CH.28
1. Why are cool-mist vaporizers rather than steam vaporizers recommended in the home
treatment of respiratory infections?
a. They are safer.
b. They are less expensive.
c. Respiratory secretions are dried by steam vaporizers.
d. A more comfortable environment is produced.
ANS: A
Cool-mist vaporizers are safer than steam vaporizers, and little evidence exists to show any
advantages to steam. The cost of cool-mist and steam vaporizers is comparable. Steam loosens
secretions, not dries them. Both cool-mist vaporizers and steam vaporizers may promote a more
comfortable environment, but cool-mist vaporizers have decreased risk for burns and growth of
organisms.
DIF: Cognitive Level: Understanding REF: p. 1165
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
2. Decongestant nose drops are recommended for a 10-month-old infant with an upper
respiratory tract infection. Instructions for nose drops should include which information?
a. Do not use for more than 3 days.
b. Keep drops to use again for nasal congestion.
c. Administer drops after feedings and at bedtime.
d. Give two drops every 5 minutes until nasal congestion subsides.
ANS: A
Vasoconstrictive nose drops such as Neo-Synephrine should not be used for more than 3 days to
avoid rebound congestion. Drops should be discarded after one illness and not used for other
children because they may become contaminated with bacteria. Drops administered before
feedings are more helpful. Two drops are administered to cause vasoconstriction in the anterior
mucous membranes. An additional two drops are instilled 5 to 10 minutes later for the posterior
mucous membranes. No further doses should be given.
DIF: Cognitive Level: Applying REF: p. 1170
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
3. The parent of an infant with nasopharyngitis should be instructed to notify the health
professional if the infant shows signs or symptoms of which condition?
a. Has a cough
b. Becomes fussy
c. Shows signs of an earache
d. Has a fever higher than 37.5 C (99 F)
ANS: C
If an infant with nasopharyngitis shows signs of an earache, it may indicate respiratory
complications and possibly secondary bacterial infection. The health professional should be
contacted to evaluate the infant. Cough can be a sign of nasopharyngitis. Irritability is common
in an infant with a viral illness. Fever is common in viral illnesses.
DIF: Cognitive Level: Applying REF: p. 1171
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
4. It is important that a child with acute streptococcal pharyngitis be treated with antibiotics to
prevent which condition?
a. Otitis media
b. Diabetes insipidus (DI)
c. Nephrotic syndrome
d. Acute rheumatic fever
ANS: D
Group A hemolytic streptococcal infection is a brief illness with varying symptoms. It is essential
that pharyngitis caused by this organism be treated with appropriate antibiotics to avoid the
sequelae of acute rheumatic fever and acute glomerulonephritis. The cause of otitis media is
either viral or other bacterial organisms. DI is a disorder of the posterior pituitary. Infections such
as meningitis or encephalitis, not streptococcal pharyngitis, can cause DI. Glomerulonephritis,
not nephrotic syndrome, can result from acute streptococcal pharyngitis.
DIF: Cognitive Level: Understanding REF: p. 1171 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
5. When caring for a child after a tonsillectomy, what intervention should the nurse do?
a. Watch for continuous swallowing.
b. Encourage gargling to reduce discomfort.
c. Apply warm compresses to the throat.
d. Position the child on the back for sleeping.
ANS: A
Continuous swallowing, especially while sleeping, is an early sign of bleeding. The child
swallows the blood that is trickling from the operative site. Gargling is discouraged because it
could irritate the operative site. Ice compresses are recommended to reduce inflammation. The
child should be positioned on the side or abdomen to facilitate drainage of secretions.
DIF: Cognitive Level: Applying REF: p. 1174
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
6. What statement best represents infectious mononucleosis?
a. Herpes simplex type 2 is the principal cause.
b. A complete blood count shows a characteristic leukopenia.
c. A short course of ampicillin is used when pharyngitis is present.
d. Clinical signs and symptoms and blood tests are both needed to establish the diagnosis.
ANS: D
The characteristics of the diseasemalaise, sore throat, lymphadenopathy, central nervous system
manifestations, and skin lesionsare similar to presenting signs and symptoms in other diseases.
Hematologic analysis (heterophil antibody and monospot) can help confirm the diagnosis.
However, not all young children develop the expected laboratory findings. Herpes-like Epstein-
Barr virus is the principal cause. Usually, an increase in lymphocytes is observed. Penicillin, not
ampicillin, is indicated. Ampicillin is linked with a discrete macular eruption in infectious
mononucleosis.
DIF: Cognitive Level: Understanding REF: p. 1176
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
7. Parents bring their 15-month-old infant to the emergency department at 3:00 AM because the
toddler has a temperature of 39 C (102.2 F), is crying inconsolably, and is tugging at the ears. A
diagnosis of otitis media (OM) is made. In addition to antibiotic therapy, the nurse practitioner
should instruct the parents to use what medication?
a. Decongestants to ease stuffy nose
b. Antihistamines to help the child sleep
c. Aspirin for pain and fever management
d. Benzocaine ear drops for topical pain relief
ANS: D
Analgesic ear drops can provide topical relief for the intense pain of OM. Decongestants and
antihistamines are not recommended in the treatment of OM. Aspirin is contraindicated in young
children because of the association with Reye syndrome.
DIF: Cognitive Level: Applying REF: p. 1181
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
8. An 18-month-old child is seen in the clinic with otitis media (OM). Oral amoxicillin is
prescribed. What instructions should be given to the parent?
a. Administer all of the prescribed medication.
b. Continue medication until all symptoms subside.
c. Immediately stop giving medication if hearing loss develops.
d. Stop giving medication and come to the clinic if fever is still present in 24 hours.
ANS: A
Antibiotics should be given for their full course to prevent recurrence of infection with resistant
bacteria. Symptoms may subside before the full course is given. Hearing loss is a complication
of OM; antibiotics should continue to be given. Medication may take 24 to 48 hours to make
symptoms subside.
DIF: Cognitive Level: Applying REF: p. 1182
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
9. An infants parents ask the nurse about preventing otitis media (OM). What information should
be provided?
a. Avoid tobacco smoke.
b. Use nasal decongestants.
c. Avoid children with OM.
d. Bottle- or breastfeed in a supine position.
ANS: A
Eliminating tobacco smoke from the childs environment is essential for preventing OM and other
common childhood illnesses. Nasal decongestants are not useful in preventing OM. Children
with uncomplicated OM are not contagious unless they show other symptoms of upper
respiratory tract infection. Children should be fed in a semivertical position to prevent OM.
DIF: Cognitive Level: Applying REF: p. 1182
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
10. Chronic otitis media with effusion (OME) differs from acute otitis media (AOM) because it
is usually characterized by which signs or symptoms?
a. Severe pain in the ear
b. Anorexia and vomiting
c. A feeling of fullness in the ear
d. Fever as high as 40 C (104 F)
ANS: C
OME is characterized by a feeling of fullness in the ear or other nonspecific complaints. OME
does not cause severe pain. This may be a sign of AOM. Vomiting, anorexia, and fever are
associated with AOM.
DIF: Cognitive Level: Understanding REF: p. 1180
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
11. A 4-year-old girl is brought to the emergency department. She has a froglike croaking sound
on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should
intervene in which manner?
a. Make her lie down and rest quietly.
b. Examine her oral pharynx and report to the physician.
c. Auscultate her lungs and prepare for placement in a mist tent.
d. Notify the physician immediately and be prepared to assist with a tracheostomy or intubation.
ANS: D
This child is exhibiting signs of respiratory distress and possible epiglottitis. Epiglottitis is
always a medical emergency requiring antibiotics and airway support for treatment. Sitting up is
the position that facilitates breathing in respiratory disease. The oral pharynx should not be
visualized. If the epiglottis is inflamed, there is the potential for complete obstruction if it is
irritated further. Although lung auscultation provides useful assessment information, a mist tent
would not be beneficial for this child. Immediate medical evaluation and intervention are
indicated.
DIF: Cognitive Level: Applying REF: p. 1185 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
12. The nurse is assessing a child with croup in the emergency department. The child has a sore
throat and is drooling. Examining the childs throat using a tongue depressor might precipitate
what condition?
a. Sore throat
b. Inspiratory stridor
c. Complete obstruction
d. Respiratory tract infection
ANS: C
If a child has acute epiglottitis, examination of the throat may cause complete obstruction and
should be performed only when immediate intubation can take place. Sore throat and pain on
swallowing are early signs of epiglottitis. Stridor is aggravated when a child with epiglottitis is
supine. Epiglottitis is caused by Haemophilus influenzae in the respiratory tract.
DIF: Cognitive Level: Understanding REF: p. 1185
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
13. The mother of a 20-month-old boy tells the nurse that he has a barking cough at night. His
temperature is 37 C (98.6 F). The nurse suspects mild croup and should recommend which
intervention?
a. Admit to the hospital and observe for impending epiglottitis.
b. Provide fluids that the child likes and use comfort measures.
c. Control fever with acetaminophen and call if cough gets worse tonight.
d. Try over-the-counter cough medicine and come to the clinic tomorrow if no improvement.
ANS: B
In mild croup, therapeutic interventions include adequate hydration (as long as the child can
easily drink) and comfort measures to minimize distress. The child is not exhibiting signs of
epiglottitis. A temperature of 37 C is within normal limits. Although a return to the clinic may be
indicated, the mother is instructed to return if the child develops noisy respirations or drooling.
DIF: Cognitive Level: Applying REF: p. 1184
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
14. The nurse encourages the mother of a toddler with acute laryngotracheobronchitis to stay at
the bedside as much as possible. What is the primary rationale for this action?
a. Mothers of hospitalized toddlers often experience guilt.
b. The mothers presence will reduce anxiety and ease the childs respiratory efforts.
c. Separation from the mother is a major developmental threat at this age.
d. The mother can provide constant observations of the childs respiratory efforts.
ANS: B
The familys presence will decrease the childs distress. It is true that mothers of hospitalized
toddlers often experience guilt and that separation from mother is a major developmental threat
for toddlers, but the main reason to keep parents at the childs bedside is to ease anxiety and
therefore respiratory effort.
DIF: Cognitive Level: Applying REF: p. 1186
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
15. An infant with bronchiolitis is hospitalized. The causative organism is respiratory syncytial
virus (RSV). The nurse knows that a child infected with this virus requires what type of
isolation?
a. Reverse isolation
b. Airborne isolation
c. Contact Precautions
d. Standard Precautions
ANS: C
RSV is transmitted through droplets. In addition to Standard Precautions and hand washing,
Contact Precautions are required. Caregivers must use gloves and gowns when entering the
room. Care is taken not to touch their own eyes or mucous membranes with a contaminated
gloved hand. Children are placed in a private room or in a room with other children with RSV
infections. Reverse isolation focuses on keeping bacteria away from the infant. With RSV, other
children need to be protected from exposure to the virus. The virus is not airborne.
DIF: Cognitive Level: Applying REF: p. 1189 TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
16. An infant has been diagnosed with staphylococcal pneumonia. Nursing care of the child with
pneumonia includes which intervention?
a. Administration of antibiotics
b. Frequent complete assessment of the infant
c. Round-the-clock administration of antitussive agents
d. Strict monitoring of intake and output to avoid congestive heart failure
ANS: A
Antibiotics are indicated for bacterial pneumonia. Often the child has decreased pulmonary
reserve, and clustering of care is essential. The childs respiratory rate and status and general
disposition are monitored closely, but frequent complete physical assessments are not indicated.
Antitussive agents are used sparingly. It is desirable for the child to cough up some of the
secretions. Fluids are essential to kept secretions as liquefied as possible.
DIF: Cognitive Level: Applying REF: p. 1193
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
17. What consideration is most important in managing tuberculosis (TB) in children?
a. Skin testing
b. Chemotherapy
c. Adequate rest
d. Adequate hydration
ANS: B
Drug therapy for TB includes isoniazid, rifampin, and pyrazinamide daily for 2 months and
isoniazid and rifampin given two or three times a week by direct observation therapy for the
remaining 4 months. Chemotherapy is the most important intervention for TB.
DIF: Cognitive Level: Applying REF: p. 1200
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
18. A toddler has a unilateral foul-smelling nasal discharge and frequent sneezing. The nurse
should suspect what condition?
a. Allergies
b. Acute pharyngitis
c. Foreign body in the nose
d. Acute nasopharyngitis
ANS: C
The irritation of a foreign body in the nose produces local mucosal swelling with foul-smelling
nasal discharge, local obstruction with sneezing, and mild discomfort. Allergies would produce
clear bilateral nasal discharge. Nasal discharge is usually not associated with pharyngitis. Acute
nasopharyngitis would have bilateral mucous discharge.
DIF: Cognitive Level: Analyzing REF: p. 1202
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
19. The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated
with sepsis. What nursing action should be included in the care of the child?
a. Force fluids.
b. Monitor pulse oximetry.
c. Institute seizure precautions.
d. Encourage a high-protein diet.
ANS: B
Careful monitoring of oxygenation and cardiopulmonary status is an important evaluation tool in
the care of the child with ARDS. Maintenance of vascular volume and hydration is important and
should be done parenterally. Seizures are not a side effect of ARDS. Adequate nutrition is
necessary, but a high-protein diet is not helpful.
DIF: Cognitive Level: Applying REF: p. 1207
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
20. The nurse is caring for a child with carbon monoxide (CO) poisoning associated with smoke
inhalation. What intervention is essential in this childs care?
a. Monitor pulse oximetry.
b. Monitor arterial blood gases.
c. Administer oxygen if respiratory distress develops.
d. Administer oxygen if childs lips become bright, cherry-red in color.
ANS: B
Arterial blood gases are the best way to monitor CO poisoning. Pulse oximetry is contraindicated
in the case of CO poisoning because the PaO2 may be normal. One hundred percent oxygen
should be given as quickly as possible, not only if respiratory distress or other symptoms
develop.
DIF: Cognitive Level: Applying REF: p. 1208
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
21. What diagnostic test for allergies involves the injection of specific allergens?
a. Phadiatop
b. Skin testing
c. Radioallergosorbent tests (RAST)
d. Blood examination for total immunoglobulin E (IgE)
ANS: B
Skin testing is the most commonly used diagnostic test for allergy. A specific allergen is injected
under the skin, and after a suitable time, the size of the resultant wheal is measured to determine
the patients sensitivity. Phadiatop is a screening test that uses a blood sample to assess for IgE
antibodies for a group of specific allergens. RAST determines the level of specific IgE
antibodies. Blood examination for total IgE would not distinguish among allergens.
DIF: Cognitive Level: Understanding REF: p. 1214
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
22. What statement is the most descriptive of asthma?
a. It is inherited.
b. There is heightened airway reactivity.
c. There is decreased resistance in the airway.
d. The single cause of asthma is an allergic hypersensitivity.
ANS: B
In asthma, spasm of the smooth muscle of the bronchi and bronchioles causes constriction,
producing impaired respiratory function. Atopy, or development of an immunoglobulin E
(IgE)mediated response, is inherited but is not the only cause of asthma. Asthma is characterized
by increased resistance in the airway. Asthma has multiple causes, including allergens, irritants,
exercise, cold air, infections, medications, medical conditions, and endocrine factors.
DIF: Cognitive Level: Understanding REF: p. 1216
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
23. What condition is the leading cause of chronic illness in children?
a. Asthma
b. Pertussis
c. Tuberculosis
d. Cystic fibrosis
ANS: A
Asthma is the most common chronic disease of childhood, the primary cause of school absences,
and the third leading cause of hospitalization in children younger than the age of 15 years.
Pertussis is not a chronic illness. Tuberculosis is not a significant factor in childhood chronic
illness. Cystic fibrosis is the most common lethal genetic illness among white children.
DIF: Cognitive Level: Understanding REF: p. 1215
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
24. A child has a chronic cough and diffuse wheezing during the expiratory phase of respiration.
This suggests what condition?
a. Asthma
b. Pneumonia
c. Bronchiolitis
d. Foreign body in trachea
ANS: A
Asthma may have these chronic signs and symptoms. Pneumonia appears with an acute onset,
fever, and general malaise. Bronchiolitis is an acute condition caused by respiratory syncytial
virus. Foreign body in the trachea occurs with acute respiratory distress or failure and maybe
stridor.
DIF: Cognitive Level: Understanding REF: p. 1215
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
25. A child with asthma is having pulmonary function tests. What rationale explains the purpose
of the peak expiratory flow rate?
a. To assess severity of asthma
b. To determine cause of asthma
c. To identify triggers of asthma
d. To confirm diagnosis of asthma
ANS: A
Peak expiratory flow rate monitoring is used to monitor the childs current pulmonary function. It
can be used to manage exacerbations and for daily long-term management. The cause of asthma
is known. Asthma is caused by a complex interaction among inflammatory cells, mediators, and
the cells and tissues present in the airways. The triggers of asthma are determined through
history taking and immunologic and other testing. The diagnosis of asthma is made through
clinical manifestations, history, physical examination, and laboratory testing.
DIF: Cognitive Level: Analyzing REF: p. 1220 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
26. Children who are taking long-term inhaled steroids should be assessed frequently for what
potential complication?
a. Cough
b. Osteoporosis
c. Slowed growth
d. Cushing syndrome
ANS: C
The growth of children on long-term inhaled steroids should be assessed frequently to evaluate
systemic effects of these drugs. Cough is prevented by inhaled steroids. No evidence exists that
inhaled steroids cause osteoporosis. Cushing syndrome is caused by long-term systemic steroids.
DIF: Cognitive Level: Understanding REF: p. 1223 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
27. One of the goals for children with asthma is to maintain the childs normal functioning. What
principle of treatment helps to accomplish this goal?
a. Limit participation in sports.
b. Reduce underlying inflammation.
c. Minimize use of pharmacologic agents.
d. Have yearly evaluations by a health care provider.
ANS: B
Children with asthma are often excluded from exercise. This practice interferes with peer
interaction and physical health. Most children with asthma can participate provided their asthma
is under control. Inflammation is the underlying cause of the symptoms of asthma. By decreasing
inflammation and reducing the symptomatic airway narrowing, health care providers can
minimize exacerbations. Pharmacologic agents are used to prevent and control asthma
symptoms, reduce the frequency and severity of asthma exacerbations, and reverse airflow
obstruction. It is recommended that children with asthma be evaluated every 6 months.
DIF: Cognitive Level: Analyzing REF: p. 1221 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
28. What drug is usually given first in the emergency treatment of an acute, severe asthma
episode in a young child?
a. Ephedrine
b. Theophylline
c. Aminophylline
d. Short-acting b2-agonists
ANS: D
Short-acting b2-agonists are the first treatment in an acute asthma exacerbation. Ephedrine and
aminophylline are not helpful in acute asthma exacerbations. Theophylline is unnecessary for
treating asthma exacerbations.
DIF: Cognitive Level: Applying REF: p. 1222
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
29. Cystic fibrosis (CF) may affect single or multiple systems of the body. What is the primary
factor responsible for possible multiple clinical manifestations in CF?
a. Hyperactivity of sweat glands
b. Hypoactivity of autonomic nervous system
c. Atrophic changes in mucosal wall of intestines
d. Mechanical obstruction caused by increased viscosity of mucous gland secretions
ANS: D
The mucous glands produce a thick mucoprotein that accumulates and results in dilation. Small
passages in organs such as the pancreas and bronchioles become obstructed as secretions form
concretions in the glands and ducts. The exocrine glands, not sweat glands, are dysfunctional.
Although abnormalities in the autonomic nervous system are present, it is not hypoactive.
Intestinal involvement in CF results from the thick intestinal secretions, which can lead to
blockage and rectal prolapse.
DIF: Cognitive Level: Understanding REF: p. 1235
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
30. What is the earliest recognizable clinical manifestation(s) of cystic fibrosis (CF)?
a. Meconium ileus
b. History of poor intestinal absorption
c. Foul-smelling, frothy, greasy stools
d. Recurrent pneumonia and lung infections
ANS: A
The earliest clinical manifestation of CF is a meconium ileus, which is found in about 10% of
children with CF. Clinical manifestations include abdominal distention, vomiting, failure to pass
stools, and rapid development of dehydration. History of malabsorption is a later sign that
manifests as failure to thrive. Foul-smelling stools and recurrent respiratory infections are later
manifestations of CF.
DIF: Cognitive Level: Understanding REF: p. 1236
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
31. What tests aid in the diagnosis of cystic fibrosis (CF)?
a. Sweat test, stool for fat, chest radiography
b. Sweat test, bronchoscopy, duodenal fluid analysis
c. Sweat test, stool for trypsin, biopsy of intestinal mucosa
d. Stool for fat, gastric contents for hydrochloride, radiography
ANS: A
A sweat test result of greater than 60 mEq/L is diagnostic of CF, a high level of fecal fat is a
gastrointestinal manifestation of CF, and a chest radiograph showing patchy atelectasis and
obstructive emphysema indicates CF. Bronchoscopy, duodenal fluid analysis, stool tests for
trypsin, and intestinal biopsy are not helpful in diagnosing CF. Gastric contents normally contain
hydrochloride; it is not diagnostic.
DIF: Cognitive Level: Applying REF: p. 1237
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
32. A child with cystic fibrosis (CF) receives aerosolized bronchodilator medication. When
should this medication be administered?
a. After chest physiotherapy (CPT)
b. Before chest physiotherapy (CPT)
c. After receiving 100% oxygen
d. Before receiving 100% oxygen
ANS: B
Bronchodilators should be given before CPT to open bronchi and make expectoration easier.
These medications are not helpful when used after CPT. Oxygen is administered only in acute
episodes, with caution, because of chronic carbon dioxide retention.
DIF: Cognitive Level: Applying REF: p. 1238
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
33. A child with cystic fibrosis is receiving recombinant human deoxyribonuclease (DNase).
What statement about DNase is true?
a. Given subcutaneously
b. May cause voice alterations
c. May cause mucus to thicken
d. Not indicated for children younger than age 12 years
ANS: B
One of the only adverse effects of DNase is voice alterations and laryngitis. DNase is given in an
aerosolized form, decreases the viscosity of mucus, and is safe for children younger than 12
years.
DIF: Cognitive Level: Understanding REF: p. 1238
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
34. The parent of a child with cystic fibrosis (CF) calls the clinic nurse to report that the child has
developed tachypnea, tachycardia, dyspnea, pallor, and cyanosis. The nurse should tell the parent
to bring the child to the clinic because these signs and symptoms are suggestive of what
condition?
a. Pneumothorax
b. Bronchodilation
c. Carbon dioxide retention
d. Increased viscosity of sputum
ANS: A
Usually the signs of pneumothorax are nonspecific. Tachypnea, tachycardia, dyspnea, pallor, and
cyanosis are significant signs and symptoms and are indicative of respiratory distress caused by
pneumothorax. If the bronchial tubes were dilated, the child would have decreased work of
breathing and would most likely be asymptomatic. Carbon dioxide retention is a result of the
chronic alveolar hypoventilation in CF. Hypoxia replaces carbon dioxide as the drive for
respiration progresses. Increased viscosity would result in more difficulty clearing secretions.
DIF: Cognitive Level: Applying REF: p. 1239
TOP: Nursing Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
35. Pancreatic enzymes are administered to the child with cystic fibrosis. What nursing
consideration should be included in the plan of care?
a. Give pancreatic enzymes between meals if at all possible.
b. Do not administer pancreatic enzymes if the child is receiving antibiotics.
c. Decrease the dose of pancreatic enzymes if the child is having frequent, bulky stools.
d. Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.
ANS: D
Enzymes may be administered in a small amount of cereal or fruit at the beginning of a meal or
swallowed whole. Enzymes should be given just before meals and snacks. Pancreatic enzymes
are not a contraindication for antibiotics. The dose of enzymes should be increased if child is
having frequent, bulky stools.
DIF: Cognitive Level: Applying REF: p. 1240
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
36. The nurse is giving discharge instructions to the parents of a 5-year-old child who had a
tonsillectomy 4 hours ago. What statement by the parent indicates a correct understanding of the
teaching?
a. I can use an ice collar on my child for pain control along with analgesics.
b. My child should clear the throat frequently to clear the secretions.
c. I should allow my child to be as active as tolerated.
d. My child should gargle and brush teeth at least three times per day.
ANS: A
Pain control after a tonsillectomy can be achieved with application of an ice collar and
administration of analgesics. The child should avoid clearing the throat or coughing and does not
need to gargle and brush teeth a certain number of times per day and should avoid vigorous
gargling and toothbrushing. Also, the childs activity should be limited to decrease the potential
for bleeding, at least for the first few days.
DIF: Cognitive Level: Applying REF: p. 1174
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
37. A child is admitted with acute laryngotracheobronchitis (LTB). The child will most likely be
treated with which?
a. Racemic epinephrine and corticosteroids
b. Nebulizer treatments and oxygen
c. Antibiotics and albuterol
d. Chest physiotherapy and humidity
ANS: A
Nebulized epinephrine (racemic epinephrine) is now used in children with LTB that is not
alleviated with cool mist. The beta-adrenergic effects cause mucosal vasoconstriction and
subsequent decreased subglottic edema. The use of corticosteroids is beneficial because the anti-
inflammatory effects decrease subglottic edema. Nebulizer treatments are not effective even
though oxygen may be required. Antibiotics are not used because it is a viral infection. Chest
physiotherapy would not be instituted.
DIF: Cognitive Level: Applying REF: p. 1186
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
38. A 6-year-old child has had a tonsillectomy. The child is spitting up small amounts of dark
brown blood in the immediate postoperative period. The nurse should take what action?
a. Notify the health care provider.
b. Continue to assess for bleeding.
c. Give the child a red flavored ice pop.
d. Position the child in a Trendelenburg position.
ANS: B
Some secretions, particularly dried blood from surgery, are common after a tonsillectomy.
Inspect all secretions and vomitus for evidence of fresh bleeding (some blood-tinged mucus is
expected). Dark brown (old) blood is usually present in the emesis, as well as in the nose and
between the teeth. Small amounts of dark brown blood should be further monitored. A red-
flavored ice pop should not be given and the Trendelenburg position is not recommended.
DIF: Cognitive Level: Applying REF: p. 1175
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
39. A 3-year-old child is experiencing pain after a tonsillectomy. The child has not taken in any
fluids and does not want to drink anything, saying, My tummy hurts. The following health care
prescriptions are available: acetaminophen (Tylenol) PO (orally) or PR (rectally) PRN, ice chips,
clear liquids. What should the nurse implement to relieve the childs pain?
a. Ice chips
b. Tylenol PO
c. Tylenol PR
d. Popsicle
ANS: C
The throat is very sore after a tonsillectomy. Most children experience moderate pain after a
tonsillectomy and need pain medication at regular intervals for at least the first 24 hours.
Analgesics may need to be given rectally or intravenously to avoid the oral route.
DIF: Cognitive Level: Applying REF: p. 1169
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
40. A 1-year-old child has acute otitis media (AOM) and is being treated with oral antibiotics.
What should the nurse include in the discharge teaching to the infants parents?
a. A follow-up visit should be done after all medicine has been given.
b. After an episode of acute otitis media, hearing loss usually occurs.
c. Tylenol should not be given because it may mask symptoms.
d. The infant will probably need a myringotomy procedure and tubes.
ANS: A
Children with AOM should be seen after antibiotic therapy is complete to evaluate the
effectiveness of the treatment and to identify potential complications, such as effusion or hearing
impairment. Hearing loss does not usually occur with acute otitis media. Tylenol should be given
for pain, and the infant will not necessarily need a myringotomy procedure.
DIF: Cognitive Level: Applying REF: p. 1178
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
41. What do the initial signs of respiratory syncytial virus (RSV) infection in an infant include?
a. Rhinorrhea, wheezing, and fever
b. Tachypnea, cyanosis, and apnea
c. Retractions, fever, and listlessness
d. Poor breath sounds and air hunger
ANS: A
Symptoms such as rhinorrhea and a low-grade fever often appear first. OM and conjunctivitis
may also be present. In time, a cough may develop. Wheezing is an initial sign as well.
Progression of illness brings on the symptoms of tachypnea, retractions, poor breath sounds,
cyanosis, air hunger, and apnea.
DIF: Cognitive Level: Applying REF: p. 1180
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
42. The nurse is caring for a 1-month-old infant with respiratory syncytial virus (RSV) who is
receiving 23% oxygen via a plastic hood. The childs SaO2 saturation is 88%, respiratory rate is
45 breaths/min, and pulse is 140 beats/min. Based on these assessments, what action should the
nurse take?
a. Withhold feedings.
b. Notify the health care provider.
c. Put the infant in an infant seat.
d. Keep the infant in the plastic hood.
ANS: B
The American Academy of Pediatrics practice parameter (2006) recommends the use of
supplemental oxygen if the infant fails to maintain a consistent oxygen saturation of at least 90%.
The health care provider should be notified of the saturation reading of 88%. Withholding the
feedings or placing the infant in an infant seat would not increase the saturation reading. The
infant should be kept in the hood, but because the saturation reading is 88%, the health care
provider should be notified to obtain orders to increase the oxygen concentration.
DIF: Cognitive Level: Applying REF: p. 1189
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
43. A 5-year-old child is admitted with bacterial pneumonia. What signs and symptoms should
the nurse expect to assess with this disease process?
a. Fever, cough, and chest pain
b. Stridor, wheezing, and ear infection
c. Nasal discharge, headache, and cough
d. Pharyngitis, intermittent fever, and eye infection
ANS: A
Children with bacterial pneumonia usually appear ill. Symptoms include fever, malaise, rapid
and shallow respirations, cough, and chest pain. Ear infection, nasal discharge, and eye infection
are not symptoms of bacterial pneumonia.
DIF: Cognitive Level: Applying REF: p. 1193
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
44. An infant with a congenital heart defect is to receive a dose of palivizumab (Synagis). What
is the purpose of this?
a. Prevent RSV infection.
b. Prevent secondary bacterial infection.
c. Decrease toxicity of antiviral agents.
d. Make isolation of infant with RSV unnecessary.
ANS: A
The only product available in the United States for prevention of RSV is palivizumab, a
humanized mouse monoclonal antibody, which is given once every 30 days (15 mg/kg) between
November and March. It is given to high-risk infants, which includes an infant with a congenital
heart defect.
DIF: Cognitive Level: Understanding REF: p. 1190
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
45. A 3-year-old is brought to the emergency department with symptoms of stridor, fever,
restlessness, and drooling. No coughing is observed. Based on these findings, the nurse should be
prepared to assist with what action?
a. Throat culture
b. Nasal pharynx washing
c. Administration of corticosteroids
d. Emergency intubation
ANS: D
Three clinical observations that are predictive of epiglottitis are absence of spontaneous cough,
presence of drooling, and agitation. Nasotracheal intubation or tracheostomy is usually
considered for a child with epiglottitis with severe respiratory distress. The throat should not be
inspected because airway obstruction can occur, and steroids would not be done first when the
child is in severe respiratory distress.
DIF: Cognitive Level: Applying REF: p. 1185
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
46. A 3-year-old child woke up in the middle of the night with a croupy cough and inspiratory
stridor. The parents bring the child to the emergency department, but by the time they arrive, the
cough is gone, and the stridor has resolved. What can the nurse teach the parents with regard to
this type of croup?
a. A bath in tepid water can help resolve this type of croup.
b. Tylenol can help to relieve the cough and stridor.
c. A cool mist vaporizer at the bedside can help prevent this type of croup.
d. Antibiotics need to be given to reduce the inflammation.
ANS: C
Acute spasmodic laryngitis (spasmodic croup, midnight croup, or twilight croup) is distinct from
laryngitis and LTB and characterized by paroxysmal attacks of laryngeal obstruction that occur
chiefly at night. The child goes to bed well or with some mild respiratory symptoms but awakens
suddenly with characteristic barking; a metallic cough; hoarseness; noisy inspirations; and
restlessness. However, there is no fever, and the episode subsides in a few hours. Children with
spasmodic croup are managed at home. Cool mist is recommended for the childs room. A tepid
water bath will not help, but steam provided by hot water may relieve the laryngeal spasm. The
child will not need Tylenol, and antibiotics are not given for this type of croup.
DIF: Cognitive Level: Applying REF: p. 1174
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
47. A 3-month-old infant is admitted to the pediatric unit for treatment of bronchiolitis. The
infants vital signs are T, 101.6 F; P, 106 beats/min apical; and R, 70 breaths/min. The infant is
irritable and fussy and coughs frequently. IV fluids are given via a peripheral venipuncture.
Fluids by mouth were initially contraindicated for what reason?
a. Tachypnea
b. Paroxysmal cough
c. Irritability
d. Fever
ANS: A
Fluids by mouth may be contraindicated because of tachypnea, weakness, and fatigue. Therefore,
IV fluids are preferred until the acute stage of bronchiolitis has passed. Infants with bronchiolitis
may have paroxysmal coughing, but fluids by mouth would not be contraindicated. Irritability or
fever would not be reasons for fluids by mouth to be contraindicated.
DIF: Cognitive Level: Applying REF: p. 1189
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
48. A child is in the hospital for cystic fibrosis. What health care providers prescription should
the nurse clarify before implementing?
a. Dornase alfa (Pulmozyme) nebulizer treatment bid
b. Pancreatic enzymes every 6 hours
c. Vitamin A, D, E, and K supplements daily
d. Proventil (albuterol) nebulizer treatments tid
ANS: B
The principal treatment for pancreatic insufficiency that occurs in cystic fibrosis is replacement
of pancreatic enzymes, which are administered with meals and snacks to ensure that digestive
enzymes are mixed with food in the duodenum. The enzymes should not be given every 6 hours,
so this should be clarified before implementing this prescription. Dornase alfa (Pulmozyme) is
given by nebulizer to decrease the viscosity of secretions, vitamin supplements are given daily,
and Proventil nebulizer treatments are given to open the bronchi for easier expectoration.
DIF: Cognitive Level: Applying REF: p. 1235
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
49. A 6-year-old child is in the hospital for status asthmaticus. Nursing care during this acute
period includes which prescribed interventions?
a. Prednisolone (Pediapred) PO every day, IV fluids, cromolyn (Intal) inhaler bid
b. Salmeterol (Serevent) PO bid, vital signs every 4 hours, spot check pulse oximetry
c. Triamcinolone (Azmacort) inhaler bid, continuous pulse oximetry, vital signs once a shift
d.
Methylprednisolone (Solumedrol) IV every 12 hours, continuous pulse oximetry, albuterol nebulizer treatments every 4
hours and prn
ANS: D
The child in status asthmaticus should be placed on continuous cardiorespiratory (including
blood pressure) and pulse oximetry monitoring. A systemic corticosteroid (oral, IV, or IM) may
also be given to decrease the effects of inflammation. Inhaled aerosolized short-acting b2-
agonists are recommended for all patients. Therefore, Solumedrol per IV, continuous pulse
oximetry, and albuterol nebulizer treatments are the expected prescribed treatments. Oral
medications would not be used during the acute stage of status asthmaticus. Vital signs once a
shift and spot pulse oximetry checks would not be often enough.
DIF: Cognitive Level: Applying REF: p. 1225
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
50. In providing nourishment for a child with cystic fibrosis (CF), what factors should the nurse
keep in mind?
a. Fats and proteins must be greatly curtailed.
b. Most fruits and vegetables are not well tolerated.
c. Diet should be high in calories, proteins, and unrestricted fats.
d. Diet should be low fat but high in calories and proteins.
ANS: C
Children with CF require a well-balanced, high-protein, high-caloric diet, with unrestricted fat
(because of the impaired intestinal absorption).
DIF: Cognitive Level: Analyzing REF: p. 1223 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
51. A quantitative sweat chloride test has been done on an 8-month-old child. What value should
be indicative of cystic fibrosis (CF)?
a. Less than 18 mEq/L
b. 18 to 40 mEq/L
c. 40 to 60 mEq/L
d. Greater than 60 mEq/L
ANS: D
Normally sweat chloride content is less than 40 mEq/L, with a mean of 18 mEq/L. A chloride
concentration greater than 60 mEq/L is diagnostic of CF; in infants younger than 3 months, a
sweat chloride concentration greater than 40 mEq/L is highly suggestive of CF.
DIF: Cognitive Level: Analyzing REF: p. 1237
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
52. A preschool child has asthma, and a goal is to extend expiratory time and increase expiratory
effectiveness. What action should the nurse implement to meet this goal?
a. Encourage increased fluid intake.
b. Recommend increased use of a budesonide (Pulmicort) inhaler.
c. Administer an antitussive to suppress coughing.
d. Encourage the child to blow a pinwheel every 6 hours while awake.
ANS: D
Play techniques that can be used for younger children to extend their expiratory time and
increase expiratory pressure include blowing cotton balls or a ping-pong ball on a table, blowing
a pinwheel, blowing bubbles, or preventing a tissue from falling by blowing it against the wall.
Increased fluids, increased use of a Pulmicort inhaler, or suppressing a cough will not increase
expiratory effectiveness.
DIF: Cognitive Level: Applying REF: p. 1233
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
53. A school-age child has asthma. The nurse should teach the child that if a peak expiratory flow
rate is in the yellow zone, this means that the asthma control is what?
a. 80% of a personal best, and the routine treatment plan can be followed.
b. 50% to 79% of a personal best and needs an increase in the usual therapy.
c. 50 % of a personal best and needs immediate emergency bronchodilators.
d. Less than 50% of a personal best and needs immediate hospitalization.
ANS: B
The interpretation of a peak expiratory flow rate that is yellow (50%79% of personal best)
signals caution. Asthma is not well controlled. An acute exacerbation may be present.
Maintenance therapy may need to be increased. Call the practitioner if the child stays in this
zone.
DIF: Cognitive Level: Applying REF: p. 1220
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
54. A family requires home care teaching with regard to preventative measures to use at home to
avoid an asthmatic episode. What strategy should the nurse teach?
a. Use a humidifier in the childs room.
b. Launder bedding daily in cold water.
c. Replace wood flooring with carpet.
d. Use an indoor air purifier with HEPA filter.
ANS: D
Allergen control includes use of an indoor air purifier with HEPA filter. Humidity should be kept
low, bedding laundered in hot water once a week, and carpet replaced with wood floors.
DIF: Cognitive Level: Applying REF: p. 1222
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
55. A school-age child with cystic fibrosis takes four enzyme capsules with meals. The child is
having four or five bowel movements per day. The nurses action in regard to the pancreatic
enzymes is based on the knowledge that the dosage is what?
a. Adequate
b. Adequate but should be taken between meals
c. Needs to be increased to increase the number of bowel movements per day
d. Needs to be increased to decrease the number of bowel movements per day
ANS: D
The amount of enzyme is adjusted to achieve normal growth and a decrease in the number of
stools to one or two per day.
DIF: Cognitive Level: Applying REF: p. 1236
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
56. A term infant is delivered, and before delivery, the medical team was notified that a
congenital diaphragmatic hernia (CDH) was diagnosed on ultrasonography. What should be done
immediately at birth if respiratory distress is noted?
a. Give oxygen.
b. Suction the infant.
c. Intubate the infant.
d. Ventilate the infant with a bag and mask.
ANS: C
Many infants with a CDH require immediate respiratory assistance, which includes endotracheal
intubation and GI decompression with a double-lumen catheter to prevent further respiratory
compromise. At birth, bag and mask ventilation is contraindicated to prevent air from entering
the stomach and especially the intestines, further compromising pulmonary function. Oxygen
and suctioning may be used for mild respiratory distress.
DIF: Cognitive Level: Analyzing REF: p. 1211 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
57. A child has a streptococcal throat infection and is being treated with antibiotics. What should
the nurse teach the parents to prevent infection of others?
a. The child can return to school immediately.
b. The organism cannot be transmitted through contact.
c. The child can return to school after taking antibiotics for 24 hours.
d. The organism can only be transmitted if someone uses a personal item of the sick child.
ANS: C
Children with streptococcal infection are noninfectious to others 24 hours after initiation of
antibiotic therapy. It is generally recommended that children not return to school or daycare until
they have been taking antibiotics for a full 24-hour period. The organism is spread by close
contact with affected personsdirect projection of large droplets or physical transfer of respiratory
secretions containing the organism.
DIF: Cognitive Level: Applying REF: p. 1173
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Safe and Effective Care Environment
58. What medication is contraindicated in children post tonsillectomy and adenoidectomy?
a.
Codeine
b. Ondansetron (Zofran)
b. Amoxil (amoxicillin)
c. Acetaminophen (Tylenol)
ANS: A
Codeine is contraindicated in pediatric patients after tonsillectomy and adenoidectomy. In 2012,
the Food and Drug Administration issued a Drug Safety Communication that codeine use in
certain children after tonsillectomy or adenoidectomy may lead to rare but life-threatening
adverse events or death. Zofran, amoxicillin, and Tylenol are not contraindicated after
tonsillectomy and adenoidectomy.
DIF: Cognitive Level: Understanding REF: p. 1175 TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. The nurse is preparing a staff education program about pediatric asthma. What concepts
should the nurse include when discussing the asthma severity classification system? (Select all
that apply.)
a. Children with mild persistent asthma have nighttime signs or symptoms less than two times a month.
b. Children with moderate persistent asthma use a short-acting b-agonist more than two times per week.
c. Children with severe persistent asthma have a peak expiratory flow (PEF) of 60% to 80% of predicted value.
d. Children with mild persistent asthma have signs or symptoms more than two times per week.
e. Children with moderate persistent asthma have some limitations with normal activity.
f. Children with severe persistent asthma have frequent nighttime signs or symptoms.
ANS: D, E, F
Children with mild persistent asthma have signs or symptoms more than two times per week and
nighttime signs or symptoms three or four times per month. Children with moderate persistent
asthma have some limitations with normal activity and need to use a short-actingb-agonist for
sign or symptom control daily. Children with severe persistent asthma have frequent nighttime
signs or symptoms and have a PEF of less than 60%.
DIF: Cognitive Level: Analyzing REF: p. 1233
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
2. The nurse is caring for a newborn with suspected congenital diaphragmatic hernia. What of the
following findings would the nurse expect to observe? (Select all that apply.)
a. Loud, harsh murmur
b. Scaphoid abdomen
c. Poor peripheral pulses
d. Mediastinal shift
e. Inguinal swelling
f. Moderate respiratory distress
ANS: B, D, F
Clinical manifestations of a congenital diaphragmatic hernia include a scaphoid abdomen, a
mediastinal shift, and moderate to severe respiratory distress. The infant would not have a harsh,
loud murmur or poor peripheral pulses. Inguinal swelling is indicative of an inguinal hernia.
DIF: Cognitive Level: Applying REF: p. 1210
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
3. What interventions can the nurse teach parents to do to ease respiratory efforts for a child with
a mild respiratory tract infection? (Select all that apply.)
a. Cool mist
b. Warm mist
c. Steam vaporizer
d. Keep child in a flat, quiet position
e. Run a shower of hot water to produce steam
ANS: A, B, C, E
Warm or cool mist is a common therapeutic measure for symptomatic relief of respiratory
discomfort. The moisture soothes inflamed membranes and is beneficial when there is hoarseness
or laryngeal involvement. A time-honored method of producing steam is the shower. Running a
shower of hot water into the empty bathtub or open shower stall with the bathroom door closed
produces a quick source of steam. Keeping a child in this environment for 10 to 15 minutes may
help ease respiratory efforts. A small child can sit on the lap of a parent or other adult. The child
should be quiet but upright, not flat. The use of steam vaporizers in the home is often
discouraged because of the hazards related to their use and limited evidence to support their
efficacy.
DIF: Cognitive Level: Applying REF: p. 1165
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
4. A tonsillectomy or adenoidectomy is contraindicated in what conditions? (Select all that
apply.)
a. Cleft palate
b. Seizure disorders
c. Blood dyscrasias
d. Sickle cell disease
e. Acute infection at the time of surgery
ANS: A, C, E
Contraindications to either tonsillectomy or adenoidectomy are (1) cleft palate because both
tonsils help minimize escape of air during speech, (2) acute infections at the time of surgery
because the locally inflamed tissues increase the risk of bleeding, and (3) uncontrolled systemic
diseases or blood dyscrasias. Tonsillectomy or adenoidectomy is not contraindicated in sickle
cell disease or seizure disorders.
DIF: Cognitive Level: Applying REF: p. 1174
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
5. The clinic nurse is administering influenza vaccinations. Which children should not receive
the live attenuated influenza vaccine (LAIV)? (Select all that apply.)
a. A child with asthma
b. A child with diabetes
c. A child with hemophilia A
d. A child with cancer receiving chemotherapy
e. A child with gastroesophageal reflux disease
ANS: A, B, D
The live attenuated influenza vaccine (LAIV) is an acceptable alternative to the IM vaccine (IIV)
for ages 2 to 49 years. It is a live vaccine administered via nasal spray. Several groups are
excluded from receiving it, including children with a chronic heart or lung disease (asthma or
reactive airways disease), diabetes, or kidney failure; children who are immunocompromised or
receiving immunosuppressants; children younger than 5 years of age with a history of recurrent
wheezing; children receiving aspirin; patients who are pregnant; children who have a severe
allergy to chicken eggs or who are allergic to any of the nasal spray vaccine components; or
children with a history of Guillain-Barr Syndrome after a previous dose. A child with hemophilia
A or gastroesophageal reflux disease would not be immunocompromised so they can receive the
LAIV.
DIF: Cognitive Level: Applying REF: p. 1177
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
6. The nurse is preparing to admit a 7-year-old child with acute laryngotracheobronchitis (LTB).
What clinical manifestations should the nurse expect to observe? (Select all that apply.)
a. Dysphagia
b. Brassy cough
c. Low-grade fever
d. Toxic appearance
e. Slowly progressive
ANS: B, C, E
Clinical manifestations of LTB include a brassy cough, low-grade fever, and slow progression.
Dysphagia and a toxic appearance are characteristics of acute epiglottitis.
DIF: Cognitive Level: Applying REF: p. 1184
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
7. The nurse is preparing to admit a 3-year-old child with acute spasmodic laryngitis. What
clinical features of hepatitis B should the nurse recognize? (Select all that apply.)
a. High fever
b. Croupy cough
c. Tendency to recur
d. Purulent secretions
e. Occurs sudden, often at night
ANS: B, C, E
Clinical features of acute spasmodic laryngitis include a croupy cough, a tendency to recur, and
occurring sudden, often at night. High fever is a feature of acute epiglottitis and purulent
secretions are seen with acute tracheitis.
DIF: Cognitive Level: Analyzing REF: p. 1184
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
8. A child is diagnosed with active pulmonary tuberculosis. What medications does the nurse
anticipate to be prescribed for the first 2 months? (Select all that apply.)
a. Isoniazid (INH)
b. Cefuroxime (Ceftin)
c. Rifampin (Rifadin)
d. Pyrazinamide (PZA)
e. Ethambutol (Myambutol)
ANS: A, C, D, E
For the child with clinically active pulmonary and extrapulmonary TB, the goal is to achieve
sterilization of the tuberculous lesion. The American Academy of Pediatrics (2012) recommends
a 6-month regimen consisting of INH, rifampin, ethambutol, and PZA given daily or twice
weekly for the first 2 months followed by INH and rifampin given two or three times a week by
DOT for the remaining 4 months (Mycobacterium tuberculosis). Cefuroxime is not part of the
regimen.
DIF: Cognitive Level: Analyzing REF: p. 1200
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
9. The nurse is interpreting a tuberculin skin test. If the nurse finds a result of an induration 5
mm or larger, in which child should the nurse document this finding as positive? (Select all that
apply.)
a. A child with diabetes mellitus
b. A child younger than 4 years of age
c. A child receiving immunosuppressive therapy
d. A child with a human immunodeficiency virus (HIV) infection
e. A child living in close contact with a known contagious case of tuberculosis
ANS: C, D, E
A tuberculin skin test with an induration of 5 mm or larger is considered to be positive if the
child is receiving immunosuppressive therapy, has an HIV infection, or is living in close contact
with a known contagious case of tuberculosis. The test would be considered positive in a child
who has diabetes mellitus or is younger than 4 years of age if the tuberculin skin test had an
induration of 10 mm or larger.
DIF: Cognitive Level: Applying REF: p. 1198
TOP: Integrated Process: Communication and Documentation
MSC: Client Needs: Health Promotion and Maintenance
10. The nurse is preparing to admit a 7-year-old child with pulmonary edema. What clinical
manifestations should the nurse expect to observe? (Select all that apply.)
a. Fever
b. Bradycardia
c. Diaphoresis
d. Pink frothy sputum
e. Respiratory crackles
ANS: C, D, E
Clinical manifestations of pulmonary edema include diaphoresis, pink frothy sputum, and
respiratory crackles. Fever or bradycardia are not manifestations of pulmonary edema.
CH.29
1. What term is defined as the volume of blood ejected by the heart in 1 minute?
a. Afterload
b. Cardiac cycle
c. Stroke volume
d. Cardiac output
ANS: D
Cardiac output is defined as the volume of blood ejected by the heart in 1 minute. Cardiac output
= Heart rate x Stroke volume. Afterload is the resistance against which the ventricles must pump
when ejecting blood (ventricular ejection). A cardiac cycle is the sequential contraction and
relaxation of both the atria and ventricles. Stroke volume is the amount of blood ejected by the
heart in any one contraction.
DIF: Cognitive Level: Understanding REF: p. 1254 TOP: Nursing Process: Diagnosis
MSC: Client Needs: Physiological Integrity
2. A chest radiography examination is ordered for a child with suspected cardiac problems. The
childs parent asks the nurse, What will the x-ray show about the heart? The nurses response
should be based on knowledge that the radiograph provides which information?
a. Shows bones of the chest but not the heart
b. Evaluates the vascular anatomy outside of the heart
c. Shows a graphic measure of electrical activity of the heart
d. Supplies information on heart size and pulmonary blood flow patterns
ANS: D
Chest radiographs provide information on the size of the heart and pulmonary blood flow
patterns. The bones of the chest are visible on chest radiographs, but the heart and blood vessels
are also seen. Magnetic resonance imaging is a noninvasive technique that allows for evaluation
of vascular anatomy outside of the heart. A graphic measure of electrical activity of the heart is
provided by electrocardiography.
DIF: Cognitive Level: Understanding REF: p. 1256
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
3. A 6-year-old child is scheduled for a cardiac catheterization. What consideration is most
important in planning preoperative teaching?
a. Preoperative teaching should be directed at his parents because he is too young to understand.
b. Preoperative teaching should be adapted to his level of development so that he can understand.
c. Preoperative teaching should be done several days before the procedure so he will be prepared.
d. Preoperative teaching should provide details about the actual procedures so he will know what to expect.
ANS: B
Preoperative teaching should always be directed to the childs stage of development. The
caregivers also benefit from these explanations. The parents may ask additional questions, which
should be answered, but the child needs to receive the information based on developmental level.
This age group will not understand in-depth descriptions. School-age children should be
prepared close to the time of the cardiac catheterization.
DIF: Cognitive Level: Applying REF: p. 1259
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
4. After returning from cardiac catheterization, the nurse monitors the childs vital signs. The
heart rate should be counted for how many seconds?
a. 15
b. 30
c. 60
d. 120
ANS: C
The heart rate is counted for a full minute to determine whether arrhythmias or bradycardia is
present. Fifteen to 30 seconds are too short for accurate assessment. Sixty seconds is sufficient to
assess heart rate and rhythm.
DIF: Cognitive Level: Applying REF: p. 1260
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
5. After returning from cardiac catheterization, the nurse determines that the pulse distal to the
catheter insertion site is weaker. How should the nurse respond?
a. Elevate the affected extremity.
b. Notify the practitioner of the observation.
c. Record data on the assessment flow record.
d. Apply warm compresses to the insertion site.
ANS: C
The pulse distal to the catheterization site may be weaker for the first few hours after
catheterization but should gradually increase in strength. Documentation of the finding provides
a baseline. The extremity is maintained straight for 4 to 6 hours. This is an expected change. The
pulse is monitored. If there are neurovascular changes in the extremity, the practitioner is
notified. The site is kept dry. Warm compresses are not indicated.
DIF: Cognitive Level: Applying REF: p. 1260
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
6. The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells
the nurse that her bandage is too wet. The nurse finds the bandage and bed soaked with blood.
What nursing action is most appropriate to institute initially?
a. Notify the physician.
b. Place the child in Trendelenburg position.
c. Apply a new bandage with more pressure.
d. Apply direct pressure above the catheterization site.
ANS: D
When bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the
percutaneous skin site to localize pressure on the vessel puncture. The physician can be notified,
and a new bandage with more pressure can be applied after pressure is applied. The nurse can
have someone else notify the physician while the pressure is being maintained. Trendelenburg
positioning would not be a helpful intervention. It would increase the drainage from the lower
extremities.
DIF: Cognitive Level: Analyzing REF: p. 1259
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
7. What statement best identifies the cause of heart failure (HF)?
a. Disease related to cardiac defects
b. Consequence of an underlying cardiac defect
c. Inherited disorder associated with a variety of defects
d. Result of diminished workload imposed on an abnormal myocardium
ANS: B
HF is the inability of the heart to pump an adequate amount of blood to the systemic circulation
at normal filling pressures to meet the bodys metabolic demands. HF is not a disease but rather a
result of the inability of the heart to pump efficiently. HF is not inherited. HF occurs most
frequently secondary to congenital heart defects in which structural abnormalities result in
increased volume load or increased pressures on the ventricles.
DIF: Cognitive Level: Understanding REF: p. 1262
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
8. The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep.
What nursing intervention is most appropriate at this time?
a. Administer oxygen.
b. Record data on the nurses notes.
c. Report data to the practitioner.
d. Place the child in the high Fowler position.
ANS: C
One of the earliest signs of HF is tachycardia (sleeping heart rate >160 beats/min) as a direct
result of sympathetic stimulation. The practitioner needs to be notified for evaluation of possible
HF. Although oxygen or a semiupright position may be indicated, the first action is to report the
data to the practitioner.
DIF: Cognitive Level: Analyzing REF: p. 1267
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
9. What drug is an angiotensin-converting enzyme (ACE) inhibitor?
a. Furosemide (Lasix)
b. Captopril (Capoten)
c. Chlorothiazide (Diuril)
d. Spironolactone (Aldactone)
ANS: B
Captopril is an ACE inhibitor. Furosemide is a loop diuretic. Chlorothiazide works on the distal
tubules. Spironolactone blocks the action of aldosterone and is a potassium-sparing diuretic.
DIF: Cognitive Level: Understanding REF: p. 1305
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
10. A 2-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner
and withhold the medication if the apical pulse is less than which rate?
a. 60 beats/min
b. 90 beats/min
c. 100 beats/min
d. 120 beats/min
ANS: B
If a 1-minute apical pulse is less than 90 beats/min for an infant or young child, the digoxin is
withheld. Sixty beats/min is the cut-off for holding the digoxin dose in an adult. One hundred to
120 beats/min is an acceptable pulse rate for the administration of digoxin.
DIF: Cognitive Level: Understanding REF: p. 1313
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
11. What clinical manifestation is a common sign of digoxin toxicity?
a. Seizures
b. Vomiting
c. Bradypnea
d. Tachycardia
ANS: B
Vomiting is a common sign of digoxin toxicity and is often unrelated to feedings. Seizures are
not associated with digoxin toxicity. The child will have a slower (not faster) heart rate but not a
slower respiratory rate.
DIF: Cognitive Level: Understanding REF: p. 1266
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
12. The parents of a young child with heart failure (HF) tell the nurse that they are nervous about
giving digoxin. The nurses response should be based on which knowledge?
a. It is a safe, frequently used drug.
b. Parents lack the expertise necessary to administer digoxin.
c. It is difficult to either overmedicate or undermedicate with digoxin.
d. Parents need to learn specific, important guidelines for administration of digoxin.
ANS: D
Digoxin has a narrow therapeutic range. The margin of safety between therapeutic, toxic, and
lethal doses is very small. Specific guidelines are available for parents to learn how to administer
the drug safely and to monitor for side effects. Parents may lack the expertise to administer the
drug at first, but with discharge preparation, they should be prepared to administer the drug
safely.
DIF: Cognitive Level: Analyzing REF: p. 1267
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
13. What nutritional component should be altered in the infant with heart failure (HF)?
a. Decrease in fats
b. Increase in fluids
c. Decrease in protein
d. Increase in calories
ANS: D
Infants with HF have a greater metabolic rate because of poor cardiac function and increased
heart and respiratory rates. Their caloric needs are greater than those of average infants, yet their
ability to take in calories is diminished by their fatigue. The diet should include increased protein
and increased fat to facilitate the childs intake of sufficient calories. Fluids must be carefully
monitored because of the HF.
DIF: Cognitive Level: Analyzing REF: p. 1268 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
14. Decreasing the demands on the heart is a priority in care for the infant with heart failure
(HF). In evaluating the infants status, which finding is indicative of achieving this goal?
a. Irritability when awake
b. Capillary refill of more than 5 seconds
c. Appropriate weight gain for age
d. Positioned in high Fowler position to maintain oxygen saturation at 90%
ANS: C
Appropriate weight gain for an infant is indicative of successful feeding and a reduction in
caloric loss secondary to the HF. Irritability is a symptom of HF. The child also uses additional
energy when irritable. Capillary refill should be brisk and within 2 to 3 seconds. The child needs
to be positioned upright to maintain oxygen saturation at 90%. Positioning is helping to decrease
respiratory effort, but the infant is still having difficulty with oxygenation.
DIF: Cognitive Level: Analyzing REF: p. 1268 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
15. The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The
nurse recognizes the risk of cerebrovascular accidents (strokes) occurring. What strategy is an
important objective to decrease this risk?
a. Minimize seizures.
b. Prevent dehydration.
c. Promote cardiac output.
d. Reduce energy expenditure.
ANS: B
In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in
hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting
cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular
accidents.
DIF: Cognitive Level: Analyzing REF: p. 1273
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
16. A 3-month-old infant has a hypercyanotic spell. What should be the nurses first action?
a. Assess for neurologic defects.
b. Prepare the family for imminent death.
c. Begin cardiopulmonary resuscitation.
d. Place the child in the kneechest position.
ANS: D
The first action is to place the infant in the kneechest position. Blow-by oxygen may be
indicated. Neurologic defects are unlikely. Preparing the family for imminent death or beginning
cardiopulmonary resuscitation should be unnecessary. The child is assessed for airway,
breathing, and circulation. Often, calming the child and administering oxygen and morphine can
alleviate the hypercyanotic spell.
DIF: Cognitive Level: Applying REF: p. 1273
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
17. A cardiac defect that allows blood to shunt from the (high pressure) left side of the heart to
the (lower pressure) right side can result in which condition?
a. Cyanosis
b. Heart failure
c. Decreased pulmonary blood flow
d. Bounding pulses in upper extremities
ANS: B
As blood is shunted into the right side of the heart, there is increased pulmonary blood flow and
the child is at high risk for heart failure. Cyanosis usually occurs in defects with decreased
pulmonary blood flow. Bounding upper extremity pulses are a manifestation of coarctation of the
aorta.
DIF: Cognitive Level: Applying REF: p. 1262
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
18. What blood flow pattern occurs in a ventricular septal defect?
a. Mixed blood flow
b. Increased pulmonary blood flow
c. Decreased pulmonary blood flow
d. Obstruction to blood flow from ventricles
ANS: B
The opening in the septal wall allows for blood to flow from the higher pressure left ventricle
into the lower pressure right ventricle. This left-to-right shunt creates increased pulmonary blood
flow. The shunt is one way, from high pressure to lower pressure; oxygenated and unoxygenated
blood do not mix. The outflow of blood from the ventricles is not affected by the septal defect.
DIF: Cognitive Level: Understanding REF: p. 1276
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
19. The physician suggests that surgery be performed for patent ductus arteriosus (PDA) to
prevent which complication?
a. Hypoxemia
b. Right-to-left shunt of blood
c. Decreased workload on the left side of the heart
d. Pulmonary vascular congestion
ANS: D
In PDA, blood flows from the higher pressure aorta into the lower pressure pulmonary vein,
resulting in increased pulmonary blood flow. This creates pulmonary vascular congestion.
Hypoxemia usually results from defects with mixed blood flow and decreased pulmonary blood
flow. The shunt is from left to right in a PDA. The closure would stop this. There is increased
workload on the left side of the heart with a PDA.
DIF: Cognitive Level: Applying REF: p. 1278 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
20. What cardiovascular defect results in obstruction to blood flow?
a. Aortic stenosis
b. Tricuspid atresia
c. Atrial septal defect
d. Transposition of the great arteries
ANS: A
Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in
the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular
congestion. Tricuspid atresia results in decreased pulmonary blood flow. The atrial septal defect
results in increased pulmonary blood flow. Transposition of the great arteries results in mixed
blood flow.
DIF: Cognitive Level: Understanding REF: p. 1279
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
21. What structural defects constitute tetralogy of Fallot?
a. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
c. Aortic stenosis, ventricular septal defect, overriding aorta, left ventricular hypertrophy
d. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
ANS: A
Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal defect,
overriding aorta, and right ventricular hypertrophy.
DIF: Cognitive Level: Understanding REF: p. 1280
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
22. The parents of a 3-year-old child with congenital heart disease are afraid to let their child
play with other children because of possible overexertion. How should the nurse reply to this
concern?
a. The parents should meet all the childs needs.
b. The child needs opportunities to play with peers.
c. Constant parental supervision is needed to avoid overexertion.
d. The child needs to understand that peers activities are too strenuous.
ANS: B
The child needs opportunities for social development. Children are able to regulate and limit
their activities based on their energy level. Parents must be encouraged to seek appropriate social
activities for the child, especially before kindergarten. The child needs to have activities that
foster independence.
DIF: Cognitive Level: Analyzing REF: p. 1285
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
23. What preparation should the nurse consider when educating a school-age child and the
family for heart surgery?
a. Unfamiliar equipment should not be shown.
b. Let the child hear the sounds of a cardiac monitor, including alarms.
c. Explain that an endotracheal tube will not be needed if the surgery goes well.
d. Discussion of postoperative discomfort and interventions is not necessary before the procedure.
ANS: B
The child and family should be exposed to the sights and sounds of the intensive care unit (ICU).
All positive, nonfrightening aspects of the environment are emphasized. The family and child
should make the decision about a tour of the unit if it is an option. The child should be shown
unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the
postoperative experience, including intravenous lines, incision, endotracheal tube, expected
discomfort, and management strategies.
DIF: Cognitive Level: Applying REF: p. 1286
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity
24. Seventy-two hours after cardiac surgery, a young child has a temperature of 38.4 C (101.1 F).
What action should the nurse perform?
a. Report findings to the practitioner.
b. Apply a hypothermia blanket.
c. Keep the child warm with blankets.
d. Record the temperature on the assessment flow sheet.
ANS: A
In the first 24 to 48 hours after surgery, the body temperature may increase to 37.8 C (100 F) as
part of the inflammatory response to tissue trauma. If the temperature is higher or fever continues
after this period, it is most likely a sign of an infection, and immediate investigation is indicated.
A hypothermia blanket is not indicated for this level of temperature. Blankets should be removed
from the child to keep the temperature from increasing. The temperature should be recorded, but
the practitioner must be notified for evaluation.
DIF: Cognitive Level: Applying REF: p. 1289
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
25. What nursing consideration is important when suctioning a young child who has had heart
surgery?
a. Perform suctioning at least every hour.
b. Suction for no longer than 30 seconds at a time.
c. Expect symptoms of respiratory distress when suctioning.
d. Administer supplemental oxygen before and after suctioning.
ANS: D
When suctioning is indicated, supplemental oxygen is administered with a manual resuscitation
bag before and after the procedure to prevent hypoxia. Suctioning should be done only as
indicated and very carefully to avoid vagal stimulation. The child should be suctioned for no
more than 5 seconds at a time. Symptoms of respiratory distress are avoided by using appropriate
technique.
DIF: Cognitive Level: Applying REF: p. 1289
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
26. The nurse notices that a child is increasingly apprehensive and has tachycardia after heart
surgery. The chest tube drainage is now 8 ml/kg/hr. What should be the nurses initial
intervention?
a. Apply warming blankets.
b. Notify the practitioner of these findings.
c. Give additional pain medication per protocol.
d. Encourage child to cough, turn, and deep breathe.
ANS: B
The practitioner is notified immediately. Increases of chest tube drainage to more than 3 ml/kg/hr
for more than 3 consecutive hours or 5 to 10 ml/kg in any 1 hour may indicate postoperative
hemorrhage. Increased chest tube drainage with apprehensiveness and tachycardia may indicate
cardiac tamponadeblood or fluid in the pericardial space constricting the heartwhich is a life-
threatening complication. Warming blankets are not indicated at this time. Additional pain
medication can be given before the practitioner drains the fluid, but the notification is the first
action. Encouraging the child to cough, turn, and deep breathe should be deferred until after
evaluation by the practitioner.
DIF: Cognitive Level: Applying REF: p. 1291
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
27. A parent of a 7-year-old girl with a repaired ventricular septal defect (VSD) calls the
cardiology clinic and reports that the child is just not herself. Her appetite is decreased, she has
had intermittent fevers around 38 C (100.4 F), and now her muscles and joints ache. Based on
this information, how should the nurse advise the mother?
a. Immediately bring the child to the clinic for evaluation.
b. Come to the clinic next week on a scheduled appointment.
c. Treat the signs and symptoms with acetaminophen and fluids because it is most likely a viral illness.
d. Recognize that the child is trying to manipulate the parent by complaining of vague symptoms.
ANS: A
These are the insidious symptoms of bacterial endocarditis. Because the child is in a high-risk
group for this disorder (VSD repair), immediate evaluation and treatment are indicated to prevent
cardiac damage. With appropriate antibiotic therapy, bacterial endocarditis is successfully treated
in approximately 80% of the cases. The childs complaints should not be dismissed. The low-
grade fever is not a symptom that the child can fabricate.
DIF: Cognitive Level: Applying REF: p. 1277
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
28. What primary nursing intervention should be implemented to prevent bacterial endocarditis?
a. Counsel parents of high-risk children.
b. Institute measures to prevent dental procedures.
c. Encourage restricted mobility in susceptible children.
d. Observe children for complications, such as embolism and heart failure.
ANS: A
The objective of nursing care is to counsel the parents of high-risk children about the need for
both prophylactic antibiotics for dental procedures and maintaining excellent oral health. The
childs dentist should be aware of the childs cardiac condition. Dental procedures should be done
to maintain a high level of oral health. Restricted mobility in susceptible children is not
indicated. Parents are taught to observe for unexplained fever, weight loss, or change in behavior.
DIF: Cognitive Level: Applying REF: p. 1273 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
29. What sign/symptom is a major clinical manifestation of rheumatic fever (RF)?
a. Fever
b. Polyarthritis
c. Osler nodes
d. Janeway spots
ANS: B
Polyarthritis, which is swollen, hot, red, and painful joints, is a major clinical manifestation. The
affected joints will change every 1 or 2 days. The large joints are primarily affected. Fever is
considered a minor manifestation of RF. Osler nodes and Janeway spots are characteristic of
bacterial endocarditis.
DIF: Cognitive Level: Analyzing REF: p. 1296
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
30. What action by the school nurse is important in the prevention of rheumatic fever (RF)?
a. Encourage routine cholesterol screenings.
b. Conduct routine blood pressure screenings.
c. Refer children with sore throats for throat cultures.
d. Recommend salicylates instead of acetaminophen for minor discomforts.
ANS: C
Nurses have a role in prevention, primarily in screening school-age children for sore throats
caused by group A streptococci. They can actively participate in throat culture screening or refer
children with possible streptococcal sore throats for testing. Routine cholesterol screenings and
blood pressure screenings do not facilitate the recognition and treatment of group A hemolytic
streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after
viral illnesses.
DIF: Cognitive Level: Applying REF: p. 1298
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
31. When caring for the child with Kawasaki disease, what should the nurse know to provide
safe and effective care?
a. Aspirin is contraindicated.
b. The principal area of involvement is the joints.
c. The childs fever is usually responsive to antibiotics within 48 hours.
d. Therapeutic management includes administration of gamma globulin and salicylates.
ANS: D
High-dose intravenous gamma globulin and salicylate therapy are indicated to reduce the
incidence of coronary artery abnormalities when given within the first 10 days of the illness.
Aspirin is part of the therapy. Mucous membranes, conjunctiva, changes in the extremities, and
cardiac involvement are seen. The fever of Kawasaki disease is unresponsive to antibiotics. It is
responsive to anti-inflammatory doses of aspirin and antipyretics.
DIF: Cognitive Level: Applying REF: p. 1298
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
32. Nursing care of the child with Kawasaki disease is challenging because of which occurrence?
a. The childs irritability
b. Predictable disease course
c. Complex antibiotic therapy
d. The childs ongoing requests for food
ANS: A
Patient irritability is a hallmark of Kawasaki disease and is the most challenging problem. A
quiet environment is necessary to promote rest. The diagnosis is often difficult to make, and the
course of the disease can be unpredictable. Intravenous gamma globulin and salicylates are the
therapy of choice, not antibiotics. The child often is reluctant to eat. Soft foods and fluids should
be offered to prevent dehydration.
DIF: Cognitive Level: Understanding REF: p. 1298
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
33. The diagnosis of hypertension depends on accurate assessment of blood pressure (BP). What
is the appropriate technique to measure a childs BP?
a. Assess BP while the child is standing.
b. Compare left arm with left leg BP readings.
c. Use a narrow cuff to ensure that the readings are correct.
d. Measure BP with the child in the sitting position on three separate occasions.
ANS: D
The diagnosis of hypertension is made after the BP is elevated on three separate occasions. Take
the BP in a quiet area with the appropriate size cuff and the child sitting. Although left arm and
left leg BP readings may be compared, it is not the procedure to diagnose hypertension. The
appropriate size cuff is indicated. The most common cause of inaccurate readings is the use of a
cuff that is too small.
DIF: Cognitive Level: Applying REF: p. 1303
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
34. What type of drug reduces hypertension by interfering with the production of angiotensin II?
a. Diuretics
b. Vasodilators
c. Beta-blockers
d. Angiotensin-converting enzyme (ACE) inhibitors
ANS: D
ACE inhibitors act by interfering with the production of angiotensin II, which is a potent
vasoconstrictor. Diuretics lower blood pressure by increasing fluid output. Vasodilators act on the
vascular smooth muscle. By causing arterial dilation, blood pressure is lowered. Beta-blockers
interfere with beta stimulation and depress renin output.
DIF: Cognitive Level: Understanding REF: p. 1307
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
35. Selective cholesterol screening is recommended for children older than the age of 2 years
with which risk factor?
a. Body mass index (BMI) = 95th percentile
b. Blood pressure = 50th percentile
c. Parent with a blood cholesterol level of 200 mg/dl
d. Recently diagnosed cardiovascular disease in a 75-year-old grandparent
ANS: A
Obesity is an indication for cholesterol screening in children. A BMI in the 95th percentile or
higher is considered obese. Children who are hypertensive meet the criteria for screening, but
blood pressure in the 50th percentile is within the normal range. A parent or grandparent with a
cholesterol level of 240 mg/dl or higher places the child at risk. Early cardiovascular disease in a
first- or second-degree relative is a risk factor. Age 75 years is not considered early.
DIF: Cognitive Level: Applying REF: p. 1303 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
36. What condition is the leading cause of death after heart transplantation?
a. Infection
b. Rejection
c. Cardiomyopathy
d. Heart failure
ANS: B
The posttransplant course is complex. The leading cause of death after cardiac transplant is
rejection. Infection is a continued risk secondary to the immunosuppression necessary to prevent
rejection. Cardiomyopathy is one of the indications for cardiac transplant. Heart failure is not a
leading cause of death.
DIF: Cognitive Level: Understanding REF: p. 1316
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
37. The nurse is giving discharge instructions to the parent of a 6-year-old child who had a
cardiac catheterization 4 hours ago. What statement by the parent indicates a correct
understanding of the teaching?
a. My child should not attend school for the next 5 days.
b. I should change the bandage every day for the next 2 days.
c. My child can take a tub bath but should avoid taking a shower for the next 4 days.
d. I should expect the site to be red and swollen for the next 3 days.
ANS: B
Discharge instructions for a parent of a child who recently had a cardiac catheterization should
include changing the bandage every day for the next 2 days. The child should avoid strenuous
exercise but can go back to school. The child should avoid a tub bath, but an older child could
take a shower the first day after the catheterization. The site should not have swelling or redness;
if there is, it should be reported to the health care practitioner.
DIF: Cognitive Level: Analyzing REF: p. 1260
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
38. A child with heart failure is on Lanoxin (digoxin). The laboratory value a nurse must closely
monitor is which?
a. Serum sodium
b. Serum potassium
c. Serum glucose
d. Serum chloride
ANS: B
A fall in the serum potassium level enhances the effects of digoxin, increasing the risk of digoxin
toxicity. Increased serum potassium levels diminish digoxins effect. Therefore, serum potassium
levels (normal range, 3.55.5 mmol/L) must be carefully monitored.
DIF: Cognitive Level: Applying REF: p. 1267
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
39. An infant has tetralogy of Fallot. In reviewing the record, what laboratory result should the
nurse expect to be documented?
a. Leukopenia
b. Polycythemia
c. Anemia
d. Increased platelet level
ANS: B
Persistent hypoxemia that occurs with tetralogy of Fallot stimulates erythropoiesis, which results
in polycythemia, an increased number of red blood cells.
DIF: Cognitive Level: Analyzing REF: p. 1267
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
40. What child has a cyanotic congenital heart defect?
a. An infant with patent ductus arteriosus
b. A 1-year-old infant with atrial septal defect
c. A 2-month-old infant with tetralogy of Fallot
d. A 6-month-old infant with repaired ventricular septal defect
ANS: C
Tetralogy of Fallot is a cyanotic congenital heart defect. Patent ductus arteriosus, atrial septal
defect, and ventricular septal defect are acyanotic congenital heart defects.
DIF: Cognitive Level: Analyzing REF: p. 1261
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
41. The nurse is teaching parents about administering digoxin (Lanoxin). What instructions
should the nurse tell the parents?
a. If the child vomits, give another dose.
b. Give the medication at regular intervals.
c. If a dose is missed, give a give an extra dose.
d. Give the medication mixed with the childs formula.
ANS: B
The family should be taught to administer digoxin at regular intervals. If a dose is missed, an
extra dose should not be given; the same schedule should be maintained. If the child vomits, do
not give a second dose. The drug should not be mixed with foods or other fluids because refusal
to consume these would result in inaccurate intake of the drug.
DIF: Cognitive Level: Applying REF: p. 1265
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
42. Heart failure (HF) is a problem after the child has had a congenital heart defect repaired. The
nurse knows a sign of HF is what?
a. Wheezing
b. Increased blood pressure
c. Increased urine output
d. Decreased heart rate
ANS: A
A clinical manifestation of heart failure is wheezing from pulmonary congestion. The blood
pressure decreases, urine output decreases, and heart rate increases.
DIF: Cognitive Level: Analyzing REF: p. 1264
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
43. The health care provider suggests surgery be performed for ventricular septal defect to
prevent what complication?
a. Pulmonary hypertension
b. Right-to-left shunt of blood
c. Pulmonary embolism
d. Left ventricular hypertrophy
ANS: A
Congenital heart defects with a large left-to-right shunt (e.g., in ventricular septal defect, patent
ductus arteriosus, or complete AV canal), which cause increased pulmonary blood flow, may
result in pulmonary hypertension. If these defects are not repaired early, the high pulmonary flow
will cause changes in the pulmonary artery vessels, and the vessels will lose their elasticity. The
blood does not shunt right to left, a pulmonary embolism is not a complication of ventricular
septal defect, and the left ventricle does not hypertrophy.
DIF: Cognitive Level: Analyzing REF: p. 1277 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
44. A 1-year-old has been admitted for complete repair of a tetralogy of Fallot. What assessment
finding should the nurse expect to be documented?
a. Weight gain
b. Pale skin color
c. Increasing cyanosis
d. Decrease in hemoglobin and hematocrit
ANS: C
Elective repair of tetralogy of Fallot is usually performed in the first year of life. Indications for
repair include increasing cyanosis and the development of hypercyanotic spells. The child would
not have a weight gain, pale skin color, or decrease in hemoglobin and hematocrit.
DIF: Cognitive Level: Analyzing REF: p. 1280
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
45. A 6-month-old infant presents to the clinic with failure to thrive, a history of frequent
respiratory infections, and increasing exhaustion during feedings. On physical examination, a
systolic murmur is detected, no central cyanosis, and chest radiography reveals cardiomegaly. An
echocardiogram is done that shows left-to-right shunting. This assessment data is characteristic
of what?
a. Tetralogy of Fallot
b. Coarctation of the aorta
c. Pulmonary stenosis
d. Ventricular septal defect
ANS: D
Heart failure is common with ventricular septal defect that causes failure to thrive, respiratory
infections, and an increase in exhaustion during feedings. There is a characteristic murmur. The
other defects do not have left-to-right shunting.
DIF: Cognitive Level: Analyzing REF: p. 1314
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
46. An infant is diagnosed with transposition of the great vessels. Prostaglandin E1 is given
intravenously. The parents ask how long the child will remain on the prostaglandin E1. What is
the appropriate response by the nurse?
a. Prostaglandin E1 will be given intermittently until corrective surgery is performed.
b. Prostaglandin E1 will be given continuously until corrective surgery is performed.
c.
Prostaglandin E1 will be given continuously throughout the preoperative and postoperative periods until the child is
stable.
d.
Prostaglandin E1 will be given intermittently throughout the preoperative and postoperative periods until the child is
stable.
ANS: B
To provide intracardiac mixing for a child with transposition of the great arteries, intravenous
prostaglandin E1 is administered continuously to keep the ductus arteriosus open to temporarily
increase blood mixing and provide an oxygen saturation of 75% or to maintain cardiac output
until surgery. It is discontinued after surgery.
DIF: Cognitive Level: Applying REF: p. 1273
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
47. What medication used to treat heart failure (HF) is a diuretic?
a. Captopril (Capten)
b. Digoxin (Lanoxin)
c. Hydrochlorothiazide (Diuril)
d. Carvedilol (Coreg)
ANS: C
Hydrochlorothiazide is a diuretic. Captopril is an ACE inhibitor, digoxin is a digital glycoside,
and carvedilol is a beta-blocker.
DIF: Cognitive Level: Analyzing REF: p. 1305
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
48. The nurse is preparing to give digoxin (Lanoxin) to a 9-month-old infant. The nurse checks
the dose and draws up 4 ml of the drug. The most appropriate nursing action is which?
a. Mix the dose with juice to disguise its taste.
b. Do not give the dose; suspect a dosage error.
c. Check the heart rate; administer digoxin if the rate is greater than 100 beats/min.
d. Check the heart rate; administer digoxin if the rate is greater than 80 beats/min.
ANS: B
Infants rarely receive more than 1 ml (50 mcg, or 0.05 mg) of digoxin in one dose; a higher dose
is an immediate warning of a dosage error. To ensure safety, compare the calculation with that of
another staff member before giving digoxin.
DIF: Cognitive Level: Applying REF: p. 1313
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
49. A 12-year-old child with Down syndrome is admitted to the hospital for surgical correction
of a heart defect. The boys mental age is that of a 3-year-old child. The nurse should prepare the
child and family for surgery by what method?
a. Extend preoperative teaching over several days.
b. Explain the surgery to the child and the parents in detail.
c. Exclude the child from preoperative teaching; teach only the parents.
d. Provide teaching to the parents, keeping the information to the child simple.
ANS: D
Important factors to consider in planning preparation strategies before cardiac surgery are the
childs cognitive developmental level, previous hospital experiences, temperament and coping
style, the timing of the preparation, and the involvement of the parents. The teaching should be
provided to the parents, keeping the information simple to the child with a mental age of 3 years
old.
DIF: Cognitive Level: Applying REF: p. 1277
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
50. Bacterial infective endocarditis (IE) should be treated with which protocol?
a. Oral antibiotics for 6 months
b. Oral antibiotics (penicillin) for 10 full days
c. IV antibiotics, diuretics, and digoxin
d. IV antibiotics (penicillin type) for 2 to 8 weeks
ANS: D
Treatment for IE includes the administration of high-dose antibiotics given intravenously for 2 to
8 weeks to completely eradicate the infecting microorganism.
DIF: Cognitive Level: Understanding REF: p. 1295 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
51. A child is recovering from Kawasaki disease (KD). The child should be monitored for
which?
a. Anemia
b. Electrocardiograph (ECG) changes
c. Elevated white blood cell count
d. Decreased platelets
ANS: B
The most serious complication of KD is the development of coronary artery aneurysms and the
potential for myocardial infarction in children with aneurysm formation. The nurse should
monitor any ECG changes.
DIF: Cognitive Level: Applying REF: p. 1299
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
52. The test that provides the most reliable evidence of recent streptococcal infection is which?
a. Throat culture
b. Mantoux test
c. Antistreptolysin O test
d. Elevation of liver enzymes
ANS: C
Antistreptolysin O (ASLO) titers measure the concentration of antibodies formed in the blood
against this product. Normally, the titers begin to rise about 7 days after onset of the infection
and reach maximum levels in 4 to 6 weeks. Therefore, a rising titer demonstrated by at least two
ASLO tests is the most reliable evidence of recent streptococcal infection.
DIF: Cognitive Level: Applying REF: p. 1297
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse is caring for a child with Kawasaki disease in the acute phase. What clinical
manifestations should the nurse expect to observe? (Select all that apply.)
a. Osler nodes
b. Cervical lymphadenopathy
c. Strawberry tongue
d. Chorea
e. Erythematous palms
f. Polyarthritis
ANS: B, C, E
Clinical manifestations of Kawasaki disease in the acute phase include cervical
lymphadenopathy, a strawberry tongue, and erythematous palms. Osler nodes are a clinical
manifestation of endocarditis. Chorea and polyarthritis are seen in rheumatic fever.
DIF: Cognitive Level: Applying REF: p. 1298
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. The nurse is caring for a child after cardiac surgery. What interventions should the nurse
implement with regard to chest tubes placed to a water-seal drainage system? (Select all that
apply.)
a. Maintain sterility.
b. Check for tube patency.
c. Do not interrupt the water-seal drainage system.
d. Clamp the chest tube when ambulating the child.
e. Measure the drainage by emptying the collection chamber every shift.
ANS: A, B, C
Nursing considerations with regard to chest tubes attached to a water-seal drainage system
include (1) do not interrupt water-seal drainage unless the chest tube is clamped, (2) check for
tube patency (fluctuation in the water-seal chamber), and (3) maintain sterility. The chest tube
should not be clamped when ambulating the child and the drainage is measured in the collection
chamber, not emptied.
DIF: Cognitive Level: Applying REF: p. 1315
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
3. The nurse is caring for a child with secondary hypertension. What renal disorders are
associated with secondary hypertension? (Select all that apply.)
a. Renal tumor
b. Hydronephrosis
c. Vesicoureteral reflux
d. Glomerulonephritis
e. Urinary tract infection
ANS: A, B, D
Renal disorders that can cause secondary hypertension include a renal tumor, hydronephrosis,
and glomerulonephritis. Vesicoureteral reflux or urinary tract infections do not cause secondary
hypertension.
DIF: Cognitive Level: Analyzing REF: p. 1303
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
4. The nurse is teaching an adolescent with hypertension foods recommended on the DASH diet.
What foods should the nurse include in the teaching session? (Select all that apply.)
a. Green beans
b. Energy drinks
c. Low-fat yogurt
d. Chocolate milk
e. Whole grain bread
ANS: A, C, E
The DASH diet provides a lower salt diet that has been associated with improvement in BP and
is believed to be beneficial for all patients with hypertension. DASH stands for Dietary
Approaches to Stop Hypertension. The DASH diet is plentiful in vegetables, fruits, whole grains,
and low-fat dairy products and low in sugar and salt. Energy drinks are high in sugar, and
chocolate milk is high in fat.
DIF: Cognitive Level: Applying REF: p. 1304
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
5. An adolescent is being placed on an ACE inhibitor. What should the nurse inform the
adolescent with regard to this medication? (Select all that apply.)
a. Stay well hydrated.
b. Increase intake of potassium.
c. Avoid rapid position changes.
d. Take the medication with meals.
e. Side effects may include a cough.
ANS: A, C, E
The adolescent should be instructed to stay well hydrated and avoid rapid position changes and
that side effects may include a cough when on ACE inhibitors. ACE inhibitors do not deplete
potassium, and they should be taken 1 hour before meals to increase absorption.
DIF: Cognitive Level: Applying REF: p. 1305
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
6. An adolescent is being placed on a beta-blocker. What should the nurse inform the adolescent
with regard to this medication? (Select all that apply.)
a. Medication may cause fatigue.
b. Side effects may include impotence.
c. Side effects may include bradycardia.
d. Take the medication 1 hour before meals.
e. Side effects may include peripheral edema.
ANS: A, B, C
The adolescent should be instructed that the medication may cause fatigue, impotence, and
bradycardia. The medications should be taken with meals and side effects do not include
peripheral edema.
DIF: Cognitive Level: Applying REF: p. 1305
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
7. An adolescent is being placed on a calcium channel blocker. What should the nurse inform the
adolescent with regard to this medication? (Select all that apply.)
a. The medication may cause fatigue.
b. The medication may increase heart rate.
c. The medication may cause constipation.
d. The medication may cause cold extremities.
e. The medication may cause peripheral edema.
ANS: B, C, E
Calcium channel blockers may cause an increase in heart rate, constipation, and peripheral
edema. Beta-blockers can cause fatigue and cold extremities, but calcium channel blockers do
not cause these potential side effects.
DIF: Cognitive Level: Applying REF: p. 1307
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
8. The nurse is teaching an adolescent with elevated triglycerides foods that should be decreased.
What foods should the nurse include in the teaching? (Select all that apply.)
a. Avocados
b. Canola oil
c. White flour
d. White rice
e. Sugary cereals
ANS: C, D, E
If triglycerides are elevated, dietary recommendations include decreasing the intake of foods
high in simple carbohydrates such as white flour, white rice, white bread, white pasta, sugary
cereals, juice, and soda. Avocados and canola oil have beneficial effects on HDL, which is the
good cholesterol.
DIF: Cognitive Level: Applying REF: p. 1309
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
9. What interventions should the nurse anticipate being administered to a child with
supraventricular tachycardia (SVT)?
a. Bed rest
b. Applying ice to the face
c. Administration of atropine
d. Administration of adenosine (Adenocor)
e. Having the child perform a Valsalva maneuver
ANS: B, D, E
The treatment of SVT depends on the degree of compromise imposed by the dysrhythmia. In
some instances, vagal maneuvers, such as applying ice to the face, massaging the carotid artery
(on one side of the neck only), or having an older child perform a Valsalva maneuver (e.g.,
exhaling against a closed glottis, blowing on the thumb as if it were a trumpet for 30 to 60
seconds), can reverse the SVT. When vagal maneuvers fail, adenosine may be used to end the
episode of SVT by impairing AV node conduction. IV adenosine is the first-line pharmacologic
measure for termination of SVT in infants and children in the emergency setting. Administration
of atropine or bed rest will not resolve SVT.
CH.30
1. The regulation of red blood cell (RBC) production is thought to be controlled by which
physiologic factor?
a. Hemoglobin
b. Tissue hypoxia
c. Reticulocyte count
d. Number of RBCs
ANS: B
Hemoglobin does not directly control RBC production. If there is insufficient hemoglobin to
adequately oxygenate the tissue, then erythropoietin may be released. When tissue hypoxia
occurs, the kidneys release erythropoietin into the bloodstream. This stimulates the marrow to
produce new RBCs. Reticulocytes are immature RBCs. The retic count can be used to monitor
hematopoiesis. The number of RBCs does not directly control production. In congenital cardiac
disorders with mixed blood flow or decreased pulmonary blood flow, RBC production continues
secondary to tissue hypoxia.
DIF: Cognitive Level: Understanding REF: p. 1324
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. What physiologic defect is responsible for causing anemia?
a. Increased blood viscosity
b. Depressed hematopoietic system
c. Presence of abnormal hemoglobin
d. Decreased oxygen-carrying capacity of blood
ANS: D
Anemia is a condition in which the number of red blood cells or hemoglobin concentration is
reduced below the normal values for age. This results in a decreased oxygen-carrying capacity of
blood. Increased blood viscosity is usually a function of too many cells or of dehydration, not of
anemia. A depressed hematopoietic system or abnormal hemoglobin can contribute to anemia,
but the definition depends on the decreased oxygen-carrying capacity of the blood.
DIF: Cognitive Level: Understanding REF: p. 1328
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
3. A mother states that she brought her child to the clinic because the 3-year-old girl was not
keeping up with her siblings. During physical assessment, the nurse notes that the child has pale
skin and conjunctiva and has muscle weakness. The hemoglobin on admission is 6.4 g/dl. After
notifying the practitioner of the results, what nursing priority intervention should occur next?
a. Reduce environmental stimulation to prevent seizures.
b. Have the laboratory repeat the analysis with a new specimen.
c. Minimize energy expenditure to decrease cardiac workload.
d. Administer intravenous fluids to correct the dehydration.
ANS: C
The child has a critically low hemoglobin value. The expected range is 11.5 to 15.5 g/dl. When
the oxygen-carrying capacity of the blood decreases slowly, the child is able to compensate by
increasing cardiac output. With the increasing workload of the heart, additional stress can lead to
cardiac failure. Reduction of environmental stimulation can help minimize energy expenditure,
but seizures are not a risk. A repeat hemoglobin analysis is not necessary. The child does not
have evidence of dehydration. If intravenous fluids are given, they can further dilute the
circulating blood volume and increase the strain on the heart.
DIF: Cognitive Level: Applying REF: p. 1329
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
4. A child with severe anemia requires a unit of red blood cells (RBCs). The nurse explains to the
child that the transfusion is necessary for which reason?
a. Allow her parents to come visit her.
b. Fight the infection that she now has.
c. Increase her energy so she will not be so tired.
d. Help her body stop bleeding by forming a clot (scab).
ANS: C
The indication for RBC transfusion is risk of cardiac decompensation. When the number of
circulating RBCs is increased, tissue hypoxia decreases, cardiac function is improved, and the
child will have more energy. Parental visiting is not dependent on transfusion. The decrease in
tissue hypoxia will minimize the risk of infection. There is no evidence that the child is currently
infected. Forming a clot is the function of platelets.
DIF: Cognitive Level: Applying REF: p. 1329
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
5. An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed
precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough. These
manifestations are most suggestive of what complication?
a. Air embolism
b. Allergic reaction
c. Hemolytic reaction
d. Circulatory overload
ANS: D
The signs of circulatory overload include distended neck veins, hypertension, crackles, a dry
cough, cyanosis, and precordial pain. Signs of air embolism are sudden difficulty breathing,
sharp pain in the chest, and apprehension. Urticaria, pruritus, flushing, asthmatic wheezing, and
laryngeal edema are signs and symptoms of allergic reactions. Hemolytic reactions are
characterized by chills, shaking, fever, pain at infusion site, nausea, vomiting, tightness in chest,
flank pain, red or black urine, and progressive signs of shock and renal failure.
DIF: Cognitive Level: Applying REF: p. 1332
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
6. What explanation provides the rationale for why iron-deficiency anemia is common during
infancy?
a. Cows milk is a poor source of iron.
b. Iron cannot be stored during fetal development.
c. Fetal iron stores are depleted by 1 month of age.
d. Dietary iron cannot be started until 12 months of age.
ANS: A
Children between the ages of 12 and 36 months are at risk for anemia because cows milk is a
major component of their diet, and it is a poor source of iron. Iron is stored during fetal
development, but the amount stored depends on maternal iron stores. Fetal iron stores are usually
depleted by ages 5 to 6 months. Dietary iron can be introduced by breastfeeding, iron-fortified
formula, and cereals during the first 12 months of life.
DIF: Cognitive Level: Analyzing REF: p. 1335
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
7. What statement best describes iron deficiency anemia in infants?
a. It is caused by depression of the hematopoietic system.
b. Diagnosis is easily made because of the infants emaciated appearance.
c. It results from a decreased intake of milk and the premature addition of solid foods.
d. Clinical manifestations are related to a reduction in the amount of oxygen available to tissues.
ANS: D
In iron-deficiency anemia, the childs clinical appearance is a result of the anemia, not the
underlying cause. Usually the hematopoietic system is not depressed. The bone marrow produces
red blood cells that are smaller and contain less hemoglobin than normal red blood cells.
Children who have iron deficiency from drinking excessive quantities of milk are usually pale
and overweight. They are receiving sufficient calories but are deficient in essential nutrients. The
clinical manifestations result from decreased intake of iron-fortified solid foods and an excessive
intake of milk.
DIF: Cognitive Level: Analyzing REF: p. 1335
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
8. What information should the nurse include when teaching the mother of a 9-month-old infant
about administering liquid iron preparations?
a. Give with meals.
b. Stop immediately if nausea and vomiting occur.
c. Adequate dosage will turn the stools a tarry green color.
d. Allow preparation to mix with saliva and bathe the teeth before swallowing.
ANS: C
The nurse should prepare the mother for the anticipated change in the childs stools. If the iron
dose is adequate, the stools will become a tarry green color. A lack of color change may indicate
insufficient iron. The iron should be given in two divided doses between meals when the
presence of free hydrochloric acid is greatest. Iron is absorbed best in an acidic environment.
Vomiting and diarrhea may occur with iron administration. If these occur, the iron should be
given with meals, and the dosage reduced and gradually increased as the child develops
tolerance. Liquid preparations of iron stain the teeth; they should be administered through a
straw and the mouth rinsed after administration.
DIF: Cognitive Level: Applying REF: p. 1338
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
9. Therapeutic management of a 6-year-old child with hereditary spherocytosis (HS) should
include which therapeutic intervention?
a. Perform a splenectomy.
b. Supplement the diet with calcium.
c. Institute a maintenance transfusion program.
d. Increase intake of iron-rich foods such as meat.
ANS: A
Splenectomy corrects the hemolysis that occurs in HS. The splenectomy is generally reserved for
children older than age 5 years with symptomatic anemia. Supplementation with calcium does
not affect the HS. Additional folic acid can prevent deficiency caused by the rapid cell turnover.
A maintenance transfusion program suppresses red blood cell formation. At this time, the risks of
transfusion are greater than those of a splenectomy. Iron supplementation does not influence the
course of HS.
DIF: Cognitive Level: Understanding REF: p. 1339
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
10. What condition occurs when the normal adult hemoglobin is partly or completely replaced by
abnormal hemoglobin?
a. Aplastic anemia
b. Sickle cell anemia
c. Thalassemia major
d. Iron deficiency anemia
ANS: B
Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which
normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a lack of
cellular elements being produced. Thalassemia major refers to a variety of inherited disorders
characterized by deficiencies in production of certain globulin chains. Iron-deficiency anemia
affects red blood cell size and depth of color but does not involve abnormal hemoglobin.
DIF: Cognitive Level: Understanding REF: p. 1339
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
11. The parents of a child with sickle cell anemia (SCA) are concerned about subsequent
children having the disease. What statement most accurately reflects inheritance of SCA?
a. SCA is not inherited.
b. All siblings will have SCA.
c. Each sibling has a 25% chance of having SCA.
d. There is a 50% chance of siblings having SCA.
ANS: C
SCA is inherited as an autosomal recessive disorder. In this inheritance pattern, each child born
to these parents has a 25% chance of having the disorder, a 25% chance of having neither SCA
nor the trait, and a 50% chance of being heterozygous for SCA (sickle cell trait). SCA is an
inherited hemoglobinopathy.
DIF: Cognitive Level: Analyzing REF: p. 1339
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
12. The clinical manifestations of sickle cell anemia (SCA) are primarily the result of which
physiologic alteration?
a. Decreased blood viscosity
b. Deficiency in coagulation
c. Increased red blood cell (RBC) destruction
d. Greater affinity for oxygen
ANS: C
The clinical features of SCA are primarily the result of increased RBC destruction and
obstruction caused by the sickle-shaped RBCs. When the sickle cells change shape, they increase
the viscosity in the area where they are involved in the microcirculation. SCA does not have a
coagulation deficit. Sickled red cells have decreased oxygen-carrying capacity and transform into
the sickle shape in conditions of low oxygen tension.
DIF: Cognitive Level: Analyzing REF: p. 1340
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
13. A school-age child is admitted in vasoocclusive sickle cell crisis (pain episode). The childs
care should include which therapeutic interventions?
a. Hydration and pain management
b. Oxygenation and factor VIII replacement
c. Electrolyte replacement and administration of heparin
d. Correction of alkalosis and reduction of energy expenditure
ANS: A
The management of crises includes adequate hydration, pain management, minimization of
energy expenditures, electrolyte replacement, and blood component therapy if indicated. Factor
VIII is not indicated in the treatment of vasoocclusive sickle cell crisis. Oxygen may prevent
further sickling, but it is not effective in reversing sickling because it cannot reach the clogged
blood vessels. Also, prolonged oxygen can reduce bone marrow activity. Heparin is not indicated
in the treatment of vasoocclusive sickle cell crisis. Electrolyte replacement should accompany
hydration. The acidosis will be corrected as the crisis is treated. Energy expenditure should be
minimized to improve oxygen utilization. Acidosis, not alkalosis, results from hypoxia, which
also promotes sickling.
DIF: Cognitive Level: Applying REF: p. 1343
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
14. A child with sickle cell anemia (SCA) develops severe chest and back pain, fever, a cough,
and dyspnea. What should be the first action by the nurse?
a. Administer 100% oxygen to relieve hypoxia.
b. Notify the practitioner because chest syndrome is suspected.
c. Infuse intravenous antibiotics as soon as cultures are obtained.
d. Give ordered pain medication to relieve symptoms of pain episode.
ANS: B
These are the symptoms of chest syndrome, which is a medical emergency. Notifying the
practitioner is the priority action. Oxygen may be indicated; however, it does not reverse the
sickling that has occurred. Antibiotics are not indicated initially. Pain medications may be
required, but evaluation by the practitioner is the priority.
DIF: Cognitive Level: Applying REF: p. 1348
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
15. In a child with sickle cell anemia (SCA), adequate hydration is essential to minimize sickling
and delay the vasoocclusion and hypoxiaischemia cycle. What information should the nurse
share with parents in a teaching plan?
a. Encourage drinking.
b. Keep accurate records of output.
c. Check for moist mucous membranes.
d. Monitor the concentration of the childs urine.
ANS: C
Children with SCA have impaired kidney function and cannot concentrate urine. Parents are
taught signs of dehydration and ways to minimize loss of fluid to the environment. Encouraging
drinking is not specific enough for parents. The nurse should give the parents and child a target
fluid amount for each 24-hour period. Accurate monitoring of output may not reflect the childs
fluid needs. Without the ability to concentrate urine, the child needs additional intake to
compensate. Dilute urine and specific gravity are not valid signs of hydration status in children
with SCA.
DIF: Cognitive Level: Applying REF: p. 1347
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
16. What statement best describes b-thalassemia major (Cooley anemia)?
a. It is an acquired hemolytic anemia.
b. Inadequate numbers of red blood cells (RBCs) are present.
c. Increased incidence occurs in families of Mediterranean extraction.
d. It commonly occurs in individuals from West Africa.
ANS: C
Individuals who live near the Mediterranean Sea and their descendants have the highest
incidence of thalassemia. Thalassemia is inherited as an autosomal recessive disorder. An
overproduction of RBCs occurs. Although numerous, the red blood cells are relatively unstable.
Sickle cell disease is common in blacks of West African descent.
DIF: Cognitive Level: Understanding REF: p. 1349
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
17. What therapeutic intervention is most appropriate for a child with b-thalassemia major?
a. Oxygen therapy
b. Supplemental iron
c. Adequate hydration
d. Frequent blood transfusions
ANS: D
The goal of medical management is to maintain sufficient hemoglobin (>9.5 g/dl) to prevent
bone marrow expansion. This is achieved through a long-term transfusion program. Oxygen
therapy and adequate hydration are not beneficial in the overall management of thalassemia. The
child does not require supplemental iron. Iron overload is a problem because of frequent blood
transfusions, decreased production of hemoglobin, and increased absorption from the
gastrointestinal tract.
DIF: Cognitive Level: Applying REF: p. 1349
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
18. Iron overload is a side effect of chronic transfusion therapy. What treatment assists in
minimizing this complication?
a. Magnetic therapy
b. Infusion of deferoxamine
c. Hemoglobin electrophoresis
d. Washing red blood cells (RBCs) to reduce iron
ANS: B
Deferoxamine infusions in combination with vitamin C allow the iron to remain in a more
chelatable form. The iron can then be excreted more easily. Use of magnets does not remove
additional iron from the body. Hemoglobin electrophoresis is used to confirm the diagnosis of
hemoglobinopathies; it does not affect iron overload. Washed RBCs remove white blood cells
and other proteins from the unit of blood; they do not affect the iron concentration.
DIF: Cognitive Level: Applying REF: p. 1353
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
19. In which condition are all the formed elements of the blood simultaneously depressed?
a. Aplastic anemia
b. Sickle cell anemia
c. Thalassemia major
d. Iron deficiency anemia
ANS: A
Aplastic anemia refers to a bone marrow failure condition in which the formed elements of the
blood are simultaneously depressed. Sickle cell anemia is a hemoglobinopathy in which normal
adult hemoglobin is partly or completely replaced by abnormal sickled hemoglobin. Thalassemia
major is a group of blood disorders characterized by deficiency in the production rate of specific
hemoglobin chains. Iron-deficiency anemia results in a decreased amount of circulating red cells.
DIF: Cognitive Level: Understanding REF: p. 1354
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
20. For children who do not have a matched sibling bone marrow donor, the therapeutic
management of aplastic anemia includes what intervention?
a. Antibiotics
b. Antiretroviral drugs
c. Iron supplementation
d. Immunosuppressive therapy
ANS: D
It is thought that aplastic anemia may be an autoimmune disease. Immunosuppressive therapy,
including antilymphocyte globulin, antithymocyte globulin, cyclosporine, granulocyte colony-
stimulating factor, and methylprednisone, has greatly improved the prognosis for patients with
aplastic anemia. Antibiotics are not indicated as the management. They may be indicated for
infections. Antiretroviral drugs and iron supplementation are not part of the therapy.
DIF: Cognitive Level: Applying REF: p. 1355 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
21. What statement is descriptive of most cases of hemophilia?
a. X-linked recessive deficiency of platelets causing prolonged bleeding
b. X-linked recessive inherited disorder in which a blood clotting factor is deficient
c. Autosomal dominant deficiency of a factor involved in the blood-clotting reaction
d. Y-linked recessive inherited disorder in which the red blood cells become moon shaped
ANS: B
The inheritance pattern in 80% of all the cases of hemophilia is X-linked recessive. The two most
common forms of the disorder are factor VIII deficiency (hemophilia A, or classic hemophilia)
and factor IX deficiency (hemophilia B, or Christmas disease). The disorder involves coagulation
factors, not platelets. The disorder does not involve red blood cells or the Y chromosome.
DIF: Cognitive Level: Understanding REF: p. 1357
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
22. The nurse is teaching the family of a child, age 8 years, with moderate hemophilia about
home care. What should the nurse tell the family to do to minimize joint injury?
a. Administer nonsteroidal anti-inflammatory drugs (NSAIDs).
b. Administer DDAVP (synthetic vasopressin).
c. Provide intravenous (IV) infusion of factor VIII concentrates.
d. Encourage elevation and application of ice to the involved joint.
ANS: C
Parents are taught home infusion of factor VIII concentrate. For moderate and severe hemophilia,
prompt IV administration is essential to prevent joint injury. NSAIDs are effective for pain relief.
They must be given with caution because they inhibit platelet aggregation. A factor VIII level of
30% is necessary to stop bleeding. DDAVP can raise the factor VIII level fourfold. Moderate
hemophilia is defined by a factor VIII activity of 4.9. A fourfold increase would not meet the
30% level. Ice and elevation are important adjunctive therapy, but factor VIII is necessary.
DIF: Cognitive Level: Applying REF: p. 1359
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
23. What condition is an acquired hemorrhagic disorder that is characterized by excessive
destruction of platelets?
a. Aplastic anemia
b. Thalassemia major
c. Idiopathic thrombocytopenic purpura
d. Disseminated intravascular coagulation
ANS: C
Idiopathic thrombocytopenic purpura is an acquired hemorrhagic disorder characterized by an
excessive destruction of platelets, discolorations caused by petechiae beneath the skin, and
normal bone marrow. Aplastic anemia refers to a bone marrow failure condition in which the
formed elements of the blood are simultaneously depressed. Thalassemia major is a group of
blood disorders characterized by deficiency in the production rate of specific hemoglobin chains.
Disseminated intravascular coagulation is characterized by diffuse fibrin deposition in the
microvasculature, consumption of coagulation factors, and endogenous generation of thrombin
and plasma.
DIF: Cognitive Level: Understanding REF: p. 1362
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
24. Care for the child with acute idiopathic thrombocytopenic purpura (ITP) includes which
therapeutic intervention?
a. Splenectomy
b. Intravenous administration of anti-D antibody
c. Use of nonsteroidal anti-inflammatory drugs (NSAIDs)
d. Helping child participate in sports
ANS: B
Anti-D antibody causes an increase in platelet count approximately 48 hours after administration.
Splenectomy is reserved for chronic severe ITP not responsive to pharmacologic management.
NSAIDs are not used in ITP. Both NSAIDs and aspirin interfere with platelet aggregation. The
nurse works with the child and parents to choose quiet activities while the platelet count is below
100,000/mm3.
DIF: Cognitive Level: Analyzing REF: p. 1362 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
25. A toddler is diagnosed with chronic benign neutropenia. The parents are being taught about
caring for their child. What information is important to include?
a. Avoid large indoor crowds and people who are ill.
b. Parenteral antibiotics are necessary to control disease.
c. Frequent rest periods are needed during the daytime.
d. List the side effects of corticosteroids used to decrease inflammation.
ANS: A
The parents are taught to minimize risk of infection by avoiding crowded areas and individuals
who are ill. Parents are also cautioned about when to notify their practitioner and administration
of granulocyte colony-stimulating factor, if indicated. Antibiotics are not needed unless the child
has an infection. The toddler does not need any additional rest as a result of the neutropenia.
Corticosteroids are not indicated.
DIF: Cognitive Level: Applying REF: p. 1365
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
26. The majority of children in the United States with human immunodeficiency virus (HIV)
infection acquired the disease by which means?
a. Through sexual contact
b. From a blood transfusion
c. By using intravenous (IV) drugs
d. Perinatally from their mothers
ANS: D
More than 90% of the children with HIV under 13 years who were reported to the Centers for
Disease Control and Prevention acquired the infection during the perinatal period. With
intervention, the number of children infected can be decreased. Sexual contact and IV drug use
are the leading causes of infection in the 14- to 19-year age group. This number is less than the
number of cases in the under 13-year age group. Transfusion has accounted for 3% to 6% of all
pediatric acquired immunodeficiency syndrome cases to date. Before 1985 and routine screening
of donated blood products, children with hemophilia were at great risk from pooled plasma
products.
DIF: Cognitive Level: Understanding REF: p. 1369
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
27. A young child with human immunodeficiency virus (HIV) is receiving several antiretroviral
drugs. What is the purpose of these drugs?
a. Cure the disease.
b. Delay disease progression.
c. Prevent spread of infection.
d. Treat Pneumocystis carinii pneumonia.
ANS: B
Although not a cure, these antiretroviral drugs can suppress viral replication, preventing further
deterioration of the immune system, and delay disease progression. At this time, cure is not
possible. Antiretroviral drugs do not prevent the spread of the disease. P. cariniiprophylaxis is
accomplished with antibiotics.
DIF: Cognitive Level: Understanding REF: p. 1370
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
28. The nurse is planning care for an adolescent with acquired immunodeficiency syndrome.
What is the priority nursing goal?
a. Prevent infection.
b. Prevent secondary cancers.
c. Identify source of infection.
d. Restore immunologic defenses.
ANS: A
As a result of the immunocompromise that is associated with human immunodeficiency virus
(HIV) infection, the prevention of infection is paramount. Although certain precautions are
justified in limiting exposure to infection, these must be balanced with the concern for the childs
normal developmental needs. Preventing secondary cancers is not currently possible. Case
finding is not a priority nursing goal in planning care for an individual. Current drug therapy is
affecting the disease progression; although not a cure, these drugs can suppress viral replication,
preventing further deterioration but not actually restoring immunologic defenses.
DIF: Cognitive Level: Applying REF: p. 1370 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
29. The school nurse is informed that a child with human immunodeficiency virus (HIV)
infection will be attending school soon. What is an important nursing intervention to include in
the plan of care?
a. Carefully follow universal precautions.
b. Inform the parents of the other children.
c. Determine how the child became infected.
d. Reassure other children that they will not become infected.
ANS: A
Universal precautions are necessary to prevent further transmission of the disease. Informing the
parents of the other children would violate the childs right to privacy. It is not within the role of
the school nurse to determine how the child became infected. Reassuring other children that they
will not become infected violates the childs privacy. General health classes can discuss
prevention of HIV transmission.
DIF: Cognitive Level: Applying REF: p. 1371
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
30. What condition is an inherited immunodeficiency disorder characterized by absence of both
humoral and cell-mediated immunity?
a. Fanconi syndrome
b. Wiskott-Aldrich syndrome
c. Acquired immunodeficiency syndrome (AIDS)
d. Severe combined immunodeficiency syndrome (SCIDS)
ANS: D
SCIDS is a genetic disorder that results in deficits of both humoral and cellular immunity.
Fanconi syndrome is a hereditary disorder of red blood cell production. Wiskott-Aldrich
syndrome is an X-linked recessive disorder with selected deficiencies of T and B lymphocytes.
AIDS is not inherited.
DIF: Cognitive Level: Understanding REF: p. 1373
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
31. The nurse is preparing a community outreach program about the prevention of iron-
deficiency anemia in infants. What statement should the nurse include in the program?
a. Whole milk can be introduced into the infants diet in small amounts at 6 months.
b. Iron supplements cannot be given until the infant is older than 1 year of age.
c. Iron-fortified cereal should be introduced to the infant at 2 months of age.
d. Breast milk or iron-fortified formula should be used for the first 12 months.
ANS: D
Prevention, the primary goal in iron-deficiency anemia, is achieved through optimal nutrition and
appropriate iron supplements. The American Academy of Pediatrics recommends feeding an
infant only breast milk or iron-fortified formula for the first 12 months of life. Whole cows milk
should not be introduced until after 12 months, iron supplements can be given during the first
year of life, and iron-fortified cereals should not be introduced until the infant is 4 to 6 months
old.
DIF: Cognitive Level: Applying REF: p. 1336
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
32. A 5-year-old child is admitted to the hospital in a sickle cell crisis. The child has been alert
and oriented but in severe pain. The nurse notes that the child is complaining of a headache and
is having unilateral hemiplegia. What action should the nurse implement?
a. Notify the health care provider.
b. Place the child on bed rest.
c. Administer a dose of hydrocodone (Vicodin).
d. Start O2 per the hospitals protocol.
ANS: A
Any number of neurologic symptoms can indicate a minor cerebral insult, such as headache,
aphasia, weakness, convulsions, visual disturbances, or unilateral hemiplegia. Loss of vision is
usually the result of progressive retinopathy and retinal detachment. The nurse should notify the
health care provider.
DIF: Cognitive Level: Applying REF: p. 1343
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
33. What pain medication is contraindicated in children with sickle cell disease (SCD)?
a. Meperidine (Demerol)
b. Hydrocodone (Vicodin)
c. Morphine sulfate
d. Ketorolac (Toradol)
ANS: A
Meperidine (pethidine [Demerol]) is not recommended. Normeperidine, a metabolite of
meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and
generalized seizures when it accumulates with repetitive dosing. Patients with SCD are
particularly at risk for normeperidine-induced seizures.
DIF: Cognitive Level: Analyzing REF: p. 1347
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
34. In anticipation of the admission of a child with hereditary spherocytosis (HS) who is
experiencing an aplastic crisis, what action should the nurse plan?
a. Secure an isolation room.
b. Prepare for a transfusion of packed red blood cells.
c. Anticipate preoperative preparation for a splenectomy.
d. Gather equipment and medication for treatment of shock.
ANS: B
In hereditary spherocytosis, aplastic crisis results in a sudden cessation of RBC production by the
bone marrow. Hemoglobin and hematocrit values drop rapidly, which results in severe anemia.
Transfusion support may be needed, and close monitoring of the childs cardiovascular status is
necessary. The nurse should prepare for a transfusion of packed red blood cells initially. An
isolation room is not needed, splenectomy would not be done at this time, and the child will not
be in shock.
DIF: Cognitive Level: Applying REF: p. 1338 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
35. A child with hemophilia A will have which abnormal laboratory result?
a. PT (ProTime)
b. Platelet count
c. Fibrinogen level
d. PTT (partial thromboplastin time)
ANS: D
The basic defect of hemophilia A is a deficiency of factor VIII. The partial thromboplastin time
measures abnormalities in the intrinsic pathway (abnormalities in factors I, II, V, VIII, IX, X,
XII, HMK, and KAL). The prothrombin time measures abnormalities of the extrinsic pathway
(abnormalities in factors I, II, V, VII, and X). Fibrinogen level is not dependent on the intrinsic
pathway. Platelets are not affected with hemophilia A.
DIF: Cognitive Level: Analyzing REF: p. 1356
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
36. A child with hemophilia A is scheduled for surgery. What precautions should the nurse
institute with this child?
a. Handle the child gently when transferring to a cart.
b. Caution the child not to brush his teeth before surgery.
c. Use tape sparingly on postoperative dressings.
d. Do not administer analgesics before surgery.
ANS: A
The goal of prevention of bleeding episodes is directed toward decreasing the risk of injury. The
child should be handled carefully when transferring to a cart. Brushing teeth, use of tape, and
giving analgesics will not risk a bleeding episode.
DIF: Cognitive Level: Applying REF: p. 1359 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
37. Nursing strategies to improve the growth and development of the child with human
immunodeficiency virus (HIV) infection should include what?
a. Provide only those foods that the child feels like eating.
b. Fortify foods with nutritional supplements to maximize quality of intake.
c. Weigh the child and measure height and muscle mass on a daily basis.
d. Provide high-fat and high-calorie meals and snacks to meet body requirements for growth.
ANS: B
HIV infection often leads to marked failure to thrive and multiple nutritional deficiencies.
Nutritional management may be difficult because of recurrent illness, diarrhea, and other
physical problems. The nurse should implement intensive nutritional interventions if the childs
growth begins to slow or weight begins to decrease. Fortifying foods with nutritional
supplements will maximize quality of intake. The child does not need to be weighed daily, and
high-fat meals and snacks should not be encouraged.
DIF: Cognitive Level: Applying REF: p. 1371 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
38. What medication is classified as an antiretroviral?
a. Dapsone (Aczone)
b. Pentamidine (Pentam)
c. Didanosine (Videx)
d. Trimethoprimsulfamethoxazole (Bactrim)
ANS: C
Classes of antiretroviral agents include nucleoside reverse transcriptase inhibitors (e.g.,
zidovudine, didanosine, stavudine, lamivudine, abacavir), nonnucleoside reverse transcriptase
inhibitors (e.g., nevirapine, delavirdine, efavirenz), and protease inhibitors (e.g., indinavir,
saquinavir, ritonavir, nelfinavir, amprenavir, lopinavir, ritonavir). Dapsone, pentamidine, and
Bactrim are anti-infectives.
DIF: Cognitive Level: Analyzing REF: p. 1370
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
39. The nurse is caring for a child with hemophilia A. The childs activity is as tolerated. What
activity is contraindicated for this child?
a. Ambulating to the cafeteria
b. Active range of motion
c. Ambulating to the playroom
d. Passive range of motion exercises
ANS: D
Passive range of motion exercises should never be part of an exercise regimen after an acute
episode because the joint capsule could easily be stretched and bleeding could recur. Active
range of motion exercises are best so that the patient can gauge his or her own pain tolerance.
The child can ambulate to the playroom or the cafeteria.
DIF: Cognitive Level: Applying REF: p. 1348 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
40. What condition precipitates polycythemia?
a. Dehydration
b. Severe infections
c. Immunosuppression
d. Prolonged tissue hypoxia
ANS: D
Oxygen transport depends on both the number of circulating RBCs and the amount of normal
hemoglobin in the cell. This explains why polycythemia (increase in the number of erythrocytes)
occurs in conditions characterized by prolonged tissue hypoxia, such as cyanotic heart defects.
Dehydration, severe infections, or immunosuppression will not precipitate polycythemia.
DIF: Cognitive Level: Understanding REF: p. 1324
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
41. The clinic nurse is evaluating lab results for a child. What recorded hemoglobin (Hgb) result
is considered within the normal range?
a. 9 g/dl
b. 10 g/dl
c. 11 g/dl
d. 12 g/dl
ANS: D
Normal hemoglobin (Hgb) determination is 11.5 to 15.5 g/dl.
DIF: Cognitive Level: Understanding REF: p. 1326
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
42. The clinic nurse is evaluating lab results for a child. What recorded hematocrit (Hct) result is
considered within the normal range?
a. 30%
b. 40%
c. 50%
d. 60%
ANS: B
Normal hematocrit (Hct) is 35% to 45%.
DIF: Cognitive Level: Understanding REF: p. 1326
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
43. The nurse is caring for a school-age child with severe anemia and activity intolerance. What
diversional activity should the nurse plan for this child?
a. Playing a musical instrument
b. Playing board or card games
c. Participating in a game of table tennis
d. Participating in decorating the hospital room
ANS: B
Plan diversional activities that promote rest but prevent boredom and withdrawal. Because short
attention span, irritability, and restlessness are common in anemia and increase stress demands
on the body, plan appropriate activities such as playing board or card games. Playing a musical
instrument, participating in a game of table tennis, or decorating the hospital room would cause
undue exertion.
DIF: Cognitive Level: Applying REF: p. 1331 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
44. The nurse is preparing to administer a unit of packed red blood cells to a hospitalized child.
What is an appropriate action that applies to administering blood?
a. Take the vital signs every 15 minutes while blood is infusing.
b. Use blood within 1 hour of its arrival from the blood bank.
c. Administer the blood with 5% glucose in a piggyback setup.
d. Administer the first 50 ml of blood slowly and stay with the child.
ANS: D
The nurse should administer the first 50 ml of blood or initial 20% of volume (whichever is
smaller) slowly and stay with the child. Vitals signs should be taken 15 minutes after initiation
and then every hour, not every 15 minutes. Blood should be used within 30 minutes, not 1 hour.
Normal saline, not 5% glucose, should be the IV solution.
DIF: Cognitive Level: Applying REF: p. 1334
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
45. What rationale explains why prolonged use of oxygen should be discouraged in a child with
anemia?
a. Prolonged use of oxygen can decrease erythropoiesis.
b. Prolonged use of oxygen can interfere with iron production.
c. Prolonged use of oxygen interferes with a childs appetite.
d. Prolonged use of oxygen can affect the synthesis of hemoglobin.
ANS: A
Oxygen administration is of limited value, because each gram of hemoglobin is able to carry a
limited amount of the gas. In addition, prolonged use of supplemental oxygen can decrease
erythropoiesis. Prolonged use of oxygen does not interfere with iron production, a childs
appetite, or affect the synthesis of hemoglobin.
DIF: Cognitive Level: Analyzing REF: p. 1348
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
46. The nurse is teaching a parent of an infant to limit the amount of formula to encourage the
intake of iron-rich food. What amount should the nurse teach to the parent?
a. 500 ml
b. 750 ml
c. 1000 ml
d. 1250 ml
ANS: C
The nurse should teach the parent to limit the amount of formula to no more than 1 1/day to
encourage intake of iron-rich solid foods.
DIF: Cognitive Level: Applying REF: p. 1336
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
47. A child with sickle cell disease is in a vasoocclusive crisis. What nonpharmacologic pain
intervention should the nurse plan?
a. Exercise as a distraction
b. Heat to the affected area
c. Elevation of the extremity
d. Cold compresses to the affected area
ANS: B
Frequently, heat to the affected area is soothing. Cold compresses are not applied to the area
because doing so enhances vasoconstriction and occlusion. Bed rest is usually well tolerated
during a crisis, although the actual rest obtained depends a great deal on pain alleviation and the
use of organized schedules of nursing care. Although the objective of bed rest is to minimize
oxygen consumption, some activity, particularly passive range of motion exercises, is beneficial
to promote circulation. Usually the best course is to let children determine their activity
tolerance. Elevating the extremity will not help in sickle cell disease.
DIF: Cognitive Level: Applying REF: p. 1348 TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
48. What immunoglobulin pattern does the nurse expect in a child recently diagnosed with
Wiskott-Aldrich syndrome?
a. Diminished levels of IgG
b. Diminished levels of IgA
c. Diminished levels of IgM
d. Diminished levels of IgE
ANS: C
The level of IgM is diminished early in the course of the disease, but levels of IgG, IgA, and IgE
may be elevated initially.
DIF: Cognitive Level: Analyzing REF: p. 1367
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
MULTIPLE RESPONSE
1. The nurse is caring for a 14-year-old child with disseminated intravascular coagulation (DIC).
What clinical manifestations should the nurse expect to observe? (Select all that apply.)
a. Petechiae
b. Chronic diarrhea
c. Hepatosplenomegaly
d. Bleeding from openings in the skin
e. Hypotension
f. Purpura
ANS: A, D, E, F
Some clinical manifestations of DIC are petechiae, bleeding from openings in the skin,
hypotension, and purpura. Hepatosplenomegaly and chronic diarrhea are clinical manifestations
of human immunodeficiency virus (HIV) infection in children.
DIF: Cognitive Level: Analyzing REF: p. 1364
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. What activity should the school nurse recommend for a child with hemophilia A? (Select all
that apply.)
a. Golf
b. Soccer
c. Rugby
d. Jogging
e. Swimming
ANS: A, D, E
Children and adolescents with severe hemophilia can participate in noncontact sports such as
swimming, golf, walking, jogging, fishing, and bowling. Contact sports such as football, boxing,
hockey, soccer, and rugby are strongly discouraged because the risk of injury outweighs the
physical and psychosocial benefits of participating in these sports.
DIF: Cognitive Level: Applying REF: p. 1360
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
3. What are signs and symptoms of anemia? (Select all that apply.)
a. Pallor
b. Fatigue
c. Dilute urine
d. Bradycardia
e. Muscle weakness
ANS: A, B, E
Signs and symptoms of anemia include, pallor, fatigue, and muscle weakness. Tachycardia, not
bradycardia, and dark urine, not dilute, are signs and symptoms of anemia.
DIF: Cognitive Level: Analyzing REF: p. 1329
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
4. The nurse is administering a unit of blood to a child. What are signs and symptoms of a
transfusion reaction? (Select all that apply.)
a. Chills
b. Shaking
c. Flank pain
d. Hypothermia
e. Sudden severe headache
ANS: A, B, C, E
Signs and symptoms of a transfusion reaction include chills, shaking, flank pain, and sudden
severe headache. Hyperthermia, not hypothermia, occurs.
DIF: Cognitive Level: Applying REF: p. 1332
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
5. The nurse is teaching parents of a child being discharged from the hospital after a splenectomy
about the risk of infection. What should the nurse include in the teaching session? (Select all that
apply.)
a. Avoid obtaining the pneumococcal vaccination for the child.
b. Avoid obtaining the meningococcal vaccination for the child.
c. The child should receive prophylactic penicillin for certain procedures.
d. Have the child immunized with the Haemophilus influenzae type b vaccination.
e. Notify the health care provider if your child develops a fever of 38.5 C (101.3 F).
ANS: C, D, E
Because of the risk of life-threatening bacterial infection after splenectomy, these children are
immunized with the pneumococcal, meningococcal, and H. influenzae type b vaccines before
surgery and receive prophylactic penicillin for several years after splenectomy. The parents
should be instructed in the importance of seeking immediate medical attention if their child
develops a fever of 38.5 C (101.3 F) or higher as a common sign of infection or postsplenectomy
sepsis.
DIF: Cognitive Level: Applying REF: p. 1339
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Health Promotion and Maintenance
6. The clinic nurse is evaluating causes for iron deficiency caused by inadequate supply of iron.
What should the nurse recognize as causes for iron deficiency caused by an inadequate iron
supply? (Select all that apply.)
a. Prematurity
b. Slow growth rate
c. Excessive milk intake
d. Severe iron deficiency in the mother
e. Exclusive breastfeeding of infant from birth to 3 months
ANS: A, C, D
Causes for iron deficiency caused by an inadequate supply of iron include prematurity, excessive
milk intake, and severe iron deficiency in the mother. Rapid growth rate, not slow, and exclusive
breastfeeding of infant after 6 months, not from birth to 3 months, can be causes of inadequate
supply of iron.
DIF: Cognitive Level: Analyzing REF: p. 1335
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
7. The clinic nurse is evaluating causes for iron deficiency due to impaired iron absorption. What
should the nurse recognize as causes for iron deficiency due to impaired iron absorption? (Select
all that apply.)
a. Gastric acidity
b. Chronic diarrhea
c. Lactose intolerance
d. Absence of phosphates
e. Inflammatory bowel disease
ANS: B, C, E
Causes for iron deficiency due to impaired iron absorption include chronic diarrhea, lactose
intolerance, and inflammatory bowel disease. Gastric alkalinity, not acidity, and the presence, not
absence, of phosphates can be causes of impaired iron absorption.
DIF: Cognitive Level: Analyzing REF: p. 1335
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
8. The nurse is preparing to admit a 1-month-old infant with severe congenital neutropenia
(Kostmann disease). What clinical features of severe congenital neutropenia should the nurse
recognize? (Select all that apply.)
a. Anemia is present.
b. Neutropenia is present.
c. The illness is severe.
d. It has a dominant inheritance pattern.
e. There are decreased eosinophils in the bone marrow.
ANS: B, C
The clinical features of severe congenital neutropenia include anemia and neutropenia, and the
illness is severe. It has an autosomal recessive inheritance pattern, and there are increased, not
decreased, eosinophils in the bone marrow.
DIF: Cognitive Level: Analyzing REF: p. 1365
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
9. The nurse is preparing to admit a 4-year-old child with chronic benign neutropenia. What
clinical features of chronic benign neutropenia should the nurse recognize? (Select all that
apply.)
a. Gingivitis is present.
b. Anemia is not present.
c. Monocytosis is present.
d. It has an autosomal recessive pattern.
e. Treatment is by bone marrow transplantation.
ANS: A, B, C
The clinical features of chronic benign neutropenia include gingivitis, no anemia, and
monocytosis. It is not inherited, and because it is benign, it does not require treatment except
antibiotics as indicated.
DIF: Cognitive Level: Analyzing REF: p. 1365
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
10. The nurse is caring for a 12-year-old child with b-thalassemia. What clinical manifestations
should the nurse expect to observe?(Select all that apply.)
a. Anorexia
b. Unexplained fever
c. Enlarged spleen or liver
d. Bronzed, freckled complexion
e. Precocious sexual development
ANS: A, B, C, D
The clinical manifestations of b-thalassemia include anorexia; unexplained fever; an enlarged
spleen or liver; and a bronzed, freckled complexion. There is delayed sexual maturation, not
precocious.
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.
