Child Health Questions

Chapter 17

Child Health Questions

107. The nurse at a playground witnesses a child fall off a swing. The nurse rushes to the child and suspects that he has a broken right leg. The nurse should take which priority action?

1. Immobilize the leg

2. Call for an ambulance

3. Remove the child’s shoes

4. Tell the child that everything will be fine

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Implementation

Content Area:

ANSWER: 1

Rationale:

When a fracture is suspected, the area is immobilized and splinted before the victim is moved. Emergency help is called for, and the nurse should remain with the child and provide realistic reassurance. Shoes are not removed because this action can cause increased trauma. Telling the child that everything will be fine is nontherapeutic.

Test-Taking Strategy:

Note the strategic word priority. Focusing on the subject, a broken right leg, will direct you to the correct option. When a fracture is suspected, remember to immobilize and splint that area. Review: care of the victim with a fracture.

Tip for the Beginning Nursing Student:

A fracture is a break or disruption in a bone’s continuity and generally occurs when traumatic or excessive force is placed on a bone. The signs and symptoms will vary depending on the location, type, and cause of injury but generally include pain at the site of injury, immobility or decreased range of motion, deformity, and edema. You will learn about fractures and the immediate interventions in your pediatrics nursing course when you study musculoskeletal disorders.

References

Hockenberry, Wilson (2011), p. 1639; Leifer (2011), p. 564.

108. A newborn infant with a diagnosis of subdural hematoma is admitted to the newborn nursery. The nurse should perform which action to assess for the major symptom associated with subdural hematoma?

1. Monitor the urine for blood.

2. Monitor the urinary output pattern.

3. Test for contractures of the extremities.

4. Test for equality of extremities when stimulating reflexes.

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Assessment/Data Collection

Content Area:

ANSWER: 4

Rationale:

A subdural hematoma can cause pressure on a specific area of the cerebral tissue. If the infant is actively bleeding, changes in the stimuli responses in the extremities on the opposite side of the body can occur. Options 1 and 2 are incorrect. Blood in the urine would indicate abdominal trauma and not be a result of the subdural hematoma. An infant, after delivery, would normally be incontinent of urine. Option 3 is incorrect because contractures would not occur this soon after delivery.

Test-Taking Strategy:

Note the words major symptom. Eliminate options 1 and 2 first because they are comparable or alike. Next focus on the infant’s condition—subdural hematoma—and recall that this condition is a neurological disorder. Remember that the method of checking for complications and active bleeding into the cranial cavity would be a neurological assessment. Checking newborn reflexes is a neurological assessment. Although contractures of extremities could occur as residual effects, they would not occur immediately; therefore, eliminate option 3. Review: the signs of subdural hematoma.

Tip for the Beginning Nursing Student:

A subdural hematoma is an accumulation of blood in the subdural space and is usually caused by an injury. It can be acute with rapid bleeding or subacute with the accumulation of blood occurring over a longer period. Because the accumulation of blood is in the cranial cavity, neurological assessment and monitoring for signs of increased intracranial pressure are priorities. You will learn about subdural hematomas in your medical-surgical nursing course and in your pediatrics (child health) nursing course when you study neurological disorders.

References

Leifer (2011), p. 563; Hockenberry, Wilson (2011), pp. 1527-1528.

109. The nurse is reviewing the record of an infant admitted to the newborn nursery. The nurse notes that the health care provider has documented bladder exstrophy. On assessment of the infant, the nurse expects to note which finding?

1. Undescended or hidden testes

2. Urinary bladder on the outside of the body

3. Opening of the urethral meatus on the ventral side of the glans penis

4. Opening of the urethral meatus below the normal placement on the glans penis

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Assessment/Data Collection

Content Area:

ANSWER: 2

Rationale:

Bladder exstrophy is a congenital anomaly characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. Option 1 describes cryptorchidism, option 3 describes epispadias, and option 4 describes hypospadias.

Test-Taking Strategy:

Focus on the subject, assessment findings associated with bladder exstrophy. Note the relationship between the prefix in the name of the disorder, ex-, and the word outside in option 2. Review: bladder exstrophy.

Tip for the Beginning Nursing Student:

Bladder exstrophy is a congenital anomaly. In the newborn infant, the nurse would note the extrusion of the urinary bladder to the outside of the body. This occurs as a result of a defect in the lower abdominal wall. The nurse should institute measures as prescribed to protect the urinary bladder and prevent injury to the bladder mucosa. Surgical intervention will be planned to correct the condition. You will learn about this congenital anomaly in your maternity nursing course when you study newborn disorders.

References

Leifer (2011), p. 678; Perry et al (2010), p. 775.

110. The nurse notes that a child with Hirschsprung disease who is scheduled for surgery has inadequate fluid volume. The nurse should plan to implement which intervention to stabilize the child’s hydration status before surgery?

1. Monitor daily weight.

2. Monitor intake and output.

3. Administer tap water enemas.

4. Administer intravenous fluids and electrolytes.

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Planning

Content Area:

ANSWER: 4

Rationale:

A child with inadequate fluid volume is stabilized with intravenous fluids and electrolytes before surgical management of the aganglionic portion of the bowel. Measurement of daily weight and intake and output assesses hydration status. Tap water enemas will alter the child’s hydration status further.

Test-Taking Strategy:

Focus on the subject, to stabilize the child’s hydration status. Eliminate options 1 and 2 because they are assessments rather than interventions. Eliminate option 3 because it will further cause a decreased fluid volume. The correct option addresses stabilization. Review: care of the child with Hirschsprung disease.

Tip for the Beginning Nursing Student:

Hirschsprung disease is also known as congenital aganglionosis or megacolon and is the result of an absence of ganglion cells in the rectum and, to varying degrees, upward in the colon. Constipation, signs of bowel obstruction, abdominal pain and distention, vomiting, and failure to thrive are manifestations. You will learn about Hirschsprung disease in your pediatrics nursing course when you study gastrointestinal disorders.

References

Christensen, Kockrow: Foundations (2011), pp. 1024-1025; Hockenberry, Wilson (2011), p. 1306.

111. The nurse provides home care instructions to the parents of a toddler newly diagnosed with hemophilia. Which statement by the parents indicates a need for further instruction?

1. “We need to pad crib rails and table corners.”

2. “We need to obtain a medical identification bracelet for our child.”

3. “If our child has any discomfort, it is acceptable to give him aspirin.”

4. “We need to have our child use a soft-bristled, small toothbrush for dental hygiene.”

Level of Cognitive Ability:

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Teaching and Learning

Content Area:

ANSWER: 3

Rationale:

In the child with hemophilia, bleeding is a priority concern. Therefore, measures are implemented to prevent this occurrence. The environment should be made as safe as possible, and the parents are instructed to pad crib side rails and table corners to prevent injury. The child should wear a Medic-Alert bracelet for identification of the disorder. The parents are instructed about dental hygiene measures, such as using a soft-bristled, small toothbrush. Neither aspirin nor aspirin-containing compounds should be used, primarily because of their antiplatelet properties. Acetaminophen (Tylenol) can be used for discomfort if needed.

Test-Taking Strategy:

Note the strategic words a need for further instruction. These words indicate a negative event query and the need to find the option that indicates an incorrect parental statement. Recalling that bleeding is the priority concern and that aspirin has antiplatelet properties will direct you to the correct option. Review: discharge teaching points for a child with hemophilia.

Tip for the Beginning Nursing Student:

Hemophilia is a hereditary bleeding disorder characterized by a deficiency of one of the factors necessary for the coagulation of blood. The severity of the disorder varies with the extent of the deficiency. Nursing care focuses on preventing bleeding and providing a safe environment. You will learn about hemophilia in your pediatrics nursing course when you study hematological disorders.

References

Christensen, Kockrow: Foundations (2011), pp. 995-996; Hockenberry, Wilson (2011), p. 1444.

112. The nurse is preparing to care for a pediatric client with an intravenous solution infusing. The nurse should ensure that which item is in place to prevent fluid overload in this client?

2. Infusion pump

3. Macrodrip infusion set

4. Large-bore intravenous catheter

Level of Cognitive Ability:

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Nursing Process/Implementation

Content Area:

ANSWER: 2

Rationale:

The most effective means of preventing irregularities in volume infusion for the pediatric client is the use of an infusion pump. This prevents both overhydration and underhydration. An armboard may be helpful in certain instances to minimize movement of the extremity with the catheter, but it is not an effective means for regulating intravenous flow. A small-bore catheter and a microdrip infusion set, rather than a macrodrip set, are used in the pediatric client.

Test-Taking Strategy:

Focus on the subject, to prevent fluid overload. The only item in the options that will accomplish this is an infusion pump. Use of an infusion pump will assist in preventing fluid overload. Review: care of the pediatric client receiving an intravenous infusion.

Tip for the Beginning Nursing Student:

When a child (or adult) is receiving fluids by the intravenous route (through a vein), the nurse needs to monitor the client and infusion closely to ensure that the fluid is infusing at the prescribed rate. If the fluid infuses too rapidly, serious complications can occur from the excess fluid. An infusion pump, which controls the amount of fluid infusing, should be used to administer intravenous fluids to a pediatric client. An important point to remember, however, is that the infusion pump (as with any device or machine) can fail or work improperly, so the nurse needs to monitor the child closely during intravenous infusion, even if an infusion pump is used. You will learn about the administration of intravenous fluids to the child in your pediatrics nursing course.

References

Hockenberry, Wilson (2011), pp. 1071-1072, 1076; Leifer (2011), pp. 506-507.

113. A mother tells the clinic nurse that she does not want her child to receive any immunizations because she has heard that they cause serious illnesses. The nurse should make which appropriate statement to the mother?

1. “Are you afraid your child is going to die from the injection?”

2. “Why are you afraid? Children are immunized every day without a problem.”

3. “There will be a slight discomfort at the time of the injection, but that is all that will happen.”

4. “I can see you are very concerned about your child. What do you think might happen after an immunization is given?”

Level of Cognitive Ability:

Client Needs:

Psychosocial Integrity

Integrated Process:

Communication and Documentation

Content Area:

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Tags: Saunders 2014-2015 Strategies for Test Success Passing Nursing S

Jul 24, 2016 | Posted by admin in NURSING | Comments Off

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