5.
1, 4, 6, 7. To achieve optimal therapeutic levels, digoxin should be given at regular intervals without variation, usually every 12 hours. Vomiting and poor feeding are signs of toxicity. If more than two consecutive doses are missed, interventions may be needed to assure therapeutic drug levels.Accidental ingestion of digoxin may be life-threat- ening and parents should be advised on safe storage practices. The medication should not be mixed with any other fl uid as refusal may result in inaccurate intake of the medication. Taking make-up doses, or taking the medication at times other than scheduled, may adversely affect serum levels. Parents should be advised to call poison control in the case of any accidental medication overdose.
CN: Pharmacological and parenteral therapies; CL: Create
6.
1. 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
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not encourage coping with the stress or promoting appropriate development.
CN: Psychosocial adaptation;
CL: Synthesize
14.
2. According to Erikson, the central psycho- social 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 confl ict in an inappropriate way. Three-year-olds are usually active and outgo- ing. These behaviors represent a change. Data are not suffi cient to suggest the child has been exposed to a sexual experience. Symptoms of depression would include withdrawal and fatigue.CN: Psychosocial adaptation;
CL: Synthesize
The Client with Rheumatic Fever
15.
1. The child’s heart rate of 150 bpm is sig- nifi cantly above its rate at the time of his admission.The nurse must notify the physician. The increase in heart rate may indicate carditis, a possible com- plication of rheumatic fever that can cause serious and life-long effects on the heart. The physician will intervene with medication and cardiac monitor- ing. While lotion may soothe the itching, the most important action for the nurse is to notify the physi- cian of the increased heart rate. Splinting will not help the infl ammation 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.
CN: Physiological adaptation;
CL: Synthesize
16.
3. The nurse should teach the parents to pro- vide for suffi cient periods of rest to decrease the cli- ent’s cardiac workload. The client’s condition does not warrant close observation unless cardiac com- plications 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 condi- tion deteriorates.
CN: Basic care and comfort;
CL: Synthesize
17.
1. 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 to be provided, based on the child’s current knowl-edge and response to teaching.
CN: Physiological adaptation;
CL: Synthesize
10.
2. With a low cardiac output and subsequent poor tissue perfusion, signs and symptoms would include pale, cool extremities; cyanosis; weak, thready pulses; delayed capillary refi ll; and decrease in level of consciousness.CN: Physiological adaptation;
CL: Analyze
11.
1. Children who have undergone open heart surgery with a patch are at risk for infection, espe- cially subacute bacterial endocarditis (SBE), for the fi rst 6 months following surgery. The newest evidence-based guidelines suggest once the patch has epithelialized, these precautions are no longer necessary. Therefore, parents are instructed about SBE precautions including the need to notify pro- viders 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 fl uid overload. Children gear their rest schedule to their activities making it unnecessary to schedule fre- quent 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.CN: Physiological adaptation;
CL: Synthesize
12.
1. Because of the hemodynamic changes that occur with open heart surgery repair, particu- larly with septal defects, transient congestive heart failure may develop. Therefore, the child’s sodium intake typically is restricted to 2 to 3 g/day. Activity restrictions are inappropriate. Typically the child is encouraged to walk the halls and unit. Risk for infection after the repair is the same as any post- operative client, therefore isolation is not neces- sary. The child may be placed in a room with other children who are not contagious. Visitors are not restricted unless the pediatric unit has restrictive visiting policies.CN: Physiological adaptation;
CL: Synthesize
13.
2. The child is exhibiting regression. Dur- ing periods of stress, children frequently revert to behaviors that were comforting in earlier develop- mental 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 discourage- ment. Having someone else hold the child doesBillings_Part 2_Chap 2_Test 3.indd 221
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or whether it is a result of daytime activities. The environmental temperature would need to be quite warmer before it could infl uence the heart rate.
Digitalis lowers the heart rate, so the rate would be decreased during the daytime.
CN: Reduction of risk potential;
CL: Analyze
22.
4. 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 recom- mended because traction is usually used to relieve muscle spasms, not typically associated with rheumatic fever. Supporting the body in good align- ment and changing the client’s position are recom- mended, but these measures are not likely to relieve pain.
CN: Reduction of risk potential;
CL: Synthesize
The Client with Kawasaki Disease
23.
2. Cardiac status must be monitored carefully in the initial phase of KD because the child is at high risk for congestive heart failure (CHF). There- fore, 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 is 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.CN: Physiological adaptation; CL: Create
24.
2, 4. Aspirin needs to be stopped because of its possible link to Reye’s syndrome. Additionally, the parents need to watch for signs and symptoms of infl uenza. Children with infl uenza frequently pres- ent with fever, cold symptoms, and gastrointestinal symptoms. Increasing the child’s fl uid 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.CN: Reduction of risk potential;
CL: Synthesize
25.
3. One of the characteristics of children with KD is irritability. They are often inconsolable. Plac- ing the child in a quiet environment may help quiet food or milk to avoid abdominal discomfort. Thenurse can also address the fact that coughing after ingesting aspirin can be caused by inadequate fl uid intake during administration.
CN: Pharmacological and parenteral therapies; CL: Analyze
18.
2. The nurse should encourage and plan to provide periods of rest for the child with rheumatic fever and carditis to allow the heart to rest. The par- ents should be made to feel that they can come and go as they need to. The child is not in critical condi- tion, so the parents do not need to be present at the child’s bedside continuously. The child should be allowed to participate in nonstrenuous activities that avoid overtaxing the heart, thus allowing the heart time to rest. There is no reason to encourage the child to eat as much as possible; in fact, overeat- ing should be discouraged because it taxes the heart muscle.CN: Physiological adaptation; CL: Create
19.
2. During the acute phase of rheumatic fever, the heart is infl amed and every effort is made to reduce the work of the heart. Bedrest with limited activity is necessary to prevent heart failure. There- fore, the most reliable indicator that activity restric- tion 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 rheu- matic fever. The chorea movements associated with rheumatic fever are self-limited and usually disap- pear in 1 to 3 months. They are unrelated to activity restrictions. Subcutaneous nodules that occur over joint surfaces also resolve over time with no treat- ment. Therefore, they are not appropriate for evalu- ating the effectiveness of activity restrictions.CN: Physiological adaptation;
CL: Evaluate
20.
1. In rheumatic fever, the connective tissue of the heart becomes infl amed, leading to carditis.The most common signs of carditis are heart mur- murs, 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 fi rst week of carditis and in 85% of clients by the third week. Signs of cardi- tis do not include hypotension or chest pain. The client may have a rapid pulse, but it is usually not irregular.
CN: Physiological adaptation;
CL: Analyze
21.
2. An 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)Billings_Part 2_Chap 2_Test 3.indd 222
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29.
3. Characteristic sickle cells tend to cause“log jams” in capillaries. This results in poor cir- culation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of the red blood cells.
The erythrocytes are sickle-shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum biliru- bin concentrations are associated with jaundice, not sickle cell disease.
CN: Physiological adaptation; CL: Apply
30.
4. Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of a newborn’s hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin S begins to replace the fetal hemoglobin. The gene for sickle cell disease is transmitted at the time of conception, not passed through the placenta. Some hemoglobin S is produced by the fetus near term.The fetus produces all its own hemoglobin from the earliest production in the fi rst trimester. Passive immunity conferred by maternal antibodies is not related to sickle cell disease, but this transmission of antibodies is important to protect the infant from various infections during early infancy.
CN: Physiological adaptation;
CL: Apply
31.
3. For the child in sickle cell crisis, Pain is the priority nursing diagnosis because the sickled cells clump and obstruct the blood vessels, lead- ing to occlusion and subsequent tissue ischemia.Although Ineffective coping may be important, it is not the priority. Decreased cardiac output is not a problem with this type of vasoocclusive crisis.
Typically, a sickle cell crisis can be precipitated by a fl uid volume defi cit or dehydration.
CN: Physiological adaptation;
CL: Analyze