Test bank for Pediatric Nursing A Case Based Approach
1st Edition by Gannon Tagher and Lisa Knapp |
9781496394224 |Chapter 1-34 | All Chapters with
Answers and Rationals
An 18-Month-Old is discharged from the hospital after having a febrile seizure secondary to exanthem
subitum (Roseola). On discharge, the mother asks the nurse if her 6-year-old twins will get sick. Which
teaching about the transmission of roseola would be most accurate?
1. The child should be isolated at home until the vesicles have dried.
2. The child does not need to be isolated from the older siblings.
3. Administer acetaminophen to the older siblings to prevent seizures.
4. Monitor older children for seizure development. - ANSWER: . 2. The route of roseola transmission is
unkown, and the disease is more commonly seen in children 6 months to 3 years of age, so siblings do
not need to be isolated.
Which would be the priority intervention for a child suspected of having varicella (chickenpox)?
1. Contact Precautions
2. Contact and Droplet Respiratory Precautions?
3. Droplet respiratory precautions?
4. Universal Precautions and standard precautions. - ANSWER: 2. Varicella (Chickenpox) is highly
contagious. Contact & Droplet respiratory precautions should be started immediately because the
primary source of transmission is secretions of the respiratory tract (droplet) and also by
contaminated objects.
Caladryl - ANSWER: A lotion containing diphenhydramine. Should not be applied if child has already
been given benadryl (diphenhydramine) because it can cause toxicity.
Which s&s would the nurse expect with rheumatic fever?
1. Ankle and Knee Joint Pain.
2. Negative group A beta strep culture.
3. Large, red "bulls eye" - appearing rash.
4. stiff neck with photophobia. - ANSWER: Ankle and knee joint pain.
The parents of a 12-month old with HIV are concerned about him receiving routine immunizations.
What will the nurse tell them about immunizations? - ANSWER: "You are concerned about your child
receiving immunizations. Let me explain why your child will NOT receive routine immunizations
today"
The nurse acknowledges a client's fears and then discusses the concerns to clarify any
misconceptions. Immunizations and influenza vaccine are recommended to prevent infection.
Immunocompromised HIV-infected children should not receive MMR and varicella live vaccines.
Nursing Assessment suspects the newborn has cystic fibrosis. Which interventions would the nurse
begin.
1. Observe frequency and nature of stools.
2. Provide Chest PT
,3. Observe for weight gain.
4. Assess parent's compliance with fluid restrictions.
5. Assess respiratory system frequently. - ANSWER: 1 & 3
Cystic fibrosis is an inherited autsomal trait, causing exocrien gland dysfunction. 7-10% present
meconium ileus, so assessing stool frequency and consistency is important.
Assessing weight is important in newborns because they lose up to 10% of their birth weight, and can
take 2 weeks for them to regain their birth weight.
Assessing the newborn's respiratory system frequently would be monitored as frequently as other
infants if the newborn has no respiratory symptoms. Chest PT would not be initiated in a newborn
without a definitive diagnosis.
Can a mother breastfeed their infant if they have PKU? - ANSWER: Yes. Breast milk has low amounts
of phenylalanine, so the mother can breast as long as the infants phenylalanine level is monitored.
Vaccines given routinely at 15 months. - ANSWER: Hib & DTaP
Which priority intervention for the newborn of a mother positive for hepatitis antigen? - ANSWER:
The newborn should receive both hepatitis B vaccine and hepatitis B immune globulin within 12 hours
of birth to prevent hepatitis B infection.
signs of intussusception - ANSWER: bloody stools or "currant jelly stools", diarrhea, Large palpable
sausage shaped mass in the abdomen, abdominal distention, grunting, dehydration Fever, and pain
(legs pulled towards abdomen)!
Flat Ribbon Stools indicate - ANSWER: Hirschsprung Disease
Treatment for Intussusception - ANSWER: Barium or air enema
Nursing Care for Intussusception - ANSWER: Document I & O
Monitor for peritonitis & perforation
Monitor and record stools
Biggest complications of Intussusception - ANSWER: Peritonitis and Perforation
Risk factors for intussusception - ANSWER: Cystic Fibrosis
Ages 3 months to 3 years old.
Complication of Mal-Rotation & Valvolus - ANSWER: Pain related to rotation of intestines around the
mesenteric artery can cut off circulation, leading to potential septic intestinal necrosis.
Which pediatric GI disorder presents with green bilious vomiting? - ANSWER: Mal-Rotation and
Valvolus
GI disorders that present with bloody stools? - ANSWER: Mal-Rotation/Valvolus & Intussusception.
Obstructive GI disorders where a palpated sausage shaped mass is felt on the abdomen. - ANSWER:
Mal-Rotation and Valvolus. Symptoms for these disorders are similar but Mal-Rotation requires
surgical intervention.
Preoperative care for Mal-Rotation/Valvolus - ANSWER: Hydration, IV antibiotics, NG tube.
Post-Operative Care for Intussusception - ANSWER: Bowel sounds should return in four hours,
progressive diet, hydration.
, Priority nursing diagnosis for intussusception - ANSWER: Acute Pain!
Which response about safety measures is the most appropriate advice for the 2 year old's mother
who had her older home remodeled to reduce the lead level? Select all that apply.
1. Wash & dry the child's hands and face before he eats.
2. it is best to use cold water to prepate the child's food to decrease lead level.
3. diet does not matter in reduce lead levels in the child.
4. Drinking two cups of milk per day helps decrease lead levels. - ANSWER: 1 & 3. Washing and drying
hands and face especially before eating, decreases lead ingestion. Hot water absorbs more lead
readily than hot water. Diet does matter; regular meals, adequate iron and calcium, and less fat help
the child absorb less lead. Drinking 2 cups of milk per day is important for children but does not help
decrease lead level.
Which would the nurse explain to parents about the inheritance of cystic fibrosis?
1. The child of parents who are both carriers of the gene for CF has a 50% chance of acquiring CF.
2. The child of a mother who has CF and a father who is a carrier of the gene for CF has a 50% chance
of acquiring CF. - ANSWER: 2. If the child is born to a parent with CF and the other is a carrier, the
child has a 50% chance of acquiring the disease and 50% chance of being a carrier of the disease.
Number 1. is wrong. If a child is born to a parents who are both carriers of the CF gene, the child has a
25% chance of acquiring the disease and a 50% chance of being a carrier of the disease.
A 2 year old has just been diagnosed with CF. The parents ask the nurse what early respiratory
symptoms they should expect to see in their child. Which is the nurse's best response?
1. Barrel shaped chest
2. Chronic productive cough
3. bronchiectasis
4. wheezing - ANSWER: Wheezing respirations and a dry nonproductive cough are common early
symptoms of CF.
A barrel shaped chest is a long-term respiratory problem that occurs with recurrent hyperinflation. A
chronic productive cough is common as pulmonary damage increases. Bronchiectasis develops in
advanced stages of CF.
Test taking hint: "chronic: implies the disease process is advanced rather than in initial stages.
The parent of a child with Cystic Fibrosis (CF) asks the nurse what will be done to relieve the child's
constipation. Which is the nurse's best response?
1. Your child likely has an obstruction and will require surgery.
2. Your child will be given IV fluids.
3. Your child will be given MiraLAX
4. Your child will be placed on fluid restrictions. - ANSWER: 3. MiraLAX will be ordered.
IV fluids may be ordered if the client is NPO for any reason. however, IV fluids will not relieve the
constipation. CF patient's commonly receive stool softeners or osmotic solution orally to relieve their
constipation.
A school age child has been diagnosed with strep throat. The parent asks the RN when the child can
go back to school. Which is the nurse's best response? - ANSWER: Children with strep are no longer
contagious 24 hours after initiation of antibiotic therapy.
The RN is revieing discharge insturctuon with a parent of a child who has a tonsillectomy a few hours
ago. The parents tell the nurse that the child is a big eater, and they want to know what foods to give
their child for the next 24 hours. What is the nurses's best response?
1. no restrictions at all
2. clear liquids only
1st Edition by Gannon Tagher and Lisa Knapp |
9781496394224 |Chapter 1-34 | All Chapters with
Answers and Rationals
An 18-Month-Old is discharged from the hospital after having a febrile seizure secondary to exanthem
subitum (Roseola). On discharge, the mother asks the nurse if her 6-year-old twins will get sick. Which
teaching about the transmission of roseola would be most accurate?
1. The child should be isolated at home until the vesicles have dried.
2. The child does not need to be isolated from the older siblings.
3. Administer acetaminophen to the older siblings to prevent seizures.
4. Monitor older children for seizure development. - ANSWER: . 2. The route of roseola transmission is
unkown, and the disease is more commonly seen in children 6 months to 3 years of age, so siblings do
not need to be isolated.
Which would be the priority intervention for a child suspected of having varicella (chickenpox)?
1. Contact Precautions
2. Contact and Droplet Respiratory Precautions?
3. Droplet respiratory precautions?
4. Universal Precautions and standard precautions. - ANSWER: 2. Varicella (Chickenpox) is highly
contagious. Contact & Droplet respiratory precautions should be started immediately because the
primary source of transmission is secretions of the respiratory tract (droplet) and also by
contaminated objects.
Caladryl - ANSWER: A lotion containing diphenhydramine. Should not be applied if child has already
been given benadryl (diphenhydramine) because it can cause toxicity.
Which s&s would the nurse expect with rheumatic fever?
1. Ankle and Knee Joint Pain.
2. Negative group A beta strep culture.
3. Large, red "bulls eye" - appearing rash.
4. stiff neck with photophobia. - ANSWER: Ankle and knee joint pain.
The parents of a 12-month old with HIV are concerned about him receiving routine immunizations.
What will the nurse tell them about immunizations? - ANSWER: "You are concerned about your child
receiving immunizations. Let me explain why your child will NOT receive routine immunizations
today"
The nurse acknowledges a client's fears and then discusses the concerns to clarify any
misconceptions. Immunizations and influenza vaccine are recommended to prevent infection.
Immunocompromised HIV-infected children should not receive MMR and varicella live vaccines.
Nursing Assessment suspects the newborn has cystic fibrosis. Which interventions would the nurse
begin.
1. Observe frequency and nature of stools.
2. Provide Chest PT
,3. Observe for weight gain.
4. Assess parent's compliance with fluid restrictions.
5. Assess respiratory system frequently. - ANSWER: 1 & 3
Cystic fibrosis is an inherited autsomal trait, causing exocrien gland dysfunction. 7-10% present
meconium ileus, so assessing stool frequency and consistency is important.
Assessing weight is important in newborns because they lose up to 10% of their birth weight, and can
take 2 weeks for them to regain their birth weight.
Assessing the newborn's respiratory system frequently would be monitored as frequently as other
infants if the newborn has no respiratory symptoms. Chest PT would not be initiated in a newborn
without a definitive diagnosis.
Can a mother breastfeed their infant if they have PKU? - ANSWER: Yes. Breast milk has low amounts
of phenylalanine, so the mother can breast as long as the infants phenylalanine level is monitored.
Vaccines given routinely at 15 months. - ANSWER: Hib & DTaP
Which priority intervention for the newborn of a mother positive for hepatitis antigen? - ANSWER:
The newborn should receive both hepatitis B vaccine and hepatitis B immune globulin within 12 hours
of birth to prevent hepatitis B infection.
signs of intussusception - ANSWER: bloody stools or "currant jelly stools", diarrhea, Large palpable
sausage shaped mass in the abdomen, abdominal distention, grunting, dehydration Fever, and pain
(legs pulled towards abdomen)!
Flat Ribbon Stools indicate - ANSWER: Hirschsprung Disease
Treatment for Intussusception - ANSWER: Barium or air enema
Nursing Care for Intussusception - ANSWER: Document I & O
Monitor for peritonitis & perforation
Monitor and record stools
Biggest complications of Intussusception - ANSWER: Peritonitis and Perforation
Risk factors for intussusception - ANSWER: Cystic Fibrosis
Ages 3 months to 3 years old.
Complication of Mal-Rotation & Valvolus - ANSWER: Pain related to rotation of intestines around the
mesenteric artery can cut off circulation, leading to potential septic intestinal necrosis.
Which pediatric GI disorder presents with green bilious vomiting? - ANSWER: Mal-Rotation and
Valvolus
GI disorders that present with bloody stools? - ANSWER: Mal-Rotation/Valvolus & Intussusception.
Obstructive GI disorders where a palpated sausage shaped mass is felt on the abdomen. - ANSWER:
Mal-Rotation and Valvolus. Symptoms for these disorders are similar but Mal-Rotation requires
surgical intervention.
Preoperative care for Mal-Rotation/Valvolus - ANSWER: Hydration, IV antibiotics, NG tube.
Post-Operative Care for Intussusception - ANSWER: Bowel sounds should return in four hours,
progressive diet, hydration.
, Priority nursing diagnosis for intussusception - ANSWER: Acute Pain!
Which response about safety measures is the most appropriate advice for the 2 year old's mother
who had her older home remodeled to reduce the lead level? Select all that apply.
1. Wash & dry the child's hands and face before he eats.
2. it is best to use cold water to prepate the child's food to decrease lead level.
3. diet does not matter in reduce lead levels in the child.
4. Drinking two cups of milk per day helps decrease lead levels. - ANSWER: 1 & 3. Washing and drying
hands and face especially before eating, decreases lead ingestion. Hot water absorbs more lead
readily than hot water. Diet does matter; regular meals, adequate iron and calcium, and less fat help
the child absorb less lead. Drinking 2 cups of milk per day is important for children but does not help
decrease lead level.
Which would the nurse explain to parents about the inheritance of cystic fibrosis?
1. The child of parents who are both carriers of the gene for CF has a 50% chance of acquiring CF.
2. The child of a mother who has CF and a father who is a carrier of the gene for CF has a 50% chance
of acquiring CF. - ANSWER: 2. If the child is born to a parent with CF and the other is a carrier, the
child has a 50% chance of acquiring the disease and 50% chance of being a carrier of the disease.
Number 1. is wrong. If a child is born to a parents who are both carriers of the CF gene, the child has a
25% chance of acquiring the disease and a 50% chance of being a carrier of the disease.
A 2 year old has just been diagnosed with CF. The parents ask the nurse what early respiratory
symptoms they should expect to see in their child. Which is the nurse's best response?
1. Barrel shaped chest
2. Chronic productive cough
3. bronchiectasis
4. wheezing - ANSWER: Wheezing respirations and a dry nonproductive cough are common early
symptoms of CF.
A barrel shaped chest is a long-term respiratory problem that occurs with recurrent hyperinflation. A
chronic productive cough is common as pulmonary damage increases. Bronchiectasis develops in
advanced stages of CF.
Test taking hint: "chronic: implies the disease process is advanced rather than in initial stages.
The parent of a child with Cystic Fibrosis (CF) asks the nurse what will be done to relieve the child's
constipation. Which is the nurse's best response?
1. Your child likely has an obstruction and will require surgery.
2. Your child will be given IV fluids.
3. Your child will be given MiraLAX
4. Your child will be placed on fluid restrictions. - ANSWER: 3. MiraLAX will be ordered.
IV fluids may be ordered if the client is NPO for any reason. however, IV fluids will not relieve the
constipation. CF patient's commonly receive stool softeners or osmotic solution orally to relieve their
constipation.
A school age child has been diagnosed with strep throat. The parent asks the RN when the child can
go back to school. Which is the nurse's best response? - ANSWER: Children with strep are no longer
contagious 24 hours after initiation of antibiotic therapy.
The RN is revieing discharge insturctuon with a parent of a child who has a tonsillectomy a few hours
ago. The parents tell the nurse that the child is a big eater, and they want to know what foods to give
their child for the next 24 hours. What is the nurses's best response?
1. no restrictions at all
2. clear liquids only
