1. 2. 3. 4.

5. 6. 7.

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9. 10.

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15. 16. 17. 18.

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Airway obstruct place the thumb side of one fist against the victims abdomen in the midline, slightly above the umbilicus and well below the tip of the xiphoid process. The rescuer grasps the fist with the other hand and delivers up to five thrust CPR on 7 y/o In a child between the ages of 1 and 8 years, 12 to 20 breaths per minute are delivered. CPR infant In an infant, the rate of chest compressions is at least 100 times per minute Basic Life Support (BLS) To assess a pulse in an infant (younger than 1 year of age), the pulse is checked at the brachial or femoral artery. The infants relatively short fat neck makes palpation of the carotid artery difficult. The popliteal and rad ial pulses are also difficult to palpate in an infant CPR Blind finger sweeps are not recommended for infants and children because of the risk of forcing the object farther down into the airway. CPR When performing cardiopulmonary resuscitation (CPR) on infants and children, the sternum is depressed one third to one half the depth of the sternum. Eriksons Psychosocial Development According to Erikson, during school-age years (6 to 12 years of age), the child begins to move toward peers and friends and away from the parents for support. The child also begins to develop special interests that reflect his or her own developing personality instead of the parents Eriksons Psychosocial Development According to Freuds psychosexual stages of development, between the ages of 3 and 6 the child is in the phallic stage. At this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns Freuds Psychosexual Development Generally, toilet training occurs during the anal stage of development. According to Freud, the child gains pleasure from the elimination of feces and from their retention. Option 2 relates to the oral stage Piagets Cognitive Development In the formal operations stage, the child has the ability to think abstractly and logically. In the concrete operations stage the child develops logical thought patterns. In the sensorimotor stage they begin to understand the environment. In the preoperational stage they have difficulty separating fantasy from reality. Kohlbergs Moral Development In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient and is not punished, then the child is being moral. The child sees actions as good or bad. If the ch ilds actions are good, the child is praised. If the childs actions a re bad, the child is punished Eriksons Psychosocial Development According to Erikson, the caregiver should not try to anticipate the newborn infants needs at all times but must allow the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infants signal would inhibit the development of trust and lead to mistrust of others. Eriksons Psychosocial Development According to Erikson, the child focuses on independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents wishes. Saying things like no or min e and having temper tantrums are common during this period of development. Being consistent and setting limits on the childs behavior are necessary elements. Car Safety Seats Children should remain in a booster seat until they are 8 to 12 years old and at least 4 feet, 9 inches tall. An infant should ride in a car in a semireclined, rear-facing position in an infant-only seat or a convertible seat until they weigh at least 20 lb and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kg (20 lb) and 1 year of age. Convertible car safety seats are used until the child weighs at least 40 lb. Vital Signs The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/min. The normal apical rate is 90 to 130 beats/min, and the average blood pressure is 90/56 mm Hg Car Safety Seats Infants who weigh up to 20 lb and are at least 1 year of age should be restrained in a car seat (convertible seat) or infant-only seat in a semireclined, rear-facing position in the back seat of the car Increased Intracranial Pressure The anterior fontanel is diamond-shaped and located on the top of the head. The fontanel should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. Development Level By age 2 years, the child can use a cup and spoon correctly but with some spilling. By age 3 to 4, the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and begin to use a knife for cutting. Behavior The phases through which young children progress when separated from their parents include protest, despair, and denial or detachment. In the stage of protest, when the parents return, the child readily goes to them. In the stage of despair, the child may not approach them readily or may cling to a parent. In denial or detachment, when the parents return, the child becomes cheerful, interested in the environment and new persons (seemingly unaware of the lost parents), friendly with the staff, and interested in developing superficial relationships

20. Behavior Toddlers often resist going to bed. Bedtime protests may be reduced by establishing a consistent beforebedtime routine and enforcing consistent limits regarding the childs bedtime behavior. Informing the child of bedtime a few minutes before it is time for bed is the most appropriate option. Most toddlers take an afternoon nap and, until their second birthday, also may require a morning nap. Firm, consistent limits are needed for temper tantrums or when toddlers try stalling tactics. 21. Safe Toys Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some of the appropriate toys. A farm set, a golf set, and jacks with marbles may contain items that the child could swallow. 22. Toilet training Bowel control usually is achieved before bladder control. The child should not be forced to sit for long periods. The ability to remove clothing is one of the physical signs of readiness. The physical ability to control the anal and urethral sphincters is achieved some time after the child is walking, probably between the age of 18 and 24 months. 23. Sleep A toddler should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, or sweetened water because of the risk of nursing (bottle-mouth) caries. If a bottle is allowed at nap time or bedtime, it should contain only water. 24. Traction for Fracture In the preschooler, play is simple and imaginative and includes activities such as crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh. A radio or sports video are most appropriate for the adolescent. Large picture books are most appropriate for the infant. 25. Sleep The adolescent needs about 8 hours of sleep per night. During this age, with an increase in social activities, school commitments, and possibly work activities, it is important that the adolescent receive enough sleep at night 26. Illness in Preschoolers Although the preschooler already may be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want to call the parents. Separation anxiety will increase if the child is put in a private room even if they have their favorite toys in the room. 27. Adolescent G/D Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of their peer group, separation from friends is a source of anxiety. Ideally, the members of the peer group will support their ill friend. 28. Communication Using monosyllabic babbling occurs between 3 and 6 months of age. Using simple words such as mama occurs between 9 and 12 months of age. Linking syllables together when communicating occurs between 6 and 9 months of age. Cooing begins at birth and continues until 2 months of age. 29. Car Safety Seats The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kg (20 lb) and 1 year of age. Convertible car safety seats are used until the child weighs at least 40 lb. 30. Vital Signs The normal apical heart rate for a 3 year old is 80 to 120 beats/min. 31. Teaching Toddlers, with their increased mobility and development of motor skills, can reach hot water or hot objects placed on counters and stoves and can reach open fires or stove burners above their eye level. The nurse should encourage parents to remain in the kitchen when preparing a meal, use the back burners on the stove, and turn pot handles inward and toward the middle of the stove. Hot liquids should never be left unattended, and the toddler should always be supervised 32. Psychological Anorexia A toddler has the skills required to feed himself or herself. The parent needs to be instructed not to feed children who can feed themselves and not to force-feed a child. To increase nutritious intake at mealtime, juice intake needs to be limited to less than 12 oz per day. At mealtime, the best option is to offer less than the toddler may eat and let the child ask for more food. 33. Regression In the hospitalized preschooler, the best option is to accept regression if it occurs. Regression is most often a result of the stress of the hospitalization. Parents may be overly concerned about regression and should be told that their child may continue the behavior at home. When regression does occur, the best approach is to ignore it while praising existing patterns of appropriate behavior. Calling the physician is not necessary. 34. Infant Care Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to do so also. Additional interventions include playing a music box, radio, or television, or having a ticking clock or metronome nearby. Hanging a bright shiny object in midline within 20 to 25 cm of the infants face and hanging mobiles with contrasting colors, such as black an d white, provide visual stimulation. Crying is an infants way of communicating; therefore, the nurse would respond to the infants crying. The mother is taught to do so also. An infant or child should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, or sweetened water because of the risk of nursing (bottle-mouth) caries. 35. Reye's Syndrome In Reyes syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral

tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be in a head-elevated position to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid. 36. Reye's Syndrome "The vomiting that occurs in Reyes syndrome is caused by cerebral edema and is a symptom of increased intracranial pressure. Small frequent meals will not affect the amount of vomiting but, if vomiting occurs, the parents should contact the health care provider. Decreasing stimuli and providing rest decrease stress on the brain tissue. Checking for jaundice will assist in identifying the presence of liver dysfunction that occurs in Reyes syndrome.

37. " 38. Generalized Tonic-Clonic Seizures Generalized tonic-clonic seizures cause rigidity of all body muscles, followed by intense jerking movements. Because airway obstruction and increased oral secretions can occur during and after the seizure, airway and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. An emergency cart would not be left at the bedside but would be available in the treatment room or nearby on the nursing unit. 39. Cerebral Palsy Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation. 40. Cerebral Palsy The goals of managing the child with cerebral palsy are early recognition and intervention to maximize the childs abilities. The disorder is not curable. The cause of the disorder cannot be eliminated. Minimizing the occurrence of emotional disturbances is best if possible, but they should not be prevented because expression of emotions is healthy for the child. 41. Autism Autistic disorder is a complex childhood disorder that involves abnormalities in behavior, social interactions, and communication. Autistic children are unable to relate to persons or to respond to social and emotional cues. Characteristically, these children engage in repetitive behaviors, including head banging, twirling in circles, biting themselves, and flapping their hands or arms. Abnormal communication patterns include verbal and nonverbal communication. A child with autism needs decreased stimulation, with limited visual and auditory distractions. A private room would be the best environment, allowing for control of visual and auditory distractions. The semiprivate and four-bed ward rooms would be too stimulating for the child with autism. Autism is not a disorder that requires contact isolation. 42. Basilar Skull Fractures Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the nature of the injury, there is a high risk of secondary infection and the probability of the catheter entering the brain through the fracture. Fluid balance is monitored closely by daily weight, intake and output measurement, and serum osmolality determination to detect early signs of water retention, excessive dehydration, and states of hypertonicity or hypotonicity. The child is maintained on an NPO status or restricted to clear liquids until it is determined that vomiting will not occur. An intravenous line is maintained to administer fluids or medications if necessary. 43. Bacterial Meningitis Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing cerebrospinal fluid obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy cerebrospinal fluid, and elevated leukocyte, elevated protein, and decreased glucose levels. 44. Bacterial Meningitis Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child also is placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Enteric precautions and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when a child has a low neutrophil count. 45. Autism Autistic disorder is a complex childhood disorder that involves abnormalities in behavior, social interactions, and communication. Autistic children are unable to relate to persons or to respond to social and emotional cues. Characteristically, these children engage in repetitive behaviors, including head banging, twirling in circles, biting themselves, and flapping their hands or arms. Abnormal communication patterns include verbal and nonverbal communication.

46. Abuse: Sexual The most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may indicate physical neglect. Bald spots on the scalp and fear of the parents most likely are associated with physical abuse. 47. Abuse: Physical The primary legal nursing responsibility when child abuse is suspected is to report the case. All states and provinces in North America have laws for mandatory reporting of child maltreatment. Suspected child abuse should be reported to the local authorities. Although documentation of assessment findings, assisting the family, and referring the family to appropriate resources and support groups are important, the primary legal responsibility is to report the suspected case. 48. Spina Bifida (Myelomeningocele type) The newborn with spina bifida is at risk for infection before the closure of the sac. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents. This prevents tearing or breakdown of the skin integrity at the site. Blood pressure may be difficult to assess during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development. A thermometer will be needed to assess temperature, but in this newborn the priority is to maintain sterile normal saline dressings over the sac. 49. Absence Seizures Absence seizures are brief episodes of altered awareness. No muscle activity occurs except eyelid fluttering or twitching. The child has a blank facial expression. These seizures last only 5 to 10 seconds, but they may occur one after another several times a day. Myoclonic seizures are brief random contractions of a muscle group that can occur on one or both sides of the body. Simple partial seizures consist of twitching of an extremity, face, or neck, or the sensation of twitching or numbness in an extremity or face or neck. 50. Increased Intracranial Pressure Decerebrate posturing is characterized by the rigid extension and pronation of the arms and legs 51. Hydrocephalus In infants with hydrocephalus, the head grows at an abnormal rate and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help prevent skin breakdown. Proteinuria is not specific to hydrocephalus. Stimulus should be kept at a minimum because of the increase in intracranial pressure. It is not necessary to check the blood pressure every 30 minutes. 52. Hydrocephalus If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is increased intracranial pressure, which then causes a high-pitched cry in the infant. The infant should not have pressure placed on the shunt side. Skin breakdown and possible compressions to the apparatus could result. This type of shunt affects the gastrointestinal system, not the genitourinary system. An infant refusing food is only a concern if the infant becomes malnourished or dehydrated, which then could raise the body temperature. Otherwise, the infants refusing baby food has no direct relationship to the shunt functioning . 53. Spina Bifida (Myelomeningocele type) Newborn infants with spina bifida (myelomeningocele type) are at risk for hydrocephalus; therefore, the head circumference should be measured to obtain a baseline. Options 1, 2, and 3 are incorrect because pulse rate will not be affected with this disorder, the specific gravity can indicate hydration status but it is not priority at this time, and abdominal masses do not occur with this disorder. 54. Increased Intracranial Pressure Late signs of increased intracranial pressure (ICP) include a significant decrease in level of consciousness, bradycardia, and fixed and dilated pupils. A bulging fontanel and dilated scalp veins are early signs of increased ICP and would be noted in an infant, not a 5-year-old child. Nausea is an early sign of increased ICP 55. Seizures During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side will prevent aspiration because saliva will drain out the corner of the childs mouth. The child is not restraine d because this could cause injury to the child. The nurse would loosen clothing around the childs neck and ensure a patent airway. Nothing is placed into the childs mouth during a seizure because this action may cause injury to the childs mouth, gums, o r teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure. 56. Strabismus Strabismus is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see. 57. Strabismus Strabismus is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. In a child diagnosed with strabismus, surgery may be indicated to realign the weakened muscles. Surgery most often is indicated when amblyopia (decreased vision in the deviated eye) is present. The surgery should be performed before the child is 2 years old 58. Myringotomy A myringotomy is the insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated. After myringotomy with insertion of tympanostomy tubes, the child may experience some discomfort. Tylenol can be given to relieve the discomfort. An opioid analgesic is not necessary, and aspirin should not be administered to a child.

59. Chlamydial Conjunctivitis Conjunctivitis is an inflammation of the conjunctiva. A diagnosis of chlamydial conjunctivitis in a child who is not sexually active should signal the health care provider to assess the child for possible sexual abuse. Allergy, infection, and trauma can cause conjunctivitis, but the causative organism is not likely to be chlamydia 60. Bacterical Conjunctivitis Conjunctivitis is an inflammation of the conjunctiva. Bacterial conjunctivitis is highly contagious, and the nurse should teach infection control measures. These include good hand washing and not sharing towels and washcloths 61. Myringotomy A myringotomy is the insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated. Parents need to be instructed that the child should not blow his or her nose for 7 to 10 days. Bath and lake water are potential sources of bacterial contamination. Diving and swimming in deep water are prohibited. The childs ears need to be kept dry 62. Tonsillectomy Tonsillectomy Because the tonsillar area is so vascular, postoperative bleeding is a concern. The prothrombin time, partial thromboplastin time, platelet count, hemoglobin and hematocrit, white blood cell count, and urinalysis are performed preoperatively. The prothrombin time results would identify a potential for bleeding. The creatinine level, sedimentation rate, and blood urea nitrogen would not determine the potential for bleeding. 63. Tonsillectomy Tonsillectomy - In the preoperative period, the child should be observed for the presence of loose teeth to decrease the risk of aspiration during surgery. Options 1 and 3 are incorrect because these are characteristics that may indicate the need for the surgery. Bleeding during surgery will be controlled via packing and suction as needed. 64. Tonsillectomy Tonsillectomy - The child should be placed in a prone or side-lying position following tonsillectomy to facilitate drainage. 65. Tonsillectomy Tonsillectomy - After tonsillectomy, suction equipment should be available, but suctioning is not performed unless there is an airway obstruction because of the risk of trauma to the oropharynx. Monitoring for bleeding is an important nursing intervention following any type of surgery. Milk and milk products are avoided initially because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding. Clear, cool liquids are encouraged. 66. Tonsillectomy Tonsillectomy - Frequent swallowing, restlessness, a fast and thready pulse, and vomiting bright red blood are signs of bleeding. An elevated blood pressure and complaints of discomfort are not indications of bleeding. 67. Myringotomy Myringotomy - A myringotomy is the insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated. The nurse must instruct parents regarding the administration of antibiotics. Antibiotics need to be taken as prescribed, and the full course needs to be completed 68. Tonsillectomy Tonsillectomy - Bad mouth odor is normal following tonsillectomy and may be relieved by drinking more liquids. Options 1, 2, and 3 are incorrect. In addition, mouthwash gargles (option 3) will irritate the throat. 69. Ear Drops Ear Drops - For children younger than age 3, the nurse instructs the parent that the auditory canal is straightened by pulling the lobe down and back. For children older than 3 years, the pinna (option 1) is pulled up and back. 70. Acute Otitis Media Acute Otitis Media - Acute otitis media is usually an infectious inflammation of the middle ear. The child will often have fever, pain, loss of appetite, and possible ear drainage. The childs fever should be treated with acetaminophen (Tylenol). The child is positioned on his or her affected side to facilitate drainage. A soft diet is recommended during the acute stage to avoid pain that can occur with chewing. Antibiotics are prescribed to treat the bacterial infection and should be administered for the full 10- to 14-day prescribed course. The ear should not be irrigated with normal saline because it can further exacerbate the inflammation. Antihistamines are not recommended. 71. Bronchiolitis w/ Dehydration Dehydration - Weight is the most reliable method of measurement of body fluid loss or gain. A weight change of 1 kg represents 1 L of fluid loss or gain. Although options 2, 3, and 4 identify components of the assessment for dehydration, these are not the most reliable determinants, because they require more subjective interpretation than weight, which is more objectively determined. 72. epiglottitis Epiglottitis - Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward while supported by arms, chin thrust out, mouth open), nasal flaring, tachycardia, a high fever, and a sore throat. Option 4 is an incorrect position. Options 1 and 3 are incorrect because epiglottitis causes a high fever and tachycardia. 73. Bronchiolitis Bronchiolitis Respiratory syncytial virus (RSV) is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands, and meticulous hand washing is necessary to decrease the spread of organisms. The infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are not necessary. 74. Respiratory Syncytial Virus (RSV) Respiratory Syncytial Virus (RSV) Ribavirin (Virazole) is an antiviral respiratory medication used mainly for hospitalized children with severe RSV. Administration is via hood, face mask, or oxygen tent. Ribavirin is not administered orally, intramuscularly, or subcutaneously. 75. Asthma Asthma Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A silent chest is an ominous sign during an asthma episode. With treatment, incre ased

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wheezing actually may signal that the childs condition is improving. Warm, dry skin indicates an improvement in condition, because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats/min. The normal respiratory rate in a 10-year-old is 16 to 20 breaths/min. Pneumonia Pneumonia Splinting of the affected side by lying on that side may decrease discomfort. To advise the mother to increase the dose or frequency of the acetaminophen is inappropriate. Lying on the left side will not be helpful in alleviating discomfort. Sudden Infant Death Syndrome (SIDS) Sudden Infant Death Syndrome (SIDS) Nurses should encourage parents to place the infant on the back (supine) for sleep. The infant may have the ability to turn to a prone position from the side-lying position. Infants in the prone position (on the stomach) may be unable to move their heads to the side, thus increasing the risk of suffocation. Cystic Fibrosis Cystic Fibrosis In a sweat test, sweating is stimulated on the childs forearm with pilocarpine, the sample is collected on absorbent material, and the amounts of sodium and chloride are measured. A sample of at least 50 mg of sweat is required for accurate results. A chloride level higher than 60 mEq/L is considered to be a positive test result. A chloride level of 40 mEq/L suggests cystic fibrosis and requires a repeat test. A chloride level of less than 40 mEq/L indicates no cystic fibrosis. Cystic Fibrosis Cystic Fibrosis Adequately protecting children with cystic fibrosis from communicable diseases by immunization is essential. In addition to the basic series of immunizations, a yearly influenza and possibly a pneumococcal vaccine also are recommended for children with cystic fibrosis. Mantoux test Mantoux test Induration measuring 10 mm or more is considered to be a positive result in children younger than 4 years of age and in those with chronic illness or at high risk for environmental exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for the highest risk groups, such as the child with an immunosuppressive condition or the child with human immunodeficiency virus infection. A reaction of 15 mm or more is positive in children 4 years of age or older without any risk factors. HIV HIV For children with human immunodeficiency virus infection, a minimum of 12 months of treatment with isoniazid is recommended. Croup Croup Croup often begins at night and may be preceded by several days of upper respiratory infection symptoms. Croup is characterized by a sudden onset of a harsh, brassy cough, sore throat, and inspiratory stridor. Symptoms usually worsen at night and are better in the day. Croup usually is accompanied by a low-grade fever, but occasionally the temperature may be as high as 104 F. Croup Croup Antibiotics are not indicated in the treatment of croup unless a bacterial infection is present Croup Croup If the use of a tent or hood is causing distress, treatment may be more effective if the child is held by the parent and a cool mist is directed toward the childs face. A mild sedative would not be administered to the child. Crying will aggravate laryngospasm and increase hypoxia, which may cause airway obstruction Bronchiolitis Bronchiolitis The infant with RSV should be isolated in a private room or in a room with another infant with RSV infection. The infant should be placed in a room near the nurses station for easy observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing gloves and a gown) reduce nosocomial transmission of RSV. Aortic stenosis Aortic stenosis The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods of time. Pallor may be noted but is not specific to this type of disorder alone Cardiac Surgery Cardiac Surgery The mother should be instructed that lotions and powders should not be applied to the incision site. Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site. Rheumatic Fever Rheumatic Fever Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child had a sore throat or an unexplained fever within the past 2 months. Rheumatic Fever Rheumatic Fever Anti-inflammatory agents, including aspirin, may be prescribed for the child with rheumatic fever. Aspirin should not be given to a child who has chickenpox or other viral infections, such as the flu. Joint pain and arthralgia are clinical manifestations of rheumatic fever. Facial edema may be associated with the development of a cardiac complication. Rheumatic Fever Rheumatic Fever A diagnosis of rheumatic fever is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive antistreptolysin O titer, Streptozyme assay, or an anti-DNase B assay

91. Kawasaki Disease Kawasaki Disease Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown origin. An acquired cell-mediated immunodeficiency disorder describes human immunodeficiency virus infection. Option 2 (chronic multisystem autoimmune disease w/ inflammation of connective tissue) describes systemic lupus erythematosus. Option 4 (autoimmune inflammation of the heart, joints, and SQ tissues) describes rheumatic fever. 92. Kawasaki Disease Kawasaki Disease In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present. 93. CHF CHF The parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. In addition, the parents should be instructed that if a dose is missed and is not identified until 4 hours later, the dose should not be administered. 94. Tricuspid Atresia Tricuspid Atresia In tricuspid atresia, no communication exists from the right atrium to the right ventricle. Option 1 (single vessel overrides both ventricles) describes truncus arteriosus. Option 4 (no communication b/t systemic and pulm circulation) describes transposition of the great arteries. Frequent episodes of hypercyanotic spells occur in tetralogy of Fallot. 95. Kawasaki Disease Kawasaki Disease Immune globulin is administered intravenously to the child with Kawasaki disease to decrease the incidence of coronary artery lesions and aneurysms and to decrease fever and inflammation 96. Tetralogy of Fallot Tetralogy of Fallot If a hypercyanotic spell occurs, the nurse immediately places the infant in a knee-chest position. This position improves systemic arterial oxygen saturation. 97. CHF CHF The early signs of congestive heart failure (CHF) include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in CHF as a result of mucosal swelling and irritation but is not an early sign. Pallor may be noted in the infant with CHF but is also not an early sign. 98. CHF CHF Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures 99. CHF CHF The most appropriate method for assessing urine output in an infant receiving diuretic therapy is to weigh the diapers. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the amount of output. Although Foley catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant and places the infant at risk for infection. 100. CHF CHF A weight gain of 0.5 kg (1 lb) in 1 day is caused by the accumulation of fluid. The nurse should assess urine output, assess for evidence of facial or peripheral edema, auscultate lung sounds, and report the weight gain to the physician. Tachypnea and an increased blood pressure would occur with fluid accumulation. Diaphoresis is a sign of CHF but is not specific to fluid accumulation, and usually occurs with exertional activities. 101. CHF CHF A patent ductus arteriosus is failure of the fetal ductus arteriosus (artery connecting the aorta and the pulmonary artery) to close. A characteristic machinery-like murmur is present and the infant may show signs of congestive heart failure. Aortic stenosis is a narrowing or stricture of the aortic valve. Atrial septal defect is an abnormal opening between the atria. Ventricular septal defect is an abnormal opening between the right and left ventricles. 102. Cleft lip After cleft lip repair, the infant should be positioned supine or on the side lateral to the repair to prevent contact of the suture lines with the bed linens. Placing the infant on the left side rather than supine immediately after surgery is best to prevent the risk of aspiration if the infant vomits. 103. Esophageal Atresia Any child who exhibits the 3 Cscoughing and choking with feedings and unexplained cyanosis should be suspected of tracheoesophageal fistula 104. GERD Small, more frequent feedings with frequent burping often are prescribed in the treatment of gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis. If thickened formula is used, cross-cutting of the nipple may be required. 105. Pyloric Stenosis Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation, and signs of dehydration, including a decrease in urine output. 106. Lactose Intolerance Lactose intolerance is the inability to tolerate lactose, the sugar found in dairy products. Removing milk and other dairy products from the diet can provide adequate relief from symptoms. Additional dietary changes may be required to provide adequate sources of calcium and, in the infant, protein and calories. 107. Celiac Disease Dietary management is the mainstay of treatment in celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn, rice, or millet. Vitamin supplements especially the fat-soluble vitamins, iron,

and folic acidmay be needed in the early period of treatment to correct deficiencies. Dietary restrictions are likely to be lifelong, although small amounts of grains may be tolerated after ulcerations have healed. 108. Intussesception Intussusception is a telescoping of one portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. The child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomiting may be present but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly like stools. Watery diarrhea and ribbon-like stools are not manifestations of this disorder. 109. Lead Poisoning Renal function is monitored closely during the administration of chelation therapy because the medications are excreted via the kidneys. Although it is important to monitor the red blood cell count for the presence of anemia in a child with lead poisoning, this laboratory result is not specific to chelation therapy. 110. Hirschsprung's Disease Hirschsprungs disease is a congenital anomaly also known as congenital aganglionosis or aganglionic megacolon. It occurs as the result of an absence of ganglion cells in the rectum and other areas of the affected intestine. Chronic constipation beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foulsmelling is a clinical manifestation of this disorder. Delayed passage or absence of meconium stool in the neonatal period is also a sign. Bowel obstruction, especially in the neonatal period, abdominal pain and distention, and failure to thrive are also clinical manifestations 111. Vomiting Vomiting will cause the loss of hydrochloric acid and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea might or might not accompany vomiting. Hyperactive bowel sounds are not necessarily associated with vomiting. 112. Diarrhea Rectal temperature measurements should be avoided if diarrhea is present. Use of a rectal thermometer can stimulate peristalsis and cause more diarrhea. Axillary and tympanic measurements of temperature would be acceptable. Most measurements are done using electronic devices. 113. Cleft Palate The mother is taught the ESSR method of feeding the child with a cleft palate: enlarge the nipple, stimulate the sucking reflex, swallow, and rest to allow the infant to finish swallowing what has been placed in the mouth 114. Imperforated Anus During the newborn assessment, this defect should be identified easily on sight. However, a rectal thermometer or tube may be necessary to determine patency if meconium is not passed in the first 24 hours after birth. Other assessment findings include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum 115. Gastroschisis Gastroschisis occurs when the bowel herniates through a defect in the abdominal wall to the right of the umbilical cord. There is no membrane covering the exposed bowel. Surgical repair will be done as soon as possible because of the risk of infection in the unprotected bowel. Therefore, the highest risk immediately after delivery would be infection. Risk for impaired parenting and risk for disorganized infant behavior are possible later nursing problems, but they would not have priority. Risk for impaired urinary elimination is unlikely because the gastrointestinal tract is affected, not the genitourinary system. 116. Appendectomy In the preoperative period, enemas or laxatives should not be administered. Additionally, heat is not applied to the abdomen. Any of these interventions can cause rupture of the appendix and resultant peritonitis. IV fluids would be started, and the child would be NPO while awaiting surgery. Usually, antibiotics are administered because of the risk of perforation. Prescribed preoperative medications most likely would be administered on call to the operating room. 117. Hepatitis Because hepatitis can be viral, standard precautions should be instituted in the hospital. The child should be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite home schooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the physician. Provision of a low-fat, wellbalanced diet is recommended. Parents are cautioned about administering any medication to the child, because normal doses of many medications may become dangerous because of the livers inability to detoxify and excrete them. Hand washing is the single most effective measure in control of hepatitis in any setting and effective hand washing can prevent the compromised child from picking up an opportunistic type of infection. 118. Potassium Chloride The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hr, potassium chloride should not be administered. Although options 1, 2, and 3 are appropriate assessments for the child with dehydration, these assessments are not related specifically to the intravenous (IV) administration of potassium chloride. 119. Diabetes Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic

ketoacidosis. Instead, hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. Cold, clammy skin, irritability, sweating, and tremors are all signs of hypoglycemia. 120. Phenylketonuria Phenylketonuria is an autosomal recessive disorder. Treatment includes dietary restriction of phenylalanine intake. Phenylketonuria is a genetic disorder that results in central nervous system damage from toxic levels of phenylalanine in the blood 121. Phenylketonuria Phenylketonuria is characterized by blood phenylalanine levels higher than 8 mg/dL. A normal level is lower than 2 mg/dL. A result of 1 mg/dL is a negative test result. 122. Diabetes An extra snack of 15 to 30 g of carbohydrates eaten before activities such as soccer practice will prevent hypoglycemia. Six graham crackers or a cup of orange juice will provide 15 to 30 g of carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be doubled. 123. Diabetes To help decrease variations in absorption from day to day, the adolescent should use one major site for injections for 2 to 3 weeks before changing major sites. The injections are rotated to different locations within that major site. 124. Diabetes When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink calorie-free liquids. Bringing the child to the clinic immediately is not necessary. Insulin doses should not be adjusted or changed. 125. Diabetes Rehydration is the initial step in resolving diabetic ketoacidosis. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose level reaches an acceptable level. Intravenously administered potassium may be required, depending on the potassium level, but would not be part of the initial treatment. 126. Tylenol After administering the acetaminophen, excess clothing and blankets should be removed. The child can be sponged with tepid water, but not cold water, because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin is not administered to a child wit h fever because of the risk of Reyes syndrome. Fluids should be encouraged to prevent dehydration, so oral fluids should not be withheld. 127. Fluid Volume Deficit Indicators that fluid volume deficit is resolving would be capillary refill less than 3 seconds, specific gravity of 1.002 to 1.025, urine output of at least 1 mL/kg/hour, and adequate tear production. Therefore, a capillary refill time shorter than 3 seconds is the only indicator that the child is improving. Urine output of less than 1 mL/kg/hr, a specific gravity of 1.030 and no tears would indicate that the deficit is not resolving. 128. Diabetes Hypoglycemia is defined as a blood glucose level lower than 70 mg/dL. Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If possible, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; the rapid-releasing sugar is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums and the blood glucose level is retested if the child does not improve within 15 to 20 minutes; if the reading remains low, additional sugar is administered. If the child remains unconscious, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. Encouraging the child to ambulate and administering regular insulin will result in a lowered blood glucose level. Providing electrolyte replacement therapy intravenously is an intervention to treat diabetic ketoacidosis. Waiting 30 minutes to confirm the blood glucose level delays necessary intervention. 129. Acute Glomerulonephritis Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. In glomerulonephritis, activity is limited and most children, because of fatigue, voluntarily restrict their activities during the active phase of the disease. Catheterization may cause a risk of infection. Fluids should never be forced. Visitors should be limited to allow for adequate rest. 130. Nephrotic Syndrome Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema. Other manifestations include weight gain, periorbital and facial edema that is most prominent in the morning, leg, ankle, labial or scrotal edema, decreased urine output and urine that is dark and frothy, abdominal swelling, and blood pressure that is normal or slightly decreased. 131. Nephrotic Syndrome Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia (hypoproteinemia), and edema. In most cases, medication and diet will control the fluid retention. The nurse must give the mother information that addresses the subject that is the parents concern. Most children experience remission with treatment . Options 1 and 4 are nontherapeutic and may add to the mothers guilt. Option 2 does not acknowledge the concern and is a stereotypical response. 132. Hemolytic-Uremic Syndrome Hemolytic-uremic syndrome (HUS) is thought to be associated with bacterial toxins, chemicals, and viruses that cause acute renal failure in children. Clinical features of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with hemolytic-uremic syndrome

undergoing peritoneal dialysis because of anuria will be on fluid restriction. Pain is not associated with hemolytic-uremic syndrome and potassium would be restricted, not encouraged, if the child was anuric. Peritoneal dialysis does not require an AV shunt (only hemodialysis). 133. Nocturnal Enuresis Primary nocturnal enuresis occurs in a child who has never been dry at night for extended periods. The condition is common in children, and most children eventually will outgrow bed-wetting without therapeutic intervention. The child is not able to sense a full bladder and does not awaken to void. The child may have delayed maturation of the central nervous system. The condition is not caused by a psychiatric problem. 134. Cryptorchidism The most common complications associated with orchiopexy are bleeding and infection. The parents are instructed in postoperative home care measures, including preventing infection, pain control, and activity restrictions. Anticholinergics are prescribed for the relief of bladder spasms and are not necessary following orchiopexy. Measurement of intake and output is not required. Cold wet compresses are not prescribed. In addition, the moisture from a wet compress presents a potential for infection. 135. Cryptorchidism All vigorous activities should be restricted for 2 weeks following surgery to promote healing and prevent injury. This will prevent dislodging of the suture, which is internal. Normally, 2-year-olds want to be active; therefore, allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parent should be taught to monitor the temperature, provide analgesics as needed, and monitor the urine output. 136. Epispadias Epispadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. The urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic facilitates entry of bacteria into the urine. 137. Nephrotic Syndrome Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia (hypoproteinemia), and edema. A child with edema from nephrotic syndrome will be at high risk for skin breakdown. Skin surfaces should be cleaned and separated with clothing to prevent irritation and resultant skin breakdown. The child will be anorexic so a risk for imbalanced nutrition, more than body requirements is not a concern. A risk for constipation or ineffective thermoregulation is not a concern with nephrotic syndrome. 138. Hypospadias At the age of 1 year, a childs fears of separation are great because the child is facing the deve lopmental task of trusting others. Options 3 and 4 may be issues if the child was older. No data in the question allow one to determine that siblings exist. 139. Hypospadias Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. 140. Bladder Exstrophy In bladder exstrophy, the bladder is exposed and external to the body. The highest priority is impaired tissue integrity related to the exposed bladder mucosa. Although the infant needs to be monitored for elimination patterns and kidney function, option 3 is not a concern for this condition. Parental knowledge deficit related to the diagnosis and treatment of the condition will need to be addressed but again is not the priority. Although infection related to the anatomical location of the defect is an appropriate nursing diagnosis, it is a potential problem and not an actual one. 141. Bladder Exstrophy In bladder exstrophy, the bladder is exposed and external to the body. In this disorder, one must take care to protect the exposed bladder tissue from drying while allowing the drainage of urine. This is accomplished best by covering the bladder with a nonadhering plastic wrap. The use of petroleum jelly gauze should be avoided because this type of dressing can dry out, adhere to the mucosa, and damage the delicate tissue when removed. Dry sterile dressings and dressings soaked in solutions (that can dry out) also damage the mucosa when removed. 142. Glomerulonephritis Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Group A beta-hemolytic streptococcal infection is a cause of glomerulonephritis. Often, the child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks 143. Glomerulonephritis Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria, resulting in dark, smoky, cola-colored or red-brown urine, is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis. 144. Nephrotic Syndrome Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The child gains weight 145. Burns Sensorium is an accurate guide to determine the adequacy of fluid resuscitation. The burn injury itself does not affect the sensorium, so the child should be alert and oriented. Any alteration in sensorium should be evaluated further. A neurological assessment would determine the level of sensorium in the child

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146. Head lice "Pediculosis capitis is an infestation of the hair and scalp with lice. The nits are visible and firmly attach to the hair shaft near the scalp. The occiput is an area in which nits can be seen. White flaky particles are indicative of dandruff. Maculopapular lesions behind the ears or lesions that extend to the hairline or neck are indicative of an infectious process, not pediculosis. 147. " 148. Eczema Eczema is a superficial inflammatory process involving primarily the epidermis. The major goals of management are to relieve pruritus, lubricate the skin, reduce inflammation, and prevent and control secondary infection. Secondary infection can occur when areas affected by eczema are scratched as a result of the itching because open skin is a portal of entry for pathogens. The lesions are not viral and they do not present as thick white crusty plaques. They appear as red and scaly lesions that can weep, ooze, and crust. They commonly occur in the antecubital and popliteal areas. Throat edema and mouth ulcers are not characteristics of this disorder. 149. Head lice Thorough home cleaning is necessary to remove any remaining lice or nits. Antilice sprays are unnecessary. In addition, they should never be used on a child or on bedding or linens. Bedding and linens should be washed with hot water and dried on a hot setting. Items that cannot be washed should be dry-cleaned or sealed in plastic bags in a warm place for 2 weeks. Combs and brushes should be soaked in a scabicide shampoo or hot water for 1 hour. 150. Scabies Scabies appears as burrows or fine, grayish-red, thread-like lines. They may be difficult to see if they are obscured by excoriation and inflammation. Purple-colored lesions may indicate various disorders, including systemic conditions. Thick, honey-colored crusts are characteristic of impetigo or secondary infection in eczema. Clusters of fluid-filled vesicles are seen in herpesvirus infection. 151. Scabies Permethrin is massaged thoroughly and gently into all skin surfaces (not just the areas that have the rash) from the head to the soles of the feet. Care should be taken to avoid contact with the eyes. The lotion should not be applied until at least 30 minutes after bathing and should be applied only to cool, dry skin. The lotion should be kept on for 8 to 14 hours, and then the child should be given a bath. The child should be clothed during the 8 to 14 hours of treatment contact time. 152. Scabies Lindane is contraindicated for children younger than 2 years. These children have more permeable skin and high systemic absorption may occur, placing the child at risk for central nervous system toxicity and seizures. Lindane also is used with caution in children between the ages of 2 and 10 years. Siblings and other household members also should be treated at the same time. Options 2 and 4 are unrelated to the use of lindane. Lindane is not recommended for use by a breast-feeding woman because the medication is secreted into breast milk. 153. Impetigo Impetigo is most common during hot, humid summer months. Impetigo may begin in an area of broken skin, such as an insect bite or atopic dermatitis. Infection may be caused by Staphylococcus aureus, group A beta-hemolytic streptococci, or a combination of these bacteria. Impetigo is extremely contagious. Lesions usually are located around the mouth and nose but may be present on the hands and extremities. 154. Impetigo The child should not attend school for 24 to 48 hours after the initiation of systemic antibiotics or 48 hours after the use of antibiotic ointment. The school should be notified of the diagnosis. Options 1, 2, and 3 are incorrect time frames. 155. Burns Some pediatric considerations in the care of a burn victim include the following: scarring is more severe in a child than in an adult; a delay in growth may occur following a burn injury; burns involving more than 10% of total body surface area require some form of fluid resuscitation; an immature immune system presents an increased risk of infection for infants and young children; the higher proportion of body fluid to mass in a child increases the risk of cardiovascular problems; and infants and young children are at increased risk for protein and calorie deficiencies because they have smaller muscle mass and less body fat than adults. 156. Fracture An absent pulse to an extremity of an affected limb could mean that the child is developing or experiencing compartment syndrome. This is an emergency situation and the physician should be notified immediately. Applying ice to an extremity with absent perfusion is incorrect. Ice may be prescribed when perfusion is adequate to decrease swelling. Administering analgesics will not improve circulation. The skin traction should not be released without a physicians order. 157. Scoliosis A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the childs abdominal contents, resulting from lengthening of the childs bod y. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or those who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Therefore options 2, 3, and 4 are incorrect. 158. Developmental Dysplasia of the Hip (DDH) In DDH, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. In the Ortolani maneuver, the examiner reduces the dislocated femoral head back into the acetabulum. A positive finding is the palpable click or clunk on movement of the femoral head over the acetabular ring. This maneuver does not result in permanent relocation. Its purpose is to note the possibility of correction by means of the Pavlik harness or spica casting. In the

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Barlow maneuver, the examiner pushes the unstable femoral head out of the acetabulum. If it dislocates, it usually relocates immediately. The purpose is to note the presence of instability. Options 1 and 2 are done to assess for the possible presence of DDH. 159. Developmental Dysplasia of the Hip (DDH) The Pavlik harness should be worn 16 to 23 hours a day and should be removed only to check the skin and for bathing. The infant can be moved when out of the harness, but the hips and buttocks should be supported carefully. The harness does not need to be removed for diaper changes or feedings. 160. Fracture When a child is in traction, the nurse would check the physicians orders to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as ordered, ensure that the weights hang freely, check the ropes for fraying and be sure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms of immobilization. The nurse would provide therapeutic and diversional play activities for the child. 161. Fracture The mother needs to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation. Options 1, 3, and 4 are appropriate instructions. 162. Club Foot Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome. 163. Scoliosis The use of lotions or powders under a brace should be avoided because they can become sticky and cake under the brace, causing irritation. Options 1, 2, and 4 are appropriate interventions in the care of a child with a brace. 164. Developmental Dysplasia of the Hip (DDH) In DDH, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Asymmetrical abduction of the affected hip, when the child is placed supine with the knees and hips flexed, would be an assessment finding in DDH in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity. 165. Juvenile Idiopathis Arthritis (JIA) During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain. Although resting the extremity is appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important. These exercises do not involve joint movement. 166. Fracture While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling and the physician is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment and the physician should be notified. 167. Anemia Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1 to 2 times the daily requirement to prevent dehydration. 168. Anemia The results of a complete blood cell count in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated. 169. Anemia An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth because the iron will stain the teeth. The parents should be instructed to brush or wipe the childs teeth after administrati on. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not added to formula or mixed with cereal or other food items. 170. Hemophilia Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Therefore, abnormal laboratory results in hemophilia indicate a prolonged partial thromboplastin time. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia. 171. Hemophilia Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Children with hemophilia need to avoid contact sports and to take precautions such as wearing elbow and knee pads and helmets with other sports. The safest activity for them is swimming. 172. Thalassemia -Thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with -thalassemia major). This disorder is found primarily in individuals of Mediterranean descent. Options 1, 3, and 4 are incorrect.

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173. Thalassemia -Thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with -thalassemia major). The major complication of chronic transfusion therapy is hemosiderosis. To prevent organ damage from too much iron in the blood, chelation drug therapy with deferoxamine (Desferal) is used. Deferoxamine is classified as an antidote for acute iron toxicity. Dalteparin is an anticoagulant used as prophylaxis for postoperative deep vein thrombosis. Meropenem is an antibiotic. Metoprolol is a blocker used to treat hypertension. 174. Anemia Sickle cell anemia is a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape and the cells become rigid and clumped together, obstructing capillary blood flow. All the clinical manifestations of sickle cell anemia result from the sickled cells being unable to flow easily through the microvasculature, and their clumping obstructs blood flow. With reoxygenation, most of the sickled red blood cells resume their normal shape. Options 1, 2, and 3 are incorrect statements. 175. Anemia Sickle cell anemia is a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape and the cells become rigid and clumped together, obstructing capillary blood flow. Therefore, oral and intravenous fluids are an important part of treatment. Meperidine (Demerol) is not recommended for the child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would thus question the order for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain in painful joints, oxygen, and a high-calorie, high-protein diet are also important parts of the treatment plan. 176. von Willebrand disease von Willebrand disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in a protein termed von Willebrand factor (vWF). The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. An elevated creatinine level is not associated with this disorder. 177. Leukemia Immunocompromised children are unable to fight varicella adequately. Chickenpox can be deadly to the immunocompromised child. If an immunocompromised child who has not had chickenpox is exposed to someone with varicella, the child should receive varicella zoster immune globulin within 96 hours of exposure. Options 1, 3, and 4 are incorrect because they do nothing to minimize the chances of developing the disease. 178. Leukemia If a child is severely thrombocytopenic and has a platelet count less than 20,000/L, bleeding prec autions need to be initiated because of the increased risk of bleeding or hemorrhage. The precautions include limiting activity that could result in head injury, using soft toothbrushes or Toothettes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories and rectal temperatures are avoided. Options 1, 2, and 3 are related to the prevention of infection rather than bleeding. 179. Increased Intracranial Pressure The brain, while well protected by the solid bony cranium, is highly susceptible to pressure that may accumulate within the enclosure. Volume and pressure must remain constant within the brain. A change in the size of the brain, such as occurs with edema, or increased volume of intracranial blood or cerebrospinal fluid without a compensatory change, will lead to an increase in intracranial pressure, which may be life-threatening. An early sign of increased intracranial pressure, vomiting, can become excessive as pressure builds up and stimulates the medulla in the brainstem, which houses the vomit center. Children with open fontanels (posterior closes at 2 to 3 months; anterior closes at 12 to 18 months) compensate for intracranial pressure changes by skull expansion and subsequent bulging fontanels. Once the fontanels have closed, nausea, excessive vomiting, diplopia, and headaches become pronounced, with headaches becoming more prevalent in older children. 180. Leukemia The confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate and biopsy. A lumbar puncture may be done to look for blast cells in the spinal fluid that indicate central nervous system disease. The white blood cell count may be normal, high, or low in leukemia. An altered platelet count occurs as a result of the disease but also may occur as a result of chemotherapy and does not confirm the diagnosis. 181. Leukemia The risk of injury to fragile mucous membranes is so high in the child with leukemia that oral, tympanic, or axillary temperature should be taken. Rectal abscesses can occur easily to damaged rectal tissue. No rectal temperatures should be taken. In addition, oral temperature taking should be avoided if the child has oral ulcers. Options 2, 3, and 4 are appropriate measures to prevent infection.

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182. Leukemia For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas aeruginosa, to which these children are susceptible. In addition, fresh fruits and vegetables harbor molds and should be avoided until the white blood cell count rises. 183. Leukemia When the child is nauseated, offering cool, clear liquids is best because they are soothing and better tolerated. One should not offer favorite foods when the child is nauseated because foods eaten during times of nausea will be associated with being sick. Supportive nutritional measures should include oral supplements with high-protein and high-calorie foods. 184. Hodgkin's disease Hodgkins disease is a neoplasm of lymphatic tissue. The presence of giant, multinucleated cells (Reed-Sternberg cells) is the hallmark of this disease. The presence of blast cells in the bone marrow indicates leukemia. The Epstein-Barr virus is associated with infectious mononucleosis. Elevated levels of vanillylmandelic acid in the urine may be found in children with neuroblastoma. 185. Hodgkin's disease Clinical manifestations specifically associated with Hodgkins disease include painless, firm, and movable adenopathy in the cervical and supraclavicular areas. Hepatosplenomegaly also is noted. Although fever, malaise, anorexia, and weight loss are associated with Hodgkins disease, these manifestations are seen in many disorders. 186. Brain Tumor Colorless drainage on the dressing indicates the presence of cerebrospinal fluid and should be reported to the physician immediately. Options 2, 3, and 4 are inaccurate nursing interventions, because they do not address the need for immediate intervention to prevent complications. 187. Brain Tumor The child is never placed in Trendelenburgs position because it increases intracranial pressure (ICP) and the risk of bleeding. In the event of shock, the physician is notified immediately before changing the childs position or increa sing intravenous fluids. Increasing intravenous fluids can cause an increase in ICP. 188. Wilms' Tumor Wilms tumor, or nephroblastoma, is the most common renal tumor in children. Arising from the renal parenchyma of the kidney, this tumor grows rapidly. The tumor may be present unilaterally and localized or bilaterally, sometimes with metastasis to other organs. Options 1, 3, and 4 are incorrect. 189. Wilms' Tumor If Wilms tumor is suspected, the tumor mass should not be palpated by the nurse. Excessive manipulation can cause seeding of the tumor and spread of the cancerous cells. Fever, hematuria, and hypertension are clinical manifestations associated with Wilms tumor. 190. Osteogenic Sarcoma A clinical manifestation of osteogenic sarcoma is progressive, insidious, and intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor. Options 1, 3, and 4 are accurate regarding osteogenic sarcoma. 191. Brain Tumor Vital signs and neurological status are assessed frequently. Special attention is given to the childs temperature, which may be elevated because of hypothalamic or brainstem involvement during surgery. A cooling blanket should be in place on the bed or readily available if the child becomes hyperthermic. Options 1 and 3 are related to functional deficits following surgery. Orthostatic hypotension is not a common clinical manifestation following brain surgery. An elevated blood pressure and widened pulse pressure may be associated with increased intracranial pressure, which is a complication following brain surgery. 192. Leukemia A common complication of treatment for leukemia is overwhelming infection secondary to neutropenia. Measures to prevent infection include the use of a private room, strict aseptic technique, restriction of visitors and health care personnel with active infection, strict hand washing, ensuring that anyone entering the childs room wears a mask, and reduci ng exposure to environmental organisms by eliminating raw fruits and vegetables from the diet and fresh flowers from the childs room and by not leaving standing water in the childs room. The other interventions listed are measures to prevent bleeding. 193. HIV/AIDS Most children infected with HIV develop symptoms within the first 9 months of life. The remainder of these infected children become symptomatic sometime before the age of 3 years. Children, with their immature immune systems, have a much shorter incubation period than adults. Options 1, 2, and 3 are incorrect. 194. HIV/AIDS The multiple complications associated with HIV are accompanied by a high level of pain. Aggressive pain management is essential for the child to have an acceptable quality of life. A nurse must acknowledge the childs pain and le t the child know that everything will be done to decrease the pain. Telling the child that movement or lack thereof will eliminate the pain is not accurate. Allowing a child to think that he or she can control the pain simply by thinking or not thinking about it oversimplifies the pain cycle associated with HIV. Giving false hope by telling the child that the pain will be taken all away is neither truthful nor realistic. 195. HIV/AIDS The most common opportunistic infection of children infected with HIV is Pneumocystis jiroveci pneumonia, which occurs most frequently between the ages of 3 and 6 months, when HIV status may be indeterminate. Cytomegalovirus infection is also characteristic of HIV infection; however, it is not the most common opportunistic infection. Although gastrointestinal disturbances and neurological abnormalities may occur in the child with HIV infection, options 1 and 2 are not specific opportunistic infections noted in the HIV-infected child.

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196. HIV/AIDS A child with AIDS who is sick or has a fever should be kept home and not brought to a day care center or other environment. Options 1, 2, and 4 are correct statements and would be actions a caretaker should take when the child has AIDS. 197. HIV/AIDS Immunizations against common childhood illnesses are recommended for all children exposed to or infected with HIV. Pneumococcal and influenza vaccines also are recommended. The varicella (chickenpox) vaccine is avoided in the child who is HIV-infected and severely immunocompromised. The hepatitis B vaccine is administered according to the recommended immunization schedule. Option 4 is not necessary and is inaccurate. 198. HIV/AIDS The preschool child will begin to conceptualize the death process as involving physical harm. A child from birth to 2 years of age will be unable to grasp the concept of illness and death. A school-age child will begin to understand that something is wrong. An adolescent will express fear, withdrawal, and denial. 199. HIV/AIDS The mother should be instructed to use a bleach solution for disinfecting contaminated objects or cleaning up spills from the childs diaper. Options 1, 2, and 4 are accurate instructions related to basic infection control. 200. HIV/AIDS The human immunodeficiency virus (HIV) attacks the immune system by destroying T lymphocytes. Infants born to HIV-positive women test positive for HIV antibody, not HIV virus. This is actually a measure of maternal antibody and is not indicative of true infection in the infant. The virus attacks the immune system. T4 cells are depleted in number and cannot signal B cells to form protective antibodies to fight off the invading virus. 201. HIV/AIDS A positive antibody test in a child younger than 18 months of age indicates only that the mother is infected, because maternal immunoglobulin G antibodies persist in infants for 6 to 9 months and, in some cases, as long as 18 months. A positive enzyme-linked immunosorbent assay (ELISA) does not indicate true HIV infection. 202. HIV/AIDS The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies. The CD4+ cell count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection, such as pneumonia. 203. HIV/AIDS AIDS is a disorder caused by the human immunodeficiency virus (HIV) and is characterized by a generalized dysfunction of the immune system. Home care instructions include the following: frequent hand washing; monitoring for fever, malaise, fatigue, weight loss, vomiting and diarrhea, and notifying the physician if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications and other medications as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; avoiding kissing the child on the mouth; and monitoring weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding sharing eating utensils. Gloves are worn for care, especially when in contact with body fluids and changing diapers (diapers are changed frequently and away from food areas) and soiled disposable diapers are folded inward, tabbed, and disposed in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution (10:1 ratio of water to bleach). 204. Mumps Mumps is transmitted via direct contact with or droplet spread from an infected person. Droplet precautions are indicated during the period of communicability (immediately before and after swelling begins). 205. Chicken Pox The communicable period for chickenpox is 1 to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed. In roseola, the communicable period is unknown. Option 2 describes diphtheria. Option 3 describes rubella. 206. Pertussis Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 3 are components of home care instructions. 207. Vaccines Occasionally, tenderness, redness, or swelling may occur at the site of the DTaP injection. This can be relieved with ice packs for the first 24 hours, followed by warm or cold compresses if the inflammation persists. Bringing the infant back to the clinic is not necessary. Option 1 may be an appropriate intervention but is not specific to the subject of the question. 208. Mononucleosis The parents need to be instructed to notify the physician if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs because this may indicate splenic rupture. Children with enlarged spleens also are instructed to avoid contact sports until splenomegaly resolves. Bed rest is not necessary, and children usually self-limit their activity. Respiratory precautions are not required, although transmission can occur via direct intimate contact or contact with infected blood. Fever is treated with acetaminophen (Tylenol). 209. Pinworms Diagnosis of pinworm infection is confirmed by direct visualization of the worms. Parents can view the sleeping childs anus with a flashlight. The worm is white, thin, about 1/2 -inch long, and moves. A simple technique, the tape test, is used to capture worms and eggs. Transparent tape is lightly touched to the anus and then applied to a slide for microscopic examination. The best specimens are obtained as the child awakens, before toileting or bathing. 210. Vaccines Diphtheria, tetanus, acellular pertussis vaccine (DTaP), Haemophilus influenzae type b conjugate vaccine (Hib), inactivated poliovirus vaccine (IPV), and pneumococcal vaccine (PCV) are administered at 4 months of age. DTaP is administered at 2, 4, 6, and between 15 and 18 months of age, and between 4 and 6 years of age. Hib is administered at 2, 4, 6,

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and between 12 and 15 months of age. IPV is administered at 2, 4, and 6 months and between 4 and 6 years of age. PCV is administered at 2, 4, 6, and between 12 and 15 months. The first dose of measles, mumps, rubella vaccine (MMR) is administered between 12 and 15 months of age; the second dose is administered at 4 to 6 years of age (if the second dose was not given by 4 to 6 years of age, it should be given at the next visit). The first dose of hepatitis B vaccine is administered at birth, the second dose is administered at 1 to 2 months, and the third dose is administered between the ages of 6 and 18 months. Varicellazoster vaccine is administered between 12 and 18 months of age. 211. Vaccines MMR vaccine is administered subcutaneously in the outer aspect of the upper arm. The gluteal muscle is not recommended for injections. It is not administered by the intramuscular route. 212. Vaccines IPV contains neomycin. A history of an anaphylactic reaction to neomycin is considered a contraindication to IPV. The presence of a minor illness such as the common cold is not a contraindication. In addition, a history of frequent respiratory infections is not a contraindication to receiving a vaccine. A local reaction to an immunization is not a contraindication to receiving a vaccine. 213. Vaccines A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to a previous dose of hepatitis B vaccine or to a component of the vaccine. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine. 214. Rubeola Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Airborne droplet precautions are required, and those in contact with the child should wear masks. The child is placed in a private room with negative air pressure. Doors remain closed. Gowns and gloves are not necessary, but standard precautions are used. Articles that are contaminated should be bagged and labeled. Special enteric precautions and protective isolation are not indicated in rubeola. 215. Rubeola The communicable period for rubeola ranges from 4 days before to 5 days after the rash appears, mainly during the prodromal stage. Options 1, 2, and 4 are accurate descriptions of rubeola. The small blue-white spots found in this communicable disease are called Kopliks spots. Option 3, the incorrect option, describes the incubation period for rubella, not rubeola. 216. Roseola The method of transmission of roseola is unknown. Options 2, 3, and 4 are not accurate transmission routes of roseola. 217. Vaccines The general contraindications for vaccines include a previous anaphylactic reaction to a vaccine or a component of a vaccine or the presence of a severe illness. The other items listed are not contraindications to receiving a vaccine. 218. Scarlet Fever Pastias sign describes a rash seen in scarlet fever that will blanch with pressure except in areas of deep creases and the folds of joints. The tongue initially is coated with a white furry covering, with red projecting papillae (white strawberry tongue). By the fourth to fifth day, the white strawberry tongue sloughs off, leaving a red swollen tongue (strawberry tongue). The pharynx is edematous and beefy red. Kopliks spots are assoc iated with rubeola (measles). These are small red spots with a bluish white center and a red base located on the buccal mucosa. Petechial red, pinpoint spots occurring on the soft palate are characteristic of rubella (German measles). 219. Med Cal 220. Med Cal 221. Med Cal 222. Med Cal 223. Med Cal 224. Med Cal 225. Med Cal 226. Med Cal 227. Med Cal 228. Med Cal 229. Hemophilia The nurse needs to stress the importance of immunizations, dental hygiene, and routine well-child care. Options 1, 2, and 3 are appropriate. The parents are also instructed in the measures to implement in the event of blunt trauma, especially trauma involving the joints, and to apply prolonged pressure to superficial wounds until the bleeding has stopped. 230. Croup The mother should be instructed to bring the child to the emergency room if the child develops stridor at rest, cyanosis, severe agitation or fatigue, or moderate to severe retractions, or is unable to take oral fluids. 231. Lactose Intolerance Breast-feeding mothers with lactose intolerance infants need to be encouraged to limit dairy products. Cheese is a dairy product. Alternative calcium sources that can be consumed by the mother include egg yolk, green leafy vegetables, dried beans, cauliflower, and molasses. 232. Conjuntivitis Viral conjunctivitis is extremely contagious. The child should be kept home from school or day care until the child has received antibiotic eye drops for 24 hours.

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233. Conjuntivitis If the child wears contact lenses, he or she should be instructed to discontinue wearing them until the infection has cleared completely. Securing new contact lenses will eliminate the chance of reinfection from contaminated contact lenses and will also lessen the risk of a corneal ulceration. 234. Otitis Media Factors that increase the risk of otitis media include exposure to illness in other children in day care centers, household smoking, bottle-feeding, and congenital conditions such as Down syndrome and cleft palate. The use of a pacifier beyond age 6 months has also been identified as a risk factor. Allergies are also thought to precipitate otitis media. 235. Leukemia A lateral recumbent position, with the knees flexed to the abdomen and the head bent with the chin resting on the chest, is assumed for a lumbar puncture. This position separates the spinal processes and facilitates needle insertion into the subarachnoid space. Options 1, 2, and 4 are incorrect positions. 236. Hodgkin's disease Radiation therapy is usually delayed until a child is 8 years of age, whenever possible, to prevent retardation of bone growth and soft tissue development. Options 1, 3, and 4 are inappropriate responses to the mother. 237. Neuroblastoma Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically, the tumor compresses adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated vanillylmandelic acid (VMA) levels. The presence of blast cells in the bone marrow occurs in leukemia. Projectile vomiting occurring most often in the morning and a positive Babinskis sign are clinical manifestations of a brain tumor. 238. Pneumonia With viral pneumonia, treatment is supportive. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and IV fluids. Antibiotics are not given. Bacterial pneumonia however, is treated with antibiotic therapy. 239. Cystic Fibrosis Cystic fibrosis (CF) is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait. 240. Transposition of Great Arteries A child with transposition of the great arteries may receive prostaglandin E1 temporarily to increase blood mixing if systemic and pulmonary mixing are inadequate to maintain adequate cardiac output. Options 1, 3, and 4 are incorrect. In addition, tet spells occur in tetralogy of Fallot. 241. Hirschsprung's Disease Hirschsprungs disease also known as congenital aganglionosis or megacolon. It is the result of an absence of ganglion cells in the rectum and to varying degrees upward in the colon. Options 2, 3, and 4 are incorrect. 242. Imperforated Anus A fresh colostomy stoma will be red and edematous, but this will decrease with time. The colostomy site will then be pink without evidence of abnormal drainage, swelling, or skin breakdown. The nurse would document these findings because this is a normal expectation. Options 1, 3, and 4 are inappropriate interventions. 243. Jaundice Jaundice, if present, is best assessed in the sclera, nail beds, and mucous membranes. Generalized jaundice will appear in the skin throughout the body. Option 4 is not an appropriate area to assess for the presence of jaundice. 244. Aspirin Overdose Initial treatment of salicylate overdose includes the administration of an emetic or gastric lavage. Activated charcoal may be administered to decrease absorption. Fluids and sodium bicarbonate may be administered intravenously to enhance excretion but would not be the initial treatment. Dialysis is used in extreme cases if the child is unresponsive to therapy. Vitamin K is the antidote for warfarin sodium (Coumadin) overdose. 245. Fracture Russells traction uses skin traction to realign a fracture in the lower extremity and immobilize the hip and knee in a flexed position. It is important to keep the hip flexion at the prescribed angle to prevent fracture malalignment. The traction may also relieve pain by reducing muscle spasms, but this is not the primary reason for this traction. The child can still move in bed with some restriction as a result of the traction. Traction is never used to restrain a child. 246. Crossed Eyes Strabismus, also called lazy eye, is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. It is normal in the young infant but should not be present after about age 4 months. Options 1, 2, and 3 are not appropriate responses to the mother of a 1-month-old infant. 247. Strabismus Patching may be used in the treatment of strabismus to strengthen the weak eye. In this treatment, the good eye is patched. This encourages the child to use the weaker eye. It is most successful when done during the preschool years. The schedule for patching is individualized and is prescribed by the ophthalmologist. 248. Meningitis To test for Kernigs sign, the leg is raised with the knee flexed. Then, the leg is exten ded at the knee. If any resistance is noted or pain is felt, the result is a positive Kernigs sign. This is a common finding in meningitis. Brudzinskis sign occurs when flexion of the head causes flexion of the hips and knees. Chvosteks sign, seen in te tany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseaus sign is a sign for tetany in whi ch carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally.

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249. Myringotomy A myringotomy is the insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated. The size and appearance of the tympanostomy tubes should be described to the parents after surgery. They should be reassured that if the tubes fall out, it is not an emergency, but that the physician should be notified. 250. Vomiting The vomiting child should be placed in an upright or side-lying position to prevent aspiration. Options 2, 3, and 4 will place the child at risk for aspiration if vomiting occurs. 251. Cleft lip Cleft lip repair is usually performed during the first few weeks of life. Early repair may improve bonding and makes feeding much easier. Revisions may be required at a later age. Options 1, 2, and 4 are incorrect 252. Intussesception Intussusception occurs when a proximal segment of the bowel prolapses into a distal segment of the bowel. It is a common cause of acute bowel obstruction in infants and young children. It is not an inflammatory process. 253. Encopresis Encopresis is defined as fecal incontinence and is a major concern if the child is constipated. Signs include evidence of soiling clothing, scratching or rubbing the anal area because of irritation, fecal odor without apparent awareness by the child, and social withdrawal. 254. Seizures During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side will prevent aspiration because saliva will drain out the corner of the childs mouth. The child is not restrained because th is could cause injury to the child. The nurse would loosen clothing around the childs neck and ensure a patent airway. Nothing is placed into the childs mouth during a seizure because this could injure the childs mouth, gums, or teeth. The nurse would s tay with the child to reduce the risk of injury and allow for observation and timing of the seizure. 255. Ewing Sarcoma Following amputation, phantom limb pain is a temporary condition that some children may experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the child. The child needs to be reassured that the condition is normal and only temporary. Options 2, 3 and 4 are not appropriate responses to the child. 256. Anemia Vitamin C (ascorbic acid) increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or juice high in vitamin C. From the options presented, option 4 is the option that identifies the food highest in vitamin C. 257. Esophageal Atresia In the immediate postoperative period, the gastrostomy tube is elevated, allowing gastric contents to pass into the small intestine and air to escape. This promotes comfort and decreases the risk of leakage at the anastomosis. Options 1, 2, and 3 are incorrect. 258. Med Cal 259. Appendicitis McBurneys point is midway between the right anterior superior iliac crest and the umbilicus. It is usually the location of greatest pain in the child with appendicitis. 260. Hydrocephalus Hydrocephalus is a condition characterized by an enlargement of the cranium because of an abnormal accumulation of cerebrospinal fluid in the cerebral ventricular system. This characteristic causes the increase in the weight of the infants head. The infant may experience significant head enlargement. Care must be exercised so that the head is well supported when the infant is fed or moved to prevent extra strain on the infants neck, and measures must be taken to prevent the development of pressure areas. Supporting the infants head and neck, when pic king up him or her, will prevent the hyperextension of the neck area and the infant from falling backward. The infant should be fed with the head elevated for proper motility of food processing. A helmet could suffocate an unattended infant during rest and sleep times, and hyperextension of the infants head could put pressure on the neck vertebrae, causing injury. 261. Seizures Parents are especially concerned about seizures that might go undetected during the night. The nurse needs to decrease parental overprotection and should suggest the use of a baby monitor at night. Options 1 and 3 identify parental understanding of the disorder. Option 4 is a common concern. The parents need to be reminded that, as the child grows, they cannot always observe their child, but that their knowledge of seizure activity and care are appropriate to minimize complications. 262. Imperforated Anus The appropriate position following surgical intervention for an imperforate anus is a side-lying position with the legs flexed, or a prone position to keep the hips elevated. These positions will reduce edema and pressure on the surgical site. Options 2, 3, and 4 will promote pressure at the surgical site. 263. Cleft Palate The mother should be instructed that straws, pacifiers, spoons, or fingers must be kept away from the childs mouth for 7 to 10 days after surgery. Additionally, the mother should be advised to avoid taking oral temperatures. A short nipple should be placed on the childs bottle and the mother should be instructed to give the chi ld baby food or baby food mixed with water. A pacifier should not be used for at least 2 weeks following the surgical repair. 264. Pyloric Stenosis Option 3 are classic symptoms of pyloric stenosis. Crying during the evening hours, appearing to be in pain, eating well, and gaining weight are clinical manifestations of colic. An infant who suddenly becomes pale, cries out, and draws the legs up to chest is demonstrating physical signs of intussusception. Stools that are ribbon-like and eating poorly are signs of congenital megacolon (Hirschsprungs disease).

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265. Erikson's Development A 2-year-old child, a toddler, is in the Autonomy versus Shame and Doubt stage. In this stage, the toddler develops a sense of control over the self and bodily functions. Trust versus Mistrust characterizes the stage of infancy. Initiative versus Guilt characterizes the preschool age. Industry versus Inferiority characterizes the school-aged child. 266. Respiratory Infection A 10-month-old is in the Trust versus Mistrust stage of psychosocial development according to Erikson. The infant is developing a sense of self, and the nurse should appropriately provide a consistent routine for the child. Hospitalization may have an adverse effect, and the nurse should touch, rock, and cuddle the infant to promote a sense of trust and provide sensory stimulation. Option 2 is an unsafe action. Option 1 will not provide sensory stimulation. The infant should not be restrained. 267. Lead Poisoning Homes that are older than 25 years may have lead paint and will most likely have lead pipes, which can contribute to lead poisoning. Breathing rapidly and diaphoresis are signs of salicylate poisoning. A sweet and fruity odor to the breath is a symptom of ketoacidosis. Pencil lead is made of graphite so it does not present a hazard to the child. Crayons are not toxic. 268. Safety Toys with small loose parts would be the priority concern. Children at this age are likely to place the small toy parts in their mouth, which could lead to aspiration and choking. The water temperature of the hot water heater is a concern but is not the greatest hazard. The mother should be aware of and taught safety measures related to safe water temperatures for bathing the children. A gate placed at the stairs of the second floor is a safety measure. A small dog as a house pet is not necessarily a hazard. 269. Leukemia Aspirin is not administered to the child with ALL because of its anticoagulant properties and because administering aspirin could lead to bleeding in the joints. Heat also would increase the pain by increasing circulation to the area. Diversional activities would not relieve the pain. 270. Dental Care The nurse should instruct the mother that proper dental care for a toddler is important. It is important to instruct the mother to substitute sweets with healthy food items to prevent dental caries. The first dental visit should be made after the first primary tooth erupts and no later than 30 months of age. It will not hurt the child if some of the toothpaste is swallowed. 271. Hemophilia In an acute period, immobilization of the joint would be prescribed. NSAIDs can prolong bleeding time and would not be prescribed for the child. Heat will increase blood flow to the area so it would promote increased bleeding to the area. Range of motion during the acute period can increase the bleeding and would be avoided at this time. 272. Hemophilia The nurse should instruct the mother to remove toys with sharp edges that may cause potential injury. Requiring that the child wear a helmet and elbow pads immediately on awakening and throughout the day is not necessary; however, these items should be worn during activities that could cause injury. It is not necessary that the child be restricted from outdoor play activity, but the activities that the child participates in should be monitored. It is not necessary to restrict play if safety measures have been implemented. 273. Conjuntivitis Bacterial conjunctivitis is highly contagious, and infection control measures should be taught. These measures include frequent hand washing and not sharing towels and washcloths regardless of the bleaching process. Options 2 and 3 are correct treatment measures. 274. Insect in Ear Insects that make their way into an ear often can be coaxed out using a flashlight or a humming noise. If this is unsuccessful, then the insect must be killed before removal. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by means of an ear forceps. The mother should be instructed not to irrigate the ear or attempt to remove the insect by using tweezers because this could damage the ear. If the mother is unsuccessful in coaxing the insect out of the ear, she should be instructed to report to the clinic or the hospital emergency department. 275. Tonsillectomy After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and extremely hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, which causes the child to clear the throat, thereby increasing the risk of bleeding. 276. Fracture A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture that occurs through only a part of the cross section of the bone; one side of the bone is fractured and the other side is bent. A comminuted fracture is a complete fracture across the shaft of the bone with splintering of the bone fragments. A compound fracture, also called an open or a complex fracture, is one in which the skin or mucous membrane has been broken and the wound extends to the depth of the fractured bone. 277. Fracture When a fracture is suspected, it is imperative that the area be splinted and immobilized before the injured person is transferred or moved. The nurse should remain with the child and provide realistic reassurance. The child would not be told that permanent damage will not occur. It is not necessary to notify the radiology department because this would be the responsibility of the emergency department staff when the child arrives, and if it had been determined that the child needs a radiograph. Although it may be necessary to contact the childs pediatrician, this is not the highest priority.

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278. Conjuntivitis Eyedrops should be administered before eye ointment is administered. The child should be placed in a supine position with the neck slightly hyperextended for administration. Blinking will increase the loss of medication. Touching the eye or eyelid during medication administration can contaminate the dropper and also cause eye injury. 279. Respiratory Syncytial Virus (RSV) When an infant is receiving ribavirin, exposure precautions need to be observed. Anyone entering the infants room should wear a gown, mask, gloves, and hair covering. Anyone who is pregnant or considering pregnancy and anyone with a history of respiratory problems or airway disease should not care for or visit the infant who is receiving ribavirin. Hand washing is absolutely necessary before leaving the room to prevent the spread of germs. 280. Inguinal Hernia With an inguinal hernia, inguinal swelling occurs when the infant cries or strains. Absence of this swelling would indicate resolution of this problem. Abdominal distention indicates a continuing gastrointestinal problem. A clean, dry incision refers to absence of wound infection after surgery. The flow of urine is not specific to an inguinal hernia. 281. Intussesception After hydrostatic reduction, the nurse observes for the passage of barium or water-soluble contrast material with stools. Options 1 and 2 are clinical indicators of intussusception. Option 4 is a sign of an unresolved gastrointestinal disorder. 282. Diabetes The glycosylated hemoglobin assay measures the glucose molecules that attach to the hemoglobin A molecules and remain there for the life of the red blood cell, approximately 120 days. This is not reversible and cannot be altered by human intervention. Daily glucose logs for the period are useful if they are kept regularly and accurately. However, they reflect only the blood glucose at the time the test was done. A fasting blood glucose test performed on the day of the clinic visit is time-limited in its scope, as is the dietary history. 283. Diabetes Blood glucose levels are a measure of the balance between diet, medication, and exercise. Options 2 and 4 imply that the data analyzed are abnormal. The question presents no data for determining growth and development status, such as height, weight, age, or behavior. Supporting normal growth and development is an important goal in managing diabetes in children, but that is not what is being evaluated here. 284. Celiac Disease The primary nursing consideration in the care of a child with celiac disease is to instruct the child and parents regarding proper dietary management. Although medications may be prescribed for the client with celiac disease, treatment focuses primarily on maintaining a gluten-free diet. Options 1, 3, and 4 are not directly related to the care of a child with celiac disease. 285. Appendicitis The most common symptom of appendicitis is a colicky, periumbilical, or lower abdominal pain located in the right quadrant. The classic signs and symptoms of intussusception are acute, colicky abdominal pain with currant jellylike stools. Clinical manifestations of Hirschsprungs disease include constipation, abdominal distention, and ribbon -like, foulsmelling stools. Peritonitis is a complication that can follow perforation or intestinal obstruction. 286. Erikson's Development Adolescents need to identify with their peers and have a strong need to belong to a group. They prefer to dress like the group and wear similar hairstyles, which are differe nt from their parents. Because Crutchfield tongs require the use of skeletal pins, hair dye is not appropriate. The child should be allowed to wear her own clothes to feel a sense of belonging to the group. Loud music may disturb others in the hospital. T he childs request for a darkened room may indicate a problem with depression that may need further evaluation and intervention. 287. Hernia A warm bath, avoidance of upright positioning, and other comfort measures to reduce crying are all simple measures to reduce a hernia. Coughing and crying increase the strain on the hernia. Likewise, physical activity and enemas of any type would increase the strain on the hernia. 288. Spina Bifida (Myelomeningocele type) A bulging or taut anterior fontanel would indicate the presence of increased intracranial pressure. Blood pressure is difficult to assess during the newborn period and is not the best indicator of intracranial pressure. Urine concentrating ability also is not well developed at the newborn stage of development. Monitoring for signs of dehydration will not provide data related to increased intracranial pressure. 289. Diabetes The child should be instructed to carry a source of glucose for ready use in the event of a hypoglycemic reaction. Hard candies such as LifeSavers will provide a source of glucose. A diet beverage is sugar-free and will not be helpful. If the blood glucose level is 60 mg/dL, a source of glucose may be needed, but it is not necessary to report to the emergency department. Glucagon is not administered if shakiness is felt but is used in an unconscious client or a client unable to swallow who is experiencing a hypoglycemic reaction. 290. Hemophilia Because the kidneys are located in the flank region of the body, trauma to the back area can cause the presence of hematuria, particularly in the child with hemophilia. The nurse would be most concerned about the childs airway and respiratory rate if the child sustained an injury to the neck region. Headache and slurred speech are associated with head trauma. 291. Heat Loss Heat loss occurs by four different mechanisms. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Evaporation of moisture from a wet body surface dissipates heat along with the moisture. In convection,

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air moving across the infants skin will transfer heat to the air. Radiation occurs when heat from the body surface radiates to the surrounding environment. 292. Intussesception A report of severe colicky abdominal pain in a healthy thriving child between 3 and 17 months of age is the classic presentation of intussusception. Typical behavior includes screaming and drawing the knees up to the chest. Options 2, 3, and 4 are important aspects of a health history but are not specific to the diagnosis of intussusception. 293. Scoliosis Scoliosis is defined as an abnormal lateral curvature in any area of the spine. The region of the spine most commonly affected is the right thoracic area, where it results in rib prominence. Scoliosis does not occur as a sequela of inflammation. Option 1 describes kyphosis, which also is known as humpback. Option 2 describes lordosis, which usually is exaggerated during pregnancy, in obesity, or in persons with large tumors. 294. Safety If a poisoning occurs, the poison control center should be contacted immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested was a strong corrosive or a petroleum-based product. Calling the pediatrician would not be the immediate action because this would delay treatment. Additionally, the pediatrician would immediately make a referral to the poison control center. The poison control center may advise the mother to bring the child to the emergency department, and if this is the case, the mother should call an ambulance. 295. Cryptorchidism Cryptorchidism (undescended testes) may occur as a result of hormone deficiency, intrinsic abnormality of a testes, or a structural problem. Diagnostic tests for this disorder are performed to assess urinary and kidney function because the kidneys and testes arise from the same germ tissue. Babinski reflex reflects neurological function. Assessing DNA synthesis and a chromosomal analysis are unrelated to this disorder. 296. Urinalysis Although many methods have been devised to collect urine from an infant, the most reliable and appropriate method is use of the urine collection device. This device is a plastic bag with an opening lined with adhesive to allow it to be attached to the perineum. Urine for certain tests, such as specific gravity, may be obtained from a diaper. Urinary catheterization is not to be done unless specifically prescribed because of the risk of infection. With infants, it is not reasonable to monitor urinary patterns and attempt to collect the specimen in a cup during voiding. 297. Glomerulonephritis Guilt is a common reaction of the parents of a child diagnosed with glomerulonephritis. Parents blame themselves for not responding more quickly to the childs initial symptoms, or they may believe they could have prevented the development of glomerular damage. Options 1, 2, and 4 may be associated with the parents reaction to the diagnosis, but they are not common parental reactions. 298. Meningitis The classic signs of meningitis include severe headache, fever, stiff neck, and a change in the level of consciousness. Photophobia also may be a prominent early symptom and is thought to be related to meningeal irritation. Although nausea, confusion, delirium, and back pain may occur in meningitis, these are not the classic signs. 299. Imperforated Anus After surgical intervention for imperforate anus, a side-lying position with the legs flexed or a prone position to keep the hips elevated can reduce edema and pressure on the surgical site. Options 1, 2, and 3 are incorrect positions. 300. Jaundice The parents of a child should be told that the jaundice may appear to get worse before it resolves. Options 1, 2, and 3 are incorrect and inappropriate responses. 301. Diarrhea If mild diarrhea occurs in a child younger than 2 years of age, a soft diet is advised as long as the child is tolerating solids. The ABCs (applesauce, strained bananas, and strained carrots), rice, potatoes, and other bland foods without dairy products are advised. Extra fluids may also be needed and may be given by adding 1 to 2 ounces of additional water to each bottle of formula or juice. 302. Cleft Palate The mother needs to be instructed that straws, pacifiers, spoons, and fingers must be kept away from the childs mouth for 7 to 10 days. Additionally, the mother should be advised to avoid taking an oral te mperature. Options 1, 2, and 4 are accurate measures to implement after cleft palate repair. 303. Esophageal Atresia Esophageal atresia with TEF represents a critical neonatal surgical emergency. While the infant is awaiting transfer to surgery, management centers on prevention of aspiration. The infant is kept supine or prone with the head of the bed elevated to decrease the chance of gastric secretions from entering the lungs. Intravenous fluids are essential. An NG tube must be in place and aspirated every 5 to 10 minutes to keep the proximal pouch clear of secretions. Monitoring the temperature and blood pressure are standard nursing interventions. 304. Hepatitis Assessment findings in a child with hepatitis include right upper quadrant tenderness and hepatomegaly. The stools will be pale and clay-colored, and urine will be dark and frothy. Jaundice may be present and will be best assessed in the sclerae, nailbeds, and mucous membranes. 305. Lead Poisoning Paint chips, soil contaminated with lead, lead solder user in plumbing, vinyl blinds, and improperly glazed pottery can be the source of toxic exposure in lead poisoning.

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306. Hirschsprung's Disease Hirschsprungs disease also is known as congenital aganglionosis or megacolon. It results from the absence of ganglion cells in the rectum and, to various degrees, up into the colon. Option 1 describes celiac disease. Option 2 describes lactose intolerance. Option 4 describes irritable bowel syndrome. 307. Hepatitis Because hepatitis A virus is not infectious 1 week after the onset of jaundice, return to school at that time is permitted if the child feels well enough. Options 1, 2, and 4 are incorrect. 308. Cleft Palate Cleft palate repair is individualized and based on the degree of deformity and size of the child. Cleft palate repair usually is performed between 6 months and 2 years of age, depending on physician preference. Early closure facilitates speech development. Options 2, 3, and 4 are incorrect. 309. Tetralogy of Fallot Children with tetralogy of Fallot, or with physiology similar to that seen with this disorder, may experience hypercyanotic episodes, or tet spells. These episodes are characterized by increased respiratory rate and depth and increased hypoxia. Immediate physician notification is not required unless other appropriate nursing interventions are unsuccessful. Options 3 and 4 are unrelated to tetralogy of Fallot. 310. Heart Surgery After heart surgery, the child may return to school in 3 weeks but needs to go half-days for the first few days. The mother also should be told that that the child cannot participate in physical education for 2 months. Options 1, 2, and 4 are incorrect. 311. Safety Medicine should not be referred to as candy. Home safety measures are simple but important. Medications should be stored in child-proof containers. The number of tablets in a container should be limited. Toxic substances should be labeled with green poison stickers on them and should be placed in a locked area out of reach of children. The poison control center telephone number should be visible near all telephones. 312. Increased Intracranial Pressure Transtentorial herniation occurs when part of the brain herniates downward and around the tentorium cerebelli. It can be unilateral or bilateral and may involve anterior or posterior portions of the brain. If a large amount of tissue is involved, the risk of death is increased because vital brain structures are compressed and become unable to perform their function. 313. Level of Consciousness Obtunded indicates that the child sleeps unless aroused and once aroused has limited interaction with the environment. Full consciousness indicates that the child is alert, awake, orientated, and interacts with the environment. Confusion indicates that the ability to think clearly and rapidly is lost, and disorientation indicates that the ability to recognize place or person is lost. 314. Head Injury Decorticate posturing is an abnormal flexion of the upper extremities and an extension of the lower extremities with possible plantar flexion of the feet. Decerebrate posturing is an abnormal extension of the upper extremities with internal rotation of the upper arms and wrists and an extension of the lower extremities with some internal rotation. 315. Head Injury Decorticate posturing indicates a lesion in the cerebral hemisphere or disruption of the corticospinal tracts. Decerebrate posturing indicates damages in the diencephalon, midbrain, or pons. 316. Communication Babbling sounds are common between the ages of 3 and 4 months. Additionally, during this age, crying becomes more differentiated. Between the ages of 1 and 3 months, the infant will produce cooing sounds. An increased interest in sounds occurs between 6 and 8 months, and the use of gestures occurs between 9 and 12 months. 317. Nutrition Breast milk or formula is the main food throughout infancy. Rice cereal mixed with breast milk or formula is introduced at 4 months of age. Strained vegetables, fruits, and meats are introduced one at a time and can begin at 6 months of age. 318. Motor Deverlopment A 24-month-old would be able to open a door using the doorknob. At age 15 months, the nurse would expect that the child could build a tower of two blocks. At age 30 months, the child would be able to snap large snaps and put on simple clothes independently. 319. Play The toddler has increased use of motor skills and enjoys manipulating small objects such as toy people, cars, and animals. Push-pull toys are appropriate for this age. Option 2 is most appropriate for an infant. Option 3 is most appropriate for a school-age child. Option 4 is most appropriate for an adolescent. 320. Lactose Intolerance Lactose intolerance causes frothy stools. Abdominal distention, crampy abdominal pain, and excessive flatus also may occur. Option 2 is a clinical manifestation of celiac disease. Option 3 is a clinical manifestation of Hirschsprungs disease. Option 4 is a clinical manifestation of irritable bowel syndrome. 321. Celiac Disease Dietary management is the mainstay of treatment for the child with celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies. 322. Constipation Mineral oil is best tolerated when it is given chilled or mixed with cold drinks. Mixing the oil with chocolate milk, blending it with ice cubes and fruit juice, or chilling it helps to disguise the taste. Administering mineral oil before meals will affect the childs appetite.

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323. Cleft Palate After cleft palate repair, the mouth is rinsed with water after feedings to clean the palate repair site. Rinsing food and residual sugars from the suture line reduces the risk of infection. Options 2, 3, and 4 are incorrect procedures. Hydrogen peroxide, povidone-iodine, and lemon and glycerin are not used because of their harmful effect to oral tissues and the suture site. 324. Pyloric Stenosis Laboratory findings in an infant with hypertropic pyloric stenosis include metabolic alkalosis as a result of the vomiting that occurs in this disorder. Additional findings include decreased serum potassium and sodium levels, increased pH and bicarbonate level, and a decreased chloride level. 325. Increased Intracranial Pressure DI can occur in a child with increased ICP. A urine specific gravity above 1.020, weight gain, and hypertension are indications of the syndrome of inappropriate antidiuretic hormone (SIADH) secretion, not DI. A high urine output would be indicative of DI. 326. Lead Poisoning If the child is receiving an IV infusion of calcium EDTA, the infusion should be stopped for 1 hour before obtaining a blood level lead concentration. Otherwise, the blood lead concentration will indicate a falsely elevated reading. Therefore, options 1, 3, and 4 are incorrect. 327. Anemia Clients with sickle cell anemia are advised to avoid strenuous activities. Quiet activities as tolerated are recommended when the client is feeling well. Increasing fluid intake is encouraged to assist in preventing sickle cell crisis. 328. Otitis Externa The nurse should provide information about ear care to children because it is not uncommon for them to put sharp or small objects, such as cotton swabs, into their ears, and these behaviors can cause injury. A face cloth on a fingertip is safe to use for ear cleaning. Acute otitis externa may cause a low-pitched tinnitus but usually does not cause dizziness unless the condition has progressed to an otitis media. Audiography is performed during a screening done at school usually every year and does not necessarily need to be performed by a special physician. 329. Rheumatic Fever In the presence of rheumatic fever, the child will exhibit leukocytosis, positive result on CRP determination, elevated ASO titer, and elevated ESR. A positive result on ANA testing is used to diagnose a wide variety of connective-tissue, vascular, and immune complex disorders and will be positive with rheumatic fever also. 330. Brain Injury Temporal lobe herniation or uncal herniation refers to a shifting of the temporal lobe laterally across the tentorial notch. This produces compression of the third cranial nerve and ipsilateral pupil dilation. If pressure continues to rise, flaccid paralysis, pupil dilation, pupil fixation, and death will result. 331. Tracheostomy When suctioning a tracheostomy in an infant, it is necessary to limit insertion and suctioning time to 5 seconds to prevent hypoxia. Options 1, 2, and 4 indicate correct suctioning procedures for the infant. 332. Vaccines In a young child, aged 3 to 6 years, the maximum volume of medication that can be safely injected into the ventral gluteal muscle is 1.5 mL. 333. Tylenol The childs rectal vault is not as long as that of an adult, and the distance required to place medications is approximately 1 to 2 cm. After insertion, the buttocks should be held together until the urge to expel the suppository has passed. 334. Ear Drops Because of the internal anatomy of the ear, if the child is 3 years of age or younger, the pinna of the ear is pulled back and down. If the child is older than 3 years, the pinna of the ear is pulled back and up. The child should lie on the unaffected side with the ear to receive the drop facing upward. 335. Pyloric Stenosis Laboratory findings in an infant with hypertrophic pyloric stenosis include metabolic alkalosis due to vomiting. These include increased blood pH and bicarbonate level, decreased serum potassium and sodium levels, and a decreased chloride level. 336. Fracture The mother needs to understand that compartment syndrome is a complication of fracture and casting and can result in permanent limb damage as a result of pressure-related tissue necrosis. The extremity is elevated to prevent swelling, and the physician is notified immediately if any signs of neurovascular impairment develop. Cold fingers could indicate neurovascular impairment and needs to be reported. A heating pad is not applied to the cast or fingers. Skin edges are checked to monitor for irritation and skin breakdown. 337. Fracture Compartment syndrome occurs as a result of pressure buildup within a tissue compartment bounded by anatomical structures such as fascia. With a fracture, this pressure increase may be secondary to the intense inflammatory response or severe bleeding caused by the bone injury, regardless of the fact that diligent nursing care is provided. Pain out of proportion to the injury despite analgesic administration is the classic sign of compartment syndrome. The nurse should constantly assess for this complication and should instruct the caregiver about the manifestations associated with this complication. 338. Scoliosis Braces for treatment of scoliosis usually are worn 16 to 23 hours a day. The skin should be kept clean and dry and inspected for signs of redness or breakdown. Therefore, risk for impaired skin integrity is the nursing diagnosis that should be included in this childs plan of care. The child will not have a risk for delayed growth and development because normal developmental milestones can be met while wearing a brace. The brace assists with posture so mobility is not an issue. The brace does not compromise the respiratory status, so gas exchange is not impaired.

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339. Anemia Sickle cell anemia is a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell: Insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. A diagnosis is established on the basis of a complete blood count, examination for sickled red blood cells in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin level and hematocrit and a decreased platelet count, an increased reticulocyte count, and the presence of nucleated red blood cells. Reticulocyte counts are increased in children with sickle cell disease because the life span of their sickled red blood cells is shortened. 340. Hemophilia Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX. 341. Leukemia Cyclophosphamide (Cytoxan) is an alkylating agent used as a chemotherapeutic agent in children with leukemia and other cancers. Its side effects include bone marrow depression (BMD), but it is platelet sparing. It also causes hemorrhagic cystitis. It does not cause constipation, as vincristine does. Vincristine, a plant alkaloid, also causes BMD. 342. Leukemia A child with myelosuppression is at risk for infection. Good hand-washing technique is necessary to prevent the spread of infection. Complete and strict isolation is not warranted, although a mask and gloves should be worn while in the childs room. Restricting oral fluids would not be an intervention to reduce the risk of infection and could actually be harm ful to the child. Live virus vaccines are not given when the child is myelosuppressed, so assessment of the childs immune sta tus should be done before administration of immunizations appropriate for age. 343. Brain Tumor If an infratentorial tumor is removed, the child is positioned flat. The pillow is placed behind the childs back, not the head, because when the pillow is behind the head proper, alignment is not maintained and this misalignment can impair circulation. The child should never be placed in a Trendelenburg position (head down) because this position increases intracranial pressure. Placing the child on the operative side is not recommended because the brain may shift suddenly to that cavity. The head is elevated above the heart when the tumor is a supratentorial one. 344. Leukemia In leukemia, normal bone marrow is replaced by malignant blast cells. As the blast cells take over the bone marrow, eventually red blood cell and platelet production is affected and the child becomes anemic and thrombocytopenic. The Reed-Sternberg cell is found in Hodgkins disease. 345. HIV/AIDS Nebulizer pieces are cleaned with warm water after each treatment and allowed to air dry. They are soaked in white vinegar and water for 30 minutes at the end of each day. Options 1, 3, and 4 are inaccurate and would damage the nebulizer equipment. 346. HIV/AIDS The immunocompromised child with an HIV infection should not receive live vaccines. With both the varicella and the MMR vaccinations, live vaccines are given. Once the childs immune status improves, these vaccinations can then be given. Option 4 is correct because the varicella vaccination would be delayed until the child is not immunocompromised. Option 3 is incorrect because the MMR vaccine would not be administered at this time. The IPV is not a live virus so it can be administered. Option 2 is incorrect because influenza vaccinations do not typically involve live viruses, so the child could receive this vaccination. 347. Pneumonia HAART consists of the combination of two nucleoside analogues, which target viral replication during the reverse transcription phase of the cell cycle, and a protease inhibitor, which targets viral replication at a different phase. Options 1, 3, and 4 are incorrect descriptions. 348. Vaccines A severe febrile illness is a reason to delay immunization but only until the child has recovered from the acute stage of the illness. Minor illness, such as a cold, otitis media, or mild diarrhea, is not a contraindication to immunization. 349. Vaccines The varicella vaccination is recommended to be administered between 12 and 18 months of age. Therefore, options 1, 3, and 4 are incorrect. 350. Vaccines Known altered immunodeficiency from long-term immunosuppressive therapy is a contraindication to MMR (measles-mumps-rubella) immunization because a live vaccine is given. The vaccines identified in options 1, 3, and 4 are not live vaccines and can be administered. 351. Hypospadias After hypospadias repair, the parents are instructed to avoid giving the child a tub bath until the stent has been removed, to prevent infection. Diapers are placed on the child to prevent contamination of the surgical site. Toilet training should not be an issue during this stressful period. Fluids should be encouraged to maintain hydration. 352. Bladder Exstrophy Bladder exstrophy is a congenital anomaly characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. The cause is not known, and a higher incidence is seen in males. Options 1, 2, and 3 are not characteristics of this disorder.

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353. Growth Hormone Deficiency Synthetic growth hormone comes in a powdered form that must be diluted for administration. It is given as a subcutaneous injection six or seven times per week as prescribed at bedtime. Parents are taught that once diluted, the hormone preparation is to be stored at 36 to 46 F (refrigerated). Injection sites should be rotated. Therefore, option 1 is correct. 354. Diabetes Isophane insulin (NPH) is an intermediate-acting insulin and peaks in approximately 6 to 12 hours. It would peak before supper if given at 7:00 AM. Short-acting insulin would peak after breakfast or mid-morning. Long-acting insulins would peak at bedtime. 355. Diabetes When mixing types of insulin, always withdraw the clear, rapid-acting insulin into the syringe first and then the longacting insulin. This procedure avoids contaminating the short-acting insulin with the longer-acting insulin. Therefore, the Regular insulin would be drawn into the syringe first, followed by the NPH insulin. When a childs insulin dosage requires th e injection of both short- and intermediate-acting insulin at the same time, it is preferable to mix the two and use a single injection. Blood glucose results between 80 and 120 mg/dL are considered to be euglycemic (normal) and the prescribed dose would be administered to maintain euglycemia. 356. Dehydration In moderate dehydration, the fontanels would be slightly sunken, the mucous membranes would be dry, and the skin color would be dusky. Also, oliguria would be present. 357. Nephrotic Syndrome Nephrotic syndrome is a kidney disorder. Clinical manifestations of nephrotic syndrome include edema, proteinuria, hypoalbuminemia, and hypercholesterolemia in the absence of hematuria and hypertension. No fever, bacteriuria, or weight loss would be noted with this syndrome. 358. Glomerulonephritis Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. The child with acute glomerulonephritis will have an excessive accumulation of water and retention of sodium, leading to circulatory congestion and edema. Excess fluid volume would be an appropriate nursing diagnosis for this disease process. No risk for infection is associated with this disease; it is a postinfectious process, usually from a pneumococcal, streptococcal, or viral infection. Hematuria is present, but the loss of blood is not enough to constitute a risk for injury. The disease is acute as opposed to chronic, and almost all children recover completely. 359. Burns A Foley catheter is inserted into the childs bladder so that urine output can be measured accurately each hour. Although pain medication may be required, the child should not be sedated. Intravenously administered fluids are not restricted and are administered at a rate sufficient to keep the childs urine output at 1 mL/kg of body mass per hour, thus reflecting adequate tissue perfusion. A nasogastric tube may or may not be required, but this is not the priority intervention. 360. Impetigo Impetigo is a highly contagious bacterial infection of the skin. Fluids are important but are not a component of the main treatment for this infection. Additionally, fluids should never be forced. Although impetigo occurs in situations of poor hygiene, a judgmental statement as indicated in option 2 is inappropriate and nontherapeutic. The infection is communicable for 48 hours beyond initiation of antibiotic treatment. 361. Eczema Eczema is a superficial inflammatory process involving primarily the epidermis. The major goals of management are to relieve pruritus, lubricate the skin, reduce inflammation, and prevent or control secondary infections. Keeping the infant content and maintaining adequate nutrition are not priority care for an infant with eczema. Antibiotic ointment should be applied only for treatment of a secondary infection as ordered by a physician. 362. Juvenile Idiopathis Arthritis (JIA) JIA is twice as likely to occur in girls than in boys. Options 1, 2, and 4 are accurate statements regarding this disorder. 363. Med Cal 364. Aspirin Overdose The client who has aspirin toxicity will present with metabolic acidosis with respiratory compensation as seen when the pH is below 7.35 mm Hg, and the HCO3 is below 22 mEq/L. The pH is indicative of the acid -base imbalance. In this case, the pH is acidotic and the HCO3 is decreased, thus indicating metabolic acidosis. The PCO2 is alkalotic, indicating partial compensation. 365. Appendicitis A client with appendicitis is more comfortable when lying in what is traditionally known as the fetal position, with the legs drawn up toward the chest. This flexed positioning assists in decreasing the pain that comes with appendicitis by decreasing the pressure on the abdominal area. Option 1 is incorrect; pain medications are not given to the client with acute appendicitis because they may mask the symptoms that accompany a ruptured appendix. Option 2 describes a nursing intervention that is necessary postoperatively. Option 3 describes an intervention that is contraindicated because heat can lead to a ruptured appendix. 366. Pneumonia Attachment is critical to optimal growth and development of children, particularly in the infant and toddler years. With the addition of oxygen therapy, the hospitalized toddler is at risk of increased anxiety. It is important to maintain the toddler in the oxygen environment at all times. Oxygen therapy is an important component of management of pneumonia and is effective only if it is used appropriately. Critical to that effectiveness is an understanding of the risks that accompany oxygen

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therapy. Preventing fire is a key nursing intervention. Wool blankets, stuffed wool toys, and many toy cars can produce sparks, which can lead to an oxygen tents catching fire. It is important to educate parents and family members not to bring these ty pes of objects to the hospital. 367. Head Injury After a head injury, bleeding from the nose or ears necessitates further evaluation. A watery discharge from the nose (rhinorrhea) that tests positive for glucose is likely to be cerebrospinal fluid (CSF) leaking from a skull fracture. On noting watery discharge from the childs nose, the nurse would initially test the drainage for glucose using reagent strips such as Dextrostix. If the results of the test are positive, the nurse would then contact the physician. 368. epiglottitis The throat of a child with suspected epiglottitis should not be examined or cultured because any stimulation with a tongue depressor or culture swab could cause laryngospasm, thus completing airway obstruction. Humidified oxygen and antipyretics are components of management. Axillary rather than oral temperatures should be taken. 369. Diabetes A blood glucose below 70 mg/dL indicates hypoglycemia. The child is attending an activity that is different from the normal routine at school. Insulin requirements change with unfamiliar situations. When signs of hypoglycemia occur, the child needs an immediate source of glucose. Regular insulin will lower the blood glucose. Although the childs mother will need to be notified of the occurrence, this is not the immediate action. There is no reason to take the child to the emergency department. 370. Dislocated Hip Bucks extension traction is a type of skin traction in which the legs are in an extended position. It is used primarily for short-term immobilization, such as in preoperative management of a child with a dislocated hip. A 90- to 90-degree femoral traction (option 2) is used for femur fractures. In this type of traction, the lower leg is put in a boot cast or supported in a sling, and a skeletal Steinmann pin or Kirschner wire is placed in the distal fragment of the fracture. Russells traction (option 3) is used for fractures of the femur or for hip and knee contractures. It uses skin traction on the lower leg with a padded sling under the knee. Balanced suspension (option 4) may be used with or without skin or skeletal traction. It is used for femur, hip, or tibial fractures. The balanced suspension suspends the leg in a desired flexed position to relax the hip and hamstring muscles and does not exert any traction directly on a body part. In balanced suspension, a Thomas splint extends from the groin to midair above the foot, and a Pearson attachment supports the lower leg. 371. Fracture When small fragments of bone are broken from the fracture shaft and lie in the surrounding tissues, the fracture is called comminuted. An open or compound fracture (option 1) is a fracture with an open wound from which the bone protrudes. In an oblique fracture (option 3), a diagonal line across the bone is noted. In a greenstick fracture (option 4), the bone is partly bent and partly broken. 372. Body Surface Area The body surface area of a child can be estimated using the West nomogram. A straight line is drawn on the nomogram between the height and the weight for the child. The point at which the line crosses the surface area column is the estimated body surface area. 373. Dislocated Hip A Pavlik harness is a device that is used to treat congenital hip dislocation. It keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum. The Pavlik harness is worn continuously for 3 to 6 months. It promotes the development of muscle and cartilage, resulting in a stable hip. 374. Leukemia A lateral recumbent position with the knees flexed to the abdomen and the head bent with the chin resting on the chest is assumed for a lumbar puncture. This position separates the spinal processes and facilitates needle insertion into the subarachnoid space. Options 1, 2, and 4 are incorrect positions. 375. Leukemia The CNS is monitored because of the risk of infiltration of blast cells into the CNS. The nurse will check the childs LOC and also will look for signs of irritability, vomiting, and lethargy. Color, motion, and sensation of the extremi ties are concerns in a neurovascular assessment. Changes in pupillary reaction most often are noted in conditions related to increased intracranial pressure. The presence of petechiae in the sclera is an objective sign of leukemia. 376. Safety A leading causes of accidental death in the adolescent population is improper use of firearms. Before implementing firearm safety goals, the nurse needs to obtain baseline data about a firearm safety history, which is done in option 3. Option 2 may then be indicated. Option 1 may or may not be effective at some point for this client. Option 4 is unreasonable. 377. Down's Syndrome Children with Down syndrome have an increased risk for developing leukemia compared with the average child. The other statements also could be true, but the nurse should first gather baseline data to determine the cause of the bruising before making other assumptions. 378. Cerebral Palsy Option 4 provides the child with maximum potential in locomotion, self-care, and socialization. The child can move around independently while lying on the abdomen anywhere the child wants to go and can interact with others as desired. Orthoses must be used all the time to aid locomotion (option 3). Option 1 does not provide for maximum socialization and normalization; rather, children with CP need to be mainstreamed as much as cognitive ability permits. Not all children with CP are intellectually challenged. Option 2 does not provide for normalization in self-care. Just as children without CP sit up and use assistive devices when eating, so should children with CP.

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379. Childhood Development In most communities, free or low-cost after-school programs or activities are available that minimize the amount of time during which school-age children are at home alone. These programs should include adult supervision, which is needed by school-age children. Options 1, 2, and 3 are inappropriate. 380. Scoliosis Bracing can halt the progression of most curvatures, although it is not curative for scoliosis. The statements in options 1, 2, and 3 represent correct understanding on the part of the child. 381. Safety The toddler is at high risk for injury as a result of developmental abilities and an unfamiliar environment. While adaptation, diversion, and consistency are important, protection from injury is the highest priority. 382. Med Cal 383. Cleft Palate Unresponsiveness may be an indication of hearing loss. A child who has a history of cleft palate should be routinely checked for hearing loss. Options 1 and 4 are unrelated to cleft palate after repair. Option 2 is normal behavior for a preschool child. Many preschoolers with vivid imaginations have imaginary friends. 384. Increased Intracranial Pressure The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants physician notification. Options 1, 2, and 4 are inaccurate interpretations. 385. Spina Bifida (Myelomeningocele type) Elevating the head will decrease the chance that cerebrospinal fluid will accumulate in the cranial cavity. The infant needs to be prone for several days to decrease the pressure on the surgical site on the back. Binders and a baby seat should not be used because of the pressure they would exert on the surgical site. 386. Cystic Fibrosis Breathing exercises are recommended for a majority of children with CF, even those with minimal pulmonary involvement. The exercises usually are performed twice daily, and they are preceded by postural drainage. The postural drainage will mobilize secretions, and the breathing exercises will then assist with expectoration. Exercises to assist in assuming correct postures and in maximizing thoracic mobility are included, such as swinging the arms and bending and twisting the trunk. The ultimate aim of these exercises is to establish a good habitual breathing pattern. 387. Diabetes Most children 9 years of age and older can understand the principles of monitoring their own insulin requirements. They usually are responsible enough to determine the appropriate intervention needed to maintain their health. The school teacher will not take responsibility for health care interventions such as this one. Parents, friends, and family cannot always be available. 388. Otitis Media In acute otitis media, symptoms and signs such as acute ear pain, fever, and a bulging yellow or red tympanic membrane usually are present. Nursing interventions focus on relieving pain. Analgesic medications such as acetaminophen (Tylenol) and ibuprofen (Motrin) are used to treat mild pain. The priority nursing diagnosis for this condition would be acute pain. Impaired skin integrity, ineffective breathing pattern, and impaired oral mucous membranes would not be priority nursing diagnoses with this condition. 389. Rheumatic Fever Rheumatic fever usually develops after a group A -hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoffs bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated antistreptosysin O titer; an elevated C-reactive protein; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkins disease. 390. Epistaxis Evaluation of the teaching is done by eliciting feedback to ensure parents understand the information. Use of a hands-on return demonstration is the best method to encourage mastery of skills and determine i f the parents have understood what was taught. Telling the parents the steps to take when a nosebleed occurs, showing a video, and giving a brochure fall under the category of relating information but would not allow the nurse to determine if the parents understood the content. 391. Down's Syndrome Down syndrome is a form of mental retardation and is a congenital condition that results in moderate to severe mental retardation. Most cases are attributable to an extra chromosome (group G) hence the name trisomy 21. Options 1, 2, and 3 are incorrect characteristics of this syndrome. 392. Blood Pressure Cuff The size of the blood pressure cuff is important. Cuffs that are too small will cause falsely elevated values, and those that are too large will cause inaccurate low values. The cuff should cover two thirds of the distance between the antecubital fossa and the shoulder. 393. Piaget's Cognitive Theory Animism means that all inanimate objects are given living meaning. Egocentric speech occurs when the child talks just for fun and cannot see anothers point of view. Object permanence, the realization that something out of sight still exists, occurs in the later stages of the sensorimotor stage of development. Global organization means that if any part of an object or situation changes, the whole thing has changed. Options 2 and 4 occur during the preoperational stage. 394. Seizures Antiseizure medications are continued for a prolonged time even if seizures are controlled. Periodic reevaluation of the child is important to assess the continued effectiveness of the medication, check serum medication levels, and determine the need to alter the dosage if indicated. Antiseizure medications have potential side effects, and parents should be informed of such effects specific to the medication the child will be taking. Withdrawal of medication follows a predesigned protocol, usually begun when the child has been seizure free for at least 2 years. When a medication is discontinued, the dosage should be reduced gradually over 1 to 2 weeks.

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395. Med Cal 396. Oral Medication The nurse should administer oral medications with the infant sitting in an upright position to prevent aspiration if the infant cries or resists. Semi-Fowlers is an upright position. Dorsal recumbent means on the back and flat, so there would be a risk of aspiration with this position. Trendelenburg is on the back with the head lowered, and prone is on the abdomen. Oral medications could not be administered to an infant in either of these positions. 397. Childhood Development The nurse utilizes developmental perspectives when administering medications. The preschool age is when the nurse can make use of magical thinking as a strategy to administer medications. Infants and toddlers are too young for this concept, and school-age children are too mature. 398. Thalassemia In thalassemia, immature erythrocytes proliferate, not mature ones. This is a progressive anemia. Defective hemoglobin is produced as a result of genetically deficient -polypeptide. This hemoglobin is unstable, disintegrates, and damages the erythrocytes. Rapid destruction of the red cells stimulates rapid production of immature red cells, and the net gain is less-than-optimally functioning red cells. Iron from the red blood cell destruction is stored in the tissues, causing multiple problems. The nurse also would note microcytosis and hypochromia. Therefore, options 1, 2, and 4 are incorrect statements. 399. Hemophilia The female offspring of an affected male and a carrier female are at risk for hemorrhage once puberty is attained and menstrual cycles begin, and depending on the severity of the hemophilia, a hysterectomy or ablation may be performed. Options 2, 3, and 4 are incorrect statements. Hemarthrosis is the result of bleeding into the joint cavity, not of aspiration. Aspirin is not given to young children and would not be given to a child with a bleeding disorder because of its effects on platelet aggregation. Seventy-two hours is too long for the joint to be rested, because maintenance of mobility is a primary concern once the bleeding episode has been arrested. 400. Anemia During vaso-occlusive sickle cell crisis, the care focuses on adequate hydration and pain management. Adequate hydration with intravenous normal saline and oral fluids maintains blood flow and decreases the severity of the vaso-occlusive crisis. Analgesics for pain management are necessary during a vaso-occlusive crisis. Splenectomy would not be done with a vaso-occlusive crisis. Acidosis is not present. Oxygen can be administered to increase tissue perfusion, but is not the priority treatment for a vaso-occlusive crisis. Passive range of motion is not recommended; bedrest is prescribed initially. 401. Vaccines The vaccination would be given. Mild fever after the DTaP is not uncommon, and the vaccination would not be withheld for that reason. It is not necessary to notify the physician about this side effect. A vaccination is withheld for true contraindications such as a previous anaphylactic reaction or sensitivity to a product in the vaccination. Drawing blood for determination of a pertussis titer would not be indicated. 402. Rheumatic Fever Rheumatic fever develops after a group A -hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoffs bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated antistreptosysin O titer; an elevated C-reactive protein level; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkins disease. 403. Fifth Disease The classic rash of erythema infectiosum, or fifth disease, affects the face. Th e discrete rose-pink maculopapular rash is the rash of exanthema subitum (roseola). The highly pruritic, profuse macule-to-papule rash is the rash of varicella (chickenpox). The discrete pinkish red maculopapular rash is the rash of rubella (German measles). 404. Subdural Hematoma A subdural hematoma can cause pressure on a specific area of the cerebral tissue. Especially if the infant is actively bleeding, such pressure can cause changes in the stimuli responses in the extremities on the opposite side of the body. Option 1 is incorrect because contractures would not occur this soon after delivery. Options 3 and 4 are incorrect. An infant, after delivery, normally would be incontinent of urine. Blood in the urine would indicate abdominal trauma and would not be a result of the hematoma. 405. Dental Care The practice of coating pacifiers with honey or using commercially available hard-candy pacifiers is discouraged. Besides being cariogenic, honey also may cause botulism, and broken-off pieces of the candy pacifier may be aspirated. Additionally, sweet milk or other fluids such as juice in a bottle taken at naptime or bedtime will bathe the teeth, producing caries. Fluoride, an essential mineral for building caries-resistant teeth, is needed, usually beginning at 6 months of age if the infant does not receive adequate fluoride content. A diet that is low in sweets and high in nutritious foods promotes dental health. 406. Fracture The school-aged child becomes organized with more direction with play activities. Such activities include collections, drawing, construction, dolls, pets, guessing games, board games, riddles, hobbies, competitive games, and listening to the radio or television. Options 1 and 2 are appropriate for a preschooler. Option 3 is appropriate for a toddler. 407. Inguinal Hernia Changing diapers as soon as they become damp helps prevent infection at the surgical site. Parents are instructed to change diapers more frequently than usual during the day and once or twice during the night. Parents are instructed to give the infant sponge baths instead of tub baths for 2 to 5 days. No restrictions on the infants activity are needed. A fev er may indicate the presence of an infection.

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