Test 3 Saunders & Davis NCLEX questions

The clinic nurse reviews the record of an infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which symptom most likely led the mother to seek health care for the infant?

1.

Diarrhea

2.

Projectile vomiting

3.

Regurgitation of feedings

4.

Foul-smelling ribbon-like stools

4

Hirschsprung's disease is a congenital anomaly also known as congenital aganglionosis or aganglionic megacolon. It occurs as the result of an absence of ganglion cells in the rectum and other areas of the affected intestine. Chronic constipation beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foul-smelling is a clinical manifestation of this disorder. Delayed passage or absence of meconium stool in the neonatal period is also a sign. Bowel obstruction especially in the neonatal period, abdominal pain and distention, and failure to thrive are also clinical manifestations. Options 1, 2, and 3 are not associated specifically with this disorder.

An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?

1.

Prone position

2.

On the stomach

3.

Left lateral position

4.

Right lateral position

3

A cleft lip is a congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic development. After cleft lip repair, the nurse avoids positioning an infant on the side of the repair or in the prone position because these positions can cause rubbing of the surgical site on the mattress. The nurse positions the infant on the side lateral to the repair or on the back upright and positions the infant to prevent airway obstruction by secretions, blood, or the tongue. From the options provided, placing the infant on the left side immediately after surgery is best to prevent the risk of aspiration if the infant vomits.

The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?

1.

Incessant crying

2.

Coughing at nighttime

3.

Choking with feedings

4.

Severe projectile vomiting

3

In esophageal atresia and tracheoesophageal fistula, the esophagus terminates before it reaches the stomach, ending in a blind pouch, and a fistula is present that forms an unnatural connection with the trachea. Any child who exhibits the "3 C's"-coughing and choking with feedings and unexplained cyanosis-should be suspected to have tracheoesophageal fistula. Options 1, 2, and 4 are not specifically associated with tracheoesophageal fistula.

The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?

1.

Provide less frequent, larger feedings.

2.

Burp the infant less frequently during feedings.

3.

Thin the feedings by adding water to the formula.

4.

Thicken the feedings by adding rice cereal to the formula.

4

Gastroesophageal reflux is backflow of gastric contents into the esophagus as a result of relaxation or incompetence of the lower esophageal or cardiac sphincter. Small, more frequent feedings with frequent burping often are prescribed in the treatment of gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis. If thickened formula is used, cross-cutting of the nipple may be required.

A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?

1.

Diarrhea

2.

Metabolic acidosis

3.

Metabolic alkalosis

4.

Hyperactive bowel sounds

3

Vomiting causes the loss of hydrochloric acid and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea might or might not accompany vomiting. Hyperactive bowel sounds are not associated with vomiting.

The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?

1.

Bile-stained fecal emesis

2.

The passage of currant jelly-like stools

3.

Failure to pass meconium stool in the first 24 hours after birth

4.

Sausage-shaped mass palpated in the upper right abdominal quadrant

3

Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum. During the newborn assessment, this defect should be identified easily on sight. A rectal thermometer or tube may be necessary, however, to determine patency if meconium is not passed in the first 24 hours after birth. Other assessment findings include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum. Options 1, 2, and 4 are findings noted in intussusception.

The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the mother about the child's symptoms?

1.

Watery diarrhea

2.

Projectile vomiting

3.

Increased urine output

4.

Vomiting large amounts of bile

2

In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation, and signs of dehydration including a decrease in urine output.

The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?

1.

Rice

2.

Oatmeal

3.

Rye toast

4.

Wheat bread

1

Celiac disease also is known as gluten enteropathy or celiac sprue and refers to an intolerance to gluten, the protein component of wheat, barley, rye, and oats. The important factor to remember is that all wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn, rice, or millet. Vitamin supplements-especially the fat-soluble vitamins, iron, and folic acid-may be needed to correct deficiencies. Dietary restrictions are likely to be lifelong.

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which symptom of this disorder documented?

1.

Watery diarrhea

2.

Ribbon-like stools

3.

Profuse projectile vomiting

4.

Bright red blood and mucus in the stools

4

Intussusception is a telescoping of one portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. A child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomiting may be present, but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly-like stools. Watery diarrhea and ribbon-like stools are not manifestations of this disorder.

Which interventions should the nurse include when preparing a care plan for a child with hepatitis? Select all that apply.

1.

Providing a low-fat, well-balanced diet.

2.

Teaching the child effective hand-washing techniques.

3.

Scheduling playtime in the playroom with other children.

4.

Notifying the health care provider (HCP) if jaundice is present.

5.

Instructing the parents to avoid administering medications unless prescribed.

6.

Arranging for indefinite home schooling because the child will not be able to return to school.

1,2,5

Hepatitis is an acute or chronic inflammation of the liver that may be caused by a virus, a medication reaction, or another disease process. Because hepatitis can be viral, standard precautions should be instituted in the hospital. The child should be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite home schooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the HCP. Provision of a low-fat, well-balanced diet is recommended. Parents are cautioned about administering any medication to the child because normal doses of many medications may become dangerous owing to the liver's inability to detoxify and excrete them. Hand-washing is the most effective measure for control of hepatitis in any setting, and effective hand-washing can prevent the immunocompromised child from contracting an opportunistic type of infection.

An infant born with an imperforate anus returns from surgery with a colostomy. The nurse assesses the stoma and notes that it is red and edematous. What is the best nursing action based on this finding?

1.

Elevate the buttocks.

2.

Document the findings.

3.

Apply ice immediately.

4.

Call the health care provide

2

A fresh colostomy stoma would be red and edematous, but this would decrease with time. The colostomy site then becomes pink without evidence of abnormal drainage, swelling, or skin breakdown. The nurse should document these findings because this is a normal expectation. Options 1, 3, and 4 are inappropriate and unnecessary interventions.

The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

1.

The nail beds

2.

The skin in the sacral area

3.

The skin in the abdominal area

4.

The membranes in the ear canal

1

Jaundice, if present, is best assessed in the sclera, nail beds, and mucous membranes. Generalized jaundice appears in the skin throughout the body. Option 3 is an inappropriate area to assess for the presence of jaundice.

The parents of a child with a cleft lip are concerned and ask the nurse when the lip will be repaired. With which statement should the nurse respond?

1.

Cleft lip cannot be repaired.

2.

Cleft-lip repair is usually performed by 6 months of age.

3.

Cleft-lip repair is usually performed during the first weeks of life.

4.

Cleft-lip repair is usually performed between 6 months and 2 years.

3

Cleft-lip repair is usually performed during the first few weeks of life. Early repair may improve bonding and makes feeding much easier. Revisions may be required at a later age. All other options are incorrect.

A 1-year-old child is diagnosed with intussusception, and the mother of the child asks the nurse to describe the disorder. Which statement is correct about intussusception?

1.

"It is an acute bowel obstruction."

2.

"It is a condition that causes an acute inflammatory process in the bowel."

3.

"It is a condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel."

4.

"It is a condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel."

4

Intussusception occurs when a proximal segment of the bowel prolapses into a distal segment of the bowel. It is not an acute bowel obstruction, but it is a common cause in infants and young children. It is not an inflammatory process.

A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse reviews the assessment findings and expects to note documentation of which sign of this disorder?

1.

Diarrhea

2.

Malaise and anorexia

3.

Nausea and vomiting

4.

Evidence of soiled clothing

4

Encopresis is defined as fecal incontinence and is a major concern if the child is constipated. Signs include evidence of soiled clothing, scratching or rubbing the anal area because of irritation, fecal odor without apparent awareness by the child, and social withdrawal.

A home care nurse instructs the mother of a 5-year-old child with lactose intolerance about dietary measures for her child. The nurse should tell the mother that it is necessary to provide which dietary supplement in the child's diet?

1.

Fats

2.

Zinc

3.

Protein

4.

Calcium

4

Lactose intolerance is the inability to tolerate lactose, the sugar found in dairy products. Removing milk and other dairy products from the diet can provide adequate relief from symptoms. This, however, can result in a deficiency of calcium. Additional dietary changes may be required to provide adequate sources of calcium and, in the infant, protein, and calories.

A nurse has been assigned to care for a neonate just delivered who has gastroschisis. Which concern should the nurse address in the client's plan of care?

1.

Infection

2.

Poor body image

3.

Decreased urinary elimination

4.

Cracking oral mucous membranes

1

Gastroschisis occurs when the bowel herniates through a defect in the abdominal wall to the right of the umbilical cord. There is no membrane covering the exposed bowel. Surgical repair will be done as soon as possible because of the risk of infection in the unprotected bowel. Therefore the highest risk immediately after delivery is infection. Because the client is a neonate, poor body image is not an immediate problem. Impaired urinary elimination is unlikely because the gastrointestinal tract is affected, not the genitourinary system. Gastroschisis involves the lower gastrointestinal system, so the oral mucous membranes are not affected.

A nurse is assigned to care for a child who is scheduled for an appendectomy. Select the prescription(s) that the nurse anticipates will be prescribed. Select all that apply.

1.

Initiate an IV line.

2.

Maintain an NPO status.

3.

Administer a Fleet enema.

4.

Administer intravenous antibiotics.

5.

Administer preoperative medications.

6.

Place a heating pad on the abdomen to decrease pain.

1,2,4,5

Appendicitis is an inflammation of the appendix. When the appendix becomes inflamed or infected, perforation may occur within a matter of hours, leading to peritonitis, sepsis, septic shock, and potential death. IV fluids would be started, and the child would be NPO while awaiting surgery. Usually antibiotics are administered because of the risk of perforation. Prescribed preoperative medications most likely would be administered on call to the operating room. In the preoperative period, enemas or laxatives should not be administered. Additionally, heat is not applied to the abdomen. Any of these interventions can cause rupture of the appendix and resultant peritonitis.

The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period?

1.

Prone position

2.

Supine with no head elevation

3.

Side-lying with the legs extended

4.

Supine with the head elevated 45 degrees

1

The appropriate position following surgical intervention for an imperforate anus is a side-lying position with the legs flexed or a prone position to keep the hips elevated. These positions will reduce edema and pressure on the surgical site. Options 2, 3, and 4 will promote pressure at the surgical site.

The nurse is providing discharge instructions to the mother of a child who had a cleft palate repair. Which statement should the nurse make to the mother?

1.

"You should use a plastic spoon to feed the child."

2.

"You need to use a short nipple on the child's bottle."

3.

"You can allow the child to use a pacifier but only for 30 minutes at a time."

4.

"You need to monitor the child's temperature for signs of infection using an oral thermometer."

2

A short nipple should be placed on the child's bottle, and the mother should be instructed to give the child baby food or baby food mixed with water. The mother should be instructed that straws, pacifiers, spoons, or fingers must be kept away from the child's mouth for 7 to 10 days after surgery. A pacifier should not be used for at least 2 weeks following the surgical repair. Additionally, the mother should be advised to avoid taking oral temperatures.

A mother brings her 5-week-old infant to the health care clinic and tells the nurse that the child has been vomiting after meals. The mother reports that the vomiting is becoming more frequent and forceful. The nurse suspects pyloric stenosis and asks the mother which assessment question to elicit data specific to this condition?

1.

"Are the stools ribbon-like and is the infant eating poorly?"

2.

"Does the infant suddenly become pale, begin to cry, and draw the legs up to the chest?"

3.

"Does the vomit contain sour undigested food without bile, and is the infant constipated?"

4.

"Does the infant cry loudly and continuously during the evening hours but nurses or takes formula well?"

3

Option 3 presents classic symptoms of pyloric stenosis. Stools that are ribbon-like and a child who is eating poorly are signs of congenital megacolon (Hirschsprung's disease). An infant who suddenly becomes pale, cries out, and draws the legs up to chest is demonstrating physical signs of intussusception. Crying during the evening hours, appearing to be in pain, eating well, and gaining weight are clinical manifestations of colic.

The nurse is caring for an infant after repair of an inguinal hernia. Which of these assessment findings indicate that the surgical repair was effective?

1.

A clean, dry incision

2.

Abdominal distention

3.

An adequate flow of urine

4.

Absence of inguinal swelling with crying

4

With an inguinal hernia, inguinal swelling occurs when the infant cries or strains. Absence of this swelling would indicate resolution of this problem. A clean, dry incision refers to absence of wound infection after surgery. Abdominal distention indicates a continuing gastrointestinal problem. The flow of urine is not specific to an inguinal hernia.

After hydrostatic reduction for intussusception, the nurse should expect to observe which client response?

1.

Abdominal distention

2.

Currant jelly-like stools

3.

Severe colicky-type pain with vomiting

4.

Passage of barium or water-soluble contrast with stools

4

Intussusception is the telescoping of one portion of the bowel into another. Hydrostatic reduction may be necessary to resolve the condition. After hydrostatic reduction, the nurse observes for the passage of barium or water-soluble contrast material with stools. Options 1 and 2 are clinical indicators of intussusception. Option 3 is a sign of an unresolved gastrointestinal disorder.

The nurse is writing out discharge instructions for the parents of a child diagnosed with celiac disease. The nurse should focus primarily on which aspect of care?

1.

Restricting activity

2.

Following a gluten-free diet

3.

Following a lactose-free diet

4.

Giving medication to manage the condition

2

The primary nursing consideration in the care of a child with celiac disease is to instruct the child and parents regarding proper dietary management. Although medications may be prescribed for the client with celiac disease, treatment focuses primarily on maintaining a gluten-free diet. Options 1, 3, and 4 are not directly related to the care of a child with celiac disease.

Parents bring their child to the emergency department and tell the nurse that the child has been complaining of colicky abdominal pain located in the lower right quadrant of the abdomen. The nurse suspects that the child has which disorder?

1.

Peritonitis

2.

Appendicitis

3.

Intussusception

4.

Hirschsprung's disease

2

The most common symptom of appendicitis is a colicky, periumbilical, or lower abdominal pain located in the right quadrant. Peritonitis is a complication that can follow organ perforation or intestinal obstruction. The classic signs and symptoms of intussusception are acute, colicky abdominal pain with currant jelly-like stools. Clinical manifestations of Hirschsprung's disease include constipation, abdominal distention, and ribbon-like, foul-smelling stools.

The nurse is providing instructions to the parents of a child with a hernia regarding measures that will promote reducing the hernia. The nurse determines that the parents understand care for their child if they make which statement?

1.

"We will encourage our child to cough every few hours on a daily basis."

2.

"We will make sure that our child participates in physical activity every day."

3.

"We will provide comfort measures to reduce any crying periods by our child."

4.

"We will be sure to give our child a Fleet enema every day to prevent constipation."

3

A warm bath, avoidance of upright positioning, and other comfort measures to reduce crying are all simple measures to reduce a hernia. Coughing and crying increase the strain on the hernia. Likewise, physical activity and enemas of any type would increase the strain on the hernia.

An emergency department nurse is performing an assessment on a child with a suspected diagnosis of intussusception. Which assessment question for the parents will elicit the most specific data related to this disorder?

1.

"Does the child have any food allergies?"

2.

"What do the bowel movements look like?"

3.

"Has the child eaten any food in the last 24 hours?"

4.

"Can you describe the type of pain that the child is experiencing?"

4

A report of severe colicky abdominal pain in a healthy, thriving child between 3 and 17 months of age is the classic presentation of intussusception. Typical behavior includes screaming and drawing the knees up to the chest. Options 1, 2, and 3 are important aspects of a health history but are not specific to the diagnosis of intussusception.

The nurse is caring for a newborn infant after surgical intervention for imperforate anus. The nurse should place the infant in which position in the postoperative period?

1.

Supine with no head elevation

2.

Side-lying with the legs flexed

3.

Side-lying with the legs extended

4.

Supine with the head elevated 30 degrees

2

After surgical intervention for imperforate anus, a side-lying position with the legs flexed or a prone position to keep the hips elevated can reduce edema and pressure on the surgical site. Options 1, 3, and 4 are incorrect positions.

The mother of a child with hepatitis A tells the home care nurse that she is concerned because the child's jaundice seems worse. Which response should the nurse make to the mother?

1.

"You need to change the child's diet."

2.

"The child probably is infectious again."

3.

"You need to call the health care provider."

4.

"In many situations, the jaundice worsens before it resolves."

4

The parents of the child should be told that jaundice may appear to worsen before it resolves. Options 1, 2, and 3 are incorrect and inappropriate responses.

The mother of an 18-month-old child tells the clinic nurse that the child has been having some mild diarrhea and describes the child's stools as "mushy." The mother tells the nurse that the child is tolerating fluids and solid foods. The most appropriate suggestion regarding the child's diet would be to give the child which items?

1.

Jell-O, strained cabbage, and custard

2.

Fluids only until the "mushy" stools stop

3.

Rice and mashed potatoes diluted with skim milk

4.

Applesauce, strained bananas, and strained carrots

4

If mild diarrhea occurs in a child younger than 2 years, a soft diet is advised as long as the child is tolerating solids. The ABCs (applesauce, strained bananas, and strained carrots), rice, potatoes, and other bland foods without dairy products are advised. Extra fluids may also be needed and may be given by adding 1 to 2 oz of additional water to each bottle of formula or juice.

A nurse provides home care instructions to the mother of a child who had a cleft palate repair 4 days ago. Which statement by the mother indicates the need for further instruction?

1.

"I will use a short nipple on the bottle."

2.

"I need to buy some straws for drinking."

3.

"I can give my child the pacifier in 2 weeks."

4.

"I will give my child baby foods or baby food mixed with water."

2

The mother needs to be instructed that straws, pacifiers, spoons, and fingers must be kept away from the child's mouth for 7 to 10 days. Additionally, the mother should be advised to avoid taking an oral temperature. Options 1, 3, and 4 are accurate measures to implement after cleft palate repair.

The nurse is preparing to care for an infant who has esophageal atresia with tracheoesophageal fistula (TEF). Surgery is scheduled to be performed in 1 hour. Intravenous fluids have been initiated, and a nasogastric (NG) tube has been inserted by the health care provider. The nurse plans care, knowing that which intervention is of highest priority during this preoperative period?

1.

Monitor the temperature.

2.

Monitor the blood pressure.

3.

Irrigate the NG tube every 5 to 10 minutes.

4.

Aspirate the NG tube every 5 to 10 minutes.

4

Esophageal atresia with TEF represents a critical neonatal surgical emergency. While the infant is awaiting transfer to surgery, management centers on prevention of aspiration. The infant is kept supine or prone with the head of the bed elevated to decrease the chance that gastric secretions will enter the lungs. Intravenous fluids are essential. An NG tube must be in place and aspirated every 5 to 10 minutes to keep the proximal pouch clear of secretions. Monitoring the temperature and monitoring blood pressure are standard nursing interventions.

A mother brings her child to the well-child clinic and expresses concern to the nurse because the child has been playing with another child diagnosed with hepatitis. The nurse performs an assessment on the child, knowing that which finding is unassociated with hepatitis?

1.

Hepatomegaly

2.

The presence of jaundice

3.

The presence of left upper abdominal quadrant pain

4.

The presence of dark-colored, frothy urine in the urine specimen

3

Assessment findings in a child with hepatitis include right upper quadrant tenderness and hepatomegaly. The stools will be pale and clay-colored, and urine will be dark and frothy. Jaundice may be present and will be best assessed in the sclerae, nail beds, and mucous membranes.

A child is diagnosed with Hirschsprung's disease. The nurse is teaching the parents about the cause of the disease. Which statement, if made by the parent, supports that teaching was successful?

1.

"Special cells are not present in the rectum, which caused the disease."

2.

"The protein part of wheat, barley, rye, and oats is not being digested fully."

3.

"The disease occurs from increased bowel motility that leads to spasm and pain."

4.

"The disease occurs because of inability to tolerate sugar found in dairy products."

1

Hirschsprung's disease also is known as congenital aganglionosis or megacolon. It results from the absence of ganglion cells in the rectum and, to various degrees, up into the colon. Option 2 describes celiac disease. Option 3 describes irritable bowel syndrome. Option 4 describes lactose intolerance.

The parents of a child with a cleft palate are concerned and ask the nurse when the palate will be repaired. The nurse should plan to base the response on which information about cleft palate repair?

1.

Cannot be repaired

2.

Repair usually is performed by age 8 weeks

3.

Repair usually is performed by 2 months of age

4.

Repair usually is performed between 6 months and 2 years

4

Cleft palate repair is individualized and is based on the degree of deformity and size of the child. Cleft palate repair usually is performed between 6 months and 2 years of age, depending on the preference of the health care provider. Early closure facilitates speech development. Options 1, 2, and 3 are incorrect.

The clinic nurse is obtaining data about a child with a diagnosis of lactose intolerance. Which data should the nurse expect to obtain on assessment?

1.

Reports of frothy stools and diarrhea

2.

Reports of foul-smelling ribbon stools

3.

Reports of profuse, watery diarrhea and vomiting

4.

Reports of diffuse abdominal pain unrelated to meals or activity1

1

Lactose intolerance causes frothy stools and diarrhea. Abdominal distention, crampy abdominal pain, and excessive flatus also may occur. Foul-smelling ribbon stool is a clinical manifestation of Hirschsprung's disease. Profuse, watery diarrhea and vomiting are clinical manifestations of celiac disease. Diffuse abdominal pain is a clinical manifestation of irritable bowel syndrome.

The nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that further instruction is needed if the mother states that she will include which food item in the child's nutritional plan?

1.

Corn

2.

Chicken

3.

Oatmeal

4.

Vitamin supplements

3

Dietary management is the mainstay of treatment for the child with celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies.

A child is diagnosed with intussusception. On performing an assessment of the child, the nurse keeps in mind which finding as a characteristic of this disorder?

1.

The presence of fecal incontinence

2.

Incomplete development of the anus

3.

The infrequent and difficult passage of dry stools

4.

Invagination of a section of the intestine into the distal bowel

4

Intussusception is an invagination of a section of the intestine into the distal bowel. It is the most common cause of bowel obstruction in children aged 3 months to 6 years. The presence of fecal incontinence describes encopresis. Encopresis generally affects preschool and school-aged children. Incomplete development of the anus describes imperforate anus, and this disorder is diagnosed in the neonatal period. The infrequent and difficult passage of dry stools describes constipation. Constipation can affect any child at any time, although the incidence peaks at age 2 to 3 years.

The nurse is caring for a 1-year-old child after cleft palate repair. On completion of feeding, the nurse should plan for which appropriate nursing action?

1.

Rinsing the mouth with water

2.

Cleaning the mouth with diluted hydrogen peroxide

3.

Using a soft lemon and glycerin swab to clean the mouth

4.

Using cotton swabs saturated with half-strength povidone-iodine (Betadine) solution to clean the mouth

1

After cleft palate repair, the mouth is rinsed with water after feedings to clean the palate repair site. Rinsing food and residual sugars from the suture line reduces the risk of infection. Options 2, 3, and 4 are incorrect procedures. Hydrogen peroxide, lemon and glycerin, and povidone-iodine are not used because of their harmful effect on oral tissues and the suture site.

The nurse is reviewing the laboratory results for an infant with suspected hypertrophic pyloric stenosis. What should the nurse expect to note as the most likely finding in this infant?

1.

Metabolic acidosis

2.

Metabolic alkalosis

3.

Respiratory acidosis

4.

Respiratory alkalosis

2

Laboratory findings in an infant with hypertropic pyloric stenosis include metabolic alkalosis as a result of the vomiting that occurs in this disorder. Additional findings include decreased serum potassium and sodium levels, increased pH and bicarbonate level, and decreased chloride level. Options 1, 3, and 4 are incorrect

A 12-year-old girl is admitted to the hospital with suspected appendicitis. What nursing interventions should be implemented preoperatively?

1.

Applying a heating pad for 5-minute intervals as prescribed

2.

Administering acetaminophen (Tylenol) as needed for pain, as prescribed

3.

Placing the adolescent in a fetal position, side-lying with legs drawn up to chest

4.

Inserting a nasogastric tube and attaching it to low intermittent suction; measuring drainage as prescribed

3

A client with appendicitis is more comfortable when lying in what is traditionally known as the fetal position, with the legs drawn up toward the chest. This flexed positioning assists in decreasing the pain that comes with appendicitis by decreasing the pressure on the abdominal area. Option 1 describes an intervention that is contraindicated because heat can lead to a ruptured appendix. Option 2 is incorrect. Pain medications are not given to the client with acute appendicitis because they may mask the symptoms that accompany a ruptured appendix. Option 4 describes a nursing intervention that may be necessary postoperatively.

The nurse is reviewing the laboratory test results for an infant suspected of having hypertrophic pyloric stenosis. The nurse should expect to note which value as the most likely laboratory finding in this infant?

1.

Blood pH of 7.50

2.

Blood pH of 7.30

3.

Blood bicarbonate of 22 mEq/L

4.

Blood bicarbonate of 19 mEq/L

1

Laboratory findings in an infant with hypertrophic pyloric stenosis include metabolic alkalosis due to vomiting. These include increased blood pH and bicarbonate level, decreased serum potassium and sodium levels, and a decreased chloride level. The normal pH is 7.35 to 7.45. The normal bicarbonate is 22 to 27 mm Hg.

The mother of an infant diagnosed with Hirschsprung's disease asks the nurse about the disorder. What should the nurse tell the mother about the disease?

1.

It is complete small intestinal obstruction.

2.

It is congenital aganglionosis or megacolon.

3.

It is severe inflammation of the gastrointestinal tract.

4.

It is condition that causes the pyloric valve to remain open.

2

Hirschsprung's disease is also known as congenital aganglionosis or megacolon. It is the result of an absence of ganglion cells in the rectum and to varying degrees upward in the colon. The remaining options are incorrect descriptions.

The nurse is preparing to care for a newborn infant who will be returning from surgery with a colostomy that was created for imperforate anus. When the infant arrives, the nurse assesses the stoma and notes that it is red and edematous. Which is the most appropriate nursing intervention?

1.

Elevate the buttocks.

2.

Document the findings.

3.

Apply ice immediately.

4.

Call the health care provider.

2

A fresh colostomy stoma will be red and edematous, but this will decrease with time. The colostomy site will then be pink without evidence of abnormal drainage, swelling, or skin breakdown. The nurse would document these findings because they represent a normal expectation. The remaining options are inappropriate interventions.

A clinic nurse is assessing the status of jaundice in a child with hepatitis. Which anatomical area will provide the best data regarding the presence of jaundice?

1.

The nail beds

2.

The skin in the sacral area

3.

The skin in the abdominal area

4.

The membranes in the ear canal

1

Jaundice, if present, is best assessed in the sclera, nail beds, and mucous membranes. Generalized jaundice will appear in the skin throughout the body. The membranes of the ear canal are not an appropriate area to assess for the presence of jaundice.

The nurse in the hospital is giving at-home feeding instructions to a family whose child is being discharged after being born with a cleft lip. Which statement by the mother would indicate that further teaching is indicated?

1.

"I am so glad that I am able to breast-feed my baby."

2.

"I must always feed my baby with a syringe and not use a nipple."

3.

"I will burp my baby very frequently so that she does not swallow a lot of air."

4.

"I will feed my baby while sitting in a chair and holding her more upright."

2

Infants with a cleft lip are fed using a special nipple. Therefore although all the interventions relate to feeding, option 2 should be clarified with the family because if they fed the baby using a syringe, the child's oral needs for sucking will not be met. Newborns should be burped frequently and fed in a somewhat upright position. These interventions are applicable to the child with a cleft lip as well. Breast-feeding is always an option and should be done unless the child is having difficulty. Most children with a small cleft lip can breast-fed.

An infant is seen in the health care provider's office for complaints of frequent vomiting and spitting up after feedings. Findings indicate that the infant is not gaining weight and gastroesophageal reflux is suspected. Which would the nurse anticipate being prescribed initially in the care of this child?

1.

Place in prone position after each feeding.

2.

Administer omeprazole (Prilosec) before feeding.

3.

Instruct parents to keep a log of feedings and any reflux present.

4.

Change the formula to predigested formula and feed small, frequent feedings.

4

For infants with frequent vomiting and spitting up, the diagnosis of gastroesophageal reflux should be considered. The initial action is to alter the formula. After the formula is changed, the family will be instructed to keep a log of feedings and any reflux with the new formula. Medication is not started until after the formula is changed. A prone position increases the risk of reflux and thus aspiration.

An infant is seen in the health care provider's office for complaints of projectile vomiting after feeding. Findings indicate that the child is fussy and is gaining weight but seems to never get enough to eat. Pyloric stenosis is suspected. Which prescription would the nurse anticipate having the highest priority in the care of this child?

1.

Administer predigested formula.

2.

Prepare the family for surgery for the child.

3.

Administer omeprazole (Prilosec) before feeding.

4.

Instruct the parents to keep a log of feedings and any reflux present.

2

Infants with projectile vomiting after feeding that are fussy should be suspected of pyloric stenosis. The treatment for this diagnosis is surgery. The other options are treatment measures that may be prescribed for gastroesophageal reflux.

A 2-year-old child with acute diarrhea has been diagnosed with mild dehydration. Which rehydration methods would the nurse expect the health care provider to prescribe?

1.

Increase intake of water with a diet high in carbohydrates.

2.

Consume oral rehydration fluid, advancing to a regular diet.

3.

Begin the BRAT diet (bananas, rice, apples, and toast or tea).

4.

Begin fluid replacement immediately with intravenous fluids.

2

Mild dehydration is usually treated at home and consists of age-appropriate diet along with oral rehydration fluids. The BRAT diet does not provide the rehydration needed in a child who is dehydrated. Water does not provide electrolyte fluid replacement, a need during dehydration. Hospitalization is not required with mild dehydration.

A child admitted to the hospital with a diagnosis of gastroenteritis and dehydration weighs 17 pounds 2 ounces. The parents state that his preadmission weight was 18 pounds 4 ounces. Based on weight alone, what type of dehydration does the nurse expect?

1.

Mild dehydration

2.

Moderate dehydration

3.

Severe dehydration

4.

Acute dehydration

2

Mild dehydration is a weight loss of 3% to 5%; moderate dehydration is 6% to 10%; severe dehydration is greater than 10% weight loss. All types of dehydration are acute situations. The answer can be determined by calculating the percent of weight loss in dehydration. Because the math calculation determines more than a 5% weight loss but less than 10% weight loss, the correct answer is moderate dehydration. By calculating the percent of weight loss, the correct answer can be determined.

The nurse is initiating nasogastric tube feedings in a child. When initiating this procedure the nurse should perform which action?

1.

Microwave the formula.

2.

Place the child in a prone position.

3.

Encourage the child to point the head downward.

4.

Position the child so that the head is slightly hyperflexed.

4

When initiating nasogastric tube feedings a child, he or she should be positioned so that the head is slightly hyperflexed or in a sniffing position with the nose pointed toward the ceiling. The formula should be warmed to room temperature, and a microwave should not be used.

The mother of a child with an umbilical hernia calls the clinic and reports to the nurse that the child has been vomiting and is complaining of pain in the abdominal area. Which instruction to the mother is most appropriate?

1.

Contact the health care provider.

2.

Keep the child on clear liquids.

3.

Apply an ice pack to the abdomen.

4.

Administer acetaminophen (Tylenol).

1

Vomiting, pain, and irreducible mass at the umbilicus are signs of a strangulated hernia. The parents should be instructed to contact the health care provider (HCP) immediately if strangulation is suspected. Options 2, 3, and 4 are incorrect, can cause harm to the child, and delay emergency treatment measures that are required.

A nurse is reviewing the health care provider's documentation in the record of a child admitted with a diagnosis of intussusception. The nurse expects to note that the health care provider has documented which manifestation?

1.

Scleral jaundice

2.

Projectile vomiting

3.

Currant jelly stools

4.

Pale-colored and hard stools

3

In the child with intussusception, bright red blood and mucus are passed through the rectum, resulting in what is commonly described as currant jelly stools. The child classically presents with severe abdominal pain that is crampy and intermittent, causing the child to draw the knees in to the chest. Vomiting may be present, but not projectile. Options 1 and 4 are not manifestations of this disorder.

A nurse is preparing to care for a newborn infant following creation of a colostomy for the treatment of imperforate anus. In the immediate postoperative period, the nurse plans to inspect the stoma and expects to note which finding in the colostomy?

1.

Bleeding

2.

Gray in color

3.

Dark blue in color

4.

Red and edematous

4

A fresh colostomy stoma will be red and edematous, but this will decrease with time. The colostomy site will then be pink, without evidence of abnormal drainage, swelling, or skin breakdown. The colostomy should not be bleeding. A gray or dark blue stoma indicates insufficient circulation and should be reported to the health care provider (HCP) immediately.

The nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which question to the mother will most specifically elicit information regarding this disorder?

1.

"Does your infant have diarrhea?"

2.

"Is your infant constantly vomiting?"

3.

"Does your infant constantly spit up feedings?"

4.

"Does your infant have foul-smelling, ribbon-like stools?"

4

Chronic constipation, beginning in the first month of life and resulting in pellet-like or ribbon stools that are foul-smelling, is a clinical manifestation of Hirschsprung's disease. Delayed passage or absence of meconium stool in the neonatal period is the primary sign. Bowel obstruction, especially in the neonatal period, abdominal pain and distention, and failure to thrive are also clinical manifestations. Options 1, 2, and 3 are not specific clinical manifestations of this disorder.

A nurse is caring for a child who was brought to the clinic complaining of severe abdominal pain and is suspected of having acute appendicitis. The child is lying on the examining table, with the knees pulled up toward the chest. The nurse assists the health care provider with further assessment of the progression of the child's pain, knowing that the health care provider will palpate the abdomen in which location?

1.

Midway between the liver and the gallbladder

2.

Midway between the left iliac crest and the umbilicus

3.

Midway between the left inguinal area and the acetabulum

4.

Midway between the right anterior superior iliac crest and the umbilicus

4

McBurney's point is usually the location of greatest pain in the child with appendicitis. McBurney's point is midway between the right anterior superior iliac crest and the umbilicus. Options 1, 2, and 3 will not appropriately assess the progression of pain in the child with appendicitis.

A nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that the mother understands the instructions when the mother states to include which food in the child's diet?

1.

Corn

2.

Wheat cereal

3.

Rye crackers

4.

Oatmeal biscuits

1

Dietary management is the mainstay of treatment in celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies. These are likely to be lifelong restrictions; although small amounts of grains may be tolerated after the ulcerations have healed.

The nurse is developing a plan of care for an infant being admitted with hypertrophic pyloric stenosis who is scheduled for pyloromyotomy. In the preoperative period, which position should the nurse suggest to document in the plan of care?

1.

In an infant seat placed in the crib

2.

Prone with the head of the bed elevated

3.

Supine with the head at a 90-degree angle

4.

Supine with the head of the bed at a 30-degree angle

2

In the preoperative period, the infant is positioned prone with the head of the bed elevated to reduce the risk of aspiration. Options 1, 3, and 4 are inappropriate positions for preventing this risk.

The nurse is preparing a plan of care for an infant who will be returning from the recovery room following the surgical repair of a cleft lip located on the right side of the lip. On return from the recovery room, the nurse should plan to place the infant in which position?

1.

Prone and flat

2.

Supine and flat

3.

On the left side

4.

On the right side

3

Following cleft lip repair, the infant should be positioned supine or on the side lateral to the repair to prevent the suture line from contacting the bed linens. Immediately after surgery, it is best to place the infant on the left side rather than supine to prevent aspiration if the infant vomits.

The nurse is providing discharge instructions to the mother of a child with herpetic gingivostomatitis. Which response by the mother indicates the need for further teaching?

1.

"I will offer my child soft, bland foods."

2.

"I will encourage my child to drink fluids."

3.

"I will give my child frozen ice pops to assist with fluid intake."

4.

"I will not give my child anything to eat for 2 days to allow the lesions to heal and crust over."

4

Parents need to be reassured that a few days without solid food will not harm the child as long as fluid intake is adequate, but an NPO status is not appropriate. Parents should also be taught to contact the health care provider (HCP) if the child develops signs of dehydration. The child would not be kept NPO; in fact, dehydration is a concern with these children. Small feedings of bland soft foods should be offered to the child. Fluid intake is very important, and the child must be encouraged to drink. Frozen ice pops, non-citrus juices, and flat soft drinks are best.

The nurse is monitoring a child with burns during treatment for burn shock. The nurse understands that which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?

1.

Skin turgor

2.

Neurological assessment

3.

Level of edema at burn site

4.

Quality of peripheral pulses

2.

Sensorium is an accurate guide to determine the adequacy of fluid resuscitation. The burn injury itself does not affect the sensorium, so the child should be alert and oriented. Any alteration in sensorium should be evaluated further. A neurological assessment would determine the level of sensorium in the child. Options 1, 3, and 4 would not provide an accurate assessment of the adequacy of fluid resuscitation.

The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin?

1.

Fine grayish red lines

2.

Purple-colored lesions

3.

Thick, honey-colored crusts

4.

Clusters of fluid-filled vesicles

1.

Scabies is a parasitic skin disorder caused by an infestation of Sarcoptes scabiei (itch mite). Scabies appears as burrows or fine, grayish red, threadlike lines. They may be difficult to see if they are obscured by excoriation and inflammation. Purple-colored lesions may indicate various disorders, including systemic conditions. Thick, honey-colored crusts are characteristic of impetigo or secondary infection in eczema. Clusters of fluid-filled vesicles are seen in herpesvirus infection.

Permethrin (Elimite) is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment?

1.

Apply the lotion to areas of the rash only.

2.

Apply the lotion and leave it on for 6 hours.

3.

Avoid putting clothes on the child over the lotion.

4.

Apply the lotion to cool, dry skin at least 30 minutes after bathing.

4.

Permethrin is massaged thoroughly and gently into all skin surfaces (not just the areas that have the rash) from the head to the soles of the feet. Care should be taken to avoid contact with the eyes. The lotion should not be applied until at least 30 minutes after bathing and should be applied only to cool, dry skin. The lotion should be kept on for 8 to 14 hours, and then the child should be given a bath. The child should be clothed during the 8 to 14 hours of treatment contact time.

The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction?

1.

"It is extremely contagious."

2.

"It is most common in humid weather."

3.

"Lesions most often are located on the arms and chest."

4.

"It might show up in an area of broken skin, such as an insect bite."

3

Impetigo is a contagious bacterial infection of the skin caused by b-hemolytic streptococci or staphylococci, or both. Impetigo is most common during hot, humid summer months. Impetigo may begin in an area of broken skin, such as an insect bite or atopic dermatitis. Impetigo is extremely contagious. Lesions usually are located around the mouth and nose, but may be present on the hands and extremities.

The clinic nurse is reviewing the health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record?

1.

The child is 18 months old.

2.

The child is being bottle-fed.

3.

A sibling is using lindane for the treatment of scabies.

4.

The child has a history of frequent respiratory infections.

1

Lindane is a pediculicide product that may be prescribed to treat scabies. It is contraindicated for children younger than 2 years because they have more permeable skin, and high systemic absorption may occur, placing the children at risk for central nervous system toxicity and seizures. Lindane also is used with caution in children between the ages of 2 and 10 years. Siblings and other household members should be treated simultaneously. Options 2 and 4 are unrelated to the use of lindane. Lindane is not recommended for use by a breast-feeding woman because the medication is secreted into breast milk.

A topical corticosteroid is prescribed by a health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream?

1.

Apply the cream over the entire body.

2.

Apply a thick layer of cream to affected areas only.

3.

Avoid cleansing the area before application of the cream.

4.

Apply a thin layer of cream and rub it into the area thoroughly.

4

Atopic dermatitis is a superficial inflammatory process involving primarily the epidermis. A topical corticosteroid may be prescribed and should be applied sparingly (thin layer) and rubbed into the area thoroughly. The affected area should be cleaned gently before application. A topical corticosteroid should not be applied over extensive areas. Systemic absorption is more likely to occur with extensive application.

The school nurse is conducting pediculosis capitis (head lice) assessments. Which finding indicates a child has a "positive" head check?

1.

Maculopapular lesions behind the ears

2.

Lesions in the scalp that extend to the hairline or neck

3.

White flaky particles throughout the entire scalp region

4.

White sacs attached to the hair shafts in the occipital area

4

Pediculosis capitis is an infestation of the hair and scalp with lice. The nits are visible and attached firmly to the hair shaft near the scalp. The occiput is an area in which nits can be seen. Maculopapular lesions behind the ears or lesions that extend to the hairline or neck are indicative of an infectious process, not pediculosis. White flaky particles are indicative of dandruff.

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply.

1.

Scarring is less severe in a child than in an adult.

2.

A delay in growth may occur after a burn injury.

3.

An immature immune system presents an increased risk of infection for infants and young children.

4.

The lower proportion of body fluid to mass in a child increases the risk of cardiovascular problems.

5.

Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area.

6.

Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

2, 3, 6

Pediatric considerations in the care of a burn victim include the following: Scarring is more severe in a child than in an adult. A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. The higher proportion of body fluid to mass in a child increases the risk of cardiovascular problems. Burns involving more than 10% of total body surface area require some form of fluid resuscitation. Infants and young children are at increased risk for protein and calorie deficiencies because they have smaller muscle mass and less body fat than adults.

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do?

1.

Eat twice the amount normally eaten at lunchtime.

2.

Take half the amount of prescribed insulin on practice days.

3.

Take the prescribed insulin at noontime rather than in the morning.

4.

Eat a small box of raisins or drink a cup of orange juice before soccer practice.

4

Hypoglycemia is a blood glucose level less than 70 mg/dL and results from too much insulin, not enough food, or excessive activity. An extra snack of 15 to 30 g of carbohydrates eaten before activities such as soccer practice would prevent hypoglycemia. A small box of raisins or a cup of orange juice provides 15 to 30 g of carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be doubled.

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?

1.

Hold the next dose of insulin.

2.

Come to the clinic immediately.

3.

Encourage the child to drink liquids.

4.

Administer an additional dose of regular insulin.

3

When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses should not be adjusted or changed.

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?

1.

Obtains a weight

2.

Takes the temperature

3.

Takes the blood pressure

4.

Checks the amount of urine output

4

In hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hour, potassium chloride should not be administered. Although options 1, 2, and 3 are appropriate assessments for a child with dehydration, these assessments are not related specifically to the IV administration of potassium chloride.

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?

1.

Sweating and tremors

2.

Hunger and hypertension

3.

Cold, clammy skin and irritability

4.

Fruity breath odor and decreasing level of consciousness

4

Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic ketoacidosis. Hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. Cold clammy skin, irritability, sweating, and tremors all are signs of hypoglycemia.

A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1 mg/dL. The nurse reviews this result and makes which interpretation?

1.

It is positive.

2.

It is negative.

3.

It is inconclusive.

4.

It requires rescreening at age 6 weeks.

2

Phenylketonuria is a genetic (autosomal recessive) disorder that results in central nervous system damage from toxic levels of phenylalanine (an essential amino acid) in the blood. It is characterized by blood phenylalanine levels greater than 20 mg/dL (normal level is 1.2 to 3.4 mg/dL in newborns and 0.8 to 1.8 mg/dL thereafter). A result of 1 mg/dL is a negative test result.

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?

1.

Potassium infusion

2.

NPH insulin infusion

3.

5% dextrose infusion

4.

Normal saline infusion

4

Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Rehydration is the initial step in resolving diabetic ketoacidosis. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose level decreases to an acceptable level. Intravenously administered potassium may be required, depending on the potassium level, but would not be part of the initial treatment.

The nurse has just administered ibuprofen (Motrin) to a child with a temperature of 38.8° C (102° F). The nurse should also take which action?

1.

Withhold oral fluids for 8 hours.

2.

Sponge the child with cold water.

3.

Plan to administer salicylate (aspirin) in 4 hours.

4.

Remove excess clothing and blankets from the child.

4

After administering ibuprofen, excess clothing and blankets should be removed. The child can be sponged with tepid water, but not cold water because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin is not administered to a child with fever because of the risk of Reye's syndrome. Fluids should be encouraged to prevent dehydration, so oral fluids should not be withheld.

A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted?

1.

The child has no tears.

2.

Urine specific gravity is 1.030.

3.

Urine output is less than 1 mL/kg/hour.

4.

Capillary refill is less than 2 seconds.

4

ndicators that fluid volume deficit is resolving would be capillary refill less than 2 seconds, specific gravity of 1.002 to 1.025, urine output of at least 1 mL/kg/hour, and adequate tear production. A capillary refill time less than 2 seconds is the only indicator that the child is improving. Urine output of less than 1 mL/kg/hour, a specific gravity of 1.030, and no tears would indicate that the deficit is not resolving.

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply.

1.

Administer regular insulin.

2.

Encourage the child to ambulate.

3.

Give the child a teaspoon of honey.

4.

Provide electrolyte replacement therapy intravenously.

5.

Wait 30 minutes and confirm the blood glucose reading.

6.

Prepare to administer glucagon subcutaneously if unconsciousness occurs.

3, 6

Hypoglycemia is defined as a blood glucose level less than 70 mg/dL. Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If possible, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; rapid-releasing glucose is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums, and the blood glucose level is retested in 15 minutes; if the reading remains low, additional glucose is administered. If the child remains unconscious, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. Encouraging the child to ambulate and administering regular insulin would result in a lowered blood glucose level. Providing electrolyte replacement therapy intravenously is an intervention to treat diabetic ketoacidosis. Waiting 30 minutes to confirm the blood glucose level delays necessary intervention.

The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis?

1.

Hypotension

2.

Brown-colored urine

3.

Low urinary specific gravity

4.

Low blood urea nitrogen level

2

Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria, resulting in dark, smoky, cola-colored or brown-colored urine, is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis.

The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome?

1.

Hypertension

2.

Generalized edema

3.

Increased urinary output

4.

Frank, bright red blood in the urine

2

Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema. Other manifestations include weight gain; periorbital and facial edema that is most prominent in the morning; leg, ankle, labial, or scrotal edema; decreased urine output and urine that is dark and frothy; abdominal swelling; and blood pressure that is normal or slightly decreased.

The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure?

1.

Restrict fluids as prescribed.

2.

Care for the arteriovenous fistula.

3.

Encourage foods high in potassium.

4.

Administer analgesics as prescribed.

1

Hemolytic-uremic syndrome is thought to be associated with bacterial toxins, chemicals, and viruses that result in acute kidney injury in children. Clinical manifestations of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with hemolytic-uremic syndrome undergoing peritoneal dialysis because of anuria would be on fluid restriction. Pain is not associated with hemolytic-uremic syndrome, and potassium would be restricted, not encouraged, if the child is anuric. Peritoneal dialysis does not require an arteriovenous fistula (only hemodialysis).

A 7-year-old child is seen in a clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The nurse should provide which information to the parents?

1.

Primary nocturnal enuresis does not respond to treatment.

2.

Primary nocturnal enuresis is caused by a psychiatric problem.

3.

Primary nocturnal enuresis requires surgical intervention to improve the problem.

4.

Most children outgrow the bed-wetting problem without therapeutic intervention.

4

Primary nocturnal enuresis occurs in a child who has never been dry at night for extended periods. The condition is common in children, and most children eventually outgrow bed-wetting without therapeutic intervention. The child is unable to sense a full bladder and does not awaken to void. The child may have delayed maturation of the central nervous system. The condition is not caused by a psychiatric problem.

The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicate that further teaching is necessary?

1.

"I'll check his temperature."

2.

"I'll give him medication so he'll be comfortable."

3.

"I'll check his voiding to be sure there's no problem."

4.

"I'll let him decide when to return to his play activities."

4

Cryptorchidism is a condition in which one or both testes fail to descend through the inguinal canal into the scrotal sac. Surgical correction may be necessary. All vigorous activities should be restricted for 2 weeks after surgery to promote healing and prevent injury. This prevents dislodging of the suture, which is internal. Normally, 2-year-olds want to be active; allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parents should be taught to monitor the temperature, provide analgesics as needed, and monitor the urine output.

The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan?

1.

"Caution should be used when straddling the infant on a hip."

2.

"Vital signs should be taken daily to check for bladder infection."

3.

"Catheterization will be necessary when the infant does not void."

4.

"Circumcision has been delayed to save tissue for surgical repair."

4

Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. Options 1, 2, and 3 are unrelated to this disorder.

The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention?

1.

Cover the bladder with petroleum jelly gauze.

2.

Cover the bladder with a nonadhering plastic wrap.

3.

Apply sterile distilled water dressings over the bladder mucosa.

4.

Keep the bladder tissue dry by covering it with dry sterile gauze.

2

In bladder exstrophy, the bladder is exposed and external to the body. In this disorder, one must take care to protect the exposed bladder tissue from drying, while allowing the drainage of urine. This is accomplished best by covering the bladder with a nonadhering plastic wrap. The use of petroleum jelly gauze should be avoided because this type of dressing can dry out, adhere to the mucosa, and damage the delicate tissue when removed. Dry sterile dressings and dressings soaked in solutions (that can dry out) also damage the mucosa when removed.

The nurse understands that which information collected during the assessment of a child recently diagnosed with glomerulonephritis is most often associated with the diagnosis?

1.

Child fell off a bike onto the handlebars

2.

Nausea and vomiting for the last 24 hours

3.

Urticaria and itching for 1 week before diagnosis

4.

Streptococcal throat infection 2 weeks before diagnosis

4

Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Group A b-hemolytic streptococcal infection is a cause of glomerulonephritis. Often, a child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The assessment data in options 1, 2, and 3 are unrelated to a diagnosis of glomerulonephritis.

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note?

1.

Hematuria

2.

Proteinuria

3.

Bacteriuria

4.

Glucosuria

3

Epispadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. The urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic facilitates entry of bacteria into the urine. Options 1, 2, and 4 are not characteristically noted in this condition.

The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply.

1.

Pallor

2.

Edema

3.

Anorexia

4.

Proteinuria

5.

Weight loss

6.

Decreased serum lipids

1, 2, 3, 4

Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The child gains weight.

A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?

1.

Administer an analgesic.

2.

Release the skin traction.

3.

Apply ice to the extremity.

4.

Notify the health care provider (HCP).

4

An absent pulse to an extremity of the affected limb after a bone fracture could mean that the child is developing or experiencing compartment syndrome. This is an emergency situation, and the HCP should be notified immediately. Administering analgesics would not improve circulation. The skin traction should not be released without an HCP's prescription. Applying ice to an extremity with absent perfusion is incorrect. Ice may be prescribed when perfusion is adequate to decrease swelling.

A child is placed in skeletal traction for treatment of a fractured femur. The nurse develops a plan of care and includes which intervention?

1.

Ensure that all ropes are outside the pulleys.

2.

Ensure that the weights are resting lightly on the floor.

3.

Restrict diversional and play activities until the child is out of traction.

4.

Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied.

4

When a child is in traction, the nurse would check the HCP's prescription to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as prescribed, ensure that the weights hang freely, check the ropes for fraying and ensure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms of immobilization. The nurse would provide therapeutic and diversional play activities for the child.

A 4-year-old child sustains a fall at home and after an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction?

1.

"The cast may feel warm as the cast dries."

2.

"I can use lotion or powder around the cast edges to relieve itching."

3.

"A small amount of white shoe polish can touch up a soiled white cast."

4.

"If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast."

2

eaching about cast care is essential to prevent complications from the cast. The parents need to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation. Options 1, 3, and 4 are appropriate statements.

The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse should make which response?

1.

"Avoid all exercise during painful periods."

2.

"Range-of-motion exercises must be performed every day."

3.

"Have the child perform simple isometric exercises during this time."

4.

"Administer additional pain medication before performing range-of-motion exercises."

3

Juvenile idiopathic arthritis is an autoimmune inflammatory disease affecting the joints and other tissues, such as articular cartilage. During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain. Although resting the extremity is appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important. These exercises do not involve joint movement.

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action?

1.

Administer an antiemetic.

2.

Increase the intravenous fluids.

3.

Place the child in a Sims's position.

4.

Notify the health care provider (HCP).

4

Scoliosis is a three-dimensional spinal deformity that usually involves lateral curvature, spinal rotation resulting in rib asymmetry, and hypokyphosis of the thorax. A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child's abdominal contents, resulting from lengthening of the child's body. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or children who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Options 1, 2, and 3 are incorrect.

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction?

1.

"I will encourage my child to perform prescribed exercises."

2.

"I will have my child wear soft fabric clothing under the brace."

3.

"I should apply lotion under the brace to prevent skin breakdown."

4.

"I should avoid the use of powder because it will cake under the brace."

3

A brace may be prescribed to treat scoliosis. Braces are not curative, but may slow the progression of the curvature to allow skeletal growth and maturity. The use of lotions or powders under a brace should be avoided because they can become sticky and cake under the brace, causing irritation. Options 1, 2, and 4 are appropriate interventions in the care of a child with a brace.

The nurse is assisting a health care provider (HCP) examining an infant with developmental dysplasia of the hip perform an Ortolani maneuver. The nurse understands that this maneuver is performed for which purpose?

1.

To assess for hip instability

2.

To assess for movement of the hips

3.

To push the femoral head out of the acetabulum

4.

To ensure that hyperextension and full range of motion exist

1

In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Ortolani's maneuver is a test to assess for hip instability. The examiner abducts the thigh and applies gentle pressure forward over the greater trochanter. A "clicking" sensation indicates a dislocated femoral head moving into the acetabulum. This maneuver does not assess for hip movement or ensure that hyperextension and full range of motion exist. Pushing the femoral head out of the acetabulum is not the purpose of Ortolani's maneuver.

A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition?

1.

Limited range of motion in the affected hip

2.

An apparent lengthened femur on the affected side

3.

Asymmetrical adduction of the affected hip when the infant is placed supine with the knees and hips flexed

4.

Symmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table

1

n developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Asymmetrical and restricted abduction of the affected hip, when the child is placed supine with the knees and hips flexed, would be an assessment finding in developmental dysplasia of the hip in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity.

Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder?

1.

"Treatment needs to be started as soon as possible."

2.

"I realize my infant will require follow-up care until fully grown."

3.

"I need to bring my infant back to the clinic in 1 month for a new cast."

4.

"I need to come to the clinic every week with my infant for the casting."

3

Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply.

1.

Use the fingertips to lift the cast while it is drying.

2.

Keep small toys and sharp objects away from the cast.

3.

Use a padded ruler or another padded object to scratch the skin under the cast if it itches.

4.

Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold.

5.

Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.

6.

Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity.

2, 5, 6

While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified.

The clinic nurse provides instructions to the parents of an infant with developmental dysplasia of the hip (DDH), regarding care of the Pavlik harness. Which instruction should the nurse include?

1.

The harness should be worn 6 hours a day.

2.

The infant should not be moved when out of the harness.

3.

The harness should be removed to check the skin and for bathing.

4.

The harness must be removed for diaper changes and feeding.

3

The Pavlik harness is used to treat developmental dysplasia of the hip. It provides support and stability to the hips. The Pavlik harness should be worn 16 to 23 hours a day and should be removed only to check the skin and for bathing. The infant may be moved when out of the harness, but the hips and buttocks should be supported carefully. The harness does not need to be removed for diaper changes or feedings.

The nurse is developing a plan of care for a 10-year-old girl with an exacerbation of eczema. Which problem should be addressed in the care for this child?

1.

The client is at risk for infection related to viral lesions.

2.

The client is at risk for infection related to scratching of pruritic lesions.

3.

The client may have poor nutritional intake related to throat edema and mouth ulcers.

4.

The client may have a negative body image related to the presence of thick, white crusty plaques over the elbows and knees.

2

Eczema is a superficial inflammatory process involving primarily the epidermis. The major goals of management are to relieve pruritus, lubricate the skin, reduce inflammation, and prevent and control secondary infection. Secondary infection can occur when areas affected by eczema are scratched as a result of the itching because open skin is a portal of entry for pathogens. The lesions are not viral, and they do not present as thick, white crusty plaques. They appear as red and scaly lesions that can weep, ooze, and crust. They commonly occur in the antecubital and popliteal areas. Throat edema and mouth ulcers are not characteristics of this disorder.

The nurse is developing a plan of care for a 6-year-old child diagnosed with acute glomerulonephritis. The nurse should include which priority intervention in the plan of care?

1.

Encourage limited activity and provide safety measures.

2.

Catheterize the child to monitor intake and output strictly.

3.

Encourage the child to talk about feelings related to illness.

4.

Encourage classmates to visit and to keep the child informed of school events.

1

Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. In glomerulonephritis, activity is limited, and most children, because of fatigue, voluntarily restrict their activities during the active phase of the disease. Catheterization may cause infection. A 6-year-old should not be encouraged to talk about feelings and may not understand the illness. The child should be allowed to express feelings in other ways, such as play. Visitors should be limited to allow for adequate rest.