Ricci Chapter 42 - Test Bank - 4th Edition

1. The nurse is teaching the mother of a 5-year-old boy with a history of

impaction how to administer enemas at home. Which response from the mother

indicates a need for further teaching?

A) "I should position him on his abdomen with knees bent."

B) "He will require 250 to 500 mL of enema solution."

C) "I should wash my hands and then wear gloves."

D) "He should retain the solution for 5 to 10 minutes."

Ans: A

Feedback:

A 5-year-old child should lie on his left side with his right leg flexed toward the

chest. An infant or toddler is positioned on his abdomen. Using 250 to 500 mL of

solution, washing hands and wearing gloves, and retaining the solution for 5 to 10

minutes are appropriate responses.

2. The nurse is taking a health history of an 11-year-old girl with recurrent

abdominal pain. Which response would lead the nurse to suspect irritable bowel

syndrome?

A) "I always feel better after I have a bowel movement."

B) "I don't take any medicine right now."

C) "The pain comes and goes."

D) "The pain doesn't wake me up in the middle of the night."

Ans: A

Feedback:

In cases of irritable bowel syndrome, the pain may be relieved by defecation. Use of

medications and pain that comes and goes or wakes the person up in the middle of

the night are all relevant findings pertinent to recurrent abdominal pain.

3. The nurse is caring for a 3-year-old girl with short bowel syndrome as a

result of trauma to the small intestine. The girl's mother is extremely anxious and

tells the nurse she is afraid she will never learn how to care for her daughter at

home. How should the nurse respond?

A) "I will help you become an expert on your daughter's care."

B) "You must learn how to care for your daughter at home."

C) "You really need the support of your husband."

D) "There is a lot to learn and you need a positive attitude."

Ans: A

Feedback:

The nurse needs to empower families to become the experts on their children's

needs and conditions via education and participation in care. The most positive

approach in this case is to let the mother know the nurse will support her and help

her become an expert on her daughter's care. Telling the mother that she must

learn how to care for her daughter or that she must have a positive attitude is not

helpful. Telling her that she needs the support of her husband is irrelevant and

unhelpful.

4. The nurse is conducting a physical examination of a child with suspected

Crohn disease. Which finding would be the most suspicious of Crohn disease?

A) Normal growth patterns

B) Perianal skin tags or fissures

C) Poor growth patterns

D) Abdominal tenderness

Ans: B

Feedback:

Perianal skin tags and/or fissures are highly suspicious of Crohn disease. Poor

growth patterns and abdominal tenderness are common to Crohn disease but are

also seen with many other conditions. Normal growth patterns would not point to

Crohn disease because of problems with absorbing nutrients.

5. The nurse is caring for an infant with a temporary ileostomy. As part of the

plan of care, the nurse monitors for skin breakdown around the stoma. If redness

occurs, what would be most appropriate to promote healing and prevent further

skin breakdown?

A) Clean the area well with a scented diaper wipe.

B) Apply a barrier/healing cream or paste on the skin.

C) Use a barrier wafer to attach the appliance.

D) Sanitize the area with an alcohol wipe after each diaper change.

Ans: B

Feedback:

The nurse should use a barrier/healing cream or paste on the skin around the

stoma to promote healing and prevent further skin breakdown. Diaper wipes that

contain fragrance or alcohol can sting if used on nonintact skin and can worsen skin

breakdown. The barrier wafer would be helpful but does not address the skin

breakdown.

6. The nurse is caring for a 4-year-old boy who has undergone an

appendectomy. The child is unwilling to use the incentive spirometer. Which

approach would be most appropriate to elicit the child's cooperation?

A) "Can you cough for me please?"

B) "You must blow in this or you might get pneumonia."

C) "If you don't try, I will have to get the healthcare provider."

D) "Can you blow this cotton ball across the tray?"

Ans: D

Feedback:

Children are more likely to cooperate with interventions if play is involved.

Encourage deep breathing by playing games. Asking the boy to cough is less likely

to engage him. Telling the child he might get pneumonia is not age appropriate and

is unhelpful. Threatening to call the healthcare provider is unhelpful and

inappropriate. Remember, however, that the incentive spirometer works on the

principle of the amount of air inhaled, not exhaled. Having the child take a deep

breath prior to blowing the cotton ball is a beginning step.

7. A nurse is caring for a 14-year-old girl scheduled for a barium swallow/upper

gastrointestinal (GI) series. Before providing instructions, what would be the

priority?

A) Screening the girl for pregnancy

B) Reminding her to drink plenty of fluids after the procedure

C) Ordering a bowel preparation

D) Reminding the girl about potential light-colored stools

Ans: A

Feedback:

Females of reproductive age must be screened for pregnancy prior to the test

because radiography is used. A bowel preparation is not necessary for a barium

swallow/upper GI series. The reminders about fluids and light-colored stools are

appropriate but are not the first priority.

8. The nurse has developed a plan of care for a 12-month-old hospitalized with

dehydration as a result of rotavirus. Which intervention would the nurse include in

the plan of care?

A) Encouraging consumption of fruit juice

B) Offering Kool-Aid or popsicles as tolerated

C) Encouraging milk products to boost caloric intake

D) Maintaining the intravenous (IV) fluid rate as ordered

Ans: D

Feedback:

The nurse should maintain an IV line and administer the IV fluid as ordered to

maintain fluid volume. High-carbohydrate fluids like fruit juice, Kool-Aid, and

popsicles should be avoided as they are low in electrolytes, increase simple

carbohydrate consumption, and can decrease stool transit time. Milk products

should be avoided during the acute phase of illness as they may worsen diarrhea.

9. The nurse is caring for a 2-month-old with a cleft palate. The child will

undergo corrective surgery at age 3 months. The mother would like to continue

breastfeeding the baby after surgery and wonders if it is possible. How should the

nurse respond?

A) "There is a good chance that you will be able to breastfeed almost

immediately."

B) "Breastfeeding is likely to be possible but check with the surgeon."

C) "After the suture line heals, breastfeeding can resume."

D) "We will have to wait and see what happens after the surgery."

Ans: B

Feedback:

Postoperatively, some surgeons allow breastfeeding to be resumed almost

immediately. However, the nurse needs to advise the mother to check with the

surgeon to determine when breastfeeding can resume. Telling the mother that she

has to wait until the suture line heals may be inaccurate. Telling her to wait and see

does not answer her question.

10. The school nurse is working with a 10-year-old girl with recurrent abdominal

pain. The girl's teacher has been less than understanding about the frequent

absences and trips to the nurse's office. How should the nurse respond?

A) "Be patient; she is trying some new medication."

B) "The pain she is having is real."

C) "The family is working toward improvement."

D) "Please do not add to this family's stress."

Ans: B

Feedback:

It is important to educate the teacher that this recurrent abdominal pain is a true

pain that the child feels and it is not "in her mind." Telling the teacher not to add to

the family's stress or that the family is working toward improvement does not

teach. The nurse must have the permission of the family to discuss the girl's

medication.

11. When examining the abdomen of a child, which technique would the nurse

use last?

A) Auscultation

B) Percussion

C) Palpation

D) Inspection

Ans: C

Feedback:

Palpation should be the last part of the abdominal examination. Inspection,

auscultation, and percussion should be done before palpation.

12. Which finding would lead the nurse to suspect that a child is experiencing

moderate dehydration?

A) Dusky extremities

B) Tenting of skin

C) Sunken fontanels

D) Hypotension

Ans: C

Feedback:

A child with moderate dehydration would exhibit sunken fontanels. Severe

dehydration would be characterized by dusky extremities, skin tenting, and

hypotension.

13. The nurse is determining maintenance fluid requirements for a child who

weighs 25 kg. How much fluid would the child need per day?

A) 1,560 mL

B) 1,600 mL

C) 1,650 mL

D) 1,700 mL

Ans: B

Feedback:

Using the following formula of 100 mL/kg for the first 10 kg, plus 50 mL/kg for the

next 10 kg, and then 20 mL/kg for the remaining kg, the child would require (100

× 10) + (50 × 10) + (20 × 5) = 1,000 + 500 + 100 = 1,600 mL in 24 hours.

14. The parents of a child diagnosed with celiac disease ask the nurse what types

of food they can offer their child. What recommendation would the nurse include in

the teaching plan?

A) Frozen yogurt

B) Rye bread

C) Creamed spinach

D) Fruit juice

Ans: D

Feedback:

For the child with celiac disease, foods containing gluten such as frozen yogurt, rye

bread, and creamed vegetables should be avoided. Fruit juice would be an

appropriate suggestion in a gluten-free diet.

15. The nurse is providing care to a child with an intussusception. The child has a

bowel movement and the nurse inspects the stool. The nurse would most likely

document the stool's appearance as having what quality?

A) Greasy

B) Clay-colored

C) Currant jelly-like

D) Bloody

Ans: C

Feedback:

The child with intussusception often exhibits currant jelly-like stools that may or

may not be positive for blood. Greasy stools are associated with celiac disease.

Cay-colored stools are observed with biliary atresia. Bloody stools can be seen with

several gastrointestinal disorders, such as inflammatory bowel disease.

16. The mother of a 3-week-old infant old brings her daughter in for an

evaluation. During the visit, the mother tells the nurse that her baby is spitting up

after feedings. Which response by the nurse would be most appropriate?

A) "We need to tell the healthcare provider about this."

B) "Infants this age commonly spit up."

C) "Your daughter might have an allergy."

D) "Don't worry; you're just feeding her too much."

Ans: B

Feedback:

In infants younger than 1 month of age, the lower esophageal sphincter is not fully

developed, so infants younger than 1 month of age frequently regurgitate after

feedings. Many children younger than 1 year of age continue to regurgitate for

several months, but this usually disappears with age. The mother's report is not a

cause for concern, so the healthcare provider does not need to be notified.

Additional information would be needed to determine if the infant had an allergy.

Although the infant's stomach capacity is small, telling the mother not to worry

does not address the mother's concern, and telling her that she is feeding the

daughter too much implies that she is doing something wrong.

17. A group of students are reviewing information about fluid balance and losses

in children in comparison to adults. The students demonstrate a need for additional

review when they state that:

A) children have a proportionately greater amount of body water than do

adults.

B) fever plays a greater role in insensible fluid losses in infants and

children.

C) a higher metabolic rate plays a major role in increased insensible fluid

losses.

D) the infant's immature kidneys have a tendency to overconcentrate

urine.

Ans: D

Feedback:

The young infant's renal immaturity does not allow the kidneys to concentrate urine

as well as in older children and adults, placing them at risk for dehydration or

overhydration. Children do have a proportionately greater amount of body water

than adults, and fever is important in promoting insensible fluid losses in infants

and children because children become febrile more readily and their fevers are

higher than those in adults. Children also experience a higher metabolic rate, which

accounts for increased insensible fluid losses and increased need for water for

excretory function.

18. An 8-month-old infant is brought to the clinic for evaluation. The mother tells

the nurse that she has noticed some white patches on the infant's tongue that look

like curdled milk after breastfeeding. The nurse suspects oral candidiasis (thrush).

Which question would the nurse use to help confirm this suspicion?

A) "Are you having breast pain when you nurse the baby?"

B) "Has he had any dairy problems recently?"

C) "Is he experiencing any vomiting lately?"

D) "How have his stools been this past week?"

Ans: A

Feedback:

The infant may develop thrush from the mother if the mother has a fungal infection

of the breast. Asking the mother about breast pain would be important because this

type of infection can cause the mother a great deal of pain with nursing. Dairy

products are not associated with oral candidiasis but are associated with the

development of infectious diarrhea in infants. Vomiting is unrelated to thrush. The

infant also may have candidal diaper rash, but this would be manifested on the skin

as a beefy-red rash with satellite lesions, not in his stools.

19. The parents of a 6-week-old boy come to the clinic for evaluation because

the infant has been vomiting. The parents report that the vomiting has been

increasing in frequency and forcefulness over the last week. The mother says,

"Sometimes, it seems like it just bursts out of his mouth." A diagnosis of

hypertrophic pyloric stenosis is suspected. When performing the physical

examination, what would the nurse most likely find?

A) Sausage-shaped mass in the upper midabdomen

B) Hard, moveable, olive-shaped mass in the right upper quadrant

C) Tenderness over the McBurney point in the right lower quadrant

D) Abdominal pain in the epigastric or umbilical region

Ans: B

Feedback:

With hypertrophic pyloric stenosis, a hard, moveable, olive-shaped mass would be

palpated in the right upper quadrant. A sausage-shaped mass in the upper

midabdomen would suggest intussusception. Tenderness over the McBurney point

would be associated with appendicitis. Epigastric or umbilical pain would be

associated with peptic ulcer disease.

20. A nursing instructor is developing a class presentation about the medications

used to treat peptic ulcer disease. Which drug class would the instructor be least

likely to include in the presentation?

A) Antibiotics

B) Proton pump inhibitors

C) Histamine antagonists

D) Prokinetics

Ans: D

Feedback:

Treatment for peptic ulcer disease includes antibiotics if Helicobacter pylori are

verified, histamine antagonists, and/or proton pump inhibitors. Prokinetics are used

to stimulate the gastrointestinal tract to help empty the stomach faster and

promote intestinal motility. They are not used for peptic ulcer disease.

21. The parents of a boy diagnosed with Hirschsprung disease are anxious and

fearful of the upcoming surgery. The mother states, "I'm worried about having to

care for our son's ostomy." Which intervention would be most helpful for the

parents?

A) Explaining to them about the diagnosis and surgery

B) Having a wound, ostomy, and continence nurse meet with them

C) Reinforcing that the ostomy will be temporary

D) Teaching them about the medications used to slow stool output

Ans: B

Feedback:

Although explaining about the diagnosis and surgery, reinforcing that the ostomy

will be temporary, and teaching them about medications would be appropriate, the

parents are voicing concerns about caring for the ostomy. Therefore, having a

wound, ostomy, and continence nurse meet with them would address these

concerns and help them deal with the anxieties and care of a newly placed stoma.

22. The nurse is providing care to a child with pancreatitis. When reviewing the

child's laboratory test results, what would the nurse expect to find? Select all that

apply.

A) Leukocytosis

B) Decreased C-reactive protein

C) Elevated serum amylase levels

D) Positive stool culture

E) Decreased serum lipase levels

Ans: A, C

Feedback:

With pancreatitis, serum amylase and lipase levels are elevated and levels three

times the normal values are extremely indicative of pancreatitis. Leukocytosis is

common with acute pancreatitis. C-reactive protein levels may be elevated. Stool

cultures are not used to evaluate this disorder. Positive stool cultures would

indicate a bacterial cause of diarrhea.

23. A child is scheduled for a lower endoscopy. What would the nurse include in

the child's plan of care in preparation for this test?

A) Explaining about the need to ingest barium

B) Establishing an intravenous access for radionuclide administration

C) Administering the prescribed bowel cleansing regimen

D) Withholding prescribed proton pump inhibitors for 5 days before

Ans: C

Feedback:

Prior to a lower endoscopy, the child must undergo bowel cleansing to allow

visualization of the lower gastrointestinal tract via a fiberoptic instrument. Barium is

ingested for an upper gastrointestinal and/or small bowel series. Radionuclides are

used with a hepatobiliary scan. Proton pump inhibitors are withheld for 5 days

before a urea breath test.

24. A group of students are reviewing information about gallbladder disease in

children. The students demonstrate a need for additional review when they state:

A) cholesterol gallstones are more frequently found in males.

B) pigment stones are found primarily in the common bile duct.

C) pancreatitis is a common complication of cholecystitis in children.

D) cholecystitis is due to chemical irritation from obstructed bile flow.

Ans: A

Feedback:

Cholesterol gallstones are seen more often in females than males and increased

risk occurs with age and onset of puberty. Pigment stones are usually found in the

common bile duct. Pancreatitis is a common complication in children with gallstone

disease. Cholecystitis is an inflammation of the gallbladder that is caused by

chemical irritation due to the obstruction of bile flow from the gallbladder into the

cystic ducts.

25. After teaching the parents of a child diagnosed with celiac disease about

nutrition, the nurse determines that the teaching was effective when the parents

identify which foods as appropriate for their child? Select all that apply.

A) Wheat germ

B) Peanut butter

C) Carbonated drinks

D) Shellfish

E) Jelly

F) Flavored yogurt

Ans: B, C, D, E

Feedback:

Foods allowed in a gluten-free diet include peanut butter, carbonated drinks,

shellfish, and jelly. Wheat germ and flavored yogurt should be avoided.

26. A group of nursing students are reviewing information about inflammatory

bowel disease in preparation for a class discussion on the topic. The students

demonstrate understanding of the material when they identify which characteristics

of Crohn disease? Select all that apply.

A) Distributed in a continuous fashion

B) Most common between the ages of 10 and 20 years

C) Elevated erythrocyte sedimentation rate

D) Low serum iron levels

E) Tenesmus

F) Loss of haustra within bowel

Ans: B, C, D

Feedback:

Crohn disease is most common between the ages of 10 and 20 years. Erythrocyte

sedimentation rate is elevated, and serum iron levels are low. Ulcerative colitis is

distributed continuously distal to proximal, with tenesmus and loss of haustra

within the bowel. Crohn disease is segmental, with disease-free skip areas

common, and the bowel wall has a cobblestone appearance.

27. After teaching the parents of a 6-year-old how to administer an enema, the

nurse determines that the teaching was successful when they state that they will

give how much solution to their child?

A) 100 to 200 mL

B) 200 to 300 mL

C) 250 to 500 mL

D) 500 to 1,000 mL

Ans: D

Feedback:

For a school-age child, typically 500 to 1,000 mL of enema solution is given. For an

infant, 250 mL or less is used; for a toddler or preschooler, 250 to 500 mL is used.

28. The nurse is caring for a 6-month-old with a cleft lip and palate. The mother

of the child demonstrates understanding of the disorder with which statements?

Select all that apply.

A) "My smoking during pregnancy didn't have anything to do with this

disorder. Smoking primarily causes low birth weight."

B) "I know my baby takes a lot longer to feed than most children this

age."

C) "It really worries me that my baby may have some other disorders

that haven't been detected yet."

D) "I wonder if my baby will develop speech problems when language

development begins?"

E) "Thankfully there are healthcare providers that specialize in correcting

this type of disorder."

Ans: B, C, D, E

Feedback:

Feeding and speech are especially difficult for the child with cleft lip and palate until

the defect is repaired. Cleft lip and palate occurs frequently in association with

other anomalies and has been identified in more than 350 syndromes. Plastic

surgeons or craniofacial specialists, oral surgeons, dentists or orthodontists, and

prosthodontists are some of the healthcare providers that specialize in repair of this

disorder. The mother is incorrect in stating that smoking is not associated with cleft

lip or palate. Maternal smoking during pregnancy is a major risk factor for the

disorder.

29. The nurse is performing a gastrointestinal assessment on a 7-year-old boy.

The parents are assisting with the history. Which assessment findings are indicative

of constipation? Select all that apply.

A) "Our child only has 3 to 4 bowel movements per week."

B) "Our child complains of pain because his bowel movements are so

hard."

C) "Our child tells us that his belly hurts a lot of the time."

D) "I can tell he holds his bowel movement much of the time because of

the way he stands."

E) "I find smears of stool in his underwear almost every day."

Ans: B, C, D, E

Feedback:

Pain, stool withholding behavior (retentive posturing), and encopresis (soiling of

fecal contents into the underwear beyond the age of expected toilet training) are all

signs of chronic functional constipation. Less than 3 bowel movements is considered

constipation.

30. The nurse is preparing to administer intravenous fluids to manage a child

with dehydration. The medical record indicates the child weighs 60 lb (27.2 kg).

How many milliliters will initially be administered? Record your answer using two

decimal places.

Ans: 545.45

Feedback:

Nursing goals for the infant or child with dehydration are aimed at restoring fluid

volume and preventing progression to hypovolemia. Provide oral rehydration to

children for mild to moderate states of dehydration. Children with severe

dehydration should receive intravenous fluids. Initially, administer 20 mL/kg of

normal saline or lactated Ringer, and then reassess the hydration status.