Ricci Chapter 37 - Test Bank - 4th Edition

1. The nurse is caring for a neonate who is suspected of having sepsis. Which assessment

findings would the nurse interpret as most indicative of sepsis?

A. Rash on face

B. Edematous neck

C. Hypothermia

D. Coughing

Answer: C

Rationale: Hypothermia is a sign of sepsis in neonates. A rash on the face is a symptom of scarlet

fever. An edematous neck is a sign of diphtheria. Paroxysmal coughing is a symptom of

pertussis.

2. The nurse is preparing a plan of care for a 5-year-old boy with chickenpox. Which nursing

intervention should be questioned?

A. Administer antipyretics as ordered.

B. Keep the child's fingernails short.

C. Monitor fluid intake and output.

D. Provide alcohol baths as needed.

Answer: D

Rationale: Treatments such as sponging the child with alcohol or cold water are not appropriate

interventions for fever management. Rather, the nurse would use tepid sponge baths and cool

compresses. Administering antipyretics, keeping the child's fingernails short, and monitoring

intake and output are appropriate.

3. The nurse is developing a teaching plan for the mother of a 4-year-old girl with cold and fever.

What would the nurse include in this teaching plan?

A. Keeping the child covered and warm

B. Calling the doctor if the child's fever lasts more than 36 hours

C. Ensuring fluid intake to prevent dehydration

D. Observing for changes in alertness resulting from brain damage

Answer: C

Rationale: Teaching the mother to ensure fluid intake is important because fever can cause

dehydration. The child should be dressed lightly. There is no need to call the doctor unless the

child's fever lasts more than 3 to 5 days or the fever is greater than 105ºF. A rapid rise to a high

fever can cause a febrile convulsion, but it does not lead to brain damage.

4. After teaching a mother how to remove a tick from her 6-year-old boy's arm, the nurse

determines that additional teaching is needed when the mother makes what statement?

A. "I'll protect my fingers with a paper towel."

B. "I'll grasp the tick and pull it away quickly."

C. "I should put the tick in a plastic bag in the freezer."

D. "I need to grasp the tick close to the child's skin."

Answer: B

Rationale: Grasping the tick and pulling it away quickly would indicate the need for additional

teaching. When removing a tick, the mother should use fine-tipped tweezers while protecting her

fingers with a tissue, paper towel, or latex gloves. The mother should grasp the tick as close to

the skin as possible and pull upward with steady, even pressure. Once removed, the mother

should place the tick in a sealable plastic bag in the freezer in case the child becomes sick and

identification of the tick is needed.

5. The nurse is performing a physical examination of an 8-year-old girl who was bitten by her

kitten. Which assessment would lead the nurse to suspect cat-scratch disease?

A. Swollen lymph nodes

B. Strawberry tongue

C. Infected tonsils

D. Swollen neck

Answer: A

Rationale: Lymph nodes, especially under the arms, can become painful and swollen due to catscratch

disease. Strawberry tongue is typical of scarlet fever. Infected tonsils and an edematous

neck are symptoms of diphtheria.

6. A group of nursing students are reviewing the six links in the chain of infection and the

nursing implications for each. The students demonstrate understanding of the information when

they identify which precaution as helping to break the chain of infection to the susceptible host?

A. Keeping linens dry and clean

B. Maintaining skin integrity

C. Washing hands frequently

D. Coughing into a handkerchief

Answer: B

Rationale: Maintaining the integrity of the child's skin and mucous membranes is a precaution

that will break the chain of infection at the susceptible host. Keeping linens dry and clean is a

precaution to take at the reservoir link. Washing hands frequently breaks the chain at the mode of

transmission. Coughing into a handkerchief is a precaution for the portal of exit.

7. The nurse is performing a physical examination on a 9-year-old boy who has experienced a

tick bite on his lower leg and is suspected of having Lyme disease. Which assessment finding

would the nurse expect to find?

A. Swelling in the neck

B. Confusion and anxiety

C. Ring-like rash on lower leg

D. Hypersalivation

Answer: C

Rationale: A ring-like rash at the site of the tick bite is characteristic for Lyme disease. Swelling

in the neck is a symptom of mumps. Confusion, anxiety, and hypersalivation are symptoms of

rabies.

8. The nurse determines that it is necessary to implement airborne precautions for children with

which infection?

A. Measles

B. Streptococcus group A

C. Rubella

D. Scarlet fever

Answer: A

Rationale: Airborne precautions are designed to reduce the risk of infectious agents transmitted

by airborne droplet nuclei or dust particles such as for children with measles, varicella, or

tuberculosis. Droplet precautions would be used for children with streptococcal group A

infections, rubella, and scarlet fever.

9. A child is diagnosed with scarlet fever. The nurse is reviewing the child's medical record,

expecting which medication to be prescribed for this child?

A. Ibuprofen

B. Acyclovir

C. Penicillin V

D. Doxycycline

Answer: C

Rationale: Penicillin V is the antibiotic of choice for the treatment of scarlet fever. Ibuprofen is

used to treat fever. Acyclovir is used to treat viral infections. Doxycycline, a tetracycline, is the

drug of choice for treating Rocky Mountain spotted fever.

10. A mother brings her 8-year-old son for evaluation because of a rash on his lower leg. Which

finding would support the suspicion that the child has Lyme disease?

A. Playing in the woods about a week ago

B. Rash is papular and vesicular

C. High fever occurring about 4 days before the rash

D. Reports of extreme pruritus with visible nits

Answer: A

Rationale: Lyme disease is caused by the bite of an infected tick, with a rash appearing 7 to 14

days after the tick bite. Ticks are commonly found in wooded areas. Therefore, reports of the

child playing in the woods about 7 days ago would support the diagnosis of Lyme disease. A

papular and vesicular rash is commonly associated with varicella (chickenpox). A high fever for

3 to 5 days before a rash suggests roseola. Extreme pruritus with visible nits would suggest

pediculosis.

11. After teaching the parents of a child with chickenpox (varicella zoster), the nurse determines

that the parents have understood the teaching when they state that their child can return to school

at which time?

A. After day 5 of the rash

B. When the rash is completely healed

C. Once the rash appears

D. After the lesions have crusted

Answer: D

Rationale: Children with chickenpox (varicella zoster) can return to school once the lesions have

crusted.

12. After teaching a class on the role of white blood cells in infection, the instructor determines

that the teaching was successful when the class identifies which type of white blood cells as

important in combating bacterial infections?

A. Neutrophils

B. Eosinophils

C. Basophils

D. Lymphocytes

Answer: A

Rationale: Elevations in certain portions of the white blood cell count reflect different processes

occurring in the body. Neutrophils function to combat bacterial infection. Eosinophils function in

allergic disorders and parasitic infections. Basophils combat parasitic infections and some

allergic disorders. Lymphocytes function in viral infections.

13. A nursing instructor is teaching a group of students about the action of antipyretic agents in

children. The instructor determines that the teaching has been successful when the students

identify which action as the primary action?

A. Cause vasodilation to promote heat loss

B. Decrease the temperature set point

C. Block release of histamine

D. Promote prostaglandin production

Answer: B

Rationale: Antipyretics act to decrease the temperature set point in children with elevated

temperatures by inhibiting the production of prostaglandins, which leads to heat loss through

vasodilation and sweating. Antihistamines block the release of histamine.

14. A nurse is instructing a parent on how to obtain a stool culture for ova and parasites from a

child with diarrhea. What would the nurse include in the teaching plan?

A. "Give the child bismuth and then collect the next specimen."

B. "Obtain the specimen from the toilet after the child has a bowel movement."

C. "Keep the specimen from coming into contact with any urine."

D. "Bring the specimen to the laboratory on the third day."

Answer: C

Rationale: A stool specimen for culture must be free of urine, water, and toilet paper. Therefore,

the parent needs to understand how to collect the specimen so that it does not come into contact

with any these. In addition, the specimen should not be retrieved out of toilet water. Mineral oil,

barium, and bismuth interfere with the detection of parasites. In such cases, specimen collection

should be delayed for 7 to 10 days. Once the specimen is collected, it should be brought to the

laboratory immediately.

15. The nurse is preparing to obtain a blood specimen via capillary heel puncture. Which action

would be most appropriate for the nurse to do?

A. Apply a cool compress for several minutes before collection.

B. Elevate the extremity used after puncturing it.

C. Squeeze the area to facilitate specimen collection.

D. Wipe away the first drop of blood with dry gauze.

Answer: D

Rationale: When obtaining a blood specimen by capillary puncture, the nurse should wipe away

the first drop of blood with a cotton ball or dry gauze pad and then collect the sample without

squeezing the foot to prevent possible hemolysis. Prior to the puncture, the nurse can apply a

commercial heel warmer or warm compress for several minutes to promote vasodilation. The

extremity being used should be placed in the dependent position after puncturing the heel.

16. The nurse is assessing the tympanic temperature of several children. The nurse documents

that the child with which temperature reading has a fever?

A. 98.2° F (36.8° C)

B. 99.2° F (37.3° C)

C. 100° F (37.8° C)

D. 100.8° F (38.2° C)

Answer: D

Rationale: A tympanic temperature greater than 100.4° F (greater than 38° C) is defined as fever.

An oral temperature of 100° F (greater than 37.8° C) would identify a fever. An axillary

temperature of 99° F (greater than 37.2° C) would identify a fever.

17. A school-aged child with an infectious disease is placed on transmission-based precautions.

If the child is not dehydrated or otherwise in distress, which nursing diagnosis would be the

priority?

A. Impaired skin integrity related to trauma secondary to pruritus and scratching

B. Fluid volume deficit related to increased metabolic demands and insensible losses

C. Social isolation related to infectivity and inability to go to the playroom

D. Deficient knowledge related to how infection is transmitted

Answer: C

Rationale: Children who are placed on transmission-based precautions are not allowed to leave

their rooms and are not allowed to go to common areas such as the playroom or schoolroom.

Thus, they are at risk for social isolation. Impaired skin integrity, fluid volume deficit, and

deficient knowledge may be appropriate but would depend on the infectious disease diagnosed.

18. When reviewing infectious diseases in the pediatric population, nursing students identify

which disease as a common childhood exanthema?

A. Mumps

B. Rabies

C. Rubella

D. West Nile virus

Answer: C

Rationale: Rubella is a common childhood exanthema. Mumps is a viral infection. Rabies is a

zoonotic infection. West Nile virus is a vector-borne disease.

19. The parents of a 5-year-old have just found out that their child has head lice. Which

statement by the parents would support the nursing diagnosis of deficient knowledge?

A. "I can't believe it. We're not unclean, poor people."

B. "We'll have to get that special shampoo."

C. "Everybody in the house will need to be checked."

D. "That explains his complaints of itching on his neck."

Answer: A

Rationale: Head lice is not an indication of poor hygiene or poverty. It occurs in all

socioeconomic groups. Thus, the parents' statement about being unclean and poor reflects a lack

of knowledge about the infection. A pediculicide is used to wash the hair to treat the infestation.

Household contacts need to be examined and treated if affected. Extreme pruritus is the most

common symptom, with nits or lice especially behind the ears or at the nape of the neck.

20. A nurse suspects that an adolescent may have community-acquired methicillin-resistant

Staphylococcus aureus (CAMRSA). What would the nurse expect to assess? Select all that

apply.

A. Participation in contact sport

B. Recent cut on the lower leg

C. History of a recent sore throat

D. Raised fluctuant lesions

E. Erythematous rash over the trunk and face

Answer: A, B, D

Rationale: With CAMRSA, skin and tissue infections are common, often appearing as a bump or

skin area that is red, swollen, painful, and warm to the touch. There also may be fluctuance and

purulent drainage. Participation in contact sports, openings in the skin such as abrasions and cuts,

contact with contaminated items and surfaces, poor hygiene, and crowded living conditions are

risk factors for CAMRSA. Recent sore throat and an erythematous rash on the trunk, face, and

possibly the extremities are associated with scarlet fever.

21. A child is diagnosed with a helminthic infection. Which treatments would the nurse expect to

be prescribed? Select all that apply.

A. Erythromycin

B. Albendazole

C. Pyrantel pamoate

D. Acyclovir

E. Metronidazole

F. Permethrin

Answer: B, C

Rationale: Drugs used to treat helminthic infections include albendazole and pyrantel pamoate.

Erythromycin is used to treat bacterial infections. Acyclovir is used to treat viral infections.

Metronidazole is used to treat trichomoniasis. Permethrin is used to treat pediculosis.

22. The client has a heavily draining wound for which there is an order to change the dressing

every 4 hours. The nurse becomes busy and does not change the dressing as ordered. Which link

in the chain of infection has the nurse allowed to flourish?

A. Susceptible host

B. Portal of exit

C. Reservoir

D. Mode of transmission

Answer: C

Rationale: The reservoir is the area where a pathogen grows and reproduces. Leaving the

dressing unchanged allows for a dark, warm, nutrient rich, and moist environment where many

organisms will thrive. A susceptible host is a person who cannot fight off an infection. The portal

of exit is the way a pathogen exits the host. The mode of transmission is the way the pathogen

travels.

23. The parents of a 7-month-old child with an infection ask the nurse about how to treat their

child's fever. After providing teaching, the parents voice understanding with which statements?

Select all that apply.

A. "If my child's fever is under 102°F , I don't need to make an appointment with the physician."

B. "Having a temperature over 38°C puts my child at risk for the infection spreading to the

bloodstream."

C. "I can use acetaminophen to help with the symptoms of the infection but it won't get rid of the

infection."

D. "Even though people get frightened, fevers are not a bad thing during an infection unless it

gets too high."

E. "Any fever is dangerous and can cause serious damage to brain cells if it goes on too long."

Answer: A, C, D

Rationale: In infants older than 3 months of age, fever less than 38.9°C (102°F) usually does not

require treatment by a physician. Antipyretics, such as acetaminophen, provide symptomatic

relief but do not change the course of the infection. A fever can actually enhance various

components of the immune response. Infants younger than 3 months of age with a rectal

temperature greater than 38°C should be seen by a physician or nurse practitioner because of

increased risk of sepsis.

24. The mother of a 4-year-old boy has contacted the physician's office. She reports her son was

exposed to someone with chickenpox. She has inquired about when her son may show if he has

gotten the disease. What information should be provided?

A. The illness should be seen in a week if he has been exposed.

B. Symptoms of the disease should show up within 24 to 48 hours of exposure.

C. The incubation period for the disease is between 10 and 21 days.

D. Younger children will have longer periods of incubation.

Answer: C

Rationale: Chickenpox is the common name for varicella. This condition has an incubation

period of 10 to 21 days.

25. The nurse is providing education to the parents of a child diagnosed with pinworms. Which

statement is most important for the nurse to include in the teaching?

A. "Seal the child's clothing in a plastic bag for at least 10 days."

B. "Be sure your child wears shoes at all times."

C. "Make sure your child washes hands before eating."

D. "After applying this special cream, leave it on for about 8 to 10 hours."

Answer: C

Rationale: The most effective measure to prevent pinworms or a recurrence is good hand

hygiene, especially after using the bathroom and before eating. Sealing the child's clothing in a

plastic bag is appropriate for pediculosis capitis. Having the child wear shoes at all times is

helpful in preventing hookworm. Use of a cream that remains on for a specified time is

associated with scabies.

26. A nurse is conducting a health history for a 1-month-old with an infectious disorder. Which

segment of the maternal health history would be most helpful for the nurse when determining if

the infant developed the infection from the mother?

A. Family history

B. Past medical history

C. Home treatments

D. Present illness history

Answer: B

Rationale: Past medical history will provide information about the mother's pregnancy and birth,

giving insight into the possibility of maternal transmission of the infection. Family history would

provide information about lack of immunizations or recent infectious or communicable diseases.

Home treatments and present illness history would provide no information about the possibility

of maternal transmission of infection.

27. The nurse is caring for a hospitalized, 1-week-old infant who appears very ill. Which

assessment finding(s) will the nurse report to the health care provider? Select all that apply.

A. Petchiae

B. Heart rate100 beats/min

C. Respiratory rate 60 breaths/min

D. Axillary temperature 97.6°F (36.5°C)

E. Characteristic of cry

Answer: A, B, C, D, E

Rationale: Sepsis is suspected in any infant under 3 months of age until laboratory findings

return. In an infant, the most important findings are hypothermia, bradycardia, and apnea.

Tachypnea care be present in both infants and children. The nurse would be concerned with the

infant's weak cry, lethargy, and an increased work of breathing such as rate, nasal flaring,

grunting, and retractions. The child with sepsis generally has an elevated termperature, but

hypothermia is seen in infants. The nurse should perform a good skin assessment. If petechiae

are present, it is indicative of a very serious infection caused by Neisseria meningitidis.

28. While hospitalized, a child develops scarlet fever. Isolation has been prescribed by the health

care provider. The nurse would place this child in what type of isolation?

A. Airborne

B. Droplet

C. Contact

D. Reverse

Answer: B

Rationale: Scarlet fever is produced by group A streptococcus. It is most seen in children ages 5

years to 15 years. It is spread by droplets from respiratory secretions by talking, coughing, or

sneezing. These droplets can travel 3 feet (1 meter). Isolation recommendations require the use

of a mask for care of the child. Airborne isolation is required for illness that also produce

droplets but these are smaller, can travel further and stay suspended in air. An N95 mask and

negative pressure room is required for this type of isolation. Contact isolation requires the use of

gowns, masks and gloves for direct contact with an infected person. Reverse isolation occurs if

the client is neutropenic.

29. The nurse is assessing a 8-month-old infant who has symptoms of poor feeding, a poor gag

reflex, listlessness and a weak cry. What is the most important question the nurse should ask the

parent about these symptoms?

A. "Have you given your infant any honey?"

B. "When did these symptoms begin?"

C. "Has your infant had any unpasteurized milk to drink?"

D. "What is the source of your family's water supply?"

Answer: A

Rationale: Infant botulism occurs when the infant ingests the spores of Clostridium botulinum.

These multiply in the intestinal track and produce toxins. The disease is caused by the ingestion

of spores from dust, improperly preserved home-canned foods and feeding an infant under 1 year

of age raw honey. The infant has poor feeding, is listless, has a weak cry, and a has poor gag

reflex--a distinguishing symptom. The nurse would ask about the water supply and unpasteurized

milk if food poisonings or parasites were suspected. Asking about the date of the infant's illness

is important, but this information does not take priority over the question about honey.

30. A child is being treated for pertussis and is prescribed azithromycin by the health care

provider. Which finding is most important for the nurse to report to the health care provider

before administering this drug?

A. Child has had previous episodes of supraventricular tachycardia (SVT).

B. Child has a potassium level of 3.7 mEq/l (3.7 mmol/l).

C. Child is also prescribed a proton pump inhibitor (PPI).

D. Child experienced a rash on the back taking this drug previously.

Answer: A

Rationale: Azithromycin is recommended for use to treat pertussis in infants older than 1 month

of age and children. It should, however, not be used in children at risk for cardiovascular events.

It may cause a potentially fatal heart rhythm, because it can lead in changes in the electrical

activity of the heart. It is espeicially important in children with prolonged QT intervals. The

finding of SVT should be reported to the health care provider before the administration of the

drug. The potassium level is within a normal range and it has no effect on the drug.

Azithromycin should not be given with any aluminum or magnesium antacids. The PPI should

be safe. A rash may indicate an allergy to the drug and should be reported, but it is not the most

important finding. The health care provider would make a determination for the drug

administration based on risks versus benefits.