28. Which statement by the nurse is most appropriate to a 15-year-old whose friend has mentioned suicide?

a.

“Tell your friend to come to the clinic immediately.”

b.

“You need to gather details about your friend’s suicide plan.”

c.

“Your friend’s threat needs to be taken seriously and immediate help for your friend is important.”

d.

“If your friend mentions suicide a second time, you will want to get your friend some help.”

ANS: C

Suicide is the third most common cause of death among American adolescents. A suicide threat from an adolescent serves as a dramatic message to others and should be taken seriously. Adolescents at risk should be targeted for supportive guidance and counseling before a crisis occurs. Instructing a 15-year-old to tell a friend to come to the clinic immediately provides the teen with limited information and does not address the concern. It is important to determine whether a person threatening suicide has a plan of action; however, the best information for the 15-year-old to have is that all threats of suicide should be taken seriously and immediate help is important. Taking time to gather details or waiting until the teen discusses it a second time may be too late.

36. Young people with anorexia nervosa are often described as being:

a.

Independent.

c.

Conforming.

b.

Disruptive.

d.

Low achieving.

ANS: C

Individuals with anorexia nervosa are described as perfectionist, academically high achievers, conforming, and conscientious. Independent, disruptive, and low achieving are not part of the behavioral characteristics of anorexia nervosa.

37. Which symptoms should the nurse expect to observe during the physical assessment of an adolescent girl with severe weight loss and disrupted metabolism associated with anorexia nervosa?

a.

Dysmenorrhea and oliguria

b.

Tachycardia and tachypnea

c.

Heat intolerance and increased blood pressure

d.

Lowered body temperature and brittle nails

ANS: D

Symptoms of anorexia nervosa include lower body temperature, severe weight loss, decreased blood pressure, dry skin, brittle nails, altered metabolic activity, and presence of lanugo hair. Amenorrhea, rather than dysmenorrhea, and cold intolerance are manifestations of anorexia nervosa. Bradycardia, rather than tachycardia, may be present.

38. An adolescent teen has bulimia. Which assessment finding should the nurse expect?

a.

Diarrhea

c.

Cold intolerance

b.

Amenorrhea

d.

Erosion of tooth enamel

ANS: D

Some of the signs of bulimia include erosion of tooth enamel, increased dental caries from vomited gastric acid, throat complaints, fluid and electrolyte disturbances, and abdominal complaints from laxative abuse. Diarrhea is not a result of the vomiting. It may occur in patients with bulimia who also abuse laxatives. Amenorrhea and cold intolerance are characteristics of anorexia nervosa, which some bulimics have. These symptoms are related to the extreme low weight.

44. Research has shown that the most successful smoking cessation programs among teens include (select all that apply):

a.

Peer-led education and support.

b.

Information on the long-term effects of smoking.

c.

Programs including the media.

d.

School-based programs.

e.

Information on the immediate effects of smoking.

ANS: A, C, D, E

Two areas of antismoking campaigns that have shown success are those that are peer-led and use media in education related to smoking prevention. School-based programs have also shown success and can be strengthened by expansion into the community and youth groups. Teens respond much better to education that focuses on the immediate effects of smoking. For the most part, smoking prevention programs that focus on the negative long-term effects of smoking have been ineffective.

43. Which is the most significant factor in distinguishing those who commit suicide from those who make suicidal attempts or threats?

a.

Social isolation

c.

Degree of depression

b.

Level of stress

d.

Desire to punish others

ANS: A

Social isolation is a significant factor in distinguishing adolescents who will kill themselves from those who will not. It is also more characteristic of those who complete suicide than of those who make attempts or threats. Level of stress, degree of depression, and desire to punish others are contributing factors in suicide, but they are not the most significant factor in distinguishing those who complete suicide from those who attempt suicide.

27. A nurse is providing a parent information regarding autism. Which statement made by the parent indicates understanding of the teaching?

a.

“Autism is characterized by periods of remission and exacerbation.”

b.

“The onset of autism usually occurs before 3 years of age.”

c.

“Children with autism have imitation and gesturing skills.”

d.

“Autism can be treated effectively with medication.”

ANS: B

The onset of autism usually occurs before 3 years of age. Autism does not have periods of remission and exacerbation. Autistic children lack imitative skills. Medications are of limited use in children with autism.

28. What should the nurse keep in mind when planning to communicate with a child who has autism?

a.

The child has normal verbal communication.

b.

The child is expected to use sign language.

c.

The child may exhibit monotone speech and echolalia.

d.

The child is not listening if she is not looking at the nurse.

ANS: C

Children with autism have abnormalities in the production of speech, such as a monotone voice or echolalia, or inappropriate volume, pitch, rate, rhythm, or intonation. The child has impaired verbal communication and abnormalities in the production of speech. Some autistic children may use sign language, but it is not assumed. Children with autism often are reluctant to initiate direct eye contact.

29. Parents have learned that their 6-year-old child has autism. The nurse may help the parents to cope by explaining that the child may:

a.

Have an extremely developed skill in a particular area.

b.

Outgrow the condition by early adulthood.

c.

Have average social skills.

d.

Have age-appropriate language skills.

ANS: A

Some children with autism have an extremely developed skill in a particular area, such as mathematics or music. No evidence supports that autism is outgrown. Autistic children have abnormal ways of relating to people (social skills). Speech and language skills are usually delayed in autistic children.

30. A child with autism is hospitalized with asthma. The nurse should plan care so that the:

a.

Parents’ expectations are met.

b.

Child’s routine habits and preferences are maintained.

c.

Child is supported through the autistic crisis.

d.

Parents need not be at the hospital.

ANS: B

Children with autism are often unable to tolerate even slight changes in routine. The child’s routine habits and preferences are important to maintain. Focus of care is on the child’s needs rather than on the parent’s desires. Autism is a lifelong condition. The presence of the parents is almost always required when an autistic child is hospitalized.

41. A child with autism spectrum disorder (ASD) is admitted to the hospital with pneumonia. The nurse should plan which priority intervention when caring for the child?

a.

Maintain a structured routine and keep stimulation to a minimum.

b.

Place the child in a room with a roommate of the same age.

c.

Maintain frequent touch and eye contact with the child.

d.

Take the child frequently to the playroom to play with other children.

ANS: A

Providing a structured routine for the child to follow is key in the management of ASD. Decreasing stimulation by using a private room, avoiding extraneous auditory and visual distractions, and encouraging the parents to bring in possessions the child is attached to may lessen the disruptiveness of hospitalization. Because physical contact often upsets these children, minimum holding and eye contact may be necessary to avoid behavioral outbursts. Children with ASD need to be introduced slowly to new situations, with visits with staff caregivers kept short whenever possible. The playroom would be too overwhelming with new people and situations and should not be a priority of care.

42. Autism is a complex developmental disorder. The diagnostic criteria for autism include delayed or abnormal functioning in which area(s) with onset before age 3 years (select all that apply)?

a.

Language as used in social communication

b.

Gross motor development

c.

Growth below the 5th percentile for height and weight

d.

Symbolic or imaginative play

e.

Social interaction

ANS: A, D, E

Language as used in social communication, symbolic or imaginative play, and social interaction are three of the areas in which autistic children may show delayed or abnormal functioning. Gross motor development and growth below the 5th percentile for height and weight are not areas in which autistic children may show delayed or abnormal functioning.

3. Approach behaviors are coping mechanisms that result in a family’s movement toward adjustment and resolution of the crisis of having a child with a chronic illness or disability. What is considered an approach behavior in parents?

a.

Are unable to adjust to a progression of the disease or condition

b.

Anticipate future problems and seek guidance and answers

c.

Look for new cures without a perspective toward possible benefit

d.

Fail to recognize seriousness of child’s condition despite physical evidence

ANS: B

The parents who anticipate future problems and seek guidance and answers are demonstrating approach behaviors. They are demonstrating positive actions in caring for their child. Avoidance behaviors include being unable to adjust to a progression of the disease or condition, looking for new cures without a perspective toward possible benefit, and failing to recognize the seriousness of the child’s condition despite physical evidence. These behaviors would suggest that the parents are moving away from adjustment or adaptation in the crisis of a child with chronic illness or disability.

4. Families progress through various stages of reactions when a child is diagnosed with a chronic illness or disability. After the shock phase, a period of adjustment usually follows. This is often characterized by:

a.

Denial.

c.

Social reintegration.

b.

Guilt and anger.

d.

Acceptance of child’s limitations.

ANS: B

For most families, the adjustment phase is accompanied by several responses that are normally part of the adjustment process. Guilt, self-accusation, bitterness, and anger are common reactions. The initial diagnosis of a chronic illness or disability often is often met with intense emotion and characterized by shock and denial. Social reintegration and acceptance of the child’s limitations is the culmination of the adjustment process.

. The nurse comes into the room of a child who was just diagnosed with a chronic disability. The child’s parents begin to yell at the nurse about a variety of concerns. The nurse’s best response is:

a.

“What is really wrong?”

b.

“Being angry is only natural.”

c.

“Yelling at me will not change things.”

d.

“I will come back when you settle down.”

ANS: B

Parental anger after the diagnosis of a child with a chronic disability is a common response. One of the most common targets for parental anger is members of the staff. The nurse should recognize the common response of anger to the diagnosis and allow the family to ventilate. “What is really wrong?” “Yelling at me will not change things,” and “I will come back when you settle down” are all possible responses, but they are not the likely reasons for this anger.

9. The feeling of guilt that the child “caused” the disability or illness is especially critical in which child?

a.

Toddler

c.

School-age child

b.

Preschooler

d.

Adolescent

ANS: B

Preschoolers are most likely to be affected by feelings of guilt that they caused the illness/disability or are being punished for wrongdoings. Toddlers are focused on establishing their autonomy. The illness will foster dependency. The school-age child will have limited opportunities for achievement and may not be able to understand limitations. Adolescents are faced with the task of incorporating their disabilities into their changing self-concept.

16. A preschooler is found digging up a pet bird that was recently buried after it died. The best explanation for this behavior is that:

a.

He has a morbid preoccupation with death.

b.

He is looking to see if a ghost took it away.

c.

The loss is not yet resolved, and professional counseling is needed.

d.

Reassurance is needed that the pet has not gone somewhere else.

ANS: D

The preschooler can recognize that the pet has died but has difficulties with the permanence. Digging up the bird gives reassurance that the bird is still present. A morbid preoccupation with death and the child looking to see if a ghost took it away are expected responses. If they persist, intervention may be required.

17. At what age do most children have an adult concept of death as being inevitable, universal, and irreversible?

a.

4 to 5 years

c.

9 to 11 years

b.

6 to 8 years

d.

12 to 16 years

ANS: C

By age 9 or 10 years, children have an adult concept of death. They realize that it is inevitable, universal, and irreversible. Preschoolers and young school-age children are too young to have an adult concept of death. Adolescents have a mature understanding of death.

18. What is most descriptive of a school-age child’s reaction to death?

a.

Is very interested in funerals and burials

b.

Has little understanding of words such as forever

c.

Imagines the deceased person to be still alive

d.

Has an idealistic view of the world and criticizes funerals as barbaric

ANS: A

The school-age child is very interested in postdeath services and may be inquisitive about what happens to the body. School-age children have an established concept of forever and have a deeper understanding of death in a concrete manner. Toddler may imagine the deceased person to still be alive. Adolescents may respond to death with an idealistic view of the world and criticize funerals as barbaric.

19. At what developmental period do children have the most difficulty coping with death, particularly if it is their own?

a.

Toddlerhood

c.

School-age

b.

Preschool

d.

Adolescence

ANS: D

Because of their mature understanding of death, remnants of guilt and shame, and issues with deviations from normal, adolescents have the most difficulty coping with death. Toddlers and preschoolers are too young to have difficulty coping with their own death. They will fear separation from parents. School-age children will fear the unknown, such as the consequences of the illness and the threat to their sense of security.

20. A school-age child is diagnosed with a life-threatening illness. The parents want to protect their child from knowing the seriousness of the illness. The nurse should explain that:

a.

This will help the child cope effectively by denial.

b.

This attitude is helpful to give parents time to cope.

c.

Terminally ill children know when they are seriously ill.

d.

Terminally ill children usually choose not to discuss the seriousness of their illness.

ANS: C

The child needs honest and accurate information about the illness, treatments, and prognosis. Children, even at a young age, realize that something is seriously wrong and that it involves them. The nurse should help parents understand the importance of honesty. The child will know that something is wrong because of the increased attention of health professionals. This would interfere with denial as a form of coping. Parents may need professional support and guidance from a nurse or social worker in this process. Children will usually tell others how much information they want about their condition.

21. The nurse is caring for a child who has just died. The parents ask to be left alone so that they can rock their child one more time. The nurse should:

a.

Grant their request.

b.

Assess why they feel that this is necessary.

c.

Discourage this because it will only prolong their grief.

d.

Kindly explain that they need to say good-bye to their child now and leave.

ANS: A

The parents should be allowed to remain with their child after the death. The nurse can remove all of the tubes and equipment and offer the parents the option of preparing the body. This is an important part of the grieving process and should be allowed if the parents desire it. It is important for the nurse to ascertain if the family has any special needs.

22. The nurse is talking with the parents of a child who died 6 months ago. They sometimes still “hear” the child’s voice and have trouble sleeping. They describe feeling “empty” and depressed. The nurse should recognize that:

a.

These are normal grief responses.

b.

The pain of the loss is usually less by this time.

c.

These grief responses are more typical of the early stages of grief.

d.

This grieving is essential until the pain is gone and the child is gradually forgotten.

ANS: A

These are normal grief responses. The process of grief work is lengthy and resolution of grief may take years, with intensification during the early years. The child will never be forgotten by the parents.

23. At the time of a child’s death, the nurse tells his mother, “We will miss him so much.” The best interpretation of this is that the nurse is:

a.

Pretending to be experiencing grief.

b.

Expressing personal feelings of loss.

c.

Denying the mother’s sense of loss.

d.

Talking when listening would be better.

ANS: B

The death of a patient is one of the most stressful aspects of a critical care or oncology nurse. Nurses experience reactions similar to those of family members because of their involvement with the child and family during the illness. Nurses often have feelings of personal loss when a patient dies. The nurse is experiencing a normal grief response to the death of a patient. There is no implication that the mother’s loss is minimized. The nurse is validating the worth of the child.

24. An appropriate nursing intervention when providing comfort and support for a child whose death is imminent is to:

a.

Limit care to essentials.

b.

Avoid playing music near the child.

c.

Explain to the child the need for constant measurement of vital signs.

d.

Whisper to the child instead of using a normal voice.

ANS: A

When death is imminent, care should be limited to interventions for palliative care. Music may be used to provide comfort for the child. Vital signs do not need to be measured frequently. The nurse should speak to the child in a clear, distinct voice.

25. What is the most appropriate response to a school-age child who asks if she can talk to her dying sister?

a.

“You need to speak loudly so she can hear you.”

b.

“Holding her hand would be better because at this point she can’t hear you.”

c.

“Although she can’t hear you, she can feel your presence so sit close to her.”

d.

“Even though she will probably not answer you, she can still hear what you say to her.”

ANS: D

Hearing is the last sense to cease before death. Talking to the dying child is important both for the child and for the family. There is no evidence that the dying process decreases hearing acuity; therefore, the sister should speak at a normal volume. The sibling should be encouraged to speak to the child, as well as sit close to the bed and hold the child’s hand.

31. Which term best describes a multidisciplinary approach to the management of a terminal illness that focuses on symptom control and support?

a.

Dying care

c.

Restorative care

b.

Curative care

d.

Palliative care

ANS: D

This is one of the definitions of palliative care. The goal of palliative care is the achievement of the highest possible quality of life for patients and their families.

32. Which best describes how preschoolers react to the death of a loved one?

a.

The preschooler is too young to have a concept of death.

b.

A preschooler is likely to feel guilty and responsible for the death.

c.

Grief is acute but does not last long at this age.

d.

Grief is usually expressed in the same way in which the adults in the preschooler’s life are expressing grief.

ANS: B

Because of egocentricity, the preschooler may feel guilty and responsible for the death. Preschoolers usually have some understanding of the meaning of death. Death is seen as a departure or some kind of sleep and they have no understanding of the permanence of death.

33. A cure is no longer possible for a young child with cancer. The nursing staff recognizes that the goal of treatment must shift from cure to palliation. Which is an important consideration at this time?

a.

The family is included in the decision to shift the goals of treatment.

b.

The decision must be made by the health professionals involved in the child’s care.

c.

The family needs to understand that palliative care takes place in the home.

d.

The decision should not be communicated to the family because it will encourage a sense of hopelessness.

ANS: A

When the child reaches the terminal stage, the nurse and physician should explore the family’s wishes. The family should help decide what interventions will occur as they plan for their child’s death.

34. The nurse and a new nurse are caring for a child who will require palliative care. Which statement made by the new nurse would indicate a correct understanding of palliative care?

a.

“Palliative care serves to hasten death and make the process easier for the family.”

b.

“Palliative care provides pain and symptom management for the child.”

c.

“The goal of palliative care is to place the child in a hospice setting at the end of life.”

d.

“The goal of palliative care is to act as the liaison between the family, child, and other health care professionals.”

ANS: B

The primary goal of palliative care is to provide pain and symptom management, not to hasten death or place the child in a hospice setting. Palliative care is provided by a multidisciplinary team whose goal it is to provide active total care for patients whose disease is no longer responding to curative treatment.

35. A nurse is planning palliative care for a child with severe pain. Which should the nurse expect to be prescribed for pain relief?

a.

Opioids as needed

c.

Distraction and relaxation techniques

b.

Opioids on a regular schedule

d.

Nonsteroidal antiinflammatory drugs

ANS: B

Pain medications for children in palliative care should be given on a regular schedule, and extra doses for breakthrough pain should be available to maintain comfort. Opioid drugs such as morphine should be given for severe pain, and the dose should be increased as necessary to maintain optimal pain relief. Techniques such as distraction, relaxation techniques, and guided imagery should be combined with drug therapy to provide the child and family strategies to control pain. Nonsteroidal antiinflammatory drugs are not sufficient to manage severe pain for children in palliative care.

38. Which are appropriate statements the nurse should make to parents after the death of their child (select all that apply)?

a.

“We feel so sorry that we couldn’t save your child.”

b.

“Your child isn’t suffering anymore.”

c.

“I know how you feel.”

d.

“You’re feeling all the pain of losing a child.”

e.

“You are still young enough to have another baby.”

ANS: A, D

By saying, “We feel so sorry that we couldn’t save your child,” the nurse is expressing personal feeling of loss or frustration, which is therapeutic. Stating, “You’re feeling all the pain of losing a child,” focuses on a feeling, which is therapeutic. The statement, “Your child isn’t suffering anymore,” is a judgmental statement, which is nontherapeutic. “I know how you feel” and “You’re still young enough to have another baby” are statements that give artificial consolation and are nontherapeutic.

39. A nurse is caring for a child who is near death. Which physical signs indicate the child is approaching death (select all that apply)?

a.

Body feels warm

b.

Tactile sensation decreasing

c.

Speech becomes rapid

d.

Change in respiratory pattern

e.

Difficulty swallowing

ANS: B, D, E

Physical signs of approaching death include tactile sensation beginning to decrease, a change in respiratory pattern, and difficulty swallowing. Even though there is a sensation of heat, the body feels cool, not warm, and speech becomes slurred, not rapid.

19. What is most descriptive of the pathophysiology of leukemia?

a.

Increased blood viscosity occurs.

b.

Thrombocytopenia (excessive destruction of platelets) occurs.

c.

Unrestricted proliferation of immature white blood cells (WBCs) occurs.

d.

The first stage of the coagulation process is abnormally stimulated.

ANS: C

Leukemia is a group of malignant disorders of the bone marrow and the lymphatic system. It is defined as an unrestricted proliferation of immature WBCs in the blood-forming tissues of the body. Increased blood viscosity may occur secondary to the increased number of WBCs. Thrombocytopenia may occur secondary to the overproduction of WBCs in the bone marrow. The coagulation process is unaffected by leukemia.

20. A boy with leukemia screams whenever he needs to be turned or moved. The most probable cause of this pain is:

a.

Edema.

c.

Petechial hemorrhages.

b.

Bone involvement.

d.

Changes within the muscles.

ANS: B

The invasion of the bone marrow with leukemic cells gradually causes a weakening of the bone and a tendency toward fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain. Edema, petechial hemorrhages, and muscular changes would not cause severe pain.

21. Myelosuppression associated with chemotherapeutic agents or some malignancies such as leukemia can cause bleeding tendencies because of a/an:

a.

Decrease in leukocytes.

c.

Vitamin C deficiency.

b.

Increase in lymphocytes.

d.

Decrease in blood platelets.

ANS: D

The decrease in blood platelets secondary to the myelosuppression of chemotherapy can cause an increase in bleeding. The child and family should be alerted to avoid risk of injury. Decrease in leukocytes, increase in lymphocytes, and vitamin C deficiency would not affect bleeding tendencies.

22. A child with leukemia is receiving triple intrathecal chemotherapy consisting of methotrexate, cytarabine, and hydrocortisone. The purpose of this is to prevent:

a.

Infection.

b.

Brain tumor.

c.

Drug side effects.

d.

Central nervous system (CNS) disease.

ANS: D

For certain children, CNS prophylactic therapy is indicated. This drug regimen is used to prevent CNS leukemia. This regimen does not prevent infection or drug side effects. If the child has a brain tumor in addition to leukemia, additional therapy would be indicated.

23. A young boy will receive a bone marrow transplant (BMT). This is possible because one of his older siblings is a histocompatible donor. This type of BMT is termed:

a.

Syngeneic.

c.

Monoclonal.

b.

Allogeneic.

d.

Autologous.

ANS: B

Allogeneic transplants are from another individual. Because he and his sibling are histocompatible, the bone marrow transplantation can be done. Syngeneic marrow is from an identical twin. There is no such thing as a monoclonal bone marrow transplant. Autologous refers to the individual’s own marrow.

24. A school-age child with leukemia experienced severe nausea and vomiting when receiving chemotherapy for the first time. The most appropriate nursing action to prevent or minimize these reactions with subsequent treatments is to:

a.

Encourage drinking large amounts of favorite fluids.

b.

Encourage child to take nothing by mouth (remain NPO) until nausea and vomiting subside.

c.

Administer an antiemetic before chemotherapy begins.

d.

Administer an antiemetic as soon as child has nausea.

ANS: C

The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy is to administer the antiemetic before the chemotherapy is begun. The goal is to prevent anticipatory symptoms. Drinking fluids will add to the discomfort of the nausea and vomiting. Encouraging the child to remain NPO will help with this episode, but the child will have the discomfort and be at risk for dehydration. Administering an antiemetic after the child has nausea does not avoid anticipatory nausea.

5. The nurse is preparing a child for possible alopecia from chemotherapy. Which suggestion should be included in the teaching?

a.

Explaining to the child that hair usually regrows in 1 year.

b.

Advising the child to expose the head to sunlight to minimize alopecia.

c.

Explaining to the child that wearing a hat or scarf is preferable to wearing a wig.

d.

Explaining to the child that, when hair regrows, it may have a slightly different color or texture.

ANS: D

Alopecia is a side effect of certain chemotherapeutic agents. When the hair regrows, it may be of different color or texture. The hair usually grows back within 3 to 6 months after the cessation of treatment. The head should be protected from sunlight to avoid sunburn. Children should choose the head covering that they prefer.

26. A common clinical manifestation of Hodgkin’s disease is:

a.

Petechiae.

b.

Bone and joint pain.

c.

Painful, enlarged lymph nodes.

d.

Enlarged, firm, nontender lymph nodes.

ANS: D

Asymptomatic, enlarged, cervical or supraclavicular lymphadenopathy is the most common presentation of Hodgkin’s disease. Petechiae are usually associated with leukemia. Bone and joint pain are not likely in Hodgkin’s disease. The enlarged nodes are rarely painful.

27. Which condition is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4⁺ T-cells?

a.

Wiskott-Aldrich syndrome

b.

Idiopathic thrombocytopenic purpura (ITP)

c.

Acquired immunodeficiency syndrome (AIDS)

d.

Severe combined immunodeficiency disease

ANS: C

AIDS is caused by the human immunodeficiency virus, which primarily attacks the CD4⁺ T-cells. Wiskott-Aldrich syndrome, ITP, and severe combined immunodeficiency disease are not viral illnesses.

28. A young child with human immunodeficiency virus is receiving several antiretroviral drugs. The purpose of these drugs is to:

a.

Cure the disease.

b.

Delay disease progression.

c.

Prevent spread of disease.

d.

Treat Pneumocystis jiroveci pneumonia.

ANS: B

Although not a cure, these antiviral drugs can suppress viral replication, preventing further deterioration of the immune system, and delay disease progression. At this time cure is not possible. These drugs do not prevent the spread of the disease. Pneumocystis jiroveci prophylaxis is accomplished with antibiotics.

29. Which immunization should be given with caution to children infected with human immunodeficiency virus?

a.

Influenza

c.

Pneumococcus

b.

Varicella

d.

Inactivated poliovirus

ANS: B

The children should be carefully evaluated before giving live viral vaccines such as varicella, measles, mumps, and rubella. The child must be immunocompetent and not have contact with other severely immunocompromised individuals. Influenza, pneumococcus, and inactivated poliovirus are not live vaccines.

30. The nurse is planning care for an adolescent with acquired immunodeficiency syndrome. The priority nursing goal is to:

a.

Prevent infection.

c.

Restore immunologic defenses.

b.

Prevent secondary cancers.

d.

Identify source of infection.

ANS: A

As a result of the immunocompromise that is associated with human immunodeficiency virus infection, the prevention of infection is paramount. Although certain precautions are justified in limiting exposure to infection, these must be balanced with the concern for the child’s normal developmental needs. Restoring immunologic defenses is not currently possible. Current drug therapy is affecting the disease progression; although not a cure, these drugs can suppress viral replication, preventing further deterioration. Case finding is not a priority nursing goal.

31. An inherited immunodeficiency disorder characterized by absence of both humoral and cell-mediated immunity is:

a.

Severe combined immunodeficiency syndrome (SCIDS).

b.

Acquired immunodeficiency syndrome.

c.

Wiskott-Aldrich syndrome.

d.

Fanconi syndrome.

ANS: A

Severe SCIDS is a genetic disorder that results in deficits of both humoral and cellular immunity. Acquired immunodeficiency syndrome is not inherited. Wiskott-Aldrich syndrome is an X-linked recessive disorder with selected deficiencies of T and B lymphocytes. Fanconi syndrome is a hereditary disorder of red cell production.

34. The parents of a child with cancer tell the nurse that a bone marrow transplant (BMT) may be necessary. What should the nurse recognize as important when discussing this with the family?

a.

BMT should be done at time of diagnosis.

b.

Parents and siblings of child have a 25% chance of being a suitable donor.

c.

Finding a suitable donor involves matching antigens from the human leukocyte antigen (HLA) system.

d.

If BMT fails, chemotherapy or radiotherapy must be continued.

ANS: C

The most successful BMTs come from suitable HLA-matched donors. The timing of a BMT depends on the disease process involved. It usually follows intensive high-dose chemotherapy and/or radiation therapy. Usually parents only share approximately 50% of the genetic material with their children. A one-in-four chance exists that two siblings will have two identical haplotypes and will be identically matched at the HLA loci. Discussing the continuation of chemotherapy or radiotherapy is not appropriate when planning the BMT. That decision will be made later.

36. What is the most common mode of transmission of human immunodeficiency virus (HIV) in the pediatric population?

a.

Perinatal transmission

c.

Blood transfusions

b.

Sexual abuse

d.

Poor hand washing

ANS: A

Perinatal transmission accounts for the highest percentage (91%) of HIV infections in children. Infected women can transmit the virus to their infants across the placenta during pregnancy, at delivery, and through breastfeeding. Cases of HIV infection from sexual abuse have been reported; however, perinatal transmission accounts for most pediatric HIV infections. In the past some children became infected with HIV through blood transfusions; however, improved laboratory screening has significantly reduced the probability of contracting HIV from blood products. Poor hand washing is not an etiology of HIV infection.

40. Which immunization should not be given to a child receiving chemotherapy for cancer?

a.

Tetanus vaccine

c.

Diphtheria, pertussis, tetanus (DPT)

b.

Inactivated poliovirus vaccine

d.

Measles, rubella, mumps

ANS: D

The vaccine used for measles, mumps, and rubella is a live virus and can result in an overwhelming infection. Tetanus vaccine, inactivated poliovirus vaccine, and DPT are not live virus vaccines.

41. The nurse is administering an intravenous chemotherapeutic agent to a child with leukemia. The child suddenly begins to wheeze and have severe urticaria. Which is the most appropriate nursing action?

a.

Stop drug infusion immediately.

b.

Recheck rate of drug infusion.

c.

Observe child closely for next 10 minutes.

d.

Explain to child that this is an expected side effect.

ANS: A

If an allergic reaction is suspected, the drug should be immediately discontinued. Any drug in the line should be withdrawn, and a normal saline infusion begun to keep the line open. Rechecking the rate of drug infusion, observing the child closely for next 10 minutes, and explaining to the child that this is an expected side effect can all be done after the drug infusion is stopped and the child is evaluated.

42. A young child with leukemia has anorexia and severe stomatitis. The nurse should suggest that the parents try which intervention?

a.

Relax any eating pressures.

b.

Firmly insist that child eat normally.

c.

Begin gavage feedings to supplement diet.

d.

Serve foods that are either hot or cold.

ANS: A

A multifaceted approach is necessary for children with severe stomatitis and anorexia. First, the parents should relax eating pressures rather than insisting the child eat normally. The nurse should suggest that the parents try soft, bland foods rather than hot or cold foods; normal saline or bicarbonate mouthwashes; and local anesthetics. The stomatitis is a temporary condition; gavage feedings are not necessary. The child can resume good food habits as soon as the condition resolves.

43. The school nurse is informed that a child with human immunodeficiency virus (HIV) will be attending school soon. Which is an important nursing intervention?

a.

Carefully follow universal precautions.

b.

Determine how the child became infected.

c.

Inform the parents of the other children.

d.

Reassure other children that they will not become infected.

ANS: A

Universal precautions are necessary to prevent further transmission of the disease. It is not the role of the nurse to determine how the child became infected. Informing the parents of other children and reassuring other children that they will not become infected is a violation of the child’s right to privacy.

44. An adolescent will receive a bone marrow transplant (BMT). The nurse should explain that the bone marrow will be administered by which route?

a.

Bone grafting

c.

Intravenous infusion

b.

Bone marrow injection

d.

Intraabdominal infusion

ANS: C

Bone marrow from a donor is infused intravenously, not intraabdominally, and the transfused stem cells will repopulate the marrow. Because the stem cells migrate to the recipient’s marrow when given intravenously, this method of administration is used rather than bone grafting or bone marrow injection.

46. Which home care instructions should the nurse provide to the parents of a child with acquired immunodeficiency syndrome (AIDS) (Select all that apply)?

a.

Give supplemental vitamins as prescribed.

b.

Yearly influenza vaccination should be avoided.

c.

Administer trimethoprim-sulfamethoxazole (Bactrim) as prescribed.

d.

Notify the physician if the child develops a cough or congestion.

e.

Missed doses of antiretroviral medication do not need to be recorded.

ANS: A, C, D

The parents should be taught that supplemental vitamins will be prescribed to aid in nutritional status. Bactrim is administered to prevent the opportunistic infection of Pneumocystis jiroveci pneumonia. The physician should be notified if the child with AIDS develops a cough and congestion. The yearly influenza vaccination is recommended, and any missed doses of antiretroviral medication need to be recorded and reported.

50. The nurse is preparing to give oral care to a school-age child with mucositis secondary to chemotherapy administered to treat leukemia. Which preparations should the nurse use for oral care on this child (Select all that apply)?

a.

Chlorhexidine gluconate (Peridex)

b.

Lemon glycerin swabs

c.

Antifungal troches (lozenges)

d.

Lip balm (Aquaphor)

e.

Hydrogen peroxide

ANS: A, C, D

Preparations that may be used to prevent or treat mucositis include chlorhexidine gluconate (Peridex) because of its dual effectiveness against candidal and bacterial infections, antifungal troches (lozenges) or mouthwash, and lip balm (e.g., Aquaphor) to keep the lips moist. Agents that should not be used include lemon glycerin swabs (irritate eroded tissue and can decay teeth), hydrogen peroxide (delays healing by breaking down protein), and milk of magnesia (dries mucosa).

51. A toddler with leukemia is on intravenous chemotherapy treatments. The toddler’s lab results are white blood cell count (WBC): 1000; neutrophils: 7%; nonsegmented neutrophils (bands): 7%. What is this child’s absolute neutrophil count (ANC)? _____ Record your answer as a whole number.

ANS:

140

To calculate an ANC for a WBC = 1000, neutrophils = 7%, and nonsegmented neutrophils (bands) = 7%, the steps are:

Step 1: 7% + 7% = 14%.

Step 2: 0.14 ´ 1000 = 140 ANC.

1. Which term is used to describe a child’s level of consciousness when the child can be aroused with stimulation?

a.

Stupor

c.

Obtundation

b.

Confusion

d.

Disorientation

ANS: C

Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion regarding time and place.

2. Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation?

a.

Coma

c.

Obtundation

b.

Stupor

d.

Persistent vegetative state

ANS: B

Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex.

4. The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as:

a.

Eye trauma.

c.

Severe brainstem damage.

b.

Neurosurgical emergency.

d.

Indication of brain death.

ANS: B

The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain. One fixed and dilated pupil is not suggestive of brain death.

8. The priority nursing intervention when a child is unconscious after a fall is to:

a.

Establish an adequate airway.

b.

Perform neurologic assessment.

c.

Monitor intercranial pressure.

d.

Determine whether a neck injury is present.

ANS: A

Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishing an adequate airway is always the first priority. A neurologic assessment and determination of neck injury are performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after airway, breathing, and circulation are maintained.

9. Which drug would be used to treat a child who has increased intracranial pressure (ICP) resulting from cerebral edema?

a.

Mannitol

c.

Atropine sulfate

b.

Epinephrine hydrochloride

d.

Sodium bicarbonate

ANS: A

For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used most frequently for rapid reduction. Epinephrine, atropine sulfate, and sodium bicarbonate are not used to decrease ICP.

10. Which statement is most descriptive of a concussion?

a.

Petechial hemorrhages cause amnesia.

b.

Visible bruising and tearing of cerebral tissue occur.

c.

It is a transient, reversible neuronal dysfunction.

d.

A slight lesion develops remote from the site of trauma.

ANS: C

A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of awareness and responsiveness resulting from trauma to the head. Petechial hemorrhages along the superficial aspects of the brain along the point of impact are a type of contusion but are not necessarily associated with amnesia. A contusion is visible bruising and tearing of cerebral tissue. Contrecoup is a lesion that develops remote from the site of trauma as a result of an acceleration/deceleration injury.

11. Which type of fracture describes traumatic separation of cranial sutures?

a.

Basilar

c.

Diastatic

b.

Compound

d.

Depressed

ANS: C

Diastatic skull fractures are traumatic separations of the cranial sutures. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. A compound fracture has the bone exposed through the skin. A depressed fracture has the bone pushed inward, causing pressure on the brain.

12. Which statement best describes a subdural hematoma?

a.

Bleeding occurs between the dura and the skull.

b.

Bleeding occurs between the dura and the cerebrum.

c.

Bleeding is generally arterial, and brain compression occurs rapidly.

d.

The hematoma commonly occurs in the parietotemporal region.

ANS: B

A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.

13. The nurse should recommend medical attention if a child with a slight head injury experiences:

a.

Sleepiness.

c.

Headache, even if slight.

b.

Vomiting, even once.

d.

Confusion or abnormal behavior.

ANS: D

Medical attention should be sought if the child exhibits confusion or abnormal behavior; loses consciousness; or has amnesia, fluid leaking from the nose or ears, blurred vision, or unsteady gait. Sleepiness alone does not require evaluation. If the child is difficult to arouse from sleep, medical attention should be obtained. Vomiting more than three times requires medical attention. Severe or worsening headache or one that interferes with sleep should be evaluated.

14. An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed. What type of head injury should the nurse suspect?

a.

Brainstem

c.

Subdural hemorrhage

b.

Skull fracture

d.

Epidural hemorrhage

ANS: A

Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are consistent with a brainstem injury. Skull fracture and subdural and epidural hemorrhages are not consistent with these signs.

15. A toddler fell out of a second-story window. She had brief loss of consciousness and vomited four times. Since admission, she has been alert and oriented. Her mother asks why a computed tomography (CT) scan is required when she “seems fine.” The nurse should explain that the toddler:

a.

May have a brain injury.

c.

May start having seizures.

b.

Needs this because of her age.

d.

Probably has a skull fracture.

ANS: A

The child’s history of the fall, brief loss of consciousness, and vomiting four times necessitate evaluation of a potential brain injury. The severity of a head injury may not be apparent on clinical examination but will be detectable on a CT scan. The need for the CT scan is related to the injury and symptoms, not the child’s age, and is necessary to determine whether a brain injury has occurred.

16. The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. The most essential part of the nursing assessment to detect early signs of a worsening condition is:

a.

Posturing.

c.

Focal neurologic signs.

b.

Vital signs.

d.

Level of consciousness.

ANS: D

The most important nursing observation is assessment of the child’s level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing indicates neurologic damage. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes.

17. A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The child’s level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. The most appropriate nursing action is to:

a.

Discuss with parents the child’s previous experiences with pain.

b.

Discuss with practitioner what analgesia can be safely administered.

c.

Explain that analgesia is contraindicated with a head injury.

d.

Explain that analgesia is unnecessary when child is not fully awake and alert.

ANS: B

A key nursing role is to provide sedation and analgesia for the child. Consultation with the appropriate practitioner is necessary to avoid conflict between the necessity to monitor the child’s neurologic status and to promote comfort and relieve anxiety. Gathering information about the child’s previous experiences with pain should be obtained as part of the assessment, but because of the severity of injury, analgesia should be provided as soon as possible. Analgesia can be used safely in individuals who have sustained head injuries and can decrease anxiety and resultant increased intracranial pressure.

18. A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. Which statement made by the mother indicates a correct understanding of the teaching?

a.

“I should expect my child to have a few episodes of vomiting.”

b.

“If I notice sleep disturbances, I should contact the physician immediately.”

c.

“I should expect my child to have some behavioral changes after the accident.”

d.

“If I notice diplopia, I will have my child rest for 1 hour.”

ANS: C

The parents are advised of probably post-traumatic symptoms that may be expected, including behavioral changes. If the child has episodes of vomiting, sleep disturbances, or diplopia, they should be immediately reported for evaluation.

20. The most common clinical manifestation of brain tumors in children is:

a.

Irritability.

c.

Headaches and vomiting.

b.

Seizures.

d.

Fever and poor fine motor control.

ANS: C

Headaches, especially on awakening, and vomiting that is not related to feeding are the most common clinical manifestations of brain tumors in children. Irritability, seizures, and fever and poor fine motor control are clinical manifestations of brain tumors, but headaches and vomiting are the most common.

21. Which statement best describes a neuroblastoma?

a.

Diagnosis is usually made after metastasis occurs.

b.

Early diagnosis is usually possible because of the obvious clinical manifestations.

c.

It is the most common brain tumor in young children.

d.

It is the most common benign tumor in young children.

ANS: A

Neuroblastoma is a silent tumor with few symptoms. In more than 70% of cases, diagnosis is made after metastasis occurs, with the first signs caused by involvement in the nonprimary site. In only 30% of cases is diagnosis made before metastasis. Neuroblastomas are the most common malignant extracranial solid tumors in children. The majority of tumors develop in the adrenal glands or the retroperitoneal sympathetic chain. They are not benign; they metastasize.

28. A child is brought to the emergency department after experiencing a seizure at school. There is no previous history of seizures. The father tells the nurse that he cannot believe the child has epilepsy. The nurse’s best response is:

a.

“Epilepsy is easily treated.”

b.

“Very few children have actual epilepsy.”

c.

“The seizure may or may not mean that your child has epilepsy.”

d.

“Your child has had only one convulsion; it probably won’t happen again.”

ANS: C

Seizures are the indispensable characteristic of epilepsy; however, not every seizure is epileptic. Epilepsy is a chronic seizure disorder with recurrent and unprovoked seizures. The treatment of epilepsy involves a thorough assessment to determine the type of seizure the child is having and the cause of events, followed by individualized therapy to allow the child to have as normal a life as possible. The nurse should not make generalized comments like “Very few children have actual epilepsy” and “Your child has had only one convulsion; it probably won’t happen again” until further assessment is made.

29. Which type of seizure involves both hemispheres of the brain?

a.

Focal

c.

Generalized

b.

Partial

d.

Acquired

ANS: C

Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. Partial seizures are caused by abnormal electrical discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure.

30. The initial clinical manifestation of generalized seizures is:

a.

Being confused.

c.

Losing consciousness.

b.

Feeling frightened.

d.

Seeing flashing lights.

ANS: C

Loss of consciousness is a frequent occurrence in generalized seizures and is the initial clinical manifestation. Being confused, feeling frightened, and seeing flashing lights are clinical manifestations of a complex partial seizure.

31. Which type of seizure may be difficult to detect?

a.

Absence

c.

Simple partial

b.

Generalized

d.

Complex partial

ANS: A

Absence seizures may go unrecognized because little change occurs in the child’s behavior during the seizure. Generalized, simple partial, and complex partial seizures all have clinical manifestations that are observable.

32. An important nursing intervention when caring for a child who is experiencing a seizure is to:

a.

Describe and record the seizure activity observed.

b.

Restrain the child when seizure occurs to prevent bodily harm.

c.

Place a tongue blade between the teeth if they become clenched.

d.

Suction the child during a seizure to prevent aspiration.

ANS: A

When a child is having a seizure, the priority nursing care is observation of the child and seizure. The nurse then describes and records the seizure activity. The child should not be restrained, and nothing should be placed in his or her mouth. This may cause injury. To prevent aspiration, if possible, the child should be placed on his or her side, facilitating drainage.

33. Which clinical manifestations would suggest hydrocephalus in a neonate?

a.

Bulging fontanel and dilated scalp veins

b.

Closed fontanel and high-pitched cry

c.

Constant low-pitched cry and restlessness

d.

Depressed fontanel and decreased blood pressure

ANS: A

Bulging fontanel, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. Closed fontanel and high-pitched cry, constant low-pitched cry and restlessness, and depressed fontanel and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation.

35. How should the nurse explain positioning for a lumbar puncture to a 5-year-old child?

a.

“You will be on your knees with your head down on the table.”

b.

“You will be able to sit up with your chin against your chest.”

c.

“You will be on your side with the head of your bed slightly raised.”

d.

“You will lie on your side and bend your knees so that they touch your chin.”

ANS: D

The child should lie on his or her side with knees bent and chin tucked in to the knees. This position exposes the area of the back for the lumbar puncture. The knee-chest position is not appropriate for a lumbar puncture. An infant can be placed in a sitting position with the infant facing the nurse and the head steadied against the nurse’s body. A side-lying position with the head of the bed elevated is not appropriate for a lumbar puncture.

36. The nurse has received report on four children. Which child should the nurse assess first?

a.

A school-age child in a coma with stable vital signs

b.

A preschool child with a head injury and decreasing level of consciousness

c.

An adolescent admitted after a motor vehicle accident who is oriented to person and place

d.

A toddler in a persistent vegetative state with a low-grade fever

ANS: B

The nurse should assess the child with a head injury and decreasing level of consciousness (LOC) first. Assessment of LOC remains the earliest indicator of improvement or deterioration in neurologic status. The next child the nurse should assess is a toddler in a persistent vegetative state with a low-grade fever. The school-age child in a coma with stable vital signs and the adolescent admitted to the hospital who is oriented to his or her surroundings would be of least worry to the nurse.

38. The nurse is caring for a child with severe head trauma after a car accident. Which is an ominous sign that often precedes death?

a.

Papilledema

c.

Doll’s head maneuver

b.

Delirium

d.

Periodic and irregular breathing

ANS: D

Periodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often precedes complete apnea. Papilledema is edema and inflammation of the optic nerve. It is commonly a sign of increased intracranial pressure. Delirium is a state of mental confusion and excitement marked by disorientation to time and place. The doll’s head maneuver is a test for brainstem or oculomotor nerve dysfunction.

39. An appropriate nursing intervention when caring for an unconscious child should be to:

a.

Change the child’s position infrequently to minimize the chance of increased intracranial pressure (ICP).

b.

Avoid using narcotics or sedatives to provide comfort and pain relief.

c.

Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.

d.

Give tepid sponge baths to reduce fever because antipyretics are contraindicated.

ANS: C

Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema. The child’s position should be changed frequently to avoid complications such as pneumonia and skin breakdown. Narcotics and sedatives should be used as necessary to reduce pain and discomfort, which can increase ICP. Antipyretics are the method of choice for fever reduction.

40. A 10-year-old boy has been hit by a car while riding his bicycle in front of the school. The school nurse immediately assesses airway, breathing, and circulation. The next nursing action should be to:

a.

Place on side.

c.

Stabilize neck and spine.

b.

Take blood pressure.

d.

Check scalp and back for bleeding.

ANS: C

After determining that the child is breathing and has adequate circulation, the next action is to stabilize the neck and spine to prevent any additional trauma. The child’s position should not be changed until the neck and spine are stabilized. Blood pressure is a later assessment. Less urgent, but an important assessment, is inspection of the scalp for bleeding.

41. A child is unconscious after a motor vehicle accident. The watery discharge from the nose tests positive for glucose. The nurse should recognize that this suggests:

a.

Diabetic coma.

c.

Upper respiratory tract infection.

b.

Brainstem injury.

d.

Leaking of cerebrospinal fluid (CSF).

ANS: D

Watery discharge from the nose that is positive for glucose suggests leaking of CSF from a skull fracture and is not associated with diabetes or respiratory tract infection. The fluid is probably CSF from a skull fracture and does not signify whether the brainstem is involved.

42. A child has been seizure-free for 2 years. A father asks the nurse how much longer the child will need to take the antiseizure medications. The nurse includes which intervention in the response?

a.

Medications can be discontinued at this time.

b.

The child will need to take the drugs for 5 years after the last seizure.

c.

A stepwise approach will be used to reduce the dosage gradually.

d.

Seizure disorders are a lifelong problem. Medications cannot be discontinued.

ANS: C

A predesigned protocol is used to wean a child gradually off antiseizure medications, usually when the child is seizure-free for 2 years and has a normal electroencephalogram. Medications must be gradually reduced to minimize the recurrence of seizures. Seizure medications can be safely discontinued. The risk of recurrence is greatest within the first year.

MULTIPLE RESPONSE

43. The treatment of brain tumors in children consists of which therapies(Select all that apply)?

a.

Surgery

b.

Bone marrow transplantation

c.

Chemotherapy

d.

Stem cell transplantation

e.

Radiation

f.

Myelography

ANS: A, C, E

Treatment for brain tumors in children may consist of surgery, chemotherapy, and radiotherapy alone or in combination. Bone marrow, stem cell, and myelographuy are transplantation therapies are not used to treat brain tumors in children.

44. Clinical manifestations of increased intracranial pressure (ICP) in infants are (Select all that apply):

a.

Low-pitched cry.

b.

Sunken fontanel.

c.

Diplopia and blurred vision.

d.

Irritability.

e.

Distended scalp veins.

f.

Increased blood pressure.

ANS: C, D, E

Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP in infants. Low-pitched cry, sunken fontanel, and increased blood pressure are not clinical manifestations associated with ICP in infants.

48. The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased ICP in an infant (Select all that apply)?

a.

Tachycardia

b.

Alteration in pupil size and reactivity

c.

Increased motor response

d.

Extension or flexion posturing

e.

Cheyne-Stokes respirations

ANS: B, D, E

Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes respirations.

A 6-year-old child is having a generalized seizure in the classroom at school. Place in order the interventions the school nurse should implement, starting with the highest-priority intervention and sequencing to the lowest-priority intervention.

a.

Take vital signs.

b.

Ease child to the floor.

c.

Allow child to rest.

d.

Turn child to the side.

e.

Integrate child back into the school environment.

49. First priority B

50. Second priority D

51. Third priority A

52. Fourth priority C

53. Fifth priority E

4. Families progress through various stages of reactions when a child is diagnosed with a chronic illness or disability. After the shock phase, a period of adjustment usually follows. This is often characterized by:

a.

Denial.

c.

Social reintegration.

b.

Guilt and anger.

d.

Acceptance of child’s limitations.

ANS: B

For most families, the adjustment phase is accompanied by several responses that are normally part of the adjustment process. Guilt, self-accusation, bitterness, and anger are common reactions. The initial diagnosis of a chronic illness or disability often is often met with intense emotion and characterized by shock and denial. Social reintegration and acceptance of the child’s limitations is the culmination of the adjustment process.

A child with attention deficit-hyperactivity disorder (ADHD) is in the clinic with parents, who complain that even though they are following the treatment plan, the child is not improving. What action can the nurse suggest to improve the effectiveness of the plan?
A. Consult with the school nurse to follow through with behavior logs.
B. Ensure the entire family is continuing to keep counseling appointments.
C. Reassure the parents that it takes a long time to see changes in behavior.
D. Teach the parents about herbal and diet therapies they can try at home.

ANS: A
The school nurse is in an ideal position to work with teachers and create behavior charts so the child’s treatment plan is followed throughout the school day. The parents have already said they are compliant with the treatment plan, so there is no need to assess if they are still going to counseling. Although it may take some children a while to make changes in behavior, simply telling the parents this information does not provide them with information they can use to make positive changes. Diet and herbal therapies are not proven treatments for ADHD.

6. A mother brings a child to the clinic with concerns about attention deficit-hyperactivity disorder (ADHD). Which behavioral assessment findings support this diagnosis? (Select all that apply.)
A. Compulsive “collecting”
B. Inability to stay in chair for a meal
C. Nonstop talking
D. Refusal to complete homework
E. Sleeping whenever possible

ANS: B, C, D
ADHD is characterized by behaviors related to inattention, hyperactivity/impulsivity, or both. The child’s inability to sit in a chair for meals, nonstop talking, and refusal to complete homework are all signs of possible ADHD. Compulsive “collecting” could relate to an anxiety disorder such as hoarding. Excessive sleeping could indicate depression.

23. The parent of 16-month-old Chris asks, “What is the best way to keep Chris from getting into our medicines at home?” The nurse should advise that:

a.

“All medicines should be locked securely away.”

b.

“The medicines should be placed in high cabinets.”

c.

“Chris just needs to be taught not to touch medicines.”

d.

“Medicines should not be kept in the homes of small children.”

ANS: A

The major reason for poisoning in the home is improper storage. Toddlers can climb, unlatch cabinets, and obtain access to high-security places. For medications, only a locked cabinet is safe. Toddlers can climb by using furniture. High places are not a deterrent to an exploring toddler. Toddlers are not able to generalize as dangerous all of the different forms of medications that may be available in the home. Teaching them not to touch medicines is not feasible. Many parents require medications for chronic illnesses. They must be taught safe storage for their home and when they visit other homes.

20. A father brings his child to the clinic with complaints that the child jumps around, gestures continuously with the hands, and makes grunting noises. He wants to know if the child has attention deficit-hyperactivity disorder (ADHD). What response by the nurse is the most appropriate?
A. “Does your child have risks for obsessive-compulsive disorder?”
B. “I don’t think so; that sounds more like a tic disorder.”
C. “Possibly; those are some classic symptoms of ADHD.”
D. “Yes, that definitely sounds like ADHD to me.”

ANS: B
Tics are sudden, painless, nonrhythmic behaviors that are either motor or vocal and appear out of context. Examples include eye blinking, facial grimacing, hand gestures, jumping, throat clearing, grunting, meaningless changes in volume and pitch of speech, and echolalia. The nurse should explain to the father that these symptoms sound more like tic disorder. The other answers are inappropriate.

5. A nurse is caring for a child with attention deficit-hyperactivity disorder (ADHD). Which medications does the nurse anticipate may be prescribed for this child? (Select all that apply.)
A. Adderall (amphetamine salts)
B. Haldol (haloperidol)
C. Prozac (fluoxetine hydrochloride)
D. Ritalin (methylphenidate hydrochloride)
E. Strattera (atomoxetine)

ANS: A, D, E
Drugs most commonly used for ADHD include stimulants such as Ritalin and Adderall, and Strattera (a nonstimulant). Haldol is an antipsychotic. Prozac is an antidepressant.

24. The most fatal type of burn in the toddler age-group is:

a.

Flame burn from playing with matches.

b.

Scald burn from high-temperature tap water.

c.

Hot object burn from cigarettes or irons.

d.

Electric burn from electrical outlets.

Flame burns from matches and lighters represent one of the most fatal types of burns in the toddler age-group. Scald burns from water, hot object burns from cigarettes or irons, and electric burns from outlets are all significant causes of burn injury. The child should be protected from these causes by reducing the temperature of the hot water in the home, keeping objects such as cigarettes and irons away from children, and placing protective guards over electrical outlets when not in use.

30. The clinic is lending a federally approved car seat to an infant’s family. The nurse should explain that the safest place to put the car seat is:

a.

Front facing in back seat.

b.

Rear facing in back seat.

c.

Front facing in front seat if an air bag is on the passenger side.

d.

Rear facing in front seat if an air bag is on the passenger side.

ANS: B

The rear-facing car seat provides the best protection for an infant’s disproportionately heavy head and weak neck. Infants should face the rear from birth to 20 pounds and as close to 1 year of age as possible. The middle of the back seat provides the safest position. Severe injuries and deaths in children have occurred from air bags deploying on impact in the front passenger seat.

31. A nurse is teaching parents about prevention and treatment of colic. Which should the nurse include in the teaching plan?

a.

Avoid use of pacifiers.

b.

Eliminate all secondhand smoke contact.

c.

Lay infant flat after feeding.

d.

Avoid swaddling the infant.

ANS: B

To prevent and treat colic, teach parents that if household members smoke, they should avoid smoking near the infant; smoking activity should preferably be confined to outside of the home. A pacifier can be introduced for added sucking. The infant should be swaddled tightly with a soft, stretchy blanket and placed in an upright seat after feedings.

14. Which statement is true about smoking in adolescence?

a.

Smoking is related to other high-risk behaviors.

b.

Smoking is more common among athletes.

c.

Smoking is less common when the adolescent’s parent(s) smokes.

d.

Smoking among adolescents is becoming more prevalent.

ANS: A

Cigarettes are considered a gateway drug. Teenagers who smoke are 11.4 times more likely to use an illicit drug. Teens who refrain from smoking often have a desire to succeed in athletics. If a parent smokes, it is more likely that the teen will smoke. Cigarette smoking has declined among all groups since the 1990s.

13. The most common cause of death in the adolescent age-group involves:

a.

Drownings.

c.

Drug overdoses.

b.

Firearms.

d.

Motor vehicles.

ANS: D

The leading cause of all adolescent deaths in the United States is motor vehicle accidents. Drownings, firearms, and drug overdoses are major concerns in adolescence but do not cause the majority of deaths.

28. Which statement by the nurse is most appropriate to a 15-year-old whose friend has mentioned suicide?

a.

“Tell your friend to come to the clinic immediately.”

b.

“You need to gather details about your friend’s suicide plan.”

c.

“Your friend’s threat needs to be taken seriously and immediate help for your friend is important.”

d.

“If your friend mentions suicide a second time, you will want to get your friend some help.”

ANS: C

Suicide is the third most common cause of death among American adolescents. A suicide threat from an adolescent serves as a dramatic message to others and should be taken seriously. Adolescents at risk should be targeted for supportive guidance and counseling before a crisis occurs. Instructing a 15-year-old to tell a friend to come to the clinic immediately provides the teen with limited information and does not address the concern. It is important to determine whether a person threatening suicide has a plan of action; however, the best information for the 15-year-old to have is that all threats of suicide should be taken seriously and immediate help is important. Taking time to gather details or waiting until the teen discusses it a second time may be too late.

42. Which is the most commonly used method in completed suicides?

a.

Firearms

c.

Self-inflected laceration

b.

Drug overdose

d.

Carbon monoxide poisoning

ANS: A

Firearms are the most commonly used instruments in completed suicides among both males and females. For adolescent boys, firearms are followed by hanging and overdose. For adolescent females, overdose and strangulation are the next most common means of completed suicide. The most common method of suicide attempt is overdose or ingestion of potentially toxic substances such as drugs. The second most common method of suicide attempt is self-inflicted laceration. Carbon monoxide poisoning is not one of the more frequent forms of suicide completion.

43. Which is the most significant factor in distinguishing those who commit suicide from those who make suicidal attempts or threats?

a.

Social isolation

c.

Degree of depression

b.

Level of stress

d.

Desire to punish others

ANS: A

Social isolation is a significant factor in distinguishing adolescents who will kill themselves from those who will not. It is also more characteristic of those who complete suicide than of those who make attempts or threats. Level of stress, degree of depression, and desire to punish others are contributing factors in suicide, but they are not the most significant factor in distinguishing those who complete suicide from those who attempt suicide.

1. The nurse is caring for a 4-year-old child immobilized by a fractured hip. Which complications should the nurse monitor?

a.

Hypocalcemia

b.

Decreased metabolic rate

c.

Positive nitrogen balance

d.

Increased production of stress hormones

ANS: B

Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased food intake, leads to hypercalcemia, and causes a negative nitrogen balance secondary to muscle atrophy. A decreased production of stress hormones occurs with decreased physical and emotional coping capacity.

2. What effect does immobilization have on the cardiovascular system?

a.

Venous stasis

b.

Increased vasopressor mechanism

c.

Normal distribution of blood volume

d.

Increased efficiency of orthostatic neurovascular reflexes

ANS: A

Because of decreased muscle contraction, the physiologic effects of immobilization include venous stasis. This can lead to pulmonary emboli or thrombi. A decreased vasopressor mechanism results in orthostatic hypotension, syncope, hypotension, decreased cerebral blood flow, and tachycardia. An altered distribution of blood volume is found, with decreased cardiac workload and exercise tolerance. Immobilization causes a decreased efficiency of orthostatic neurovascular reflexes, with an inability to adapt readily to the upright position and pooling of blood in the extremities in the upright position.

3. Which condition can result from the bone demineralization associated with immobility?

a.

Osteoporosis

c.

Pooling of blood

b.

Urinary retention

d.

Susceptibility to infection

ANS: A

Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi. Urinary retention is secondary to the effect of immobilization on the urinary tract. Pooling of blood is a result of the cardiovascular effects of immobilization. Susceptibility to infection can result from the effects of immobilization on the respiratory and renal systems.

5. Which term is used to describe a type of fracture that does not produce a break in the skin?

a.

Simple

c.

Complicated

b.

Compound

d.

Comminuted

ANS: A

If a fracture does not produce a break in the skin, it is called a simple or closed fracture. A compound or open fracture is one with an open wound through which the bone protrudes. A complicated fracture is one in which the bone fragments damage other organs or tissues. A comminuted fracture occurs when small fragments of bone are broken from the fractured shaft and lie in the surrounding tissue. These are rare in children.

6. An advantage to using a fiberglass cast instead of a plaster cast is that a fiberglass cast:

a.

Is less expensive.

c.

Molds closely to body parts.

b.

Dries rapidly.

d.

Has a smooth exterior.

ANS: B

A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which takes 10 to 72 hours to dry. Synthetic casts are more expensive. Plaster casts mold closer to body parts. Synthetic casts have a rough exterior, which may scratch surfaces.

7. The nurse is teaching the parents of a 7-year-old child who has just had a cast applied for a fractured arm with the wrist and elbow immobilized. Which instructions should be included in the teaching?

a.

Swelling of the fingers is to be expected for the next 48 hours.

b.

Immobilize the shoulder to decrease pain in the arm.

c.

Allow the affected limb to hang down for 1 hour each day.

d.

Elevate casted arm when resting and when sitting up.

ANS: D

The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return. Swelling of the fingers may indicate neurovascular damage and should be reported immediately. Permanent damage can occur within 6 to 8 hours. Joints above and below the cast on the affected extremity should be moved. The child should not engage in strenuous activity for the first few days. Rest with elevation of the extremity is encouraged.

8. The nurse uses the palms of the hands when handling a wet cast to:

a.

Assess dryness of the cast.

c.

Keep the patient’s limb balanced.

b.

Facilitate easy turning.

d.

Avoid indenting the cast.

ANS: D

Wet casts should be handled by the palms of the hands, not the fingers, to prevent creating pressure points. Assessing dryness, facilitating easy turning, or keeping the patient’s limb balanced are not reasons for using the palms of the hand rather than the fingers when handling a wet cast.

9. What would cause a nurse to suspect that an infection has developed under a cast?

a.

Complaint of paresthesia

c.

Increased respirations

b.

Cold toes

d.

“Hot spots” felt on cast surface

ANS: D

If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so a window can be made in the cast to observe the site. The “five Ps” of ischemia from a vascular injury include pain, pallor, pulselessness, paresthesia, and paralysis. Paresthesia is an indication of vascular injury, not infection. Cold toes may be indicative of too tight a cast and need further evaluation. Increased respirations may indicate a respiratory infection or pulmonary emboli. This should be reported, and the child should be evaluated.

10. A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What should the nurse suggest to remove this material?

a.

Soak in a bathtub.

c.

Apply powder to absorb material.

b.

Vigorously scrub the leg.

d.

Carefully pick material off of the leg.

ANS: A

Simple soaking in the bathtub is usually sufficient for the removal of the desquamated skin and sebaceous secretions. It may take several days to eliminate the accumulation completely. The parents and child should be advised not to scrub the leg vigorously or forcibly remove this material because it may cause excoriation and bleeding. Oil or lotion, but not powder, may provide comfort for the child.

11. Which type of traction uses skin traction on the lower leg and a padded sling under the knee?

a.

Dunlop

c.

Russell

b.

Bryant’s

d.

Buck’s extension

ANS: C

Russell traction uses skin traction on the lower leg and a padded sling under the knee. The combination of longitudinal and perpendicular traction allows realignment of the lower extremity and immobilizes the hips and knees in a flexed position. Dunlop traction is an upper extremity traction used for fractures of the humerus. Bryant’s traction is skin traction with the legs flexed at a 90-degree angle at the hip. Buck’s extension traction is a type of skin traction with the legs in an extended position. It is used primarily for short-term immobilization, before surgery with dislocated hips, for correcting contractures, or for bone deformities such as Legg-Calvé-Perthes disease.

12. Four-year-old David is placed in Buck’s extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses that the skin of his right foot is pale with an absence of pulse. What should the nurse do first?

a.

Notify the practitioner of the changes noted.

b.

Give the child medication to relieve the pain.

c.

Reposition the child and notify the physician.

d.

Chart the observations and check the extremity again in 15 minutes.

ANS: A

The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner. Pain medication should be given after the practitioner is notified. This is an emergency condition; immediate reporting is indicated. The findings should be documented with ongoing assessment.

13. An appropriate nursing intervention when caring for a child in traction is to:

a.

Remove adhesive traction straps daily to prevent skin breakdown.

b.

Assess for tightness, weakness, or contractures in uninvolved joints and muscles.

c.

Provide active range-of-motion exercises to affected extremity 3 times a day.

d.

Keep child in one position to maintain good alignment.

ANS: B

Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles. The adhesive straps should be released/replaced only when absolutely necessary. Active, passive, or active with resistance exercises should be carried out for the unaffected extremity only. Movement is expected with children. Each time the child moves, the nurse should check to ensure that proper alignment is maintained.

14. The nurse is teaching a family how to care for their infant in a Pavlik harness to treat developmental dysplasia of the hip. What should be included?

a.

Apply lotion or powder to minimize skin irritation.

b.

Remove the harness several times a day to prevent contractures.

c.

Return to the clinic every 1 to 2 weeks.

d.

Place a diaper over harness, preferably using a superabsorbent disposable diaper that is relatively thin.

ANS: C

Infants have a rapid growth pattern. The child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness. The harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.

15. A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, the nurse should explain that:

a.

Traction is tried first.

b.

Surgical intervention is needed.

c.

Frequent, serial casting is tried first.

d.

Children outgrow this condition when they learn to walk.

ANS: C

Serial casting, the preferred treatment, is begun shortly after birth before discharge from the nursery. Successive casts allows for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy. Surgical intervention is done only if serial casting is not successful. Children do not improve without intervention.

16. Which term is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine?

a.

Scoliosis

c.

Lordosis

b.

Ankylosis

d.

Kyphosis

ANS: D

Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine. Scoliosis is a complex spinal deformity usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis. Ankylosis is the immobility of a joint. Lordosis is an accentuation of the cervical or lumbar curvature beyond physiologic limits.

17. When does idiopathic scoliosis become most noticeable?

a.

Newborn period

c.

During preadolescent growth spurt

b.

When child starts to walk

d.

Adolescence

ANS: C

Idiopathic scoliosis is most noticeable during the preadolescent growth spurt and is seldom apparent before age 10 years.

18. The primary method of treating osteomyelitis is:

a.

Joint replacement.

c.

Intravenous antibiotic therapy.

b.

Bracing and casting.

d.

Long-term corticosteroid therapy.

ANS: C

Osteomyelitis is an infection of the bone, most commonly caused byStaphylococcus aureus. The treatment of choice is antibiotics. Joint replacement, bracing and casting, and long-term corticosteroids are not indicated for infectious processes.

19. Osteosarcoma is the most common bone cancer in children. Where are most of the primary tumor sites?

a.

Femur

c.

Pelvis

b.

Humerus

d.

Tibia

ANS: A

Osteosarcoma is the most frequently encountered malignant bone cancer in children. The peak incidence is between ages 10 and 25 years. More than half occur in the femur. After the femur, most of the remaining sites are the humerus, tibia, pelvis, jaw, and phalanges.

20. What is most descriptive of the therapeutic management of osteosarcoma?

a.

Treatment usually consists of surgery and chemotherapy.

b.

Amputation of the affected extremity is rarely necessary.

c.

Intensive irradiation is the primary treatment.

d.

Bone marrow transplantation offers the best chance of long-term survival.

ANS: A

The optimal therapy for osteosarcoma is a combination of surgery and chemotherapy. Amputation is frequently required. Intensive irradiation and bone marrow transplantation are usually not part of the therapeutic management.

4. Which statement is accurate concerning a child’s musculoskeletal system and how it may be different from an adult’s?

a.

Growth occurs in children as a result of an increase in the number of muscle fibers.

b.

Infants are at greater risk for fractures because their epiphyseal plates are not fused.

c.

Because soft tissues are resilient in children, dislocations and sprains are less common than in adults.

d.

Children’s bones have less blood flow.

ANS: C

Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. A child’s growth occurs because of an increase in size rather than an increase in the number of the muscle fibers. Fractures in children younger than 1 year are unusual because a large amount of force is necessary to fracture their bones. A child’s bones have greater blood flow than an adult’s bones.

25. When infants are seen for fractures, which nursing intervention is a priority?

a.

No intervention is necessary. It is not uncommon for infants to fracture bones.

b.

Assess the family’s safety practices. Fractures in infants usually result from falls.

c.

Assess for child abuse. Fractures in infants are often nonaccidental.

d.

Assess for genetic factors.

ANS: C

Fractures in infants warrant further investigation to rule out child abuse. Fractures in children younger than 1 year are unusual because of the cartilaginous quality of the skeleton; a large amount of force is necessary to fracture their bones. Infants should be cared for in a safe environment and should not be falling. Fractures in infancy are usually nonaccidental rather than related to a genetic factor.

26. Which nursing intervention is appropriate to assess for neurovascular competency in a child who fell off the monkey bars at school and hurt his arm?

a.

The degree of motion and ability to position the extremity.

b.

The length, diameter, and shape of the extremity.

c.

The amount of swelling noted in the extremity and pain intensity.

d.

The skin color, temperature, movement, sensation, and capillary refill of the extremity.

ANS: D

A neurovascular evaluation includes assessing skin color and temperature, ability to move the affected extremity, degree of sensation experienced, and speed of capillary refill in the extremity. The degree of motion in the affected extremity and ability to position the extremity are incomplete assessments of neurovascular competency. The length, diameter, and shape of the extremity are not assessment criteria in a neurovascular evaluation. Although the amount of swelling is an important factor in assessing an extremity, it is not a criterion for a neurovascular assessment.

27. Which interaction is part of the discharge plan for a school-age child with osteomyelitis who is receiving home antibiotic therapy?

a.

Instructions for a low-calorie diet

b.

Arrangements for tutoring and schoolwork

c.

Instructions for a high-fat, low-protein diet

d.

Instructions for the parent to return the child to team sports immediately

ANS: B

Promoting optimal growth and development in the school-age child is important. It is important to continue schoolwork and arrange for tutoring if indicated. The child with osteomyelitis should be on a high-calorie, high-protein diet. The child with osteomyelitis may need time for the bone to heal before returning to full activities.

30. Kristin, age 10 years, sustained a fracture in the epiphyseal plate of her right fibula when she fell off of a tree. When discussing this injury with her parents, the nurse should consider which statement?

a.

Healing is usually delayed in this type of fracture.

b.

Growth can be affected by this type of fracture.

c.

This is an unusual fracture site in young children.

d.

This type of fracture is inconsistent with a fall.

ANS: B

Detection of epiphyseal injuries is sometimes difficult, but fractures involving the epiphysis or epiphyseal plate present special problems in determining whether bone growth will be affected. Healing of epiphyseal injuries is usually prompt. The epiphysis is the weakest point of the long bones. This is a frequent site of damage during trauma.

32. The nurse is preparing an adolescent with scoliosis for a Luque-rod segmental spinal instrumentation procedure. Which consideration should the nurse include?

a.

Nasogastric intubation and urinary catheter may be required.

b.

Ambulation will not be allowed for up to 3 months.

c.

Surgery eliminates the need for casting and bracing.

d.

Discomfort can be controlled with nonpharmacologic methods.

ANS: A

Luque-rod segmental spinal instrumentation is a surgical procedure. Nasogastric intubation and urinary catheterization may be required. Ambulation is allowed as soon as possible. Depending on the instrumentation used, most patients walk by the second or third postoperative day. Casting and bracing are required postoperatively. The child usually has considerable pain for the first few days after surgery. Intravenous opioids should be administered on a regular basis.

37. The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome (Select all that apply)?

a.

Palpable distal pulse

b.

Capillary refill to extremity of <3 seconds

c.

Severe pain not relieved by analgesics

d.

Tingling of extremity

e.

Inability to move extremity

ANS: C, D, E

Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the extremity of <3 seconds are expected findings.

4. A young girl has just injured her ankle at school. In addition to calling the child’s parents, the most appropriate immediate action by the school nurse is to:

a.

Apply ice.

b.

Observe for edema and discoloration.

c.

Encourage child to assume a comfortable position.

d.

Obtain parental permission for administration of acetaminophen or aspirin.

ANS: A

Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be rested, be elevated, and have compression applied. Observing for edema and discoloration, encouraging the child to assume a comfortable position, and obtaining parental permission or administration of acetaminophen or aspirin are not immediate priorities.

21. The leading cause of death during the toddler period is:

a.

Injuries.

c.

Congenital disorders.

b.

Infectious diseases.

d.

Childhood diseases.

ANS: A

Injuries are the single most common cause of death in children ages 1 through 4 years. It is the period of highest death rate from injuries of any childhood age-group except adolescence. Infectious and childhood diseases are less common cause of deaths in this age-group. Congenital disorders are the second leading cause of death in this age-group.

7. What is the most appropriate classroom intervention for a child with attention deficit hyperactivity disorder (ADHD) for the school nurse to suggest?
a. Seat the child in the back of the room to prevent distractions for other children.
b. Pair the child with a student buddy to offer reminders to pay attention.
c. Divide work assignments into shorter periods with breaks in between.
d. Separate the child from others to increase his focus on schoolwork.

ANS: C
The child with ADHD needs breaks between periods of work and study.

12. A nurse is planning to speak with a parent support group about childhood autism. What will the nurse include?
a. Significant signs of the disorder manifest by 1 year of age.
b. The earliest signs of autism are impulsivity and overactivity.
c. Autism is usually diagnosed when the child goes to elementary school.
d. Medications can cure childhood autism.

ANS: A
Failure to use eye contact and look at others, poor attention span, and poor orienting to one’s name are significant signs of dysfunction by 1 year of age.

30. A child is diagnosed with attention deficit hyperactivity disorder (ADHD). Which characteristics would the nurse assess in this child? (Select all that apply.)
a. Social anxiety
b. Impulsivity
c. Hyperactivity
d. Distractability
e. Inattention

ANS: B, C, D, E
ADHD is characterized by inattention, hyperactivity, impulsivity, and distractibility.

26. Which is descriptive of attention deficit hyperactivity disorder (ADHD)?
a. Manifestations exhibited are so bizarre that the diagnosis is fairly easy.
b. Manifestations affect every aspect of the child’s life but are most obvious in the classroom.
c. Learning disabilities associated with ADHD eventually disappear when adulthood is reached.
d. Diagnosis of ADHD requires that all manifestations of the disorder be present.

ANS: B
ADHD affects every aspect of the child’s life, but the disruption is most obvious in the classroom. The behaviors exhibited by the child with ADHD are not unusual aspects of behavior. The difference lies in the quality of motor activity and developmentally inappropriate inattention, impulsivity, and hyperactivity that the child displays. Some children experience decreased symptoms during late adolescence and adulthood, but a significant number carry their symptoms into adulthood. Any given child will not have every symptom of the condition. The manifestations may be numerous or few, mild or severe, and will vary with the child’s developmental level.

2. Which strategies should the school nurse recommend implementing in the classroom for a child with attention deficit hyperactive disorder (ADHD)? (Select all that apply.)
a. Schedule heavier subjects to be taught in the afternoon.
b. Accompany verbal instructions by written format.
c. Limit number of breaks taken during instructional periods.
d. Allow more time for testing.
e. Reduce homework and classroom assignments.

ANS: B, D, E
Children with ADHD need an orderly, predictable, and consistent classroom environment with clear and consistent rules. Homework and classroom assignments may need to be reduced, and more time may need to be allotted for tests to allow the child to complete the task. Verbal instructions should be accompanied by visual references such as written instructions on the blackboard. Schedules may need to be arranged so that academic subjects are taught in the morning when the child is experiencing the effects of the morning dose of medication. Regular and frequent breaks in activity are helpful because sitting in one place for an extended time may be difficult.

A child with attention deficit hyperactivity disorder has been prescribed Dextroamphetamine (Dexedrine). For what effects should the nurse tell the parents to monitor the child? Select all that apply.

a) Hypotension

b) Appetite suppression

c) Weight loss

d) Weight gain

e) Insomnia

• Appetite suppression
• Weight loss
• Insomnia

Explanation:

Dextroamphetamine (Dexedrine) is a commonly prescribed drug to treat symptoms of ADHD. Insomnia, weight loss and appetite suppression are the common side effects associated with this drug. The nurse should educate the parents on monitoring these effects. Hypotension and weight gain are not common side effects of this drug.