunt?

a. Meningitis
b. Gastrointestinal upset
c. Hydrocephalus resolution
d. Growth of the child since the initial shunting

ANS: D

An elective revision of a ventriculoperitoneal shunt would most likely be done to accommodate the childs growth. Meningitis would require an emergent replacement or revision of the shunt. Gastrointestinal upset alone would not indicate the need for shunt revision. Noncommunicating hydrocephalus will not resolve without surgical intervention.

The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt. What issues should be addressed?

a. Most childhood activities must be restricted.
b. Cognitive impairment is to be expected with hydrocephalus.
c. Wearing head protection is essential until the child reaches adulthood.
d. Shunt malfunction or infection requires immediate treatment.

ANS: D

Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately. Limits should be appropriate to the childs developmental age. Except for contact sports, the child will have few restrictions. Cognitive impairment depends on the extent of damage before the shunt was placed.

A 6-year-old child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating
hydrocephalus. What sign or symptom does the child have that indicates a revision is necessary?

a. Tachycardia
b. Gastrointestinal upset
c. Hypotension
d. Alteration in level of consciousness

ANS: D

In older children, who are usually admitted to the hospital for elective or emergency shunt revision, the most valuable indicators of increasing intracranial pressure are an alteration in the childs level of consciousness,
complaint of headache, and changes in interaction with the environment.

When taking the history of a child hospitalized with Reye syndrome, the nurse should not be surprised if a week ago the child had recovered from what?

a. Measles
b. Influenza
c. Meningitis
d. Hepatitis

ANS: B

The etiology of Reye syndrome is not well understood, but most cases follow a common viral illness, typically influenza or varicella.

If an intramuscular (IM) injection is administered to a child who has Reye syndrome, the nurse should monitor for what?

a. Bleeding
b. Infection
c. Poor absorption
d. Itching at the injection site

ANS: A

The nurse should watch for bleeding from the site. Because of related liver dysfunction with Reye syndrome, laboratory studies, such as prolonged bleeding time, should be monitored to determine impaired coagulation.

A 23-month-old child is admitted to the hospital with a diagnosis of meningitis. She is lethargic and very irritable with a temperature of 102 F. What should the nurses care plan include?

a. Observing the childs voluntary movement
b. Checking the Babinski reflex every 4 hours
c. Checking the Brudzinski reflex every 1 hour
d. Assessing the level of consciousness (LOC) and vital signs every 2 hours

ANS: D

Observation of vital signs, neurologic signs, LOC, urinary output, and other pertinent data is carried out at frequent intervals on a child with meningitis. The nurse should avoid actions that cause pain or increase discomfort, such as lifting the childs head, so the Brudzinski reflex should not be checked hourly. Checking the Babinski reflex or childs voluntary movements will not help with assessing the childs status.

A lumbar puncture (LP) is being done on an infant with suspected meningitis. The nurse expects which results for the cerebrospinal fluid that can confirm the diagnosis of meningitis?

a. WBCs; glucose
b. RBCs; normal WBCs
c. glucose; normal RBCs
d. Normal RBCs; normal glucose

ANS: A

A lumbar puncture is the definitive diagnostic test. The fluid pressure is measured and samples are obtained for culture, Gram stain, blood cell count, and determination of glucose and protein content. The findings are usually diagnostic. The patient generally has an elevated white blood cell count, often predominantly polymorphonuclear leukocytes. The glucose level is reduced, generally in proportion to the duration and severity of the infection.

The nurse is preparing to admit a neonate with bacterial meningitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.)

a. Jaundice
b. Cyanosis
c. Poor tone
d. Nuchal rigidity
e. Poor sucking ability

ANS: A, B, C, E

Clinical manifestations of bacterial meningitis in a neonate include jaundice, cyanosis, poor tone, and poor sucking ability. The neck is usually supple in neonates with meningitis, and there is no nuchal rigidity.

The nurse is preparing to admit an adolescent with bacterial meningitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.)

a. Fever
b. Chills
c. Headache
d. Poor tone
e. Drowsiness

ANS: A, B, C, E

Clinical manifestations of bacterial meningitis in an adolescent include, fever, chills, headache, and drowsiness. Hyperactivity is present, not poor tone

The nurse is caring for a child with meningitis. What acute complications of meningitis should the nurse
continuously assess the child for? (Select all that apply.)

a. Seizures
b. Cerebral palsy
c. Cerebral edema
d. Hydrocephalus
e. Cognitive impairments

ANS: A, C, E

Acute complications of meningitis include syndrome of inappropriate antidiuretic hormone (SIADH), subdural effusions, seizures, cerebral edema and herniation, and hydrocephalus. Long-term complications include cerebral palsy, cognitive impairments, learning disorder, attention deficit hyperactivity disorder, and seizures.

What is an appropriate nursing intervention when caring for an unconscious child?

a. Change the child's position infrequently to minimize the chance of increased ICP
b. Avoid using narcotics or sedatives to provide comfort and pain relief
c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral
edema
d. Give tepid sponge baths to reduce fever because antipyretics are contraindicated

ANS: C

Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema. The child's position should be changed frequently to avoid complications such as pneumonia and skin breakdown. Narcotics and sedatives should be used as necessary to reduce pain and discomfort, which can increase ICP. Antipyretics are the method of choice for fever reduction.

When should the nurse recommend medical attention for a child with a slight head injury?

a. Experiences sleepiness
b. Vomits
c. Has a headache
d. Is confused or has abnormal behavior

ANS: D

Medical attention should be sought if the child exhibits confusion or abnormal behavior, loses consciousness, has amnesia, has fluid leaking from the nose or ears, complains of blurred vision, or has an unsteady gait. Sleepiness alone does not require evaluation. If the child is difficult to arouse from sleep, medical attention should be obtained. Vomiting more than three times requires medical attention. Severe or worsening headache or one that interferes with sleep should be evaluated.

An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed. The nurse should suspect which type of head injury?

a. Brainstem
b. Skull fracture
c. Subdural hemorrhage
d. Epidural hemorrhage

ANS: A

Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are consistent with a brainstem injury. Skull fracture, subdural hemorrhage, and epidural hemorrhage are not consistent with brainstem injuries.

A toddler fell out of a second-story window. She had a brief loss of consciousness and vomited four times. Since admission, she has been alert and oriented. Her mother asks why a computed tomography (CT) scan is required when she "seems fine." Which explanation should the nurse give?

a. Your child may have a brain injury and the CT can rule one out.
b. The CT needs to be done because of your child's age.
c. Your child may start to have seizures and a baseline CT should be done.
d. Your child probably has a skull fracture and the CT can confirm this diagnosis.

ANS: A

The child's history of the fall, brief loss of consciousness, and vomiting four times
necessitates evaluation of a potential brain injury. The severity of a head injury may not be apparent on clinical examination but will be detectable on a CT scan. The need for the CT scan is related to the injury and symptoms, not the child's age. The CT scan is necessary to determine whether a brain injury has occurred.

A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The child's level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. What is the most appropriate nursing action?

a. Discuss with parents the child's previous experiences with pain
b. Discuss with practitioner what analgesia can be safely administered
c. Explain that analgesia is contraindicated with a head injury
d. Explain that analgesia is unnecessary when child is not fully awake and alert

ANS: B

A key nursing role is to provide sedation and analgesia for the child. Consultation with the appropriate practitioner is necessary to avoid conflict between the necessity to monitor the child's neurologic status and the promotion of comfort and relief of anxiety. Information on the child's previous experiences with pain should be obtained as part of the assessment, but because of the severity of injury, analgesia should be provided as soon as possible. Analgesia can be safely used in individuals who have sustained head injuries and can decrease anxiety and resultant increased ICP.

When caring for the child with Reye syndrome, what is the priority nursing intervention?

a. Monitor intake and output
b. Prevent skin breakdown
c. Observe for petechiae
d. Do range-of-motion exercises

ANS: A

Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema. Preventing skin breakdown, observing for petechiae, and doing range-of-motion exercises are important interventions in the care of a critically ill or comatose child. Careful monitoring of intake and output is a priority.

An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should be included in the child's postoperative care? (Select all that apply.)

a. Observe closely for signs of infection.
b. Pump the shunt reservoir to maintain patency.
c. Administer sedation to decrease irritability.
d. Maintain Trendelenburg position to decrease pressure on the shunt.
e. Maintain an accurate record of intake and output.
f. Monitor for abdominal distention

ANS: A, E, F

Infection is a major complication of ventriculoperitoneal shunts. Observation for signs of infection is a priority nursing intervention. Intake and output should be measured carefully. Abdominal distention could be a sign of peritonitis or a postoperative ileus. Pumping of the
shunt may cause obstruction or other problems and should not be performed unless indicated by the neurosurgeon. Pain management rather than sedation should be the goal of therapy. The child is kept flat to avoid too rapid a reduction of intracranial fluid.

The nurse is evaluating the laboratory results on cerebral spinal fluid (CSF) from a 3-year-old
child with bacterial meningitis. Which findings confirm bacterial meningitis? (Select all that apply.)

a. Elevated white blood cell (WBC) count
b. Decreased glucose
c. Normal protein
d. Elevated red blood cell (RBC) count

ANS: A, B

The cerebrospinal fluid analysis in bacterial meningitis shows elevated WBC count, decreased glucose, and increased protein content. There should not be RBCs evident in the CSF fluid.

The nurse is caring for a neonate with suspected meningitis. Which clinical manifestations should the nurse prepare to assess if meningitis is confirmed? (Select all that apply.)

a. Headache
b. Photophobia
c. Bulging anterior fontanel
d. Weak cry
e. Poor muscle tone

ANS: C, D, E

Assessment findings in a neonate with meningitis include bulging anterior fontanel, weak cry, and poor muscle tone. Headache and photophobia are signs seen in an older child.

The nurse is planning care for a child recently diagnosed with diabetes insipidus (DI). What intervention should be included?

a. Encourage the child to wear medical identification.
b. Discuss with the child and family ways to limit fluid intake.
c. Teach the child and family how to do required urine testing.
d. Reassure the child and family that this is usually not a chronic or life-threatening illness.

ANS: A

DI is a potentially life-threatening disorder if the voluntary demand for fluid is suppressed or the child does not have access to fluids. Medical alert identification should be worn. Fluid intake is not restricted in children with DI. The child is unable to concentrate urine and can rapidly become dehydrated. Fluid intake may be limited during diagnosis, when the lack of intake will result in decreased urinary output and dehydration. Urine testing is not required in DI. Changes in body weight provide information about approximate fluid balance. This is a lifelong disorder that requires supplemental vasopressin throughout life.

Intranasal administration of desmopressin acetate (DDAVP) is used to treat which condition?

a. Hypopituitarism
b. Diabetes insipidus (DI)
c. Syndrome of inappropriate antidiuretic hormone (SIADH)
d. Acute adrenocortical insufficiency

ANS: B

DDAVP is the treatment of choice for DI. It is administered intranasally through a flexible tube. The childs response pattern is variable, with effectiveness lasting from 6 to 24 hours.

What form of diabetes is characterized by destruction of pancreatic beta cells, resulting in insulin deficiency?

a. Type 1 diabetes
b. Type 2 diabetes
c. Gestational diabetes
d. Maturity-onset diabetes of the young (MODY)

ANS: A

Type 1 diabetes is characterized by the destruction of the pancreatic beta cells, which leads to absolute insulin deficiency. Type 2 diabetes results usually from insulin resistance. The pancreatic beta cells are not destroyed in gestational diabetes. MODY is an autosomal dominant monogenetic defect in beta cell function that is characterized by impaired insulin secretion with minimum or no defects in insulin action.

What statement is characteristic of type 1 diabetes mellitus?

a. Onset is usually gradual.
b. Ketoacidosis is infrequent.
c. Peak age incidence is 10 to 15 years.
d. Oral agents are available for treatment.

ANS: C

Type 1 diabetes mellitus typically usually has its onset before the age of 20 years, with a peak incidence between ages 10 and 15 years. Type 1 has an abrupt onset, in contrast to type 2, which has a more gradual appearance. Ketoacidosis occurs when insulin is unavailable and the body uses sources other than glucose for cellular metabolism. Ketoacidosis is more common in type 1 diabetes than in type 2. At this time, oral agents are available only for type 2 diabetes.

What clinical manifestation is considered a cardinal sign of diabetes mellitus?

a. Nausea
b. Seizures
c. Impaired vision
d. Frequent urination

ANS: D

Hallmarks of diabetes mellitus are glycosuria, polyuria, and polydipsia. Nausea and seizures are not clinical manifestations of diabetes mellitus. Impaired vision is a long-term complication of the disease.

The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise. What effect does exercise have on a type 1 diabetic?

a. Exercise increases blood glucose.
b. Extra insulin is required during exercise.
c. Additional snacks are needed before exercise.
d. Excessive physical activity should be restricted.

ANS: C

Exercise lowers blood glucose levels, decreasing the need for insulin. Extra snacks are provided to maintain the blood glucose levels. Exercise is encouraged and not restricted unless indicated by other health conditions.

To help an adolescent deal with diabetes, the nurse needs to consider which characteristic of adolescence?

a. Desire to be unique
b. Preoccupation with the future
c. Need to be perfect and similar to peers
d. Awareness of peers that diabetes is a severe disease

ANS: C

Adolescence is a time when the individual has a need to be perfect and similar to peers. Having diabetes makes adolescents different from their peers. Adolescents do not wish to be unique; they desire to fit in with the peer group. An adolescent is usually not future oriented. Awareness of peers that diabetes is a severe disease would further alienate the adolescent with diabetes. The peer group would focus on the differences.

A school-age child with diabetes gets 30 units of NPH insulin at 0800. According to when this insulin peaks, the child should be at greatest risk for a hypoglycemic episode between when?

a. Lunch and dinner
b. Breakfast and lunch
c. 0830 to his midmorning snack
d. Bedtime and breakfast the next morning

ANS: A

Intermediate-acting (NPH and Lente) insulins reach the blood 2 to 6 hours after injection. The insulins peak 4 to 14 hours later and stay in the blood for about 14 to 20 hours.

What statement applies to the current focus of the dietary management of children with diabetes?

a. Measurement of all servings of food is vital for control.
b. Daily calculate specific amounts of carbohydrates, fats, and proteins.
c. The number of calories for carbohydrates remains constant on a daily basis; protein and fat calories
are liberal.
d. The intake ensures day-to-day consistency in total calories, protein, carbohydrates, and moderate
fat while allowing for a wide variety of foods.

ANS: D

Essentially the nutritional needs of children with diabetes are no different from those of healthy children. Children with diabetes need no special foods or supplements. They need sufficient calories to balance daily expenditure for energy and to satisfy the requirement for growth and development.

During the summer many children are more physically active. What changes in the management of the child with diabetes should be expected as a result of more exercise?

a. food intake
b. food intake
c. risk of hyperglycemia
d. risk of insulin reaction

ANS: A

Exercise is encouraged and never restricted unless indicated by other health conditions. Exercise lowers blood glucose levels, depending on the intensity and duration of the activity. Consequently, exercise should be included as part of diabetes management, and the type and amount of exercise should be planned around the childs interests and capabilities. However, in most instances, childrens activities are unplanned, and the resulting decrease in blood glucose can be compensated for by providing extra snacks before (and, if the exercise is prolonged, during) the activity. In addition to a feeling of well-being, regular exercise aids in utilization of food and often results in a reduction of insulin requirements.

A 12-year-old girl is newly diagnosed with diabetes when she develops ketoacidosis. How should the nurse structure a successful education program?

a. Essential information is presented initially.
b. Teaching should take place in the childs semiprivate room.
c. Education is focused toward the parents because the child is too young.
d. All information needed for self-management of diabetes is taught at once.

ANS: A

Diagnosis of type 1 diabetes can be traumatic for the child and family. Most families are not psychologically ready for the complex teaching that is needed for self-management. Most structured diabetes education programs begin with essential or survival information followed by the complex background material when the family is better able to learn. Teaching can take place either as an outpatient or as an inpatient. The actual teaching area should be free from distractions that would interfere with learning. A semiprivate room would have many individuals entering and leaving the room, causing distraction. A 12-year-old child who is cognitively age appropriate needs to be included in the educational process. Most children older than the age of 8 years can be involved in blood glucose monitoring and insulin administration. Teaching all information needed for self management of diabetes at once would be too overwhelming for a family in crisis.

The nurse is preparing a community outreach program for adolescents about the characteristic differences between type 1 and type 2 diabetes mellitus (DM). What concepts should the nurse include? (Select all that apply.)

a. Type 1 DM has an abrupt onset.
b. Type 1 DM is often controlled with oral glucose agents.
c. Type 1 DM occurs primarily in whites.
d. Type 2 DM always requires insulin therapy.
e. Type 2 DM frequently has a familial history.
f. Type 2 DM occurs in people who are overweight.

ANS: A, C, E, F

Characteristics of type 1 DM include having an abrupt onset, primarily occurring in whites, and not being controlled with oral glucose agents (insulin is required for therapy). Type 2 DM frequently has a familial history, occurs in people who are overweight, and does not always require insulin therapy (it is used in 20% to 30% of patients).

The nurse is preparing to admit a 7-year-old child with type 2 diabetes. What clinical features of type 2 diabetes should the nurse recognize? (Select all that apply.)

a. Oral agents are effective.
b. Insulin is usually needed.
c. Ketoacidosis is infrequent.
d. Diet only is often effective.
e. Chronic complications frequently occur.

ANS: A, C, D

The clinical features of type 2 diabetes include the following: oral agents are effective, ketoacidosis is infrequent, and diet only is often effective. Insulin is only needed in 20% to 30% of cases and chronic complications occur infrequently.

The nurse is conducting a staff in-service on childhood endocrine disorders. Diabetes insipidus is a disorder of:

a. anterior pituitary.
b. posterior pituitary.
c. adrenal cortex.
d. adrenal medulla.

ANS: B

The principal disorder of posterior pituitary hypofunction is diabetes insipidus. The anterior pituitary produces hormones such as GH, thyroid-stimulating hormone, adrenocorticotropic hormone, gonadotropin, prolactin, and melanocyte-stimulating hormone. The adrenal cortex produces aldosterone, sex hormones, and glucocorticoids. The adrenal medulla produces catecholamines.

Type 1 diabetes mellitus is suspected in an adolescent. Which clinical manifestation may be present?

a. Moist skin
b. Weight gain
c. Fluid overload
d. Poor wound healing

ANS: D

Poor wound healing may be present in an individual with type 1 diabetes mellitus. Dry skin, weight loss, and dehydration are clinical manifestations of type 1 diabetes mellitus.

The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise. Which should the nurse explain about exercise in type 1 diabetes?

a. Exercise will increase blood glucose.
b. Exercise should be restricted.
c. Extra snacks are needed before exercise.
d. Extra insulin is required during exercise.

ANS: C

Exercise lowers blood glucose levels, which can be compensated for by extra snacks. Exercise lowers blood glucose and is encouraged and not restricted, unless indicated by other health conditions. Extra insulin is contraindicated because exercise decreases blood glucose levels.

Janeway lesions

Painless hemorrhagic areas on palms and soles in bacterial endocarditis

Osler nodes

Red, painful, intradermal nodes found on pads of the phalanges in bacterial endocarditis

Aschoff nodules

Small nodules composed of cells and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis

What is the most common cause of cerebral palsy (CP)?

a. Central nervous system (CNS) diseases
b. Birth asphyxia
c. Cerebral trauma
d. Neonatal encephalopathy

ANS: D

Approximately 80% of CP is caused by unknown prenatal causes. Neonatal encephalopathy in term and preterm infants is believed to play a significant role in the development of CP. CNS diseases such as meningitis or encephalitis can result in CP. Birth asphyxia does contribute to some cases of CP. Cerebral trauma, including shaken baby syndrome, can result in CP.

Spastic cerebral palsy (CP) is characterized by which clinical manifestations?

a. Athetosis, dystonic movements
b. Tremors, lack of active movement
c. Hypertonicity; poor control of posture, balance, and coordinated motion
d. Wide-based gait; poor performance of rapid, repetitive movements

ANS: C

Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic CP. Athetosis and dystonic movements are part of the classification of dyskinetic or athetoid CP. Tremors and lack of active movement may indicate other neurologic disorders. A wide-based gait and poor
performance of rapid, repetitive movements are part of the classification of ataxic CP.

What type of cerebral palsy (CP) is the most common type?

a. Ataxic
b. Spastic
c. Dyskinetic
d. Mixed type

ANS: B

Spastic CP is the most common clinical type. Early manifestations are usually generalized hypotonia, or decreased tone that lasts for a few weeks or may extend for months or as long as 1 year. It is replaced by increased stretch reflexes, increased muscle tone, and weakness. Ataxic, dyskinetic, and mixed type are less
common forms of CP.

The parents of an infant with cerebral palsy (CP) ask the nurse if their child will have cognitive impairment. The nurses response should be based on which knowledge?

a. Affected children have some degree of cognitive impairment.
b. Around 20% of affected children have normal intelligence.
c. About 45% of affected children have normal intelligence.
d. Cognitive impairment is expected if motor and sensory deficits are severe.

ANS: C

Children with CP have a wide range of intelligence, and 40% to 50% are within normal limits. A large percentage of children with CP do not have mental impairment. Many individuals who have severely limiting physical impairment have the least amount of intellectual compromise.

Gingivitis is a common problem in children with cerebral palsy (CP). What preventive measure should be included in the plan of care?

a. High-carbohydrate diet
b. Meticulous dental hygiene
c. Minimum use of fluoride
d. Avoidance of medications that contribute to gingivitis

ANS: B

Meticulous oral hygiene is essential. Many children with CP have congenital enamel defects, highcarbohydrate diets, poor nutritional intake, and difficulty closing their mouths. These, coupled with the childs spasticity or clonic movements, make oral hygiene difficult. Children with CP have high carbohydrate intake and retention, which contribute to dental caries. Use of fluoride should be encouraged through fluoridated water or supplements and toothpaste. Certain medications such as phenytoin do contribute to gingival hyperplasia. If that is the drug of choice, then meticulous oral hygiene must be used

What is a major goal of therapy for children with cerebral palsy (CP)?

a. Cure the underlying defect causing the disorder.
b. Reverse the degenerative processes that have occurred.
c. Prevent the spread to individuals in close contact with the child.
d. Recognize the disorder early and promote optimum development.

ANS: D

The goals of therapy include early recognition and promotion of an optimum developmental course to enable affected children to attain their potential within the limits of their dysfunction. The disorder is permanent, and therapy is chiefly symptomatic and preventive. It is not possible at this time to reverse the degenerative processes. CP is not contagious.

The parents of a child with spastic cerebral palsy (CP) state that their child seems to have significant pain. In addition to systemic pharmacologic management, the nurse includes which teaching?

a. Patterning
b. Positions to reduce spasticity
c. Stretching exercises after meals
d. Topical analgesics for muscle spasms

ANS: B

Parents and children are taught positions to assume while sitting and recumbent that reduce spasticity. The American Academy of Pediatrics has stated that patterning should not be used for neurologically disabled children. Patterning attempts to alter abnormal tone and posture and elicit desired movements through positional manipulation or other means of modifying or augmenting sensory output. Stretching should be done after appropriate analgesic medication has been given and is effective. Topical analgesia is not effective for the muscle spasms of spastic CP.

A child, age 3 years, has cerebral palsy (CP) and is hospitalized for orthopedic surgery. His mother says he has difficulty swallowing and cannot hold a utensil to feed himself. He is slightly underweight for his height. What is the most appropriate nursing action related to feeding this child?

a. Bottle or tube feed him a specialized formula until he gains sufficient weight.
b. Stabilize his jaw with caregivers hand (either from a front or side position) to facilitate swallowing.
c. Place him in a well-supported, semireclining position.
d. Place him in a sitting position with his neck hyperextended to make use of gravity flow.

ANS: B

Jaw control is compromised in many children with CP. More normal control is achieved if the feeder stabilizes the oral mechanisms from the front or side of the face. Bottle or tube feeding will not improve feeding without jaw support. The semireclining position and hyperextended neck position increase the chances of aspiration.

An 8-year-old girl with moderate cerebral palsy (CP) recently began joining a regular classroom for part of the day. Her mother asks the school nurse about joining the after-school Girl Scout troop. The nurses response should be based on which knowledge?

a. Most activities such as Girl Scouts cannot be adapted for children with CP.
b. After-school activities usually result in extreme fatigue for children with CP.
c. Trying to participate in activities such as Girl Scouts leads to lowered self-esteem in children with CP.
d. Recreational activities often provide children with CP with opportunities for socialization and recreation.

ANS: D

After-school and recreational activities serve to stimulate childrens interest and curiosity. They help the children adjust to their disability, improve their functional ability, and build self-esteem. Increasing numbers of programs are adapted for children with physical limitations. Almost all activities can be adapted. The child should participate to her level of energy. Self-esteem increases as a result of the positive feedback the child receives from participation.

The nurse is preparing a staff education in-service session for a group of new graduate nurses who will be working in a long-term care facility for children; many of the children have cerebral palsy (CP). What statement should the nurse include in the training?

a. Children with dyskinetic CP have a wide-based gait and repetitive movements.
b. Children with spastic pyramidal CP have a positive Babinski sign and ankle clonus.
c. Children with hemiplegia CP have mouth muscles and one lower limb affected.
d. Children with ataxic CP have involvement of pharyngeal and oral muscles with dysarthria.

ANS: B

CP has a variety of clinical classifications. Spastic pyramidal CP includes manifestations such as a positive Babinski sign and ankle clonus; ataxic CP has a wide-based gait and repetitive movements; hemiplegia CP is characterized by motor dysfunction on one side of the body with upper extremity more affected than lower limbs; and dyskinetic CP involves the pharyngeal and oral muscles, causing drooling and dysarthria.

The nurse should suspect a child has cerebral palsy (CP) if the parent says what?

a. My 6-month-old baby is rolling from back to prone now.
b. My 4-month-old doesnt lift his head when on his tummy.
c. My 8-month-old can sit without support.
d. My 10-month-old is not walking.

ANS: B

Delayed gross motor development is a universal manifestation of CP. The child shows a delay in all motor accomplishments, and the discrepancy between motor ability and expected achievement tends to increase with successive developmental milestones as growth advances. The infant who does not lift his head when on the tummy is showing a gross motor delay, as that is seen at 0 to 3 months. The other statements are within normal growth and development expectations.

The nurse is caring for a 4-year-old child with cerebral palsy (CP). The child, developmentally, is at an infant stage. Appropriate developmental stimulation for this child should be what?

a. Playing pat-a-cake with the child
b. None so the child does not become overstimulated
c. Putting a colorful mobile with music on the bed
d. Giving the child a coloring book and crayons

ANS: C

Incorporating play into the therapeutic program for a child with CP often requires great ingenuity and inventiveness from those involved in the childs care. Objects and toys are chosen for the childs developmental stage to provide needed sensory input using a variety of shapes, forms, and textures. Nurses can help parents integrate therapy into play activities in natural ways.

A toddler with spastic cerebral palsy needs to be transported to the radiology department. What
transportation method should the nurse use to take the toddler to the radiology department?

a. A stretcher
b. A wheelchair
c. A wagon with pillows
d. Carried in the nurses arms

ANS: C

A wagon with pillows would support the child with spastic cerebral palsy better than a stretcher or wheelchair. A wagon would give the child a wheelchair experience, so the nurse should not carry the child.

What is the rationale for orthopedic surgery for a child with cerebral palsy?

a. To cure spasticity
b. To improve function
c. For cosmetic purposes
d. To prevent the need of physical therapy

ANS: B

Orthopedic surgery is used primarily to improve function rather than for cosmetic purposes and is followed by physical therapy. It will not cure spasticity.

A feeding technique the nurse can teach to parents of a child with cerebral palsy to improve use of the lips and the tongue to facilitate speech is which?

a. Feeding pureed foods
b. Placing food on the tongue
c. Placing food at the side of the tongue
d. Placing food directly into the mouth with a spoon

ANS: C

Feeding techniques such as forcing the child to use the lips and tongue in eating facilitate speech. An example of this technique is placing food at the side of the tongue, first one side and then the other, and making the child use the lips to take food from a spoon rather than placing it directly on the tongue. Feeding pureed foods would not encourage use of the lips and tongue.

The nurse is teaching the family of an infant with cerebral palsy how to administer a diazepam (Valium) pill by gastrostomy tube. What should the nurse include in the teaching session?

a. The pill should be crushed and mixed with a small amount of water.
b. The pill should be crushed and mixed with the infants formula.
c. After administering the medication, flush the tube with air.
d. Before administering the medication, check the placement of the tube.

ANS: A

Pills may be crushed and mixed with small amounts of water but not other liquids, such as formula or elixir medications, because these may act together to form a sludge that can interfere with gastrostomy tube function. When crushed pills or tablets are administered, flush the feeding tube with more water after instilling the dissolved pill in water. The tube should not be flushed with air, and placement does not need to be checked because it is directly into the stomach.

The nurse is teaching the family with a child with cerebral palsy (CP) strategies to prevent constipation. What should the nurse include in the teaching session? (Select all that apply.)

a. Increase fluid intake.
b. Increase fiber in the diet.
c. Administer stool softeners daily as prescribed.
d. Increase the amount of dairy products in the diet.
e. Allow the child to decide when to try to have a bowel movement.

ANS: A, B, C

A variety of factors, including decreased mobility, decreased fluid intake, a fear of toileting, poor positioning on the toilet, and lack of fiber intake may be responsible for constipation for a child with CP. Stool softeners, laxatives, and a bowel management program may be required to prevent chronic constipation. The child should be placed on the toilet or encouraged to have a bowel movement at the same time each day. Dairy products can cause constipation.

The nurse is preparing to admit a 7-year-old child with ataxic cerebral palsy. What clinical manifestations of ataxic cerebral palsy should the nurse expect to observe? (Select all that apply.)

a. Wide-based gait
b. Rapid, repetitive movements performed poorly
c. Slow, twisting movements of the trunk or extremities
d. Hypertonicity with poor control of posture, balance, and coordinated motion
e. Disintegration of movements of the upper extremities when the child reaches for objects

ANS: A, B, E

Clinical manifestations of ataxic cerebral palsy include a wide-based gait; rapid, repetitive movements performed poorly; and disintegration of movements of the upper extremities when the child reaches for objects. Slow, twisting movements of the trunk are seen with dyskinetic cerebral palsy, and hypertonicity with poor control of posture, balance, and coordinated motion are seen with spastic cerebral palsy.

What are some of the associated disabilities seen with cerebral palsy? (Select all that apply.)

a. Visual impairment
b. Hearing impairment
c. Speech difficulties
d. Intellectual impairment
e. Associated heart defects

ANS: A, B, C, D

Some of the disabilities associated with CP are visual impairment, hearing impairment, behavioral problems,
communication and speech difficulties, seizures, and intellectual impairment. Additional sensory deficits such as hypersensitivity, hyposensitivity, and balance difficulties may occur in children with CP.

The nurse is planning a staff in-service on childhood spastic cerebral palsy. What characterizes spastic cerebral palsy?

a. Hypertonicity and poor control of posture, balance, and coordinated motion
b. Athetosis and dystonic movements
c. Wide-based gait and poor performance of rapid, repetitive movements
d. Tremors and lack of active movement

ANS: A

Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic cerebral palsy. Athetosis and dystonic movements are part of the classification of dyskinetic (athetoid) cerebral palsy. Wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic cerebral palsy. Tremors and lack of active movement may indicate other neurologic disorders.

The parents of a child with cerebral palsy ask the nurse whether any drugs can decrease their child's spasticity. The nurse's response should be based on which statement?

a. Anticonvulsant medications are sometimes useful for controlling spasticity.
b. Medications that would be useful in reducing spasticity are too toxic for use with
children.
c. Many different medications can be highly effective in controlling spasticity.
d. Implantation of a pump to deliver medication into the intrathecal space to decrease
spasticity has recently become available.

ANS: D

Baclofen, given intrathecally, is best suited for children with severe spasticity that interferes with activities of daily living and ambulation. Anticonvulsant medications are used when seizures occur in children with cerebral palsy. The intrathecal route decreases the side effects of the drugs that reduce spasticity. Few medications are currently available for the control of spasticity.

The nurse is conducting reflex testing on infants at a well-child clinic. Which reflex finding should be reported as abnormal and considered as a possible sign of cerebral palsy?

a. Tonic neck reflex at 5 months of age
b. Absent Moro reflex at 8 months of age
c. Moro reflex at 3 months of age
d. Extensor reflex at 7 months of age

ANS: D
Establishing a diagnosis of cerebral palsy (CP) may be confirmed with the persistence of primitive reflexes: (1) either the asymmetric tonic neck reflex or persistent Moro reflex (beyond 4 months of age) and (2) the crossed extensor reflex. The tonic neck reflex normally disappears between 4 and 6 months of age. The crossed extensor reflex, which normally disappears by 4 months, is elicited by applying a noxious stimulus to the sole of one foot with the knee extended. Normally, the contralateral foot responds with extensor, abduction, and then adduction movements. The possibility of CP is suggested if these reflexes occur after 4 months.

What is a physiologic effect of immobilization on children?

a. Metabolic rate increases.
b. Venous return improves because the child is in the supine position.
c. Circulatory stasis can lead to thrombus and embolus formation.
d. Bone calcium increases, releasing excess calcium into the body (hypercalcemia).

ANS: C

The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. The metabolic rate decreases with immobilization. With the loss of muscle contraction, there is a decreased venous return to the heart. Calcium leaves the bone during immobilization, leading to bone demineralization and increasing the calcium ion concentration in the blood.

What condition can result from the bone demineralization associated with immobility?

a. Osteoporosis
b. Pooling of blood
c. Urinary retention
d. Susceptibility to infection

ANS: A

Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi. Pooling of blood is a result of the cardiovascular effects of immobilization. Urinary retention is secondary to the effect of immobilization on the urinary tract. Susceptibility to infection can result from the effects of immobilization on the respiratory and renal systems.

What measure is important in managing hypercalcemia in a child who is immobilized?

a. Provide adequate hydration.
b. Change position frequently.
c. Encourage a diet high in calcium.
d. Provide a diet high in calories for healing.

ANS: A

Vigorous hydration is indicated to prevent problems with hypercalcemia. Suggested intake for an adolescent is 3000 to 4000 ml/day of fluids. Diuretics are used to promote the removal of calcium. Changing position is important for skin and respiratory concerns. Calcium in the diet is restricted when possible. A high-protein diet served as frequent snacks with favored foods is recommended. A high-calorie diet without adequate protein will not promote healing.

The nurse is caring for an immobilized preschool child. What intervention is helpful during this period of immobilization?

a. Encourage wearing pajamas.
b. Let the child have few behavioral limitations.
c. Keep the child away from other immobilized children if possible.
d. Take the child for a walk by wagon outside the room.

ANS: D

Transporting the child outside of the room by stretcher, wheelchair, or wagon increases environmental stimuli and provides social contact. Street clothes are preferred for hospitalized children. This decreases the sense of illness and disability. The child needs appropriate limits for both adherence to the medical regimen and developmental concerns. It is not necessary to keep the child away from other immobilized children.

The nurse is teaching parents the proper use of a hipkneeanklefoot orthosis (HKAFO) for their 4-year-old child. The parents demonstrate basic essential knowledge by making what statement?

a. Alcohol will be used twice a day to clean the skin around the brace.
b. Weekly visits to the orthotist are scheduled to check screws for tightness.
c. Initially, a burning sensation is expected and the brace should remain in place.
d. Condition of the skin in contact with the brace should be checked every 4 hours.

ANS: D

This type of brace has several contact points with the childs skin. To minimize the risk of skin breakdown and facilitate use of the brace, vigilant skin monitoring is necessary. Alcohol should not be used on the skin. It is drying. Parents are capable of checking and tightening the screws when necessary. If a burning sensation occurs, the brace should be removed. If several complaints of burning occur, the orthotist should be contacted.

Immobilization causes what effect on metabolism?

a. Hypocalcemia
b. Decreased metabolic rate
c. Positive nitrogen balance
d. Increased levels of stress hormones

ANS: B

Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased food intake. Immobilization leads to hypercalcemia and a negative nitrogen balance secondary to muscle atrophy. Decreased production of stress hormones occurs with decreased physical and emotional coping capacity.

A 7-year-old child has just had a cast applied for a fractured arm with the wrist and elbow immobilized. What information should be included in the home care instructions?

a. No restrictions of activity are indicated.
b. Elevate casted arm when both upright and resting.
c. The shoulder should be kept as immobile as possible to avoid pain.
d. Swelling of the fingers is to be expected. Notify a health professional if it persists more than 48 hours.

ANS: B

The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return. The child should not engage in strenuous activity for the first few days. Rest with elevation of the extremity is encouraged. Joints above and below the cast on the affected extremity should be moved. Swelling of the fingers may indicate neurovascular damage and should be reported immediately. Permanent damage can occur within 6 to 8 hours.

The nurse uses the five Ps to assess ischemia in a child with a fracture. What finding is considered a late and ominous sign?

a. Petaling
b. Posturing
c. Paresthesia
d. Positioning

ANS: C

Paresthesia distal to the injury or cast is an ominous sign that requires immediate notification of the practitioner. Permanent muscle and tissue damage can occur within 6 hours. The other signs of ischemia that need to be reported are pain, pallor, pulselessness, and paralysis. Petaling is a method of placing protective or smooth edges on a cast. Posturing is not a sign of peripheral ischemia. Finding a position of comfort can be difficult with a fracture. It would not be an ominous sign unless pain was increasing or uncontrollable.

A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What technique should the nurse suggest to remove this material?

a. Soak in a bathtub.
b. Vigorously scrub the leg.
c. Carefully pick material off the leg.
d. Apply powder to absorb the material.

ANS: A

Simply soaking in the bathtub is usually sufficient for removal of the desquamated skin and sebaceous secretions. Several days may be required to eliminate the accumulation completely. The parents and child should be advised not to scrub the leg vigorously or forcibly remove this material because it may cause excoriation and bleeding. Oil or lotion, but not powder, may provide comfort for the child.

A child with a hip spica cast is being prepared for discharge. Recognizing that caring for a child at home is complex, the nurse should include what instructions for the parents discharge teaching?

a. Turn every 8 hours.
b. Specially designed car restraints are necessary.
c. Diapers should be avoided to reduce soiling of the cast.
d. Use an abduction bar between the legs to aid in turning.

ANS: B

Standard seat belts and car seats may not be readily adapted for use by children in some casts. Specially designed car seats and restraints meet safety requirements. The child must have position changes much more frequently than every 8 hours. During feeding and play activities, the child should be moved for both physiologic and psychosocial benefit. Diapers and other strategies are necessary to maintain cleanliness. The abduction bar is never used as an aid for turning. Putting pressure on the bar may damage the integrity of the cast.

What is an appropriate nursing intervention when caring for a child in traction?

a. Removing adhesive traction straps daily to prevent skin breakdown
b. Assessing for tightness, weakness, or contractures in uninvolved joints and muscles
c. Providing active range of motion exercises to affected extremity three times a day
d. Keeping child prone to maintain good alignment

ANS: B

Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles. The adhesive straps should be released or replaced only when absolutely necessary. Active, passive, or active with resistance exercises should be carried out for the unaffected extremity only. Movement is expected with children. Each time the child moves, the nurse should check to ensure that proper alignment is maintained.

A 4-year-old child is placed in Buck extension traction for Legg-Calv-Perthes disease. He is crying with pain as the nurse assesses the skin of his right foot and sees that it is pale with an absence of pulse. What should the nurse do first?

a. Reposition the child and notify the practitioner.
b. Notify the practitioner of the changes noted.
c. Give the child medication to relieve the pain.
d. Chart the observations and check the extremity again in 15 minutes.

ANS: B

The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner. This is an emergency condition. Pain medication should be given after the practitioner is notified. The findings should be documented with ongoing assessment.

The nurse is teaching the parent of a 4-year-old child with a cast on the arm about care at home. What statement by the parent indicates a correct understanding of the teaching?

a. I should have the affected limb hang in a dependent position.
b. I will use an ice pack to relieve the itching.
c. I should avoid keeping the injured arm elevated.
d. I will expect the fingers to be swollen for the next 3 days.

ANS: B

Teaching the parent to use an ice pack to relieve the itching is an important aspect when planning discharge for a child with a cast. The affected limb should not be allowed to hang in a dependent position for more than 30 minutes. The affected arm should be kept elevated as much as possible. If there is swelling or redness of the fingers, the parent should notify the health care provider.

The nurse is teaching the parents of a 1-month-old infant with developmental dysplasia of the hip about preventing skin breakdown under the Pavlik harness. What statement by the parent would indicate a correct understanding of the teaching?

a. I should gently massage the skin under the straps once a day to stimulate circulation.
b. I will apply a lotion for sensitive skin under the straps after my baby has been given a bath to prevent skin irritation.
c. I should remove the harness several times a day to prevent contractures.
d. I will place the diaper over the harness, preferably using a superabsorbent disposable diaper that is relatively thin.

ANS: A

To prevent skin breakdown with an infant who has developmental dysplasia of the hip and is in a Pavlik harness, the parent should gently massage the skin under the straps once a day to stimulate circulation. The parent should not apply lotions or powder because this could irritate the skin. The parent should not remove the harness, except during a bath, and should place the diaper under the straps.

A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, what should the nurse explain?

a. Traction is tried first.
b. Surgical intervention is needed.
c. Frequent, serial casting is tried first.
d. Children outgrow this condition when they learn to walk.

ANS: C

Serial casting is begun shortly after birth, before discharge from the nursery. Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy. Serial casting is the preferred treatment. Surgical intervention is done only if serial casting is not successful. Children do not improve without intervention.

An infant is born with one lower limb deficiency. When is the optimum time for the child to be fitted with a functional prosthetic device?

a. As soon as possible after birth
b. When the infant is developmentally ready to stand up
c. At about ages 12 to 15 months, when most children are walking
d. At about 4 years, when the healthy limb is not growing so rapidly

ANS: B

An infant should be fitted with a functional prosthetic leg when the infant is developmentally ready to pull to a standing position. When the infant begins limb exploration, a soft prosthesis can be used. The child should begin using the prosthesis as part of his or her normal development. This will match the infants motor readiness.

The nurse knows that parents need further teaching with regard to the treatment of congenital clubfoot when they state what?

a. We'll keep the cast dry.
b. Were happy this is the only cast our baby will need.
c. We'll watch for any swelling of the foot while the cast is on.
d. Were getting a special car seat to accommodate the cast.

ANS: B

The common approach to clubfoot management and treatment is the Ponseti method. Serial casting is begun shortly after birth. Weekly gentle manipulation and stretching of the foot along with placement of serial longleg casts allow for gradual repositioning of the foot. The extremity or extremities are casted until maximum correction is achieved, usually within 6 to 10 weeks. If parents state that this is the only cast the infant will need, they need further teaching.

A child has just returned from surgery for repair of a fractured femur. The child has a long-leg cast on. The toes on the leg with the cast are edematous, but they have color, sensitivity, and movement. What action should the nurse take?

a. Call the health care provider to report the edema.
b. Elevate the foot and leg on pillows.
c. Apply a warm moist pack to the foot.
d. Encourage movement of toes.

ANS: B

During the first few hours after a cast is applied, the chief concern is that the extremity may continue to swell to the extent that the cast becomes a tourniquet, shutting off circulation and producing neurovascular complications (compartment syndrome). One measure to reduce the likelihood of this problem is to elevate the body part and thereby increase venous return. The health care provider does not need to be notified because edema is expected and warm moist packs will not decrease the edema. The child should move the toes, but that will not help reduce the edema.

What should the nurse plan for an immobilized child in cervical traction to prevent deep vein thrombosis (DVT)?

a. Elevate the childs legs.
b. Place a foot cradle on the bed.
c. Place a pillow under the childs knees.
d. Assist the child to dorsiflex the feet and rotate the ankles.

ANS: D

For a child who is immobilized, circulatory stasis and DVT development are prevented by instructing patients to change positions frequently, dorsiflex their feet and rotate the ankles, sit in a bedside chair periodically, or ambulate several times daily. Elevating the legs or placing a foot cradle on the bed will not prevent DVTs. A pillow under the knee would impair circulation, not improve it.

The nurse is teaching a child with a cast about cast removal. What should the nurse teach the child about cast removal?

a. The cast cutter will be a quiet machine.
b. You will feel cold as the cast is removed.
c. You will feel a tickly sensation as the cast is removed.
d. The cast cutter cuts through the cast like a circular saw.

ANS: C

Cutting the cast to remove it or to relieve tightness is frequently a frightening experience for children. They

The nurse is caring for a child immobilized because of Russel traction. What interventions should the nurse implement to prevent renal calculi? (Select all that apply.)

a. Monitor output.
b. Encourage the patient to drink apple juice.
c. Encourage milk intake.
d. Ensure adequate fluids.
e. Encourage the patient to drink cranberry juice.

ANS: A, D, E

To prevent renal calculi in a child who is immobilized, a nurse should monitor output; ensure adequate fluids; and encourage cranberry juice, which acidifies urine. Apple juice and milk alkalize the urine, so they should not be encouraged.

The nurse is assisting with application of a synthetic cast on a child with a fractured humerus. What are the advantages of a synthetic cast over a plaster of Paris cast? (Select all that apply.)

a. Less bulky
b. Drying time is faster
c. Molds readily to body part
d. Permits regular clothing to be worn
e. Can be cleaned with small amount of soap and water

ANS: A, B, D, E

The advantages of synthetic casts over plaster of Paris casts are that they are less bulky, dry faster, permit regular clothes to be worn, and can be cleaned. Plaster of Paris casts mold readily to a body part, but synthetic casts do not mold easily to body parts.

A child has had a short-arm synthetic cast applied. What should the nurse teach to the child and parents about cast care? (Select all that apply.)

a. Relieve itching with heat.
b. Elevate the arm when resting.
c. Observe the fingers for any evidence of discoloration.
d. Do not allow the child to put anything inside the cast.
e. Examine the skin at the cast edges for any breakdown.

ANS: B, C, D, E

Cast care involves elevating the arm, observing the fingers for evidence of discoloration, not allowing the child to put anything inside the cast, and examining the skin at the edges of the cast for any breakdown. Ice, not heat, should be applied to relieve itching.

The nurse is conducting preoperative teaching to parents and their child about an external fixation device. What should the nurse include in the teaching session? (Select all that apply.)

a. Pin care
b. Crutch walking
c. Modifications in activity
d. Observing pin sites for infection
e. Full weight bearing will be allowed after 24 hours

ANS: A, B, C, D

The device is attached surgically by securing a series of external full or half rings to the bone with wires. Children and parents should be instructed in pin care, including observation for infection and loosening of pins. Partial weight bearing is allowed, and the child needs to learn to walk with crutches. Alterations in activity
include modifications at school and in physical education. Full weight bearing is not allowed until the distraction is completed and bone consolidation has occurred.

The nurse is caring for a 4-year-old child immobilized by a fractured hip. Which complication should the nurse monitor related to the child's immobilization status?

a. Metabolic rate increases
b. Increased joint mobility leading to contractures
c. Bone calcium increases, releasing excess calcium into the body (hypercalcemia)
d. Venous stasis leading to thrombi or emboli formation

ANS: D

The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. The metabolic rate decreases with immobilization. Loss of joint mobility leads to contractures. Bone demineralization with osteoporosis and hypercalcemia occur with immobilization.

The nurse should monitor for which effect on the cardiovascular system when a child is immobilized?

a. Venous stasis
b. Increased vasopressor mechanism
c. Normal distribution of blood volume
d. Increased efficiency of orthostatic neurovascular reflexes

ANS: A

The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. A decreased vasopressor mechanism results in orthostatic hypotension, syncope, hypotension, decreased cerebral blood flow, and tachycardia. An altered distribution of blood volume is found with decreased cardiac workload and exercise tolerance. Immobilization causes a decreased efficiency of orthostatic neurovascular reflexes with an inability to adapt readily to the upright position and with pooling of blood in the extremities in the upright position.

Which can result from the bone demineralization associated with immobility?

a. Osteoporosis
b. Urinary retention
c. Pooling of blood
d. Susceptibility to infection

ANS: A

Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi. Urinary retention is secondary to the effect of immobilization on the urinary tract. Pooling of blood is a result of the cardiovascular effects of immobilization. Susceptibility to infection can result from the effects of immobilization on the respiratory and renal systems.

The nurse is conducting a staff in-service on casts. Which is an advantage to using a fiberglass cast instead of a plaster of Paris cast?

a. Cheaper
b. Dries rapidly
c. Molds closely to body parts
d. Smooth exterior

ANS: B

A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which takes 10 to 72 hours to dry. Synthetic casts are more expensive and have a rough exterior, which may scratch surfaces. Plaster casts mold closer to body parts.

The nurse is conducting teaching to parents of a 7-year-old child who fractured an arm and is being discharged with a cast. Which instruction should be included in the teaching?

a. Swelling of the fingers is to be expected for the next 48 hours.
b. Immobilize the shoulder to decrease pain in the arm.
c. Allow the affected limb to hang down for 1 hour each day.
d. Elevate casted arm when resting and when sitting up.

ANS: D

The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return. Swelling of the fingers may indicate neurovascular damage and should be reported immediately. Permanent damage can occur within 6 to 8 hours. Joints above and below the cast on the affected extremity should be moved. The affected limb should not hang down for any length of time.

The nurse uses the palms of the hands when handling a wet cast for which reason?

a. To assess dryness of the cast
b. To facilitate easy turning
c. To keep the patient's limb balanced
d. To avoid indenting the cast

ANS: D

Wet casts should be handled by the palms of the hands, not the fingers, to avoid creating pressure points. Assessing dryness, facilitating easy turning, and keeping the patient's limb balanced are not reasons for using the palms of the hand rather than the fingers when handling a wet cast.

Which should cause a nurse to suspect that an infection has developed under a cast?

a. Complaint of paresthesia
b. Cold toes
c. Increased respirations
d. "Hot spots" felt on cast surface

ANS: D

If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so that a window can be made in the cast to observe the site. The five Ps of ischemia from a vascular injury are pain, pallor, pulselessness, paresthesia, and paralysis. Paresthesia is an indication of vascular injury, not infection. Cold toes may be indicative of too tight a cast and need further evaluation. Increased respirations may be indicative of a respiratory tract infection or pulmonary emboli. This should be reported, and child should be evaluated.

A child is upset because when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. Which should the nurse suggest to remove this material?

a. Soak in a bathtub.
b. Vigorously scrub leg.
c. Apply powder to absorb material.
d. Carefully pick material off leg.

ANS: A

Simple soaking in the bathtub is usually sufficient for the removal of the desquamated skin and sebaceous secretions. It may take several days to eliminate the accumulation completely. The parents and child should be advised not to scrub the leg vigorously or forcibly remove this material because it may cause excoriation and bleeding. Oil or lotion, but not powder, may provide comfort for the child.

A neonate is born with bilateral mild talipes equinovarus (clubfoot). When the parents ask the nurse how this will be corrected, the nurse should give which explanation?

a. Traction is tried first.
b. Surgical intervention is needed.
c. Frequent, serial casting is tried first.
d. Children outgrow this condition when they learn to walk.

ANS: C

Serial casting is begun shortly after birth before discharge from nursery. Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy. Serial casting is the preferred treatment. Surgical intervention is done only if serial casting is not successful. Children do not improve without intervention.

The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome? (Select all that apply.)

a. Palpable distal pulse
b. Capillary refill to extremity less than 3 seconds
c. Severe pain not relieved by analgesics
d. Tingling of extremity
e. Inability to move extremity

ANS: C, D, E

Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the extremity less than 3 seconds are expected findings.

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