Correct answer: B. Underweight for height.

This figure indicates elevation of the papilla, without breast buds, considered stage 1 and typical of a preadolescent. Figure 1 shows stage 2, breast bud enlargement; there is elevation of the breast and the diameter of the areola has increased. Figure 2 shows stage 3, enlargement of the breast and areola. Figure 4 shows stage 4, in which there is projection of areola and papilla to form a secondary mound above the level of the breast.

Correct answer: A. "The vaccine is most effective against cervical cancer if given before becoming sexually active."

Vaccines are preventative in nature and ideally given before exposure. Focusing on the benefits of cancer prevention is most appropriate, as opposed to discussing with parents the potential that their child may become sexually active without their knowledge. It is true HPV is most common in adolescents and women in their late twenties, but parents still may not perceive that their child is at risk. Discussing the possibility of exposure through assault raises fears and does not focus on prevention.

Correct answer: C. Positive self-identity.

Relieving dysmenorrhea in adolescence is crucial for the female’s development of positive self-identity, of which positive body image and sexual identity are important components. Menstruation should not be viewed as painful and debilitating. Positive peer relations and a sense of independence would develop with a positive self-identity. Sense of autonomy, according to Erikson, is the developmental task of toddlers that, if successfully mastered, leads to a sense of self-control.

Correct answer: B. The reasons they choose to use alcohol.

Information about why adolescents choose to use alcohol or other drugs can be used to determine whether they are becoming responsible users or problem users. The senior students likely know the legal implications of drinking, and the nurse will establish a more effective relationship with the students by understanding motivations for use. The type of alcohol and when and with whom they are using it are not the first data to obtain when assessing the situation.

Correct answer: C. Placing a car seat in a front-seat, front-facing position.

It is recommended that children up to 2 years of age ride in a rear-facing car seat. The middle of the back seat is considered the safest area of the car. Burns are a major cause of childhood accidents, and using fire screens in front of fireplaces can help prevent children from getting too close to a fire in a fireplace. Toys that contain loose parts or plastic eyes that can be swallowed or aspirated by small children should be avoided. Parents should inspect all toys for these parts before giving one to a child. Poisonings are most commonly caused by improper storage of a toxic substance. Keeping toxic substances in a childproof container in a locked cabinet and continually observing the child’s activities can prevent most poisonings.

Correct answer: D. Occurs 2 years later.

Adolescent boys lag about 2 years behind adolescent girls in growth. Most girls are 1 to 2 inches taller than boys at the beginning of adolescence but tend to stop growing approximately 2?to 3?years after menarche with the closure of the epiphyseal lines of the long bones.

Correct answer: D. Discuss their feelings with their child.

Parents need to discuss with their adolescent how they perceive his behavior and how they feel about it. Moodiness is characteristic of adolescents. The adolescent may have a reason for or not be aware of his behavior. Restricting the adolescent’s activities will not change his mood or the way he responds to others. It may increase his unacceptable responses. Counseling may not be needed at this time if the parents are open to communicating and listening to the adolescent. Talking to other parents may be of some help, but what is helpful to others may not be helpful to their child.

Correct answer: C. Itching of the scalp.

The most common characteristic of head lice infestation (pediculosis capitis) is severe itching. The head is the most common site of lice infestation. If the child scratches, scaling may occur. Itching also occurs when lice infest other parts of the body. Scratch marks are almost always found when lice are present. Weeping on the scalp surface may be an indication of an infection or other dermatologic condition. Hemorrhagic spots are not a symptom of head lice, but may be caused by scratch marks.

Correct answer: C. Pediculosis usually is spread by close contact with infested children.

Lice are spread by close personal contact and by contact with infested clothing, bed and bathroom linens, and combs and brushes. Lice are more common in school-age children than in adults because of the close contact in school and the common practice of sharing possessions. Lice are not commonly spread by hand contact. There is no immunity conferred by having head lice. Adults can have head lice, particularly if they come in close contact with their children’s infested clothing or linens.

Correct answer: D. "It’s a fungal infection of the scalp."

Ringworm of the scalp is caused by a fungus of the dermatophyte group of the species. Overexposure to the sun would result in sunburn. Mites, such as chiggers or ticks, produce bites on the skin, resulting in inflammation. An allergic reaction commonly is manifested by hives, rash, or anaphylaxis.

Correct answer: D. The growth of the causative organism into new cells is prevented with long-term use.

Griseofulvin is an antifungal agent that acts by binding to the keratin that is deposited in the skin, hair, and nails as they grow. This keratin is then resistant to the fungus. But as the keratin is normally shed, the fungus enters new, uninfected cells unless drug therapy continues. Long-term administration of griseofulvin does not prevent sensitivity or allergic reactions. As the body adjusts to a new substance over time, side effects are variable and do not necessarily decrease.

Correct answer: D. Hands.

The adult pinworm emerges from the rectum and colon at night onto the perianal area to lay its eggs. Itching and scratching introduces the eggs to the hands, from where they can easily reinfect the child or infect others. Nightclothes and bed linens can be sources of infection. The eggs can also be transmitted by dust in the home. Although transmission through contaminated food and water supplies is possible, it is rare. Contaminated animals can spread histoplasmosis and salmonella. The spread of infections by toilet seats has not been supported by research.

Correct answer: A. Skin infection.

The care of a child with chickenpox focuses primarily on preventing infection in the lesions. The lesions cause severe itching, and organisms are ordinarily introduced into the lesion through scratching. Acid-base imbalance rarely occurs with chickenpox. Malnutrition is a chronic problem associated with the ingestion of an inadequate diet over a long period. It is not associated with chickenpox. Secondary infection in the lesions, not the respiratory tract, is most common.

Correct answer: A. Ability to see at 20 feet what she should see at 60 feet.

A child with 20/60 vision sees at 20 feet what those with 20/20 vision see at 60 feet. A visual acuity of 20/200 is considered to be the boundary of legal blindness.

Correct answer: C. "I will ignore the temper tantrum."

Children who have temper tantrums should be ignored as long as they are safe. They should not receive either positive or negative reinforcement to avoid perpetuating the behavior. Temper tantrums are a toddler’s way of achieving independence.

Correct answer: A. 1 to 2 years earlier in girls than in boys.

Girls experience the onset of adolescence about 1 to 2 years earlier than boys. The reason for this is not understood.

Correct answer: D. Take no particular precautionary measures.

The cause of infectious mononucleosis is thought to be the Epstein-Barr virus. No precautionary measures are recommended for clients with mononucleosis. The virus is believed to be spread only by direct intimate contact.

Correct answer: C. Enlarged lymph glands.

Mononucleosis usually has an insidious onset, with fatigue and the inability to maintain usual activity levels as the most common symptoms. The lymph nodes are typically enlarged, and the spleen also may be enlarged. Fever and a sore throat often accompany mononucleosis. A persistent nonproductive cough can follow an upper respiratory tract infection. A blush-like generalized skin rash is more characteristic of rubella.

Correct answer: B. If the child reaches puberty and becomes pregnant when receiving the vaccine, the risks to the fetus are high.

After receiving the MMR vaccine, the person develops a mild form of the disease, stimulating the body to develop immunity. Administration to a pregnant adolescent early in pregnancy puts the fetus at risk for deformity or spontaneous abortion. Some authorities recommend withholding the immunization for rubella until after puberty because a woman does not always know when she is pregnant and a fetus could be placed in jeopardy. However, the risk of contracting the disease is not lower at this age. There is no difference in the reaction to the vaccine at this age or in an older child. Swelling of the joints is a rare complication of the rubella vaccine.

Correct answer: B. "We can see you without your parents’ consent but have to report any positive results to the public health department."

While some areas may specify a minimum age for treatment (usually 12 to 14 years), generally adolescents have the right to seek treatment for sexually transmitted infections without their parents’ permission. These records are not shared with parents without the client’s permission. However, adolescents must be made aware that certain infections, including gonorrhea, must be reported by law to public health agencies. Partner notification will also take place, but methods vary.

Correct answer: D. Check nationally published immunization guidelines.

National advisory committees on immunization practices review vaccination evidence and update recommendations yearly. Current vaccination catch-up schedules are readily available on their Websites. The lack of vaccinations is a strong indicator that the child probably does not have a primary care provider. Even if the client had a provider, however, that person might be difficult to reach on a weekend during the timeframe of a vaccination clinic. If consulted, the pharmacist would most likely have to review the latest guidelines that are equally available to the nurse. Reading the manufacturer’s inserts for multiple vaccines would be time consuming and synthesis of the information could possibly lead to errors.

Correct answer: D. Report the event through a national immunization surveillance system.

Any unusual event that occurs after the administration of a vaccination should be reported through a national immunization surveillance system. In the United States, it is the Vaccine Adverse Event Reporting System (VAERS). In Canada, it is Canadian Adverse Events Following Immunization Surveillance System (CAEFISS). A high fever, with or without a seizure, that occurs within 6 weeks of vaccination may have been caused by the vaccine. A febrile seizure is considered a moderate reaction that warrants caution with future chicken pox vaccination. Reporting the incident to the manufacturer does not help build the same body of knowledge as reporting the problem through the national surveillance system.

Correct answer: B. A result of developing self-concept.

An adolescent’s body is undergoing rapid changes. Adolescence is a time of integrating these rapidly occurring physical changes into the self-concept to achieve the developmental task of a positive self-identity. Thus, most adolescents spend much time worrying about their personal appearance. This behavior is not abnormal narcissism, a method of procrastination, or a way of testing the parents’ limits.

Correct answer: B. Guide the tongue blade while the child is holding it to depress the tongue to visualize the throat.

If the child does not stick out his tongue so the nurse can visualize the throat, it is appropriate to use a tongue blade. Having the child participate by holding the tongue blade while the nurse guides it to facilitate visualization of the throat is appropriate technique. It is not useful to remove the tongue blade or have the child hold it because the nurse will need to use the tongue blade to depress the tongue. It is preferable to engage the child’s cooperation before asking the parent to restrain the child.

Correct answer: D. Intrinsic factor, absent.

The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestine and folic acid needs vitamin B12 for deoxyribonucleic acid synthesis of RBCs. The gastric analysis is done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stages of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 in the intestinal tract. A sedimentation rate of 16 mm/h is normal for both men and women and is a nonspecific test to detect the presence of inflammation; it is not specific to anemias. An RBC value within the normal range does not indicate an anemia.

Correct answer: A. "When it is done you will get to see your mommy and get a Popsicle."

When preparing a child for a procedure the nurse should use neutral words, focus on sensory experiences, and emphasize the positive aspects at the end. Being reunited with parents and having an ice pop would be considered pleasurable events. Children this age fear bodily harm. To reduced anxiety, the nurse should use the word "fixed" instead of "removed" to describe what is being done to the tonsils. Using the terms "put to sleep" and "IV" may be threatening. Additionally, directing a play experience to focus on IV insertion may be counterproductive as the child may have little recollection of this aspect of the procedure.

Correct answer: C. Drooling of bright red secretions.

After a tonsillectomy and adenoidectomy, drooling bright red blood is considered an early sign of hemorrhage. Often, because of discomfort in the throat, children tend to avoid swallowing; instead, they drool. Frequent swallowing would also be an indication of hemorrhage because the child attempts to clear the airway of blood by swallowing. Secretions may be slightly blood-tinged because of a small amount of oozing after surgery. However, bright red secretions indicate bleeding. A pulse rate of 95 bpm is within the normal range for a 5-year-old child, as is a blood pressure of 95/56 mm Hg. A small amount of blood that is partially digested, and therefore dark brown, is often present in postoperative emesis.

Correct answer: B. Cream of chicken soup and orange sherbet.

For the first few days after a tonsillectomy and adenoidectomy, liquids and soft foods are best tolerated by the child while the throat is sore. Children typically do not chew their food thoroughly, and solid foods are to be avoided because they are difficult to swallow. Although meat loaf would be considered a soft food, uncooked carrots would not be. Pork is frequently difficult to chew. Foods that have sharp edges, such as potato chips, are contraindicated because they are hard to chew and may cause more throat discomfort.

Correct answer: C. 7 to 10 days after surgery.

The risk of hemorrhage from a tonsillectomy is greatest when the tissue begins sloughing and the scabs fall off. This typically happens 7 to 10 days after a tonsillectomy.

Correct answer: B. Oral contraceptives.

When a person is taking amoxicillin as well as an oral contraceptive it renders the contraceptive less effective. Because pregnancy can occur in such a situation, the nurse should advise the client to use additional means of birth control during the time she is taking the antibiotic. There are no risks associated with the concurrent use of amoxicillin and antacids, vitamins, or food.

Correct answer: D. Talk to the mother first so that the toddler can get used to the new person.

Toddlers should be approached slowly, because they are wary of strangers and need time to get used to someone they do not know. The best approach is to ignore them initially and to focus on talking to the parents. The child will likely resist being held by a stranger, so the nurse should not pick up or hold the child until the child indicates a readiness to be approached or the mother indicates that it is okay.

Correct answer: C. Crackers.

Crackers, because they crumble and easily dissolve, are not commonly aspirated. Because children commonly eat popcorn hulls or pieces that have not popped, popcorn can be easily aspirated. Toddlers frequently do not chew their food well, making raw vegetables a commonly aspirated food. Round candy is often difficult to chew and comes in large pieces, making it easily aspirated.

Correct answer: B. Protest.

Young children have specific reactions to separation and hospitalization. In the protest stage, the toddler physically and verbally attacks anyone who attempts to provide care. Here, the child is fussing and crying and visibly pushes the nurse away. In the despair stage, the toddler becomes withdrawn and obviously depressed (eg, not engaging in play activities and sleeping more than usual). Regression is a return to a developmentally earlier phase because of stress or crisis (eg, a toddler who could feed himself before this event is not doing so now). Denial or detachment occurs if the toddler’s stay in the hospital without the parent is prolonged because the toddler settles in to the hospital life and denies the parents’ existence (eg, not reacting when the parents come to visit).

Correct answer: D. Gags.

The three cardinal signs indicating that a child is truly choking and requires immediate life-saving interventions include inability to speak, blue color (cyanosis), and collapse. Vomiting does not occur while a child is unable to breathe. Once the object is dislodged, however, vomiting may occur. Gasping, a sudden intake of air, indicates that the child is still able to inhale. When a child is choking, air is not being exchanged, so gagging will not occur.

Correct answer: B. "You should bring your child to the emergency room tonight so the bead can be removed as soon as possible."

The bead should be removed by a health care professional as soon as possible to prevent the risk of aspiration and tissue necrosis. Unskilled individuals should not attempt to remove an object from the nose as they may push the object further increasing the risk for aspiration. Two-year-old children are not skilled at blowing their nose and may breathe in, further increasing the risk of aspiration.

Correct answer: A. Intercostal retractions.

Intercostal retractions indicate an increase in respiratory effort, which is a sign of respiratory distress. During an asthma attack, secretions are thick, the cough is tight, and respiration is difficult (and shortness of breath may occur). If mucous secretions are copious but thin, the client can expectorate them, which indicates an improvement in the condition. If the cough is productive it means the bronchospasms and the inflammation have been resolved to the extent that the mucus can be expectorated. A respiratory rate of 20 breaths/min would be considered normal and no intervention would be needed.

Correct answer: D. Swimming.

Swimming is appropriate for this child because it requires controlled breathing, assists in maintaining cardiac health, enhances skeletal muscle strength, and promotes ventilation and perfusion. Stop-and-start activities, such as soccer, track, and gymnastics, commonly trigger symptoms in asthmatic clients.

Correct answer: B. Wheezing on expiration.

The child who is experiencing an asthma attack typically demonstrates wheezing on expiration initially. This results from air moving through narrowed airways secondary to bronchoconstriction. The child’s expiratory phase is normally longer than the inspiratory phase. Expiration is passive as the diaphragm relaxes. During an asthma attack, secretions are thick and are not usually expelled until the bronchioles are more relaxed. At the beginning of an asthma attack the cough will be tight but not productive. Fever is not always present unless there is an infection that may have triggered the attack.

Correct answer: B. All of the above

Coughing, especially at night and in the absence of an infection, is a common symptom of asthma. Early signs of respiratory distress include restlessness, tachypnea, tachycardia, and diaphoresis. Other signs also include hypertension, nasal flaring, grunting, wheezing, and intercostal retractions. A heart rate of 95 bpm is normal for a toddler. Malaise typically does not indicate respiratory distress.

Correct answer: D. The child needs to use his/her short-acting inhaled beta2-agonist medication.

The peak flow of 180 L/min is in the yellow zone, or 50% to 80% of the child’s personal best. This means that the child’s asthma is not well controlled, thereby necessitating the use of a short-acting beta2-agonist medication to relieve the bronchospasm. A peak flow reading greater than 80% of the child’s personal best (in this case, 220 L/min or better) would indicate that the child’s asthma is in the green zone or under good control. A peak flow reading in the red zone, or less than 50% of the child’s personal best (135 L/min or less), would require notification of the health care provider or a trip to the emergency department. Cromolyn sodium (Intal) is not used for short-term treatment of acute bronchospasm. It is used as part of a long-term therapy regimen to help desensitize mast cells and thereby help to prevent symptoms.

Correct answer: D. Obtain a peak flow reading.

Problems of chest pain in children and adolescents are rarely cardiac. With a history of asthma, the most likely cause of the chest pain is related to the asthma. Therefore, the nurse should check the adolescent’s peak flow reading to evaluate the status of the air flow. Calling the adolescent’s parent would be appropriate, but this would be done after the nurse obtains the peak flow reading and additional assessment data. Having the adolescent lie down may be an option, but more data need to be collected to help establish a possible cause. Because the adolescent has not experienced any asthma problems for a long time, it would be inappropriate for the nurse to administer a short-acting bronchodilator at this time.

Correct answer: D. Call a parent to obtain more information.

Because persistent coughing may indicate an asthma attack and a 7-year-old child would be able to provide only minimal history information, it would be important to obtain information from the parent. Although determining the child’s heart rate is an important part of the assessment, it would be done after the history is obtained. More information needs to be obtained before giving the child a nebulizer treatment. Although it may be necessary for the parent to come and pick up the child, a thorough assessment including history information should be obtained first.

Correct answer: A. Keep the humidity in the home between 50% and 60%.

To help reduce allergic triggers in the home, the nurse should recommend that the humidity level be kept between 50% and 60%. Doing so keeps the air moist and comfortable for breathing. When air is dry, the risk for respiratory infections increases. Too high a level of humidity increases the risk for mold growth. Typically, the child with asthma should sleep in the top bunk bed to minimize the risk of exposure to dust mites. The risk of exposure to dust mites increases when the child sleeps in the bottom bunk bed because dust mites fall from the top bed, settling in the bottom bed. Scented sprays should be avoided because they may trigger an asthmatic episode. Ideally, carpeting should be avoided in the home if the child has asthma. However, if it is present, carpeting in the child’s room should be vacuumed often, possibly daily, to remove dust mites and dust particles.

Correct answer: A. "Although our child’s disease is serious, we try not to let it be the focus of our family."

Positive adjustment to a chronic condition requires placing the child’s illness in its proper perspective. Children with asthma need to be treated as normally as possible within the scope of the limitations imposed by the illness. They also need to learn how to manage exacerbations and then resume as normal a life as possible. Trying to keep the child happy at all costs is inappropriate and can lead to the child’s never learning how to accept responsibility for behavior and get along with others. Although minimizing the child’s risk for exposure to infections is important, the child needs to be with his or her peers to ensure appropriate growth and development. Children with a chronic illness need to be involved in their care so that they can learn to manage it. Some parents tend to overprotect their child with a chronic illness. This overprotectiveness may cause a child to have an exaggerated feeling of importance or later, as an adolescent, to rebel against the overprotectiveness and the parents.

Correct answer: C. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor."

Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of red blood cells in this condition.

Correct answer: A. The child needs these pancreatic enzymes to help the digestive system absorb fats, carbohydrates, and proteins.

The child must take the pancreatic enzyme supplement with meals and snacks to help absorb nutrients so he can grow and develop normally. In cystic fibrosis, the normally liquid mucus is tenacious and blocks three digestive enzymes from entering the duodenum and digesting essential nutrients. Without the supplemental pancreatic enzyme, the child will have voluminous, foul, fatty stools due to the undigested nutrients and may experience developmental delays due to malnutrition. Dehydration is not a problem related to cystic fibrosis. The pancreatic enzymes have no effect on the viscosity of the tenacious mucus. Diarrhea is not caused by failing to take the pancreatic enzyme supplement.

Correct answer: D. Congenital enzyme deficiency.

This client presented with the typical signs of glucose-6-phosphate dehydrogenase (G6PD)-deficiency anemia. Ten percent of Blacks inherit an X-linked recessive disorder of the G6PD enzyme in the red blood cell (RBC). When cells with decreased levels of G6PD are exposed to certain drugs, such as sulfonamides, acetylsalicylic acid, thiazide diuretics, and vitamin K, the RBC may hemolyze and anemia and jaundice may occur. The reaction is self-limited as soon as the causative agent is withheld. No further treatment is necessary except counseling to prevent acute incidence by avoiding exposure to specific drugs. There is no need for increased folic acid, restricted activity in hot weather, or blood transfusions.

Correct answer: C. Monitoring the client for indications of constipation.

Monitoring intake and output is the most important nursing action when administering an aminoglycoside, such as gentamicin, because a decrease in output is an early sign of renal damage. Daily weight monitoring is not indicated when the client is receiving an aminoglycoside. Constipation and bleeding are not adverse effects of aminoglycosides.

Correct answer: D. Before meals.

Postural drainage, which aids in mobilizing the thick, tenacious secretions commonly associated with CF, is usually performed before meals to avoid the possibility of vomiting or regurgitating food. Although the child with CF needs frequent rest periods, this is not an important factor in scheduling postural drainage. However, the nurse would not want to interrupt the child’s rest period to perform the treatment. Inhalation treatments are usually given before postural drainage to help loosen secretions.

Correct answer: B. High-calorie diet.

CF affects the exocrine glands. Mucus is thick and tenacious, sticking to the walls of the pancreatic and bile ducts and eventually causing obstruction. Because of the difficulty with digestion and absorption, a high-calorie, high-protein, high-carbohydrate, moderate-fat diet is indicated.

Correct answer: D. Large and foul-smelling.

In children with CF, poor digestion and absorption of foods, especially fats, results in frequent bowel movements that are bulky, large, and foul-smelling. The stools also contain abnormally large quantities of fat, which is called steatorrhea. An adolescent experiencing good control of the disease would describe soft stools with little odor. Stool described as loose with bits of food indicates diarrhea. Stool described as hard with streaks of blood may indicate constipation.

Correct answer: A. Child’s favorite doll.

The child’s favorite doll would be a good choice of toys. The doll provides support and is familiar to the child. Although a 3-year-old may enjoy puzzles, a 100-piece jigsaw puzzle is too complicated for an ill 3-year-old child. In view of the child’s lung pathology, a fuzzy stuffed animal would not be advised because of its potential as a reservoir for dust and bacteria, possibly predisposing the child to additional respiratory problems. Scissors, paper, and paste are not appropriate for a 3-year-old unless the child is supervised closely.

Correct answer: C. Formation of fibrous cysts in various body organs.

CF is characterized by a dysfunction in the body’s mucus-producing exocrine glands. The mucus secretions are thick and sticky rather than thin and slippery. The mucus obstructs the bronchi, bronchioles, and pancreatic ducts. Mucus plugs in the pancreatic ducts can prevent pancreatic digestive enzymes from reaching the small intestine, resulting in poor digestion and poor absorption of various food nutrients. Fibrous cysts do not form in various organs. Cystic fibrosis is an autosomal recessive inherited disorder and does not involve any reaction to the formation of antibodies against streptococcus.

Correct answer: C. Respiratory rate and rhythm within expected range.

After treatment, the client outcome would be that respiratory status would be within normal limits, as evidenced by a respiratory rate and rhythm within expected range. Absence of chills and fever, although related to an underlying problem causing the respiratory problem (eg, the infection), do not specifically relate to the respiratory problem of ineffective airway clearance. The child’s ability to engage in age-related activities may provide some evidence of improved respiratory status. However, this outcome criterion is more directly related to activity intolerance. Although the child’s ability to tolerate his or her usual diet may indirectly relate to respiratory function, this outcome is more specifically related to an imbalanced nutrition that may or may not be related to the child’s respiratory status.

Correct answer: C. Swimming.

Swimming would be the most appropriate suggestion because it coordinates breathing and movement of all muscle groups and can be done on an individual basis or as a team sport. Because track events, baseball, and javelin throwing usually are performed outdoors, the child would be breathing in large amounts of dust and dirt, which would be irritating to her mucous membranes and pulmonary system. The strenuous activity and increased energy expenditure associated with track events, in conjunction with the dust and possible heat, would play a role in placing the child at risk for an upper respiratory tract infection and compromising her respiratory function.

Correct answer: B. Congenital enzyme deficiency.

This client presented with the typical signs of glucose-6-phosphate dehydrogenase (G6PD)-deficiency anemia. Ten percent of Blacks inherit an X-linked recessive disorder of the G6PD enzyme in the red blood cell (RBC). When cells with decreased levels of G6PD are exposed to certain drugs, such as sulfonamides, acetylsalicylic acid, thiazide diuretics, and vitamin K, the RBC may hemolyze and anemia and jaundice may occur. The reaction is self-limited as soon as the causative agent is withheld. No further treatment is necessary except counseling to prevent acute incidence by avoiding exposure to specific drugs. There is no need for increased folic acid, restricted activity in hot weather, or blood transfusions.

Correct answer: A. "What did the infant look like when you found him?"

Because this is an especially disturbing and upsetting time for the parents, they must be approached in a sensitive manner. Asking what the infant looked like when found allows the parents to verbalize what they saw and felt, thereby helping to minimize their feelings of guilt without implying any blame, neglect, wrongdoing, or abuse. Asking if the child was wrapped in a blanket or lying on his stomach, or when the parents last checked on the infant, implies that the parents did something wrong or failed in their care of the infant, thus blaming them for the event.

Correct answer: B. Start chest compressions.

The 2010 CPR guidelines call for a CAB approach. When breathlessness is determined, the priority nursing action is checking a pulse and beginning compressions. After 30 compressions, the nurse opens the airway and gives 2 breaths. Oxygen therapy would not be initiated at this time, because the child is not breathing. Also, administering oxygen therapy would interfere with providing mouth-to-mouth resuscitation.

Correct answer: A. 10 breaths/min.

Rescue breaths should be delivered slowly at a volume that makes the chest rise and fall. For a 5-year-old child, the rate is 10 breaths per minute. If the nurse is also administering chest compressions, the rate is 2 breaths for every 15 compressions.

Correct answer: A. Begin 2-person CPR at a ratio of 2 breaths to 15 compressions.

CPR is done on children for heart rate of less than 60 with signs of poor perfusion. Rescuers should use a 15:2 compression to ventilation ratio for 2-rescuer CPR for a child. Breaths without compressions are indicated only for respiratory arrests where the heart rate remains above 60. The AED/defibrillator should be used as soon as it is ready, but rescuers should not discontinue compressions until the device is ready for use. The ratio for 2-person CPR in adults is 30:2.

Correct answer: D. "I should deliver chest compression at a rate of 100 per minute."

To maintain the best perfusion, it is recommended that compressions be given at a rate of 100 per minute in a ratio of 30 compressions to 2 breaths for 1-rescuer CPR. Children still are more likely to have had a respiratory arrest than a cardiac arrest and are more likely to respond to opening the airway and rescue breaths. Therefore, it is recommended that unless the collapse was witnessed, a sole rescuer should attempt 5 cycles of CPR before leaving to call for help. Using 2 to 3 fingers for chest compressions is recommended for infant CPR only. Abdominal thrusts are no longer recommended for unconscious victims.

Correct answer: A. Pupillary dilation.

The nurse should use mechanical force-back slaps and chest thrusts-in an attempt to dislodge the object. Blind finger sweeps are not appropriate in infants and children because the foreign body may be pushed back into the airway. Subdiaphragmatic abdominal thrusts are not used for infants aged 1 year or younger because of the risk of injury to abdominal organs. If the object is not visible when opening the mouth, time is wasted in looking for it. Action is required to dislodge the object as quickly as possible.

Correct answer: A. Use blind finger sweeps.

To deliver back slaps, the nurse should place the infant face down, straddled over the nurse’s arm, with the head lower than the trunk and the head supported. This position, together with the back slaps, facilitates dislodgment and removal of a foreign object and minimizes aspiration if vomiting occurs. Placing the infant with the head up and raised above the trunk would not aid in dislodging and removing the foreign object. In addition, this position places the infant at risk for aspiration should vomiting occur. Placing the head to one side may minimize the risk of aspiration. However, it would not help with removal of an object that is dislodged by the back slaps. Placing the infant with the head parallel to the nurse and supported at the buttocks is more appropriate for burping the infant.

Correct answer: D. Head up and raised above the trunk.

The nurse should first obtain a bag-mask device and assist with CPR by giving breaths at 2 breaths/15 compressions. The LPN is using correct technique by using two to three fingers on the chest to administer chest compressions. The encircling hand technique may also be used during two-person infant CPR. The heel of both hands is used for older children and adolescents. The compression rate is at least 100/min.

Correct answer: B. Heel of the hand.

Back slaps are delivered rapidly and forcefully with the heel of the hand between the infant’s shoulder blades. Slowly delivered back slaps are less likely to dislodge the object. Using the heel of the hand allows more force to be applied than when using the palm or the whole hand, increasing the likelihood of loosening the object. The fingertips would be used to deliver chest compressions to an infant younger than 1 year of age.

Correct answer: B. Observe the child closely.

Crying indicates that the airway obstruction has been relieved. No additional thrusts are needed. However, the child needs to be observed closely for complications, including respiratory distress. Tapping or shaking the shoulders is used initially to determine unresponsiveness in someone who appears unconscious. Delivering chest or back slaps could jeopardize the child’s now-patent airway. Because the obstruction has been relieved, there is no need to sweep the child’s mouth. Additionally, blind finger sweeps are contraindicated because the object may be pushed further back, possibly causing a complete airway obstruction.

Correct answer: A. Maintain the child in an undisturbed, upright position.

This child is in severe respiratory distress with the potential for complete airway obstruction. The nurse should refrain from disturbing the child at this time to avoid irritating the epiglottis and causing it to completely obstruct the child’s airway. The child may be intubated or undergo a tracheotomy. However, initially, the child should be kept as calm as possible with as little disruption as possible. Any attempt to restrain the child, draw blood, insert an IV, or examine her throat could result in total airway obstruction.

Correct answer: C. Avoid exposure to others with acute infections.

Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complementary therapies to reduce stress. Eight hours of rest and naps are good for spacing and pacing activity and rest.

Correct answer: D. Notify the primary care provider immediately.

The nurse may be having difficulty calming the child because the child is experiencing increasing respiratory distress. The normal respiratory rate for a 21-month-old is 25 to 30 breaths/min. The child’s respiratory rate is 48 breaths/min. Therefore the primary care provider needs to be notified immediately. Typically, acetaminophen is not given to a child unless the temperature is 101�F (38.6�C) or higher. Letting the toddler cry is inappropriate with croup because crying increases respiratory distress. Offering fluids every few minutes to a toddler experiencing increasing respiratory distress would do little, if anything, to calm the child. Also, the child would have difficulty coordinating breathing and swallowing, possibly increasing the risk of aspiration.

Correct answer: C. All of the above

Viral pharyngitis is treated with symptomatic, supportive therapy. Treatment includes use of a cool mist vaporizer, feeding a soft or liquid diet, and administration of acetaminophen for comfort. Viral infections do not respond to antibiotic administration. The child does not need to be on secretion precautions because viral pharyngitis is not contagious.

Correct answer: A. Assess the infant’s oxygen saturation.

In an infant with these symptoms, the first action by the nurse would be to obtain an oxygen saturation reading to determine how well the infant is oxygenating, which is valuable information for an infant having trouble breathing. Because the father probably can provide no other information, checking the heart rate would be the second action done by the nurse. Then the nurse would obtain the infant’s weight.

Correct answer: B. Refer the infant to the emergency department.

Based on the assessment findings of increased respiratory rate, retractions, and wheezing, this infant needs further evaluation, which could be obtained in an emergency department. Without a definitive diagnosis, administering a nebulizer treatment would be outside the nurse’s scope of practice unless there was a prescription for such a treatment. Sending the infant for a radiograph may not be in the nurse’s scope of practice. The findings need to be reported to a primary care provider who can then determine whether or not a chest radiograph is warranted. The infant is exhibiting signs and symptoms of respiratory distress and is too ill to send out with just instructions on cold care for the mother.

Correct answer: C. Offering small amounts of fluids frequently.

An infant with bronchiolitis will have increased respirations and will tire more quickly, so it is best and easiest for the infant to take fluids more often in smaller amounts. The parents also would be instructed to watch for signs of increased difficulty breathing, which signal possible complications. Healthy infants and even those with bronchiolitis should sleep in the supine position. Calling the clinic for an episode of vomiting would not be necessary. However, the parents would be instructed to call if the infant cannot keep down any fluids for a period of more than 4 hours. Parents would not need to record how much the infant drinks. Chest physiotherapy is not indicated because it does not help and further irritates the infant.

Correct answer: B. All of the above

RSV can be spread through direct contact such as kissing the face of an infected person, and it can be spread through indirect contact by touching surfaces covered with infected secretions. Handwashing is one of the best ways to reduce the risk of disease transmission. Palivizumab can prevent severe RSV infections but is only recommended for the most at-risk infants and children. RSV is typically contagious for 3 to 8 days. RSV frequently manifests in older children as cold-like symptoms. Infected school-age children frequently spread the virus to other family members.

Correct answer: A. A 1-year-old with a heart defect.

RSV may be spread through both direct and indirect contact. While contact and standard precautions should be employed, a measure to further decrease the risk of nosocomial infections is to avoid assigning the same nurse caring for an RSV client to a client at risk for infection. A private room is preferred, but if this is not an option the nurse should understand that children 2 years of age and younger are most at risk for RSV, especially if they have other chronic problems such as a heart defect. From an infection control perspective, pairing two clients with RSV is ideal. RSV infections are less likely to pose a serious problem in older children.

Correct answer: C. Contact the prescriber to request a prescription change.

Restarting an IV for one dose of a medication may not be in the infant’s best interest when the medication can be given in an alternate form. The prescriber should be contacted to determine IM or PO options. Rocephin may be given IM, but changing the route of a medication administration requires a prescription. Failing to complete an entire course of antibiotics contributes to the emergence of antibiotic resistance and would rarely be the best option.

Correct answer: B. "Reporting the error helps to identify system problems to improve client safety."

Client safety is enhanced when the emphasis on medication errors is to determine the root cause. All errors should be reported so systems can identify patterns that contribute to errors. Here, the similar names probably contributed to the error. The nurse who commits the error knows all the relevant information and is in the best position to report it. While the primary care provider should be notified, it is a nursing responsibility to report errors, not a primary care provider choice. Relating mistakes to a nurse’s position focuses on personal blame.

Correct answer: A. Both of the above

To ensure client safety in obtaining telephone prescriptions, the prescription must be received by a registered nurse. The nurse should write the prescription, read the prescription back to the primary care provider, and receive confirmation from the primary care provider that the prescription is correct. It is not necessary to ask the unit clerk to listen to the prescription, to require the primary care provider to come to the hospital to write the prescription on the chart, or to have the nursing supervisor cosign the telephone prescription.

Correct answer: C. Starting oxygen.

The infant is experiencing signs and symptoms of respiratory distress indicating the need for oxygen therapy. Sedation will not improve the infant’s respiratory distress and would likely cause further respiratory depression. If the infant’s respiratory status continues to decline, she may need to be transferred to the PICU. Oxygen should be the priority as it may improve the infant’s respiratory status. A chest CT is not indicated. However, a CXR would be another appropriate recommendation for this infant.

Correct answer: D. Apply pressure just above the catheter insertion site.

Direct pressure is the first measure that should be used to control bleeding. Taking the vital signs will not control the bleeding. This should be done while another person is being sent to notify the primary health care provider. The dressing can be reinforced after the bleeding has been contained.

Correct answer: D. Explain that the child will need a large bandage after the procedure.

The catheter insertion site will be covered with a bandage. This is important for preschool children to know as they are very concerned about bodily harm. The best time to prepare a preschool child for an invasive procedure is the night before. Bringing a favorite toy to the hospital will help decrease the child’s anxiety. To prevent bleeding, the child will be expected to keep the extremity straight for 4 to 6 hours after the procedure, either in bed or on the parent’s lap.

Correct answer: D. Catheter placed in the right femoral vein.

In children, cardiac catheterization usually involves a right-sided approach because septal defects permit entry into the left side of the heart. The catheter is usually inserted into the femoral vein through a percutaneous puncture. Echocardiography involves the use of ultra-high-frequency sound waves. A cutdown procedure is rarely used. The catheterization is usually performed under local, not general, anesthesia with sedation.

Correct answer: A. Digoxin enables the heart to pump more effectively with a slower and more regular rhythm.

Digoxin’s effect is to slow the rate of the electrical conduction through the heart and increase the strength of the heart’s contraction. Signs of toxicity include anorexia and decreased heart rate. Digoxin should be taken 1 hour before meals or 2 hours after meals in order to obtain better absorption of the drug. If the child vomits within 15 minutes of administration, the dose should not be repeated because it is not known how much of the medication has been absorbed.

Correct answer: C. Alterations in levels of consciousness.

Clinical signs of low cardiac output and poor tissue perfusion include pale, cool extremities, cyanosis or mottled skin, delayed capillary refill, weak, thready pulses, oliguria, and alterations in level of consciousness. An adequate urine output for a child over 1 year should be 1 mL/kg/h. Therefore 60 mL/4 h is satisfactory. Strong peripheral pulses indicate adequate cardiac output. Drainage from the chest tube should show fluctuation in the drainage compartment of the chest drainage system. The fluid level normally fluctuates as proof that the apparatus is airtight. On about the 3rd postoperative day, the fluctuation ceases indicating the lungs have fully expanded.

Correct answer: D. Place the child in a knee-to-chest position.

The child is experiencing a tet or hypoxic episode. Therefore the nurse should place the child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from the lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of Fallot. As a result, the blood then entering the systemic circulation has higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position in the crib, or the mother learns to put the infant over her shoulder while holding the child in a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may need a sedative. Once the child is in the position, the nurse may assess for an irregular heart rate and rhythm. Explaining to the child that it will only hurt for a short time does nothing to alleviate the hypoxia.

Correct answer: D. Building the teaching on the child’s current level of knowledge.

Before developing any teaching program for a child, the nurse’s first step is to assess the child to determine what is already known. Most older preschool children have some understanding of a condition present since birth. However, the child’s interest will soon be lost if familiar material is repeated too often. The nurse can then organize the information in a sequence, because there are several steps to be demonstrated. These exercises do not require the use of equipment. The nurse should judge the amount and complexity of the information to be provided, based on the child’s current knowledge and response to teaching.

Correct answer: D. Administrating furosemide (Lasix) to decrease systemic venous congestion.

Pulmonary stenosis can cause right-sided CHF, resulting in venous congestion. Removing accumulated fluid is a primary goal of treatment in right-sided CHF. Lasix is used to reduce venous congestion. It is important to educate the family about signs and symptoms of CHF but treating the client’s CHF is the priority. Lovenox is an anticoagulant and will not help improve left ventricular contractility. It is important to assess vital signs frequently in the child with CHF but assessments do not treat the problem.

Correct answer: B. Record the urine output in the chart.

Urine output for an infant weighing 9 kg should be 1 mL/kg/h. 16 mL of urine output is more than adequate for 1 hour so the nurse should record the output in the chart. There is no reason to notify the primary health care provider regarding adequate urine output. The infant has adequate output so there is no need for a fluid bolus. A fluid bolus could also cause the infant to become fluid overloaded, increasing the workload on the heart. There is no information in the question indicating that the child is hypervolemic.

Correct answer: B. Notify all health care providers before invasive procedures for the next 6 months.

Children who have undergone open heart surgery with a patch are at risk for infection, especially subacute bacterial endocarditis (SBE), for the first 6 months following surgery. The newest evidence-based guidelines suggest that once the patch has epithelialized, these precautions are no longer necessary. Therefore, parents are instructed about SBE precautions including the need to notify providers before invasive procedures so antibiotics can be prescribed for that time period. Having the child drink a very large amount of water may lead to fluid overload. Children gear their rest schedule to their activities making it unnecessary to schedule frequent rest periods. Bananas and citrus fruit are high in potassium, but there is no evidence provided that the child has an elevated serum potassium requiring restriction.

Correct answer: D. Play therapy.

The child is exhibiting regression. During periods of stress, children frequently revert to behaviors that were comforting in earlier developmental stages; play therapy is one way to help the child cope with the stress. Teaching a new skill most likely would add more stress. Parents should be instructed to praise positive behaviors and ignore regressive behaviors rather than calling attention to them through encouragement or discouragement. Having someone else hold the child does not encourage coping with the stress or promoting appropriate development

Correct answer: D. "This may be how your child expresses feeling a need for attention."

According to Erikson, the central psychosocial task of a preschooler is to develop a sense of industry versus guilt. Any environmental situation may affect the child. In this situation the sibling is probably feeling less attention from the mother and trying to resolve the conflict in an inappropriate way. Three-year-olds are usually active and outgoing. These behaviors represent a change. Data are not sufficient to suggest the child has been exposed to a sexual experience. Symptoms of depression would include withdrawal and fatigue.

Correct answer: B. Report the heart rate to the primary health care provider.

The child’s heart rate of 150 bpm is significantly above its rate at the time of his admission. The nurse must notify the primary health care provider. The increase in heart rate may indicate carditis, a possible complication of rheumatic fever that can cause serious and life-long effects on the heart. The primary health care provider will intervene with medication and cardiac monitoring. While lotion may soothe the itching, the most important action for the nurse is to notify the primary health care provider of the increased heart rate. Splinting will not help the inflammation that is causing the painful joints. The painful joints migrate and will subside with time. The temperature is not elevated at this time, and does not require intervention.

Correct answer: D. Provide for adequate periods of rest between activities.

The nurse should teach the parents to provide for sufficient periods of rest to decrease the client’s cardiac workload. The client’s condition does not warrant close observation unless cardiac complications develop. The child’s activity level will be based on the results of the sedimentation rate, c-reactive protein, heart rate, and cardiac function. The family does not need to be with the client 24 hours a day unless carditis develops and his condition deteriorates.

Correct answer: C. "I hear ringing in my ears."

Tinnitus is an adverse effect of prolonged aspirin therapy and the child should be examined by a health care provider for hearing loss. Itchy skin commonly accompanies the rash associated with rheumatic fever and the nurse can encourage lotion use. The nurse teaches clients to take aspirin with food or milk to avoid abdominal discomfort. The nurse can also address the fact that coughing after ingesting aspirin can be caused by inadequate fluid intake during administration.

Correct answer: B. The resting heart rate is between 60 and 100 bpm.

During the acute phase of rheumatic fever, the heart is inflamed and every effort is made to reduce the work of the heart. Bed rest with limited activity is necessary to prevent heart failure. Therefore, the most reliable indicator that activity restriction has been effective is a resting heart rate between 60 and 100 bpm, normal for a 7-year-old child. No permanent damage to the joints occurs with rheumatic fever. The chorea movements associated with rheumatic fever are self-limited and usually disappear in 1 to 3 months. They are unrelated to activity restrictions. Subcutaneous nodules that occur over joint surfaces also resolve over time with no treatment. Therefore, they are not appropriate for evaluating the effectiveness of activity restrictions.

Correct answer: C. Heart murmur.

In rheumatic fever, the connective tissue of the heart becomes inflamed, leading to carditis. The most common signs of carditis are heart murmurs, tachycardia during rest, cardiac enlargement, and changes in the electrical conductivity of the heart. Heart murmurs are present in about 75% of all clients during the first week of carditis and in 85% of clients by the third week. Signs of carditis do not include hypotension or chest pain. The client may have a rapid pulse, but it is usually not irregular.

Correct answer: A. Normal activity during waking hours.

above-average pulse rate that is out of proportion to the degree of activity is an early sign of heart failure in a client with rheumatic fever. The sleeping pulse is used to determine whether the mild tachycardia persists during sleep (inactivity) or whether it is a result of daytime activities. The environmental temperature would need to be quite warmer before it could influence the heart rate. Digitalis lowers the heart rate, so the rate would be decreased during the daytime.

Correct answer: D. Using a bed cradle to avoid the weight of bed linens on joints.

For a child with arthritis associated with rheumatic fever, the joints are usually so tender that even the weight of bed linens can cause pain. Use of a bed cradle is recommended to help remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not positioned in extension, to ensure that they remain functional. Applying gentle traction to the joints is not recommended because traction is usually used to relieve muscle spasms, not typically associated with rheumatic fever. Supporting the body in good alignment and changing the client’s position are recommended, but these measures are not likely to relieve pain.

Correct answer: D. Monitoring intake and output every hour.

Cardiac status must be monitored carefully in the initial phase of KD because the child is at high risk for congestive heart failure (CHF). Therefore, the nurse needs to assess the child frequently for signs of CHF, which would include respiratory distress and decreased urine output. Vital signs would be obtained more often than every 6 hours because of the risk of CHF. Although minimizing skin discomfort would be important, it does not take priority over monitoring the child’s hourly intake and output. Passive range-of-motion exercises would be done if the child develops arthritis.

Correct answer: A. Both of the above

Aspirin needs to be stopped because of its possible link to Reye syndrome. Additionally, the parents need to watch for signs and symptoms of influenza. Children with influenza frequently present with fever, cold symptoms, and gastrointestinal symptoms. Increasing the child’s fluid intake and weighing the child daily are not needed at this time because the child is not ill. Keeping the child home from school is not necessary, because the child is not ill and has already been exposed.