NUR 235 Exam #4 Questions

Which anatomical differences make caring for children with respiratory disorders different than caring for adults?

- shorter airway (4 mm in diameter compared to 20 mm)
- flexible larynx is susceptible to spasms
- flexible trachea is susceptible to collapse
- decreased amount of alveoli
- underdeveloped lungs
- infants are obligatory nose breathers (until 4 weeks)

T or F? An infant's metabolic rate is almost twice as high as an adult's metabolic rate.

True. This creates a higher oxygen demand.

When should oral feedings be discontinued for infants?

If the infant is in respiratory distress. IV feedings & fluids should be initiated until oral intake is acceptable.

What is the ideal position for optimal chest expansion?

supine with HOB elevated 45 degrees

What are the S/S of respiratory distress?

- tachypnea & tachycardia
- intercostal retractions
- paradoxical breathing
- restlessness
- grunting
- nasal flaring
- diaphoresis (except in neonates)
- clubbing of fingertips
- acrocyanosis (normal in infants up to 48 hours)

Methods used to increase oxygenation and improve & monitor respiratory functioning include...

- pulse oximetry
- oxygen therapy
- nebulized aerosol
- MDI or dry powder inhaler
- chest physiotherapy
- suctioning (NT, OT, ET, tracheal)
- artificial airway insertion

Nursing management for nebulized aerosol therapy includes...

- determine which type of device should be used (i.e. mouthpiece, mask, or blow-by)
- assess VS and O2 saturation prior to & after administration
- monitor for bronchospasms
- *teach child to take slow, deep breaths by mouth*

Describe the proper way to use a metered-dose inhaler.

- shake the inhaler 5-6 times
- attach the spacer
- take a deep breath and exhale
- use the open-mouth or closed-mouth method
- press the inhaler and take a *slow, deep breath*
- hold breath for 5-10 seconds
- wait at least 1 minute between puffs if an additional puff is needed
- *rinse mouth out after use*

Describe the proper way to use a dry powder inhaler.

- *DO NOT SHAKE the device*
- exhale completely
- place device between the lips and take a *fast, deep breath*
- hold breath for 5-10 seconds
- wait prescribed length of time if an additional puff is needed
- rinse the inhaler, cap, and spacer once daily

When should chest physiotherapy be performed in relation to mealtimes to prevent GI upset?

- at least 1 hour before eating
- at least 2 hours after eating

Which oxygen delivery device provides the most accurate control of oxygen administration?

Venturi mask

How long should each suctioning pass be performed on infants and children?

- infants: less than 5 seconds
- children: less than 10 seconds

T or F? Suctioning is performed as you insert the catheter.

False. You should suction as you withdraw the catheter, rolling the catheter between the fingers.

Treatment options for allergic rhinitis include...

- *nasal corticosteroids (i.e. fluticasone)*
- 1st & 2nd generation antihistamines (based on age)
- beta adrenergic decongestants (i.e. pseudoephedrine)
- mast cell stabilizer (i.e. cromolyn)
- leukotriene modifiers (i.e. montelukast)
- anticholinergics (i.e. ipratropium)

What are the S/S of otitis media?

- *earache & tugging at the ears*
- *bulging, red, or opaque eardrum*
- *purulent, foul-smelling drainage*
- nonspecific S/S of infection (i.e. fever, N/V, crying, anorexia)

Methods used to prevent ear infections can include...

- breastfeeding
- discontinue pacifier after 6 months
- feed children sitting straight up
- avoid smoking in the house
- immunizations (i.e. PCV 13 @ 2, 4, 6 months & flu vaccine beginning @ 6 months)

What are the S/S of otitis externa?

- *tenderness of the tragus and/or pinna*
- edematous auricle
- purulent drainage

What is the main difference between the S/S of nasopharyngitis and pharyngitis?

With pharyngitis, there is no sneezing or irritation of the nose.

Which medications are not recommended for nasopharyngitis?

- antihistamines
- antibiotics

What are relative indications for a tonsillectomy?

- three or more episodes of tonsillitis per year
- chronic tonsillitis
- streptococcus carrier

What are absolute indications for a tonsillectomy?

- recurrent peritonsillar abscesses
- airway obstruction

Indications for an adenoidectomy include...

- hypertrophied adenoids
- obstruction of the nasal passages
- recurrent adenoiditis or sinusitis
- sleep apnea
- mouth breathing

Nursing management post-operative for a tonsillectomy includes...

- *check for evidence of bleeding* (i.e. frequent swallowing, restlessness, bright red emesis, tachycardia, pallor)
- place in side-lying or prone position immediately post-op to facilitate drainage
- DO NOT give red or purple popsicles
- DO NOT use a tongue depressor for assessment
- provide an ice collar
- administer analgesics & antiemetics

Patient & family teaching for a tonsillectomy includes...

- *no using a straw*
- *no coughing, sneezing, or blowing nose*
- no milk products
- no hot, spicy, or acidic foods for up to two weeks
- may progress to soft diet post-op day 2

What are the S/S of bacterial tracheitis?

- *stridor at rest*
- hypoxia
- increased work of breathing
- fever

When is one considered protected from influenza after receiving the vaccine?

2 weeks

Types of antivirals given to reduce the effects of influenza and shorten length of the illness include...

- *oseltamivir (Tamiflu; given to children >1 year old & should begin within 48 hours from symptom onset)*
- zanamivir
- rimantadine
- amantadine

What are the S/S of laryngomalacia?

- *inspiratory stridor in the first 2 weeks of life that increases after feedings, emotional distress, or laying down flat*
- *crowing noise with respirations*
- difficulty feeding
- mild tachypnea
- suprasternal retractions
- normal VS and O2 saturation

What are the four types of croup syndrome?

- laryngitis (least serious)
- laryngotracheobronchitis (most common)
- laryngotracheitis (serious)
- epiglottitis (most serious)

What are the S/S of epiglottitis? (remember AIR RAID)

- A: airway closed
- I: increased pulse
- R: restlessness
- R: retractions
- A: anxiety increased
- *I: inspiratory stridor*
- *D: drooling*

What are the S/S of epiglottitis? (remember ADD AIR NURSE)

- A: abnormal positioning (tripod)
- D: drooling
- D: difficulty speaking
- A: apprehension
- I: increased temperature (high)
- R: rapid onset
- N: nasal flaring
- U: using accessory muscles
- R: retractions
- S: stridor (inspiratory)
- E: enlarged epiglottis

Which activities can cause laryngospasms with epiglottitis and should be avoided at all costs?

- assessing the oral cavity
- taking an oral temperature
- emotional distress (crying)

What are the S/S of acute spasmodic laryngitis?

- *nighttime barky, seal-like cough*
- *nighttime episodes of laryngeal obstruction*
- pain with speaking
- loss of voice
- weak or faint cry
- afebrile
- stridor

Treatment options for croup syndrome include...

- provide cool, moist humidification
- administer humidified oxygen
- promote rest
- ensure adequate hydration
- *administer racemic epinephrine*
- *administer corticosteroids*
- *administer antibiotics*

What are the S/S of laryngotracheobronchitis?

- *history of upper respiratory infection*
- *characteristic croupy cough (bark-like, crowing cough)*
- expiratory wheezing or inspiratory stridor
- varying degrees of respiratory distress
- hoarseness
- restlessness
- fever

What is often the first sign of respiratory distress in children?

restlessness

Why are 1st generation antihistamines not considered a first line treatment option for upper respiratory conditions in children and should generally be avoided in treatment?

They produce sedative effects

What are the S/S of bronchitis?

- *persistent, dry, hacking cough*
- wheezing (from ages 12-36 months)
- resolution in 5-10 days

Examples of 2nd generation antihistamines include... (include age that administration can begin)

- cetirizine (6 months and older)
- fexofenadine (6 months and older)
- loratadine (2 years and older)

What are the S/S of bronchiolitis?

- *initially: S/S of viral URI (i.e. rhinorrhea, sneezing)*
- *wheezing and/or crackles*
- *dry, nonproductive cough*
- low grade fever
- possible ear or eye infection
- tachypnea
- increased work of breathing

Treatment options for bronchiolitis include...

- supplemental oxygen
- respiratory treatments
- IV fluid administration
- suctioning (as needed)
- *bronchodilators not recommended*
- *corticosteroid use controversial*

Medications used in the PREVENTION of RSV include...

- RespiGam (immune globulin)
- IM palivizumab (monoclonal antibody)

Types of pneumonia include...

- viral
- bacterial
- fungal
- mycoplasma
- aspiration

What are the S/S of pneumonia?

- *recent history of URI*
- *high fever*
- chills
- chest pain
- productive or unproductive cough
- tachypnea
- dehydration
- adventitious breath sounds
- *S/S of respiratory distress*

Diagnostic tests for pneumonia include...

- *blood cultures*
- sputum gram stain
- chest X-ray
- lung aspiration & biopsy

The PCV13 vaccine (used in prevention of pneumonia) is administered when?

- 2, 4, & 6 months
- 12-15 months

The DTaP vaccine (used in prevention of pertussis, diphtheria, and tetanus)? is administered when?

- 2, 4, & 6 months
- 15-18 months
- 7-8 years (Tdap)

What are the S/S of pertussis?

- *initially presents as URI*
- *intense coughing attacks typically occurring at night*
- *characteristic crowing (whoop) sound after coughing episode*
- absence of classic whoop sound (in infants)
- presence of apnea (in infants)
- chronic cough (lasting up to 10 weeks)

What are the S/S of tuberculosis?

- dry, persistent cough
- weight loss
- anorexia
- fatigue
- night sweats

Which four drugs are given in combination to treat active tuberculosis?

- *isoniazid*
- *rifampin*
- ethambutol
- streptomycin

What are the S/S of obstructive sleep apnea?

- observed cessation of breathing
- snoring
- mouth breathing
- daytime neurobehavioral problems
- enuresis

Treatment options for ARDS include...

- *administration of surfactant*
- mechanical ventilation
- ECMO
- nitric oxide administration

If asthmatic symptoms do not resolve in ______ minutes following asthma treatment, immediate medical attention should be sought.

30

Long term asthma medications used for maintenance include...

- inhaled corticosteroids (i.e. budesonide, fluticasone)
- mast cell stabilizers (i.e. cromolyn)
- long-acting B2 agonists (i.e. salmeterol, formoterol)
- methylxanthines (i.e. theophylline)
- leukotriene modifiers (i.e. montelukast, zafirlukast)

Short term asthma medications used as a rescue method include...

- *short-acting B2 agonists (i.e. albuterol, terbutaline)*
- anticholinergics (i.e. atropine, ipratropium)
- corticosteroids (i.e. prednisone, methylprednisolone)

What are the S/S of cystic fibrosis?

- history of recurrent respiratory infections
- *increase in amount and viscosity of secretions*
- *salty taste on skin*
- *voracious appetite with weight loss*
- crackles, wheezes, or diminished breath sounds
- digital clubbing
- barrel chest
- protruding abdomen, thin extremities
- malabsorption
- large, bulky stools
- infertility issues
- chronic pain (in older children)

Treatment options for cystic fibrosis include...

- *chest physiotherapy*
- aerosolized agents (i.e. albuterol, dornase alfa)
- antibiotics (for acute & chronic infections)
- anti-inflammatory agents
- vitamins A, D, E, K (should be taken every day)
- high-protein diet
- *pancreatic enzymes (pancrelipase (Creon))*
- *dornase alfa (Pulmozyme)*

Diagnostic tests for cystic fibrosis include...

- *sweat chloride test*
- DNA testing
- chest & abdominal X-ray
- stool analysis
- duodenal analysis

The kidneys produce these three hormones...

- erythropoietin
- renin
- active form of vitamin D

Treatment options for enuresis include...

- *desmopressin acetate* (antidiuretic hormone)
- *imipramine hydrochloride* (TCA)
- *oxybutynin chloride* (anticholinergic)
- conditioning therapy
- Kegel & pelvic exercises
- retention control measures (i.e. consuming a large amount of fluid to stretch the bladder)

Patient and family teaching for the management of enuresis should include...

- void prior to bedtime
- restrict fluids 2 hours before bedtime
- avoid caffeinated or carbonated drinks
- use positive reinforcement
- have the child change the bed linens & clothing following an incident
- wake the child at scheduled intervals during the night to void
- administer prescribed medications

What are the S/S of vesicoureteral reflux?

- frequent UTIs
- suprapubic pain
- urinary incontinence
- family history of VUR
- enlarged bladder

If a patient with an inguinal hernia experiences any of these S/S, immediate medical attention should be provided...

- general "unwell" feeling
- pain in the groin area
- N/V
- bloating, fullness of the abdomen
- fever

What are the S/S of a Wilms tumor?

- prominent mass in the abdomen or waistband area
- may or may not have pain present
- hypertension
- fever
- hematuria
- non-specific cancer symptoms (i.e. fatigue, weight loss)
- respiratory dysfunction (indicating metastasis to the lungs)

What are the S/S of nephrotic syndrome?

- *massive proteinuria* (>50 mg/kg/day in urinalysis)
- *foamy urine*
- *weight gain*
- *edema* (around eyes, scrotal & sacral, ascites, pretibial)
- *hypertension*
- anorexia
- fatigue

Lab values associated with nephrotic syndrome include...

- *proteinuria*
- decreased serum protein
- decreased serum albumin
- decreased serum calcium
- increased cholesterol
- increased ESR
- possible increased serum sodium

Treatment options for nephrotic syndrome include...

- high dose corticosteroid therapy
- diuretic therapy
- IV albumin infusion
- low sodium, high potassium diet
- possible fluid restriction (for severe cases)

Nursing management for nephrotic syndrome includes...

- *monitor VS, especially BP*
- *strict I&O*
- monitor electrolyte values (especially K+)
- monitor abdominal girth
- encourage ambulation
- cluster care & provide rest periods
- monitor and prevent infection (R/T corticosteroid administration)

What are the S/S of acute glomerulonephritis?

- *painless hematuria* (may be tea-colored or bright red)
- *generalized body edema*
- *oliguria*
- *proteinuria*
- *N/V*
- *encephalopathy*
- hypertension
- irritability
- lethargy
- anorexia
- low grade fever

Treatment options for acute glomerulonephritis include...

- antibiotic therapy (to eradicate the offending organism)
- antihypertensive drugs
- diuretic therapy
- NAS diet
- possible fluid restriction
- correction of electrolyte imbalances

What are the S/S of hemolytic uremic syndrome?

- *main triad of symptoms* (hemolytic anemia, thrombocytopenia, & acute kidney injury)
- *bruising, purpura, or rectal bleeding*
- *hematochezia*
- pallor
- hallucinations
- stupor, lethargy
- hypertension

Treatment options for hemolytic uremic syndrome include...

- fluid replacement
- antihypertensive drugs
- blood transfusion
- possible dialysis
- *no anti-motility drugs*
- *avoid undercooked, unwashed, & unpasteurized foods*

What are the S/S of acute kidney injury?

- *initial oliguria or anuria followed by a period of abrupt diuresis*
- *electrolyte imbalance* (hyperkalemia, hyponatremia)
- edema
- change in LOC
- seizures
- cardiac arrhythmia
- tachypnea

Treatment options for acute kidney injury include...

- *treat underlying cause*
- IV fluid replacement with isotonic fluid
- renal replacement therapy (i.e. hemodialysis)
- seizure management
- antihypertensive drugs
- diuretic therapy
- correction of metabolic acidosis
- correction of electrolyte imbalance

Bowel sounds are considered absent (paralytic ileus) if you listen for longer than ______ minutes in each quadrant and do not hear any.

5

When should iron-fortified foods be introduced? When should vitamin D supplements be introduced?

- iron: 4-6 months
- vitamin D: first few days of life

Why are infants at a greater risk for fluid imbalance than children and adults?

Half of their birth weight is water and they experience a higher insensible loss.

Describe the weight loss experienced with each level of dehydration.

- mild: 3-5%
- moderate: 6-9%
- severe: >10%

What are the S/S of mild dehydration?

- *capillary refill >2 seconds*
- *possible slight thirst*
- blood pressure, pulse, behavior, mucous membranes, and anterior fontanel within expected findings

What are the S/S of moderate dehydration?

- capillary refill between 2-4 seconds
- possible thirst and irritability
- slight tachycardia & tachypnea
- normal to orthostatic blood pressure
- dry mucous membranes, decreased tears & skin turgor
- normal to sunken anterior fontanel

When does the anterior fontanel close?

between 12-18 months

What are the S/S of severe dehydration?

- capillary refill >4 seconds
- extreme thirst
- tachycardia & hyperpnea
- orthostatic blood pressure
- very dry mucus membranes & tented skin
- no tearing, sunken eyeballs
- sunken anterior fontanel
- oliguria or anuria

Describe normal creatinine levels for infants vs. older children.

- infants: 0.2-0.4
- child: 0.3-0.7
- older children: 0.6-1.2

What is fluid replacement level for a newborn (0-72 hours)?

60-100 mL/kg/day

What is fluid replacement for children between 0-10 kg?

100 mL/kg/day

What is fluid replacement for children between 11-20 kg?

1000 mL + 50 mL/kg for every kg over 10 kg

What is fluid replacement for children over 20 kg?

1500 mL + 20 mL/kg for every kg over 20 kg

Describe methods used for rehydration in dehydrated children.

- *attempt oral rehydration first for mild & moderate cases* (even if NG tube is required)
- *no caffeinated or carbonated beverages, no juice*
- provide frequent, small amounts
- advance diet slowly
- *administer parenteral fluid therapy as prescribed* (for severe dehydration or if a child experiences continued vomiting)

For oral rehydration, Pedialyte, rather than water, should be provided for children under _______ months of age.

4

What are the S/S of Hirschsprung's disease?

- *failure to pass meconium in the first 24 hours*
- *constipation from birth*
- *ribbon-like or watery stools*
- poor weight gain
- protuberant abdomen
- vomiting

Treatment options for Hirschsprung's disease includes...

- *surgical removal of aganglionic section of bowel*
- temporary colostomy
- isotonic enemas
- high protein, high calorie, low fiber diet
- administer antibiotics (if enterocolitis develops)

Treatment options for GERD include...

- small, frequent meals
- thicken infants formula
- avoid foods that cause reflux
- elevate HOB following meals
- avoid exposure to smoke
- burp infants frequently
- administer PPI or H2 receptor antagonist
- Nissen fundoplication

Pre-operative nursing management for a cleft lip includes...

- assess ability to suck
- feed in upright position
- encourage breast feeding or a wide-based nipple for bottles
- squeeze infant's cheeks together during feeding
- burp infant frequently
- may require specialized bottle or gavage feeding (for palate involvement)

Post-operative nursing management for a cleft lip repair includes...

- maintain patent airway
- place in side-lying position or supine & upright
- apply restraints to maintain integrity of repair site
- resume feedings as tolerated
- use water or diluted hydrogen peroxide to clean incision site
- gently suction secretions
- prevent crying
- rinse mouth after feedings

What are the S/S of tracheoesophageal fistula (TEF)?

- *overabundance of secretions* (causing excessive drooling & mucus in nasopharynx)
- *cyanosis with feeding*
- *choking with feeding*
- resistance with passage of a feeding tube

Postoperative nursing management of tracheoesophageal fistula surgery includes...

- *monitor for pneumonia & aspiration*
- perform frequent suctioning
- elevate HOB 30 to 45 degrees
- perform chest tube care
- administer PPIs
- tube feedings 2-3 days post surgery
- oral feedings 5-7 days post surgery (if no leaks present)

What are the S/S of hypertrophic pyloric stenosis?

- *vomiting occurring after a feeding that progresses to projectile vomiting as the condition worsens*
- *peristaltic wave that moves from L to R when lying supine*
- constant hunger
- poor weight gain
- dehydration

What are the S/S of intussusception?

- *sudden, severe abdominal pain*
- *sausage shaped abdominal mass*
- *stools mixed with blood and mucus (currant jelly-like)*
- tender, distended abdomen
- vomiting
- fever

What are the S/S of celiac disease?

- vitamin B12 & iron deficiencies
- delayed growth & development
- foul-smelling diarrhea
- vomiting
- weight loss
- dental enamel defects
- dermatitis herpetiformis (blistering, pruritic skin rash)

Sudden pain resolution with appendicitis may indicate what?

appendix rupture, possibly leading to peritonitis