Pediatric Exam (1-23)

1-A child with autism spectrum disorder is being admitted to an acute care unit. Which is the most important nursing action? 1. Placing the child in a private room away from the nurses' station 2. Placing the child in a private room near the playroom 3. Placing the child in a semi-private room near the nurses' station 4. Placing the child in a semi-private room with another child with autism spectrum disorder Explanation: Children with autism spectrum disorder (ASD) often exhibit sensory processing problems; they may be hyper- or hypo-sensitive to sounds, lights, movement, touch, taste, and smells. A calming environment with minimal stimulation should be provided; a private room away from the nurses' station is the best location. The nurse can also facilitate a calming environment by: Using a quiet or monotone voice when speaking to the child Using eye contact and gestures carefully Moving slowly Limiting visual clutter Maintaining minimal lighting Providing the child with a single object to focus on (Option 2) A private room is an appropriate placement; however, the noise and activity from the playroom may be distracting to the child with ASD. (Option 3) A semi-private room near the nurses' station is likely to have a stimulating environment due to the noise, lighting, and work pace in the area. (Option 4) Placing the child in a semi-private room with another child with ASD does not promote a calming environment. Educational objective: Because children with autism spectrum disorder often exhibit sensory processing problems, they need a calming environment with minimal stimulation. 2-The nurse who is caring for a 1-month-old with Tetralogy of Fallot will report which finding to the health care provider as a priority? 1. Hemoglobin level of 24.9 g/dL (249 g/L) 2. Murmur on heart auscultation 3. Oxygen saturation of 82% on room air 4. Poor weight gain Explanation: The normal range for hemoglobin in a 1-month-old is 12.5-20.5 g/dL (125-205 g/L). Hemoglobin of 24.9 g/dL (249 g/L) is diagnostic of polycythemia (elevated hemoglobin levels). Infants with cyanotic cardiac defects can develop polycythemia as a compensatory mechanism due to prolonged tissue hypoxia. Polycythemia will increase blood viscosity, placing an infant at risk for stroke or thromboembolism (Option 1). Clubbing is another manifestation of prolonged hypoxia. (Option 2) Cardiac murmur is expected in heart defects. This is not a priority to report. (Option 3) Tetralogy of Fallot (TOF) is a cyanotic cardiac defect. Infants with TOF will normally maintain oxygen saturations of 65%-85% until the defect is surgically corrected. (Option 4) Poor weight gain is common with congenital heart defects. This finding is not a priority. Feeding intolerance, tachypnea, and dyspnea usually indicate severe hypoxemia. Educational objective: Poor oxygenation can cause elevated levels of hemoglobin (polycythemia), which increase blood viscosity. Thickened serum puts infants at risk for stroke or thromboembolism. An infant with polycythemia must stay hydrated. 3-The nurse plans care for a child being admitted with a diagnosis of measles. Which of the following will the nurse include in the plan of care? Select all that apply. 1. Limit visitors to 20 minutes of contact with the client 2. Place child on airborne precautions in a negative-pressure room 3. Recommend postexposure prophylaxis for unvaccinated, susceptible family members 4. Restrict child from eating raw vegetables or fruits 5. Wear a gown, gloves, and mask during all client contact Explanation: Measles, or rubeola, is a highly contagious disease that can affect people of all ages. The incidence of the disease had been drastically reduced in the United States; however, there has been a resurgence of cases due to increased travel to foreign countries and a rise in the number of nonvaccinated children. Measles is spread through the air when infected persons cough and sneeze, and the virus can remain in the air for up to 2 hours. The disease starts with fever, cough, runny nose, and conjunctivitis. Soon after, a rash appears on the face and slowly spreads downward on the body. Vaccine against measles is available and is up to 97% effective. Postexposure vaccination is recommended for exposed persons who cannot show immunity by vaccination or by having had the disease previously. Hospitalized clients with measles are placed on airborne precautions in a negative-pressure room. Supplementation with vitamin A has been shown to reduce eye damage, blindness, and morbidity by up to 50% and is recommended by the World Health Organization (Options 2 and 3). (Option 1) Limiting exposure is not necessary as long as those in contact with the client use the appropriate personal protective equipment. (Option 4) Restricting the child from eating raw fruits and vegetables is needed for neutropenic precautions (not measles). (Option 5) Clients with measles are placed on airborne precautions in a negative-pressure room. Masks (ideally N95 respirators) are required. Gown, gloves, and face shield are required only if substantial spraying of respiratory fluids is anticipated. Educational objective: Clients with measles are highly contagious and should be placed on airborne precautions in a negative-pressure room. Health care providers should use N95 respirators or masks during client exposure. Unvaccinated family members are susceptible and should be advised to receive postexposure prophylaxis. 4-The nurse in the pediatric clinic is triaging telephone messages. The nurse should call the parent of which child first? 1. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear 2. 4-year-old post adenotonsillectomy who is now reporting ear pain 3. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics 4. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice today Explanation: The child with a recent tonsillectomy is at highest safety risk. Postoperative hemorrhage from tonsillectomy is uncommon but may occur up to 14 days after surgery. During the healing process, white scabs will form at the surgical sites. Sloughing then occurs approximately 7 days after the procedure, increasing the risk for bleeding. Caregivers should be taught to observe for signs of bleeding (eg, frequent swallowing or throat clearing). The child may also experience increased pain. The nurse should instruct this parent that the child should not resume strenuous activity or contact sports for at least 7-14 days post surgery. (Option 1) Tympanostomy tubes or grommets are pressure-equalizing tubes placed in the tympanic membrane to facilitate drainage of middle ear fluid (eg, for eustachian tube dysfunction or recurrent otitis media with effusion). One of this child's tubes has most likely fallen out of the eardrum. No immediate intervention is required; however, the health care provider should be notified. (Option 2) Clients often report ear pain (otalgia) following adenotonsillectomy due to irritation of the 9th cranial nerve (glossopharyngeal) in the throat, causing referred pain to the ears. This is a normal, expected finding. (Option 3) The contagious period for strep throat starts at the onset of symptoms and lasts through the first 24 hours of beginning antibiotic treatment. This client is able to return to activities and does not require an immediate call back. Educational objective: The risk of post-tonsillectomy hemorrhage persists for up to 14 days after surgery, and resuming strenuous activity too early increases this risk. The potential for bleeding is higher 7-10 days postoperatively while sloughing occurs. 5-Which of the following statements made by the mother of a child recently diagnosed with celiac disease indicates a need for further teaching? 1. "I will need to read the labels of all processed foods." 2. "It is okay if my child eats rice, corn, and potatoes." 3. "My child can have small amounts of foods containing wheat as long as she remains symptom free." 4. "My child will need to be on a gluten-free diet for the rest of her life." Explanation: The following are important principles to teach clients with celiac disease: 1. All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats. 2. Rice, corn, and potatoes are gluten free and are allowed on the diet. 3. Deficient vitamins (mainly fat-soluble vitamins), iron, and folic acid should be replaced. 4. Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten free. 5. Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from the diet reduces the risk of nutritional deficiencies and intestinal cancer (lymphoma). 6. Eating even small amounts of gluten will damage the intestinal villi although the client may have no clinical symptoms. All sources of gluten must be eliminated from the diet (Option 3). Educational objective: All sources of gluten must be eliminated from the diet of a client with celiac disease; consuming small amounts, even in the absence of clinical symptoms, will increase the risk of damage to the intestinal villi. Clients can have foods containing rice, corn, and potatoes. They should read food labels and follow the diet for the rest of their lives. 6-A 1-month-old infant has received a diagnosis of phenylketonuria (PKU). Which statements about PKU are true? Select all that apply. 1. A low-phenylalanine diet is required 2. Meat and dairy products should not be introduced to the diet 3. Phenylketonuria is a self-limiting disease that resolves by adulthood 4. Special infant formula is required 5. Tyrosine should be removed from the diet Explanation: Phenylketonuria (PKU) is a genetic inborn error of metabolism. Individuals with PKU lack the required enzyme (phenylalanine hydroxylase) for converting the amino acid phenylalanine into the amino acid tyrosine. As unconverted phenylalanine builds up, irreversible neurologic damage can occur. A low-phenylalanine diet is the only treatment for PKU (Option 1). Phenylalanine cannot be totally eliminated from the diet as it is an essential amino acid and necessary for normal development. The diet must meet nutritional needs while maintaining phenylalanine levels within a safe range (2-6 mg/dL for clients under age 12). There is no known age at which the diet can be discontinued safely, and lifetime dietary restrictions are recommended for optimum health (Option 3). Dietary management of the client with PKU includes: 1. Monitoring serum levels of phenylalanine 2. Including synthetic proteins and special formulas (eg, Lofenalac, Phenyl-Free) in the diet (Option 4) 3. Eliminating high-protein/phenylalanine foods (eg, meats, eggs, milk) from the diet (Option 2) 4. Encouraging consumption of natural foods low in phenylalanine (most fruits and vegetables) (Option 5) Restriction of dietary tyrosine is not necessary. Tyrosine levels in clients with PKU may be normal or slightly decreased. Educational objective: Phenylketonuria requires lifetime dietary restrictions. Infants should be given special formulas (eg, Lofenalac). For children and adults, high-phenylalanine foods (eg, meats, eggs, milk) should be restricted and replaced with protein substitutes. 7-A 5-year-old child is receiving morphine sulfate for pain. Which statement by the caregiver indicates that further teaching is necessary? 1. "I will call the nurse if my child begins to act aggressively." 2. "I'm concerned that my child thinks the pain is punishment." 3. "My child is playing and so does not need pain medication." 4. "The FACES pain scale seems to be working very well." Explanation: The child who is playing or sleeping might still be experiencing pain but is using distraction as a coping mechanism. This statement by the caregiver indicates that further teaching is needed. (Option 1) Preschool-age children may become physically or verbally aggressive when in pain. (Option 2) The preschool-age child experiences magical thinking and might feel that pain is a punishment for wrongdoing. (Option 4) Age-appropriate pain scales can be used to assess pain in children. The FACES pain rating scale consists of 6 cartoon faces with expressions from no pain to worst pain. Educational objective: A child's expression of pain varies based on developmental stage and past experiences with pain. The nurse should use age-appropriate pain scales. A child who is asleep or playing may be experiencing pain. 8-The registered nurse is teaching the parent of a 6-year-old about behavioral strategies for treating fecal incontinence due to functional constipation. Which statement by the parent indicates a need for further teaching? 1. "I will give my child a picture book to look at during toilet time." "I will give my child a reward for each bowel movement while sitting on the toilet." 2. "I will keep a log of my child's bowel movements, laxative use, and episodes of soiling." 3. 4. "I will schedule regular toilet sitting time for my child." Explanation: Fecal incontinence (ie, encopresis, soiling) refers to the repeated passage of stool in inappropriate places by children age ≥4 years. In more than 80% of cases, it is due to functional constipation (retentive type); in about 20% of cases, it may be caused by psychosocial triggers (nonretentive type). Management of fecal incontinence/constipation primarily includes 3 components: Disimpaction followed by prolonged laxative therapy, dietary changes (increased fiber and fluid intake), and behavior modification. Behavioral strategies are used to promote and restore regular toileting habits and to gain the child's cooperation and participation in the treatment program. Behavioral interventions include the following: Regularly schedule toilet sitting times 5-10 minutes after meals for 10-15 minutes (Option 4) Provide a quiet activity for the child during toilet sitting, which will help pass the time and make the experience more "enjoyable" (Option 1) Initiate a reward system to boost the child's participation in the treatment program; the reward would be given for effort, not for success of evacuation in the toilet (children with retentive encopresis have dysfunctional anal sphincters and little control over bowel movements; giving a reward for something the child has no control over would not be effective) (Option 2) Keep a diary or log of toilet sitting times, stooling, medications, and episodes of soiling to evaluate the success of the treatment (Option 3) Educational objective: A reward system is one of the behavioral strategies used in the treatment of functional incontinence (due to constipation). The reward is given to encourage the child's involvement in the treatment to restore normal bowel function. Rewards are given for the child's effort and participation, not for having bowel movements while sitting on the toilet. 9-The parents of a hospitalized preschooler are concerned because their toilet-trained child has started wetting the bed. Which response by the nurse is most helpful? 1. "Discipline your child by taking away playroom privileges." 2. "It is normal for your child to regress while hospitalized." 3. "Restricting fluids at nighttime will solve this problem." 4. "Your child is acting out due to the hospitalization." Explanation: Regression during hospitalization is a normal response to the stress of an unfamiliar environment, the fear and pain of invasive procedures, and the change in a child's normal routine. Toilet-trained children may start bed-wetting, and children who gave up the bottle or pacifier may ask for it. It is important for the nurse to explain that this behavior is completely normal and that the child will gain back previous milestones after discharge. (Option 1) Firm discipline would be counterproductive at this time. Punishment by restricting playtime would create more stress for the child. (Option 3) Limiting fluids at nighttime, voiding before bedtime, and involving the child in planning (eg, changing wet linens) are all appropriate interventions for enuresis. However, the first step is to reassure the parents and then teach them therapeutic interventions. (Option 4) Misbehaving is not an unusual behavior for a preschooler. Acting out would not be due exclusively to the hospitalization. Educational objective: Hospitalization can be very stressful for a child. Regressive behaviors during hospitalization are a normal response to changes in routine. The nurse should inform the caregivers that this behavior is temporary and that the child will regain lost milestones rapidly after discharge. 10-The nurse is discussing child safety with the parents of a 12-month-old who is just beginning to walk. Which statement by the parents indicates a need for further instruction? 1. "Our swimming pool is fenced in with a lock on the gate." 2. "We have installed childproof gates at the top and bottom of our stairs." 3. "We need to lower the mattress in our child's crib." 4. "When we can't be watching, we put our child in a mobile child walker." Explanation: Due to the relatively high incidence of injuries associated with child walkers, the American Academy of Pediatrics has recommended a ban on the manufacture and sale of mobile infant walkers. Accidents associated with child walkers include: Rolling down stairs (the most common cause of injury) Burns – children can reach high in a walker, enabling them to grab hot pot handles, reach heaters and fireplaces, or grab a hot cup of liquid off a counter or table Drowning – a child can fall into a bathtub or pool while in a mobile walker Poisoning – the child can reach higher objects Even if a parent is close by and watching a child in a walker, an accident may not be preventable. Children can move quickly and the parent or caregiver may not be able to respond quickly enough. Safer alternatives to mobile baby walkers include stationary walkers (no wheels) and play areas. If parents or caregivers insist on using a baby walker, they should be advised to choose one that meets the American Society for Testing and Materials safety standards. Walkers with braking mechanisms stop if at least one wheel drops off the riding surface. (Option 1) This is an appropriate action; swimming pools should be surrounded by fences with childproof locks to prevent accidental drowning. Wading pools and all water containers should be emptied after each use. (Option 2) This is an appropriate action; childproof gates should be installed on stairs and at the entrances to rooms that could pose danger to a child. (Option 3) This is an appropriate action; as children grow taller and can stand, they may be able to crawl over the crib rails and fall. Educational objective: Mobile baby walkers are associated with injuries such as falls and drowning as they can easily tip over. Children can also reach higher places while in a baby walker, enabling them to pull hot objects and dangerous substances off counters and tables. 11-A nurse is teaching the parent of an infant who had a febrile seizure about appropriate interventions. Which instruction is appropriate to include in the teaching? 1. "Give acetaminophen or ibuprofen every 6-8 hours to control fever." 2. "Give the infant frequent tepid sponge baths to control the fever." 3. "If he develops another seizure, wait 15 minutes to see if the seizure subsides." 4. "Place ice bags under the arms and around the neck to control fever." Explanation: Febrile seizures are an alarming experience for parents. They most commonly occur in children between ages 6 months to 6 years, with the peak of incidence occurring at age 18 months. The etiology is unknown. Simple febrile seizure management typically involves reassurance regarding the benign nature of most febrile seizures, and education about the risk of recurrence (around 30%) and seizure safety precautions (eg, side-lying positioning, removal from harmful environments). Parents should use antipyretics such as acetaminophen or ibuprofen to control fevers and make the child more comfortable. However, there is no evidence that antipyretics reduce the risk of future febrile seizures (Option 1). After the administration of antipyretics, additional cooling methods that may be beneficial for reducing fever include applying cool, damp compresses to the forehead; increasing air circulation in the room; and wearing loose or minimal clothing to increase skin exposure to air. However, care should be taken to prevent shivering, which can further raise the metabolic rate above that caused by fever. (Options 2 and 4) Bathing an infant in tepid water and placing ice bags under the arms and around the neck are not recommended techniques as these induce shivering, increase metabolic activity, have no antiseizure effects, and cause discomfort for the child. These cooling techniques are more effective for a child experiencing hyperthermia (eg, with heat stroke). (Option 3) Parents should be instructed to call 911 and seek medical assistance for a seizure lasting more than 5 minutes. Neurologic damage can occur with frequent and prolonged seizures. Educational objective: Febrile seizures, although alarming, are generally benign. Parents should be instructed on appropriate cooling methods (eg, antipyretics, cool compresses), seizure safety precautions, and the avoidance of shivering. 12-A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect? 1. Black, sticky stools 2. Greasy, foul-smelling stools 3. Stools mixed with blood and mucus 4. Thin, "ribbon-like" stools Explanation: Intussusception is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen, which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly"). Initially, some infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently, episodes of sudden abdominal pain (cramping), drawing the knees up to the chest, and inconsolable crying are seen. After an episode, the infant may vomit and then appear otherwise normal. Assessment may show a sausage-shaped abdominal mass. (Option 1) Melena (dark red or black, sticky stool) is an indication of an upper gastrointestinal (UGI) bleed. Gastritis is a common cause of UGI bleeding in infants and toddlers. (Option 2) Oily or bulky, foul-smelling stool is an indication of excess fat in the stool (steatorrhea) from malabsorption. This is characteristic of pancreatic insufficiency, cystic fibrosis, or celiac disease. (Option 4) Thin, ribbon-like stool is characteristic of Hirschsprung disease (congenital aganglionic megacolon). Bowel obstruction is caused by failure of the internal sphincter to relax. Educational objective: The classic symptom triad of intussusception is abdominal pain, "currant jelly" stools, and a sausageshaped abdominal mass. However, it is more common for clients to have episodes of sudden abdominal pain, inconsolable crying, and vomiting followed by periods of normal behavior. 13-The nurse has received report on 4 pediatric clients. Which client should the nurse assess first? 1. Client with coarctation of the aorta and diminished femoral pulses 2. Client with patent ductus arteriosus and a loud machinery-like murmur 3. Client with tetralogy of Fallot and oxygen saturation of 80% on room air 4. Client with ventricular septal defect; tachypnea and diaphoresis during feedings Explanation: Ventricular septal defect is an acyanotic congenital heart defect causing blood to shunt from the left side of the heart to the right (left-sided heart has higher pressure than right-sided). An increase in pulmonary blood flow causes an increase in workload of the right heart and pulmonary arteries, resulting in pulmonary hypertension. Eventually, blood does not go to the lungs, but instead the pressure on the right side of the heart increases, resulting in shunt reversal. This causes more blood to be shunted to the left ventricle, followed by the left atrium, and then back into the lungs (heart failure). Tachypnea is due to pulmonary volume overload. Diaphoresis is an indication that an infant is expending too much energy during feeding. This client should be assessed first and evaluated for other signs of congestive heart failure (CHF). (Option 1) Coarctation of the aorta (COA) is an obstructive congenital heart defect resulting in decreased cardiac output. Children with COA will have stronger pulses in the upper extremities and diminished pulses in the lower extremities. This is expected until the obstruction is repaired surgically. (Option 2) A patent ductus arteriosus (PDA) occurs when fetal circulation persists after birth. A continuous machinery-like murmur is a normal finding with a PDA. (Option 3) Tetralogy of Fallot (TOF) is a cyanotic congenital heart defect. Right-sided (venous) blood is shunted through the left ventricle via the ventricular septal defect due to the resistance at the pulmonary artery (pulmonary stenosis, one of the componentsf TOF). This will cause abnormally low oxygen saturation (often in the range of 65%-85%), which is expected until the defect is repaired surgically. Educational objective: All left-to-right cardiac shunts (eg, ventricular septal defect, atrial septal defect) will cause an increase in pulmonary blood flow. Shunt reversal can eventually result in heart failure. Children should be kept in an upright position and offered small, frequent feedings to decrease workload of the heart and lungs. 14-A 12-month old infant is brought to the clinic for routine immunizations. Which conditions would cause the nurse to question administration? Select all that apply. 1. Flu shot and a history of anaphylactic reaction to eggs 2. Haemophilus influenzae type b vaccine and local redness/swelling after last immunization 3. Hepatitis A vaccine and current "cold" with temperature of 99 F (37.2 C) [0%] 4. Measles, mumps, rubella vaccine and exposure to chicken pox (varicella-zoster) recently [0%] 5. Pneumococcal vaccine and allergy to penicillins [0%] 6. Varicella-zoster vaccine and diagnosed with leukemia [0%] Explanation: Vaccines should be administered at specific ages and intervals as passive placental immunity decreases and the child's immune system is developed enough to produce antibodies in response to the vaccine. Severely immunocompromised children (eg, corticosteroid therapy, chemotherapy, AIDS) generally should not receive live vaccines (eg, measles, mumps, rubella; rotavirus; intranasal influenza; yellow fever; varicella-zoster vaccine). Passive immunization may be the only option for children with severe immunosuppression or those unable to mount an antibody immune response (Option 6). Giving a vaccine to a child who has allergies to a vaccine component (eg, eggs, neomycin, gelatin, yeast) is contraindicated. The child should also be screened for an allergy to latex (eg, lips swell with bananas, kiwis, or latex balloons) (Option 1). Common misperceptions of contraindications to immunization: Mild illness (with or without an elevated temperature) (Option 3) Currently taking antibiotics Mild site reactions (eg, swelling, erythema, soreness) (Option 2) Recent infection exposure (Option 4) Penicillin allergy (Option 5) Educational objective: Clients cannot receive a vaccine if allergic to its components. Immunocompromised clients should not receive live vaccines. Local reactions, minor illness, exposure to an infectious source, and allergies to nonvaccine components are not contraindications to immunization. 15-The nurse teaching the parents of a child diagnosed with cystic fibrosis will advise the parents to choose foods that satisfy which recommended diet? 1. Gluten-free with added protein 2. High calorie, high protein, high fat 3. High protein, low fat, low phosphate 4. High protein, low fat, low sodium Explanation: In cystic fibrosis (CF), a protein responsible for transporting sodium and chloride is defective and causes the secretions from the exocrine glands to be thicker and stickier than normal. These abnormal secretions plug smaller airway passages and ducts in the gastrointestinal (GI) tract. The thick secretions block pancreatic ducts, resulting in a deficient amount of pancreatic enzymes entering the bowel to aid in digestion and nutrient absorption. Clients require multiple vitamin supplements and supplemental pancreatic enzymes that are administered with meals. To meet the growth needs of clients with CF, a diet high in calories, fat, and protein is required. (Options 1, 3, and 4) A gluten-free diet is required for clients with celiac disease who cannot tolerate barley, rye, oats, or wheat (mnemonic: BROW). Low-phosphate diets are indicated for clients with certain kidney disorders. Low-sodium diets are indicated for volume overload states (eg, heart failure, ascites) and hypertension. Educational objective: Cystic fibrosis causes damage to the GI tract and pancreas, leading to impaired absorption of nutrients and resulting growth deficits. Clients must consume a diet high in calories, fat, and protein. 16-A 14-year-old is scheduled for surgery to treat scoliosis. The child will be hospitalized for about a week and then discharged home to recuperate for 3-4 weeks before returning to school. What is the best activity the nurse can recommend to promote age-specific growth and development during this time? 1. Attending selected after-school events and social activities 2. Keeping up with schoolwork 3. Reading teen magazines 4. Visits from friends Explanation: During adolescence, being with a peer group is part of the process of achieving individual identity, the most important developmental task at this age. An adolescent's friends have more influence than parents, teachers, or any other adults. Social relationships and activities help to provide a sense of belonging, acceptance, and approval. Having face-to-face visits and spending time with friends will help counteract feelings of isolation and loneliness during the client's recuperative period. In addition, the client is at risk for body image disturbance related to the scoliosis and surgery. The client may be particularly sensitive about body image and needs understanding and acceptance from peers. (Option 1) The client can attend school functions or social activities with friends when off all pain medication and when the spine has healed sufficiently. (Option 2) It is important for the client to keep up with schoolwork, but it is not a priority for recovery. (Option 3) Reading teen magazines can be a diversionary activity and may help distract the client from any pain, but it is not a priority. Educational objective: Friends play a significant role in the adolescent's quest for identity and provide a source of support, belonging, and understanding. Interacting with friends during recuperation after surgery is important to help counteract feelings of loneliness and isolation. 17-The clinic nurse is caring for a 3-year-old client. Which task, if not observed or reported by the parents as accomplished, will cause the nurse concern? 1. Catches a ball at least 50% of the time 2. Copies a square with a pencil or crayon 3. Eats with a spoon 4. Hops on one foot Explanation: Things that most children can do by a certain age are considered developmental milestones. These include the following areas of development: social/emotional, language/communication, cognitive, and physical. Each child develops in a unique pattern, and ages are considered as general guidelines for assessing development. Normally, a toddler develops the ability to use a spoon by 18 months. Therefore, a 3-year-old should be able to eat with a spoon. (Option 1) Catching a ball 50% of the time is a developmental expectation for a 4-year-old. (Option 2) A 4-year-old can copy or draw a square with a pencil or crayon. Copying shapes other than a circle is a developmental expectation for a 5-year-old. (Option 4) Hopping on one foot is a developmental expectation for a 4-year-old. Educational objective: A 3-year-old should be able to eat with a spoon. 18-The public health nurse conducts a teaching program for parents of infants. Which statement by a participant indicates that teaching has been successful? 1. "I can offer my 7-month-old an egg white omelet with soft, mushy vegetables." 2. "I will switch my 1-year-old to low-fat milk instead of commercial formula." 3. "It is safe to sweeten my 4-month-old infant's formula with honey." 4. "My infant should be able to pick up small finger foods by age 10 months." Explanation: The pincer grasp, a thumb to forefinger movement, develops at age 8-10 months. This is the time to start offering small finger foods, such as Cheerios or cut-up pieces of nutritious foods. Caregivers should inform their health care provider if the infant does not achieve this significant milestone in fine motor development. (Option 1) Egg whites should not be offered to infants age less than 1 year. Protein in egg whites can cause an allergic reaction. (Option 2) Infants should be transitioned to whole milk, not low-fat milk, at age 1 year. Due to its rapid growth, the child's brain requires the fat found in whole milk. (Option 3) Formula should never be sweetened. Honey (especially raw or wild) should not be offered to a child age less than 1 year due to an immature gut system that is susceptible to Clostridium botulinum (botulism) infection. Educational objective: The pincer grasp should be present by age 10 months. Offering small, soft finger foods allows the infant to develop fine motor skills. The child will also enjoy the ability to self-feed and explore a variety of nutritious foods. 19-The mother of a 6-year-old child with cystic fibrosis (CF) has received instruction on the use of pancreatic enzymes. Which statement made by the mother indicates a need for further teaching? 1. "I need to monitor the total amount of this medication that I give to my child every day." 2. "I should give this medication with or just before my child has a meal or snack." 3. "It is okay for my child to chew this medication." 4. "It is okay to open the capsule and sprinkle the medicine on a tablespoon of applesauce Explanation: In CF, unusually thick mucus obstructs the pancreatic ducts, preventing pancreatic enzymes (amylase, trypsin, and lipase) from reaching the small intestine. The result is malabsorption of carbohydrates, fats, and proteins; the inability to absorb fat-soluble vitamins (A, D, E, and K) is of particular concern. Gastrointestinal signs and symptoms of CF include flatulence, abdominal cramping, ongoing diarrhea, and/or steatorrhea. Nutritional therapy includes the administration pancreatic enzyme supplements with or just before every meal or snack (Option 2). These enzymes are enteric-coated beads designed to dissolve only in an alkaline environment similar to that of the small intestine. They must not be mixed with a substance that would cause them to dissolve prior to reaching the jejunum. Capsule contents may be sprinkled on applesauce, yogurt, or acidic, soft, room-temperature foods with pH <4.5. Capsules should be swallowed whole and not crushed or chewed; chewing the capsules could cause irritation of the oral mucosa. Excessive intake of pancreatic enzymes can result in fibrosing colonopathy (Option 1). (Option 4) This is a true statement; some children have difficulty taking a whole capsule. Capsule contents can be sprinkled in acidic substances such as applesauce. Capsules should not be taken with milk as they can cause it to curdle. Educational objective: Pancreatic enzyme supplements are used to aid the absorption of carbohydrates, fats, and proteins in a child with CF. They are taken with or just before every meal (not as needed); should be swallowed whole or sprinkled on an acidic food; and should not be crushed or chewed. They should not be taken with milk. Excessive intake could result in fibrosing colonopathy. 20-The nurse is performing a physical assessment on a 2-year-old with cold symptoms and a fever at home of 101.7 F (38.7 C). The parent is concerned about the child's ability to cooperate during the examination. Place the components of assessment in the order the nurse would perform them. All options must be used. Your Response/ Incorrect Response Interact with the parent in a friendly manner Play with the child using a finger puppet Auscultate the child's heart and lungs Take the child's vital signs Measure the child's height and weight Correct Response Interact with the parent in a friendly manner Play with the child using a finger puppet Measure the child's height and weight Auscultate the child's heart and lungs Take the child's vital signs Explanation: Always complete the assessment by performing the least invasive parts first and then progressing to the most invasive. By first establishing a rapport with the parent (Option 2), the nurse will elicit the child's trust and cooperation. Playing with the child will help the child relax and perceive the nurse as less of a threat (Option 4). Measuring the child's height and weight should be performed next (Option 3). Auscultation of the heart and lungs should then be performed. Allowing the child to play with the equipment first will make this part of the assessment easier (Option 1). Taking vital signs can be difficult as a blood pressure cuff can be perceived as painful (Option 5); once the child is upset, it becomes difficult to continue with the assessment. A temperature of 101.7 F (38.7 C) is not serious in a child, especially if there are signs and symptoms of an upper respiratory infection. Educational objective: Performing a physical assessment in a toddler can be challenging. The nurse should establish a rapport with the parent and then attempt to gain the child's trust. Playing with the child can make the experience easier on the nurse, parents, and child. The nurse should always perform the least invasive procedures first, explain them in simple terms, and praise the child throughout the assessment. 21-A nurse on a pediatric unit is admitting a school-aged child with suspected Reye syndrome. Which information obtained during the history taking is most consistent with this condition? 1. No history of varicella vaccine administration 2. Recent exposure to bats 3. Recent influenza infection 4. Recent use of acetaminophen for fever Explanation: Children who develop Reye syndrome often have had a recent viral infection, especially varicella (chicken pox) or influenza. Clinical manifestations include fever, lethargy, acute encephalopathy, and altered hepatic function. Elevated serum ammonia levels are an expected laboratory finding. Acute encephalopathy manifests with vomiting and a severely altered level of consciousness; it can rapidly progress to seizures and/or coma. The risk of developing Reye syndrome increases if aspirin therapy is used to treat the fever associated with varicella or influenza. As a result of this awareness, there has been a significant increase in the use of acetaminophen or ibuprofen for fever management in children. (Option 1) Although a child who has not received the varicella vaccine may have an increased risk of developing chicken pox, this evidence alone is not enough to substantiate suspected Reye syndrome. (Option 2) Recent exposure to bats would place the child at risk for rabies, a severe infection affecting the nervous system. This finding would not be indicative of Reye syndrome. (Option 4) The use of aspirin to treat fever, especially in clients with Kawasaki disease, can be associated with Reye syndrome. Acetaminophen is an appropriate antipyretic choice to reduce the risk of Reye syndrome. Educational objective: Reye syndrome is characterized by fever, acute encephalopathy, and altered hepatic function. It often develops following a viral infection, especially varicella or influenza. The risk of developing Reye syndrome increases if aspirin therapy is used to treat fever. 22-A nurse is teaching the parent of a child who has a new diagnosis of absence seizures. Which statement by the parent indicates understanding of the teaching? 1. "My child may experience incontinence." 2. "My child may seem confused afterwards." 3. "My child may stare and seem inattentive." 4. "My child will notice unusual odors prior to the event." Explanation: Absence seizures occur in children age 4-12 and usually disappear at puberty. Clinical manifestations include a brief loss of consciousness and an appearance of inattention or daydreaming (the absence attack) without loss of postural body tone. However, slight loss of tone may lead to dropping objects held in hands. Most absence seizures last less than 10 seconds and often go unrecognized. Following an attack, behavior and awareness return immediately to normal. The child does not experience a postictal period but usually has no recollection that a seizure has occurred. A child may have multiple absence seizures each day. Treatment includes the use of anticonvulsant medication(s). (Options 1, 2, and 4) Altered sensory perceptions (eg, awareness of odors [aura]), postictal confusion, and incontinence are clinical manifestations of complex partial or tonic-clonic seizures. Educational objective: Absence seizures are characterized by a brief loss of consciousness and an appearance of inattention or daydreaming without loss of postural tone. Most absence seizures last less than 10 seconds. The seizures occur in children age 4-12, and multiple seizures may occur daily. 23-A 4-year-old healthy child is brought in for routine vaccinations. Prior to this visit, the client had received all age-appropriate immunizations. Which vaccines should the child expect to receive at this clinic visit? Select all that apply. 1. Diphtheria, tetanus, pertussis (DTaP) 2. Hepatitis A (Hep A) 3. Inactivated poliovirus (IPV) 4. Measles, mumps, rubella (MMR) 5. Varicella Explanation: The schedule of recommended routine immunizations for 4- to 6-year-olds includes diphtheria, tetanus, and pertussis (DTaP); inactivated poliovirus (IPV); measles, mumps, and rubella (MMR); and varicella. Annual influenza vaccine injections or nasal spray (FluMist) is also recommended. (Option 2) The hepatitis A (Hep A) vaccine is typically given in a 2-dose series between age 12-24 months, with 6-18 months between doses. As this client is known to be current on all early childhood vaccinations, there is no indication to administer a dose of the Hep A vaccine. Educational objective: The recommended immunization schedule for 4- to 6-year-olds includes DTaP, IPV, MMR, and varicella. Children should also receive an annual influenza vaccination.