1. The American Association on Intellectual and Developmental Disabilities (AAIDD), formerly
the American Association on Cognitive Impairment, classifies cognitive impairment based on
what parameter?
a. Age of onset
b. Subaverage intelligence
c. Adaptive skill domains
d. Causative factors for cognitive impairment
ANS: C
The AAIDD has categorized cognitive impairment into adaptive skill domains. The child must
demonstrate functional impairment in at least two of the following adaptive skill domains:
communication, self-care, home living, social skills, use of community resources, self-direction,
health and safety, functional academics, leisure, and work. Age of onset before 18 years is part of
the former criteria. Low intelligence quotient (IQ) alone is not the sole criterion for cognitive
impairment. Etiology is not part of the classification.
2. Secondary prevention for cognitive impairment includes what activity?
a. Genetic counseling
b. Avoidance of prenatal rubella infection
c. Preschool education and counseling services
d. Newborn screening for treatable inborn errors of metabolism
ANS: D
Secondary prevention involves activities that are designed to identify the condition early and
initiate treatment to avert cerebral damage. Inborn errors of metabolism such as hypothyroidism,
phenylketonuria, and galactosemia can cause cognitive impairment. Genetic counseling and
avoidance of prenatal rubella infections are examples of primary prevention strategies to
preclude the occurrence of disorders that can cause cognitive impairment. Preschool education
and counseling services are examples of tertiary prevention. These are designed to include early
identification of conditions and provision of appropriate therapies and rehabilitation services.
3. What is a primary goal in caring for a child with cognitive impairment?
a. Developing vocational skills
b. Promoting optimum development
c. Finding appropriate out-of-home care
d. Helping child and family adjust to future care
ANS: B
The goal for children with cognitive impairment is the promotion of optimum social, physical,
cognitive, and adaptive development as individuals within a family and community. Vocational
skills are only one part of that goal. The focus must also be on the family and other aspects of
development. Out-of-home care is considered part of the childs development. Optimum
development includes adjustment for both the family and child.
4. One of the techniques that has been especially useful for learners having cognitive impairment
is called fading. What description best explains this technique?
a. Positive reinforcement when tasks or behaviors are mastered
b. Repeated verbal explanations until tasks are faded into the childs development
c. Negative reinforcement for specific tasks or behaviors that need to be faded out
d. Gradually reduces the assistance given to the child so the child becomes more independent
ANS: D
Fading is physically taking the child through each sequence of the desired activity and gradually
fading out the physical assistance so the child becomes more independent. Positive
reinforcement when tasks or behaviors are mastered is part of behavior modification. An
essential component is ignoring undesirable behaviors. Verbal explanations are not as effective as
demonstration and physical guidance. Consistent negative reinforcement is helpful, but positive
reinforcement that focuses on skill attainment should be incorporated.
5. The parents of a child with cognitive impairment ask the nurse for guidance with discipline.
What should the nurses recommendation be based on?
a. Discipline is ineffective with cognitively impaired children.
b. Cognitively impaired children do not require discipline.
c. Behavior modification is an excellent form of discipline.
d. Physical punishment is the most appropriate form of discipline.
ANS: C
Discipline must begin early. Limit-setting measures must be clear, simple, consistent, and
appropriate for the childs mental age. Behavior modification, especially reinforcement of desired
behavior and use of time-out procedures, is an appropriate form of behavior control. Aversive
strategies should be avoided in disciplining the child.
6. What intervention is most appropriate to facilitate social development of a child with a
cognitive impairment?
a. Provide age-appropriate toys and play activities.
b. Avoid exposure to strangers who may not understand cognitive development.
c. Provide peer experiences, such as infant stimulation and preschool programs.
d. Emphasize mastery of physical skills because they are delayed more often than verbal skills.
ANS: C
The acquisition of social skills is a complex task. Initially, an infant stimulation program should
be used. Children of all ages need peer relationships. Parents should enroll the child in preschool.
When older, they should have peer experiences similar to those of other children such as group
outings, Boy and Girl Scouts, and Special Olympics. Providing age-appropriate toys and play
activities is important, but peer interactions facilitate social development. Parents should expose
the child to individuals who do not know the child. This enables the child to practice social skills.
Verbal skills are delayed more often than physical skills.
7. The nurse is discussing sexuality with the parents of an adolescent girl who has a moderate
cognitive impairment. What factor should the nurse consider when dealing with this issue?
a. Sterilization is recommended for any adolescent with cognitive impairment.
b. Sexual drive and interest are very limited in individuals with cognitive impairment.
c. Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct.
d. Sexual intercourse rarely occurs unless the individual with cognitive impairment is sexually abused.
ANS: C
Adolescents with moderate cognitive impairment may be easily persuaded and lack judgment. A
well-defined, concrete code of conduct with specific instructions for handling certain situations
should be defined for the adolescent. Permanent contraception by sterilization presents moral and
ethical issues and may have psychologic effects on the adolescent. It may be prohibited in some
states. The adolescent needs to have practical sexual information regarding physical development
and contraception. Cognitively impaired individuals may desire to marry and have families. The
adolescent needs to be protected from individuals who may make intimate advances.
8. The mother of a young child with cognitive impairment asks for suggestions about how to
teach her child to use a spoon for eating. The nurse should make which recommendation?
a. Do a task analysis first.
b. Do not expect this task to be learned.
c. Continue to spoon feed the child until the child tries to do it alone.
d. Offer only finger foods so spoon feeding is unnecessary.
ANS: A
Successful teaching begins with a task analysis. The endpoint (self-feeding, toilet training, and so
on) is broken down into the component steps. The child is then guided to master the individual
steps in sequence. Depending on the childs functional level, using a spoon for eating should be
an achievable goal. The child requires demonstration and then guided training for each
component of the self-feeding. Feeding finger foods so spoon feeding is unnecessary eliminates
some of the intermediate steps that are necessary to using a fork and spoon. For socialization
purposes, it is desirable that a child use feeding implements.
9. A newborn assessment shows a separated sagittal suture, oblique palpebral fissures, a
depressed nasal bridge, a protruding tongue, and transverse palmar creases. These findings are
most suggestive of which condition?
a. Microcephaly
b. Cerebral palsy
c. Down syndrome
d. Fragile X syndrome
ANS: C
These are characteristics associated with Down syndrome. An infant with microcephaly has a
small head. Cerebral palsy is a diagnosis not usually made at birth; no characteristic physical
signs are present. The infant with fragile X syndrome has increased head circumference; long,
wide, or protruding ears; a long, narrow face with a prominent jaw; hypotonia; and a high-arched
palate.
10. A 2-week-old infant with Down syndrome is being seen in the clinic. His mother tells the
nurse that he is difficult to hold, that hes like a rag doll. He doesnt cuddle up to me like my other
babies did. What is the nurses best interpretation of this lack of clinging or molding?
a. Sign of detachment and rejection
b. Indicative of maternal deprivation
c. A physical characteristic of Down syndrome
d. Suggestive of autism associated with Down syndrome
ANS: C
Infants with Down syndrome have hypotonicity of muscles and hyperextensibility of joints,
which complicate positioning. The limp, flaccid extremities resemble the posture of a rag doll.
Holding the infant is difficult and cumbersome, and parents may feel that they are inadequate. A
lack of clinging or molding is characteristic of Down syndrome, not detachment. There is no
evidence of maternal deprivation. Autism is not associated with Down syndrome, and it would
not be evident at 2 weeks of age.
11. Many of the clinical features of Down syndrome present challenges to caregivers. Based on
these features, what intervention should be included in the childs care?
a. Delay feeding solid foods until the tongue thrust has stopped.
b. Modify the diet as necessary to minimize the diarrhea that often occurs.
c. Provide calories appropriate to the childs mental age.
d. Use a cool-mist vaporizer to keep the mucous membranes moist and secretions liquefied.
ANS: D
The constant stuffy nose forces the child to breathe by mouth, drying the mucous membranes and
increasing the susceptibility to upper respiratory tract infections. A cool-mist vaporizer will keep
the mucous membranes moist and liquefy secretions. Respiratory tract infections combined with
cardiac anomalies are the primary cause of death in the first years. The child has a protruding
tongue, which makes feeding difficult. The parents must persist with feeding while the child
continues the physiologic response of the tongue thrust. The child is predisposed to constipation.
Calories should be appropriate to the childs weight and growth needs, not mental age.
12. What description applies to fragile X syndrome?
a. Chromosomal defect affecting only females
b. Second most common genetic cause of cognitive impairment
c. Most common cause of uninherited cognitive impairment
d. Chromosomal defect that follows the pattern of X-linked recessive disorders
ANS: B
Fragile X syndrome is the most common inherited cause of cognitive impairment and the second
most common genetic cause of cognitive impairment after Down syndrome. Fragile X primarily
affects males and follows the pattern of X-linked dominant inheritance with reduced penetrance.
13. The nurse should suspect a hearing impairment in an infant who fails to demonstrate which
behavior?
a. Babbling by age 12 months
b. Eye contact when being spoken to
c. Startle or blink reflex to sound
d. Gesturing to indicate wants after age 15 months
ANS: A
The absence of babbling or inflections in voice by at least age 7 months is an indication of
hearing difficulties. Lack of eye contact is not indicative of a hearing loss. An infant with a
hearing impairment might react to a loud noise but not respond to the spoken word. The child
with hearing impairment uses gestures rather than vocalizations to express desires at this age.
14. The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing
aid is making an annoying whistling sound that the child cannot hear. What intervention is the
most appropriate nursing action?
a. Ignore the sound.
b. Suggest he reinsert the hearing aid.
c. Ask him to reverse the hearing aids in his ears.
d. Suggest he raise the volume of the hearing aid.
ANS: B
The whistling sound is acoustic feedback. The nurse should have the child remove the hearing
aid and reinsert it, making sure no hair is caught between the ear mold and the ear canal.
Ignoring the sound or suggesting he raise the volume of the hearing aid would be annoying to
others. The hearing aids are molded specifically for each ear.
15. What technique facilitates lip reading by a hearing-impaired child?
a. Speak at an even rate.
b. Avoid using facial expressions.
c. Exaggerate pronunciation of words.
d. Repeat in exactly the same way if child does not understand.
ANS: A
Help the child learn and understand how to read lips by speaking at an even rate. Avoiding using
facial expressions, exaggerating pronunciation of words, and repeating in exactly the same way
if the child does not understand interfere with the childs understanding of the spoken word.
16. What condition is defined as reduced visual acuity in one eye despite appropriate optical
correction?
a. Myopia
b. Hyperopia
c. Amblyopia
d. Astigmatism
ANS: C
Amblyopia, or lazy eye, is reduced visual acuity in one eye. Amblyopia is usually caused by one
eye not receiving sufficient stimulation. The resulting poor vision in the affected eye can be
avoided with the treatment of the primary visual defect such as strabismus. Myopia, or
nearsightedness, refers to the ability to see objects clearly at close range but not a distance.
Hyperopia, or farsightedness, is the ability to see objects at a distance but not at close range.
Astigmatism is unequal curvatures in refractive apparatus.
17. The school nurse is caring for a child with a penetrating eye injury. Emergency treatment
includes what intervention?
a. Place a cool compress on eye during transport to the emergency department.
b. Irrigate the eye copiously with a sterile saline solution.
c. Remove the object with a lightly moistened gauze pad.
d. Apply a Fox shield to the affected eye and any type of patch to the other eye.
ANS: D
The nurses role in a penetrating eye injury is to prevent further injury to the eye. A Fox shield (if
available) should be applied to the injured eye and a regular eye patch to the other eye to prevent
bilateral movement. Placing cool compress on the eye during transport to emergency department,
irrigating eye copiously with a sterile saline solution, or removing object with a lightly
moistened gauze pad may cause more damage to the eye.
18. A father calls the emergency department nurse saying that his daughters eyes burn after
getting some dishwasher detergent in them. The nurse recommends that the child be seen in the
emergency department or by an ophthalmologist. The nurse also should recommend which action
before the child is transported?
a. Keep the eyes closed.
b. Apply cold compresses.
c. Irrigate the eyes copiously with tap water for 20 minutes.
d. Prepare a normal saline solution (salt and water) and irrigate the eyes for 20 minutes.
ANS: C
The first action is to flush the eyes with clean tap water. This will rinse the detergent from the
eyes. Keeping the eyes closed and applying cold compresses may allow the detergent to do
further harm to the eyes during transport. Normal saline is not necessary. The delay can allow the
detergent to cause continued injury to the eyes.
19. A 5-year-old child has bilateral eye patches in place after surgery yesterday morning. Today
he can be out of bed. What nursing intervention is most important at this time?
a. Speak to him when entering the room.
b. Allow him to assist in feeding himself.
c. Orient him to his immediate surroundings.
d. Reassure him and allow his parents to stay with him.
ANS: C
Safety is the priority concern. Because he can now be out of bed, it is imperative that he knows
about his physical surroundings. Speaking to the child is a component of nursing care that is
expected with all clients unless contraindicated. Unless additional impairments are present, his
meal tray should be set up, and he should be able to feed himself. Reassuring him and allowing
his parents to stay with him are essential parts of nursing care for all children.
20. Autism is a complex developmental disorder. The diagnostic criteria for autism include
delayed or abnormal functioning in which area with onset before age 3 years?
a. Parallel play
b. Gross motor development
c. Ability to maintain eye contact
d. Growth below the fifth percentile
ANS: C
One hallmark of autism spectrum disorders is the childs inability to maintain eye contact with
another person. Parallel play is play typical of toddlers and is usually not affected. Social, not
gross motor, development is affected by autism. Physical growth and development are not
usually affected.
21. What intervention should be included in the nursing care of a child with autism spectrum
disorder (ASD)?
a. Assign multiple staff to care for the child.
b. Communicate with the child at his or her developmental level.
c. Provide a wide variety of foods for the child to try.
d. Place the child in a semiprivate room with a roommate of a similar age.
ANS: B
Children with ASD require individualized care. The nurse needs to communicate with the child
at the childs developmental level. Consistent caregivers are essential for children with ASD. The
same staff members should care for the child as much as possible. Children with ASD do not
adapt to changing situations. The same foods should be provided to allow the child to adjust. A
private room is desirable for children with ASD. Stimulation is minimized.
22. What suggestion by the nurse for parents regarding stuttering in children is most helpful?
a. Offer rewards for proper speech.
b. Encourage the child to take it easy and go slow when stuttering.
c. Help the child by supplying words when he or she is experiencing a block.
d. Give the child plenty of time and the impression that you are not in a hurry.
ANS: D
Hesitancy and dysfluency should be considered a normal part of speech development. An
important approach is to allow the child plenty of time to speak. Promising rewards for proper
speech places additional pressure on the child. Encouraging the child to take it easy and go slow
when stuttering draws attention to the dysfluency. The child needs to complete a sentence and
thought without being interrupted.
23. What observation in a child should indicate the need for a referral to a specialist regarding a
communication impairment?
a. At 2 years of age, the child fails to respond consistently to sounds.
b. At 3 years of age, the child fails to use sentences of more than five words.
c. At 4 years of age, the child has impaired sentence structure.
d. At 5 years of age, the child has poor voice quality.
ANS: A
If a 2-year-old child fails to respond consistently to sounds, it is an indication for referral to a
specialist regarding communication impairment. At age 3 years, the child failing to use sentences
of three words would be an indication for referral; impaired sentence structure would be seen in a
5-year-old child and poor voice quality in an older child who has a communication impairment.
24. The nurse is performing a physical assessment on a 3-year-old child. The parents state that
the child excessively rubs the eyes and often tilts the head to one side. What visual impairment
should the nurse suspect?
a. Strabismus
b. Astigmatism
c. Hyperopia, or farsightedness
d. Myopia, or nearsightedness
ANS: D
Clinical manifestations of myopia include excessive eye rubbing, head tilting, difficulty reading,
headaches, and dizziness. Strabismus, astigmatism, and hyperopia have other clinical
manifestations.
25. The community nurse is planning prevention measures designed to avoid conditions that can
cause cognitive impairment. Taking folic acid supplements during pregnancy to prevent neural
tube defects is which type of prevention strategy?
a. Primary
b. Secondary
c. Tertiary
d. Rehabilitative
ANS: A
Primary prevention strategies are those designed to avoid conditions that cause cognitive
impairment. Use of folic acid supplements during pregnancy to prevent neural tube defects is a
primary prevention strategy. Secondary prevention activities are those designed to identify the
condition early and initiate treatment to avert cerebral damage. Tertiary prevention strategies are
those concerned with treatment to minimize long-term consequences. Rehabilitation services is
an example of tertiary prevention.
26. The nurse is teaching a preschool child with a cognitive impairment how to throw a ball
overhand. What teaching strategy should the nurse use for this child?
a. Demonstrate how to throw a ball overhand.
b. Explain the reason for throwing a ball overhand.
c. Show pictures of children throwing balls overhand.
d. Explain to the child how to throw the ball overhand.
ANS: A
Children with cognitive impairment have a deficit in discrimination, which means that concrete
ideas are much easier to learn effectively than abstract ideas. Therefore, demonstration is
preferable to verbal explanation, and the nurse should direct learning toward mastering a skill
rather than understanding the scientific principles underlying a procedure. Demonstrating how to
throw the ball is the best teaching strategy.
27. The camp nurse is choosing a toy for a child with cognitive impairment to play with during
swimming time. What toy should the nurse choose to encourage improvement of developmental
skills?
a. Dive rings
b. An inner tube
c. Floating ducks
d. A large beach ball
ANS: D
Toys are selected for their recreational and educational value. For example, a large inflatable
beach ball is a good water toy; encourages interactive play; and can be used to learn motor skills
such as balance, rocking, kicking, and throwing. Dive rings, an inner tube, and floating ducks are
not interactive toys.
28. The nurse is teaching feeding strategies to a parent of a 12-month-old infant with Down
syndrome. What statement made by the parent indicates a need for further teaching?
a. If the food is thrust out, I will reefed it.
b. I will use a small, long, straight-handled spoon.
c. I will place the food on the top of the tongue.
d. I know the tongue thrust doesnt indicate a refusal of the food.
ANS: C
Parents of a child with Down syndrome need to know that the tongue thrust does not indicate
refusal to feed but is a physiologic response. Parents are advised to use a small but long, straight-
handled spoon to push the food toward the back and side of the mouth. If food is thrust out, it
should be refed. If the parent indicates placing the food on the tongue, further teaching is needed.
29. The nurse is counseling a pregnant 35-year-old woman about estimated risk of Down
syndrome. What is the estimated risk for a woman who is 35 years of age?
a. One in 1200
b. One in 900
c. One in 350
d. One in 100
ANS: C
The estimated risk of Down syndrome for a 35-year-old woman is one in 350. One in 1200 is the
risk for a 25-year-old woman, one in 900 is the risk for a 30-yearold woman, and one in 100 is
the risk for a 40-year-old woman.
30. The nurse is teaching parents of a child with cataracts about the upcoming treatment. The
nurse should give the parents what information about the treatment of cataracts?
a. The treatment may require more than one surgery.
b. It is corrected with biconcave lenses that focus rays on the retina.
c. Cataracts require surgery to remove the cloudy lens and replace it.
d. Treatment is with a corrective lenses; no surgery is necessary.
ANS: C
Treatment for cataracts requires surgery to remove the cloudy lens and replace it (with an
intraocular lens implant, removable contact lens, or prescription glasses). Treatment for
glaucoma may require more than one surgery. Anisometropia is treated with corrective lenses.
Myopia is corrected with biconcave lenses that focus rays on the retina.
31. What action should the school nurse take for a child who has a hematoma (black eye) with no
hemorrhage into the anterior chamber?
a. Apply a warm moist pack.
b. Have the child keep the eyes open.
c. Apply ice for the first 24 hours.
d. Refer to an ophthalmologist immediately.
ANS: C
The care for a hematoma eye injury with no hemorrhage into the anterior chamber is to apply ice
for the first 24 hours. A warm moist pack should not be applied, and the child should keep the
eyes closed. Referral to an ophthalmologist is recommended if hyphema (hemorrhage into the
anterior chamber) is present.
MULTIPLE RESPONSE
1. The nurse is preparing an education program on hearing impairment for a group of new staff
nurses. What concepts should be included? (Select all that apply.)
a. A child with a slight hearing loss is usually unaware of a hearing difficulty.
b. A clinical manifestation of a hearing impairment in children is avoidance of social interaction.
c. A child with a severe hearing loss may hear a loud voice if nearby.
d. Children with sensorineural hearing loss can benefit from the use of a hearing aid.
e. A clinical manifestation of hearing impairment in an infant is lack of the startle reflex.
f. Identification of a hearing loss after the first year is essential to facilitate language development in children.
ANS: A, B, C, E
When discussing hearing impairment in children, the nurse should include information about
differences in hearing losses, such as with a slight hearing loss, the child is usually unaware of a
hearing difficulty, and with a severe loss, the child may hear a loud noise if it is nearby. An infant
with a hearing loss may lack the startle response, and a hearing impaired child may avoid social
interaction. Children with a sensorineural hearing loss would not benefit from a hearing aid.
Identification of a hearing loss is imperative in the first 3 to 6 months to facilitate language and
educational development for children.
2. The nurse understands that which gestational disorders can cause a cognitive impairment in
the newborn? (Select all that apply.)
a. Prematurity
b. Postmaturity
c. Low birth weight
d. Physiological jaundice
e. Large for gestational age
ANS: A, B, C
Prematurity, postmaturity, and low birth weight can be causes of cognitive impairment in
newborns. Physiological jaundice and large for gestational age are not associated causes of
cognitive impairment in newborns.
3. The clinic nurse is assessing an infant. What are early signs of cognitive impairment the nurse
should discuss with the health care provider? (Select all that apply.)
a. Head lag at 11 months of age
b. No pincer grasp at 4 months of age
c. Colicky incidents at 3 months of age
d. Unable to speak two to three words at 24 months of age
e. Unresponsiveness to the environment at 12 months of age
ANS: A, D, E
Early signs of cognitive impairment include gross motor delay (head lag should be established by
6 months, and head lag still present at 11 months is a delay), language delay (normal language
development is speaking two to three words by age 12 months; if unable to speak two to three
words at 24 months, that is a delay), and unresponsiveness to the environment at 12 months. No
pincer grasp at 4 months of age is normal (palmar grasp is the expected finding), and colicky
incidents at 3 months of age is a normal finding.
4. The nurse is teaching parents of a child with a cognitive impairment signs that indicate the
child is developmentally ready for dressing training. What signs should the nurse include that
indicate the child is developmentally ready for dressing training? (Select all that apply.)
a. Can follow verbal commands
b. Can sit quietly for 1 to 2 minutes
c. Can master every task of dressing
d. Can follow physical gestures or cues
e. Can relate clothing to the appropriate body part
ANS: A, D, E
Children are considered developmentally ready for dressing training if they can sit quietly for 3
to 5 minutes (not 1 to 2) while working on a task; can follow physical gestures or cues; can
follow verbal commands; and can relate clothing to the appropriate body part, such as socks to
feet. As with other self-help skills, the child may not be able to master every task but should be
evaluated for evidence of willingness to participate at his or her level of readiness.
5. The nurse is assessing a child with Down syndrome. The nurse recognizes that which are
possible comorbidities that can occur with Down syndrome? (Select all that apply.)
a. Diabetes mellitus
b. Hodgkins disease
c. Congenital heart defects
d. Respiratory tract infections
e. Acute megakaryoblastic leukemia
ANS: C, D, E
Children with Down syndrome often have multiple comorbidities, contributing to numerous
other conditions. Respiratory tract infections are prevalent; when combined with cardiac
anomalies, they are the chief cause of death, particularly during the first year. The incidence of
leukemia is several times more frequent than expected in the general population, and in about
half of the cases, the type is acute megakaryoblastic leukemia.
6. A child has a slight (2640 dB) degree of hearing loss. The nurse recognizes this amount of
hearing loss can have what effect? (Select all that apply.)
a. No speech defects
b. Difficulty hearing faint speech
c. Usually is unaware of the hearing difficulty
d. Can distinguish vowels but not consonants
e. Unable to understand conversational speech
ANS: A, B, C
A child with a slight degree of hearing loss has no speech defects, may have difficulty hearing
faint speech, and is usually unaware of the hearing difficulty. The ability to distinguish vowels
but not consonants is an effect of severe hearing loss and being unable to understand
conversational speech is an effect of moderately severe hearing loss.
7. What risk factors can cause a sensorineural hearing impairment in an infant? (Select all that
apply.)
a. Cat scratch disease
b. Bacterial meningitis
c. Childhood case of measles
d. Childhood case of chicken pox
e. Administration of aminoglycosides for more than 5 days
ANS: B, C, E
Risk criteria for sensorineural hearing impairment in infants include bacterial meningitis; a case
of measles; and administration of ototoxic medications (e.g., gentamicin, tobramycin,
kanamycin, streptomycin), including but not limited to the aminoglycosides, for more than 5
days. Cat scratch disease and a childhood case of chicken pox are not risk factors that can cause
a sensorineural hearing impairment.
8. The nurse is teaching parents the signs of a hearing impairment in infants. What should the
nurse include as signs? (Select all that apply.)
a. Lack of a fencing reflex
b. Lack of a startle reflex to a loud sound
c. Awakened by loud environmental noises
d. Failure to localize a sound by 6 months of age
e. Response to loud noises as opposed to the voice
ANS: B, D, E
The fencing reflex is elicited when the infant is placed on his or her back; it does not indicate a
hearing impairment. Awakening by a loud environmental noise is a normal response.
9. The nurse is teaching parents the signs of a hearing impairment in a child. What should the
nurse include as signs? (Select all that apply.)
a. Outgoing behavior
b. Yelling to express pleasure
c. Asking to have statements repeated
d. Foot stamping for vibratory sensation
e. Failure to develop intelligible speech by age 24 months
ANS: B, C, D, E
Signs of a hearing impairment in a child include yelling to express pleasure, asking to have
statements repeated, foot stamping for vibratory sensation, and failure to develop intelligible
speech by age 24 months. The childs behavior is shy, not outgoing.
10. The nurse should plan which actions to assist the stuttering child? (Select all that apply.)
a. Ask the child to stop and start over.
b. Promise a reward for proper speech.
c. Set a good example by speaking clearly.
d. Give the child plenty of time to finish sentences.
e. Look directly at the child while he or she is speaking.
ANS: C, D, E
Actions to be encouraged to help the stuttering child include setting a good example by speaking
clearly, giving the child plenty of time to finish sentences, and looking directly at the child while
he or she is speaking. Asking the child to stop and start over and promising a reward for proper
speech are actions to be avoided with stuttering children.
11. The nurse should plan which actions to facilitate lipreading for a child with a hearing
impairment? (Select all that apply.)
a. Face the child directly.
b. Speak at eye level.
c. Keep sentences short.
d. Speak at a fast, even-paced rate.
e. Establish eye contact and show interest.
ANS: A, B, C, E
To facilitate lipreading, the nurse should plan to face the child directly, speak at eye level, keep
sentences short, and establish eye contact and show interest. The nurse should plan to speak at a
slow rate, not a fast one.
12. What are indications for a referral regarding a communication impairment in a school-age
child? (Select all that apply.)
a. Barely audible voice quality
b. Vocal pitch inappropriate for age
c. Intonation noted during speaking
d. Maintains a rhythm while speaking
e. Distortion of sounds after age 7 years
ANS: A, B, E
Barely audible voice quality, vocal pitch inappropriate for age, and distortion of sounds after age
7 years are indications for a referral regarding a communication impairment. Intonation noted
while speaking and maintaining a rhythm while speaking are normal characteristics of speech.
CH.23
1. A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse
knows that before this young woman can be examined, consent must be obtained from which
source?
a. Herself
b. Her mother
c. Court order
d. Legal guardian
ANS: A
Contraceptive advice is one of the conditions that is considered medically emancipated. The
adolescent is able to provide her own informed consent.
2. The nurse needs to take the blood pressure of a preschool boy for the first time. What action
would be best in gaining his cooperation?
a. Tell him that this procedure will help him get well faster.
b. Take his blood pressure when a parent is there to comfort him.
c. Explain to him how the blood flows through the arm and why the blood pressure is important.
d. Permit him to handle the equipment and see the cuff inflate and deflate before putting the cuff in place.
ANS: D
A preschooler is at the stage of preoperational thought. The nurse needs to explain the procedure
in simple terms and allow the child to see how the equipment works. This will help allay fears of
bodily harm. Blood pressure measurement is used for assessment, not therapy, and will not help
him get well faster. Although the parent will be able to support the child, he may still be
uncooperative. Also, the assessment of blood pressure may be needed before the parent is
available. Explaining to a preschooler how the blood flows through the artery and why the blood
pressure is important is too complex.
3. A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her
mother puts the hospital gown on her, but the child is crying because she wants to leave on her
underpants. What is the most appropriate nursing action at this time??
a. Allow her to wear her underpants.
b. Discuss with her mother why this is important to the child.
c. Ask her mother to explain to her why she cannot wear them.
d. Explain in a kind, matter-of-fact manner that this is hospital policy.
ANS: A
It is appropriate for the child to leave her underpants on. If necessary, the underpants can be
removed after she has received the initial medications for anesthesia. This allows her some
measure of control in this procedure. The mother should not be required to make the child more
upset. The child is too young to understand what hospital policy means.
4. Using knowledge of child development, what approach is best when preparing a toddler for a
procedure?
a. Avoid asking the child to make choices.
b. Plan for a teaching session to last about 20 minutes.
c. Demonstrate on a doll how the procedure will be done.
d. Show the necessary equipment without allowing child to handle it.
ANS: C
Prepare toddlers for procedures by using play. Demonstrate on a doll but avoid the childs favorite
doll because the toddler may think the doll is really feeling the procedure. In preparing a toddler
for a procedure, the child is allowed to participate in care and help whenever possible. Teaching
sessions for toddlers should be about 5 to 10 minutes. Use a small replica of the equipment and
allow the child to handle it.
5. The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture.
The child tells the nurse he does not want to lose his blood. What approach is best by the nurse?
a. Explain that it will not be painful.
b. Suggest to him that he not worry about losing just a little bit of blood.
c. Discuss with him how his body is always in the process of making blood.
d. Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure.
ANS: C
School-age children can understand that blood can be replaced. Explain the procedure to him
using correct scientific and medical terminology. The venipuncture will be uncomfortable. It is
inappropriate to tell him it will not hurt. Even though the nurse considers it a simple procedure,
the boy is concerned. Telling him not to worry will not allay his fears.
6. A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold
her during the procedure. How should the nurse respond?
a. Holding your child is unsafe.
b. Holding may help your child relax.
c. Hospital policy prohibits this interaction.
d. Holding your child is unnecessary given the childs age.
ANS: B
The mothers preference for assisting, observing, or waiting outside the room should be assessed,
as well as the childs preference for parental presence. The childs choice should be respected.
This will most likely help the child through the procedure. If the mother and child agree, then the
mother is welcome to stay. Her familiarity with the procedure should be assessed and potential
safety risks identified (mother may sit in chair). Hospital policies should be reviewed to ensure
that they incorporate family-centered care.
7. A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed
tomography scan of the abdomen. To encourage the child to drink, what should the nurse do?
a. Give him a large cup with ice so it tastes better.
b. Restrict him to his room until he drinks the GoLYTELY.
c. Use little cups and make a game to reward him for each cup he drinks.
d. Tell him that if he does not finish drinking by a set time, the practitioner will be angry.
ANS: C
One liter of GoLYTELY is difficult for many children to drink. By using small cups, the child
will find the amount less overwhelming. Then a game can be made in which some type of reward
(sticker, reading another page of a book) is given for each cup. A large cup of ice would make it
more difficult because the child would see it as too much and ice adds additional fluid to be
consumed. Negative reinforcement may work if the child wishes to be out of his room. A
practitioner may or may not be angry if he does not finish drinking by a set time; this is a threat
that may or may not be true. If the child is having difficulty drinking, this would most likely not
be effective.
8. A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the
child, what is the priority intervention?
a. Administering preoperative antibiotic
b. Verifying that the child and procedure are correct
c. Ensuring that the toddler has been NPO since midnight
d. Informing the parents where they can wait during the procedure
ANS: B
The most important intervention is to ensure that the correct child is going to the operating room
for the identified procedure. It is the nurses responsibility to verify identification of the child and
what procedure is to be done. If an antibiotic is ordered, administering it is important, but correct
identification is a priority. Clear liquids can be given up to 2 hours before surgery. If the child
was NPO (taking nothing by mouth) since midnight, intravenous fluids should be administered.
Parents should be encouraged to accompany the child to the preoperative area. Many institutions
allow parents to be present during induction.
9. A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The
orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the
childs heart rate is 20 beats/min less than it was preoperatively. What should be the nurses next
action?
a. Follow the orders and check in 2 hours.
b. Ask the parents if this is the childs usual heart rate.
c. Recheck the pulse and blood pressure in 15 minutes.
d. Notify the surgeon that the child is probably going into shock.
ANS: C
In a 5-year-old child, this is a significant change in vital signs. The nurse should assess the child
to see if his condition mirrors a drop in heart rate. The assessment and vital signs should be
redone in 15 minutes to determine whether the childs condition is stable. When a disparity in
vital signs or other assessment data is observed, the nurse should reassess sooner. Most parents
will not know their childs heart rate. It is important to determine how the child is recovering
from surgery. The nurse should collect additional information before notifying the surgeon. This
includes blood pressure, respiratory rate, and pain status.
10. A 10-year-old child requires daily medications for a chronic illness. Her mother tells the
nurse that the child continually forgets to take the medicine unless reminded. What nursing
action is most appropriate to promote adherence to the medication regimen?
a. Establish a contract with her, including rewards.
b. Suggest time-outs when she forgets her medicine.
c. Discuss with her mother the damaging effects of her rescuing the child.
d. Ask the child to bring her medicine containers to each appointment so they can be counted.
ANS: A
Many factors can contribute to the childs not taking the medication. The nurse should resolve
those issues such as unpleasant side effects, difficulty taking medicine, and time constraints
before school. If these factors do not contribute to the issue, then behavioral contracting is
usually an effective method to shape behaviors in children. Time-outs provide negative
reinforcement. If part of a contract, negative consequences can work, but they need to be
structured. Discussing with her mother the damaging effects of her rescuing the child is not the
most appropriate action to encourage compliance. For a school-age child, parents should refrain
from nagging and rescuing the child. This child is old enough to partially assume responsibility
for her own care. If the child brings her medicine containers to each appointment so they can be
counted, this will help determine if the medications are being taken, but it will not provide
information about whether the child is taking them by herself.
11. A 7-year-old is identified as being at risk for skin breakdown. What intervention should the
nursing care plan include?
a. Massaging reddened bony prominences
b. Teaching the parents to turn the child every 4 hours
c. Ensuring that nutritional intake meets requirements
d. Minimizing use of extra linens, which can irritate the childs skin
ANS: C
Children who are hospitalized and NPO (taking nothing by mouth) for several days are at risk for
nutritional deficiencies and skin breakdown. If NPO status is prolonged, parenteral nutrition
should be considered. Massaging bony prominences can cause deep tissue damage. This should
be avoided. Although parents can participate, turning the child is the nurses responsibility. If the
child is alert and can move, position shifts should be done more frequently. If the child does not
move, the nurse should reposition every 2 hours. The number of linens is not an issue. The child
should not be dragged across the sheet. Children should be lifted and moved to avoid friction and
shearing.
12. A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his
regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What
nursing action is the most appropriate?
a. Request these favorite foods for him.
b. Identify healthier food choices that he likes.
c. Explain that he needs fruits and vegetables.
d. Reward him with ice cream at the end of every meal that he eats.
ANS: A
Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate
nutrition, the nurse should request favorite foods for the child. The foods he likes provide
nutrition and can be supplemented with additional fruits and vegetables. Ice cream and other
desserts should not be used as rewards or punishment.
13. A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry
represents best documentation of his breakfast meal?
a. Tolerated breakfast well
b. Finished all of breakfast ordered
c. One pancake, eggs, and 240 ml OJ
d. No documentation is needed for this age child.
ANS: C
Specific information is necessary for hospitalized children. It is essential to be able to identify
caloric intake and eating patterns for assessment and intervention purposes. That he tolerated
breakfast well only provides information that the child did not become ill with the meal. Even if
he finished all his breakfast, an evaluation cannot be completed unless the quantity of food
ordered is known. Nutritional information is essential, especially for children with chronic
illnesses.
14. A child, age 7 years, has a fever associated with a viral illness. She is being cared for at
home. What is the principal reason for treating fever in this child?
a. Relief of discomfort
b. Reassurance that illness is temporary
c. Prevention of secondary bacterial infection
d. Avoidance of life-threatening complications
ANS: A
The principal reason for treating fever is the relief of discomfort. Relief measures include
pharmacologic and environmental intervention. The most effective is the use of pharmacologic
agents to lower the set point. Although the nurse can reassure the child that the illness is
temporary, the child is often uncomfortable and irritable. Intervention helps the child and family
minimize the discomfort. Most fevers result from viral, not bacterial, infections. Few life-
threatening events are associated with fever. The use of antipyretics does not seem to reduce the
incidence of febrile seizures.
15. A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as
acetaminophen. How should the nurse respond to the parents?
a. Febrile seizures can result.
b. Antipyretics may cause malignant hyperthermia.
c. Antipyretics are of no value in treating hyperthermia.
d. Liver damage may occur in critically ill children.
ANS: C
Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already
normal. Cooling measures are used instead. Antipyretics do not cause seizures. Malignant
hyperthermia is a genetic myopathy that is triggered by anesthetic agents. Antipyretic agents do
not have this effect. Acetaminophen can result in liver damage if too much is given or if the liver
is already compromised. Other antipyretics are available, but they are of no value in
hyperthermia.
16. The nurse gives an injection in a patients room. How should the nurse dispose of the needle?
a. Remove the needle from the syringe and dispose of it in a proper container.
b. Dispose of the syringe and needle in a rigid, puncture-resistant container in the patients room.
c. Close the safety cover on the needle and return it to the medication preparation area for proper disposal.
d. Place the syringe and needle in a rigid, puncture-resistant container in an area outside of the patients room.
ANS: B
All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant, tamper-proof
container located near the site of use. Consequently, these containers should be installed in the
patients room. Needles and syringes are disposed of uncapped and unbroken. A used needle
should not be transported to an area distant from use for disposal.
17. A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-
resistant Staphylococcus aureus (MRSA) infection. The nurse recognizes that in addition to a
private room, the child is placed on what precautions?
a. Droplet
b. Contact
c. Airborne
d. Standard
ANS: B
MRSA is an increasingly significant source of hospital-acquired infections. This organism meets
the criteria of being epidemiologically important and can be transmitted by direct contact. Gowns
and gloves should be worn when exposed to potentially contagious materials, and meticulous
hand washing is required. S. aureus is not an organism that is spread through airborne or droplet
mechanisms. Additional precautions, beyond Standard Precautions, are needed to prevent spread
of this organism.
18. An 11-month-old hospitalized boy is restrained because he is receiving intravenous (IV)
fluids. His grandmother has come to stay with him for the afternoon and asks the nurse if the
restraints can be removed. What nurses response is best?
a. Restraints need to be kept on all the time.
b. That is fine as long as you are with him.
c. That is fine if we have his parents consent.
d. The restraints can be off only when the nursing staff is present.
ANS: B
The restraints are necessary to protect the IV site. If the child has appropriate supervision,
restraints are not necessary. The nurse should remove the restraints whenever possible. When
parents or staff members are present, the restraints can be removed and the IV site protected.
Parental permission is not needed for restraint removal.
19. A nurse must do a venipuncture on a 6-year-old child. What consideration is important in
providing atraumatic care?
a. Use an 18-gauge needle if possible.
b. Show the child the equipment to be used before the procedure.
c. If not successful after four attempts, have another nurse try.
d. Restrain the child completely.
ANS: B
To provide atraumatic care the child should be able to see the equipment to be used before the
procedure begins. Use the smallest gauge needle that permits free flow of blood. A two-try-only
policy is desirable, in which two operators each have only two attempts. If insertion is not
successful after four punctures, alternative venous access should be considered. Restrain the
child only as needed to perform the procedure safely; use therapeutic hugging.
20. A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When
preparing for a lumbar puncture, what should the nurse do?
a. Set up a tray with equipment the same size as for adults.
b. Apply EMLA to the puncture site 15 minutes before the procedure.
c. Prepare the child for conscious sedation being used for the procedure.
d. Reassure the parents that the test is simple, painless, and risk free.
ANS: C
Because of the urgency of the childs condition, conscious sedation should be used for the
procedure. Pediatric spinal trays have smaller needles than do adult trays. EMLA should be
applied approximately 60 minutes before the procedure; the emergency nature of the spinal tap
precludes its use. A spinal tap is not a simple procedure and does have associated risks; analgesia
will be given for the pain.
21. Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is
the most appropriate way to collect small amounts of urine for these tests?
a. Apply a urine collection bag to the perineal area.
b. Tape a small medicine cup inside of the diaper.
c. Aspirate urine from cotton balls inside the diaper with a syringe without a needle.
d. Use a syringe without a needle to aspirate urine from a superabsorbent disposable diaper.
ANS: C
To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from
the diaper. Diapers with superabsorbent gels absorb the urine; if these are used, place a small
gauze dressing or cotton balls inside the diaper to collect the urine and aspirate the urine with a
syringe. For frequent urine sampling, the collection bag would be too irritating to the childs skin.
It is not feasible to tape a small medicine cup to the inside of the diaper; the urine will spill from
the cup.
22. A child has a central venous access device for intravenous (IV) fluid administration. A blood
sample is needed for a complete blood count, hemogram, and electrolytes. What is the
appropriate procedure to implement for this blood sample?
a. Perform a new venipuncture to obtain the blood sample.
b. Interrupt the IV fluid and withdraw the blood sample needed.
c. Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed.
d. Flush the line and central venous device with saline and then aspirate the required amount of blood for the sample.
ANS: C
The blood specimen obtained must reflect the appropriate hemodilution of the blood and
electrolyte concentration. The nurse needs to withdraw the amount of fluid that is in the device
and discard it. The next sample will come from the childs circulating blood. With a central
venous device, the trauma of a separate venipuncture can be avoided. The blood sample will be
diluted with either the IV fluid being administered or the saline.
23. The nurse has just collected blood by venipuncture in the antecubital fossa. What should the
nurse do next?
a. Keep the childs arm extended while applying a Band-Aid to the site.
b. Keep the childs arm extended and apply pressure to the site for a few minutes.
c. Apply a Band-Aid to the site and keep the arm flexed for 10 minutes.
d. Apply a gauze pad or cotton ball to the site and keep the arm flexed for several minutes.
ANS: B
Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation. Pressure
should be applied before a bandage or gauze pad is applied.
24. An appropriate method for administering oral medications that are bitter to an infant or small
child should be to mix them with which?
a. Bottle of formula or milk
b. Any food the child is going to eat
c. One teaspoon of something sweet-tasting such as jam
d. Carbonated beverage, which is then poured over crushed ice
ANS: C
Mix the drug with a small amount (about 1 tsp) of sweet-tasting substance. This will make the
medication more palatable to the child. The medication should be mixed with only a small
amount of food or liquid. If the child does not finish drinking or eating, it is difficult to determine
how much medication was consumed. Medication should not be mixed with essential foods and
milk. The child may associate the altered taste with the food and refuse to eat this food in the
future.
25. The practitioner has ordered a liquid oral antibiotic for a toddler with otitis media. The
prescription reads 1 1/2 tsp four times per day. What should the nurse consider in teaching the
mother how to give the medicine?
a. A measuring spoon should be used, and the medication must be given every 6 hours.
b. The mother is not able to handle this regimen. Long-acting intramuscular antibiotics should be administered.
c. A hollow-handled medication spoon is advisable, and the medication should be equally spaced while the child is awake.
d.
A household teaspoon should be used and the medicine given when the child wakes up, around lunch time, at dinner time,
and before bed.
ANS: C
A hollow-handled medication spoon allows the mother to measure the correct amount of
medication. The order is written for four times a day; every 6 hours dosing is not necessary.
There is no indication that the mother is not able to adhere to the medication regimen. She is
asking for clarification so she can properly care for her child. Long-acting intramuscular
antibiotics are not indicated. Household teaspoons vary greatly and should not be used.
26. Guidelines for intramuscular administration of medication in school-age children include
what standard?
a. Inject medication as rapidly as possible.
b. Insert needle quickly, using a dartlike motion.
c. Have the child stand if at all possible and if the child is cooperative.
d. Penetrate the skin immediately after cleansing the site while the skin is moist.
ANS: B
The needle should be inserted quickly in a dartlike motion at a 90-degree angle unless
contraindicated. Inject medications slowly. Allow skin preparation to dry completely before the
skin is penetrated. Place the child in a lying or sitting position.
27. What is an advantage of the ventrogluteal muscle as an injection site in young children?
a. Easily accessible from many directions
b. Free of significant nerves and vascular structures
c. Can be used until child reaches a weight of 9 kg (20 lb)
d. Increased subcutaneous fat, which provides sustained drug absorption
ANS: B
Being free of significant nerves and vascular structure is one of the advantages of the
ventrogluteal site. In addition, it is considered less painful than the vastus lateralis. The major
disadvantage is lack of familiarity by health professionals and controversy over whether the site
can be used before weight bearing. The vastus lateralis is a more accessible site. The
ventrogluteal muscle site has safely been used from newborn through adulthood. Clinical
guidelines address the need for the child to be walking. The site has less subcutaneous tissue,
which facilitates intramuscular deposition of the drug rather than subcutaneous.
28. When teaching a mother how to administer eye drops, where should the nurse tell her to
place them?
a. At the lacrimal duct
b. On the sclera while the child looks to the outside
c. In the conjunctival sac when the lower eyelid is pulled down
d. Carefully under the eyelid while it is gently pulled upward
ANS: C
The lower eyelid is pulled down, forming a small conjunctival sac. The solution or ointment is
applied to this area. The medication should not be administered directly on the eyeball. The
lacrimal duct is not the appropriate placement for the eye medication. It will drain into the
nasopharynx, and the child will taste the drug.
29. What is the best method to verify the placement of a nasogastric tube before each use?
a. Radiologic confirmation
b. Auscultation of injected air
c. Aspiration of stomach contents
d. Verification of tape placement on tube
ANS: C
Visual inspection and pH check of stomach contents is a reliable method of determining
placement before each use. Radiologic examination should be obtained after initial placement
but would be too cumbersome to do before each use. Auscultation is an unreliable method to
confirm tube placement because of the similarity of sounds produced by air in the bronchus,
esophagus, or pleural space. Verification of tape placement on the tube can be inaccurate if the
tube has moved within the tape or become dislodged from the stomach.
30. Parents are being taught how to feed their infant using a newly placed gastrostomy tube (G-
tube). What is essential information for the parents to receive?
a. Verify placement before each feeding.
b. Use a syringe with a plunger to give the infant bolus feedings.
c. Position the infant on the right side during and after the feeding.
d. Beefy red tissue around the G-tube site must be reported to the practitioner.
ANS: C
Positioning on the right side during and after feedings helps minimize the risk of aspiration. It is
not necessary to verify placement before each feeing. G-tubes are inserted into the stomach and
sutured in place. If the tube is through the skin, it is in the stomach. Feedings should be given by
gravity flow. The plunger may be used to initiate the feeding, but then the formula should be
allowed to flow. Beefy red tissue around the G-tube site is normal granulation tissue that is
expected.
31. What is a priority intervention for an infant with a temporary colostomy for Hirschsprung
disease?
a. Teaching how to irrigate the colostomy
b. Protecting the skin around the colostomy
c. Discussing the implications of a colostomy during puberty
d. Using simple, straightforward language to prepare the child
ANS: B
Protection of the peristomal skin is a major priority. Well-fitting appliances and skin protectants
are used. Teaching how to irrigate a colostomy is not necessary because colostomies are not
irrigated in infants. The colostomy is usually reversed within 6 months to 1 year. The parents, not
the infant, need to be prepared for the surgery.
32. A 1-month-old infant is admitted to the hospital. The infants mother is 17 years old and
single and lives with her parents. Who signs the informed consent for the 1-month-old infant?
a. The infants mother
b. The maternal grandparents of the infant
c. The paternal grandparents of the infant
d. Both the infants mother and the maternal grandparents
ANS: A
An emancipated minor is one who is legally under the age of majority but is recognized as
having the legal capacity of an adult under circumstances prescribed by state law, such as
pregnancy, marriage, high school graduation, independent living, or military service.
33. A preschool child needs a dressing change. To prepare the child, what strategy should the
nurse implement?
a. Explain the procedure using medical terminology.
b. Plan a 30-minute teaching session.
c. Give choices when possible but avoid delay.
d. Allow time after the procedure for questions and discussion.
ANS: C
Involving children helps to gain their cooperation. Permitting choices gives them some measure
of control. The other options would not be appropriate for a preschool child.
34. The nurse on a pediatric unit is writing guidelines for age-specific preparation of children for
procedures based on developmental characteristics. What guideline is accurate?
a. Inform toddlers about an upcoming procedure 2 hours before the procedure is to be performed.
b. Inform school-age children about an upcoming procedure immediately before the procedure is scheduled to occur.
c. Discourage parent presence during procedures on infants and toddlers.
d. Use simple diagrams of anatomy and physiology to explain a procedure to a school-age child.
ANS: D
To assist the school-age child in meeting Ericksons developmental stage of industry, using
simple diagrams of anatomy and physiology to explain a procedure is the accurate guideline.
Toddlers should be told about a procedure right before the procedure. School-age children should
know about the procedure in advance, not right before, and parents should be present for
procedures for infants and toddlers.
35. A laboratory technician is performing a blood draw on a toddler. The toddler is holding still
but crying loudly. The nurse should take which action?
a. Have the lab technician stop the procedure until the child stops crying.
b. Do nothing. Its Okay for a child to cry during a painful procedure.
c. Tell the child to stop crying; its only a small prick.
d. Tell the child to stop crying because the procedure is almost over.
ANS: B
The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other
emotion. It is natural for children to strike out in frustration or to try to avoid stress-provoking
situations. The child needs to know that it is all right to cry.
36. At which age should a nurse keep teaching time short (5 minutes)?
a. Infant
b. Toddler
c. Preschool
d. School age
ANS: B
Toddlers have limited time concept, and teaching time should be kept short (510 minutes).
37. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What
nursing action is appropriate?
a. Retake the temperature in 15 minutes after giving the Tylenol.
b. Place a warm blanket on the child so chilling does not occur.
c. Check to be sure the Tylenol dose does not exceed 15 mg/kg.
d. Use cold compresses instead of Tylenol to control the fever.
ANS: C
Nurses must have an understanding of the safe dosages of medications they administer to
children, as well as the expected actions, possible side effects, and signs of toxicity. The
recommended doses of acetaminophen should never be exceeded.
38. The nurse is administering an IM injection into a vastus lateralis muscle of a 6-month-old
infant. What should the length of the needle and amount to be given be?
a. 5/8 to 1 inch; 0.5 to 1.0 ml
b. 1 inch to 1 1/2 inch; 1.0 to 2.0 ml
c. 1 inch to 1 1/2 inch; 0.5 to 1.0 ml
d. 5/8 to 1 inch; 0.75 to 2 ml
ANS: A
The length of a needle for an infant should be 5/8 to 1 inch, and the amount of solution should
not exceed 1 ml.
39. The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin
administering intravenous antibiotics. The child starts to cry and tells the nurse, Do it later, okay?
What action should the nurse take?
a. Postpone starting the IV until the next shift.
b. Start the IV line and then allow for expression of feelings.
c. Change the route of the antibiotics to PO.
d. Postpone starting the IV line until the child is ready.
ANS: B
A school-age child may try to delay the procedure, but it is best to complete the procedure and
allow time for the child to express his or her feelings. The nurse should not postpone
administering the antibiotic, change it to PO, or wait to start the IV line until the child is ready.
40. The nurse is preparing to administer a liquid medication by a nasogastric feeding tube. What
is the first thing the nurse should do?
a. Check placement of the tube.
b. Check the pH of the gastric aspirate.
c. Flush the tube with a small amount of water.
d. Give the medication and then flush with a small amount of water.
ANS: B
The most accurate way to check the position of the nasogastric tube is by checking the pH.
Auscultation as a verification tool is reliable only 60% to 80% of the time and should not be used
without additional methods. The tube should not be flushed or the medication administered until
placement of the tube is checked.
41. To facilitate the administration of an oral medication to a preschool-age child, what action
should the nurse take?
a. Dilute the medication in a large amount of favorite liquid and allow the child to hold the cup.
b. Set limits about the need to take medication and offer praise immediately after the task is accomplished.
c. Mix the medication in a moderate amount of the childs favorite food.
d. Explain the purpose of the medication and allow the child time to express resistance before giving the medication.
ANS: B
Nurses who approach children with confidence and who convey the impression that they expect
to be successful are less likely to encounter difficulty. It is best to approach a child as though
cooperation is expected. The medication should not be placed in a favorite liquid or food.
Allowing the child time to express resistance will delay administration of the medication.
42. A 2-year-old child has to receive Rocephin IM injections every 12 hours. What nursing
intervention should be implemented for the child?
a. Hold the child while rocking in a chair after each injection.
b. Prepare the child several hours before the injection is given.
c. Allow the child to watch a younger child receive an injection.
d. Encourage the child to draw a picture of the pain experienced when an injection is given.
ANS: A
After the procedure, the child continues to need reassurance that he or she performed well and is
accepted and loved. The other options are not appropriate for a toddler.
43. When checking the intravenous (IV) site on a child, the nurse should take which action?
a. Look at the site.
b. Ask the child if the site hurts.
c. Look at the site while palpating the area.
d. Take all the tape off, assess the site, and redress.
ANS: C
To appropriately check the intravenous (IV) site, the nurse should look at the site and palpate the
area. The other options would not be adequate assessments of the site.
MULTIPLE RESPONSE
1. The nurse is caring for a 12-year-old child who is on fall precautions secondary to seizures.
What interventions should be included in the childs care plan? (Select all that apply.)
a. Place a call light and desired items within reach.
b. Keep the bed in the highest position with the two side rails up.
c. Turn off the lights and television at night.
d. Keep personal belongings and clutter contained in one area of the floor.
e. Have the child wear an appropriate-size gown and nonskid footwear.
ANS: A, E
Prevention of falls requires alterations in the environment, including keeping call light and
desired items within reach and having the child wear appropriate-size gowns and nonskid
footwear. The bed should be in the lowest position possible with all the side rails up; at least a
dim light should be left on at night; and personal belongings and clutter should not be on the
floorthey should be in a cabinet.
2. What methods should the nurse use to measure compliance to a treatment plan? (Select all that
apply.)
a. Pill counts
b. Chemical assays
c. Direct observation
d. Third-party reporting
e. Monitoring therapeutic response
ANS: A, B, C, E
Assessment of compliance must include direct measurement techniques. Pill counts, chemical
assays, direct observation, and monitoring therapeutic response are direct measurement
techniques. Third-party reporting would not always be available and would not be a method to
measure compliance.
3. What interventions should the nurse implement to prevent a pressure ulcer in a critically ill
child? (Select all that apply.)
a. Nutrition consults
b. Using skin moisturizers
c. Turning the child every 2 hours
d. Using plastic disposable underpads
e. Using draw sheets to minimize shear
ANS: A, B, C, E
Interventions found to prevent pressure ulcers in critically ill children include nutrition consults,
using skin moisturizers, turning the child every 2 hours, and using draw sheets to minimize shear.
Dryweave underpads, not underpads with plastic, should be used to reduce moisture.
4. The nurse is preparing to obtain a nasal washing from a child. What equipment should the
nurse gather for the procedure? (Select all that apply.)
a. Sterile water
b. A sterile swab
c. Syringe with tubing
d. Sterile normal saline
e. Tracheal suction catheter
ANS: C, D
Nasal washings may be obtained to identify viral pathogens and guide therapy in some
respiratory conditions. The child is placed supine, and 1 to 3 ml of sterile normal saline is
instilled with a sterile syringe (without a needle) into one nostril. The contents are aspirated with
a syringe with 5 cm (2 inches) of 18- to 20-gauge tubing. The saline is quickly instilled and then
aspirated to recover the nasal specimen. A tracheal suction catheter would not trap the mucus.
Normal saline is used, not sterile water. A sterile swab is used for a throat culture, not for nasal
washings.
5. The clinic nurse is teaching parents about when to call the office immediately for a child with
a fever. What should the nurse include in the teaching session? (Select all that apply.)
a. The child has a stiff neck.
b. The fever is over 40.6 C (105 F).
c. The child is younger than 2 months.
d. The fever has lasted for more than 3 days.
e. The fever went away for more than 24 hours and then returned.
ANS: A, B, C
Parents should call the office immediately if a child has a fever over 40.6 C (105 F), the child is
younger than 2 months, or the child has a stiff neck. Parents are to call within 24 hours if the
fever went away for more than 24 hours and then returned or the fever has lasted for more than 3
days.
6. What strategies should the nurse implement to assist in feeding a sick child? (Select all that
apply.)
a. Serve large portions.
b. Make mealtimes pleasant.
c. Avoid foods that are highly seasoned.
d. Provide finger foods for young children.
e. Ensure a variety of foods, textures, and colors.
ANS: B, C, D, E
To assist in feeding a sick child mealtimes should be pleasant; highly seasoned foods should be
avoided; finger foods should be provided for young children; and a variety of foods, textures,
and colors should be ensured. Small portions, not large, should be served.
7. What disease processes require contact isolation? (Select all that apply.)
a. Rotavirus
b. Hepatitis A
c. Streptococcal pharyngitis
d. Mycoplasmal pneumonia
e. Respiratory syncytial virus
ANS: A, B, E
In addition to Standard Precautions, use contact precautions for patients known or suspected to
have serious illnesses easily transmitted by direct patient contact or by contact with items in the
patients environment. Examples of such illnesses include rotavirus, hepatitis A, and respiratory
syncytial virus. Streptococcal pharyngitis and mycoplasmal pneumonia require droplet
precautions.
8. What disease processes require airborne precautions? (Select all that apply.)
a. Measles
b. Varicella
c. Pertussis
d. Meningitis
e. Tuberculosis
ANS: A, B, E
In addition to Standard Precautions, use airborne precautions for patients known or suspected to
have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include
measles, varicella (including disseminated zoster), and tuberculosis. Pertussis and meningitis
require droplet precautions.
9. What are the advantages of an implanted port (Port-a-Cath)? (Select all that apply.)
a. Reduced risk of infection
b. Reduced cost for the family
c. Placed completely under the skin
d. Easy to use for self-administered infusions
e. Removal does not require a surgical procedure
ANS: A, B, C
The advantages of an implanted port include reduced risk of infection, reduced cost for the
family, and placed completely under the skin. Because it is implanted and must be accessed, it is
not easy to use for self-administered infusions, and removal does require a surgical procedure.
10. What play activities should the nurse implement to encourage fluid intake for a child? (Select
all that apply.)
a. Have a tea party.
b. Use a crazy straw.
c. Cut gelatin into fun shapes.
d. Place liquid in large Styrofoam cups.
e. Make ice pops using the childs favorite juice.
ANS: A, B, C, E
Play activities to encourage fluid intake for a child include tea parties, crazy straws, cutting
gelatin into fun shapes, and making ice pops using the childs favorite juice. Small cups, not large
Styrofoam cups, should be used.
CH.24
1. What substance is released from the posterior pituitary gland and promotes water retention in
the renal system?
a. Renin
b. Aldosterone
c. Angiotensin
d. Antidiuretic hormone (ADH)
ANS: D
ADH is released in response to increased osmolality and decreased volume of intravascular fluid;
it promotes water retention in the renal system by increasing the permeability of renal tubules to
water. Renin release is stimulated by diminished blood flow to the kidneys. Aldosterone is
secreted by the adrenal cortex. It enhances sodium reabsorption in renal tubules, promoting
osmotic reabsorption of water. Renin reacts with a plasma globulin to generate angiotensin,
which is a powerful vasoconstrictor. Angiotensin also stimulates the release of aldosterone.
2. Nurses should be alert for increased fluid requirements in which circumstance?
a. Fever
b. Mechanical ventilation
c. Congestive heart failure
d. Increased intracranial pressure
ANS: A
Fever leads to great insensible fluid loss in young children because of increased body surface
area relative to fluid volume. The mechanically ventilated child has decreased fluid
requirements. Congestive heart failure is a case of fluid overload in children. Increased
intracranial pressure does not lead to increased fluid requirements in children.
3. What factor predisposes an infant to fluid imbalances?
a. Decreased surface area
b. Lower metabolic rate
c. Immature kidney functioning
d. Decreased daily exchange of extracellular fluid
ANS: C
The infants kidneys are functionally immature at birth and are inefficient in excreting waste
products of metabolism. Infants have a relatively high body surface area (BSA) compared with
adults. This allows a higher loss of fluid to the environment. A higher metabolic rate is present as
a result of the higher BSA in relation to active metabolic tissue. The higher metabolic rate
increases heat production, which results in greater insensible water loss. Infants have a greater
exchange of extracellular fluid, leaving them with a reduced fluid reserve in conditions of
dehydration.
4. What is the required number of milliliters of fluid needed per day for a 14-kg child?
a. 800
b. 1000
c. 1200
d. 1400
ANS: C
For the first 10 kg of body weight, a child requires 100 ml/kg. For each additional kilogram of
body weight, an extra 50 ml is needed.
10 kg 100 ml/kg/day = 1000 ml
4 kg 50 ml/kg/day = 200 ml
1000 ml + 200 ml = 1200 ml/day
Eight hundred to 1000 ml is too little; 1400 ml is too much.
5. An infant is brought to the emergency department with the following clinical manifestations:
poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which
situation?
a. Water excess
b. Sodium excess
c. Water depletion
d. Potassium excess
ANS: C
These clinical manifestations indicate water depletion or dehydration. Edema and weight gain
occur with water excess or overhydration. Sodium or potassium excess would not cause these
symptoms.
6. Clinical manifestations of sodium excess (hypernatremia) include which signs or symptoms?
a. Hyperreflexia
b. Abdominal cramps
c. Cardiac dysrhythmias
d. Dry, sticky mucous membranes
ANS: D
Dry, sticky mucous membranes are associated with hypernatremia. Hyperreflexia is associated
with hyperkalemia. Abdominal cramps, weakness, dizziness, nausea, and apprehension are
associated hyponatremia. Cardiac dysrhythmias are associated with hypokalemia.
7. What laboratory finding should the nurse expect in a child with an excess of water?
a. Decreased hematocrit
b. High serum osmolality
c. High urine specific gravity
d. Increased blood urea nitrogen
ANS: A
The excess water in the circulatory system results in hemodilution. The laboratory results show a
falsely decreased hematocrit. Laboratory analysis of blood that is hemodiluted reveals decreased
serum osmolality and blood urea nitrogen. The urine specific gravity is variable relative to the
childs ability to correct the fluid imbalance.
8. What clinical manifestation(s) is associated with calcium depletion (hypocalcemia)?
a. Nausea, vomiting
b. Weakness, fatigue
c. Muscle hypotonicity
d. Neuromuscular irritability
ANS: D
Neuromuscular irritability is a clinical manifestation of hypocalcemia. Nausea and vomiting
occur with hypercalcemia and hypernatremia. Weakness, fatigue, and muscle hypotonicity are
clinical manifestations of hypercalcemia.
9. What type of dehydration occurs when the electrolyte deficit exceeds the water deficit?
a. Isotonic dehydration
b. Hypotonic dehydration
c. Hypertonic dehydration
d. Hyperosmotic dehydration
ANS: B
Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the
serum hypotonic. Isotonic dehydration occurs in conditions in which electrolyte and water
deficits are present in balanced proportion. Hypertonic dehydration results from water loss in
excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding
children fluids with high amounts of solute. Hyperosmotic dehydration is another term for
hypertonic dehydration.
10. What amount of fluid loss occurs with moderate dehydration?
a. <50 ml/kg
b. 50 to 90 ml/kg
c. <5% total body weight
d. >15% total body weight
ANS: B
Moderate dehydration is defined as a fluid loss of between 50 and 90 ml/kg. Mild dehydration is
defined as a fluid loss of less than 50 ml/kg. Weight loss up to 5% is considered mild
dehydration. Weight loss over 15% is severe dehydration.
11. Physiologically, the child compensates for fluid volume losses by which mechanism?
a. Inhibition of aldosterone secretion
b. Hemoconcentration to reduce cardiac workload
c. Fluid shift from interstitial space to intravascular space
d. Vasodilation of peripheral arterioles to increase perfusion
ANS: C
Compensatory mechanisms attempt to maintain fluid volume. Initially, interstitial fluid moves
into the intravascular compartment to maintain blood volume. Aldosterone is released to promote
sodium retention and conserve water in the kidneys. Hemoconcentration results from the fluid
volume loss. With less circulating volume, tachycardia results. Vasoconstriction of peripheral
arterioles occurs to help maintain blood pressure.
12. Ongoing fluid losses can overwhelm the childs ability to compensate, resulting in shock.
What early clinical sign precedes shock?
a. Tachycardia
b. Slow respirations
c. Warm, flushed skin
d. Decreased blood pressure
ANS: A
Shock is preceded by tachycardia and signs of poor tissue perfusion and decreased pulse
oximetry values. Respirations are increased as the child attempts to compensate. As a result of
the poor peripheral circulation, the child has skin that is cool and mottled with decreased
capillary refilling after blanching. In children, lowered blood pressure is a late sign and may
accompany the onset of cardiovascular collapse.
13. The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an
infant?
a. Weight loss and decreased heart rate
b. Capillary refill of less than 2 seconds and no tears
c. Increased skin elasticity and sunken anterior fontanel
d. Dry mucous membranes and generally ill appearance
ANS: D
A good predictor of a fluid deficit of at least 5% is any two four factors: capillary refill of more
than 2 seconds, absent tears, dry mucous membranes, and ill general appearance. Weight loss is
associated with fluid deficit, but the degree needs to be quantified. Heart rate is usually elevated.
Skin elasticity is decreased, not increased. The anterior fontanel is depressed.
14. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical
manifestation is suggestive of water intoxication?
a. Oliguria
b. Weight loss
c. Irritability and seizures
d. Muscle weakness and cardiac dysrhythmias
ANS: C
Irritability, somnolence, headache, vomiting, diarrhea, and generalized seizures are
manifestations of water intoxication. Urinary output is increased as the child attempts to maintain
fluid balance. Weight gain is usually associated with water intoxication. Muscle weakness and
cardiac dysrhythmias are not associated with water intoxication.
15. What physiologic state(s) produces the clinical manifestations of nervous system stimulation
and excitement, such as overexcitability, nervousness, and tetany?
a. Metabolic acidosis
b. Respiratory alkalosis
c. Metabolic and respiratory acidosis
d. Metabolic and respiratory alkalosis
ANS: D
The major symptoms and signs of alkalosis include nervous system stimulation and excitement,
including overexcitability, nervousness, tingling sensations, and tetany that may progress to
seizures. Acidosis (both metabolic and respiratory) has clinical signs of depression of the central
nervous system, such as lethargy, diminished mental capacity, delirium, stupor, and coma.
Respiratory alkalosis has the same symptoms and signs as metabolic alkalosis.
16. What is an approximate method of estimating output for a child who is not toilet trained?
a. Have parents estimate output.
b. Weigh diapers after each void.
c. Place a urine collection device on the child.
d. Have the child sit on a potty chair 30 minutes after eating.
ANS: B
Weighing diapers will provide an estimate of urinary output. Each 1 g of weight is equivalent to
1 ml of urine. Having parents estimate output would be inaccurate. It is difficult to estimate how
much fluid is in a diaper. The urine collection device would irritate the childs skin. It would be
difficult for a toddler who is not toilet trained to sit on a potty chair 30 minutes after eating.
17. The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The
superficial veins on his hand and arm are not readily visible. What intervention should increase
the visibility of these veins?
a. Gently tap over the site.
b. Apply a cold compress to the site.
c. Raise the extremity above the level of the body.
d. Use a rubber band as a tourniquet for 5 minutes.
ANS: A
Gently tapping the site can sometimes cause the veins to be more visible. This is done before the
skin is prepared. Warm compresses (not cold) may be useful. The extremity is held in a
dependent position. A tourniquet may be helpful, but if too tight, it could cause the vein to burst
when punctured. Five minutes is too long.
DIF: Cognitive Level: Applying REF: p. 961
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
18. When caring for a child with an intravenous (IV) infusion, what is an appropriate nursing
action?
a. Change the insertion site every 24 hours.
b. Check the insertion site frequently for signs of infiltration.
c. Use a macrodropper to facilitate reaching the prescribed flow rate.
d. Avoid restraining the child to prevent undue emotional stress.
ANS: B
The nursing responsibility for IV therapy is to calculate the amount to be infused in a given
length of time; set the infusion rate; and monitor the apparatus frequently, at least every 1 to 2
hours, to make certain that the desired rate is maintained, the integrity of the system remains
intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the infusion
does not stop. Insertion sites do not need to be changed every 24 hours unless a problem is found
with the site. This exposes the child to significant trauma. A minidropper (60 drops/ml) is the
recommended IV tubing in pediatric patients. Intravenous sites should be protected. This may
require soft restraints on the child.
DIF: Cognitive Level: Applying REF: p. 961
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
19. The nurse determines that a childs intravenous infusion has infiltrated. The infused solution
is a vesicant. What is the most appropriate nursing action?
a. Stop the infusion and apply ice.
b. End the infusion and notify the practitioner.
c. Slow the infusion rate and notify the practitioner.
d. Discontinue the infusion and apply warm compresses.
ANS: B
A vesicant causes cellular damage when even minute amounts escape into the tissue. The
intravenous infusion is immediately stopped, the extremity is elevated, the practitioner is
notified, and the treatment protocol is initiated. The applying of heat or ice depends on the fluid
that has extravasated. The catheter is left in place until it is no longer needed.
DIF: Cognitive Level: Applying REF: p. 972
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
20. Several types of long-term central venous access devices are used. What is a benefit of using
an implanted port (e.g., Port-a-Cath)?
a. You do not need to pierce the skin for access.
b. It is easy to use for self-administered infusions.
c. The patient does not need to limit regular physical activity, including swimming.
d. The catheter cannot dislodge from the port even if the child plays with the port site.
ANS: C
No limitations on physical activity are needed. The child is able to participate in all regular
physical activities, including bathing, showering, and swimming. The skin over the device is
pierced with a Huber needle to access. Long-term central venous access devices are difficult to
use for self-administration. The port is placed under the skin. If the child manipulates the device
and plays with the actual port, the catheter can be dislodged.
DIF: Cognitive Level: Applying REF: p. 979 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
21. The nurse is teaching the family of a child with a long-term central venous access device
about signs and symptoms of bacteremia. What finding indicates the presence of bacteremia?
a. Hypertension
b. Pain at the entry site
c. Fever and general malaise
d. Redness and swelling at the entry site
ANS: C
Fever, chills, general malaise, and an ill appearance can be signs of bacteremia and require
immediate intervention. Hypotension would be indicative of sepsis and possible impending
cardiovascular collapse. Pain, redness, and swelling at the entry site indicate local infection.
DIF: Cognitive Level: Applying REF: p. 979
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
22. What flush solution is recommended for intravenous catheters larger than 24 gauge?
a. Saline
b. Heparin
c. Alteplase
d. Heparin and saline combination
ANS: A
The recommended solution for flushing venous access devices is saline. The turbulent flow flush
with saline is effective for catheters larger than 24 gauge. The use of heparin does not increase
the longevity of the venous access device. In 24-gauge catheters, heparin may offer an
advantage. Alteplase is used for treating catheter-related occlusions in children. The heparin and
saline combination does not offer any advantage over saline or heparin individually.
DIF: Cognitive Level: Applying REF: p. 977
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
23. The nurse is teaching a parent of a 10-year-old child who will be discharged with a venous
access device (VAD). What statement by the parent indicates a correct understanding of the
teaching?
a. I should have my child wear a protective vest when my child wants to participate in contact sports.
b. I should apply pressure to the entry site to the vein, not the exit site, if the VAD is accidentally removed.
c. I can expect my child to have feelings of general malaise for 1 week after the VAD is inserted.
d.
I should give my child a sponge bath for the first 2 weeks after the VAD is inserted; then I can allow my child to take a
bath.
ANS: B
The parents of a child with a VAD should be taught to apply pressure to the entry site to the vein,
not the exit site, if the VAD is accidentally removed. The child should not participate in contact
sports, even with a protective vest, to prevent the VAD from becoming dislodged. General
malaise is a sign of an infection, not an expected finding after insertion of the VAD. The child
can shower or take a bath after insertion of the VAD; the child does not need a sponge bath for
any length of time.
DIF: Cognitive Level: Analyzing REF: p. 979
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
24. What type of diarrhea is associated with an inflammation of the mucosa and submucosa in
the ileum and colon caused by infectious agents?
a. Osmotic
b. Secretory
c. Cytotoxic
d. Dysenteric
ANS: D
Dysenteric diarrhea is associated with an inflammation of the mucosa and submucosa in the
ileum and colon caused by infectious agents such as Campylobacter,
Salmonella, or Shigella organisms. Edema, mucosal bleeding, and leukocyte infiltration occur.
Osmotic diarrhea occurs when the intestine cannot absorb nutrients or electrolytes. It is
commonly seen in malabsorption syndromes such as lactose intolerance. Secretory diarrhea is
usually a result of bacterial enterotoxins that stimulate fluid and electrolyte secretion from the
mucosal crypt cells, the principal secretory cells of the small intestine. Cytotoxic diarrhea is
characterized by the viral destruction of the villi of the small intestine. This results in a smaller
intestinal surface area, with a decreased capacity for fluid and electrolyte absorption.
DIF: Cognitive Level: Understanding REF: p. 952
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
25. What condition is often associated with severe diarrhea?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: A
Metabolic acidosis results from the increased absorption of short-chain fatty acids produced in
the colon. There is an increase in lactic acid from tissue hypoxia secondary to hypovolemia.
Bicarbonate is lost through the stool. Ketosis results from fat metabolism when glycogen stores
are depleted. Metabolic alkalosis and respiratory alkalosis do not occur from severe diarrhea.
DIF: Cognitive Level: Understanding REF: p. 952
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
26. What organism is a parasite that causes acute diarrhea?
a. Shigella organisms
b. Salmonella organisms
c. Giardia lamblia
d. Escherichia coli
ANS: C
G. lamblia is a parasite that represents 10% of nondysenteric illness in the United
States. Shigella, Salmonella, and E. coli are bacterial pathogens.
DIF: Cognitive Level: Understanding REF: p. 948
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
27. A school-age child with diarrhea has been rehydrated. The nurse is discussing the childs diet
with the family. What food or beverage should be tolerated best?
a. Clear fluids
b. Carbonated drinks
c. Applesauce and milk
d. Easily digested foods
ANS: D
Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the
child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a
regular diet has no adverse effects and actually lessens the severity and duration of the illness.
Clear fluids (e.g., fruit juices and gelatin) and carbonated drinks have high carbohydrate content
and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild
diuretic. In some children, lactose intolerance will develop with diarrhea, and cows milk should
be avoided in the recovery stage.
DIF: Cognitive Level: Applying REF: p. 988
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
28. A school-age child with acute diarrhea and mild dehydration is being given oral rehydration
solutions (ORS). The childs mother calls the clinic nurse because he is also occasionally
vomiting. The nurse should recommend which intervention?
a. Bring the child to the hospital for intravenous fluids.
b. Alternate giving ORS and carbonated drinks.
c. Continue to give ORS frequently in small amounts.
d. Keep child NPO (nothing by mouth) for 8 hours and resume ORS if vomiting has subsided.
ANS: C
Children who are vomiting should be given ORS at frequent intervals and in small amounts.
Intravenous fluids are not indicated for mild dehydration. Carbonated beverages are high in
carbohydrates and are not recommended for the treatment of diarrhea and vomiting. The child is
not kept NPO because this would cause additional fluid losses.
DIF: Cognitive Level: Implementation REF: p. 954
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
29. A 7-year-old child with acute diarrhea has been rehydrated with oral rehydration solution
(ORS). The nurse should recommend that the childs diet be advanced to what kind of diet?
a. Regular diet
b. Clear liquids
c. High carbohydrate diet
d. BRAT (bananas, rice, applesauce, and toast or tea) diet
ANS: A
It is appropriate to advance to a regular diet after ORS has been used to rehydrate the child. Clear
liquids are not appropriate for hydration or afterward. A high carbohydrate diet may contribute to
loose stools because of the low electrolyte content and high osmolality. The BRAT diet has little
nutritional value and is high in carbohydrates.
DIF: Cognitive Level: Implementation REF: p. 954 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
30. What is the most frequent cause of hypovolemic shock in children?
a. Sepsis
b. Blood loss
c. Anaphylaxis
d. Heart failure
ANS: B
Blood loss is the most frequent cause of hypovolemic shock in children. Sepsis causes septic
shock, which is overwhelming sepsis and circulating bacterial toxins. Anaphylactic shock results
from extreme allergy or hypersensitivity to a foreign substance. Heart failure contributes to
hypervolemia, not hypovolemia.
DIF: Cognitive Level: Understanding REF: p. 959
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
31. What type of shock is characterized by a hypersensitivity reaction causing massive
vasodilation and capillary leaks, which may occur with drug or latex allergy?
a. Neurogenic shock
b. Cardiogenic shock
c. Hypovolemic shock
d. Anaphylactic shock
ANS: D
Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance.
Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal
transmission after a spinal cord injury. Cardiogenic shock is decreased cardiac output.
Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood
pressure, and low central venous pressure.
DIF: Cognitive Level: Understanding REF: p. 959
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
32. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child
and becomes decompensated shock?
a. Thirst
b. Irritability
c. Apprehension
d. Confusion and somnolence
ANS: D
Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and
apprehension are signs of compensated shock.
DIF: Cognitive Level: Understanding REF: p. 960
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
33. The nurse suspects shock in a child 1 day after surgery. What should be the initial nursing
action?
a. Place the child on a cardiac monitor.
b. Obtain arterial blood gases.
c. Provide supplemental oxygen.
d. Put the child in the Trendelenburg position.
ANS: C
The initial nursing action for a patient in shock is to establish ventilatory support. Oxygen is
provided, and the nurse carefully observes for signs of respiratory failure, which indicates a need
for intubation. Cardiac monitoring would be indicated to assess the childs status further, but
ventilatory support comes first. Oxygen saturation monitoring should be begun. Arterial blood
gases would be indicated if alternative methods of monitoring oxygen therapy were not
available. The Trendelenburg position is not indicated and is detrimental to the child. The head-
down position increases intracranial pressure and decreases diaphragmatic excursion and lung
volume.
DIF: Cognitive Level: Understanding REF: p. 961
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
34. What explains physiologically the edema formation that occurs with burns?
a. Vasoconstriction
b. Reduced capillary permeability
c. Increased capillary permeability
d. Diminished hydrostatic pressure within capillaries
ANS: C
With a major burn, capillary permeability increases, allowing plasma proteins, fluids, and
electrolytes to be lost into the interstitial space, causing edema. Maximum edema in a small
wound occurs about 8 to 12 hours after injury. In larger injuries, the maximum edema may not
occur until 18 to 24 hours later. Vasodilation occurs, causing an increase in hydrostatic pressure.
DIF: Cognitive Level: Analyzing REF: p. 963
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
35. What is a systemic response to severe burns in a child?
a. Metabolic alkalosis
b. Decreased metabolic rate
c. Increased renal plasma flow
d. Abrupt drop in cardiac output
ANS: D
The initial physiologic response to a burn injury is a dramatic change in circulation. A
precipitous drop in cardiac output precedes any change in circulating blood or plasma volumes.
A circulating myocardial depressant factor associated with severe burn injury is thought to be the
cause. Metabolic acidosis usually occurs secondary to the disruption of the bodys buffering
action resulting from fluid shifting to extravascular space. There is a greatly accelerated
metabolic rate in burn patients, supported by protein and lipid breakdown. With the loss of
circulating volume, there is decreased renal blood flow and depressed glomerular filtration.
DIF: Cognitive Level: Understanding REF: p. 975
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
36. A child is admitted with extensive burns. The nurse notes burns on the childs lips and singed
nasal hairs. The nurse should suspect what condition in the child?
a. A chemical burn
b. A hot-water scald
c. An electrical burn
d. An inhalation injury
ANS: D
Evidence of an inhalation injury includes burns of the face and lips, singed nasal hairs, and
laryngeal edema. Clinical manifestations may be delayed for up to 24 hours. Chemical burns,
electrical burns, and burns associated with hot-water scalds would not produce singed nasal hair.
DIF: Cognitive Level: Analyzing REF: p. 993
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
37. What is the most immediate threat to life in children with thermal injuries?
a. Shock
b. Anemia
c. Local infection
d. Systemic sepsis
ANS: A
The immediate threat to life in children with thermal injuries is airway compromise and profound
shock. Anemia is not of immediate concern. During the healing phase, local infection or sepsis is
the primary complication.
DIF: Cognitive Level: Analyzing REF: p. 972
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
38. After the acute stage and during the healing process, what is the primary complication from
burn injury?
a. Shock
b. Asphyxia
c. Infection
d. Renal shutdown
ANS: C
During the healing phase, local infection or sepsis is the primary complication. Respiratory
problems, primarily airway compromise, and shock are the primary complications during the
acute stage of burn injury. Renal shutdown is not a complication of the burn injury but may be a
result of the profound shock.
DIF: Cognitive Level: Analyzing REF: p. 975
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
39. What sign is one of the first to indicate overwhelming sepsis in a child with burn injuries?
a. Seizures
b. Bradycardia
c. Disorientation
d. Decreased blood pressure
ANS: C
Disorientation in the burn patient is one of the first signs of overwhelming sepsis and may
indicate inadequate hydration. Seizures, bradycardia, and decreased blood pressure are not initial
manifestations of overwhelming sepsis.
DIF: Cognitive Level: Understanding REF: p. 976
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
40. A toddler sustains a minor burn on the hand from hot coffee. What is the first action in
treating this burn?
a. Apply burn ointment.
b. Put ice on the burned area.
c. Cover the hand with gauze dressing.
d. Hold the hand under cool running water.
ANS: D
In minor burns, the best method to stop the burning process is to hold the burned area under cool
running water. Ointments are not applied to a new burn; the ointment will contribute to the
burning. Ice is not recommended. Gauze dressings do not stop the burning process.
DIF: Cognitive Level: Applying REF: p. 977
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
41. What finding is the most reliable guide to the adequacy of fluid replacement for a small child
with burns?
a. Absence of thirst
b. Falling hematocrit
c. Increased seepage from burn wound
d. Urinary output of 1 to 2 ml/kg of body weight/hr
ANS: D
Replacement fluid therapy is delivered to provide a urinary output of 30 ml/hr in older children
or 1 to 2 ml/kg of body weight/hr for children weighing less than 30 kg (66 lb). Thirst is the
result of a complex set of interactions and is not a reliable indicator of hydration. Thirst occurs
late in dehydration. A falling hematocrit would be indicative of hemodilution. This may reflect
fluid shifts and may not accurately represent fluid replacement therapy. Increased seepage from a
burn wound would be indicative of increased output, not adequate hydration.
DIF: Cognitive Level: Applying REF: p. 978 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
42. What is the purpose of a high-protein diet for a child with major burns?
a. Promote growth
b. Improve appetite
c. Minimize protein breakdown
d. Diminish risk of stress-induced hyperglycemia
ANS: C
Initially after major burns, there is a hypometabolic phase, which lasts for 2 or 3 days. A
hypermetabolic phase follows, characterized by increased body temperature, oxygen and glucose
consumption, carbon dioxide production, glycogenolysis, proteolysis, and lipolysis. This
response continues for up to 9 months. A diet high in protein and calories is necessary. Healing,
not growth, is the primary consideration. Many children have poor appetites, and
supplementation is necessary. Hypoglycemia, not hyperglycemia, can occur from the stress of
burn injury because the liver glycogen stores are rapidly depleted.
DIF: Cognitive Level: Applying REF: p. 979 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
43. Fentanyl and midazolam (Versed) are given before dbridement of a childs burn wounds.
What is the purpose of using these medications?
a. Facilitate healing
b. Provide pain relief
c. Minimize risk of infection
d. Decrease amount of dbridement needed
ANS: B
Partial-thickness burns require dbridement of devitalized tissue to promote healing. The
procedure is painful and requires analgesia and sedation before the procedure. Fentanyl and
midazolam provide excellent intravenous sedation and analgesia to control procedural pain in
children with burns.
DIF: Cognitive Level: Analyzing REF: p. 980
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
44. Hydrotherapy is required to treat a child with extensive partial-thickness burn wounds. What
is the purpose of hydrotherapy?
a. Provide pain relief
b. Dbride the wounds
c. Destroy bacteria on the skin
d. Increase peripheral blood flow
ANS: B
Soaking in a tub or showering once or twice a day acts to loosen and remove sloughing tissue,
exudate, and topical medications. The hydrotherapy cleanses the wound and the entire body and
helps maintain range of motion. Appropriate pain medications are necessary. Dressing changes
are extremely painful. The total bacterial count of the skin is reduced by the hydrotherapy, but
this is not the primary goal. There may be an increase in peripheral blood flow, but the primary
purpose is for wound dbridement.
DIF: Cognitive Level: Applying REF: p. 980
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
45. What is the nursing action related to the applying of biologic or synthetic skin coverings for a
child with partial-thickness burns of both legs?
a. Splint the legs to prevent movement.
b. Observe wounds for signs of infection.
c. Monitor closely for manifestations of shock.
d. Examine dressings for indications of bleeding.
ANS: B
When applied early to a superficial partial-thickness injury, biologic dressings stimulate
epithelial growth and faster wound healing. If the dressing covers areas of heavy microbial
contamination, infection occurs beneath the dressing. In the case of partial-thickness burns, such
infection may convert the wound to a full-thickness injury. Infection is the primary concern when
biologic dressings are used.
DIF: Cognitive Level: Applying REF: p. 982
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
46. What is an effective strategy to reduce the stress of burn dressing procedures?
a. Involve the child and give choices as feasible.
b. Explain to the child why analgesics cannot be used.
c. Reassure the child that dressing changes are not painful.
d. Encourage the child to master stress with controlled passivity.
ANS: A
Children who have an understanding of the procedure and some perceived control demonstrate
less maladaptive behavior. They respond well to participating in decisions and should be given as
many choices as possible. Analgesia and sedation can and should be used. The dressing change
procedure is very painful and stressful. Misinformation should not be given to the child.
Encouraging the child to master stress with controlled passivity is not a positive coping strategy.
DIF: Cognitive Level: Applying REF: p. 988 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
47. What consideration is important for the nurse when changing dressings and applying topical
medication to a childs abdomen and leg burns?
a. Apply topical medication with clean hands.
b. Wash hands and forearms before and after dressing change.
c. If dressings have adhered to the wound, soak in hot water before removal.
d. Apply dressing so that movement is limited during the healing process.
ANS: B
Frequent hand and forearm washing is the single most important element of the infection-control
program. Topical medications should be applied with a tongue blade or gloved hand. Dressings
that have adhered to the wound can be removed with tepid water or normal saline. Dressings are
applied with sufficient tension to remain in place but not so tightly as to impair circulation or
limit motion.
DIF: Cognitive Level: Analyzing REF: p. 988
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
48. What is a strategy used to minimize scarring with burn injury in a child?
a. Applying of drying agents on skin
b. Use of loose-fitting garments over healing areas
c. Limitation of period without pressure to areas of scarring
d. Immobilization of extremities while healing is occurring
ANS: C
Uniform pressure to the scar decreases the blood supply and forces the collagen into a more
normal alignment. When pressure is removed, blood supply to the scar is immediately increased;
therefore, periods without pressure should be brief to avoid nourishment of the hypertrophic
tissue. Moisturizing agents are used with massage to help stretch tissue and prevent contractures.
Compression garments, not loose-fitting garments, are indicated. Range of motion exercises are
done to minimize contractures.
DIF: Cognitive Level: Analyzing REF: p. 989
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
49. Prevention of burn injury is important anticipatory guidance. In the infant and toddler period,
which mode is the most common cause of burn?
a. Matches
b. Electrical cords
c. Hot liquids in the kitchen
d. Microwave-heated foods
ANS: C
Infants and toddlers are most commonly injured by hot liquids in the kitchen and bathroom. This
often occurs as a result of inadequate supervision of this curious and energetic age group.
Matches and lighters are seen as toys by young children and should be kept out of reach. Older
toddlers and preschool children are at risk of chewing on electrical cords and placing objects in
outlets. Microwave-heated fluids and foods can become superheated, resulting in oral burns.
DIF: Cognitive Level: Analyzing REF: p. 992 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
50. The nurse is teaching a group of female adolescents about toxic shock syndrome and the use
of tampons. What statement by a participant indicates a need for additional teaching?
a. I can alternate using a tampon and a sanitary napkin.
b. I should wash my hands before inserting a tampon.
c. I can use a superabsorbent tampon for more than 6 hours.
d. I should call my health care provider if I suddenly develop a rash that looks like sunburn.
ANS: C
Teaching female adolescents about the association between toxic shock syndrome and the use of
tampons is important. The teaching should include not using superabsorbent tampons; not
leaving the tampon in for longer than 4 to 6 hours; alternating the use of tampons with sanitary
napkins; washing hands before inserting a tampon to decrease the chance of introducing
pathogens; and informing a health care provider if a sudden high fever, vomiting, muscle pain,
dizziness, or a rash that looks like a sunburn appears.
DIF: Cognitive Level: Applying REF: p. 958
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
51. The nurse is caring for an 18-month-old child with rotavirus. What clinical manifestations
should the nurse expect to observe?
a. Severe abdominal cramping and bloody diarrhea
b. Mild fever and vomiting followed by onset of watery stools
c. Colicky abdominal pain and vomiting
d. High fever, diarrhea, and lethargy
ANS: B
Rotavirus is one of the most common pathogens that cause gastroenteritis in children younger
than the age of 2 years. Clinical manifestations include mild to moderate fever and vomiting
followed by the onset of watery stools. The fever and vomiting usually abate in 1 or 2 days, but
the diarrhea persists for 5 to 7 days. Severe abdominal cramping and bloody diarrhea are seen
with Escherichia coliinfection; colicky abdominal pain and vomiting are seen with salmonella
infection; and high fever, diarrhea, and lethargy are seen with infection by Salmonella typhi.
DIF: Cognitive Level: Applying REF: p. 954
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
MULTIPLE RESPONSE
1. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock
in children. What clinical manifestations related to decompensated shock should the nurse
include? (Select all that apply.)
a. Tachypnea
b. Oliguria
c. Confusion
d. Pale extremities
e. Hypotension
f. Thready pulse
ANS: A, B, C, D
As shock progresses, perfusion in the microcirculation becomes marginal despite compensatory
adjustments, and the signs are more obvious. Signs include tachypnea, oliguria, confusion, and
pale extremities, as well as decreased skin turgor and poor capillary filling. Hypotension and a
thready pulse are clinical manifestations of irreversible shock.
DIF: Cognitive Level: Applying REF: p. 960
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. In what condition should the nurse be alert for altered fluid requirements in children? (Select
all that apply.)
a. Oliguric renal failure
b. Increased intracranial pressure
c. Mechanical ventilation
d. Compensated hypotension
e. Tetralogy of Fallot
f. Type 1 diabetes mellitus
ANS: A, B, C
The nurse should recognize that conditions such as oliguric renal failure, increased intracranial
pressure, and mechanical ventilation can cause an increase or a decrease in fluid requirements.
Conditions such as hypotension, tetralogy of Fallot, and diabetes mellitus (type 1) do not cause
an alteration in fluid requirements.
DIF: Cognitive Level: Applying REF: p. 946
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
3. What clinical manifestations should be observed in a 2-year-old child with hypotonic
dehydration? (Select all that apply.)
a. Thick, doughy feel to the skin
b. Slightly moist mucous membranes
c. Absent tears
d. Very rapid pulse
e. Hyperirritability
ANS: B, C, D
Clinical manifestations of hypotonic dehydration include slightly moist mucous membranes,
absent tears, and a very rapid pulse. A thick, doughy feel to the skin and hyperirritability are
signs of hypertonic dehydration.
DIF: Cognitive Level: Applying REF: p. 952
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
4. The nurse is caring for a child with hypokalemia. The nurse evaluates the child for which signs
and symptoms of hypokalemia? (Select all that apply.)
a. Twitching
b. Hypotension
c. Hyperreflexia
d. Muscle weakness
e. Cardiac arrhythmias
ANS: B, D, E
Signs and symptoms of hypokalemia are hypotension, muscle weakness, and cardiac
arrhythmias. Twitching and hyperreflexia are signs of hyperkalemia.
DIF: Cognitive Level: Applying REF: p. 950 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
5. The nurse is caring for a child with hypercalcemia. The nurse evaluates the child for which
signs and symptoms of hypercalcemia?(Select all that apply.)
a. Tetany
b. Anorexia
c. Constipation
d. Laryngospasm
e. Muscle hypotonicity
ANS: B, C, E
Signs and symptoms of hypercalcemia are anorexia, constipation, and muscle hypotonicity.
Tetany and laryngospasm are signs of hypocalcemia.
DIF: Cognitive Level: Applying REF: p. 951 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
6. The nurse is caring for a child with hypernatremia. The nurse evaluates the child for which
signs and symptoms of hypernatremia?(Select all that apply.)
a. Apathy
b. Lethargy
c. Oliguria
d. Intense thirst
e. Dry, sticky mucos
ANS: B, C, E
Signs and symptoms of hypernatremia are nausea; oliguria; and dry, sticky mucos. Apathy and
lethargy are signs of hyponatremia.
CH.25
1. Urinary tract anomalies are frequently associated with what irregularities in fetal
development?
a. Myelomeningocele
b. Cardiovascular anomalies
c. Malformed or low-set ears
d. Defects in lower extremities
ANS: C
Although unexplained, there is a frequent association between malformed or low-set ears and
urinary tract anomalies. During the newborn examination, the nurse should have a high suspicion
about urinary tract structure and function if ear anomalies are present. Children who have
myelomeningocele may have impaired urinary tract function secondary to the neural defect.
When other congenital defects are present, there is an increased likelihood of other issues with
other body systems. Cardiac and extremity defects do not have a strong association with renal
anomalies.
DIF: Cognitive Level: Understanding REF: p. 1000
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. What urine test result is considered abnormal?
a. pH 4.0
b. WBC 1 or 2 cells/ml
c. Protein level absent
d. Specific gravity 1.020
ANS: A
The expected pH ranges from 4.8 to 7.8. A pH of 4.0 can be indicative of urinary tract infection
or metabolic alkalosis or acidosis. Less than 1 or 2 white blood cells per milliliter is the expected
range. The absence of protein is expected. The presence of protein can be indicative of
glomerular disease. A specific gravity of 1.020 is within the anticipated range of 1.001 to 1.030.
Specific gravity reflects level of hydration in addition to renal disorders and hormonal control
such as antidiuretic hormone.
DIF: Cognitive Level: Analyzing REF: p. 1002
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
3. What diagnostic test allows visualization of renal parenchyma and renal pelvis without
exposure to external-beam radiation or radioactive isotopes?
a. Renal ultrasonography
b. Computed tomography
c. Intravenous pyelography
d. Voiding cystourethrography
ANS: A
The transmission of ultrasonic waves through the renal parenchyma allows visualization of the
renal parenchyma and renal pelvis without exposure to external-beam radiation or radioactive
isotopes. Computed tomography uses external radiation, and sometimes contrast media are used.
Intravenous pyelography uses contrast medium and external radiation for radiography. Contrast
medium is injected into the bladder through the urethral opening. External radiation for
radiography is used before, during, and after voiding in voiding cystourethrography.
DIF: Cognitive Level: Understanding REF: p. 1011
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
4. What name is given to inflammation of the bladder?
a. Cystitis
b. Urethritis
c. Urosepsis
d. Bacteriuria
ANS: A
Cystitis is an inflammation of the bladder. Urethritis is an inflammation of the urethra. Urosepsis
is a febrile urinary tract infection with systemic signs of bacterial infection. Bacteriuria is the
presence of bacteria in the urine.
DIF: Cognitive Level: Understanding REF: p. 1004
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
5. The nurse is teaching a client to prevent future urinary tract infections (UTIs). What factor is
most important to emphasize as the potential cause?
a. Poor hygiene
b. Constipation
c. Urinary stasis
d. Congenital anomalies
ANS: C
Urinary stasis is the single most important host factor that influences the development of UTIs.
Urine is usually sterile but at body temperature provides an excellent growth medium for
bacteria. Poor hygiene can be a contributing cause, especially in females because their short
urethras predispose them to UTIs. Urinary stasis then provides a growth medium for the bacteria.
Intermittent constipation contributes to urinary stasis. A full rectum displaces the bladder and
posterior urethra in the fixed and limited space of the bony pelvis, causing obstruction,
incomplete micturition, and urinary stasis. Congenital anomalies can contribute to UTIs, but
urinary stasis is the primary factor in many cases.
DIF: Cognitive Level: Applying REF: p. 1005
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
6. A girl, age 5 1/2 years, has been sent to the school nurse for urinary incontinence three times
in the past 2 days. The nurse should recommend to her parent that the first action is to have the
child evaluated for what condition?
a. School phobia
b. Glomerulonephritis
c. Urinary tract infection (UTI)
d. Attention deficit hyperactivity disorder (ADHD)
ANS: C
Girls between the ages of 2 and 6 years are considered high risk for UTIs. This child is showing
signs of a UTI, including incontinence in a toilet-trained child and possible urinary frequency or
urgency. A physiologic cause should be ruled out before psychosocial factors are investigated.
Glomerulonephritis usually manifests with decreased urinary output and fluid retention. ADHD
can contribute to urinary incontinence because the child is distracted, but the first manifestation
was incontinence, not distractibility.
DIF: Cognitive Level: Applying REF: p. 1008
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
7. What recommendation should the nurse make to prevent urinary tract infections (UTIs) in
young girls?
a. Avoid public toilet facilities.
b. Limit long baths as much as possible.
c. Cleanse the perineum with water after voiding.
d. Ensure clear liquid intake of 2 L/day.
ANS: D
Adequate fluid intake minimizes urinary stasis. The recommended fluid intake is 50 ml/kg or 100
ml/lb per day. The average 5- to 6-year-old weighs approximately 18 kg (40 lb), so she should
drink 2 L/day of fluid. There is no evidence that using public toilet facilities increases UTIs.
Long baths are not associated with increased UTIs. Proper hand washing and perineal cleansing
are important, but no evidence exists that these decrease UTIs in young girls.
DIF: Cognitive Level: Applying REF: p. 1010
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
8. In teaching the parent of a newly diagnosed 2-year-old child with pyelonephritis related to
vesicoureteral reflux (VUR), the nurse should include which information?
a. Limit fluids to reduce reflux.
b. Give cranberry juice twice a day.
c. Have siblings examined for VUR.
d. Surgery is indicated to reverse scarring.
ANS: C
Siblings are at high risk for VUR. The incidence of reflux in siblings is approximately 36%. The
other children should be screened for early detection and to potentially reduce scarring. Fluids
are not reduced. The efficacy of cranberry juice in reducing infection in children has not been
established. Surgery may be necessary for higher grades of VUR, but the scarring is not
reversible.
DIF: Cognitive Level: Applying REF: p. 1010
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
9. What pathologic process is believed to be responsible for the development of postinfectious
glomerulonephritis?
a. Infarction of renal vessels
b. Immune complex formation and glomerular deposition
c. Bacterial endotoxin deposition on and destruction of glomeruli
d. Embolization of glomeruli by bacteria and fibrin from endocardial vegetation
ANS: B
After a streptococcal infection, antibodies are formed, and immune-complex reaction occurs. The
immune complexes are trapped in the glomerular capillary loop. Infarction of renal vessels
occurs in renal involvement in sickle cell disease. Bacterial endotoxin deposition on and
destruction of glomeruli is not a mechanism for postinfectious glomerulonephritis. Embolization
of glomeruli by bacteria and fibrin from endocardial vegetation is the pathology of renal
involvement with bacterial endocarditis.
DIF: Cognitive Level: Understanding REF: p. 1013
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
10. The nurse notes that a child has lost 3.6 kg (8 lb) after 4 days of hospitalization for acute
glomerulonephritis. What is the most likely cause of this weight loss?
a. Poor appetite
b. Reduction of edema
c. Restriction to bed rest
d. Increased potassium intake
ANS: B
This amount of weight loss in this period is a result of the improvement of renal function and
mobilization of edema fluid. Poor appetite and bed rest would not result in a weight loss of 8 lb
in 4 days. Foods with substantial amounts of potassium are avoided until renal function is
normalized.
DIF: Cognitive Level: Understanding REF: p. 1014
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
11. What measure of fluid balance status is most useful in a child with acute glomerulonephritis?
a. Proteinuria
b. Daily weight
c. Specific gravity
d. Intake and output
ANS: B
A record of daily weight is the most useful means to assess fluid balance and should be kept for
children treated at home or in the hospital. Proteinuria does not provide information about fluid
balance. Specific gravity does not accurately reflect fluid balance in acute glomerulonephritis. If
fluid is being retained, the excess fluid will not be included. Also proteinuria and hematuria
affect specific gravity. Intake and output can be useful but are not considered as accurate as daily
weights. In children who are not toilet trained, measuring output is more difficult.
DIF: Cognitive Level: Analyzing REF: p. 1015 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
12. The parent of a child hospitalized with acute glomerulonephritis asks the nurse why blood
pressure readings are being taken so often. What knowledge should influence the nurses reply?
a. The antibiotic therapy contributes to labile blood pressure values.
b. Hypotension leading to sudden shock can develop at any time.
c. Acute hypertension is a concern that requires monitoring.
d. Blood pressure fluctuations indicate that the condition has become chronic.
ANS: C
Blood pressure monitoring is essential to identify acute hypertension, which is treated
aggressively. Antibiotic therapy is usually not indicated for glomerulonephritis. Hypertension,
not hypotension, is a concern in glomerulonephritis. Blood pressure control is essential to
prevent further renal damage. Blood pressure fluctuations do not provide information about the
chronicity of the disease.
DIF: Cognitive Level: Applying REF: p. 1015
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
13. What laboratory finding, in conjunction with the presenting symptoms, indicates minimal
change nephrotic syndrome?
a. Low specific gravity
b. Decreased hemoglobin
c. Normal platelet count
d. Reduced serum albumin
ANS: D
Total serum protein concentrations are reduced, with the albumin fractions significantly reduced.
Specific gravity is high and proportionate to the amount of protein in the urine. Hemoglobin and
hematocrit are usually normal or elevated. The platelet count is elevated as a result of
hemoconcentration.
DIF: Cognitive Level: Analyzing REF: p. 1017
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
14. What is the primary objective of care for the child with minimal change nephrotic syndrome
(MCNS)?
a. Reduce blood pressure.
b. Lower serum protein levels.
c. Minimize excretion of urinary protein.
d. Increase the ability of tissue to retain fluid.
ANS: C
The objectives of therapy for the child with MCNS include reducing the excretion of urinary
protein, reducing fluid retention, preventing infection, and minimizing complications associated
with therapy. Blood pressure is usually not elevated in minimal change nephrotic syndrome.
Serum protein levels are already reduced as part of the disease process. This needs to be
reversed. The tissue is already retaining fluid as part of the edema. The goal of therapy is to
reduce edema.
DIF: Cognitive Level: Understanding REF: p. 1017 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
15. A hospitalized child with minimal change nephrotic syndrome is receiving high doses of
prednisone. What nursing goal is appropriate for this child?
a. Stimulate appetite.
b. Detect evidence of edema.
c. Minimize risk of infection.
d. Promote adherence to the antibiotic regimen.
ANS: C
High-dose steroid therapy has an immunosuppressant effect. These children are particularly
vulnerable to upper respiratory tract infections. A priority nursing goal is to minimize the risk of
infection by protecting the child from contact with infectious individuals. Appetite is increased
with prednisone therapy. The amount of edema should be monitored as part of the disease
process, not necessarily related to the administration of prednisone. Antibiotics would not be
used as prophylaxis.
DIF: Cognitive Level: Analyzing REF: p. 1019 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
16. The nurse is teaching a child experiencing severe edema associated with minimal change
nephrotic syndrome about his diet. The nurse should discuss what dietary need?
a. Consuming a regular diet
b. Increasing protein
c. Restricting fluids
d. Decreasing calories
ANS: C
During the edematous stage of active nephrosis, the child has restricted fluid and sodium intake.
As the edema subsides, the child is placed on a diet with increased salt and fluids. A regular diet
is not indicated. There is no evidence that a diet high in protein is beneficial or has an effect on
the course of the disease. Calories sufficient for growth and tissue healing are essential. With the
child having little appetite and the fluid and salt restrictions, achieving adequate nutrition is
difficult.
DIF: Cognitive Level: Applying REF: p. 1019
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
17. A child is admitted for minimal change nephrotic syndrome (MCNS). The nurse recognizes
that the childs prognosis is related to what factor?
a. Admission blood pressure
b. Creatinine clearance
c. Amount of protein in urine
d. Response to steroid therapy
ANS: D
Corticosteroids are the drugs of choice for MCNS. If the child has not responded to therapy
within 28 days of daily steroid administration, the likelihood of subsequent response decreases.
Blood pressure is normal or low in MCNS. It is not correlated with prognosis. Creatinine
clearance is not correlated with prognosis. The presence of significant proteinuria is used for
diagnosis. It is not predictive of prognosis.
DIF: Cognitive Level: Analyzing REF: p. 1019 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
18. A 12-year-old child is injured in a bicycle accident. When considering the possibility of renal
trauma, the nurse should consider what factor?
a. Flank pain rarely occurs in children with renal injuries.
b. Few nonpenetrating injuries cause renal trauma in children.
c. Kidneys are immobile, well protected, and rarely injured in children.
d. The amount of hematuria is not a reliable indicator of the seriousness of renal injury.
ANS: D
Hematuria is consistently present with renal trauma. It does not provide a reliable indicator of the
seriousness of the renal injury. Flank pain results from bleeding around the kidney. Most injuries
that cause renal trauma in children are of the nonpenetrating or blunt type and usually involve
falls, athletic injuries, and motor vehicle accidents. In children, the kidneys are more mobile, and
the outer borders are less protected than in adults.
DIF: Cognitive Level: Applying REF: p. 1018
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
19. What condition is the most common cause of acute renal failure in children?
a. Pyelonephritis
b. Tubular destruction
c. Severe dehydration
d. Upper tract obstruction
ANS: C
The most common cause of acute renal failure in children is dehydration or other causes of poor
perfusion that may respond to restoration of fluid volume. Pyelonephritis and tubular destruction
are not common causes of acute renal failure. Obstructive uropathy may cause acute renal
failure, but it is not the most common cause.
DIF: Cognitive Level: Understanding REF: p. 1022
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
20. A child is admitted in acute renal failure (ARF). Therapeutic management to rapidly provoke
a flow of urine includes the administration of what medication?
a. Propranolol (Inderal)
b. Calcium gluconate
c. Mannitol (Osmitrol) or furosemide (Lasix) (or both)
d. Sodium, chloride, and potassium
ANS: C
In ARF, if hydration is adequate, mannitol or furosemide (or both) is administered to provoke a
flow of urine. If glomerular function is intact, an osmotic diuresis will occur. Propranolol is a
beta-blocker; it will not produce a rapid flow of urine in ARF. Calcium gluconate is administered
for its protective cardiac effect when hyperkalemia exists. It does not affect diuresis. Electrolyte
measurements must be done before administration of sodium, chloride, or potassium. These
substances are not given unless there are other large, ongoing losses. In the absence of urine
production, potassium levels may be elevated, and additional potassium can cause cardiac
dysrhythmias.
DIF: Cognitive Level: Analyzing REF: p. 1027 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
21. What major complication is associated with a child with chronic renal failure?
a. Hypokalemia
b. Metabolic alkalosis
c. Water and sodium retention
d. Excessive excretion of blood urea nitrogen
ANS: C
Chronic renal failure leads to water and sodium retention, which contributes to edema and
vascular congestion. Hyperkalemia, metabolic acidosis, and retention of blood urea nitrogen are
complications of chronic renal failure.
DIF: Cognitive Level: Analyzing REF: p. 1030
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
22. What diet is most appropriate for the child with chronic renal failure (CRF)?
a. Low in protein
b. Low in vitamin D
c. Low in phosphorus
d. Supplemented with vitamins A, E, and K
ANS: C
Dietary phosphorus may need to be restricted by limiting protein and milk intake. Substances
that bind phosphorus are given with meals to prevent its absorption, which enables a more liberal
intake of phosphorus-containing protein. Protein is limited to the recommended daily allowance
for the childs age. Further restriction is thought to negatively affect growth and
neurodevelopment. Vitamin D therapy is administered in children with CRF to increase calcium
absorption. Supplementation of vitamins A, E, and K, beyond normal dietary intake, is not
advised in children with CRF. These fat-soluble vitamins can accumulate.
DIF: Cognitive Level: Analyzing REF: p. 1030
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
23. What nursing consideration is most important when caring for a child with end-stage renal
disease (ESRD)?
a. Children with ESRD usually adapt well to minor inconveniences of treatment.
b. Children with ESRD require extensive support until they outgrow the condition.
c. Multiple stresses are placed on children with ESRD and their families until the illness is cured.
d.
Multiple stresses are placed on children with ESRD and their families because childrens lives are maintained by drugs
and artificial means.
ANS: D
Stressors on the family are often overwhelming because of the progressive deterioration. The
child progresses from renal insufficiency to uremia to dialysis and transplantation, each of which
requires intensive therapy and supportive care. The treatment of ESRD is intense and requires
multiple examinations, dietary restrictions, and medications. Adherence to the regimen is often
difficult for children and families because of the progressive nature of the renal failure. ESRD
has an unrelenting course that has no known cure. Children do not outgrow the renal failure.
DIF: Cognitive Level: Analyzing REF: p. 1033 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
24. The nurse is caring for an adolescent who has just started dialysis. The child always seems
angry, hostile, or depressed. The nurse should recognize that this is most likely related to what
underlying cause?
a. Physiologic manifestations of renal disease
b. The fact that adolescents have few coping mechanisms
c. Neurologic manifestations that occur with dialysis
d. Resentment of the control and enforced dependence imposed by dialysis
ANS: D
Older children and adolescents need to feel in control. Dialysis forces the adolescent into a
dependent relationship, which results in these behaviors. Being angry, hostile, or depressed are
functions of the age of the child, not neurologic or physiologic manifestations of the dialysis.
DIF: Cognitive Level: Analyzing REF: p. 1037
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
25. What statement is an advantage of peritoneal dialysis compared with hemodialysis?
a. Protein loss is less extensive.
b. Dietary limitations are not necessary.
c. It is easy to learn and safe to perform.
d. It is needed less frequently than hemodialysis.
ANS: C
Peritoneal dialysis is the preferred form of dialysis for parents, infants, and children who wish to
remain independent. Parents and older children can perform the treatments themselves. Protein
loss is not significantly different. The dietary limitations are necessary, but they are not as
stringent as those for hemodialysis. Treatments are needed more frequently but can be done at
home.
DIF: Cognitive Level: Analyzing REF: p. 1036 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
26. What statement is descriptive of renal transplantation in children?
a. It is an acceptable means of treatment after age 10 years.
b. Children can receive kidneys only from other children.
c. It is the preferred means of renal replacement therapy in children.
d. The decision for transplantation is difficult because a relatively normal lifestyle is not possible.
ANS: C
Renal transplantation offers the opportunity for a relatively normal life and is the preferred
means of renal replacement therapy in end-stage renal disease. It can be done in children as
young as age 6 months. Both children and adults can serve as donors for renal transplant
purposes. Renal transplantation affords the child a more normal lifestyle than dependence on
dialysis.
DIF: Cognitive Level: Understanding REF: p. 1038
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
27. The nurse is conducting discharge teaching with the parent of a 7-year-old child with
minimal change nephrotic syndrome (MCNS). What statement by the parent indicates a correct
understanding of the teaching?
a. My child needs to stay home from school for at least 1 more month.
b. I should not add additional salt to any of my childs meals.
c. My child will not be able to participate in contact sports while receiving corticosteroid therapy.
d. I should measure my childs urine after each void and report the 24-hour amount to the health care provider.
ANS: B
Children with MCNS can be treated at home after the initial phase with appropriate discharge
instructions, including a salt restriction of no additional salt to the childs meals. The child may
return to school but should avoid exposure to infected playmates. Participation in contact sports
is not affected by corticosteroid therapy. The parent does not need to measure the childs urine on
a daily basis but may be instructed to test for albumin.
DIF: Cognitive Level: Applying REF: p. 1019
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
28. What is the narrowing of preputial opening of foreskin called?
a. Chordee
b. Phimosis
c. Epispadias
d. Hypospadias
ANS: B
Phimosis is the narrowing or stenosis of the preputial opening of the foreskin. Chordee is the
ventral curvature of the penis. Epispadias is the meatal opening on the dorsal surface of the
penis. Hypospadias is a congenital condition in which the urethral opening is located anywhere
along the ventral surface of the penis.
DIF: Cognitive Level: Understanding REF: p. 1040
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
29. Identification and treatment of cryptorchid testes should be done by age 2 years. What is an
important consideration?
a. Medical therapy is not effective after this age.
b. Treatment is necessary to maintain the ability to be fertile when older.
c. The younger child can tolerate the extensive surgery needed.
d. Sexual reassignment may be necessary if treatment is not successful.
ANS: B
The longer the testis is exposed to higher body heat, the greater the likelihood of damage. To
preserve fertility, surgery should be done at an early age. Surgical intervention is the treatment of
choice. Simple orchiopexy is usually performed as an outpatient procedure. The surgical
procedure restores the testes to the scrotum. This helps the boy to have both testes in the scrotum
by school age. Sexual reassignment is not indicated when the testes are not descended.
DIF: Cognitive Level: Understanding REF: p. 1041
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
30. Congenital defects of the genitourinary tract, such as hypospadias, are usually repaired as
early as possible to accomplish what?
a. Minimize separation anxiety.
b. Prevent urinary complications.
c. Increase acceptance of hospitalization.
d. Promote development of normal body image.
ANS: D
Promoting development of normal body image is extremely important. Surgery involving sexual
organs can be upsetting to children, especially preschoolers, who fear mutilation and castration.
Proper preprocedure preparation can facilitate coping with these issues. Preventing urinary
complications is important for defects that affect function, but for all external defects, repair
should be done as soon as possible.
DIF: Cognitive Level: Analyzing REF: p. 1043 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
31. The parents of a 2-year-old boy who had a repair of exstrophy of the bladder at birth ask
when they can begin toilet training their son. The nurse replies based on what knowledge?
a. Most boys in the United States can be toilet trained at age 3 years.
b. Training can begin when he has sufficient bladder capacity.
c. Additional surgery may be necessary to achieve continence.
d. They should begin now because he will require additional time.
ANS: C
After repair of the bladder exstrophy, the childs bladder is allowed to increase capacity. Several
surgical procedures may be necessary to create a urethral sphincter mechanism to aid in urination
and ejaculation. With the lack of a urinary sphincter, toilet training is unlikely. The child cannot
hold the urine in the bladder. Bladder capacity is one component of continence. A functional
sphincter is also needed.
DIF: Cognitive Level: Applying REF: p. 1045
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
32. An infant has been diagnosed with bladder obstruction. What do symptoms of this disorder
include?
a. Renal colic
b. Strong urinary stream
c. Urinary tract infections
d. Posturination dribbling
ANS: D
Symptoms of bladder obstruction include poor force of urinary stream, intermittency of voided
stream, feelings of incomplete bladder emptying, and posturination dribbling. They may also
include urinary frequency, nocturia, nocturnal enuresis, and urgency. Renal colic is a symptom of
upper urinary tract obstruction. Children with bladder obstruction have a weak urinary stream.
Urinary tract infections are not associated with bladder obstruction.
DIF: Cognitive Level: Applying REF: p. 1006
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
33. The parents of a child born with ambiguous genitalia tell the nurse that family and friends are
asking what caused the baby to be this way. Tests are being done to assist in gender assignment.
What should the nurses intervention include?
a. Explain the disorder so they can explain it to others.
b. Help parents understand that this is a minor problem.
c. Suggest that parents avoid family and friends until the gender is assigned.
d. Encourage parents not to worry while the tests are being done.
ANS: A
Explaining the disorder to parents so they can explain it to others is the most therapeutic
approach while the parents await the gender assignment of their child. Ambiguous genitalia is a
serious issue for the family. Careful testing and evaluation are necessary to aid in gender
assignment to avoid lifelong problems for the child. Suggesting that parents avoid family and
friends until the gender is assigned is impractical and would isolate the family from their support
system while awaiting test results. The parents will be concerned. Telling them not to worry
without giving them specific alternative actions would not be effective.
DIF: Cognitive Level: Applying REF: p. 1043
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
34. Parents of a newborn with ambiguous genitalia want to know how long they will have to wait
to know whether they have a boy or a girl. The nurse answers the parents based on what
knowledge?
a. Chromosome analysis will be complete in 7 days.
b. A physical examination will be able to provide a definitive answer.
c. Additional laboratory testing is necessary to assign the correct gender.
d. Gender assignment involves collaboration between the parents and a multidisciplinary team.
ANS: D
Gender assignment is a complex decision-making process. Endocrine, genetic, social,
psychologic, and ethical elements of sex assignment have been integrated into the process.
Parent participation is included. The goal is to enable the affected child to grow into a well-
adjusted, psychosocially stable person. Chromosome analysis usually takes 2 or 3 days. A
physical examination reveals ambiguous genitalia, but additional testing is necessary. A correct
gender may not be identifiable.
DIF: Cognitive Level: Analyzing REF: p. 1043
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
35. Surgery is performed on a child to correct cryptorchidism. The parents understand the reason
for the surgery if they tell the nurse this was done to do what?
a. Prevent damage to the undescended testicle.
b. Prevent urinary tract infections.
c. Prevent prostate cancer.
d. Prevent an inguinal hernia.
ANS: A
If the testes do not descend spontaneously, orchiopexy is performed before the childs second
birthday, preferably between 1 and 2 years of age. Surgical repair is done to (1) prevent damage
to the undescended testicle by exposure to the higher degree of body heat in the undescended
location, thus maintaining future fertility; (2) decrease the incidence of malignancy formation,
which is higher in undescended testicles; (3) avoid trauma and torsion; (4) close the processus
vaginalis; and (5) prevent the cosmetic and psychologic disability of an empty scrotum. Parents
understand the teaching if they respond the surgery is done to prevent damage.
DIF: Cognitive Level: Analyzing REF: p. 1041
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
36. What is an appropriate nursing intervention for a child with minimal change nephrotic
syndrome (MCNS) who has scrotal edema?
a. Place an ice pack on the scrotal area.
b. Place the child in an upright sitting position.
c. Elevate the scrotum with a rolled washcloth.
d. Place a warm moist pack to the scrotal area.
ANS: C
In children hospitalized with MCNS, elevating edematous parts may be helpful to shift fluid to
more comfortable distributions. Areas that are particularly edematous, such as the scrotum,
abdomen, and legs, may require support. The scrotum can be elevated with a rolled washcloth.
Ice or heat should not be used. Sitting the child in an upright position will not decrease the
scrotal edema.
DIF: Cognitive Level: Applying REF: p. 1017
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
37. What do the clinical manifestations of minimal change nephrotic syndrome include?
a. Hematuria, bacteriuria, and weight gain
b. Gross hematuria, albuminuria, and fever
c. Hypertension, weight loss, and proteinuria
d. Massive proteinuria, hypoalbuminemia, and edema
ANS: D
Massive proteinuria, hypoalbuminemia, and edema are clinical manifestations of minimal change
nephrotic syndrome. Hematuria and bacteriuria are not seen, and there is usually weight loss, not
gain. The blood pressure is normal or hypotensive.
DIF: Cognitive Level: Understanding REF: p. 1017
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
38. For minimal change nephrotic syndrome (MCNS), prednisone is effective when what occurs?
a. Appetite increases and blood pressure is normal
b. Urinary tract infection is gone and edema subsides
c. Generalized edema subsides and blood pressure is normal
d. Diuresis occurs as urinary protein excretion diminishes
ANS: D
Studies suggest that the duration of steroid treatment for the initial episode should be at least 3
months. In most patients, diuresis occurs as the urinary protein excretion diminishes within 7 to
21 days after the initiation of steroid therapy. The blood pressure is normal with MCNS, so
remaining so is not an improvement. There is no urinary tract infection with MCNS.
DIF: Cognitive Level: Understanding REF: p. 1017
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
39. A nurse is evaluating the effectiveness of teaching regarding care of a child with minimal
change nephrotic syndrome (MCNS) that is in remission after administration of prednisone. The
nurse realizes further teaching is required if the parents state what?
a. We will keep our child away from anyone who is ill.
b. We will be sure to administer the prednisone as ordered.
c. We will encourage our child to eat a balanced diet, but we will watch his salt intake.
d. We understand our child will not be able to attend school, so we will arrange for home schooling.
ANS: D
The child with MCNS in remission can attend school. The child needs socialization and will be
socially isolated if home schooled. The other statements are accurate for home care for a child
with MCNS.
DIF: Cognitive Level: Applying REF: p. 1020
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
40. A parent asks the nurse what would be the first indication that acute glomerulonephritis was
improving. What would be the nurses best response?
a. Blood pressure will stabilize.
b. Your child will have more energy.
c. Urine will be free of protein.
d. Urine output will increase.
ANS: D
The first sign of improvement in acute glomerulonephritis is an increase in urinary output with a
corresponding decrease in body weight. With diuresis, the child begins to feel better, the appetite
improves, and the blood pressure decreases to normal with the reduction of edema. Gross
hematuria diminishes, in part because of dilution of the red blood cells in the more dilute urine.
Renal function and hypocomplementemia usually normalize by 8 weeks.
DIF: Cognitive Level: Applying REF: p. 1012
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
41. A child is admitted with acute glomerulonephritis. What should the nurse expect the
urinalysis during this acute phase to show?
a. Bacteriuria and hematuria
b. Hematuria and proteinuria
c. Bacteriuria and increased specific gravity
d. Proteinuria and decreased specific gravity
ANS: B
Urinalysis during the acute phase characteristically shows hematuria, proteinuria, and increased
specific gravity. Proteinuria generally parallels the hematuria but is not usually the massive
proteinuria seen in nephrotic syndrome. Gross discoloration of urine reflects its red blood cell
and hemoglobin content. Microscopic examination of the sediment shows many red blood cells,
leukocytes, epithelial cells, and granular and red blood cell casts. Bacteria are not seen, and urine
culture results are negative.
DIF: Cognitive Level: Analyzing REF: p. 1012 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
42. A child with acute glomerulonephritis is in the playroom and experiences blurred vision and
a headache. What action should the nurse take?
a. Check the urine to see if hematuria has increased.
b. Obtain the childs blood pressure and notify the health care provider.
c. Obtain serum electrolytes and send urinalysis to the laboratory.
d. Reassure the child and encourage bed rest until the headache improves.
ANS: B
The premonitory signs of encephalopathy are headache, dizziness, abdominal discomfort, and
vomiting. If the condition progresses, there may be transient loss of vision or hemiparesis,
disorientation, and generalized tonic-clonic seizures. The health care provider should be notified
of these symptoms.
DIF: Cognitive Level: Applying REF: p. 1014
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
43. The nurse is preparing to admit a child to the hospital with a diagnosis of acute
poststreptococcal glomerulonephritis. The nurse understands that the peak age at onset for this
disease is what?
a. 2 to 4 years
b. 5 to 7 years
c. 8 to 10 years
d. 11 to 13 years
ANS: B
The peak age at onset for acute poststreptococcal glomerulonephritis is 5 to 7 years of age.
DIF: Cognitive Level: Understanding REF: p. 1013
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
44. The nurse is preparing to admit a child to the hospital with a diagnosis of minimal change
nephrotic syndrome. The nurse understands that the peak age at onset for this disease is what?
a. 2 to 3 years
b. 4 to 5 years
c. 6 to 7 years
d. 8 to 9 years
ANS: A
The peak age at onset for minimal change nephrotic syndrome is 2 to 3 years of age.
DIF: Cognitive Level: Understanding REF: p. 1017
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
MULTIPLE RESPONSE
1. The nurse is admitting a 9-year-old child with hemolytic uremic syndrome. What clinical
manifestations should the nurse expect to observe? (Select all that apply.)
a. Hematuria
b. Anorexia
c. Hypertension
d. Purpura
e. Proteinuria
f. Periorbital edema
ANS: B, C, D
Clinical manifestations of hemolytic uremic syndrome include anorexia; hypertension; and
purpura, which persists for several days to 2 weeks. Gross hematuria is seen in acute
glomerulonephritis. Substantial proteinuria and periorbital edema are common manifestations in
nephrotic syndrome.
DIF: Cognitive Level: Applying REF: p. 1023
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. The nurse is caring for a child with a urinary tract infection who is on intravenous gentamicin
(Garamycin). What interventions should the nurse plan for this child with regard to this
medication? (Select all that apply.)
a. Encourage fluids.
b. Monitor urinary output.
c. Monitor sodium serum levels.
d. Monitor potassium serum levels.
e. Monitor serum peak and trough levels.
ANS: A, B, E
Garamycin can cause renal toxicity and ototoxicity. Fluids should be encouraged and urinary
output and serum peak and trough levels monitored. It is not necessary to monitor potassium
sodium levels for patients taking this medication.
DIF: Cognitive Level: Applying REF: p. 1007 TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
3. The nurse is caring for a child with a urinary tract infection who is on
trimethoprimsulfamethoxazole (Bactrim). What side effects of this medication should the nurse
teach to the parents and the child? (Select all that apply.)
a. Rash
b. Urticaria
c. Pneumonitis
d. Renal toxicity
e. Photosensitivity
ANS: A, B, E
Side effects of Bactrim are rash, urticaria, and photosensitivity. Pneumonitis and renal toxicity
are not side effects of Bactrim.
DIF: Cognitive Level: Applying REF: p. 1007
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
4. The nurse is caring for a child with acute renal failure. What laboratory findings should the
nurse expect to find? (Select all that apply.)
a. Hyponatremia
b. Hyperkalemia
c. Metabolic alkalosis
d. Elevated blood urea nitrogen level
e. Decreased plasma creatinine level
ANS: A, B, D
A child with acute renal failure would have hyponatremia, hyperkalemia, and elevated blood
urea nitrogen levels. The child would have metabolic acidosis, not alkalosis, and the plasma
creatinine levels would be increased, not decreased.
DIF: Cognitive Level: Analyzing REF: p. 1025 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
5. What signs and symptoms are indicative of a urinary tract disorder in the neonatal period
(birth to 1 month)? (Select all that apply.)
a. Edema
b. Bradypnea
c. Frequent urination
d. Poor urinary stream
e. Failure to gain weight
ANS: C, D, E
Signs and symptoms of a urinary tract disorder in the neonatal period are frequent urination, poor
urinary stream, and failure to gain weight. The respirations would be rapid, not slow, and
dehydration, not edema, occurs.
DIF: Cognitive Level: Analyzing REF: p. 1001
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
6. What signs and symptoms are indicative of a urinary tract disorder in the infancy period (124
months)? (Select all that apply.)
a. Pallor
b. Poor feeding
c. Hypothermia
d. Excessive thirst
e. Frequent urination
ANS: A, B, D, E
Signs and symptoms of a urinary tract disorder in the infancy period are pallor, poor feeding,
excessive thirst, and frequent urination. Hyperthermia is seen, not hypothermia.
DIF: Cognitive Level: Analyzing REF: p. 1001
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
7. What signs and symptoms are indicative of a urinary tract disorder in the childhood period (2
to 14 years)? (Select all that apply.)
a. Fatigue
b. Dehydration
c. Hypotension
d. Growth failure
e. Blood in the urine
ANS: A, D, E
Signs and symptoms of a urinary tract disorder in the childhood period are fatigue, growth
failure, and blood in the urine. Edema is noted, not dehydration, and hypertension is present, not
hypotension.
DIF: Cognitive Level: Analyzing REF: p. 1001
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
8. What dietary instructions should the nurse give to parents of a child in the oliguria phase of
acute glomerulonephritis with edema and hypertension? (Select all that apply.)
a. High fat
b. Low protein
c. Encouragement of fluids
d. Moderate sodium restriction
e. Limit foods high in potassium
ANS: D, E
Dietary restrictions depend on the stage and severity of acute glomerulonephritis, especially the
extent of edema. A regular diet is permitted in uncomplicated cases, but sodium intake is usually
limited (no salt is added to foods). Moderate sodium restriction is usually instituted for children
with hypertension or edema. Foods with substantial amounts of potassium are generally
restricted during the period of oliguria. Protein restriction is reserved only for children with
severe azotemia resulting from prolonged oliguria. A low-protein, high-fat diet with
encouragement of fluids would not be recommended.
DIF: Cognitive Level: Applying REF: p. 1015
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
9. What dietary instructions should the nurse give to parents of a child with minimal change
nephrotic syndrome with massive edema?(Select all that apply.)
a. Soft diet
b. High protein
c. Fluid restricted
d. No salt added at the table
e. Restriction of foods high in sodium
ANS: D, E
The child with minimal change nephrotic syndrome maintains a regular diet, not soft. However,
salt is restricted during periods of massive edema and while the patient is on corticosteroid
therapy; no salt is added at the table, and foods with very high salt content are excluded.
Although a low-sodium diet will not remove edema, its rate of increase may be reduced. Water is
seldom restricted. A diet generous in protein is logical, but there is no evidence that it is
beneficial or alters the outcome of the disease.
DIF: Cognitive Level: Applying REF: p. 1019
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
10. What dietary instructions should the nurse give to parents of a child undergoing chronic
hemodialysis? (Select all that apply.)
a. High protein
b. Fluid restriction
c. High phosphorus
d. Sodium restriction
e. Potassium restriction
ANS: B, D, E
Dietary limitations are necessary in patients undergoing chronic dialysis to avoid biochemical
complications. Fluid and sodium are restricted to prevent fluid overload and its associated
symptoms of hypertension, cerebral manifestations, and congestive heart failure. Potassium is
restricted to prevent complications related to hyperkalemia; phosphorus restriction helps prevent
parathyroid hyperactivity and its attendant risk of abnormal calcification in soft tissues. Adequate
protein, not high intake, is necessary to maximize growth potential. Fluid limitations are
determined by residual urinary output and the need to limit intradialytic weight gain.
DIF: Cognitive Level: Applying REF: p. 1016
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
11. A child is hospitalized in acute renal failure and has a serum potassium greater than 7 mEq/L.
What temporary measures that will produce a rapid but transient effect to reduce the potassium
should the nurse expect to be prescribed? (Select all that apply.)
a. Dialysis
b. Calcium gluconate
c. Sodium bicarbonate
d. Glucose 50% and insulin
e. Sodium polystyrene sulfonate (Kayexalate)
ANS: B, C, D
Several measures are available to reduce the serum potassium concentration, and the priority of
implementation is usually based on the rapidity with which the measures are effective.
Temporary measures that produce a rapid but transient effect are calcium gluconate, sodium
bicarbonate, and glucose 50%, and insulin. Definitive but slower-acting measures are then
implemented which include administration of a cation exchange resin such as sodium
polystyrene sulfonate (Kayexalate), 1 g/kg, administered orally or rectally, and/or dialysis.
DIF: Cognitive Level: Analyzing REF: p. 1028
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
12. Parents of a child who will need hemodialysis ask the nurse, What are the advantages of a
fistula over a graft or external access device for hemodialysis? What response should the nurse
give? (Select all that apply.)
a. It is ready to be used immediately.
b. There are fewer complications with a fistula.
c. There is less restriction of activity with a fistula.
d. It produces dilation and thickening of the superficial vessels.
e. The fistula does not require a needle insertion at each dialysis.
ANS: B, C, D
The creation of a subcutaneous (internal) arteriovenous fistula by anastomosing a segment of the
radial artery and brachiocephalic vein produces dilation and thickening of the superficial vessels
of the forearm to provide easy access for repeated venipuncture. Fewer complications and less
restriction of activity are observed with the use of a fistula. Both the graft and the fistula require
needle insertion at each dialysis. The fistula cannot be used immediately.
DIF: Cognitive Level: Applying REF: p. 1036
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
13. What are signs and symptoms of a possible kidney transplant rejection in a child? (Select all
that apply.)
a. Fever
b. Hypotension
c. Diminished urinary output
d. Decreased serum creatinine
e. Swelling and tenderness of graft area
ANS: A, C, E
The child with a kidney transplant who exhibits any of the following should be evaluated
immediately for possible rejection: fever, diminished urinary output, and swelling and tenderness
of graft area. Hypertension, not hypotension, and increased, not decreased, serum creatinine are
signs of rejection.
CH.26
1. What test is used to screen for carbohydrate malabsorption?
a. Stool pH
b. Urine ketones
c. C urea breath test
d. ELISA stool assay
ANS: A
The anticipated pH of a stool specimen is 7.0. A stool pH of less than 5.0 is indicative of
carbohydrate malabsorption. The bacterial fermentation of carbohydrates in the colon produces
short-chain fatty acids, which lower the stool pH. Urine ketones detect the presence of ketones in
the urine, which indicates the use of alternative sources of energy to glucose. The C urea breath
test measures the amount of carbon dioxide exhaled. It is used to determine the presence
of Helicobacter pylori. ELISA (enzyme-linked immunosorbent assay) detects the presence of
antigens and antibodies. It is not useful for disorders of metabolism.
DIF: Cognitive Level: Understanding REF: p. 1055
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. A toddlers mother calls the nurse because she thinks her son has swallowed a button type of
battery. He has no signs of respiratory distress. The nurses response should be based on which
premise?
a. An emergency laparotomy is very likely.
b. The location needs to be confirmed by radiographic examination.
c. Surgery will be necessary if the battery has not passed in the stool in 48 hours.
d. Careful observation is essential because an ingested battery cannot be accurately detected.
ANS: B
Button batteries can cause severe damage if lodged in the esophagus. If both poles of the battery
come in contact with the wall of the esophagus, acid burns, necrosis, and perforation can occur.
If the battery is in the stomach, it will most likely be passed without incident. Surgery is not
indicated. The battery is metallic and is readily seen on radiologic examination.
DIF: Cognitive Level: Applying REF: p. 1068 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
3. The mother of a child with cognitive impairment calls the nurse because her son has been
gagging and drooling all morning. The nurse suspects foreign body ingestion. What physiologic
occurrence is most likely responsible for the presenting signs?
a. Gastrointestinal perforation may have occurred.
b. The object may have been aspirated.
c. The object may be lodged in the esophagus.
d. The object may be embedded in stomach wall.
ANS: C
Gagging and drooling may be signs of esophageal obstruction. The child is unable to swallow
saliva, which contributes to the drooling. Signs of gastrointestinal (GI) perforation include chest
or abdominal pain and evidence of bleeding in the GI tract. If the object was aspirated, the child
would most likely have coughing, choking, inability to speak, or difficulty breathing. If the
object was embedded in the stomach wall, it would not result in symptoms of gagging and
drooling.
DIF: Cognitive Level: Applying REF: p. 1071
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
4. What is a high-fiber food that the nurse should recommend for a child with chronic
constipation?
a. White rice
b. Popcorn
c. Fruit juice
d. Ripe bananas
ANS: B
Popcorn is a high-fiber food. Refined rice is not a significant source of fiber. Unrefined brown
rice is a fiber source. Fruit juices are not a significant source of fiber. Raw fruits, especially those
with skins and seeds, other than ripe bananas, have high fiber.
DIF: Cognitive Level: Applying REF: p. 1074 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
5. A 2-year-old child has a chronic history of constipation and is brought to the clinic for
evaluation. What should the therapeutic plan initially include?
a. Bowel cleansing
b. Dietary modification
c. Structured toilet training
d. Behavior modification
ANS: A
The first step in the treatment of chronic constipation is to empty the bowel and allow the
distended rectum to return to normal size. Dietary modification is an important part of the
treatment. Increased fiber and fluids should be gradually added to the childs diet. A 2-year-old
child is too young for structured toilet training. For an older child, a regular schedule for toileting
should be established. Behavior modification is part of the overall treatment plan. The child
practices releasing the anal sphincter and recognizing cues for defecation.
DIF: Cognitive Level: Understanding REF: p. 1072
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
6. What statement best describes Hirschsprung disease?
a. The colon has an aganglionic segment.
b. It results in frequent evacuation of solids, liquid, and gas.
c. The neonate passes excessive amounts of meconium.
d. It results in excessive peristaltic movements within the gastrointestinal tract.
ANS: A
Mechanical obstruction in the colon results from a lack of innervation. In most cases, the
aganglionic segment includes the rectum and some portion of the distal colon. There is decreased
evacuation of the large intestine secondary to the aganglionic segment. Liquid stool may ooze
around the blockage. The obstruction does not affect meconium production. The infant may not
be able to pass the meconium stool. There is decreased movement in the colon.
DIF: Cognitive Level: Understanding REF: p. 1074
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
7. What procedure is most appropriate for assessment of an abdominal circumference related to a
bowel obstruction?
a. Measuring the abdomen after feedings
b. Marking the point of measurement with a pen
c. Measuring the circumference at the symphysis pubis
d. Using a new tape measure with each assessment to ensure accuracy
ANS: B
Pen marks on either side of the tape measure allow the nurse to measure the same spot on the
childs abdomen at each assessment. The child most likely will be kept NPO (nothing by mouth)
if a bowel obstruction is present. If the child is being fed, the assessment should be done before
feedings. The symphysis pubis is too low. Usually the largest part of the abdomen is at the
umbilicus. Leaving the tape measure in place reduces the trauma to the child.
DIF: Cognitive Level: Applying REF: p. 1067
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
8. A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary
colostomy will be necessary. How should the nurse prepare this child?
a. It is unnecessary because of childs age.
b. It is essential because it will be an adjustment.
c. Preparation is not needed because the colostomy is temporary.
d. Preparation is important because the child needs to deal with negative body image.
ANS: B
The childs age dictates the type and extent of psychologic preparation. When a colostomy is
performed, it is necessary to prepare the child who is at least preschool age by telling him or her
about the procedure and what to expect in concrete terms, with the use of visual aids. The
preschooler is not yet concerned with body image.
DIF: Cognitive Level: Applying REF: p. 1075
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
9. A child has a nasogastric (NG) tube after surgery for Hirschsprung disease. What is the
purpose of the NG tube?
a. Prevent spread of infection.
b. Monitor electrolyte balance.
c. Prevent abdominal distention.
d. Maintain accurate record of output.
ANS: C
The NG tube is placed to suction out gastrointestinal secretions and prevent abdominal
distention. The NG tube would not affect infection. Electrolyte content of the NG drainage can
be monitored. Without the NG tube, there would be no drainage. After the NG tube is placed, it is
important to maintain an accurate record of intake and output. This is not the reason for
placement of the tube.
DIF: Cognitive Level: Applying REF: p. 1077
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
10. A parent of an infant with gastroesophageal reflux asks how to decrease the number and total
volume of emesis. What recommendation should the nurse include in teaching this parent?
a. Surgical therapy is indicated.
b. Place in prone position for sleep after feeding.
c. Thicken feedings and enlarge the nipple hole.
d. Reduce the frequency of feeding by encouraging larger volumes of formula.
ANS: C
Thickened feedings decrease the childs crying and increase the caloric density of the feeding.
Although it does not decrease the pH, the number and volume of emesis are reduced. Surgical
therapy is reserved for children who have failed to respond to medical therapy or who have an
anatomic abnormality. The prone position is not recommended because of the risk of sudden
infant death syndrome. Smaller, more frequent feedings are more effective than less frequent,
larger volumes of formula.
DIF: Cognitive Level: Applying REF: p. 1093
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
11. After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has
somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to
perform at this time?
a. Notify the practitioner.
b. Insert the NG tube so feedings can be given.
c. Replace the NG tube to maintain gastric decompression.
d. Leave the NG tube out because it has probably been in long enough.
ANS: A
When surgery is performed on the upper gastrointestinal tract, usually the surgical team replaces
the NG tube because of potential injury to the operative site. The decision to replace the tube or
leave it out is made by the surgical team. Replacing the tube is also usually done by the
practitioner because of the surgical site.
DIF: Cognitive Level: Applying REF: p. 1077
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
12. An adolescent with irritable bowel syndrome comes to see the school nurse. What
information should the nurse share with the adolescent?
a. A low-fiber diet is required.
b. Stress management may be helpful.
c. Milk products are a contributing factor.
d. Pantoprazole (a proton pump inhibitor) is effective in treatment.
ANS: B
Irritable bowel syndrome is believed to involve motor, autonomic, and psychologic factors.
Stress management, environmental modification, and psychosocial intervention may reduce
stress and gastrointestinal symptoms. A high-fiber diet with psyllium supplement is often
beneficial. Milk products can exacerbate bowel problems caused by lactose intolerance.
Antispasmodic drugs, antidiarrheal drugs, and simethicone are beneficial for some individuals.
Proton pump inhibitors have no effect.
DIF: Cognitive Level: Applying REF: p. 1078
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
13. What clinical manifestation should be the most suggestive of acute appendicitis?
a. Rebound tenderness
b. Bright red or dark red rectal bleeding
c. Abdominal pain that is relieved by eating
d. Colicky, cramping, abdominal pain around the umbilicus
ANS: D
Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain becomes
constant and may shift to the right lower quadrant. Rebound tenderness is not a reliable sign and
is extremely painful to the child. Bright or dark red rectal bleeding and abdominal pain that is
relieved by eating are not signs of acute appendicitis.
DIF: Cognitive Level: Understanding REF: p. 1079
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
14. When caring for a child with probable appendicitis, the nurse should be alert to recognize
which sign or symptom as a manifestation of perforation?
a. Anorexia
b. Bradycardia
c. Sudden relief from pain
d. Decreased abdominal distention
ANS: C
Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation.
Anorexia is already a clinical manifestation of appendicitis. Tachycardia, not bradycardia, is a
manifestation of peritonitis. Abdominal distention usually increases in addition to an increase in
pain (usually diffuse and accompanied by rigid guarding of the abdomen).
DIF: Cognitive Level: Applying REF: p. 1079
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
15. The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis.
What intervention is appropriate to relieve the abdominal discomfort during the evaluation?
a. Place in the Trendelenburg position.
b. Apply moist heat to the abdomen.
c. Allow the child to assume a position of comfort.
d. Administer a saline enema to cleanse the bowel.
ANS: C
The child should be allowed to take a position of comfort, usually with the legs flexed. The
Trendelenburg position will not help with the discomfort. If appendicitis is a possibility,
administering laxative or enemas or applying heat to the area is dangerous. Such measures
stimulate bowel motility and increase the risk of perforation.
DIF: Cognitive Level: Applying REF: p. 1081
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
16. What statement is most descriptive of Meckel diverticulum?
a. It is acquired during childhood.
b. Intestinal bleeding may be mild or profuse.
c. It occurs more frequently in females than in males.
d. Medical interventions are usually sufficient to treat the problem.
ANS: B
Bloody stools are often a presenting sign of Meckel diverticulum. It is associated with mild to
profuse intestinal bleeding. Meckel diverticulum is the most common congenital malformation of
the gastrointestinal tract and is present in 1% to 4% of the general population. It is more common
in males than in females. The standard therapy is surgical removal of the diverticulum.
DIF: Cognitive Level: Understanding REF: p. 1083
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
17. One of the major differences in clinical presentation between Crohn disease (CD) and
ulcerative colitis (UC) is that UC is more likely to cause which clinical manifestation?
a. Pain
b. Rectal bleeding
c. Perianal lesions
d. Growth retardation
ANS: B
Rectal bleeding is more common in UC than CD. Pain, perianal lesions, and growth retardation
are common manifestations of CD.
DIF: Cognitive Level: Understanding REF: p. 1084
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
18. Nutritional management of the child with Crohn disease includes a diet that has which
component?
a. High fiber
b. Increased protein
c. Reduced calories
d. Herbal supplements
ANS: B
The child with Crohn disease often has growth failure. Nutritional support is planned to reduce
ongoing losses and provide adequate energy and protein for healing. Fiber is mechanically hard
to digest. Foods containing seeds may contribute to obstruction. A high-calorie diet is necessary
to minimize growth failure. Herbal supplements should not be used unless discussed with the
practitioner. Vitamin supplementation with folic acid, iron, and multivitamins is recommended.
DIF: Cognitive Level: Understanding REF: p. 1086
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
19. What information should the nurse include when teaching an adolescent with Crohn disease
(CD)?
a. How to cope with stress and adjust to chronic illness
b. Preparation for surgical treatment and cure of CD
c. Nutritional guidance and prevention of constipation
d. Prevention of spread of illness to others and principles of high-fiber diet
ANS: A
CD is a chronic illness with a variable course and many potential complications. Guidance about
living with chronic illness is essential for adolescents. Stress management techniques can help
with exacerbations and possible limitations caused by the illness. At this time, there is no cure for
CD. Surgical intervention may be indicated for complications that cannot be controlled by
medical and nutritional therapy. Nutritional guidance is an essential part of management.
Constipation is not usually an issue with CD. CD is not infectious, so transmission is not a
concern. A low-fiber diet is indicated.
DIF: Cognitive Level: Understanding REF: p. 1086
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
20. A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what
potential complication?
a. Hyperkalemia
b. Hyperchloremia
c. Metabolic acidosis
d. Metabolic alkalosis
ANS: D
Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions.
Potassium and chloride ions are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.
DIF: Cognitive Level: Applying REF: p. 1091
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
21. What term describes invagination of one segment of bowel within another?
a. Atresia
b. Stenosis
c. Herniation
d. Intussusception
ANS: D
Intussusception occurs when a proximal section of the bowel telescopes into a more distal
segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in
lymphatic and venous obstruction. Atresia is the absence or closure of a natural opening in the
body. Stenosis is a narrowing or constriction of the diameter of a bodily passage or orifice.
Herniation is the protrusion of an organ or part through connective tissue or through a wall of the
cavity in which it is normally enclosed.
DIF: Cognitive Level: Understanding REF: p. 1091
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
22. A school-age child with celiac disease asks for guidance about snacks that will not exacerbate
the disease. What snack should the nurse suggest?
a. Pizza
b. Pretzels
c. Popcorn
d. Oatmeal cookies
ANS: C
Celiac disease symptoms result from ingestion of gluten. Corn and rice do not contain gluten.
Popcorn or corn chips will not exacerbate the intestinal symptoms. Pizza and pretzels are usually
made from wheat flour that contains gluten. Also, in the early stages of celiac disease, the child
may be lactose intolerant. Oatmeal contains gluten.
DIF: Cognitive Level: Applying REF: p. 1096
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
23. An infant with short bowel syndrome is receiving total parenteral nutrition (TPN). The
practitioner has added continuous enteral feedings through a gastrostomy tube. The nurse
recognizes this as important for which reason?
a. Wean the infant from TPN the next day
b. Stimulate adaptation of the small intestine
c. Give additional nutrients that cannot be included in the TPN
d. Provide parents with hope that the child is close to discharge
ANS: B
Long-term survival without TPN depends on the small intestines ability to increase its absorptive
capacity. Continuous enteral feedings facilitate the adaptation. TPN is indicated until the child is
able to receive all nutrition via the enteral route. Before this is accomplished, the small intestine
must adapt and increase in cell number and cell mass per villus column. TPN is formulated to
meet the infants nutritional needs. Continuous enteral feedings through a gastrostomy tube is a
positive sign, but the infants ability to tolerate increasing amounts of enteral nutrition is only one
factor that determines readiness for discharge.
DIF: Cognitive Level: Analyzing REF: p. 1097
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
24. Melena, the passage of black, tarry stools, suggests bleeding from which source?
a. The perianal or rectal area
b. The upper gastrointestinal (GI) tract
c. The lower GI tract
d. Hemorrhoids or anal fissures
ANS: B
Melena is denatured blood from the upper GI tract or bleeding from the right colon. Blood from
the perianal or rectal area, hemorrhoids, or lower GI tract would be bright red.
DIF: Cognitive Level: Understanding REF: p. 1098
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
25. A child with acute gastrointestinal bleeding is admitted to the hospital. The nurse observes
which sign or symptom as an early manifestation of shock?
a. Restlessness
b. Rapid capillary refill
c. Increased temperature
d. Increased blood pressure
ANS: A
Restlessness is an indication of impending shock in a child. Capillary refill is slowed in shock.
The child will feel cool. The blood pressure initially remains within the normal range and then
declines.
DIF: Cognitive Level: Analyzing REF: p. 1099
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
26. What signs or symptoms are most commonly associated with the prodromal phase of acute
viral hepatitis?
a. Bruising and lethargy
b. Anorexia and malaise
c. Fatigability and jaundice
d. Dark urine and pale stools
ANS: B
The signs and symptoms most common in the prodromal phase are anorexia, malaise, lethargy,
and easy fatigability. Bruising would not be an issue unless liver damage has occurred. Jaundice
is a late sign and often does not occur in children. Dark urine and pale stools would occur during
the onset of jaundice (icteric phase) if it occurs.
DIF: Cognitive Level: Understanding REF: p. 1102
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
27. What immunization is recommended for all newborns?
a. Hepatitis A vaccine
b. Hepatitis B vaccine
c. Hepatitis C vaccine
d. Hepatitis A, B, and C vaccines
ANS: B
Universal vaccination for hepatitis B is recommended for all newborns. Hepatitis A vaccine is
recommended for infants starting at 12 months. No vaccine is currently available for hepatitis C.
DIF: Cognitive Level: Understanding REF: p. 1103
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
28. The nurse is discussing home care with a mother whose 6-year-old child has hepatitis A.
What information should the nurse include?
a. Advise bed rest until 1 week after the icteric phase.
b. Teach infection control measures to family members.
c. Inform the mother that the child cannot return to school until 3 weeks after onset of jaundice.
d. Reassure the mother that hepatitis A cannot be transmitted to other family members.
ANS: B
Hand washing is the single most effective measure in preventing and controlling hepatitis.
Hepatitis A can be transmitted through the fecaloral route. Family members must be taught
preventive measures. Rest and quiet activities are essential and adjusted to the childs condition,
but bed rest is not necessary. The child is not infectious 1 week after the onset of jaundice and
may return to school as activity level allows.
DIF: Cognitive Level: Applying REF: p. 1104
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
29. What therapeutic intervention provides the best chance of survival for a child with cirrhosis?
a. Nutritional support
b. Liver transplantation
c. Blood component therapy
d. Treatment with corticosteroids
ANS: B
The only successful treatment for end-stage liver disease and liver failure may be liver
transplantation, which has improved the prognosis for many children with cirrhosis. Liver
transplantation reflects the failure of other medical and surgical measures to prevent or treat
cirrhosis. Nutritional support is necessary for the child with cirrhosis, but it does not stop the
progression of the disease. Blood components are indicated when the liver can no longer produce
clotting factors. It is supportive therapy, not curative. Corticosteroids are not used in end-stage
liver disease.
DIF: Cognitive Level: Understanding REF: p. 1105
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
30. The nurse observes that a newborn is having problems after birth. What should indicate a
tracheoesophageal fistula?
a. Jitteriness
b. Meconium ileus
c. Excessive frothy saliva
d. Increased need for sleep
ANS: C
Excessive frothy saliva is indicative of a tracheoesophageal fistula. The child is unable to
swallow the secretions, so there are excessive amounts of saliva in the mouth. Jitteriness is
associated with several disorders, including electrolyte imbalances. Meconium ileus is associated
with cystic fibrosis. Increased need for sleep is not associated with a tracheoesophageal fistula.
DIF: Cognitive Level: Understanding REF: p. 1107
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
31. The nurse is caring for a neonate with a suspected tracheoesophageal fistula. What should
nursing care include?
a. Feed glucose water only.
b. Elevate the patients head for feedings.
c. Raise the patients head and give nothing by mouth.
d. Avoid suctioning unless the infant is cyanotic.
ANS: C
When a newborn is suspected of having a tracheoesophageal fistula, the most desirable position
is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that
any source of aspiration be removed at once; oral feedings are withheld. The oral pharynx should
be kept clear of secretions by oral suctioning. This is to prevent the cyanosis that is usually the
result of laryngospasm caused by overflow of saliva into the larynx.
DIF: Cognitive Level: Analyzing REF: p. 1109
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
32. The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24
hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the
gastrostomy tube include?
a. Keep the tube clamped.
b. Suction the tube as needed.
c. Leave the tube open to gravity drainage.
d. Lower the tube to a point below the level of the stomach.
ANS: C
In the immediate postoperative period, the gastrostomy tube is open to gravity drainage. This
usually is continued until the infant is able to tolerate feedings. The tube is unclamped in the
postoperative period to allow for the drainage of secretions and air. Gastrostomy tubes are not
suctioned on an as-needed basis. They may be connected to low suction to facilitate drainage of
secretions. Lowering the tube to a point below the level of the stomach would create too much
pressure.
DIF: Cognitive Level: Applying REF: p. 1110
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
33. What should preoperative care of a newborn with an anorectal malformation include?
a. Frequent suctioning
b. Gastrointestinal decompression
c. Feedings with sterile water only
d. Supine position with head elevated
ANS: B
Gastrointestinal decompression is an essential part of nursing care for a newborn with an
anorectal malformation. This helps alleviate intraabdominal pressure until surgical intervention.
Suctioning is not necessary for an infant with this type of anomaly. Feedings are not indicated
until it is determined that the gastrointestinal tract is intact. Supine position with head elevated is
indicated for infants with a tracheoesophageal fistula, not anorectal malformations.
DIF: Cognitive Level: Applying REF: p. 1118
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
34. A child who has just had definitive repair of a high rectal malformation is to be discharged.
What should the nurse address in the discharge preparation of this family?
a. Safe administration of daily enemas
b. Necessity of firm stools to keep suture line clean
c. Bowel training beginning as soon as the child returns home
d. Changes in stooling patterns to report to the practitioner
ANS: D
The parents are taught to notify the practitioner if any signs of an anal stricture or other
complications develop. Constipation is avoided because a firm stool will place strain on the
suture line. Daily enemas are contraindicated after surgical repair of a rectal malformation. Fiber
and stool softeners are often given to keep stools soft and avoid tension on the suture line. The
child needs to recover from the surgical procedure. Then bowel training may begin, depending
on the childs developmental and physiologic readiness.
DIF: Cognitive Level: Applying REF: p. 1118
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
35. The parents of a newborn with an umbilical hernia ask about treatment options. The nurses
response should be based on which knowledge?
a. Surgery is recommended as soon as possible.
b. The defect usually resolves spontaneously by 3 to 5 years of age.
c. Aggressive treatment is necessary to reduce its high mortality.
d. Taping the abdomen to flatten the protrusion is sometimes helpful.
ANS: B
The umbilical hernia usually resolves by ages 3 to 5 years of age without intervention. Umbilical
hernias rarely become problematic. Incarceration, where the hernia is constricted and cannot be
reduced manually, is rare. Umbilical hernias are not associated with a high mortality rate. Taping
the abdomen flat does not help heal the hernia; it can cause skin irritation.
DIF: Cognitive Level: Applying REF: p. 1114
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
36. The nurse is preparing to care for a newborn with an omphalocele. The nurse should
understand that care of the infant should include what intervention?
a. Initiating breast- or bottle-feedings to stabilize the blood glucose level
b. Maintaining pain management with an intravenous opioid
c. Covering the intact bowel with a nonadherent dressing to prevent injury
d. Performing immediate surgery
ANS: C
Nursing care of an infant with an omphalocele includes covering the intact bowel with a
nonadherent dressing to prevent injury or placing a bowel bag or moist dressings and a plastic
drape if the abdominal contents are exposed. The infant is not started on any type of feeding but
has a nasogastric tube placed for gastric decompression. Pain management is started after
surgery, but surgery is not done immediately after birth. The infant is medically stabilized before
different surgical options are considered.
DIF: Cognitive Level: Applying REF: p. 1113 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
37. What should the nurse consider when providing support to a family whose infant has just
been diagnosed with biliary atresia?
a. The prognosis for full recovery is excellent.
b. Death usually occurs by 6 months of age.
c. Liver transplantation may be needed eventually.
d. Children with surgical correction live normal lives.
ANS: C
Untreated biliary atresia results in progressive cirrhosis and death usually by 2 years of age.
Surgical intervention at 8 weeks of age is associated with somewhat better outcomes. Liver
transplantation is also improving outcomes for 10-year survival. Even with surgical intervention,
most children require supportive therapy. With early intervention, 10-year survival rates range
from 27% to 75%.
DIF: Cognitive Level: Applying REF: p. 1105
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
38. A 3-day-old infant presents with abdominal distention, is vomiting, and has not passed any
meconium stools. What disease should the nurse suspect?
a. Pyloric stenosis
b. Intussusception
c. Hirschsprung disease
d. Celiac disease
ANS: C
The clinical manifestations of Hirschsprung disease in a 3-day-old infant include abdominal
distention, vomiting, and failure to pass meconium stools. Pyloric stenosis would present with
vomiting but not distention or failure to pass meconium stools. Intussusception presents with
abdominal cramping and celiac disease presents with malabsorption.
DIF: Cognitive Level: Analyzing REF: p. 1074
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
39. A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy.
What should postoperative teaching to the parents include?
a. Dilating the stoma
b. Assessing bowel function
c. Limitation of physical activities
d. Measures to prevent prolapse of the rectum
ANS: B
In the postoperative period, the nurse involves the parents in the care of the child with a
temporary colostomy, allowing them to help with feedings and observe for signs of wound
infection or irregular passage of stool (constipation or true incontinence). Some children will
require daily anal dilatations in the postoperative period to avoid anastomotic strictures but not
stoma dilatations. Physical activities should be encouraged. There is not a risk of prolapse of the
rectum in Hirschsprung disease, just strictures.
DIF: Cognitive Level: Applying REF: p. 1075
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
40. An infant is born with a gastroschisis. Care preoperatively should include which priority
intervention?
a. Prone position
b. Sterile water feedings
c. Monitoring serum laboratory electrolytes
d. Covering the defect with a sterile bowel bag
ANS: D
Initial management of a gastroschisis involves covering the exposed bowel with a transparent
plastic bowel bag or loose, moist dressings. The infant cannot be placed prone, and feedings will
be withheld until surgery is performed. Electrolyte laboratory values will be monitored but not
before covering the defect with a sterile bowel bag.
DIF: Cognitive Level: Applying REF: p. 1113 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
41. What is the purpose in using cimetidine (Tagamet) for gastroesophageal reflux?
a. The medication reduces gastric acid secretion.
b. The medication neutralizes the acid in the stomach.
c. The medication increases the rate of gastric emptying time.
d. The medication coats the lining of the stomach and esophagus.
ANS: A
Pharmacologic therapy may be used to treat infants and children with gastroesophageal reflux
disease. Both H2-receptor antagonists (cimetidine [Tagamet], ranitidine [Zantac], or famotidine
[Pepcid]) and proton pump inhibitors (esomeprazole [Nexium], lansoprazole [Prevacid],
omeprazole [Prilosec], pantoprazole [Protonix], and rabeprazole [Aciphex]) reduce gastric
hydrochloric acid secretion.
DIF: Cognitive Level: Analyzing REF: p. 1077 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
42. A health care provider prescribes feedings of 1 to 2 oz Pedialyte every 3 hours and to
advance to 1/2 strength Similac with iron as tolerated postoperatively for an infant who had a
pyloromyotomy. The nurse should decide to advance the feeding if which occurs?
a. The infants IV line has infiltrated.
b. The infant has not voided since surgery.
c. The infants mother states the infant is tolerating the feeding okay.
d. The infant is taking the Pedialyte without vomiting or distention.
ANS: D
After a pyloromyotomy, feedings are usually instituted within 12 to 24 hours, beginning with
clear liquids. They are offered in small quantities at frequent intervals. Supervision of feedings is
an important part of postoperative care. The feedings are advanced only if the infant is taking the
clear liquids without vomiting or distention. Feedings would not be advanced if the infant has not
voided, the IV line becomes infiltrated, or the mother states the infant is tolerating the feedings.
DIF: Cognitive Level: Applying REF: p. 1063
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
43. The nurse is assisting a child with celiac disease to select foods from a menu. What foods
should the nurse suggest?
a. Hamburger on a bun
b. Spaghetti with meat sauce
c. Corn on the cob with butter
d. Peanut butter and crackers
ANS: C
Treatment of celiac disease consists primarily of dietary management. Although a gluten-free
diet is prescribed, it is difficult to remove every source of this protein. Some patients are able to
tolerate restricted amounts of gluten. Because gluten occurs mainly in the grains of wheat and
rye but also in smaller quantities in barley and oats, these foods are eliminated. Corn, rice, and
millet are substitute grain foods. Corn on the cob with butter would be gluten free.
DIF: Cognitive Level: Applying REF: p. 1096
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
44. An infant with short bowel syndrome will be on total parenteral nutrition (TPN) for an
extended period of time. What should the nurse monitor the infant for ?
a. Central venous catheter infection, electrolyte losses, and hyperglycemia
b. Hypoglycemia, catheter migration, and weight gain
c. Venous thrombosis, hyperlipidemia, and constipation
d. Catheter damage, red currant jelly stools, and hypoglycemia
ANS: A
Numerous complications are associated with short bowel syndrome and long-term TPN.
Infectious, metabolic, and technical complications can occur. Sepsis can occur after improper
care of the catheter. The gastrointestinal tract can also be a source of microbial seeding of the
catheter. The nurse should monitor for catheter infection, electrolyte losses, and hyperglycemia.
Hypoglycemia, weight gain, constipation, or red currant jelly stools are not characteristics of
short bowel syndrome with extended TPN.
DIF: Cognitive Level: Applying REF: p. 1097
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
45. A child is being admitted to the hospital with acute gastroenteritis. The health care provider
prescribes an antiemetic. What antiemetic does the nurse anticipate being prescribed?
a. Ondansetron (Zofran)
b. Promethazine (Phenergan)
c. Metoclopramide (Reglan)
d. Dimenhydrinate (Dramamine)
ANS: A
Ondansetron reduces the duration of vomiting in children with acute gastroenteritis. This would
be the expected prescribed antiemetic. Adverse effects with earlier generation antiemetics (e.g.,
promethazine and metoclopramide) include somnolence, nervousness, irritability, and dystonic
reactions and should not be routinely administered to children. For children who are prone to
motion sickness, it is often helpful to administer an appropriate dose of dimenhydrinate
(Dramamine) before a trip, but it would not be ordered as an antiemetic.
DIF: Cognitive Level: Analyzing REF: p. 1069 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
46. The nurse should instruct parents to administer a daily proton pump inhibitor to their child
with gastroesophageal reflux at which time?
a. Bedtime
b. With a meal
c. Midmorning
d. 30 minutes before breakfast
ANS: D
Proton pump inhibitors are most effective when administered 30 minutes before breakfast so that
the peak plasma concentrations occur with mealtime. If they are given twice a day, the second
best time for administration is 30 minutes before the evening meal.
DIF: Cognitive Level: Applying REF: p. 1078
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
47. An infant had a gastrostomy tube placed for feedings after a Nissen fundoplication and bolus
feedings are initiated. Between feedings while the tube is clamped, the infant becomes irritable,
and there is evidence of cramping. What action should the nurse implement?
a. Burp the infant.
b. Withhold the next feeding.
c. Vent the gastrostomy tube.
d. Notify the health care provider.
ANS: C
If bolus feedings are initiated through a gastrostomy after a Nissen fundoplication, the tube may
need to remain vented for several days or longer to avoid gastric distention from swallowed air.
Edema surrounding the surgical site and a tight gastric wrap may prohibit the infant from
expelling air through the esophagus, so burping does not relieve the distention. Some infants
benefit from clamping of the tube for increasingly longer intervals until they are able to tolerate
continuous clamping between feedings. During this time, if the infant displays increasing
irritability and evidence of cramping, some relief may be provided by venting the tube. The next
feeding should not be withheld, and calling the health care provider is not necessary.
DIF: Cognitive Level: Applying REF: p. 1078
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
48. What intervention is contraindicated in a suspected case of appendicitis?
a. Enemas
b. Palpating the abdomen
c. Administration of antibiotics
d. Administration of antipyretics for fever
ANS: A
In any instance in which severe abdominal pain is observed and appendicitis is suspected, the
nurse must be aware of the danger of administering laxatives or enemas. Such measures
stimulate bowel motility and increase the risk of perforation. The abdomen is palpated after other
assessments are made. Antibiotics should be administered, and antipyretics are not
contraindicated.
DIF: Cognitive Level: Analyzing REF: p. 1080 TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
49. The nurse is caring for a child with Meckel diverticulum. What type of stool does the nurse
expect to observe?
a. Steatorrhea
b. Clay colored
c. Currant jellylike
d. Loose stools with undigested food
ANS: C
In Meckel diverticulum the bleeding is usually painless and may be dramatic and occur as bright
red or currant jellylike stools, or it may occur intermittently and appear as tarry stools. The stools
are not clay colored, steatorrhea, or loose with undigested food.
DIF: Cognitive Level: Understanding REF: p. 1083
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
50. The nurse is evaluating the laboratory results of a stool sample. What is a normal finding?
a. The laboratory reports a stool pH of 5.0.
b. The laboratory reports a negative guaiac.
c. The laboratory reports low levels of enzymes.
d. The laboratory reports reducing substances present.
ANS: B
The normal stool finding is a negative guaiac. Stool pH should be 7.0 to 7.5. A stool pH <5.0 is
suggestive of carbohydrate malabsorption; colonic bacterial fermentation produces short-chain
fatty acids, which lower stool pH. There should be no enzymes or reducing substances present in
a normal stool sample.
DIF: Cognitive Level: Analyzing REF: p. 1056 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
MULTIPLE RESPONSE
1. The nurse is teaching a parent of a 6-month-old infant with gastroesophageal reflux (GER)
before discharge. What instructions should the nurse include? (Select all that apply.)
a. Elevate the head of the bed in the crib to a 90-degree angle while the infant is sleeping.
b. Hold the infant in the prone position after a feeding.
c. Discontinue breastfeeding so that a formula and rice cereal mixture can be used.
d. The infant will require the Nissen fundoplication after 1 year of age.
e. Prescribed cimetidine (Tagamet) should be given 30 minutes before feedings.
ANS: B, E
Discharge instructions for an infant with GER should include the prone position (up on the
shoulder or across the lap) after a feeding. Use of the prone position while the infant is sleeping
is still controversial. The American Academy of Pediatrics recommends the supine position to
decrease the risk of sudden infant death syndrome even in infants with GER. Prescribed
cimetidine or another proton pump inhibitor should be given 30 minutes before the morning and
evening feeding so that peak plasma concentrations occur with mealtime. The head of the bed in
the crib does not need to be elevated. The mother may continue to breastfeed or express breast
milk to add rice cereal if recommended by the health care provider; thickening breast milk or
formula with cereal is not recommended by all practitioners. The Nissen fundoplication is only
done on infants with GER in severe cases with complications.
DIF: Cognitive Level: Applying REF: p. 1078
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
2. The nurse is preparing to admit a 3-year-old child with intussusception. What clinical
manifestations should the nurse expect to observe? (Select all that apply.)
a. Absent bowel sounds
b. Passage of red, currant jellylike stools
c. Anorexia
d. Tender, distended abdomen
e. Hematemesis
f. Sudden acute abdominal pain
ANS: B, D, F
Intussusception occurs when a proximal segment of the bowel telescopes into a more distal
segment, pulling the mesentery with it and leading to obstruction. Clinical manifestations of
intussusception include the passage of red, currant jellylike stools; a tender, distended abdomen;
and sudden acute abdominal pain. Absent bowel sounds, anorexia, and hematemesis are clinical
manifestations observed in other types of gastrointestinal dysfunction.
DIF: Cognitive Level: Applying REF: p. 1093
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
3. The school nurse is teaching a group of adolescents about avoiding contaminated water during
a mission trip. What should the nurse include in the teaching? (Select all that apply.)
a. Ice
b. Meats
c. Raw vegetables
d. Unpeeled fruits
e. Carbonated beverages
ANS: A, B, C, D
The best measure during travel to areas where water may be contaminated is to allow children to
drink only bottled water and carbonated beverages (from the container through a straw supplied
from home). Children should also avoid tap water, ice, unpasteurized dairy products, raw
vegetables, unpeeled fruits, meats, and seafood.
DIF: Cognitive Level: Applying REF: p. 1102
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
4. The nurse is teaching parents about high-fiber foods that can prevent constipation. What foods
should the nurse include in the teaching?(Select all that apply.)
a. Oranges
b. Bananas
c. Lima beans
d. Baked beans
e. Raisin bran cereal
ANS: C, D, E
Lima beans have 13.2 g of fiber in 1 cup, baked beans have 10.4 g of fiber in 1 cup, and raisin
bran cereal has 7.3 g of fiber in 1 cup. One orange has only 3.1 g of fiber, and 1 banana has only
3.1 g of fiber, so they are not recommended as high-fiber foods.
DIF: Cognitive Level: Applying REF: p. 1073
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
5. The nurse is teaching parents of a child with gastroesophageal reflux (GER) disease foods that
can exacerbate acid reflux. What foods should be included in the teaching session? (Select all
that apply.)
a. Citrus
b. Bananas
c. Spicy foods
d. Peppermint
e. Whole wheat bread
ANS: A, C, D
Avoidance of certain foods that exacerbate acid reflux (e.g., caffeine, citrus, tomatoes, alcohol,
peppermint, spicy or fried foods) can improve mild GER symptoms. Bananas and whole wheat
bread will not exacerbate acid reflux.
DIF: Cognitive Level: Applying REF: p. 1076
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
6. The nurse is preparing to admit a 6-year-old child with irritable bowel syndrome (IBS). What
clinical manifestations should the nurse expect to observe? (Select all that apply.)
a. Flatulence
b. Constipation
c. No urge to defecate
d. Absence of abdominal pain
e. Feeling of incomplete evacuation of the bowel
ANS: A, B, E
Children with IBS often have alternating diarrhea and constipation, flatulence, bloating or a
feeling of abdominal distention, lower abdominal pain, a feeling of urgency when needing to
defecate, and a feeling of incomplete evacuation of the bowel.
DIF: Cognitive Level: Applying REF: p. 1078
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
7. The nurse is caring for a child with celiac disease. The nurse understands that what may
precipitate a celiac crisis? (Select all that apply.)
a. Exercise
b. Infections
c. Fluid overload
d. Electrolyte depletion
e. Emotional disturbance
ANS: B, D, E
A celiac crisis can be precipitated by infections, electrolyte depletion, and emotional disturbance.
Exercise or fluid overload does not precipitate a crisis.
DIF: Cognitive Level: Understanding REF: p. 1096
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
8. The nurse is preparing to admit a 6-year-old child with celiac disease. What clinical
manifestations should the nurse expect to observe?(Select all that apply.)
a. Steatorrhea
b. Polycythemia
c. Malnutrition
d. Melena stools
e. Foul-smelling stools
ANS: A, C, E
Clinical manifestations of celiac disease include impaired fat absorption (steatorrhea and foul-
smelling stools) and impaired nutrient absorption (malnutrition). Anemia, not polycythemia, is a
manifestation, and melena stools do not occur.
DIF: Cognitive Level: Applying REF: p. 1096
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
9. The nurse is preparing to admit a 10-year-old child with appendicitis. What clinical
manifestations should the nurse expect to observe?(Select all that apply.)
a. Fever
b. Vomiting
c. Tachycardia
d. Flushed face
e. Hyperactive bowel sounds
ANS: A, B, C
Clinical manifestations of appendicitis include fever, vomiting, and tachycardia. Pallor is seen,
not a flushed face, and the bowel sounds are hypoactive or absent, not hyperactive.
DIF: Cognitive Level: Applying REF: p. 1079
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
10. The nurse is preparing to admit a 2-month-old child with hypertrophic pyloric stenosis. What
clinical manifestations should the nurse expect to observe? (Select all that apply.)
a. Weight loss
b. Bilious vomiting
c. Abdominal pain
d. Projectile vomiting
e. The infant is hungry after vomiting
ANS: A, D, E
Clinical manifestations of hypertrophic pyloric stenosis include weight loss, projectile vomiting,
and hunger after vomiting. The vomitus is nonbilious, and there is no evidence of pain or
discomfort, just chronic hunger.
DIF: Cognitive Level: Applying REF: p. 1092
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
11. The nurse is preparing to admit a 6-month-old child with gastroesophageal reflux disease.
What clinical manifestations should the nurse expect to observe? (Select all that apply.)
a. Spitting up
b. Bilious vomiting
c. Failure to thrive
d. Excessive crying
e. Respiratory problems
ANS: A, C, D, E
Clinical manifestations of gastroesophageal reflux disease include spitting up, failure to thrive,
excessive crying, and respiratory problems. Hematemesis, not bilious vomiting, is a
manifestation.
DIF: Cognitive Level: Applying REF: p. 1076
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
12. The nurse is preparing to admit a 5-year-old child with hepatitis A. What clinical features of
hepatitis A should the nurse recognize?(Select all that apply.)
a. The onset is rapid.
b. Fever occurs early.
c. There is usually a pruritic rash.
d. Nausea and vomiting are common.
e. The mode of transmission is primarily by the parenteral route.
ANS: A, B, D
Clinical features of hepatitis A include a rapid onset, fever occurring early, and nausea and
vomiting. A rash is rare, and the mode of transmission is by the fecaloral route, rarely by the
parenteral route.
DIF: Cognitive Level: Understanding REF: p. 1101
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
13. The nurse is preparing to admit a 7-year-old child with hepatitis B. What clinical features of
hepatitis B should the nurse recognize?(Select all that apply.)
a. The onset is rapid.
b. Rash is common.
c. Jaundice is present
d. No carrier state exists.
e. The mode of transmission is principally by the parenteral route.
ANS: B, C, E
Clinical features of hepatitis B include a rash, jaundice, and the mode of transmission principally
by the parenteral route. The onset is insidious, not rapid, and a carrier state does exist.
DIF: Cognitive Level: Understanding REF: p. 1101
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
14. The nurse is preparing to admit a 7-year-old child with Crohn disease. What clinical
manifestations should the nurse expect to observe? (Select all that apply.)
a. Pain is common.
b. Weight loss is severe.
c. Rectal bleeding is common.
d. Diarrhea is moderate to severe.
e. Anal and perianal lesions are rare.
ANS: A, B, D
Clinical manifestations of Crohn disease include pain, severe weight loss, and moderate to severe
diarrhea. Rectal bleeding is rare, but anal and perianal lesions are common.
CH.31
1. What childhood cancer may demonstrate patterns of inheritance that suggest a familial basis?
a. Leukemia
b. Retinoblastoma
c. Rhabdomyosarcoma
d. Osteogenic sarcoma
ANS: B
Retinoblastoma is an example of a pediatric cancer that demonstrates inheritance. The absence of
the retinoblastoma gene allows for abnormal cell growth and the development of retinoblastoma.
Chromosome abnormalities are present in many malignancies. They do not indicate a familial
pattern of inheritance. The Philadelphia chromosome is observed in almost all individuals with
chronic myelogenous leukemia. There is no evidence of a familial pattern of inheritance for
rhabdomyosarcoma or osteogenic sarcoma cancers.
DIF: Cognitive Level: Understanding REF: p. 1379
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. As part of the diagnostic evaluation of a child with cancer, biopsies are important for staging.
What statement explains what staging means?
a. Extent of the disease at the time of diagnosis
b. Rate normal cells are being replaced by cancer cells
c. Biologic characteristics of the tumor or lymph nodes
d. Abnormal, unrestricted growth of cancer cells producing organ damage
ANS: A
Staging is a description of the extent of the disease at the time of diagnosis. Staging criteria exist
for most tumors. The stage usually relates directly to the prognosis; the higher the stage, the
poorer the prognosis. The rate that normal cells are being replaced by cancer cells is not a
definition of staging. Classification of the tumor refers to the biologic characteristics of the
tumor or lymph nodes. Abnormal, unrestricted growth of cancer cells producing organ damage
describes how cancer cells grow and can cause damage to an organ.
DIF: Cognitive Level: Understanding REF: p. 1400 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
3. What statement related to clinical trials developed for pediatric cancers is most accurate?
a. Are accessible only in major pediatric centers
b. Do not require consent for standard therapy
c. Provide the best available therapy compared with an expected improvement
d. Are standardized to provide the same treatment to all children with the disease
ANS: C
Most clinical trials have a control group in which the patients receive the best available therapy
currently known. The experimental group(s) receives treatment that is thought to be even better.
The protocol outlines the therapy plan. Protocols are developed for many pediatric cancers. They
can be accessed by pediatric oncologists throughout the United States. Consent is always
required in treatment of children, especially for research protocols. The protocol is designed to
optimize therapy for children based on disease type and stage.
DIF: Cognitive Level: Understanding REF: p. 1382 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
4. Chemotherapeutic agents are classified according to what feature?
a. Side effects
b. Effectiveness
c. Mechanism of action
d. Route of administration
ANS: C
Chemotherapeutic agents are classified according to mechanism of action. For example,
antimetabolites resemble essential metabolic elements needed for growth but are different
enough to block further deoxyribonucleic acid (DNA) synthesis. Although the side effect profiles
may be similar for drugs within a classification, they are not the basis for classification. Most
chemotherapeutic regimens contain combinations of drugs. The effectiveness of any one drug is
relative to the cancer type, combination therapy, and protocol for administration. The route of
administration is determined by the pharmacodynamics and pharmacokinetics of each drug.
DIF: Cognitive Level: Understanding REF: p. 1383
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
5. What type of chemotherapeutic agent alters the function of cells by replacing a hydrogen atom
of a molecule?
a. Plant alkaloids
b. Antimetabolites
c. Alkylating agents
d. Antitumor antibiotics
ANS: C
Alkylating agents replace a hydrogen atom with an alkyl group. The irreversible combination of
alkyl groups with nucleotide chains, particularly deoxyribonucleic acid (DNA), causes
unbalanced growth of unaffected cell constituents so that the cell eventually dies. Plant alkaloids
arrest the cell in metaphase by binding to proteins needed for spindle formation. Antimetabolites
resemble essential metabolic elements needed for growth but are different enough to block
further DNA synthesis. Antitumor antibiotics are natural substances that interfere with cell
division by reacting with DNA in such a way as to prevent further replication of DNA and
transcription of ribonucleic acid (RNA).
DIF: Cognitive Level: Understanding REF: p. 1383
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
6. What side effect commonly occurs with corticosteroid (prednisone) therapy?
a. Alopecia
b. Anorexia
c. Nausea and vomiting
d. Susceptibility to infection
ANS: D
Corticosteroids have immunosuppressive effects. Children who are taking prednisone are
susceptible to infections. Hair loss is not a side effect of corticosteroid therapy. Children taking
corticosteroids have increased appetites. Gastric irritation, not nausea and vomiting, is a potential
side effect. The medicine should be given with food.
DIF: Cognitive Level: Understanding REF: p. 1404
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
7. What chemotherapeutic agent is classified as an antitumor antibiotic?
a. Cisplatin (Platinol AQ)
b. Vincristine (Oncovin)
c. Methotrexate (Texall)
d. Daunorubicin (Cerubidine)
ANS: D
Daunorubicin is an antitumor antibiotic. Cisplatin is classified as an alkylating agent. Vincristine
is a plant alkaloid. Methotrexate is an antimetabolite.
DIF: Cognitive Level: Understanding REF: p. 1383
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
8. The nurse is administering an intravenous chemotherapeutic agent to a child with leukemia.
The child suddenly begins to wheeze and have severe urticaria. What nursing action is most
appropriate to initiate?
a. Recheck the rate of drug infusion.
b. Stop the drug infusion immediately.
c. Observe the child closely for next 10 minutes.
d. Explain to the child that this is an expected side effect.
ANS: B
When an allergic reaction is suspected, the drug is immediately discontinued. Any drug in the
line should be withdrawn, and a normal saline infusion begun to keep the line open. The
intravenous infusion is stopped to minimize the amount of drug that infuses. The infusion rate
can be confirmed at a later time. Observation of the child for 10 minutes is essential, but it is
done after the infusion is stopped. These signs are indicative of an allergic reaction, not an
expected response.
DIF: Cognitive Level: Applying REF: p. 1384
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
9. Total-body irradiation is indicated for what reason?
a. Palliative care
b. Lymphoma therapy
c. Definitive therapy for leukemia
d. Preparation for bone marrow transplant
ANS: D
Total-body irradiation is used as part of the destruction of the childs immune system necessary
for a bone marrow transplant. The child is at great risk for complications because there is no
supportive therapy until engraftment of the donor marrow takes place. Irradiation for palliative
care is done selectively. The area that is causing pain or potential obstruction is irradiated.
Lymphoma and leukemia are treated through a combination of modalities. Total-body irradiation
is not indicated.
DIF: Cognitive Level: Understanding REF: p. 1384
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
10. The parents of a child with cancer tell the nurse that a bone marrow transplant (BMT) may be
necessary. What information should the nurse recognize as important when discussing this with
the family?
a. BMT should be done at the time of diagnosis.
b. Parents and siblings of the child have a 25% chance of being a suitable donor.
c. If BMT fails, chemotherapy or radiotherapy will need to be continued.
d. Finding a suitable donor involves matching antigens from the human leukocyte antigen (HLA) system.
ANS: D
The most successful BMTs come from suitable HLA-matched donors. The timing of a BMT
depends on the disease process involved. It usually follows intensive high-dose chemotherapy or
radiotherapy. Usually, parents only share approximately 50% of the genetic material with their
children. A one in four chance exists that two siblings will have two identical haplotypes and will
be identically matched at the HLA loci. The decision to continue chemotherapy or radiotherapy if
BMT fails is not appropriate to discuss with the parents when planning the BMT. That decision
will be made later.
DIF: Cognitive Level: Applying REF: p. 1385
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
11. An adolescent will receive a bone marrow transplant (BMT). The nurse should explain that
the bone marrow will be administered by which method?
a. Bone grafting
b. Intravenous infusion
c. Bone marrow injection
d. Intraabdominal infusion
ANS: B
Bone marrow from a donor is infused intravenously, and the transfused stem cells migrate to the
recipients marrow and repopulate it.
DIF: Cognitive Level: Applying REF: p. 1386
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
12. After chemotherapy is begun for a child with acute leukemia, prophylaxis to prevent acute
tumor lysis syndrome includes which therapeutic intervention?
a. Hydration
b. Oxygenation
c. Corticosteroids
d. Pain management
ANS: A
Acute tumor lysis syndrome results from the release of intracellular metabolites during the initial
treatment of leukemia. Hyperuricemia, hypocalcemia, hyperphosphatemia, and hyperkalemia can
result. Hydration is used to reduce the metabolic consequences of the tumor lysis. Oxygenation is
not helpful in preventing acute tumor lysis syndrome. Allopurinol, not corticosteroids, is
indicated for pharmacologic management. Pain management may be indicated for supportive
therapy of the child, but it does not prevent acute tumor lysis syndrome.
DIF: Cognitive Level: Analyzing REF: p. 1387 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
13. Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents
should include which therapeutic intervention?
a. Restrict oral fluids.
b. Institute strict isolation.
c. Use good hand-washing technique.
d. Give immunizations appropriate for age.
ANS: C
Good hand washing minimizes the exposure to infectious organisms and decreases the chance of
infection spread. Oral fluids are encouraged if the child is able to drink. If possible, the
intravenous route is not used because of the increased risk of infection from parenteral fluid
administration. Strict isolation is not indicated. When the child is immunocompromised, the
vaccines are not effective. If necessary, the appropriate immunoglobulin is administered.
DIF: Cognitive Level: Applying REF: p. 1393
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
14. In teaching parents how to minimize or prevent bleeding episodes when the child is
myelosuppressed, the nurse includes what information?
a. Meticulous mouth care is essential to avoid mucositis.
b. Rectal temperatures are necessary to monitor for infection.
c. Intramuscular injections are preferred to intravenous ones.
d. Platelet transfusions are given to maintain a count greater than 50,000/mm3.
ANS: A
The decrease in blood platelets secondary to the myelosuppression of chemotherapy can cause an
increase in bleeding. The child and family are taught how to perform good oral hygiene to
minimize gingival bleeding and mucositis. Rectal temperatures are avoided to minimize the risk
of ulceration. Hygiene is also emphasized. Intramuscular injections are avoided because of the
risk of bleeding into the muscle and of infection. Platelet transfusions are usually not given
unless there is active bleeding or the platelet count is less than 10,000/mm3. The use of platelets
when not necessary can contribute to antibody formation and increased destruction of platelets
when transfused.
DIF: Cognitive Level: Applying REF: p. 1392 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
15. A school-age child with leukemia experienced severe nausea and vomiting when receiving
chemotherapy for the first time. What is the most appropriate nursing action to prevent or
minimize these reactions with subsequent treatments?
a. Administer the chemotherapy between meals.
b. Give an antiemetic before chemotherapy begins.
c. Have the child bring favorite foods for snacks.
d. Keep the child NPO (nothing by mouth) until nausea and vomiting subside.
ANS: B
The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy is
to administer a 5-hydroxytryptamine-3 receptor antagonist (e.g., ondansetron) before the
chemotherapy is begun. The goal is to prevent anticipatory signs and symptoms. The child will
experience nausea with chemotherapy whether or not food is present in the stomach. Because
some children develop aversions to foods eaten during chemotherapy, refraining from offering
favorite foods is advised. Keeping the child NPO until nausea and vomiting subside will help
with this episode, but the child will have discomfort and be at risk for dehydration.
DIF: Cognitive Level: Applying REF: p. 1393
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
16. A young child with leukemia has anorexia and severe stomatitis. What approach should the
nurse suggest that the parents try?
a. Relax any eating pressures.
b. Firmly insist that the child eat normally.
c. Serve foods that are either hot or cold.
d. Provide only liquids because chewing is painful.
ANS: A
A multifaceted approach is necessary for children with severe stomatitis and anorexia. First, the
parents should relax eating pressures. The nurse should suggest that the parents try soft, bland
foods; normal saline or bicarbonate mouthwashes; and local anesthetics. Insisting that the child
eat normally is not suggested. For some children, not eating may be a way to maintain some
control. This can set the child and caregiver in opposition to each other. Hot and cold foods can
be painful on ulcerated mucosal membranes. Substitution of high-calorie foods that the child
likes and can eat should be used.
DIF: Cognitive Level: Applying REF: p. 1394
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
17. The nurse is preparing a child for possible alopecia from chemotherapy. What information
should the nurse include?
a. Wearing hats or scarves is preferable to a wig.
b. Expose head to sunlight to stimulate hair regrowth.
c. Hair may have a slightly different color or texture when it regrows.
d. Regrowth of hair usually begins 12 months after chemotherapy ends.
ANS: C
Alopecia is a side effect of certain chemotherapeutic agents and cranial irradiation. When the
hair regrows, it may be of a different color or texture. Children should choose the head covering
they prefer. A wig should be selected similar to the childs own hairstyle and color before the hair
loss. The head should be protected from sunlight to avoid sunburn. The hair usually grows back
within 3 to 6 months after the cessation of treatment.
DIF: Cognitive Level: Applying REF: p. 1395
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
18. What pain management approach is most effective for a child who is having a bone marrow
test?
a. Relaxation techniques
b. Administration of an opioid
c. EMLA cream applied over site
d. Conscious or unconscious sedation
ANS: D
Children need explanations before each procedure that is being done to them. Effective
pharmacologic and nonpharmacologic measures should be used to minimize pain associated with
procedures. For bone marrow aspiration, conscious or unconscious sedation should be used.
Relaxation, opioids, and EMLA can be used to augment the sedation.
DIF: Cognitive Level: Applying REF: p. 1396 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
19. The nurse is caring for a child receiving chemotherapy for leukemia. The childs granulocyte
count is 600/mm3 and platelet count is 45,000/mm3. What oral care should the nurse recommend
for this child?
a. Rinsing mouth with water
b. Daily toothbrushing and flossing
c. Lemon glycerin swabs for cleansing
d. Wiping teeth with moistened gauze or Toothettes
ANS: B
Oral care is essential for children receiving chemotherapy to prevent infections and other
complications. When the childs granulocyte count is above 500/mm3 and platelet count is above
40,000/mm3, daily brushing and flossing are recommended. Rinsing the mouth with water is not
effective for oral hygiene. Lemon glycerin swabs are avoided because they have a drying effect
on the mucous membranes, and the lemon may irritate eroded tissue and decay the childs teeth.
Wiping teeth with moistened gauze or Toothettes is recommended when the childs granulocyte
count is below 500/mm3 and platelet count is below 40,000/mm3.
DIF: Cognitive Level: Applying REF: p. 1397 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
20. What immunization should not be given to a child receiving chemotherapy for cancer?
a. Tetanus vaccine
b. Inactivated poliovirus vaccine
c. Diphtheria, pertussis, tetanus (DPT)
d. Measles, mumps, rubella (MMR)
ANS: D
The vaccine used for MMR is a live virus and can cause serious disease in immunocompromised
children. The tetanus vaccine, inactivated poliovirus vaccine, and DPT are not live vaccines and
can be given to immunosuppressed children. The immune response is likely to be suboptimum,
so delaying vaccination is usually recommended.
DIF: Cognitive Level: Analyzing REF: p. 1397
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
21. What description identifies the pathophysiology of leukemia?
a. Increased blood viscosity
b. Abnormal stimulation of the first stage of coagulation process
c. Unrestricted proliferation of immature white blood cells (WBCs)
d. Thrombocytopenia from an excessive destruction of platelets
ANS: C
Leukemia is a group of malignant disorders of the bone marrow and lymphatic system. It is
defined as an unrestricted proliferation of immature WBCs in the blood-forming tissues of the
body. Increased blood viscosity may result secondary to the increased number of WBCs. The
coagulation process is unaffected by leukemia. Thrombocytopenia may occur secondary to the
overproduction of WBCs in the bone marrow.
DIF: Cognitive Level: Understanding REF: p. 1399
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
22. A child with leukemia is receiving intrathecal chemotherapy to prevent which condition?
a. Infection
b. Brain tumor
c. Central nervous system (CNS) disease
d. Drug side effects
ANS: C
Children with leukemia are at risk for invasion of the CNS with leukemic cells. CNS
prophylactic therapy is indicated. Intrathecal chemotherapy does not prevent infection or drug
side effects. A brain tumor in a child with leukemia would be a second tumor, and additional
appropriate therapy would be indicated.
DIF: Cognitive Level: Applying REF: p. 1401 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
23. A parent tells the nurse that 80% of children with the same type of leukemia as his sons have
a 5-year survival. He believes that because another child on the same protocol as his son has just
died, his son now has a better chance of success. What is the best response by the nurse?
a. It is sad for the other family but good news for your child.
b. Each child has an 80% likelihood of 5-year survival.
c. The data suggest that 20% of the children in the clinic will die. There are still many hurdles for your son.
d. You should avoid the grieving family because you will be benefiting from their loss.
ANS: B
This is a common misconception for parents. The success data are based on numerous factors,
including the effectiveness of the protocol and the childs response. These are aggregate data that
apply to each child and do not depend on the success or failure in other children. The failure of
one child in a protocol does not improve the success rate for other children. Although the son
does face more hurdles, these are aggregate data, not specific to the clinic. It may be difficult for
this family to be supportive given their concerns about their child. Families usually form support
groups in pediatric oncology settings, and support during bereavement is common.
DIF: Cognitive Level: Applying REF: p. 1421
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
24. What is a common clinical manifestation of Hodgkin disease?
a. Petechiae
b. Bone and joint pain
c. Painful, enlarged lymph nodes
d. Nontender enlargement of lymph nodes
ANS: D
Asymptomatic, enlarged cervical or supraclavicular lymphadenopathy is the most common
presentation of Hodgkin disease. Petechiae are usually associated with leukemia. Bone and joint
pain are not likely in Hodgkin disease. The enlarged nodes are rarely painful.
DIF: Cognitive Level: Understanding REF: p. 1403
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
25. What are the most common clinical manifestations of brain tumors in children?
a. Headaches and vomiting
b. Blurred vision and ataxia
c. Hydrocephalus and clumsy gait
d. Fever and poor fine motor control
ANS: A
Headaches, especially on awakening, and vomiting that is not related to feeding are the most
common clinical manifestations of brain tumors in children. Diplopia (double vision), not blurred
vision, can be a presenting sign of brainstem glioma. Ataxia is a clinical manifestation of brain
tumors, but headaches and vomiting are the most common. Hydrocephalus can be a presenting
sign in infants when the sutures have not closed. Children at this age are usually not walking
steadily. Poor fine motor coordination may be a presenting sign of astrocytoma, but headaches
and vomiting are the most common presenting signs of brain tumors.
DIF: Cognitive Level: Understanding REF: p. 1406
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
26. A 5-year-old child is being prepared for surgery to remove a brain tumor. Preparation for
surgery should be based on which information?
a. Removal of the tumor will stop the various signs and symptoms.
b. Usually the postoperative dressing covers the entire scalp.
c. He is not old enough to be concerned about his head being shaved.
d. He is not old enough to understand the significance of the brain.
ANS: B
The child should be told what he will look and feel like after surgery. This includes the
anticipated size of the dressing. The nurse can demonstrate on a doll the expected size and shape
of the dressing. Some of the symptoms may be alleviated by removal of the tumor, but
postsurgical headaches and cerebellar symptoms such as ataxia may be aggravated. Children
should be prepared for the loss of their hair, and it should be removed in a sensitive, positive
manner if the child is awake. Children at this age have poorly defined body boundaries and little
knowledge of internal organs. Intrusive experiences are frightening, especially those that disrupt
the integrity of the skin.
DIF: Cognitive Level: Applying REF: p. 1409
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
27. Essential postoperative nursing management of a child after removal of a brain tumor
includes which nursing care?
a. Turning and positioning every 2 hours
b. Measuring all fluid intake and output
c. Changing the dressing when it becomes soiled
d. Using maximum lighting to ensure accurate observations
ANS: B
After brain surgery, cerebral edema is a risk. Careful monitoring is essential. All fluids, including
intravenous antibiotics, are included in the intake. Turning and positioning depend on the
surgical procedure. When large tumors are removed, the child is usually not positioned on the
operative side. The dressing is not changed. It is reinforced with gauze after the amount of
drainage is marked and estimated. A quiet, dimly lit environment is optimum to decrease
stimulation and relieve discomfort such as headaches.
DIF: Cognitive Level: Applying REF: p. 1410 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
28. An adolescent is scheduled for a leg amputation in 2 days for treatment of osteosarcoma.
What approach should the nurse implement?
a. Answer questions with straightforward honesty.
b. Avoid discussing the seriousness of the condition.
c. Explain that although the amputation is difficult, it will cure the cancer.
d. Help the adolescent accept the amputation as better than a long course of chemotherapy.
ANS: A
Honesty is essential to gain the childs cooperation and trust. The diagnosis of cancer should not
be disguised with falsehoods. The adolescent should be prepared for the surgery so there is time
for reflection about the diagnosis and subsequent treatment. This allows questions to be
answered. To accept the need for radical surgery, the child must be aware of the lack of
alternatives for treatment. Amputation is necessary, but it will not guarantee a cure.
Chemotherapy is an integral part of the therapy with surgery. The child should be informed of the
need for chemotherapy and its side effects before surgery.
DIF: Cognitive Level: Analyzing REF: p. 1413
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
29. What is an important priority in dealing with the child suspected of having Wilms tumor?
a. Intervening to minimize bleeding
b. Monitoring temperature for infection
c. Ensuring the abdomen is protected from palpation
d. Teaching parents how to manage the parenteral nutrition
ANS: C
Wilms tumor, or nephroblastoma, is the most common malignant renal and intraabdominal tumor
of childhood. The abdomen is protected, and palpation is avoided. Careful handling and bathing
are essential to prevent trauma to the tumor site. Before chemotherapy, the child is not
myelosuppressed. Bleeding is not usually a risk. Infection is a concern after surgery and during
chemotherapy, not before surgery. Parenteral therapy is not indicated before surgery.
DIF: Cognitive Level: Understanding REF: p. 1415 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
30. The mother of an infant tells the nurse that sometimes there is a whitish glow in the pupil of
his eye. The nurse should suspect which condition?
a. Brain tumor
b. Retinoblastoma
c. Neuroblastoma
d. Rhabdomyosarcoma
ANS: B
When the nurse examines the eye, the light will reflect off of the tumor, giving the eye a whitish
appearance. This is called a cats eye reflex. Brain tumors are not usually visible. Neuroblastoma
usually arises from the adrenal medulla and sympathetic nervous system. The most common
presentation sites are in the abdomen, head, neck, or pelvis. Supraorbital ecchymosis may be
present with distant metastasis. Rhabdomyosarcoma is a soft tissue tumor that derives from
skeletal muscle undifferentiated cells.
DIF: Cognitive Level: Understanding REF: p. 1418
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
31. The nurse is caring for a 6-year-old child with acute lymphoblastic leukemia (ALL). The
parent states, My child has a low platelet count, and we are being discharged this afternoon.
What do I need to do at home? What statement is most appropriate for the nurse to make?
a. You should give your child aspirin instead of acetaminophen for fever or pain.
b. Your child should avoid contact sports or activities that could cause bleeding.
c. You should feed your child a bland, soft, moist diet for the next week.
d. Your child should avoid large groups of people for the next week.
ANS: B
A child with a low platelet count needs to avoid activities that could cause bleeding such as
playing contact sports, climbing trees, using playground equipment, or bike riding. The child
should be given acetaminophen, not aspirin, for fever or pain; the child does not need to be on a
soft, bland diet or avoid large groups of people because of the low platelet count.
DIF: Cognitive Level: Applying REF: p. 1392 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
32. One pediatric oncologic emergency is acute tumor lysis syndrome. Symptoms that this may
be occurring include what?
a. Muscle cramps and tetany
b. Respiratory distress and cyanosis
c. Thrombocytopenia and sepsis
d. Upper extremity edema and neck vein distension
ANS: A
Risk factors for development of tumor lysis syndrome include a high white blood cell count at
diagnosis, large tumor burden, sensitivity to chemotherapy, and high proliferative rate. In
addition to the described metabolic abnormalities, children may develop a spectrum of clinical
symptoms, including flank pain, lethargy, nausea and vomiting, muscle cramps, pruritus, tetany,
and seizures. Respiratory distress and cyanosis occur with hyperleukocytosis. Thrombocytopenia
and sepsis occur with disseminated intravascular coagulation. Upper extremity edema and neck
vein distention occur with superior vena cava syndrome.
DIF: Cognitive Level: Analyzing REF: p. 1386
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
33. A child has an absolute neutrophil count (ANC) of 500/mm3. The nurse should expect to be
administering which prescribed treatment?
a. Platelets
b. Packed red blood cells
c. Zofran (ondansetron)
d. G-CSF (Neupogen) daily
ANS: D
G-CSF (filgrastim [Neupogen], pegfilgrastim [Neulasta]) directs granulocyte development and
can decrease the duration of neutropenia following immunosuppressive therapy. G-CSF is
discontinued when the ANC surpasses 10,000/mm3.
DIF: Cognitive Level: Applying REF: p. 1391 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
34. What specific gravity of the urine is desired so that hemorrhagic cystitis is prevented?
a. 1.035
b. 1.030
c. 1.025
d. 1.005
ANS: D
Sterile hemorrhagic cystitis is a side effect of chemical irritation to the bladder from
chemotherapy or radiotherapy. It can be prevented by a liberal oral or parenteral fluid intake (at
least one and a half times the recommended daily fluid requirement). The urine should be dilute
so 1.005 is the expected specific gravity.
DIF: Cognitive Level: Analyzing REF: p. 1395
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
35. A child, age 10 years, has a neuroblastoma and is in the hospital for additional chemotherapy
treatments. What laboratory values are most likely this childs?
a. White blood cell count, 17,000/mm3; hemoglobin, 15 g/dl
b. White blood cell count, 3,000/mm3; hemoglobin, 11.5 g/dl
c. Platelets, 450,000/mm3; hemoglobin, 12 g/dl
d. White blood cell count, 10,000/mm3; platelets, 175,000/mm3
ANS: B
Chemotherapy is the mainstay of therapy for extensive local or disseminated neuroblastoma. The
drugs of choice are vincristine, doxorubicin, cyclophosphamide, cisplatin, etoposide, ifosfamide,
and carboplatin. These cause immunosuppression, so the laboratory values will indicate a low
white blood cell count and hemoglobin.
DIF: Cognitive Level: Analyzing REF: p. 1411
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
36. Calculate the absolute neutrophil count (ANC) for the following: WBC count of 5000 mm3;
neutrophils (segs) of 10%; and nonsegmented neutrophils (bands) of 12%.
a. 110/mm3
b. 500/mm3
c. 1100/mm3
d. 5000/mm3
ANS: C
Determine the total percentage of neutrophils (polys, or segs, and bands). Multiply white blood
cell (WBC) count by percentage of neutrophils.
WBC = 1000/mm3, neutrophils = 7%, and nonsegmented neutrophils (bands) = 7%
Step 1: 10% + 12% = 22%
Step 2: 0.22 5000 = 1100/mm3 ANC
DIF: Cognitive Level: Applying REF: p. 1391 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
37. A child has been diagnosed with a Wilms tumor. What should preoperative nursing care
include?
a. Careful bathing and handling
b. Monitoring of behavioral status
c. Maintenance of strict isolation
d. Administration of packed red blood cells
ANS: A
Careful bathing and handling are important in preventing trauma to the Wilms tumor site.
DIF: Cognitive Level: Applying REF: p. 1416
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
38. What is appropriate mouth care for a toddler with mucosal ulceration related to
chemotherapy?
a. Mouthwashes with plain saline
b. Lemon glycerin swabs for cleansing
c. Mouthwashes with hydrogen peroxide
d. Swish and swallow with viscous lidocaine
ANS: A
Administering mouth care is particularly difficult in infants and toddlers. A satisfactory method
of cleaning the gums is to wrap a piece of gauze around a finger; soak it in saline or plain water;
and swab the gums, palate, and inner cheek surfaces with the finger. Mouth rinses are best
accomplished with plain water or saline because the child cannot gargle or spit out excess fluid.
Avoid agents such as lemon glycerin swabs and hydrogen peroxide because of the drying effects
on the mucosa. Lidocaine should be avoided in young children.
DIF: Cognitive Level: Applying REF: p. 1385
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
39. The nurse should expect to care for which age of child if the admitting diagnosis is
retinoblastoma?
a. Infant or toddler
b. Preschool- or school-age child
c. School-age or adolescent child
d. Adolescent
ANS: A
The average age of the child at the time of diagnosis is 2 years, and bilateral and hereditary
disease is diagnosed earlier than unilateral and nonhereditary disease.
DIF: Cognitive Level: Understanding REF: p. 1418
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
40. Postoperative positioning for a child who has had a medulloblastoma brain tumor
(infratentorial) removed should be which?
a. Trendelenburg
b. Head of bed elevated above heart level
c. Flat on operative side with pillows behind the head
d. Flat, on either side with pillows behind the back
ANS: D
The child with an infratentorial procedure is usually positioned flat and on either side. Pillows
should be placed against the childs back, not head, to maintain the desired position. The
Trendelenburg position is contraindicated in both infratentorial and supratentorial surgeries
because it increases intracranial pressure and the risk of hemorrhage.
DIF: Cognitive Level: Applying REF: p. 1410
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
41. A child is receiving vincristine (Oncovin). The nurse should monitor for which side effect of
this medication?
a. Diarrhea
b. Photosensitivity
c. Constipation
d. Ototoxicity
ANS: A
Vincristine, and to a lesser extent vinblastine, can cause various neurotoxic effects. One of the
more common neurotoxic effects is severe constipation caused from decreased bowel
innervation.
DIF: Cognitive Level: Applying REF: p. 1412
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
42. What chemotherapeutic agent can cause an anaphylactic reaction?
a. Prednisone (Deltasone)
b. Vincristine (Oncovin)
c. L-Asparaginase (Elspar)
d. Methotrexate (Trexall)
ANS: C
A potentially fatal complication is anaphylaxis, especially from L-asparaginase, bleomycin,
cisplatin, and etoposide (VP-16).
DIF: Cognitive Level: Understanding REF: p. 1383
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
43. A child with cancer being treated with chemotherapy is receiving a platelet transfusion. The
nurse understands that the transfused platelets should survive the body for how many days?
a. 1 to 3 days
b. 4 to 6 days
c. 7 to 9 days
d. 10 to 12 days
ANS: A
Transfused platelets generally survive in the body for 1 to 3 days. The peak effect is reached in
about 1 hour and decreased by half in 24 hours.
DIF: Cognitive Level: Understanding REF: p. 1392
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
44. Daily toothbrushing and flossing can be encouraged for the child on chemotherapy when the
platelet count is above which?
a. 10,000/mm3
b. 20,000/mm3
c. 30,000/mm3
d. 40,000/mm3
ANS: D
Daily toothbrushing and flossing are encouraged in children with platelet counts above
40,000/mm3.
DIF: Cognitive Level: Analyzing REF: p. 1397 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
45. A parent of a hospitalized child on chemotherapy asks the nurse if a sibling of the
hospitalized child should receive the varicella vaccination. The nurse should give which
response?
a. The sibling can get a varicella vaccination.
b. The sibling should not get a varicella vaccination.
c. The sibling should wait until the child is finished with chemotherapy.
d. The sibling should get varicella-zoster immune globulin if exposed to chickenpox.
ANS: A
Siblings and other family members can receive the live measles, mumps, and rubella vaccine and
the varicella vaccine without risk to the child who is immunosuppressed.
DIF: Cognitive Level: Applying REF: p. 1397
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
46. The nurse is collecting a 24-hour urine sample on a child with suspected diagnosis of
neuroblastoma. What finding in the urine is expected with neuroblastomas?
a. Ketones
b. Catecholamines
c. Red blood cells
d. Excessive white blood cells
ANS: B
Neuroblastomas, particularly those arising on the adrenal glands or from a sympathetic chain,
excrete the catecholamines epinephrine and norepinephrine. Urinary excretion of catecholamines
is detected in approximately 95% of children with adrenal or sympathetic tumors.
DIF: Cognitive Level: Analyzing REF: p. 1412 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
47. A child with osteosarcoma is experiencing phantom limb pain after an amputation. What
prescribed medication is effective for short-term phantom pain relief?
a. Phenytoin (Dilantin)
b. Gabapentin (Neurontin)
c. Valproic Acid (Depakote)
d. Phenobarbital (Phenobarbital)
ANS: B
A recent Cochrane review reported that various medications have been used for phantom limb
pain but complete pain relief has been unsuccessful. Morphine, gabapentin, and ketamine are
effective for short-term pain relief.
DIF: Cognitive Level: Applying REF: p. 1414
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
MULTIPLE RESPONSE
1. The nurse is precepting a new graduate nurse at an ambulatory pediatric hematology and
oncology clinic. What cardinal signs of cancer in children should the nurse make the new nurse
aware of? (Select all that apply.)
a. Sudden tendency to bruise easily
b. Transitory, generalized pain
c. Frequent headaches
d. Excessive, rapid weight gain
e. Gradual, steady fever
f. Unexplained loss of energy
ANS: A, C, F
The cardinal signs of cancer in children include a sudden tendency to bruise easily; frequent
headaches, often with vomiting; and an unexplained loss of energy. Other cardinal signs include
persistent, localized pain; excessive, rapid weight loss; and a prolonged, unexplained fever.
DIF: Cognitive Level: Applying REF: p. 1381
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
2. A child on chemotherapy has developed rectal ulcers. What interventions should the nurse
teach to the child and parents to relieve the discomfort of rectal ulcers? (Select all that apply.)
a. Warm sitz baths
b. Use of stool softeners
c. Record bowel movements
d. Use of an opioid for discomfort
e. Occlusive ointment applied to the area
ANS: A, B, C, E
If rectal ulcers develop, meticulous toilet hygiene, warm sitz baths after each bowel movement,
and an occlusive ointment applied to the ulcerated area promote healing; the use of stool
softeners is necessary to prevent further discomfort. Parents should record bowel movements
because the child may voluntarily avoid defecation to prevent discomfort. Opioids would cause
increased constipation.
DIF: Cognitive Level: Applying REF: p. 1394
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
3. What are favorable prognostic criteria for acute lymphoblastic leukemia? (Select all that
apply.)
a. Male gender
b. CALLA positive
c. Early preB cell
d. 2 to 10 years of age
e. Leukocyte count ?7?50,000/mm3
ANS: B, C, D
Favorable prognostic criteria for acute lymphoblastic leukemia include CALLA positive, early
preB cell, and age 2 to 10 years. Leukocyte count less, not greater, than 50,000/mm3 and female,
not male, gender are favorable prognostic criteria.
DIF: Cognitive Level: Analyzing REF: p. 1400 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
4. The nurse should teach the family that which residual disabilities can occur for a child being
treated for a brain tumor? (Select all that apply.)
a. Ataxia
b. Anorexia
c. Dysphagia
d. Sensory deficits
e. Crania nerve palsies
ANS: A, C, D, E
Even with children who are long-term survivors after treatment for a brain tumor, residual
disabilities, such as short stature, cranial nerve palsies, sensory defects, motor abnormalities
(especially ataxia), intellectual deficits, dysphagia, dysgraphia, and behavioral problems, may
occur. Anorexia is not a residual disability.
DIF: Cognitive Level: Applying REF: p. 1411
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
5. The nurse is caring for a child with retinoblastoma that was treated with an enucleation. What
interventions should the nurse plan for care of an eye socket after enucleation? (Select all that
apply.)
a. Clean the prosthesis.
b. Change the eye pad daily.
c. Keep the opposite eye covered initially.
d. Irrigate the socket daily with a prescribed solution.
e. Apply a prescribed antibiotic ointment after irrigation.
ANS: B, D, E
Care of the socket is minimal and easily accomplished. The wound itself is clean and has little or
no drainage. If an antibiotic ointment is prescribed, it is applied in a thin line on the surface of
the tissues of the socket. To cleanse the site, an irrigating solution may be ordered and is instilled
daily or more frequently if necessary before application of the antibiotic ointment. The dressing
consists of an eye pad changed daily. The prosthesis is not placed until the socket has healed. The
opposite eye is not covered.
DIF: Cognitive Level: Applying REF: p. 1420
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
6. What guidelines should the nurse follow when handling chemotherapeutic agents? (Select all
that apply.)
a. Use clean technique.
b. Prepare medications in a safety cabinet.
c. Wear gloves designed for handling chemotherapy.
d. Wear face and eye protection when splashing is possible.
e. Discard gloves and protective clothing in a special container.
ANS: B, C, D, E
Safe handling of chemotherapeutic agents includes preparing medications in a safety cabinet,
wearing gloves designed for handling chemotherapy, wearing face and eye protection when
splashing is possible, and discarding gloves and protective clothing in a special container.
Aseptic, not clean, technique should be used.
DIF: Cognitive Level: Applying REF: p. 1384
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
7. What strategies should the nurse implement to increase nutritional intake for the child
receiving chemotherapy? (Select all that apply.)
a. Allow the child any food tolerated.
b. Fortify foods with nutritious supplements.
c. Allow the child to be involved in food selection.
d. Encourage the parents to place pressure on the importance of eating.
e. Encourage the child to eat favorite foods during infusion of chemotherapy medications.
ANS: A, B, C
To increase nutritional intake for the child receiving chemotherapy, the nurse should allow the
child any food tolerated, fortify foods with nutritious supplements, and allow the child to be
involved in food selection. The parents should be encouraged to reduce pressure placed on
eating. Some children develop aversions to certain foods if they are eaten during chemotherapy.
It is best to refrain from offering the childs favorite foods while the child is receiving
chemotherapy.
