Developmental Concepts for Infants and Children: Critical Periods and Developmental Tasks, Exams of Pediatrics

Download Developmental Concepts for Infants and Children: Critical Periods and Developmental Tasks and more Exams Pediatrics in PDF only on Docsity! TEST BANK PEDIATRIC PHYSICAL EXAMINATION 3®° EDITION DUDERSTADT Physical =e salle isiolg Contents Chapter 1: Approach to Care and Assessment of Children and Adolescents .............................................................................. 3 MULTIPLE CHOICE ..................................................................................................................................................................... 3 MULTIPLE RESPONSE .............................................................................................................................................................. 14 OTHER .................................................................................................................................................................................... 15 Chapter 2. Physical Assessment Parameters ........................................................................................................................... 16 MULTIPLE CHOICE ................................................................................................................................................................... 16 MULTIPLE RESPONSE .............................................................................................................................................................. 26 Chapter 3. Developmental Surveillance and Screening ............................................................................................................ 28 MULTIPLE RESPONSE .......................................................................................................................................................... 33 Chapter 4. Comprehensive Health Gathering .......................................................................................................................... 36 Chapter 5. Environmental Health History ................................................................................................................................ 43 MULTIPLE RESPONSE .............................................................................................................................................................. 49 Chapter 6 Newborn Assessment ............................................................................................................................................. 50 Chapter 7. Skin ....................................................................................................................................................................... 64 MULTIPLE RESPONSE .............................................................................................................................................................. 72 Chapter 8. Heart and Vascular System.................................................................................................................................... 74 MULTIPLE RESPONSE .............................................................................................................................................................. 87 Chapter 9. Chest and Respiratory System ............................................................................................................................... 89 Chapter 10. Head and Neck .................................................................................................................................................. 108 A .......................................................................................................................................................................................... 108 B .......................................................................................................................................................................................... 108 C........................................................................................................................................................................................... 108 Feedback .............................................................................................................................................................................. 109 B .......................................................................................................................................................................................... 109 C........................................................................................................................................................................................... 109 D .......................................................................................................................................................................................... 109 A .......................................................................................................................................................................................... 110 Feedback .............................................................................................................................................................................. 110 D .......................................................................................................................................................................................... 110 Feedback .............................................................................................................................................................................. 110 Feedback .............................................................................................................................................................................. 111 Feedback .............................................................................................................................................................................. 111 Feedback .............................................................................................................................................................................. 112 Feedback .............................................................................................................................................................................. 112 Feedback .............................................................................................................................................................................. 112 DIncorrect. Swelling over the occipitoparietal region of the skull is not called parietus sepitus. Chapter 11. Lymphatic System ............................................................................................................................................................................................. 113 Critical periods are blocks of time during which children are ready to master specific developmental tasks. Children can master these tasks more easily during particular periods of time in their growth and developmental process. Infancy is a dynamic time of development that requires frequent evaluations to assess appropriate developmental progress. Infants in a nurturing environment will develop appropriately and will not necessarily need stimulation specific to their developmental stage. Normal growth and development are orderly and proceed in a predictable pattern on the basis of each individuals abilities and potentials. 3. Which factor has the greatest influence on child growth and development? a. Culture b. Environment c. Genetics d. Nutrition ANS: C Genetic factors (heredity) determine each individuals growth and developmental rate. Although factors such as environment, culture, nutrition, and family can influence genetic traits, they do not eliminate the effect of the genetic endowment, which is permanent. Culture is a significant factor that influences how children grow toward adulthood. Culture influences both growth and development but does not eliminate inborn genetic influences. Environment has a significant role in determining growth and development both before and after birth. The environment can influence how and to which extent genetic traits are manifested, but environmental factors cannot eliminate the effect of genetics. Nutrition is critical for growth and plays a significant role throughout childhood. 4. A nurse is planning a teaching session with a child. According to Piagetian theory, the period of cognitive development in which the child is able to distinguish fact from fantasy is the period of cognitive development. a. sensorimotor b. formal operations c. concrete operations d. preoperational ANS: C Concrete operations is the period of cognitive development in which childrens thinking is shifted from egocentric to being able to see anothers point of view. They develop the ability to distinguish fact from fantasy. The sensorimotor stage occurs in infancy and is a period of reflexive behavior. During this period, the infants world becomes more permanent and organized. The stage ends with the infant demonstrating some evidence of reasoning. Formal operations is a period in development in which new ideas are created through previous thoughts. Analytic reason and abstract thought emerge in this period. The preoperational stage is a period of egocentrism in which the childs judgments are illogical and dominated by magical thinking and animism. 5. The theorist who viewed developmental progression as a lifelong series of conflicts that need resolution is: a. Erikson. b. Freud. c. Kohlberg. d. Piaget. ANS: A Erik Erikson viewed development as a series of conflicts affected by social and cultural factors. Each conflict must be resolved for the child to progress emotionally, with unsuccessful resolution leaving the child emotionally disabled. Sigmund Freud proposed a psychosexual theory of development in which certain parts of the body assume psychological significance as foci of sexual energy. The foci shift as the individual moves through the different stages (oral, anal, phallic, latency, and genital) of development. Lawrence Kohlberg described moral development as having three levels (preconventional, conventional, and postconventional). His theory closely parallels Piagets. Jean Piagets cognitive theory interprets how children learn and think and how this thinking progresses and differs from adult thinking. Stages of his theory include sensorimotor, preoperations, concrete operations, and formal operations. 6. What does the nurse need to know when observing chronically ill children at play? a. Play is not important to hospitalized children. b. Children need to have structured play periods. c. Childrens play is an indication of a childs response to treatment. d. Play is to be discouraged because it tires hospitalized children. ANS: C Play for all children is an activity woven with meaning and purpose and is a mechanism for mastering their environment. For chronically ill children, play can indicate their state of wellness and response to treatment. Play is important to all children in all environments. Although childrens play activities appear unorganized and at times chaotic, play has purpose and meaning. Imposing structure on play interferes with the tasks being worked on. Children who have fewer energy reserves still require play. For these children, less-active play activities will be important. 7. Which child is most likely to be frightened by hospitalization? a. A 4-month-old infant admitted with a diagnosis of bronchiolitis b. A 2-year-old toddler admitted for cystic fibrosis c. A 9-year-old child hospitalized with a fractured femur d. A 15-year-old adolescent admitted for abdominal pain ANS: B Toddlers are most likely to be frightened by hospitalization because their thought processes are egocentric, magical, and illogical. They feel very threatened by unfamiliar people and strange environments. Young infants are not as likely to be frightened as toddlers by hospitalization because they are not as aware of the environment. The 9-year-old childs cognitive ability is c. The child is able to pronounce consonants clearly. d. The child uses language to express abstract thought. ANS: B The 4-year-old child is able to use correct grammar in sentence structure and typically has difficulty in pronouncing consonants. Simple sentences and a 300-word vocabulary are appropriate for a 2-year-old child. The use of language to express abstract thought is developmentally appropriate for the adolescent. 12. Which should the nurse evaluate before administering the Denver Developmental Screening Test II (DDST-II)? a. The childs height and weight b. The parents ability to comprehend the results c. The childs mood d. The parentchild interaction ANS: C The results of the screening test are valid if the child acted in a normal and expected manner. The childs height and weight are not relevant to the DDST-II screening process. The parents ability to understand the results of the screening is not relevant to the validity of the test. The parentchild interaction is not significantly relevant to the test results. 13. Which children are at greater risk for not receiving immunizations? a. Children who attend licensed day care programs b. Children entering school c. Children who are home schooled d. Young adults entering college ANS: C Home schooled children are at risk for being underimmunized and need to be monitored. All states require immunizations for children in day care programs and entering school. Most colleges require a record of immunizations as part of a health history. 14. Which developmental assessment instrument is appropriate to assess a 5-year-old child? a. Brazelton Behavioral Scale b. Denver Developmental Screening Test II (DDST-II) c. Dubowitz Scale d. New Ballard Scale ANS: B The DDST-II is used for infants and children between birth and 6 years of age. Brazeltons Behavioral Scale is used for newborn assessment. The Dubowitz Scale is used for estimation of gestational age. The New Ballard Scale is used for newborn screening. 15. A 2-month-old child has not received any immunizations. Which immunizations should the nurse give? a. DTaP, Hib, HepB, IPV, varicella b. DTaP, Hib, HepB, MMR, IPV c. DTaP, Hib, HepB, PCV, IPV, rotavirus d. DTaP, Hib, HepB, PCV, IPV, HepA ANS: C DTaP, Hib, HepB, PCV, IPV, and rotavirus are appropriate immunizations for an unimmunized 2-month-old child. The child should not receive varicella until at or after 12 months of age. MMR is not given to children until at or after 12 months of age. HepA is recommended for all children at 1 year of age. 16. You are preparing immunizations for a 12-month-old child who is immunocompromised. Which immunization cannot be given? a. DTaP b. HepA c. IPV d. Varicella ANS: D Children who are immunologically compromised should not receive live viral vaccines. Varicella is a live vaccine, and should not be given except in special circumstances. DTaP, HepA, and IPV can be safely given. 17. Which immunization can cause fever and rash to occur 1 to 2 weeks after administration? a. HepB b. DTaP c. Hib d. MMR ANS: D MMR is a live virus vaccine and can cause fever and rash 1 to 2 weeks after administration. HepB, DTaP, and Hib do not cause fever or rash. 18. A nurse is teaching an adolescent about Tanner stages. Which statement best describes Tanner staging? a. Predictable stages of puberty that are based on chronological age b. Staging of puberty based on the initiation of menarche and nocturnal emissions c. Predictable stages of puberty that are based on primary and secondary sexual characteristics d. Staging of puberty based on the initiation of primary sexual characteristics ANS: C typically does not decrease rebelliousness or increase feelings of security. Increasing peer involvement does not typically increase self-esteem. Allowing teenagers to choose the method of discipline is not realistic and typically does not reduce rebelliousness. MULTIPLE RESPONSE 1. The nurse is preparing immunizations for a healthy 11-year-old boy who has received all his primary immunizations. Which immunizations will the nurse consider? Select all that apply. a. Meningococcal b. DTaP c. OPV d. Smallpox ANS: A, B Meningococcal conjugate vaccine should be given to all children at age 11 to 12 years. The American Academy of Pediatrics recommends one dose of DTaP vaccine for children at age 11 to 12 years, as long as they have received the primary DTaP series. Oral polio vaccine is no longer administered in the U.S. The current smallpox vaccine is not recommended for healthy, low-risk children younger than 18 years of age. 2. Parents of a 4-month-old child ask the nurse what they can do to help relieve the discomfort of teething. The nurse should include which suggestions for the parents? Select all that apply. a. Provide warm liquids. b. Rub the gums with aspirin. c. Over-the-counter topical medications for gum pain relief can be used as directed. d. Administer acetaminophen (Tylenol) as directed. e. Provide a hard food such as a frozen bagel for chewing. ANS: C, D, E To help parents cope with teething, nurses can suggest that they provide cool liquids and hard foods (e.g., dry toast, Popsicles, frozen bagels) for chewing. Hard, cold teethers and ice wrapped in cloth may also provide comfort for inflamed gums. Nurses should explain to parents that over- the-counter topical medications for gum pain relief should be used only as directed. Home remedies, such as rubbing the gums with whiskey or aspirin, should be discouraged, but acetaminophen administered as directed for the childs age can relieve discomfort. OTHER 1. Place in order the gross motor developmental milestones a nurse expects to assess in an infant. Begin with the earliest gross motor milestone expected and progress to the last gross motor milestone attained. a. Turns from abdomen to back b. Lifts head off of bed when in a prone position c. Walks holding on to furniture d. Turns from back to abdomen e. Sits unsupported ANS: B, A, D, E, C The infant lifts its head off of the bed when in a prone position at 3 months, turns from abdomen to back at 4 to 5 months, turns from back to abdomen at 6 to 7 months, sits unsupported at 8 to 9 months, and can walk holding on to furniture at 10 to 12 months. Chapter 2. Physical Assessment Parameters MULTIPLE CHOICE 1. The nurse is performing an abdominal assessment on a child. When percussing over the stomach, the nurse should hear which sound? a. Tympany b. Resonance c. Flatness d. Dullness ANS: A Tympany is a high-pitched, loud-intensity sound heard over air-filled body parts such as the stomach and bowel. Resonance is a low-pitched, low-intensity sound elicited over hollow organs such as the lungs. Flatness is a high-pitched, soft-intensity sound elicited by percussing over solid masses such as bone or muscle. Dullness is a medium-pitched, medium-intensity sound elicited when percussing over high-density structures such as the liver. 2. A nurse is preparing to begin an assessment on a newly admitted child. The nurse should be aware that the single most important component of a pediatric physical examination is: a. assessment of heart and lungs. b. measurement of height and weight. c. documentation of parental concerns. d. obtaining an accurate history. ANS: D An accurate history is most helpful in identifying problems and potential problems. Heart and lung assessment and documentation of parental concerns are not as important as an accurate history. A single measurement of height and weight is not as significant as determining growth over time. The childs growth pattern can be elicited from the history. 7. A nurse is teaching unlicensed assistive personnel (UAP) how to take accurate blood pressure on children. The nurse knows the UAPs have understood the teaching if they state that to obtain an accurate measurement of a childs blood pressure, the cuff should cover which portion of the childs upper arm? a. Two-thirds b. Three-fourths c. One-half d. One-third ANS: A The blood pressure cuff should cover two-thirds of the childs upper arm to get an accurate reading. A cuff that covers more than two-thirds of the childs upper arm will result in a false low reading. A cuff that covers less than two-thirds of the childs upper arm will result in a false high reading. 8. Which chart should the nurse use to assess the visual acuity of an 8-year-old child? a. Lea chart b. Snellen chart c. HOTV chart d. Tumbling E chart ANS: B The Snellen chart is used to assess the vision of children older than 6 years of age. The Lea chart tests vision using four different symbols designed for use with preschool children. The HOTV chart tests vision by using graduated letters and is designed for use with children ages 3 to 6 years. The Tumbling E chart uses the letter E in various directions and is designed for use with children ages 3 to 6 years. 9. Which action is appropriate when the nurse is assessing breath sounds of an 18-month- old crying child? a. Ask the parent to quiet the child so the nurse can listen. b. Auscultate breath sounds and chart that the child was crying. c. Encourage the child to play with the stethoscope to distract and to calm down the child before auscultating. d. Document that data are not available because of noncompliance. ANS: C Distracting the child with an interesting activity can assist the child to calm down so an accurate assessment can be made. Asking a parent to quiet the child may or may not work. Auscultating while the child is crying typically results in less than optimal data. Documenting that the child is not compliant is not appropriate. An assessment needs to be completed. 10. Which is the most appropriate site for the nurse to use to measure a pulse rate on a 1-year- old child? a. Apical b. Radial c. Carotid d. Femoral ANS: A Apical pulse rates are taken in children younger than 2 years. Radial pulse rates may be taken in children older than 2 years. It is difficult to palpate the carotid pulse in an infant. The femoral pulse is palpated when comparing peripheral pulses, but it is not used to measure an infants pulse rate. 11. What is the most appropriate action for the nurse to take when a crying toddler has a blood pressure measurement of 120/70 mm Hg? a. Notify the physician of the measurement. b. Document the blood pressure reading and check it again in 4 hours. c. Quiet the child and retake the blood pressure. d. Ask the parent if the child has a history of hypertension. ANS: C Blood pressure is elevated when a child is upset and crying. Quieting the child before retaking the blood pressure is appropriate. Notifying the physician is not necessary until accurate data are obtained. Documenting the blood pressure and waiting 4 hours before taking another measurement is inappropriate because this reading is not within the normal range. Asking the parent about a history of hypertension is irrelevant when a child is upset and crying as blood pressure is elevated. 12. What term should be used in the nurses documentation to describe auscultation of breath sounds that are short, popping, and discontinuous on inspiration? a. Pleural friction rub b. Bronchovesicular sounds c. Crackles d. Wheeze ANS: C Crackles are short, popping, discontinuous sounds heard on inspiration. A pleural friction rub has a grating, coarse, low-pitched sound. Bronchovesicular sounds are auscultated over mainstem bronchi. They are clear, without any adventitious sounds. Wheezes are musical, high-pitched, predominant sounds heard on expiration. 13. Which strategy should be the best approach when initiating the physical examination of a 9- month-old infant? a. Undress the infant and do a head-to-toe examination. d. Head circumference ANS: D Head circumference is measured on all children from birth to 3 years. Blood pressure measurements are taken on all children at every ambulatory visit. Weight and height are measured at every well-child examination. 18. The nurse inspecting the skin of a dark-skinned child notices an area that is a dusky red or violet color. This skin coloration is associated with which? a. Cyanosis b. Erythema c. Vitiligo d. Nevi ANS: B In dark-skinned children, erythema appears as dusky red or violet skin coloration. Cyanosis in a dark-skinned child would appear as a black coloration of the skin. Vitiligo refers to areas of depigmentation. Nevi are areas of increased pigmentation. 19. The nurse palpated the anterior fontanel of a 14-month-old infant and found that it was closed. What would this finding indicate? a. This is a normal finding. b. This finding indicates premature closure of cranial sutures. c. This is an abnormal finding and the child should have a developmental evaluation. d. This is an abnormal finding and the child should have a neurological evaluation. ANS: A The anterior fontanel should be completely closed by 12 to 18 months of age. A closed anterior fontanel at 14 months of age does not indicate premature closure of cranial sutures, is not abnormal, and does not indicate the need for a neurological examination. 20. A nurse is conducting vision screening on preschool children. Which of the following corresponds with the normal range for visual acuity of a 4-year-old child? a. 20/50 to 20/80 b. 20/40 to 20/70 c. 20/30 to 20/40 d. 20/20 to 20/30 ANS: C 20/30 to 20/40 is the normal range for visual acuity at 4 years of age. 20/50 to 20/80 is the normal range for visual acuity at 4 months of age. 20/40 to 20/70 is the normal range for visual acuity at 1 year of age. 20/20 to 20/30 is the normal range for visual acuity at 5 years of age. 21. A child begins to squirm and giggle when the nurse begins to palpate the abdomen. What is the best approach for the nurse to use with a child who is ticklish? a. Skip the abdominal palpation. b. Touch the abdomen firmly as the child takes short, quick breaths. c. Press the abdomen with the child bearing down and holding the breath. d. Palpate with the childs hand under the examiners hand. ANS: D Placing the childs hand on the abdomen and the examiners hand on top of the childs hand with fingers touching the abdomen gives the child some control and reduces the sensation of tickling. Abdominal palpation should not be eliminated from the physical assessment. To help the child relax, the nurse would ask the child to take deep breaths. Bearing down and holding the breath would tighten the abdominal muscles. 22. Which cranial nerve is assessed when the child is asked to imitate the examiners wrinkled frown, wrinkled forehead, smile, and raised eyebrow? a. Accessory b. Hypoglossal c. Trigeminal d. Facial ANS: D The facial nerve is assessed as described in the question. To assess the accessory nerve, the examiner palpates and notes the strength of the trapezius and sternocleidomastoid muscles against resistance. To assess the hypoglossal nerve, the examiner asks the child to stick out the tongue. To assess the trigeminal nerve, the child is asked to identify a wisp of cotton on the face. The corneal reflex and temporal and masseter muscle strength are evaluated. 23. Which assessment finding is considered a neurological soft sign in a 7-year-old child? a. Plantar reflex b. Poor muscle coordination c. Stereognostic function d. Graphesthesia ANS: B Poor muscle coordination is a neurological soft sign. The plantar reflex is a normal response. When the lateral aspect of the sole of the foot is stroked in a movement curving medially from the heel to the ball, the response will be plantar flexion of the toes. Stereognostic function refers to the ability to identify familiar objects placed in each hand. Graphesthesia is the ability to identify letters or numbers traced on the palm or back of the hand with a blunt point. MULTIPLE RESPONSE the muscles of respiration. 3. The temperature of a patient is measured every 6 hours at 6 AM, 12 PM, 6 PM, and 12 AM. Which temperature reading is expected to be low due to a normal variation? a. The measurement at 6 AM b. The measurement at 12 PM c. The measurement at 6 PM d. The measurement at 12 AM ANS: A Feedback A Early in the morning is the time of the lowest temperature of the day due to circadian rhythms. B A low temperature due to circadian rhythms is not expected at this time. C The highest temperature occurs in the late afternoon and early evening due to circadian rhythms. D A low temperature due to circadian rhythms is not expected at this time. 4. Which statement is correct regarding taking or interpreting axillary temperatures? a. Axillary temperatures should not be used in patients less than 2 years of age. b. Readings may be less accurate. c. The thermometer is left in place for no more than 3 minutes. d. The thermometer is placed in the axilla with the shoulder abducted. ANS: B Feedback A The axilla is a common site for temperature measurement on infants and children. B Multiple studies have shown temperature measurements at the axillary site are less accurate compared with alternative sites. C The thermometer is left in place until the audible signal occurs and the temperature appears on the screen. D Place the probe in the middle of the axilla, with the arm held against the body (adducted). 5. A temperature of 99.8 F taken in the axilla is equivalent to which temperature value taken orally? a. 100.8 F b. 99.8 F c. 98.8 F d. 97.8 F ANS: A Feedback A Normal temperature readings from the axilla are about 1 F below the normal oral temperature. B Normal temperature readings from the axilla are about 1 F below the normal oral temperature. C Normal temperature readings from the axilla are about 1 F below the normal oral temperature. D Normal temperature readings from the axilla are about 1 F below the normal oral temperature. 6. The nurse suspects an irregularity in the rhythm of the patients radial pulse. What is the most appropriate action for this nurse to take at this time? a. Document this rhythm as normal for the patient. b. Use a Doppler to check the brachial pulse. c. Count the patients apical pulse for a full minute. d. Count the radial pulse again for 15 seconds and multiply by 4. ANS: C Feedback A An irregular rhythm is not a normal finding. The pulsation between each beat should be the same or regular. B A Doppler is not indicated in this case; it is used when the pulse cannot be palpated. C When an irregular pulse is palpated, the nurse counts the number of pulsations for a full minute. D Counting the radial pulse again for 15 seconds and multiplying by 4 may reconfirm the initial findings, but does not provide additional data for the nurse on this patient. 7. The patient with a respiratory rate that is within normal limits is the whose respiratory rate is breaths/min. a. 16-month-old; 36 b. 6-year-old; 20 c. 14-year-old;26 d. 40-year-old; 10 ANS: B Feedback A A toddlers respiratory rate ranges from 24 to 32. B A school-age childs respiratory rate ranges from 18 to 26. C An adolescents respiratory rate ranges from 12 to 16. D An adults respiratory rate ranges from 12 to 20. 8. A nurse is taking vital signs of an adult patient whose oxygen saturation is 96%. The patients temperature is 102 F, blood pressure is 130/86, pulse is 100 beats/min, and respiratory rate is 26 breaths/min. Which factor may be contributing to the elevated respiratory rate? a. The patients temperature b. The patients oxygen saturation c. The patients pulse rate d. The patients blood pressure ANS: A Feedback A Fever is a factor that may increase respiratory rate, and this patients temperature is 102 F. B The patients oxygen saturation is a measure of the oxygen carried by hemoglobin and it is within expected limitsabove 90%. C The patients pulse rate may be due to the high temperature, but a pulse of 100 does not contribute to an elevated respiratory rate in this case. D The patients blood pressure is higher than normal, but does not contribute to an elevated respiratory rate in this case. 9. Nurses understand that a patients diastolic pressure represents which physiologic function? a. The pressure needed to open the aortic and pulmonic valves b. The pressure in blood vessels when the ventricles contract c. Tympanic temperature d. Rectal temperature e. Temporal artery temperature ANS: B, E Correct: Inner core temperature is measured indirectly because the probe is placed near an artery. For oral temperature, the probe is placed near the carotid artery and the temporal artery is used for the temporal artery temperature. Incorrect: For axillary, tympanic, and rectal temperatures, the probe is not placed close to any major blood vessels. 2. Which method of temperature measurement does a nurse choose when assessing children? Select all that apply. a. Axillary temperature b. Rectal temperature c. Temporal artery temperature d. Oral temperature e. Tympanic membrane temperature ANS: A, C, D, E Correct: Axillary, temporal artery, oral, and tympanic membrane temperatures are appropriate for children. Incorrect: Rectal temperature measurement is considered safe and accurate for adults only. 3. Which action by the nurse results in the patients blood pressure measurement being falsely high? Select all that apply. a. Using a blood pressure cuff that is too narrow for the patients upper arm b. Deflating the blood pressure cuff too rapidly c. Wrapping the blood pressure cuff too loosely d. Reinflating the blood pressure cuff before it completely deflates e. Positioning the patients arm above the level of the heart ANS: A, C, D, E Correct: Using a blood pressure cuff that is too narrow for the patients upper arm, wrapping the cuff too loosely, reinflating the cuff before it completely deflates, and positioning the patients arm above the level of the heart all result in readings that are falsely high. Incorrect: Deflating the blood pressure cuff too rapidly causes the blood pressure reading to be falsely low. 4. Which action by the nurse results in the patients blood pressure measurement being falsely low? Select all that apply. a. Using a blood pressure cuff that is too wide for the patients arm b. Not inflating the blood pressure cuff enough c. Positioning the patients arm above the level of the heart d. Wrapping the cuff too loosely around the arm e. Deflating the cuff too rapidly ANS: A, B, E Correct: Using a blood pressure cuff that is too wide for the patients arm, not inflating the blood pressure cuff enough, and deflating the cuff too rapidly could result in a false low reading. Incorrect: Positioning the patients arm above the level of the heart and wrapping the cuff too loosely around the arm causes the blood pressure to be falsely high. 5. The nurse taking a patients blood pressure recognizes that several factors may cause an increased blood pressure reading. Which factors below can increase blood pressure? Select all that apply. a. The patient rates pain at a level of 7 on a scale of 0 to 10. b. The cuff was reinflated before being completely deflated. c. The patient drank cold milk just before the reading. d. The time of day is late afternoon. e. The cuff is too wide for the extremity. ANS: A, B, D Correct: Rating pain at a level of 7 on a scale of 0 to 10, reinflating the cuff before being completely deflated, and taking the reading in late afternoon are all factors that can increase blood pressure. Incorrect: Drinking cold milk just before the reading will not affect blood pressure, but drinking caffeine such as coffee or cola may increase blood pressure. A wide cuff makes the reading lower than it actually is rather than higher. COMPLETION 1. A female patient admitted with fluid retention has been in diuretic therapy to remove fluid. She weighed 187 lb on admission. Today she weighs 179 lb. Since admission, this patient has lost L from fluid loss. ANS: 3.6 1 kg (2.2 lb) = 1 L; 187 179 = 8 lb weight loss divided by 2.2 = 3.6 L. Chapter 4. Comprehensive Health Gathering 1. The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? a. To provide an opportunity for interaction between the patient and the nurse b. To provide a form for obtaining the patients biographic information c. To document the normal and abnormal findings of a physical assessment d. To provide a database of subjective information about the patients past and current health ANS: D The purpose of the health history is to collect subjective datawhat the person says about him or herself. The other options are not correct. 2. When the nurse is evaluating the reliability of a patients responses, which of these statements would be correct? The patient: a. Has a history of drug abuse and therefore is not reliable. b. Provided consistent information and therefore is reliable. c. Smiled throughout interview and therefore is assumed reliable. d. Would not answer questions concerning stress and therefore is not reliable. ANS: B b. Grav 6, Term 4, (S)Ab-2, Living 4 c. Patient has had four living babies. d. Patient has been pregnant six times. ANS: B Obstetric history includes the number of pregnancies (gravidity), number of deliveries in which the fetus reached term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (abortions), and number of children living (living). This is recorded: Grav Term Preterm Ab Living . For any incomplete pregnancies, the duration is recorded and whether the pregnancy resulted in a spontaneous (S) or an induced (I) abortion. 8. A patient tells the nurse that he is allergic to penicillin. What would be the nurses best response to this information? a. Are you allergic to any other drugs? b. How often have you received penicillin? c. Ill write your allergy on your chart so you wont receive any penicillin. d. Describe what happens to you when you take penicillin. ANS: D Note both the allergen (medication, food, or contact agent, such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, or difficulty breathing). With a drug, this symptom should not be a side effect but a true allergic reaction. 9. The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: a. Emphysema. b. Head trauma. c. Mental illness. d. Fractured bones. ANS: C Questions concerning any family history of heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast and ovarian cancers, colon cancer, sickle cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and tuberculosis should be asked. 10. The review of systems provides the nurse with: a. Physical findings related to each system. b. Information regarding health promotion practices. c. An opportunity to teach the patient medical terms. d. Information necessary for the nurse to diagnose the patients medical problem. ANS: B The purposes of the review of systems are to: (1) evaluate the past and current health state of each body system, (2) double check facts in case any significant data were omitted in the present illness section, and (3) evaluate health promotion practices. 11. Which of these statements represents subjective data the nurse obtained from the patient regarding the patients skin? a. Skin appears dry. b. No lesions are obvious. c. Patient denies any color change. d. Lesion is noted on the lateral aspect of the right arm. ANS: C The history should be limited to patient statements or subjective datafactors that the person says were or were not present. 12. The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? a. Do you perform testicular self-examinations? b. Have you ever noticed any pain in your testicles? c. Have you had any problems with passing urine? d. Do you have any history of sexually transmitted diseases? ANS: A Health promotion for a man would include the performance of testicular self-examinations. The other questions are asking about possible disease or illness issues. 13. Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? a. I broke my right leg in a car accident 2 weeks ago. b. The pain is decreasing, but I still need to take acetaminophen. c. I check the color of my toes every evening just like I was taught. d. Im able to transfer myself from the wheelchair to the bed without help. ANS: D Functional assessment measures a persons self-care ability in the areas of general physical health or absence of illness. The other statements concern health or illness issues. 14. In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? a. This has been a difficult year for you. b. I dont know how anyone could handle that much stress in 1 year! c. What did you do to cope with the loss of both your husband and mother? How the child reacted to previous hospitalizations and any complications should be assessed. If the child reacted poorly, then he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure. 2. As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles- mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? a. No further MMR immunizations are needed. b. MMR vaccination needs to be repeated at 4 to 6 years of age. c. MMR immunization needs to be repeated every 4 years until age 21 years. d. A recommendation cannot be made until the physician is consulted. ANS: B Because of recent outbreaks of measles across the United States, the American Academy of Pediatrics recommends two doses of the MMR vaccine, one at 12 to 15 months of age and one at age 4 to 6 years. 3. In obtaining a review of systems on a healthy 7-year-old girl, the health care provider knows that it would be important to include the: a. Last glaucoma examination. b. Frequency of breast self-examinations. c. Date of her last electrocardiogram. d. Limitations related to her involvement in sports activities. ANS: D When reviewing the cardiovascular system, the health care provider should ask whether any activity is limited or whether the child can keep up with her peers. The other items are not appropriate for a child this age. 4. When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed? a. Family history b. Review of systems c. Functional assessment d. Reason for seeking care ANS: C Functional assessment includes interpersonal relationships and home environment. Family history includes illnesses in family members; a review of systems includes questions about the various body systems; and the reason for seeking care is the rationale for requesting health care. 5. The nurse is obtaining a health history on an 17-year-old woman. Which of the following areas of questioning would be most useful at this time? a. Sexual history b. Childhood illnesses c. General health for the past 10 years d. Current health promotion activities ANS: D It is important for the nurse to recognize positive health measures, such as what the person has been doing to help him or herself stay well and to live to an older age. The other responses are not pertinent to a patient of this age. 6. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? a. The functional assessment assesses how the individual is coping with life at home. b. It determines how children are meeting developmental milestones. c. The functional assessment can identify any problems with memory the individual may be experiencing. d. It helps determine how a person is managing day-to-day activities. ANS: D The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment. 7. The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? a. Chest pain b. Clammy skin c. Serum potassium level at 4.2 mEq/L d. Body temperature of 100 F ANS: A A symptom is a subjective sensation (e.g., chest pain) that a person feels from a disorder. A sign is an objective abnormality that the examiner can detect on physical examination or in laboratory reports, as illustrated by the other responses. 8. A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? a. It is a sharp, burning pain in my stomach. b. I also have the sweats and nausea when I feel this pain. c. I think this pain is telling me that something bad is wrong with me. d. This pain happens every time I sit down to use the computer. ANS: D MULTIPLE RESPONSE 1. The nurse is assessing a patients headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply. a. Where is the headache pain? b. Did you have these headaches as a child? c. On a scale of 1 to 10, how bad is the pain? d. How often do the headaches occur? e. What makes the headaches feel better? f. Do you have any family history of headaches? ANS: A, C, D, E The mnemonic PQRSTU may help the nurse remember to address the critical characteristics that need to be assessed: (1) P: provocative or palliative; (2) Q: quality or quantity; (3) R: region or radiation; (4) S: severity scale; (5) T: timing; and (6) U: understand the patients perception. Asking, Where is the pain? reflects region. Asking the patient to rate the pain on a 1 to 10 scale reflects severity. Asking How often reflects timing. Asking what makes the pain better reflects provocative. The other options reflect health history and family history. 2. The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply. a. How much junk food does your child eat? b. How many teeth has he lost, and when did he lose them? c. Is he able to tie his shoelaces? d. Does he take a childrens vitamin? e. Can he tell time? f. Does he have any food allergies? ANS: B, C, E Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history. Chapter 6 Newborn Assessment 1. 1. A mother brings her 9 month infant in for a routine visit. What milestone would be appropriate for the doctor to ask if the infant is meeting? 1. Walking 2. Speaking in two word phrases 3. Rolls back to stomach and stomach to back 4. All of the above ANS: 3 Feedback 1. Between 1012 months of age, an infant can walk 2. Between 1416 months of age, an infant can speak two word phrases 3.Between 6 and 9 months of age, an infant can roll from back to stomach and stomach to back. 4. Many infants will not be walking at this age. It is too soon for word phrases to be developed. The child should be rolling. 1. 2. A 5 day old infant comes in for a newborn checkup. On assessment of the newborn, you note that the skin is jaundice in color. The anterior fontanel is slightly sunken. Per mom, the infant has only had 2 diapers today. The infant is strictly breastfed and this is moms first child. She states baby is having trouble latching on. A bilirubin level is sent and comes back at 18. You identify this newborn to be dehydrated and is most likely to have breast milk jaundice. Which nursing intervention(s) will be required for this baby? 1. 1. Phototherapy 2. 2. Providing support and education for the lactating mother 3. 3. Strict monitoring of intake and output 4. 4. All of the above ANS 4 Feedback 1.Phototherapy will be required to help decrease the level of bilirubin. 2.It is important to provide the mother with support and education and offer a lactation specialist. 3. This infant is dehydrated so it will be necessary to monitor strict I & Os. 4.Breast Milk Jaundice occurs in 12% of breastfed babies. At early onset there are poor feeding patterns and bilirubin levels may spike to 19. It is important to provide the mother with support and education and offer a lactation specialist. This infant is dehydrated so it will be necessary to monitor strict I & Os. Phototherapy will be required to help decrease the level of bilirubin. 1. 3. Apgar scores measure heart rate, respiratory rate, reflex irritability, color and : 1. 1. Rigidity 2. 2. Muscle tone 3. 3. Birth weight 4. 4. Capillary refill ANS: 2 Feedback 1. Not assessed for the APGAR score 2. Apgar scores measure 5 areas: respiratory rate, heart rate, muscle tone, color and reflex irritability. The higher score indicates adequate adaptation. Scores are done at 1 minute and 5 minutes after birth. 3. Not assessed for the APGAR score 4.Not assessed the APGAR score 1. 4. A mother on the postpartum unit asked to have her infant back from the nursery so that she can breastfeed. The nurse brings the newborn to the room and hands the baby to the mother. She asks the mother to let her know how long the baby feeds. What vital step did the nurse forget to take before giving the baby to the mother? 1. 1. The nurse should have made sure that the baby was latching correctly 8. A pregnant woman with a history of a clotting disorder is required to self-administer heparin during her pregnancy. After delivery, the infant will be at greater risk for: 1. Low blood sugar 2. Decrease Vitamin K 3. Increased Vitamin K 4. High blood sugar ANS: 2 Feedback 1. Anticoagulants do not effect blood sugar 2. An infant of a mother who is treated with anticoagulants are at risk for decreased vitamin K levels 3. Anticoagulants have the opposite effect on vitamin K 4.Anticoagulants do not effect blood sugar 9. A part of injury prevention is making and keeping infant appointments. The required checkups and vaccinations are at: 1. 3 months, 6 months, 9 months 2. 2 months, 4 months, 6 months and 1 year 3. 2 months, 4 months, 6 month, 9 months and 1 year 4. 2 months, 4 months, 9 months and 1 year ANS: 3 Feedback 1. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age. 2. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age. 3. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age. 4. It is recommended that a routine check-up with vaccinations be done at 2 months, 4 months, 6 months, 9 months and 1 year of age. 10. You are taking care of an infant who was admitted with dehydration. His weight is 6kg. You have been watching his I & Os. What would you expect the infants urinary output to be in order to maintain adequate hydration? 1. 0.52 ml/kg/hr 2. 0.52.5 ml/kg/hr 3. 13 ml/kg/hr 4. As long as he is having wet diapers it doesnt matter ANS: 3 Feedback 1.Urine output is not in normal range 2.Urine output is not in normal range 3. Urine output for the newborn/infant should be 13 cc/kg/hr, in the hospital, to maintain adequate fluid maintenance 4. Measuring I & O is important to assess kidney function in a dehydrated patient 11. A mother brings her newborn daughter to the ER with concerns that she is having vaginal bleeding. You know this is normal and called what? 1. Pseudomenstruation 2. Milia 3. Vernix caseosa 4. Toxicum ANS: 1 Feedback 1. Pseudomenstruation is thin white or blood tinged mucus that may be present due to maternal withdrawal of hormones. 2. Incorrect term 3.Incorrect term 4.Incorrect term 12. While interviewing the mother of an infant, you note that the mother gets frustrated as she explains that her baby has been up all night crying at least 3 times a week for the last 2 weeks. She states that she has tried everything and feels hopeless. What would be the BEST response from you as the nurse? 1. Believe me, I know. I have a newborn too. 2. Have you tried warm milk? 3. Its ok to be frustrated and feel overwhelmed. 4. You are doing nothing wrong. This can be a common occurrence in infants and you should not feel guilty. ANS: 4 Feedback 1. It is important that education is provided to the mother or caregiver so that they know the irritability is not a reflection of their parenting skills. 2. Infants do not have the enzyme to absorb milk thus would cause more stomach upset 3. Acknowledgement of the mothers feelings is important. Mother needs educated about Infant Colic. 4. The mother is describing Infant Colic. This can be very frustrating for mothers. They can feel helpless, hopeless and like a terrible mother. It is important that education is provided to the mother or caregiver so that they know the irritability is not a reflection of their parenting skills. 13. The benefits of breast-feeding are 1. Decreased risk of obesity 2. Convenience 3. Promotes positive bonding with infant and mother 1. Tylenol 2. Kangaroo care 3. Sucrose 4. Nonnutritive sucking 5. Choice 3 and 4 ANS: 5 Feedback 1. Does not produce an endogenous response 2. While this comforts a neonate it does not have an endogenous opioid pathway 3. The administration of sucrose and the application of nonnutritive sucking are theorized to activate endogenous opioid pathways (natural pain relievers produced in the brain) with resulting calming and pain- relieving effects. 4. The administration of sucrose and the application of nonnutritive sucking are theorized to activate endogenous opioid pathways (natural pain relievers produced in the brain) with resulting calming and pain- relieving effects. 5. The administration of sucrose and the application of nonnutritive sucking are theorized to activate endogenous opioid pathways (natural pain relievers produced in the brain) with resulting calming and pain- relieving effects. 18. A mother of a newborn baby boy is unsure of whether or not to have her son circumcised. She asks the nurse what is recommended by the AAP. The nurse tells her that as of 1999, the AAPs recommendation is: 1. They highly recommend routine circumcisions 2. They strongly recommend circumcision only if the parents are worried about infections 3. They have no current stance 4. They do not recommend routine circumcisions ANS: 4 Feedback 1. The current position statement issued in 1999 does not recommend routine circumcision of the newborn. 2. The infection rate does not change with a circumcision 3.The current position statement issued in 1999 does not recommend routine circumcision of the newborn. 4.The current position statement issued in 1999 does not recommend routine circumcision of the newborn. 19. Which of the following interfere with the absorption of some medications in neonates and infants? 1. Immature kidney function 2. Absence of hydrochloric acid 3. Less pancreatic enzymes 4.All of the above Feedback 1.Immature kidney function influences absorption 2.The lack of hydrochloric acid influences absorption 3.A neonate has less pancreatic enzymes 4.In neonates there is an absence of hydrochloric acid, and in infants, less pancreatic enzymes and immature kidney function which may interfere with absorption of some medications. 20. The nurse is doing discharge teaching and instructs the parents to notify their healthcare provider with any of these important concerns regarding the newborn/infant. 1. Temperature over 99.3 degrees Fahrenheit 2. Vomiting 3. Decreased wet diapers 4. All of the above ANS: 4 Feedback 1.A temperature greater than 99.3 degrees Fahrenheit, especially in a newborn, may be a sign of sepsis 2.Vomiting and decreased wet diapers can be a sign on dehydration 3.Vomiting and decreased wet diapers can be a sign on dehydration 4.A temperature greater than 99.3 degrees Fahrenheit, especially in a newborn, may be a sign of sepsis. Vomiting and decreased wet diapers can be a sign on dehydration. Infants and children have less reserve than adults and can become dehydrated quickly. 21. The nurse is assessing pain on a 1 year old. What is the appropriate pain scale to use? 1. NIPS 2. FACES 3. FLACC 4. CHOPS ANS: 3 Feedback 1.Not recommended for this age range 2.Not recommended for this age range 3. FLACC or the Face, Legs, Activity, Cry, Consolability scale is a measurement used to assess pain for children between the ages of 2 months-7 years or until the child is able to understand the concept of pain (then the FACES scale can be used). 4. Not recommended for this age range 22. On assessment of a 6 month old infant you note that the anterior fontanel is flat and soft and the posterior fontanel is no longer palpable. This is an appropriate finding because the posterior fontanel closes at: 1. 6 months 2. 4 months 1.AAP recommends that all infants be placed on their backs for sleep in a bare naked crib. This means just a fitted sheet, no bumpers, blankets, pillows or toys. These are all suffocation hazards. The infant should not be tightly swaddled and arms should be free. Tightly swaddled infants are at risk for overheating and at greater risk for SIDS. 2.A pillow can increase the chance for suffocation 3. The infant should only be placed on her belly when awake and supervised 4. AAP recommends that all infants be placed on their backs for sleep in a bare naked crib. This means just a fitted sheet, no bumpers, blankets, pillows or toys. These are all suffocation hazards. The infant should not be tightly swaddled and arms should be free. Tightly swaddled infants are at risk for overheating and at greater risk for SIDS. Chapter 7. Skin 1. What should be included in teaching a parent about the management of small red macules and vesicles that become pustules around the childs mouth and cheek? a. Keep the child home from school for 24 hours after initiation of antibiotic treatment. b. Clean the rash vigorously with Betadine three times a day. c. Notify the physician for any itching. d. Keep the child home from school until the lesions are healed. ANS: A To prevent the spread of impetigo to others, the child should be kept home from school for 24 hours after treatment is initiated. Good hand washing is imperative in preventing the spread of impetigo. The lesions should be washed gently with a warm soapy washcloth three times a day. Washcloth should not be shared with other members of the family. Itching is common and does not necessitate medical treatment. Rather, parents should be taught to clip the childs nails to prevent maceration of the lesions. The child may return to school 24 hours after initiation of antibiotic treatment. 2. When taking a history of a child with cellulitis, which information would be most pertinent for the nurse to assess? a. Any medication the child is taking b. Enlarged, mobile, and nontender lymph nodes c. Childs urinalysis results d. Recent infections or signs of infection ANS: D Cellulitis may follow an upper respiratory infection, sinusitis, otitis media, or a tooth abscess. The affected area is red, hot, tender, and indurated. Medication history is important, but the history of recent infections is more relevant to the diagnosis. Lymph nodes may be enlarged (lymphadenitis), but they are not mobile and are nontender. Lymphangitis may be seen, with red streaking of the surrounding area. An abnormal urinalysis result is not usually associated with cellulitis. 3. Which statement made by a parent indicates an understanding about the management of a child with cellulitis? a. I am supposed to continue the antibiotic until the redness and swelling disappear. b. I have been putting ice on my sons arm to relieve the swelling. c. I should call the doctor if the redness disappears. d. I have been putting a warm soak on my sons arm every 4 hours. ANS: D Warm soaks applied every 4 hours while the child is awake increase circulation to the infected area, relieve pain, and promote healing. The parent should not discontinue antibiotics when signs of infection disappear. To ensure complete healing, the parent should understand that the entire course of antibiotics should be given as prescribed. A warm soak is indicated for the treatment of cellulitis. Ice will decrease circulation to the affected area and inhibit the healing process. The disappearance of redness indicates healing and is not a reason to seek medical advice. 4. What should the parents of an infant with thrush (oral candidiasis) be taught about medication administration? a. Give nystatin suspension with a syringe without a needle. b. Apply nystatin cream to the affected area twice a day. c. Give nystatin just before the infant is fed. d. Rub nystatin suspension onto the oral mucous membranes with a gloved finger after feedings. ANS: D It is important to apply the nystatin suspension to the affected areas, which is best accomplished by rubbing it onto the gums and tongue, after feedings, every 6 hours, until 3 to 4 days after symptoms have disappeared. Medication may not reach the affected areas when it is squirted into the infants mouth. Rubbing the suspension onto the gum ensures contact with the affected areas. Nystatin cream is used for diaper rash caused by Candida. To prolong contact with the affected areas, the medication should be administered after a feeding. 5. What beverage should the parents of a child with ringworm be taught to give along with the prescribed griseofulvin (Fulvicin)? a. Water b. A carbonated drink c. Milk d. Fruit juice ANS: C Griseofulvin is insoluble in water. Giving the medication with a high-fat meal or milk increases absorption. Carbonated drinks do not contain fat, which aids in the absorption of griseofulvin. Fruit juice does not contain any fat; fat aids absorption of the medication. 6. Which assessment is applicable to the care of a child with herpetic gingivostomatitis? a. Comparison of range of motion for the upper and lower extremities b. Urine output, mucous membranes, and skin turgor ANS: A Small red papules with peripheral scaling in a sharply demarcated area involving the anterior thighs, lower abdomen, and perineum are characteristic of primary candidiasis. A shiny, parchment-like erythematous rash on the buttocks, medial thighs, mons pubis, and scrotum, but not in the folds, is suggestive of irritant contact dermatitis. Intertrigo is identified by a red macerated area of sharp demarcation in the groin folds. It can also develop in the gluteal and neck folds. Seborrheic dermatitis is recognized by salmon-colored, greasy lesions with a yellowish scale found primarily in skin-fold areas or on the scalp. 11. The depth of a burn injury may be classified as: a. localized or systemic. b. superficial, superficial partial thickness, deep partial thickness, or full thickness. c. electrical, chemical, or thermal. d. minor, moderate, or major. ANS: B The vocabulary to classify the depth of burn is superficial, partial thickness, or full thickness. These terms refer to the effect of the burn injury. For example, is there a reaction in the area of the burn (localized) or throughout the body (systemic)? Electrical, chemical, or thermal are terms that refer to the cause of the burn injury. Minor, moderate, or major are terms that refer to the severity of the burn injury. 12. What is the major difference between caring for an infant with burns and an adolescent with burns? a. An increased risk of cardiovascular problems in the infant b. A decreased need for caloric intake in the infant c. An increased risk for hypervolemia in the adolescent d. A decreased need for electrolyte replacement in the infant ANS: A The higher proportion of body fluid to body mass in infants increases the risk of cardiovascular problems because of a less effective cardiovascular response to changing intravascular volume. Infants are at an increased risk for protein and calorie deficiency because they have smaller muscle mass and lower body fat. Hypovolemia is a risk for all burn patients; however, the risk is higher for the infant than for the adolescent. There is an increased risk for electrolyte loss in the infant because of the larger body surface area. 13. Which procedure is contraindicated in the care of a child with a minor partial-thickness burn injury wound? a. Cleaning the affected area with mild soap and water b. Applying antimicrobial ointment to the burn wound c. Changing dressings daily d. Leaving all loose tissue or skin intact ANS: D All loose skin and tissue should be debrided because it can become a breeding ground for infectious organisms. Cleaning with mild soap and water is important to the healing process. Antimicrobial ointment is used on the burn wound to fight infection. Clean dressings are applied daily to prevent wound infection. When dressings are changed, the condition of the burn wound can be assessed. 14. The process of burn shock continues until which physiological mechanism occurs? a. Heart rate returns to normal. b. Airway swelling decreases. c. Body temperature regulation returns to normal. d. Capillaries regain their seal. ANS: D Within minutes of the burn injury, the capillary seals are lost with a massive fluid leakage into the surrounding tissue, resulting in burn shock. The process of burn shock continues for approximately 24 to 48 hours, when capillary seals are restored. The heart rate will be increased throughout the healing process because of increased metabolism. Airway swelling subsides over a period of 2 to 5 days after injury. Body temperature regulation will not be normal until healing is well under way. 15. To assess the child with severe burns for adequate perfusion, the nurse monitors which area? a. Distal pulses b. Skin turgor c. Urine output d. Mucous membranes ANS: C Urine output reflects the adequacy of end-organ perfusion. Distal pulses may be affected by many variables. Urine output is the most reliable indicator of end-organ perfusion. Skin turgor is often difficult to assess on burn patients because the skin is not intact. Mucous membranes do not reflect end-organ perfusion. 16. Which medication would be best for the nurse to administer before a dressing change for the severely burned child? a. Codeine b. Benadryl c. Morphine d. Acetaminophen ANS: C Morphine is the drug of choice for pain management in the severely burned child. It should be administered intravenously. Codeine may be used to diminish pain between dressing changes. Chapter 8. Heart and Vascular System 1. A nurse is conducting a class for nursing students about fetal circulation. Which statement is accurate about fetal circulation and should be included in the teaching session? a. Oxygen is carried to the fetus by the umbilical arteries. b. Blood from the inferior vena cava is shunted directly to the right ventricle through the foramen ovale. c. Pulmonary vascular resistance is high because the lungs are filled with fluid. d. Blood flows from the ductus arteriosus to the pulmonary artery. ANS: C Resistance in the pulmonary circulation is very high because the lungs are collapsed and filled with fluid. Oxygen and nutrients are carried to the fetus by the umbilical vein. The inferior vena cava empties blood into the right atrium. The direction of blood flow and the pressure in the right atrium propel most of this blood through the foramen ovale into the left atrium. Most of the blood in the pulmonary artery flows though the ductus arteriosus into the descending aorta. 2. Which postoperative intervention should be questioned for a child after a cardiac catheterization? a. Continue intravenous (IV) fluids until the infant is tolerating oral fluids. b. Check the dressing for bleeding. c. Assess the peripheral circulation on the affected extremity. d. Keep the affected leg flexed and elevated. ANS: D The child should be positioned with the affected leg straight for 4 to 6 hours after the procedure. IV fluid administration continues until the child is taking and retaining adequate amounts of oral fluids. The insertion site dressing should be observed frequently for bleeding. The nurse should also look under the child to check for pooled blood. Peripheral perfusion is monitored after catheterization. Distal pulses should be palpable, although they may be weaker than in the contralateral extremity. 3. Which information should be included in the nurses discharge instructions for a child who underwent a cardiac catheterization earlier in the day? a. The pressure dressing is changed daily for the first week. b. The child may soak in the tub beginning tomorrow. c. Contact sports can be resumed in 2 days. d. The child can return to school on the third day after the procedure. ANS: D The child can return to school on the third day after the procedure. It is important to emphasize follow-up with the cardiologist. The day after the cardiac catheterization, the pressure dressing is removed and replaced with a Band-Aid. The catheter insertion site is assessed daily for healing. Any bleeding or sign of infection, such as drainage, must be reported to the cardiologist. Bathing is limited to a shower, sponge bath, or a brief tub bath (no soaking) for the first 1 to 3 days after the procedure. Strenuous exercise such as contact sports, swimming, or climbing trees is avoided for up to 1 week after the procedure. 4. A nurse is preparing to assess a 9-month-old infant admitted to the hospital for further evaluation of an atrial septal defect (ASD). Which should the nurse do first for the cardiac assessment? a. Percussion b. Palpation c. Auscultation d. History and inspection ANS: D The assessment should begin with the least threatening interventionsthe history and inspection. Assessment progression includes inspection, auscultation, and palpation because each step includes more touching. Percussion of the chest is usually deferred. Palpation can be threatening to the child because it requires a significant amount of physical contact. For this reason it is not the initial step in a cardiac assessment. Auscultation requires touching the child and is not the initial step in a cardiac assessment. 5. In which situation is there a risk that a newborn infant will have a congenital heart defect (CHD)? a. Trisomy 21 detected on amniocentesis b. Family history of myocardial infarction c. Father has type 1 diabetes mellitus d. Older sibling was born with Turners syndrome ANS: A The incidence of congenital heart disease is approximately 50% in children with trisomy 21 (Down syndrome). A family history of congenital heart disease, not acquired heart disease, increases the risk of giving birth to a child with CHD. Infants born to mothers who are insulin dependent have an increased risk of CHD. Infants identified as having certain genetic defects, such as Turners syndrome, have a higher incidence of CHD. A family history is not a risk factor. 6. Before giving a dose of digoxin (Lanoxin), the nurse checked an infants apical heart rate and it is 114 beats per minute. What should the nurse do next? a. Administer the dose as ordered. b. Hold the medication until the next dose. c. Wait and recheck the apical heart rate in 30 minutes. d. Notify the physician about the infants heart rate. ANS: A not a compensatory mechanism to chronic hypoxia. Anemia may develop as a result of increased blood viscosity. 11. Which statement made by a parent indicates understanding of activity restrictions for a child after cardiac surgery? a. My child needs to get extra rest for a few weeks. b. My son is really looking forward to riding his bike next week. c. Im so glad we can attend services as a family this coming Sunday. d. I am going to keep my child out of day care for 6 weeks. ANS: D Settings in which large groups of people are present should be avoided for 4 to 6 weeks after discharge, including day care. The child should resume his regular bedtime and sleep schedule after discharge. Activities during which the child could fall, such as riding a bicycle, are avoided for 4 to 6 weeks after discharge. Large crowds of people should be avoided for 4 to 6 weeks after discharge, including public worship. 12. A child had a ventricular septal defect surgically repaired 3 months ago. Which antibiotic prophylaxis is indicated for an upcoming dental procedure? a. No antibiotic prophylaxis is necessary. b. Amoxicillin is taken orally 1 hour before the procedure. c. Oral penicillin is given for 7 to 10 days before the procedure. d. Parenteral antibiotics are administered for 4 to 8 weeks after the procedure. ANS: B The standard prophylactic agent is amoxicillin given orally 1 hour before the procedure. Antibiotic prophylaxis is indicated for the first 6 months after surgical repair. Antibiotic prophylaxis is not given for this period of time. The treatment for infective endocarditis involves parenteral antibiotics for 4 to 8 weeks. 13. A nurse is assessing a 7-day-old infant. The nurse detects a soft murmur. The nurse notifies the primary care physician because the nurse is aware that fetal shunts are closed in the infant at what point in time? a. When the umbilical cord is cut b. Within several days of birth c. Within a month after birth d. By the end of the first year of life ANS: B In the normal neonate, fetal shunts functionally close in response to pressure changes in the systemic and pulmonary circulations and to increased oxygen content. This process may take several days to complete. With the neonates first breath, gas exchange is transferred from the placenta to the lungs. The separation of the fetus from the umbilical cord does not contribute to the establishment of neonatal circulation. 14. When assessing a child for possible congenital heart defects, where should the nurse measure blood pressure? a. The right arm b. The left arm c. All four extremities d. Both arms while the child is crying ANS: C When a congenital heart defect is suspected, the blood pressure should be measured in all four extremities while the child is quiet. Discrepancies between upper and lower extremities may indicate cardiac disease. Blood pressure measurements when the child is crying are likely to be elevated; thus, the readings will be inaccurate. Blood pressure measurements for upper and lower extremities are compared during an assessment for congenital heart defects. 15. What should be the nurses first action when planning to teach the parents of an infant with a congenital heart defect? a. Assess the parents readiness to learn. b. Gather literature for the parents. c. Secure a quiet place for teaching. d. Discuss the plan with the nursing team. ANS: A Any effort to organize the right environment, plan, or literature is of no use if the parents are not ready to learn. A baseline assessment of prior knowledge should be taken into consideration before developing any teaching plan. Locating a quiet place for meeting with parents is appropriate; however, an assessment should be done before any teaching is done. Discussing a teaching plan with the nursing team is appropriate after an assessment of the parents knowledge and readiness. 16. A nurse is explaining a patent ductus arteriosus defect to the parents of a preterm infant. The parents indicate understanding of the defect when they state that a patent ductus arteriosus: a. involves a defect that results in a right-to-left shunting of blood in the heart. b. involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close. c. is a stenotic lesion that must be surgically corrected at birth. d. causes an abnormal opening between the four chambers of the heart. ANS: B Patent ductus arteriosus is failure of the fetal shunt between the aorta and the pulmonary artery to close. A patent ductus arteriosus allows blood to flow from the high-pressure aorta to the low- pressure pulmonary artery, resulting in a left-to-right shunt. Patent ductus arteriosus is not a stenotic lesion. Patent ductus arteriosus can be closed both medically and surgically. c. Removing oxygen while the infant is crying d. Organizing care to provide rest periods ANS: D Nursing care should be planned to allow for periods of undisturbed rest. Diapers must be weighed for an accurate record of output. The head of the bed should be raised to decrease the work of breathing. Oxygen should be administered during stressful periods such as when the child is crying. 22. Which strategy is appropriate when feeding the infant with congestive heart failure? a. Continue the feeding until a sufficient amount of formula is taken. b. Limit feedings to no more than 30 minutes. c. Always bottle feed every 4 hours. d. Feed larger volumes of concentrated formula less frequently. ANS: B The infant with congestive heart failure may tire easily so the feeding should not continue beyond 30 minutes. If inadequate amounts of formula are taken, gavage feedings should be considered. Infants with congestive heart failure may be breast-fed or fed a smaller volume of concentrated formula. Feedings every 3 hours is a frequently used interval. If the infant were fed less frequently than every 3 hours, more formula would need to be consumed and would tire the infant. 23. A nurse is teaching an adolescent about primary hypertension. Which statement made by the adolescent indicates an understanding about primary hypertension? a. Primary hypertension should be treated with diuretics as soon as it is detected. b. Congenital heart defects are the most common cause of primary hypertension. c. Primary hypertension may be treated with weight reduction. d. Primary hypertension is not affected by exercise. ANS: C Primary hypertension in children may be treated with weight reduction and exercise programs. If ineffective, pharmacological intervention may be needed. Primary hypertension is considered to be an inherited disorder. 24. A nurse is planning care for a child with secondary hypertension. The nurse plans to include which initial treatment of secondary hypertension? a. Weight control and diet b. Treating the underlying disease c. Administration of digoxin d. Administration of beta-adrenergic receptor blockers ANS: B Identification of the underlying disease should be the first step in treating secondary hypertension. Weight control and diet are a nonpharmacological treatment for primary hypertension. Digoxin is indicated in the treatment of congestive heart failure. Beta-adrenergic receptor blockers are indicated in the treatment of primary hypertension. 25. Which should the nurse include in discharge teaching for the child with a cardiac arrhythmia? a. CPR instructions b. Repeating digoxin if the child vomits c. Resting if dizziness occurs d. Checking the childs pulse after digoxin administration ANS: A The parents and significant others in the childs life should have CPR training. The digoxin dose is not repeated if the child vomits. Dizziness is a symptom the child should be taught to report to adults so the physician can be notified. The childs pulse should be counted before the medication is given. The dose is withheld if the pulse is below the parameters set by the physician. 26. A nurse is assigned to care for an infant with an unrepaired tetralogy of Fallot. What should the nurse do first when the baby is crying and becomes severely cyanotic? a. Place the infant in a knee-chest position. b. Administer oxygen. c. Administer morphine sulfate. d. Notify the physician. ANS: A Placing the infant in a knee-chest position will decrease venous return so that smaller amounts of highly saturated blood reach the heart. Administering oxygen is indicated after placing the infant in a knee-chest position. Administering morphine sulfate calms the infant. It is indicated after the infant has been placed in a knee-chest position. The physician should be notified after the infant has been placed in a knee-chest position. 27. The nurse caring for a child with a diagnosis of rheumatic fever should assess the child for which finding? a. Sore throat b. Elevated blood pressure c. Desquamation of the fingers and toes d. Tender, warm, inflamed joints ANS: D Arthritis, characterized by tender, warm, erythematous joints, is one of the major manifestations of rheumatic fever. The child may have had a sore throat previously associated with a group A beta-hemolytic streptococcal infection a few weeks earlier. A sore throat is not a manifestation of rheumatic fever. Hypertension is not associated with rheumatic fever. Desquamation of the fingers and toes is a manifestation of Kawasaki syndrome. or bluer than normal. A respiratory rate of 36 at rest for an infant is within normal expectations and it is expected that the appetite will increase slowly. Chapter 9. Chest and Respiratory System 1. A nurse in the labor and delivery room is assessing respirations on a newborn. The nurse understands that which change in the respiratory system occurs postnatally? a. Respirations are stimulated by hypoxemia. b. It takes up to 48 hours for most of the alveoli to expand. c. Surfactant in the lungs interferes with lung expansion. d. Pulmonary blood flow decreases after birth. ANS: A A postnatal change in the respiratory system is the stimulation of respiration by hypoxemia, hypercarbia, cold, tactile stimulation, and a possible decrease in the concentration of prostaglandin E2. Inflation of the normal lung is complete within a few breaths, and most alveoli have expanded within the first hour of life. Surfactant in the lungs lowers surface tension and facilitates lung expansion. Pulmonary blood flow increases after birth. 2. Which information should the nurse teach families about reducing exposure to pollens and dust? a. Replace wood and tile floors with wall-to-wall carpeting. b. Do not use an air conditioner. c. Put dust-proof covers on pillows and mattresses. d. Keep humidity in the house above 60%. ANS: C Covering mattresses and pillows with dust-proof covers will reduce exposure to dust. Carpets retain dust. To reduce exposure to dust, carpeting should be replaced with wood, tile, slate, or vinyl. These floors can be cleaned easily. For anyone with pollen allergies, it is best to keep windows closed and to run the air conditioner. A humidity level above 60% promotes dust mites. It is recommended that household humidity be kept between 40% and 50% to reduce dust mites inside the house. 3. A child has had cold symptoms for more than 2 weeks, a headache, nasal congestion with purulent nasal drainage, facial tenderness, and a cough that increases during sleep. The nurse recognizes these symptoms are characteristic of which respiratory condition? a. Allergic rhinitis b. Bronchitis c. Asthma d. Sinusitis ANS: D Sinusitis is characterized by signs and symptoms of a cold that do not improve after 14 days, a low-grade fever, nasal congestion and purulent nasal discharge, headache, tenderness, a feeling of fullness over the affected sinuses, halitosis, and a cough that increases when the child is lying down. The classic symptoms of allergic rhinitis are watery rhinorrhea, itchy nose, eyes, ears, and palate, and sneezing. Symptoms occur as long as the child is exposed to the allergen. Bronchitis is characterized by a gradual onset of rhinitis and a cough that is initially nonproductive but may change to a loose cough. The manifestations of asthma may vary, with wheezing being a classic sign. The symptoms presented in the question do not suggest asthma. 4. The child with chronic otitis media with effusion should be evaluated for which problem? a. Brain abscess b. Meningitis c. Hearing loss d. Perforation of the tympanic membrane ANS: C Chronic otitis media with effusion is the most common cause of hearing loss in children. The infection of acute otitis media can spread to surrounding tissues, causing a brain abscess or meningitis. Inflammation and pressure from acute otitis media may result in perforation of the tympanic membrane. 5. The nurse should expect the initial plan of care for a 9-month-old child with an acute otitis media infection to include: a. symptomatic treatment and observation for 48 to 72 hours after diagnosis. b. an oral antibiotic, such as amoxicillin, several times a day for 7 days. c. pneumococcal conjugate vaccine. d. myringotomy with tympanoplasty tubes. ANS: A For select children 6 months of age or older with acute otitis media, as an alternative to initiating antibiotic therapy, once diagnosed, acute otitis media is treated by initiating symptomatic treatment and observation for 48 to 72 hours. Acute otitis media may be treated with a 5- to 10- day course of oral antibiotics. When treatment is indicated, amoxicillin at a divided dose of 80 to 90 mg/kg/day given either every 8 or 12 hours for 5 to 10 days may be ordered. Pneumococcal conjugate vaccine helps to prevent ear infections but is not included in the initial plan of care for a child with acute otitis media. Surgical intervention is considered when the child has persistent ear infections despite antibiotic therapy or with otitis media with effusion that persists for more than 3 months and is associated with hearing loss. 6. Which statement made by a parent indicates understanding about treatment of streptococcal pharyngitis? a. I guess my child will need to have his tonsils removed. b. A couple of days of rest and some ibuprofen will take care of this. c. I should give the penicillin three times a day for 10 days. d. I am giving my child prednisone to decrease the swelling of the tonsils. 11. A 5-year-old child is brought to the emergency department with copious drooling and a croaking sound on inspiration. Her mother states that the child is very agitated and only wants to sit upright. What should be the nurses first action in this situation? a. Prepare intubation equipment and call the physician. b. Examine the childs oropharynx and call the physician. c. Obtain a throat culture for respiratory syncytial virus (RSV). d. Obtain vital signs and listen to breath sounds. ANS: A The 5-year-old child has symptoms of epiglottitis, is acutely ill, and requires emergency measures. If epiglottitis is suspected, the nurse would never examine the childs throat. Inspection of the epiglottis is done only by a physician because it could trigger airway obstruction. A throat culture could precipitate a complete respiratory obstruction. Vital signs can be assessed after emergency equipment is readied. 12. Which action for care can be taught to the parents of a 3-year-old child with pneumonia who is not hospitalized? a. Offer the child only cool liquids. b. Offer the child a favorite warm liquid drink. c. Use a warm mist humidifier. d. Call the physician for a respiratory rate less than 28 breaths/minute. ANS: B Offering the child favorite fluids will facilitate oral intake. Warm liquids are preferable as they help loosen secretions. Cool mist humidifiers are preferred to warm mist humidifiers. Warm mist is a safety concern and could cause burns if touched by the child. Typically parents are not taught to count their childrens respirations and report abnormalities to the physician. Even if this were the case, a respiratory rate of less than 28 breaths/minute is normal for a 3-year-old child. The expected respiratory rate for a 3-year-old child is 20 to 30 breaths/minute. 13. Which sign is indicative of respiratory distress in infants? a. Nasal flaring b. Respiratory rate of 55 breaths/minute c. Irregular respiratory pattern d. Abdominal breathing ANS: A Infants have difficulty breathing through their mouths; therefore, nasal flaring is usually accompanied by extra respiratory efforts. It also allows more air to enter as the nares flare. A respiratory rate of 55 breaths/minute would be a normal assessment for an infant. Tachypnea would be a respiratory rate of 60 to 80 breaths/minute. Irregular respirations are normal in the infant. Abdominal breathing is common because the diaphragm is the neonates major breathing muscle. 14. Once an allergen is identified in a child with allergic rhinitis, what would be the treatment of choice? a. Use appropriate medications. b. Begin desensitization injections. c. Eliminate the allergen. d. Remove the adenoids. ANS: C The first priority is to attempt to remove the causative agent from the childs environment. Medications are not a first-line treatment but can be helpful in controlling allergic rhinitis. Immunotherapy is usually the final component of controlling allergic rhinitis. Adenoids are tissues that can swell with constant rhinitis; however, a surgical procedure is not indicated for allergic rhinitis. Dealing with the cause is the first priority. 15. A child has returned to the postsurgical floor after having had a tonsillectomy. Which assessment finding should the nurse report to the physician? a. Vomiting bright red blood b. Pain at the surgical site c. Pain on swallowing d. The ability to only take small sips of liquids ANS: A Vomiting bright red blood and swallowing frequently are signs of bleeding postoperatively and should be reported to the physician. It is normal for the child to have pain at the surgical site and on swallowing. Only clear liquids are offered immediately after surgery, and small sips would be preferred. 16. Teaching safety precautions with the administration of antihistamines is important due to which common side effect? a. Dry mouth b. Excitability c. Drowsiness d. Dry mucous membranes ANS: C Drowsiness is a safety hazard when alertness is needed, especially with a teenage driver. Nonsedating brands should be used. A dry mouth is not a safety issue. Excitability may affect rest or sleep, but drowsiness is the most important safety hazard. Dry mucous membranes are not a safety issue. 17. Which is an appropriate beverage for the nurse to give to a child who had a tonsillectomy earlier in the day?