Pediatric Nursing An Introductory Text 11th edition by Debra L. Price-Test Bank

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Pediatric Nursing An Introductory Text 11th edition by Debra L. Price-Test Bank

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Pediatric Nursing An Introductory Text 11th edition by Debra L. Price-Test Bank

Price: Pediatric Nursing, 11th Edition

 

Chapter 02: Care of the Child with Medical/Surgical Needs

 

Testbank

 

MULTIPLE CHOICE

 

  1. A nurse who may have a private practice in the office of a pediatrician or a family practice physician is:
a. A school nurse
b. A home health nurse
c. A pediatric nurse practitioner
d. Any licensed LVN or RN

 

 

ANS:   C

A pediatric nurse practitioner may conduct a private practice in the office of a pediatrician or family practice physician performing physical examinations and general well-child services such as school-based clinics or health clinics.

 

DIF:    Cognitive Level: Application             REF:    p. 8                  OBJ:    2

TOP:    The Pediatric Nurse Practitioner        KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. A newly admitted 5-year-old asks if he can wear his cowboy shirt. The nurses response will be based on the understanding that wearing his own clothes will
a. Make child feel more comfortable
b. Present an infection control problem
c. Make caring for the child more difficult
d. Not be permitted

 

 

ANS:   A

Allowing the child to wear his own clothes helps to bridge the gap between home and hospital. Wearing clothes from home should not pose an infection control problem. The nurse can assess the clothing and determine if this is a risk.

 

DIF:    Cognitive Level: Application             REF:    p. 10                OBJ:    4

TOP:    The Hospital Setting                          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. A 4-year-old is going to have a dressing change that may be painful and frightening, therefore the nurse will perform this procedure in:
a. The patient room, because the surroundings are familiar
b. The treatment room, so the child will not associate negative feelings with the patient room
c. The playroom, so the child will be distracted by other children
d. A screened-off area in the hall to reduce visual stimulation

 

 

ANS:   B

Painful and frightening procedures are accomplished in the treatment room. The child needs to feel safe and secure in the patient room. Performing the procedure in front of other children is inappropriate.

 

DIF:    Cognitive Level: Application             REF:    pp. 11-12         OBJ:    4

TOP:    The Hospital Setting                          KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The nurse clarifies that the purpose of the pediatric unit playroom is to provide:
a. A safe place for children to go when the nurses take a break
b. An incentive for patients to choose this hospital
c. An activity area to alleviate the stress of hospitalization
d. An environment to determine if the child is well enough for discharge

 

 

ANS:   C

Playrooms provide a place for children to play and interact with other children. Many units include a play therapist or a child life specialist in attendance.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 10                OBJ:    3

TOP:    Playrooms       KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The nurse assesses that a 2-year-old who cries continuously after his mother leaves, watches the door for her return, and then finally exhausts himself and goes to sleep is in the separation anxiety phase of:
a. Despair
b. Denial
c. Protest
d. Depression

 

 

ANS:   C

The child is in the protest stage. Depression is not a stage of separation.

 

DIF:    Cognitive Level: Application             REF:    p. 11                OBJ:    3

TOP:    The Childs Reaction to Hospitalization

KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The parents of a 3-year-old who is scheduled to have surgery the following week ask the home health nurse if a tour of the pediatric unit prior to the procedure is wise. The nurse responds:
a. Yes, because it allows the parents to meet the people that will be taking care of their child.
b. No, because it will overwhelm and frighten your child.
c. No, because it will be an infection control risk.
d. Yes, because parents will not be allowed to stay with the child in the hospital.

 

 

ANS:   A

A prehospitalization tour or class will help to alleviate the anxiety of the parent and child. The child will be with his parents during the tour. It is not an infection control risk. The parents will be encouraged to stay with the child.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 15                OBJ:    5

TOP:    The Familys Reaction to Hospitalization

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity

 

  1. When greeting a newly admitted pediatric patient and family, the nurse should:
a. Stand erect in a confident manner
b. Show warmth and friendliness to the child and family
c. Be polite and formal to show respect
d. Hurry through the interview to lessen the stress on the child

 

 

ANS:   B

The nurse will greet the child at eye level. Towering over the child is frightening. The nurse should be warm and friendly. The nurse should be calm and unhurried when talking with the child and family.

 

DIF:    Cognitive Level: Application             REF:    p. 16                OBJ:    4

TOP:    Therapeutic Relationships                  KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The school nurse would consider a recommendation for referral to Shriners Hospital to the parents of a child with:
a. A developmental retardation
b. A cleft lip
c. An orthopedic deformity
d. A behavioral problem

 

 

ANS:   C

Shriners Hospitals is a network of pediatric specialty hospitals in which children younger than 18 years of age with orthopedic conditions or burns are treated without cost.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 9                  OBJ:    2

TOP:    Shriners Hospitals                             KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. The nurse performing a review of systems on an 8-month-old infant who is awake and calm should make the initial assessment:
a. Examination of the ears with an otoscope
b. Auscultation of the heart, lungs, and bowel sounds
c. Obtaining a rectal temperature
d. Palpation of the abdomen

 

 

ANS:   B

Auscultation of the heart, lungs, and abdomen should be the initial assessment as it is the least stressful, especially if the child has had an opportunity to handle the stethoscope.

 

DIF:    Cognitive Level: Application             REF:    p. 17                OBJ:    7

TOP:    Systems Review                                 KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When auscultating the heart of a 3-year-old girl, an irregular heartbeat is assessed. The nurse recognizes that:
a. This is normal for a child younger than 4 years of age
b. The arrhythmia should be documented and reported to the charge nurse
c. This may be caused by anxiety and should be rechecked in 1 hour
d. This is an emergency, and help should be called

 

 

ANS:   B

A child of 3 years of age should have a regular rhythm. An irregular heart rhythm should be documented and reported to the nurse in charge immediately. Arrhythmias do not pose an immediate threat.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 18                OBJ:    7

TOP:    Systems Review                                 KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When referring a child and family to a hospice service, the nurse considers that to qualify for hospice, the child must:
a. Have adequate insurance coverage
b. Be in an active therapeutic protocol
c. Have a terminal diagnosis
d. Have less than 6 months to live

 

 

ANS:   D

To qualify for hospice, a patient must have less than 6 months to live. These services are supplied either in the hospital or at home.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 9                  OBJ:    2

TOP:    Vital Signs      KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The parents of a hospitalized 2-year-old are distressed that the child no longer is toilet trained and now requires a diaper. The nurses best response to this would be:
a. Dont worry. Your child will regain toilet training in a few days.
b. We can start a bladder training program that will restore toilet training.
c. Toddlers often regress when stressed. Using a diaper now is appropriate.
d. You need to strongly enforce toilet training practices now.

 

 

ANS:   C

With the stress of hospitalization, toddlers may abandon recently acquired skills. When the stress is manageable, the skills will return.

 

DIF:    Cognitive Level: Application             REF:    p. 11                OBJ:    5

TOP:    Regression      KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The parents of a 3-year-old who is hospitalized with mumps and is in isolation ask if their child may be allowed out of bed. The nurses most helpful response would be:
a. No. A child with an infectious disease needs to stay in bed.
b. Yes. Your child may go anywhere in the unit.
c. No. Your child will spread the mumps if allowed out of bed.
d. Yes. Your child can walk around here in the room, but not out in the hall.

 

 

ANS:   D

A toddler who feels like getting out of bed and walking should do so; however, keep in mind that a child with an infectious disease should stay within the confines of the room.

 

DIF:    Cognitive Level: Application             REF:    p. 12                OBJ:    10

TOP:    Toddler Activity                                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When a 4-year-old asks the nurse if an injection will hurt, the most therapeutic response would be:
a. No. It is over so quickly you will not feel a thing.
b. Yes. You can see how sharp the needle is, so it will hurt when it goes in.
c. No. A big 4-year-old like you wont be bothered by a little needle stick.
d. Yes. There will be a little sting, but hugging this bear will help.

 

 

ANS:   D

The nurse should be truthful about procedures. Honesty helps the child not to feel betrayed. Preparation for a painful procedure should be done immediately before the procedure so as not to draw out the anticipation.

 

DIF:    Cognitive Level: Application             REF:    p. 12                OBJ:    4

TOP:    Preparation for a Painful Procedure

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The pediatric nurse takes into consideration that the most stressful procedure for a preschooler would be:
a. Casting a broken arm
b. Circumcision
c. Suturing a laceration on the hand
d. Removing sutures from the face

 

 

ANS:   B

Preschoolers fear mutilation during hospitalization, particularly invasive procedures that involve the genital area.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 12                OBJ:    5

TOP:    Preschoolers Fear of Mutilation        KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. After the nurse has lowered the crib rail on the bed of a 6-month-old, in order to prevent the child from rolling out of bed, the nurse should:
a. Restrain the child with a sheet
b. Stand touching the side of the bed
c. Place the child perpendicular to the side rail
d. Ask assistance from the parent or coworker to hold the child

 

 

ANS:   C

Placing the child perpendicular to the side rails prevents the child from rolling off the bed.

 

DIF:    Cognitive Level: Application             REF:    p. 22                OBJ:    9

TOP:    Safety             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A 6-year-old newly diagnosed with Type I diabetes is going home today. Her parents have been taught how to manage her disease, but the nurse is concerned that they may not remember everything that was taught. The nurse can best help the parents by:
a. Instructing the parents that they can bring their child back to the unit for additional help as needed
b. Beginning discharge planning as soon as the order for discharge has been written by the attending physician
c. Providing the family with written instructions regarding diet, medications, activity, and procedures needed by the child
d. Delaying informing the parents of the impending discharge to prevent stress and anxiety for the parents and child

 

 

ANS:   C

Providing written instructions about all aspects of care will reinforce teaching and provide an important resource for the parents. The parents need to be informed of discharge as soon as possible so that they can begin making arrangements and can prepare for departure.

 

DIF:    Cognitive Level: Synthesis                REF:    p. 22                OBJ:    8

TOP:    Discharge Planning                            KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A child is admitted with an infectious disease and is placed in an isolation room. In order to assess this child, the nurse should:
a. Use his or her own stethoscope, and wipe it thoroughly with antiseptic after each use
b. Use a stethoscope reserved for this patient in the room
c. Use a sterile stethoscope each time the patient is assessed
d. Remove the used equipment each day for disinfection

 

 

ANS:   B

A patient in isolation will have equipment for daily care placed in the isolation room. A sterile stethoscope is not needed. Equipment is kept in the room until the patient is discharged. Removing the equipment daily will increase exposure risk to others.

 

DIF:    Cognitive Level: Application             REF:    p. 25                OBJ:    10

TOP:    Preventing the Transmission of Infection

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. Because the child in isolation is not permitted to go to the playroom, the nurse explains that toys that are:
a. Brought from the playroom will have to be thrown away
b. Washable can be brought from the playroom and later disinfected
c. From the playroom must be sealed in a plastic bag
d. For the childs use must be brought from home

 

 

ANS:   B

The child can have toys when in isolation, but they must be washable. Children do not have to bring their own toys to play.

 

DIF:    Cognitive Level: Application             REF:    p. 25                OBJ:    10

TOP:    Preventing the Transmission of Infection

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The best restraint for an 8-month-old with sutures after the repair of a cleft lip would be:
a. Elbow restraint
b. Mummy restraint
c. Jacket restraint
d. No restraint at all

 

 

ANS:   A

The elbow restraint is the best choice as it is useful in the prevention of the child touching the face. Mummy or jacket restraints are excessive and not particularly helpful with a facial injury.

 

DIF:    Cognitive Level: Application             REF:    p. 24                OBJ:    11

TOP:    Restraints        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse is caring for a 5-year-old who had surgery yesterday. In order to evaluate the degree of pain the child is experiencing, the nurse will:
a. Expect the child to complain if she is in pain
b. Observe for verbal and nonverbal cues that the child is in pain
c. Give pain medication if the child is crying
d. Ask the child to rate her pain on a scale of 1 to 10

 

 

ANS:   B

Children do not always complain if they are in pain. They are frightened by the events and their surroundings. The nurse should evaluate for both verbal and nonverbal cues of pain. Children may not always cry if they are in pain. Conversely, they may be crying for another reason. Children at this age cannot rate their pain in this way. The nurse would use a pictorial pain scale.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 28                OBJ:    12

TOP:    The Child in Pain                                KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse assesses an 8-month-old who had abdominal surgery yesterday as showing an occasional grimace, is kicking legs constantly, is squirming and tense, moans and whimpers occasionally, and is difficult to console. Using the FLACC scale, the nurse would document a score of:
a. 4
b. 5
c. 6
d. 7

 

 

ANS:   D

RAT: Occasional grimacing = 1, kicking = 2, squirming and tense = 1, occasional moaning = 1, difficult to console = 2. This is a total score of 7.

 

DIF:    Cognitive Level: Application             REF:    p. 29                OBJ:    11

TOP:    Pain Assessment (FLACC)                KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse who is admitting a child with severe asthma is alarmed when the parents confess that they have been giving the child Echinacea because this herbal remedy may cause:
a. Severe headache
b. Increased asthma
c. Increased blood pressure
d. Liver inflammation

 

 

ANS:   B

The herbal remedy Echinacea may cause increased asthma or anaphylaxis.

 

DIF:    Cognitive Level: Application             REF:    p. 17                OBJ:    6

TOP:    Alternative Remedies                         KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Pharmacological Therapies

 

COMPLETION

 

  1. The nurse recommends a method for children to act out situations that are part of their hospital experience through __________.

 

ANS:

Dramatic play

Dramatic play allows small children to work through emotions and stressors that they may not be able to verbalize.

 

DIF:    Cognitive Level: Knowledge             REF:    p. 13                OBJ:    4

TOP:    The Childs Reaction to Hospitalization

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. The nurse takes into consideration that a Mexican-American family may seek the advice of a __________ , a folk healer, for treatment or herbal remedies.

 

ANS:

Curandero

The curandero is used by the Hispanic community as a folk healer or spiritual healer.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 19                OBJ:    5

TOP:    Curandero       KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

MULTIPLE RESPONSE

 

  1. The role of the school nurse has been expanded to include such services as: (Select all that apply.)
a. Provision of health counseling
b. Student advocate
c. Administration of selected immunizations
d. Health screenings
e. Complete physical examinations (system review)

 

 

ANS:   A, B, C, D

School nurses may provide health counseling and education and health screenings, and act as student advocate.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 9                  OBJ:    2

TOP:    Duties of the School Nurse                KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. The school nurse recommends to a family that they consider the use of an outpatient clinic for the upcoming tonsillectomy of their child because the advantages of this service are: (Select all that apply.)
a. Reduction of risk of infection
b. Less stress to the child
c. Reduced cost
d. Requires no insurance coverage
e. No prolonged separation of the child from the family

 

 

ANS:   A, B, C, E

Outpatient surgery, although it may require insurance coverage, has the advantages of reduced risk of infection and reduced cost. The child is less stressed as there is no familial separation.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 9                  OBJ:    3

TOP:    Outpatient Surgery                             KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. The nurse who is in the role of case manager has the responsibilities of: (Select all that apply.)
a. Making home care arrangements
b. Performing hands-on care of the patient in the home
c. Monitoring the continuum of care
d. Managing medical care
e. Assessing the needs of the patient and family

 

 

ANS:   A, C, D, E

The case manager arranges for home care by organizing medical care, assessing the needs of the patient and family, and organizing the availability of necessary equipment. The case manager does not do hands-on care.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 9                  OBJ:    2

TOP:    The Case Manager                              KEY:   Nursing Process Step: N/A

MSC:   NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. The family of a hospitalized 12-year-old who has been burned confides to the nurse that the patients 6-year-old sister is distressed about where her brother has gone. They ask what might allay her fears. The nurse suggests: (Select all that apply.)
a. Allow the sister to visit in the hospital
b. Explain in detail about the painful surgery and necessary care
c. Encourage the sibling to send cards
d. Request that the patient call his sister on the telephone
e. Report the daily progress to the sibling

 

 

ANS:   A, C, D, E

Keeping siblings informed and in touch helps to allay concerns. Telephone calls and sending of cards is helpful. Explaining in detail about the treatment may increase anxiety in a sibling.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 15                OBJ:    5

TOP:    Sibling Concerns                                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. A patient in an isolation room is experiencing projectile vomiting. In order to assist this patient, the personal protective equipment that the nurse should don would be: (Select all that apply.)
a. Gloves
b. Mask
c. Gown
d. Protective eyewear
e. Head cover

 

 

ANS:   A, C, D

Standard precautions call for the use of gloves and gowns; because there is a problem with projectile vomiting, protective eyewear should be included. Head cover is not necessary.

 

DIF:    Cognitive Level: Comprehension       REF:    pp. 25-26         OBJ:    12

TOP:    Preventing the Spread of Infection    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse reviews nursing implementations that can help relieve the stressors of hospitalization for a child to include: (Select all that apply.)
a. Providing a consistent caregiver
b. Keeping explanations to a minimum
c. Encouraging parents to stay with the child
d. Discouraging play in order to keep the child calm
e. Allowing the child to make as many choices as possible

 

 

ANS:   A, C, E

Consistent caregivers, presence of the parent(s), and allowing as many choices as possible will relieve the stress of hospitalization. Explanations should be frequent and age-appropriate, and play should be encouraged.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 15                OBJ:    4

TOP:    The Childs Reaction to Hospitalization

KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Psychological Integrity: Coping and Adaptation

Price: Pediatric Nursing, 11th Edition

 

Chapter 12: Cardiac Disorders

 

Testbank

 

MULTIPLE CHOICE

 

  1. The nurse draws a picture of fetal circulation showing how blood flows from the right atrium to the left atrium through the:
a. Ductus arteriosus
b. Foramen ovale
c. Ductus venous
d. Pulmonary arteries

 

 

ANS:   B

In fetal circulation, the blood flows through a hole in the septum between the atria called the foramen ovale. The opening closes at birth.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 227              OBJ:    1

TOP:    Foramen Ovale                                   KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse caring for a 6-month-old child with tetralogy of Fallot, which allows a right to left shunting, would expect to assess in this child:
a. Cyanosis
b. Dyspnea
c. Bradycardia
d. Hypotension

 

 

ANS:   A

A defect that allows unoxygenated blood to be mixed with oxygenated blood in the circulating blood volume will result in cyanosis.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 229              OBJ:    3

TOP:    Tetralogy of Fallot                             KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse caring for a 6-month-old child who had cardiac catheterization the same morning, with the insertion site in the left groin, will include in the post-operative care:
a. Keep the left extremity straight for 4 to 6 hours
b. Remove the dressing over the insertion site to assess for bleeding
c. Keep both legs flexed
d. Discourage the parents from holding the baby

 

 

ANS:   A

The extremity on the side of the puncture should be kept straight for 4 to 6 hours. The dressing over the site should not be removed, but it should be assessed for bleeding through the dressing. Parents may hold the infant if they keep the leg straight.

 

DIF:    Cognitive Level: Application             REF:    p. 230              OBJ:    4

TOP:    Cardiac Catheterization                     KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The school nurse recognizes an indicator of a possible congenital heart defect when a first grader assumes a squatting position during periods of physical activity. This procedure helps the child by:
a. Allowing blood to leave the heart more forcefully through the aorta
b. Occluding the femoral veins and reducing the work of the right side of the heart
c. Reducing the cramping sensation in the legs due to poor function of the left side of the heart
d. Easing respiratory effort by compressing the abdominal organs

 

 

ANS:   B

This position is assumed by instinct as it occludes the venous return, reducing the work of the right side of the heart and improving oxygenation.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 230              OBJ:    2

TOP:    Squatting Position                              KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is aware that when the body experiences frequent hypoxemia, it compensates by:
a. Producing more white blood cells
b. Producing more red blood cells
c. Dilating the pulmonary artery
d. Increasing urinary output to reduce blood volume

 

 

ANS:   B

Chronic hypoxia causes the body to compensate with the production of more red blood cells, resulting in a condition called polycythemia.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 230              OBJ:    3

TOP:    Polycythemia                                      KEY:   Nursing Process Step: Planning

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse caring for a 9-month-old child with a mixed-type congenital heart defect who is also diagnosed as physiologic failure to thrive assesses that this size deficit is most likely due to:
a. Inadequate systemic circulation related to the heart defect
b. Inability to metabolize nutrients
c. Inadequate intake related to the child trying to nurse and breathe at the same time
d. Inappropriate types of formula offered to the infant

 

 

ANS:   C

These children fail to thrive because they have difficulty feeding as they try to nurse and breathe. Children become fatigued with the effort and stop nursing.

 

DIF:    Cognitive Level: Application             REF:    p. 230              OBJ:    3

TOP:    Failure to Thrive                                 KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse caring for an African-American baby with a mixed congenital heart defect will assess cyanosis by observing the babys:
a. Sclera
b. Mucous membranes of the mouth
c. Hollows beneath the eyes
d. Earlobes

 

 

ANS:   B

Cyanosis can be assessed in children with a dark complexion by assessing the oral mucous membranes, the palms of the hands, and the bottoms of the feet.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 230              OBJ:    3

TOP:    Cyanosis         KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. When assessing clubbed fingers in an 8-year-old child with a mixed congenital cardiac defect, the nurse is aware that this sign is due to:
a. Intermittent hypertension
b. Shunting of the blood from left to right
c. Chronic hypoxia
d. Vasoconstriction

 

 

ANS:   C

Chronic hypoxia in children with a mixed CHD causes pooling of the blood in the capillaries, which results in clubbing of the fingers.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 230              OBJ:    3

TOP:    Clubbing of the Fingers                     KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is aware that the child with an atrial septal defect may be a candidate for a repair with an Amplatzer device if:
a. The defect is high in the atrial septum
b. The child has not experienced cyanotic spells
c. The child is at a normal weight for his or her age
d. The defect has a small diameter

 

 

ANS:   D

Rather than putting the child through open heart surgery, an occluding device called an Amplatzer can be placed in the defect if the defect is small enough. This device can be placed during cardiac catheterization.

 

DIF:    Cognitive Level: Application             REF:    p. 232              OBJ:    2

TOP:    Amplatzer Devices                             KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Reduction of Risk

 

  1. The nurse who is assessing a child with patent ductus arteriosus, which is a defect that increases pulmonary congestion, would anticipate finding:
a. A machine-like murmur
b. A weak, thready pulse on exertion
c. A history absent of infections
d. A child of normal weight and height

 

 

ANS:   A

The patent ductus creates a machine-like murmur. The child will have a full bounding pulse on exertion, a history of frequent respiratory infections, and possible failure to thrive.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 231              OBJ:    2

TOP:    Patent Ductus Arteriosus                   KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. One of the characteristics of children who have atrial septal defects is that these children:
a. Are always slightly cyanotic and short of breath
b. Are usually asymptomatic
c. Have unpredictable outcomes from surgical correction
d. Are not at risk for infective endocarditis

 

 

ANS:   B

These children usually have no symptoms.

 

DIF:    Cognitive Level: Application             REF:    p. 232              OBJ:    3

TOP:    Atrial Septal Defect                           KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

  1. The nurse assessing a 10-year-old child diagnosed with coarctation of the aorta anticipates that this child will have:
a. Bounding pulses in the upper extremities and weak pulses in the lower extremities
b. Chest pain on exertion
c. Edema in the lower extremities
d. A harsh diastolic murmur

 

 

ANS:   A

Coarctation of the aorta is a narrowing of the aorta that causes bounding pulses in the upper extremities, leaving weak pulses in the lower extremities. There is no pain or edema.

 

DIF:    Cognitive Level: Application             REF:    p. 233              OBJ:    N/A

TOP:    Coarctation of the Aorta                    KEY:   Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The parents of a 9-month-old child who has been diagnosed with coarctation of the aorta are anxious to have the defect repaired quickly. The nurses best response will be based on the knowledge that:
a. The repair can be done when the child has tripled the birth weight
b. The repair will be done in stages over a period of several months
c. Repair at such an early age will almost assure recurrence
d. Surgical repair is the only option

 

 

ANS:   C

Repair of a coarctation is best done between 3 and 6 years of age. Repair done earlier than that presents a high rate of recurrence. Surgery can be delayed by using an aortic balloon to open the aorta.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 233              OBJ:    N/A

TOP:    Coarctation of the Aorta                    KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Reduction of Risk

 

  1. When the baby with tetralogy of Fallot becomes irritable and begins to cyanose, the nurse should:
a. Lift the baby to a sitting position
b. Position the baby on the right side with the head elevated
c. Administer oxygen per nasal cannula
d. Place the baby in a kneechest position

 

 

ANS:   D

The baby should be placed in a kneechest position. This decreases blood flow to the lower extremities and increases blood flow to the upper body and head. Oxygen is not helpful.

 

DIF:    Cognitive Level: Application             REF:    p. 233              OBJ:    3

TOP:    Tet Spells        KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse explains that the medication Prostaglandin E1 is being given to their child with transposition of the great vessels to:
a. Increase blood flow to the system
b. Keep the ductus arteriosus open
c. Stimulate the production of red blood cells
d. Decrease pulmonary congestion

 

 

ANS:   B

The administration of Prostaglandin E1 has been found beneficial in keeping the ductus arteriosus open after birth. This opening allows oxygenated blood to enter the systemic circulation. Without a patent ductus or a septal defect, the child would not have access to oxygenated blood.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 234              OBJ:    3

TOP:    Prostaglandin E1                                KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. The nurse caring for a 22-pound 1-year-old child who has had open heart su

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