Pediatric Exam (24-35)

24-The school nurse is conducting an educational session for middle school teachers that is designed to heighten awareness of school bullying. The nurse recognizes that further instruction is needed when one of the teachers makes which comment? 1. "Bullying is a normal part of childhood growth and development." 2. "Children with physical disabilities are more vulnerable to bullying." 3. "Most children who are victims of a school bully do not tell an adult about it." 4. "The most common form of bullying is verbal aggression, such as insults and intimidation." Explanation: Despite increased media coverage, articles, and discussion about school bullying, myths and "old" attitudes toward school bullying persist. A number of parents and teachers continue to perceive bullying as a normal part of childhood, with the attitude of "kid will be kids." Some may even believe that bullying is "fun" and will help make those who are bullied stronger over time. These beliefs are one of the most common reasons why teachers and parents may ignore bullying behavior. The consequences of bullying are lasting harm and distress, including anxiety, depression, school adjustment problems, sleep difficulties, and even death. (Option 2) This is a true statement. Children who bully often target those who seem different or are physically weak. Children with disabilities are easy targets. (Option 3) This is a true statement. Most victims of bullying are afraid to tell an adult for fear that the bullying will get worse. They may also feel embarrassed that they appear to be a "weakling." (Option 4) Bullying includes physical, verbal, and psychological aggression. Studies indicate that verbal abuse (eg, yelling obscenities, derogatory remarks, intimidation) is the most common type of bullying. Physical bullying tends to decrease from middle school to high school, but verbal bullying intensifies. Verbal attacks are more difficult to identify as they occur when adults are out of earshot. Educational objective: Bullying is not a part of normal childhood growth and development. It is abusive behavior that can have lasting and harmful physical and psychological effects on its victims. 25-The school nurse assesses an 8-year-old with a history of asthma. The nurse notes mild wheezing and coughing. Which action should the nurse perform first? 1. Assess the client's peak expir 2. Call the health care provider (HC 3. Educate the client about avoidin 4. Notify the client's parents Explanation: Symptoms of an asthma exacerbation include wheezing, chest tightness, dyspnea, cough (may be nocturnal, dry, productive), and retractions. A cough is often the earliest sign of an asthma exacerbation in children. or Bronchospasm leads to CO2 trapping and retention. The bronchospasm forces the client to work harder to exhale and the expiratory phase becomes prolonged. The nurse needs to further assess this client to validate the severity of the exacerbation before implementing an intervention. By assessing the client's peak expiratory flow, the nurse can determine the severity of the symptoms. The nurse will also need to assess the client's respiratory rate and lung sounds. (Option 2) Additional information is needed before notifying the HCP to determine the severity of the client's current condition. (Options 3 and 4) The client's parents do need to be notified and discuss asthma triggers with the nurse. However, these are not a priority as the client is currently symptomatic. Educational objective: The nurse must determine the severity of a client's condition before implementing an intervention. By assessing this client's peak expiratory flow, the nurse can determine the severity of the asthma symptoms. 26-A nurse is reviewing the laboratory values for a 3-year-old client with nephrotic syndrome. The nurse interprets the results to most clearly reflect which physiologic process related to nephrotic syndrome? Click on the exhibit button for additional information. 1. Glomerular injury 2. Hepatic impairment 3. Inherited hypercholesterolemia 4. Malnutrition Explanation: Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. Below are the 4 classic manifestations of nephrotic syndrome: Massive proteinuria – caused by increased glomerular permeability Hypoalbuminemia – resulting from excess protein loss in the urine Edema – specifically periorbital and peripheral edema and ascites; caused by low serum protein and albumin as fluid is pulled into interstitial spaces and body cavities Hyperlipidemia – related to increased compensatory protein and lipid production by the liver Additional symptoms include decreased urine output, fatigue, pallor, and weight gain. The most common cause of nephrotic syndrome in children is minimal change nephrotic syndrome, which is generally considered idiopathic. Less common secondary causes may be related to systemic disease or infection, such as glomerulonephritis, drug toxicity, or acquired immunodeficiency syndrome. (Option 2) Ascites and edema are often associated with liver disease. However, these symptoms result from fluid shifts related to hypoalbuminemia in nephrotic syndrome. (Option 3) Lipid levels (normal total cholesterol <200 mg/dL [5.2 mmol/L]) can increase with nephrotic syndrome as the liver produces increased lipids and proteins to compensate for protein loss. (Option 4) Although low serum albumin (normal 3.5-5.0 g/dL [35-50 g/L]) could result from malnutrition, hypoalbuminemia in nephrotic syndrome is related to massive proteinuria (negative to trace protein on urinalysis is usually considered normal). Educational objective: Nephrotic syndrome is a collection of symptoms resulting from glomerular injury. The 4 characteristic manifestations are proteinuria, edema, hypoalbuminemia, and hyperlipidemia. 27-The nurse is teaching a 9-year-old child with asthma how to use a metered-dose inhaler (MDI). Place the instructions in the appropriate order. All options must be used. Unordered Options Your Response/ Correct Response Exhale completely Deliver one puff of medication into spacer Place lips tightly around the mouth piece Rinse mouth with water Shake MDI and attach it to spacer Take a slow deep breath and hold for 10 seconds Shake MDI and attach it to spacer Exhale completely Place lips tightly around the mouth piece Deliver one puff of medication into spacer Take a slow deep breath and hold for 10 seconds Rinse mouth with water The proper method of delivering a dose via MDI includes the following steps: 1. First shake MDI and attach it to the spacer. 2. Exhale completely to optimize inhalation of the medication. 3. Place lips tightly around the mouth piece. 4. Deliver a single puff of medication into spacer. 5. Take a slow, deep breath and hold it for 10 seconds to allow for effective medication distribution. 6. After the dose, rinse mouth with water to remove any left-over medication from oral mucous membranes. Spit out the water to ensure no medication is swallowed. Educational objective: Any child under age 12 should use a spacer with the MDI to ensure the entire dose is inhaled appropriately. 28-A school-age child is brought to the emergency department due to nausea, vomiting, and severe right lower quadrant pain. The child's white blood cell count is 17,000/mm3 (17.0 x 109/L). Which statement by the child is of most concern to the nurse? 1. "I am hungry and they will not let me eat." 2. "I don't like hospitals and I want to go home." 3. "I'm so tired." 4. "My belly doesn't hurt anymore." Explanation: A child with acute-onset right lower quadrant abdominal pain, nausea, and vomiting and a high white blood cell count likely has acute appendicitis. Appendicitis is a serious condition that usually requires emergency surgery due to the risk of appendix rupture. The pain results from swelling and inflammation of the appendix. However, once the appendix ruptures, pain is relieved only temporarily and will return with full-blown peritonitis and sepsis. (Option 1) Clients diagnosed with appendicitis often need immediate surgery. The client will be placed NPO until surgery is performed to remove the appendix. (Option 2) This is a normal statement that will be made by many children. (Option 3) Tiredness is nonspecific and could be due to many reasons (eg, pain medication). Educational objective: Appendicitis is an acute condition that needs immediate surgical intervention to prevent appendix rupture and subsequent peritonitis and sepsis. 29-What is the best activity for a school-aged child hospitalized for vaso-occlusive sickle cell crisis? 1. Finger painting 2. Playing a game of Chinese checkers in the activity room 3. Playing video games 4. Watching a favorite movie Explanation: A child in vaso-occlusive sickle cell crisis will be experiencing a high level of pain due to the occlusion of small blood vessels from increased red blood cell sickling. Supportive and symptomatic treatment includes round-the-clock pain management with opioids, intravenous fluids for hydration, and bed rest to decrease energy expenditure and oxygen demand. Age-specific nonpharmacologic strategies should also be implemented to manage pain and help limit the amount of needed narcotic analgesia. For a school-aged child, such activities include distraction (watching TV, listening to music, reading), relaxation, guided imagery, warm soaks, positioning, and gentle massage. (Option 1) Finger painting is messy and best done in the activity room; it is not appropriate for a child confined to bed. (Option 2) A child must be on bed rest when in vaso-occlusive sickle cell crisis. Playing a game in the activity room does not maintain bed rest and would be too stimulating for the child. (Option 3) Playing video games may be too exciting and stimulating for the child; an environment low in stimuli will promote rest. Educational objective: Supportive and symptomatic treatment for vaso-occlusive sickle cell crisis includes pain management and bed rest. Nonpharmacologic measures to alleviate pain include distraction (watching TV, listening to music, reading), relaxation, guided imagery, warm soaks, positioning, and gentle massage. 30-The nurse provides discharge teaching for the parents of a child newly diagnosed with hemophilia A. Which statements by the parents indicate that teaching has been effective? Select all that apply. 1. "A high-calorie, high-protein diet is best for our child." 2. "It is extremely important that we do not allow our child to become dehydrated." 3. "Our child should wear a medical alert bracelet at all times." 4. "We should avoid giving our child over-the-counter medicine containing aspirin." 5. "We should encourage a noncontact sport such as swimming." Explanation: Hemophilia is a hereditary bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention, including: Avoid medications such as ibuprofen and aspirin that have platelet inhibition properties (Option 4). Avoid intramuscular injections; subcutaneous injections are preferred. Avoid contact sports and safety hazards; noncontact activities (eg, swimming, jogging, tennis) and use of protective equipment (eg, helmets, padding) are encouraged (Option 5). Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes should be used. MedicAlert bracelets should be worn at all times (Option 3). (Option 1) Malnutrition is not commonly associated with hemophilia; a regular diet is indicated. Clients with cystic fibrosis are at risk for malnutrition and need a high-calorie diet. (Option 2) Dehydration is not commonly associated with hemophilia. Avoiding dehydration is important for those with sickle cell anemia. Educational objective: Parents of a child with hemophilia should encourage noncontact sports, avoid giving medications that inhibit platelet aggregation, know how to control bleeding when it occurs, and ensure that the child wears a MedicAlert bracelet at all times. 31-The nurse is assessing a 3-year-old client in the emergency department and finds dyspnea, high fever, irritability, and open-mouthed drooling with leaning forward. The parents report that the symptoms started rather abruptly. The client has not received age-appropriate vaccinations. Which set of actions should the nurse anticipate? 1. 20-gauge needle insertion at the mid-axillary line for pleural aspiration 2. 4 L oxygen at 100% per nasal cannula with bilevel positive airway pressure (BPAP) ventilation standing by 3. Intubation in the operating room with a prepared tracheotomy kit standing by 4. Nebulized racemic epinephrine with pediatric anesthesiologist standing by Explanation: Epiglottitis should be considered first in a 3-7-year-old child with acute respiratory distress, toxic appearance (eg, sitting up, leaning forward, drooling), stridor, and high-grade fever. Tachycardia and tachypnea are also present. This is a pediatric emergency and should be managed with endotracheal intubation; however, intubation of such clients is difficult, and preparation for possible tracheostomy is also standard. The complications of epiglottitis are serious and include sudden airway obstruction. (Option 1) This is a recommended therapy for spontaneous tension pneumothorax, which is demonstrated by tracheal deviation; absent lung sounds; and severe, abrupt hypotension and dyspnea. (Option 2) Neither oxygenation nor BPAP is acceptable in acute epiglottitis as the trachea can close completely from edema. (Option 4) This is the appropriate therapy for croup, not epiglottitis. Croup is notably distinct for the hacking cough, which does not occur in epiglottitis. Educational objective: When assessing a client with symptoms suggestive of epiglottitis (eg, acutely ill, drooling, leaning forward, dyspnea), the nurse should prepare for an emergency airway. 32-The clinic nurse has reinforced teaching about accident prevention for the mother of a 4-monthold. Which statement by the mother indicates that teaching has been effective? 1. "I will keep my baby in the front-facing car seat." 2. "I will keep the crib rail up in the highest position." 3. "It is time to place safety plugs in the electric outlets." 4. "It is time to remove the mobile from my child's crib." Explanation: Providing for an infant's safety is an ongoing process and is correlated with growth and development and expected developmental milestones. By age 4-5 months, an infant is able to turn over and can easily fall from an inadequately guarded height. Keeping crib rails in their highest position and maintaining one hand on the infant at all times when using a changing table will prevent falls. (Option 1) It is recommended that infants and toddlers ride in a rear-facing car seat until age 2 years or until they reach the maximum weight or height allowed by the car seat manufacturer. (Option 3) Safety plugs should be placed in electrical outlets when the infant is capable of placing objects into the outlet. (Option 4) The crib mobile will need to be removed by age 5 months or when the child begins to push up on hands and knees due to risk of strangulation. Educational objective: Prevention of accidents in the 4-month-old consists of preventing falls by placing crib rails at their highest position and keeping one hand on the child who is on a changing table; preventing suffocation by avoiding the use of blankets, bumper pads, and pillows in the crib; placing the child supine for sleep; and using a rear-facing car seat. 33-Click on the area where the nurse should place the thumbs or fingers to provide chest compressions for an infant. Explanation: Two techniques are acceptable for performing chest compressions for a neonate. Two thumbs are placed on the middle third of the sternum, with the fingers encircling the chest and supporting the back. The thumbs should be positioned side by side on the middle third of the sternum just below the nipple line. This is preferred as it may result in improved cardiac perfusion. If the infant is extremely small or the rescuer's thumbs are extremely large, the thumbs may have to be superimposed (one on top of the other). The xiphoid portion of the sternum should not be compressed as it may damage the neonate's liver. The other alternative (especially if the resuscitator's hands are too small to encircle the chest) is to place 2 fingers (the index and middle finger) of one hand on the sternum just below the nipple line. The other hand should support the newborn's back. This is preferred if access is needed to the umbilical cord or in single rescuer situations. During compressions, the sternum is compressed approximately 1/3 of the anteroposterior chest diameter at a rate of 100-120/min (compression-ventilation ratio is 30:2 for 1 rescuer and 15:2 for 2 rescuers). The thumbs or fingers should not be lifted off the sternum during the relaxation phase. Educational objective: In neonatal resuscitation, the nurse's fingers/thumbs are placed at the middle third of the sternum, slightly below the nipple line. The xiphoid portion of the sternum should not be compressed as it may damage the neonate's liver. 34-An overweight toddler is diagnosed with iron deficiency anemia. Which is the most likely explanation for the anemia? 1. Excessive intake of meat products 2. Excessive intake of milk 3. Gastrointestinal blood loss 4. Impaired iron transfer from the mother Explanation: Iron deficiency anemia is the most common chronic nutritional disorder in children. There are many risk factors for iron deficiency, including insufficient dietary intake, premature birth, delayed introduction of solid food, and consumption of cow's milk before age 1 year. One common cause in toddlers is excessive milk intake, over 24 oz/day. In addition to becoming overweight, toddlers who consume too much milk develop iron deficiency due to the likely exclusion of iron-rich foods in favor of milk, a poor source of available iron. Treatment of iron deficiency anemia includes oral iron supplementation and increased consumption of iron-rich foods (eg, leafy green vegetables, red meats, poultry, dried fruit, fortified cereal). It is also important to limit milk intake (16-24 oz/day) in toddlers to ensure a balanced diet. (Option 1) Red meat and other meat products are considered good sources of dietary iron. However, clients may be at risk for obesity if meat consumption exceeds protein and caloric needs. (Option 3) Gastrointestinal blood loss, which can occur if infants under age 1 year are fed cow's milk, is a potential cause of iron deficiency anemia. However, excessive milk intake is a more common cause, particularly in clients over age 1 year. (Option 4) Impaired or decreased iron transfer is a potential cause of iron deficiency anemia, particularly in preterm infants or infants born in multiples. However, iron stores received from the mother are typically depleted by age 5-6 months (2-3 months for preterm infants); after this point, iron must be acquired through dietary sources. Because this client is a toddler (age 1-3 years), impaired iron transfer is not a likely cause of the current anemia. Educational objective: Iron deficiency anemia is the most common nutritional disorder in children. Risk factors include premature birth, cow's milk before age 1 year, and excessive milk intake in toddlers. Prevention and treatment are achieved through proper nutrition (eg, meat, leafy green vegetables, fortified cereal) and supplementation. 35-A nurse is talking with the parent of a 6-year-old regarding sleep and rest. Which information should be included? Active play before bedtime promotes restful sleep 1. Bedtime hours should be established 2. Rest needs are related to the high rate of growth in this age group 3. Seven to 8 hours of sleep are required 4. Explanation: During the school-age years (6-12), sleep needs of a child depend on health status, activity level, and age. Children in this age group need approximately 11 hours of sleep daily at age 5 and 9 hours at age 12 (Option 4). Children are often unaware of their level of fatigue. Bedtimes should be established to prevent fatigue the next day. Bedtime issues are usually not a concern, although many children retain bedtime rituals such as reading or listening to music. (Option 1) Quiet activity (eg, coloring, reading) prior to bedtime should be planned to promote restful sleep. (Option 3) Growth rate is slowed during the school-age years, which accounts for variations in sleep needs. Educational objective: Sleep needs of school-age children are dependent on health status, activity level, and age. Required sleep averages 11 hours (for 5-year-olds) to 9 hours (for 12-year-olds). It is important to establish bedtime hours and bedtime rituals. These children usually do not need daytime naps if they have slept well at night.