Final exam Block III part 2
A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing around when a blood specimen is obtained. The child's color becomes blue and respiratory rate increases to 44 bpm. Which of the following actions would the nurse do first?
the child is experiencing a "tet spell" or hypoxic episode. Therefore the nurse should place the child in a knee-to-chest position.
The mother of a child with tetralogy of Fallot asks the nurse why her child has clubbed fingers. The nurse bases the response on the understanding that clubbing is due to which of the following?
Clubbing of the fingers is one common finding in the child with persistent hypoxia leading to tissue changes in the body because of the low oxygen content of the blood (hypoxemia). It apparently results from tissue fibrosis and hypertrophy from the hypoxemia and from an increase in capillaries in the area, which occur as the body attempts to improve blood supply. Clubbing of the fingers is associated with polycythemia, not anemia. Polycythemia results from the body's attempt to increase oxygen levels in the tissues.
A chest x-ray examination is ordered for a child with suspected cardiac problems. The child's parent asks the nurse, "What will the x-ray show about the heart?" The nurse's response should be based on knowledge that the x-ray film will do which of the following?
Chest x-ray films provide information on the size of the heart and pulmonary blood flow patterns.
A nurse is preparing for the admission of a child with a diagnosis of acute-stage Kawasaki disease. On assessment of the child, the nurse expects to note which clinical manifestation of the acute stage of the disease?
In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes.
The nurse should recognize that congestive heart failure (CHF) is which of the following?
CHF is the inability of the heart to pump an adequate amount of blood to the system
CHF is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body's metabolic demands. CHF is not a disease but rather a result of the inability of the heart to pump efficiently. CHF is not inherited. CHF occurs most frequently secondary to congenital heart defects in which structural abnormalities result in increased volume load or increased pressures on the ventricles.
The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. The nurse should do which of the following?
Report data to the practitioner
One of the earliest signs of CHF is tachycardia (sleeping heart rate >160 beats/min) as a direct result of sympathetic stimulation. The practitioner needs to be notified for evaluation of possible CHF. Although oxygen or a semiupright position may be indicated, the first action is to report the data to the practitioner.
The infant with congestive heart failure (CHF) has a need for:
ANS: D increased calories.
Infants with CHF have a greater metabolic rate because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of average infants, yet their ability to take in calories is diminished by their fatigue. The diet should include increased protein and increased fat to facilitate the child's intake of sufficient calories. Fluids must be carefully monitored because of the CHF.
The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes the risk of cerebrovascular accidents (strokes) occurring. Which of the following is an important objective to decrease this risk?
ANS: B Prevent dehydration.
In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes.
The school nurse sees a 14-year-old child who presents with fatigue and a nagging cough of three weeks' duration that has become productive with thick mucus and is much worse at night. The school nurse suspects pertussis (whooping cough), because vaccine protection wanes in 5-10 years. What is the school nurse's first nursing action?
Answer: A Isolate the child and contact the parents.
Isolation is necessary to prevent the disease from spreading to classmates by aerosolized droplet infection. The remaining interventions are important, but are not the first nursing action, because the entire school population might be at risk.
Which of the following is most likely associated with a cerebrovascular accident (CVA) resulting from congenital heart disease?
Answer: A Polycythemia
The child with congenital heart disease develops polycythemia resulting from an inadequate mechanism to compensate for decreased oxygen saturation.
Pertussis vaccination should begin at which age?
ANS: B 2months
The acellular pertussis vaccine is recommended by the American Academy of Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. The vaccine is not given after age 7 years, when the risks of the vaccine become greater than those of pertussis. The first dose is usually given at the 2-month well-child visit. The infant is highly susceptible to pertussis, which can be a life-threatening illness in this age-group.
Which of the following statements best describes Hirschsprung disease?
ANS: A The colon has an aganglionic segment.
Mechanical obstruction in the colon results from a lack of innervation. In most cases the aganglionic segment occludes the rectum and some portion of the distal colon. There is decreased evacuation of the large intestine secondary to the aganglionic segment. Liquid stool may ooze around the blockage. The obstruction does not affect meconium production. The infant may not be able to pass the meconium stool. There is decreased movement in the colon.
Abdominal circumferences are monitored on a child with progressive abdominal distention secondary to a bowel obstruction. The appropriate procedure for assessment includes:
ANS: B marking the point of measurement with a pen.
Pen marks on either side of the tape measure allow the nurse to measure the same spot on the child's abdomen at each assessment. The child most likely will be kept NPO (nothing by mouth) if a bowel obstruction is present. If the child is being fed, the assessment should be done before feedings. The symphysis pubis is too low. Usually the largest part of the abdomen is at the umbilicus. Leaving the tape measure in place reduces the trauma to the child.
A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child is which of the following?
ANS: B Essential because it will be an adjustment
The child's age dictates the type and extent of psychologic preparation. When a colostomy is performed, it is necessary to prepare the child who is at least preschool age by telling him or her about the procedure and what to expect in concrete terms, with the use of visual aids. The preschooler is not yet concerned with body image.
A child has a nasogastric (NG) tube after surgery for Hirschsprung disease. The purpose of the NG tube is which of the following?
ANS: C Prevent abdominal distention
The NG tube is placed to suction out gastrointestinal secretions and prevent abdominal distention. The NG tube would not affect infection. Electrolyte content of the NG drainage can be monitored. Without the NG tube, there would be no drainage. Once the NG tube is placed, it is important to maintain an accurate record of intake and output. This is not the reason for placement of the tube.
The nurse is assessing an infant with Hirschsprung's disease. The nurse can expect the infant to:
Ans: Have a scaphoid-shaped abdomen
The child with Hirschsprung's disease will have a scaphoid or hollowed abdomen.
Which antibiotic is contraindicated for the treatment of infections in infants and young children?
Ans: Tetracyn (tetracycline)
Tetracycline is contraindicated for use in infants and young children because it stains the teeth and arrests bone development. Answers B, C, and D are incorrect because they can be used to treat infections in infants and children.
Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea?
Answer: Notify the physician immediately
For the child with Hirschsprung disease, fever and explosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physicianshould be notified immediately. Generally, becauseof the intestinal obstruction and inadequatepropulsive intestinal movement, antidiarrheals arenot used to treat Hirschsprung disease. The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes.Hirschsprung disease typically presents with chronic constipation.
A newborn's failure to pass meconium within the first 24 hours after birth may indicate which of the following?
Answer: Hirschsprung disease
Failure to pass meconium within the first 24 hoursafter birth may be an indication of Hirschsprungdisease, a congenital anomaly resulting in mechanicalobstruction due to inadequate motility in anintestinal segment. Failure to pass meconium is notassociated with celiac disease, intussusception, orabdominal wall defect.
Which of the following clinical manifestations would be the most suggestive of acute appendicitis?
ANS: Colicky, cramping, abdominal pain around the umbilicus
Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain becomes constant and may shift to the right lower quadrant. Rebound tenderness is not a reliable sign and is extremely painful to the child. Bright or dark red rectal bleeding and abdominal pain that is relieved by eating are not signs of acute appendicitis.
When caring for a child with probable appendicitis, the nurse should be alert to recognize which of the following as a sign of perforation?
ANS: Sudden relief from pain
Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Anorexia is already a clinical manifestation of appendicitis. Tachycardia, not bradycardia, is a manifestation of peritonitis. Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).
The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. Which of the following is appropriate to relieve the abdominal discomfort during the evaluation?
ANS: Allow child to assume position of comfort.
The child should be allowed to take a position of comfort, usually with the legs flexed.
When assessing a child for possible intussusception, which of the following would be least likely to provide valuable information?
Answer c. Family history
Because intussusception is not believed to have a familial tendency, obtaining a family history would provide the least amount of information. Stool inspection, pain pattern, and abdominal palpation would reveal possible indicators of intussusception.Current, jelly-like stools containing blood and mucus are an indication of intussusception. Acute,episodic abdominal pain is characteristics of intussusception. A sausage-shaped mass may be palpated in the right upper quadrant.
A newborn's failure to pass meconium within 24 hours after birth may indicate which of the following?
Answer Aganglionic Mega colon
Failure to pass meconium of newborn during the first 24 hours of life may indicate Hirschsprung disease or Congenital Aganglionic Megacolon, an anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. B, C,and D are not associated in the failure to pass meconium of the newborn.
While assessing a child with pyloric stenosis, the nurse is likely to note which of the following?
Answer: Projectile vomiting
Projectile vomiting is a key symptom of pyloric stenosis. Regurgitation is seen more commonly withGER. Steatorrhea occurs in malabsorption disorders such as celiac disease. "Currant jelly"stools are characteristic of intussusception
A 2-year old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
Answer: "currant jelly" stools
A child with intussusception has stools that contain blood and mucus, which are described as"currant jelly" stools.
A child with pyloric stenosis is having excessive vomiting. Which of the following is a potential complication?
ANS: D. Metabolic alkalosis
Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Potassium and chloride ions are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.
Invagination of one segment of bowel within another is called which of the following?
ANS: D Intussusception
Intussusception occurs when a proximal section of the bowel telescopes into a more distal segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction. Atresia is the absence or closure of a natural opening in the body. Stenosis is a narrowing or constriction of the diameter of a bodily passage or orifice. Herniation is the protrusion of an organ or part through connective tissue or through a wall of the cavity in which it is normally enclosed.
The nurse is preparing to admit a 3-year-old with intussusception.
Which of the following clinical manifestations would the nurse expect
to observe? Select all that apply
a. Absent bowel sounds
b. Passage of red, currant jelly-like stools
d. Tender, distended abdomen
f. Sudden acute abdominal pain
ANS: B, D, F
Passage of red, currant jelly-like stools, Tender, distended abdomen, Sudden acute abdominal pain
Intussusception occurs when a proximal segment of the bowel telescopes into a more distal segment, pulling the mesentery with it and leading to obstruction. Clinical manifestations of intussusception include the passage of red, currant jelly-like stools; a tender, distended abdomen; and sudden acute abdominal pain. Absent bowel sounds, anorexia, and hematemesis are clinical manifestations observed in other types of gastrointestinal dysfunction.
A toddler's mother calls the nurse because she thinks her son has swallowed a button type of battery. He has no signs of respiratory distress. The nurse's response should be based on which of the following?
ANS: B The location needs to be confirmed by x-ray examination.
Button batteries can cause severe damage if lodged in the esophagus. If both poles of the battery come in contact with the wall of the esophagus, acid burns, necrosis, and perforation can occur. If the battery is in the stomach, it will most likely be passed without incident. Surgery is not indicated. The battery is metallic and is readily seen on radiologic examination.
Which of the following statements accurately describes physical development during the school-age years?
ANS: C Boys and girls double strength and physical capabilities.
Boys and girls double both strength and physical capabilities. Their consistent refinement in coordination increases their poise and skill. In middle childhood, growth in height and weight occurs at a slower pace. Between the ages of 6 and 12 years, children grow 5 cm/yr and gain 3 kg/yr. Their weight will almost double. Although the strength increases, muscles are still functionally immature when compared with those of adolescents. This age-group is more easily injured by overuse. Children take on a slimmer look with longer legs in middle childhood.
The parents of 9-year-old twin children tell the nurse, "They have filled up their bedroom with collections of rocks, shells, stamps, and bird nests." The nurse should recognize that this is which of the following?
ANS: Characteristic of cognitive development at this age
Classification skills involve the ability to group objects according to the attributes they have in common. School-age children can place things in a sensible and logical order, group and sort, and hold a concept in their mind while they make decisions based on that concept. Individuals who are not twins engage in classification at this age. Psychosocial behavior at this age is described according to Erikson's stage of industry versus inferiority.
Which of the following statements characterizes moral development in the older school-age child?
ANS: The child is able to judge an act by the intentions that prompted it rather than just by the consequences
Older school-age children are able to judge an act by the intentions that prompted the behavior rather than just by the consequences. Rule violation is likely to be viewed in relation to the total context in which it appears. Rules and judgments become less absolute and authoritarian. The situation and the morality of the rule itself influence reactions.
An 8-year-old girl tells the nurse that she has cancer because God is
punishing her for "being bad." The nurse should interpret
this as being which of the following?
a. A common belief at this age
b. Indicative of excessive family pressure
c. Faith that forms the basis for most religions
d. Suggestive of a failure to develop a conscience
Children at this age may view illness or injury as a punishment for a real or imagined misbehavior. School-age children expect to be punished and tend to choose a punishment that they think "fits the crime." This is a common belief and not related to excessive family pressure. Many faiths do not include a God that causes cancer in response for "bad" behavior. This statement reflects the child's belief in what is right and wrong.
What is the role of the peer group in the life of school-age children?
ANS: Provides them with security as they gain independence from their parents
Peer-group identification is an important factor in gaining independence from parents. Through peer relationships, children learn ways to deal with dominance and hostility. They also learn how to relate to people in positions of leadership and authority and how to explore ideas and the physical environment. A child's concept of appropriate sex roles is influenced by relationship with peers.
Which of the following is descriptive of the social development of school-age children?
ANS: Children frequently have "best friends."
Identification with peers is a strong influence in children's gaining independence from parents. Interaction among peers leads to the formation of close friendships with same-sex peers—"best friends." Daily relationships with age-mates in the school setting provide important social interaction for school-age children. During later school years, groups are composed predominantly of children of the same sex. Conforming to the rules of the peer group provides children with a sense of security and relieves them of the responsibility of making decisions.
Which of the following statements best describes the relationship school-age children have with their families?
ANS: Children frequently have "best friends."
School-age children need and want restrictions placed on their behavior, and they are not prepared to cope with all the problems of their expanding environment. Although increased independence is the goal of middle childhood, they feel more secure knowing that an authority figure can implement controls and restriction. In the middle-school years, children prefer peer-group activities to family activities and want to spend more time in the company of peers. Family values usually take precedence over peer value systems.
A parent asks about whether a 7-year-old is able to care for a dog. Based on the child's age, the nurse suggests:
ANS: c. a dog can help the child develop confidence and emotional health.
Pets have been observed to influence a child's self-esteem. They can have a positive effect on physical and emotional health and can teach children the importance of nurturing and nonverbal communication. Most 7-year-olds are capable of caring for a pet with supervision. Caring for a pet should be a positive experience. It should not be used to identify weaknesses. The pet chosen does not matter as much as the child's being responsible for a pet.
Which of the following is descriptive of the play of school-age children?
ANS: Knowing the rules of a game gives an important sense of belonging.
Play involves increased physical skill, intellectual ability, and fantasy. Children form groups and cliques and develop a sense of belonging to a team or club. At this age, children begin to see the need for rules. Conformity and ritual permeate their play. Their games have fixed and unvarying rules, which may be bizarre and extraordinarily rigid. With team play, children learn about competition and the importance of winning, an attribute highly valued in the United States but not in all cultures.
Which of the following is characteristic of dishonest behavior in children ages 8 to 10 years?
ANS: Lying is used to meet expectations set by others that they have been unable to attain.
Older school-age children may lie to meet expectations set by others to which they have been unable to measure up. Cheating usually becomes less frequent as the child matures. Young children may lack a sense of property rights; older children may steal to supplement an inadequate allowance, or it may be an indication of serious problems. In this age-group, children are able to distinguish between fact and fantasy.
A 9-year-old girl often comes to the school nurse complaining of stomach pains. Her teacher says she is completing her school work satisfactorily, but lately has been somewhat aggressive and stubborn in the classroom. The school nurse should recognize this as which of the following?
ANS: Signs of stress
Signs of stress include stomach pains or headache, sleep problems, bed-wetting, changes in eating habits, aggressive or stubborn behavior, reluctance to participate, or regression to earlier behaviors. The child is completing school work satisfactorily; any developmental delay would have been diagnosed earlier. The teacher reports that this is a departure from the child's normal behavior. Adjustment issues would most likely be evident soon after a change. Medical intervention is not immediately required. Recognizing that this constellation of symptoms can indicate stress, the nurse should help the child identify sources of stress and how to use stress reduction techniques. The parents are involved in the evaluation process.
When reviewing the allergy history of a patient, the nurse notes that the patient is allergic to penicillin. Based on this finding, the nurse would question an order for which class of antibiotics?
Allergy to penicillin may also result in hypersensitivity to cephalosporins. The other options are not correct
When teaching a patient who will be taking tetracycline, which of the following instructions should the nurse share?
ANS: "Avoid direct sunlight and tanning beds while on this medication."
Drug-related photosensitivity occurs when patients take tetracyclines, and it may continue for several days after therapy. Milk and cheese products result in decreased levels of tetracycline when the two are taken together. Antacids also interfere with absorption and should not be taken with tetracycline.
When reviewing the medication orders for a patient who is taking penicillin, the nurse notes that the patient is also taking the oral anticoagulant warfarin (Coumadin). What possible effect may occur as the result of an interaction between these drugs?
ANS: The penicillin will cause an enhanced anticoagulant effect of the warfarin.
Administering penicillin reduces the vitamin K in the gut (intestines); therefore, enhanced anticoagulant effect of warfarin may occur.
A patient is receiving his third intravenous dose of a penicillin drug. He calls the nurse to report that he is feeling "anxious" and is having trouble breathing. What will the nurse do first?
ANS: Stop the antibiotic infusion.
Hypersensitivity reactions are characterized by wheezing; shortness of breath; swelling of the face, tongue, or hands; itching; or rash. The nurse should immediately stop the antibiotic infusion, have someone notify the physician, and stay with the patient to monitor the patient's vital signs and condition. Checking for allergies should have been done before the infusion.
A patient is admitted with a fever of 102.8 F (39.3 ° C), origin unknown. Assessment reveals cloudy, foul-smelling urine that is dark amber in color. Orders have just been written to obtain urine and blood cultures and to administer an antibiotic intravenously stat (now). The nurse will complete these orders in which sequence?
ANS: Blood and urine cultures, ampicillin dose
Culture specimens should be obtained before initiating drug therapy; otherwise, the presence of antibiotics in the tissues may result in misleading culture and sensitivity results.
The nurse is reviewing medications for the treatment of asthma. Which
drugs are used for acute asthma attacks? Select all that
A. Zafirlukast (Accolate) tablet
B. Albuterol (Proventil) nebulizer solution
F. Aminophylline IV infusion
ANS: B, C, F
B. Albuterol (Proventil) nebulizer solution
F. Aminophylline IV infusion
Fluticasone is an inhaled corticosteroid; zafirlukast and montelukast are antileukotriene drugs. These types of medications are used for asthma prophylaxis. Albuterol (a beta2-agonist) and epinephrine (a beta1- and beta2-agonist) are used for acute bronchospasms. Aminophylline can be used for mild to moderate asthma attacks.
The nurse is monitoring the drug levels for a patient who is receiving theophylline. Which drug level is considered within therapeutic limits?
ANS: 14 mcg/mL
Although the optimal level may vary from patient to patient, most standard references have suggested that the therapeutic range for theophylline blood level is 10 to 20 mcg/mL. However, most clinicians now advise levels between 5 and 15 mcg/mL.
When educating a patient recently placed on inhaled corticosteroids, the nurse will discuss which potential adverse effects?
ANS: Oral candidiasis and dry mouth
Oral candidiasis and dry mouth are two possible adverse effects of inhaled corticosteroids.
A patient has prescriptions for two inhalers. One inhaler is a bronchodilator, and the other is a corticosteroid. Which instruction regarding these inhalers should the nurse give to the patient?
ANS: "The bronchodilator should be taken first."
An inhaled beta2-agonist may be used before the inhaled corticosteroid to provide bronchodilation before administration of the antiinflammatory drug.
After receiving a nebulizer treatment with a beta-agonist, a patient complains of feeling slightly nervous and wonders if her asthma is getting worse. What is the nurse's best response?
ANS: "This is an expected adverse effect. Let me take your pulse."
Nervousness, tremors, and cardiac stimulation are possible and expected adverse effects of beta-agonists. The other options are not correct responses.
The physician has changed a patient's medication regimen to include the leukotriene receptor antagonist zileuton (Zyflo) to treat her asthma. The nurse should emphasize which point about this medication?
ANS: It should be taken every day on a continuous schedule, even if symptoms improve.
These drugs are indicated for chronic, not acute, asthma and should be taken every day on a continuous schedule, even if symptoms improve. These drugs are taken orally.
A patient is in an urgent-care center with an acute asthma attack. The nurse expects that which medication will be used for initial treatment?
ANS: A beta2 agonist such as albuterol (Proventil)
The beta-agonists are commonly used during the acute phase of an asthmatic attack to reduce airway constriction quickly and to restore airflow to normal levels. The other drugs listed are not appropriate for acute asthma attacks. Anticholinergic drugs are used to prevent attacks; leukotriene receptor antagonists and corticosteroids are used to reduce airway inflammation.
A patient is taking a xanthine derivative as part of treatment for chronic obstructive pulmonary disease. The nurse will monitor for adverse effects associated with the use of xanthine derivatives, including
The common adverse effects of the xanthine derivatives include nausea, vomiting, and anorexia. In addition, gastroesophageal reflux has been observed to occur during sleep in patients taking these drugs. Cardiac adverse effects include sinus tachycardia, extrasystole, palpitations, and ventricular dysrhythmias. Transient increased urination and hyperglycemia are other possible adverse effects.
A patient is taking intravenous aminophylline for a severe exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect when evaluating for a therapeutic response to the medication?
ANS: Increased ease of breathing
The therapeutic effects of bronchodilating drugs such as xanthine derivatives include increased ease of breathing.
The nurse who is administering aminoglycoside therapy must monitor the patient closely for signs of toxicity as manifested by which of the following?
Select all that apply
B. Hearing loss
F. Rising serum creatinine level
Patients on aminoglycoside therapy must be monitored for signs of nephrotoxicity (rising serum creatinine level) and ototoxicity (hearing loss, dizziness). The other options are not signs of toxicity.