81.
When obtaining the initial health history from a 10-year-old child with abdominal pain and suspected appendicitis, which of the following questions would be most helpful in eliciting data to help support the diagnosis?■ 1. “Where did the pain start?”
■ 2. “What did you do for the pain?”
■ 3. “How often do you have a bowel movement?”
■ 4. “Is the pain continuous, or does it let up?”
82.
When developing the plan of care for a school- age child with a suspected diagnosis of appendicitis who is complaining of severe abdominal pain, which of the following measures should the nurse expect to include in the child’s plan of care?■ 1. Application of a heating pad.
■ 2. Insertion of a rectal tube.
■ 3. Application of an ice bag.
■ 4. Administration of an intravenous narcotic.
83.
Which of the following assessment fi ndings should alert the nurse to suspect appendicitis in a male adolescent complaining of severe abdominal pain?■ 1. Abdomen appears slightly rounded.
■ 2. Bowel sounds are heard twice in 2 minutes.
■ 3. All four abdominal quadrants reveal tympany.
■ 4. The client demonstrates a cremasteric refl ex.
84.
An adolescent male client scheduled for an emergency appendectomy is to be transferred directly from the emergency room to the operating room. Which of the following statements by the cli- ent should the nurse interpret as most signifi cant?■ 1. “All of a sudden it doesn’t hurt at all.”
■ 2. “The pain is centered around my navel.”
■ 3. “I feel like I’m going to throw up.”
■ 4. “It hurts when you press on my stomach.”
85.
Which of the following should be the priority assessment for an adolescent on return to the nurs- ing unit after an appendectomy?■ 1. The dressing on the surgical site.
■ 2. Intravenous fl uid infusion site.
■ 3. Nasogastric (NG) tube function.
■ 4. Amount of pain.
86.
An adolescent who has had an appendec- tomy and developed peritonitis has nausea. Which of the following should the nurse do fi rst?■ 1. Administer an antiemetic.
■ 2. Irrigate the nasogastric (NG) tube.
■ 3. Notify the surgeon.
■ 4. Take the blood pressure.
87.
When developing the postoperative plan of care for an adolescent who has undergone an appen- dectomy for a ruptured appendix, in which of the following positions should the nurse expect to place the client during the early postoperative period?■ 1. The semi-Fowler’s position.
■ 2. Supine.
■ 3. Lithotomy position.
■ 4. Prone.
92.
The health care team wishes to establish a policy regarding sleep positions for infants with gastroesophageal refl ux (GER). The fi rst step should be to search for:■ 1. Policies from other hospitals.
■ 2. Data from retrospective studies.
■ 3. Published national standards.
■ 4. Expert opinions.
93.
The nurse is assisting another member of the health care team who is placing a peripherally inserted catheter in a 10-year-old with peritonitis from a ruptured appendix. The family is present in the treatment room to support the child. The nurse observes the other team member has contaminated a sterile glove. The nurse should:■ 1. Discuss the incident with the team member after the event.
■ 2. Report the incident to the nursing unit manager.
■ 3. Tell the team member the glove is contaminated.
■ 4. Ask the family to leave before confronting the team member.
94.
The hospital is responding to a mass casualty disaster with adult and pediatric victims. After real- locating staff, the charge nurse on the pediatric fl oor should:■ 1. Ask parents to leave to free up the parent sleep areas for incoming victims.
■ 2. Review the census for clients that are candi- dates for early discharge.
■ 3. Initiate paper charting back-up.
■ 4. Change taking all vital signs to every 8 hours.
95.
Eight hours ago, an infant withHirschsprung’s disease had surgery to create a colos- tomy. Which of the following fi ndings should alert the nurse to notify the physician immediately?
■ 1. A 3-cm increase in abdominal circumference.
■ 2. Periods of occasional fussiness.
■ 3. Absence of bowel sounds since surgery.
■ 4. Evidence of the infant’s returning appetite.
88.
Which of the following is a normal response from an adolescent who has just returned to her room after an appendectomy?■ 1. “I’ll need plastic surgery for this scar.”
■ 2. “I’m worried about the size of my scar.”
■ 3. “I don’t want to have any pain.”
■ 4. “What will my boyfriend say about the scar?”
89.
Which of the following client actions should the nurse judge to be a healthy coping behavior for a male adolescent after an appendectomy?■ 1. Insisting on wearing a T-shirt and gym shorts rather than pajamas.
■ 2. Avoiding interactions with other adolescents on the nursing unit.
■ 3. Refusing to fi ll out the menu, and allowing the nurse to do so.
■ 4. Not taking telephone calls from friends so he can rest.
90.
The nurse prepares to teach an adolescent scheduled for an appendectomy about what to expect. The adolescent says, “I would rather look this up on the Internet.” The nurse should:■ 1. Explain that completing a teaching checklist is required by the hospital.
■ 2. Help the client fi nd information on the Internet.
■ 3. Provide the client with written information instead.
■ 4. Explain that information found on the Inter- net cannot be trusted.
Managing Care Quality and Safety
91.
The health care team has noticed an increase in I.V. infi ltrations on the pediatric fl oor. As part of a Plan, Do, Study, Act quality improvement plan the team should do the following in which order?2. Decide to monitor I.V. gauges.
3. Perform chart audits.
4. Write a new I.V. insertion policy.
1. Analyze the data.
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infant. There is no need to keep the infant’s fi ngers out of the mouth preoperatively. The fi ngers will not harm the defect or cause an infection.
CN: Reduction of risk potential;
CL: Synthesize
3.
1. An infant with a cleft lip and palate typi- cally swallows large amounts of air while being fed and therefore should be burped frequently. The soft palate defect allows air to be drawn into the pharynx with each swallow of formula. The stomach becomes distended with air, and regurgitation, possibly with aspiration, is likely if the infant is not burped fre- quently. Feeding frequently, even in small amounts, would not prevent swallowing of large amounts of air. A nipple placed in the back of the mouth is likely to cause the infant to gag and aspirate. Hold- ing the infant in a lying position during feedings can also lead to regurgitation and aspiration of formula.The infant should be fed in an upright position.
CN: Physiological adaptation;
CL: Synthesize
4.
4. Half-strength hydrogen peroxide is recom- mended for cleaning the suture line after cleft lip repair. The bubbling action of the hydrogen perox- ide is effective for removing debris. Normal saline also may be used. Mouthwashes frequently contain alcohol, which can be irritating. Also, mouthwashes are not as effective in removing debris as half- strength peroxide solutions are. Povidone-iodine solution is not used because the iodine contained in the solution can be absorbed through the skin, lead- ing to toxicity. A mild antiseptic solution has some antibacterial properties but is ineffective in remov- ing suture-line debris.CN: Physiological adaptation; CL: Apply
5.
1. To keep the infant from disturbing the suture line by placing fi ngers or other objects in the mouth, either intentionally or accidentally, the restraints should be in place at all times. They should be removed for a short period, however, so that the underlying skin can be checked for any redness or breakdown. While the restraints are removed, the parents should be instructed to manu- ally restrain the hands and arms.CN: Reduction of risk potential;
CL: Evaluate
6.
3. The optimal time for cleft palate repair depends on many factors. However, it is best done before speech develops and the child learns faulty speech habits as a result of the defect, usu- ally before 12 to 15 months of age. Tooth eruption usually begins at about 6 months of age. The child should weigh about 10 kg (22 lb) at 6 months, but the important consideration is to schedule surgery before speech patterns begin to develop. An infantAnswers, Rationales, and Test Taking Strategies
The answers and rationales for each question follow below, along with keys ( ) to the client need (CN) and cognitive level (CL) for each question. Use these keys to further develop your test-taking skills.
For additional information about test-taking skills and strategies for answering questions, refer to pages 10–21, and pages 25–26 in Part 1 of this book.
The Client with Cleft Lip and Palate
1.
4. Apply elbow restraints.
2. Maintain suffi cient fl uid and caloric intake.
3. Provide emotional comfort to the child.
5. Teach the parents proper feeding methods.
1. Maintain a clear and adequate airway.
The nurse should fi rst ensure that the child has a patent airway, because swelling and secretions fol- lowing surgery can block the airway. Next, the nurse should restrain the infant’s arms to keep him from rubbing with his hands or fi ngers on the incision line, which could cause scarring and damage to the incision. The child will need adequate nourishment and fl uids as soon as he recovers from anesthesia.
The nurse must comfort the child, and try to prevent him from crying as much as possible, because crying puts a strain on the suture line and can cause scar- ring. The nurse should involve the parents in the child’s care and feeding as soon as possible after she has assessed the child’s ability to safely ingest his feedings.
CN: Physiological adaptation;
CL: Synthesize
2.
3. Before corrective surgery for a cleft lip, the infant needs to consume formula. Methods for feed- ing may need to be adjusted to fi t the infant’s needs, because the infant with a cleft lip experiences a decreased ability to suck, which interferes with the infant’s ability to compress the nipple. A spe- cial feeder may be used to feed the infant to ensure adequate caloric intake. Problems with infection and skin integrity in the mouth are uncommon because the areas of the defect are not open areas. Although crying may cause the infant to swallow more air because of the defect, crying poses no harm to theBillings_Part 2_Chap 2_Test 4.indd 238
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11.
2. Although a TEF can include several different structural anomalies, the most common type involves a blind upper pouch and a fi stula from the esophagus into the trachea. Other types include a blind pouch at the end of the esophagus with no connection to the trachea and a normal trachea and esophagus with an opening that connects them. A tightened muscle below the stomach and projectile vomiting of normal amounts of formula are characteristic of pyloric steno- sis. Aganglionic megacolon is a lack of autonomic parasympathetic ganglion cells in a portion of the lower intestine. Gastroschisis occurs when the bowel herniates through a defect in the abdominal wall and no membrane covers the exposed bowel.CN: Physiological adaptation;
CL: Evaluate
12.
2. With a TEF, overfl ow of secretions into the larynx leads to laryngospasm. This obstruc- tion to inspiration stimulates the strong contrac- tion of accessory muscles of the thorax to assist the diaphragm in breathing. This produces substernal retractions. The laryngospasm that occurs with a TEF resolves quickly when secretions are removed from the oropharynx area. A brassy cough is related to a relatively constant laryngeal narrowing, usu- ally caused by edema. It is not an indication of the need to suction. A decreased activity level and an increased respiratory rate in an infant with a TEF are usually the result of hypoxia, a relatively long-term and constant phenomenon in infants with a TEF.CN: Physiological adaptation;
CL: Analyze
13.
1. The best way to prevent air from enter- ing the stomach when feeding an infant through a gastrostomy tube is to open the clamp after all the formula has been placed in the syringe barrel. Doing so prevents air from mixing with the formula and thus being introduced into the stomach. Pouring all the formula into the barrel after opening the clamp, maintaining a continuous fl ow of formula down the side of the barrel after unclamping the tube, and allowing a small amount of formula to enter the stomach before adding more formula to the barrel permit air to enter the stomach.CN: Reduction of risk potential;
CL: Apply
14.
4. The nurse can help meet the psychological needs of an infant being fed through a gastrostomy tube by rocking the infant after a feeding. The infant soon learns to associate eating with a pleasurable experience and learns to trust the caregiver. Rock- ing the infant will not promote peristalsis or prevent regurgitation. Holding the baby will not relieve pres- sure on the surgical site. However, holding the child right after feeding promotes comfort and pleasure.CN: Psychosocial adaptation; CL: Apply may learn to start drinking from a cup as early as 6 to
7 months of age, possibly up to the fi rst birthday.
CN: Physiological adaptation; CL: Apply
7.
1. A cup is the preferred drinking or eating utensil after repair of a cleft palate. At the age when repair is done, the child is ordinarily able to drink from a cup. Use of a cup avoids having to place a utensil in the mouth, which would increase the potential for injury to the suture lines.CN: Physiological adaptation;
CL: Synthesize
8.
3. Immediately after a surgical repair of a cleft palate, the child is placed on the abdomen with the head turned to the side to lessen the chance of aspiration by allowing secretions to drain out. Posi- tioning the child on the back places the child at risk for aspiration should any regurgitation or vomiting occur, even in low Fowler’s position with the head to the side or in reverse Trendelenburg position with the head tilted forward.CN: Physiological adaptation;
CL: Synthesize
The Client with Tracheoesophageal Fistula
9.
3. The drooling and excessive mucus pro- duction is highly suggestive of a tracheoesopha- geal fi stula. The initial diagnosis is made when an orogastric catheter cannot be passed to the stomach.A lactation consult would be warranted only after determining feedings were safe to continue. While cyanosis can be a sign of sepsis and hypoglycemia, the cyanosis is most likely related to the excessive secretions and airway patency.
CN: Management of care; CL: Synthesize
10.
1. The parents of children born with defects often have feelings of guilt and ask what they might have done to cause the condition or how they might have avoided it. It is important to allow parents to express their feelings and to accept these feelings as normal reactions. Explaining that the parents are not at fault would not be appropriate until they have dealt with their feelings of guilt. Encouraging long- term planning generally is of little benefi t to parents who are emotionally distraught. Additionally, the parents may interpret this as ignoring their feelings and confi rming that they played a role in causing their child’s anomaly. Urging the parents to visit their infant as often as possible would generally be of little help and could appear to the parents as though they are being “talked out” of their feelings.CN: Psychosocial adaptation;
CL: Synthesize
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Therefore, this child probably has a good chance of being potty trained and will not need to wear protective pads. Extra fl uids and a high-fi ber diet are not required to prevent constipation. Children with high anorectal anomalies may or may not achieve continence.
CN: Physiological adaptation;
CL: Evaluate
20.
3. After surgical repair for an imperforate anus, the infant should be positioned either supine with the legs suspended at a 90-degree angle or on either side with the hips elevated to prevent pres- sure on the perineum. A neonate who is placed on the abdomen pulls the legs up under the body, which puts tension on the perineum, as does positioning the neonate on the back with the legs extended straight out.CN: Physiological adaptation;
CL: Synthesize
21.
3. The neonate responds to pain with total body movement and brief, loud crying that ceases with distraction. After age 6 months, an infant reacts to pain with intense physical resistance and tries to escape by rolling away. A toddler reacts to pain by withdrawing the affected part.CN: Health promotion and maintenance;
CL: Apply
22.
2. Encouraging the parents to hold their neonate promotes parent–infant attachment. Parent–infant bonding is based on a relationship that begins when the parent fi rst touches the infant. Both the parents and the infant have predictable steps that they go through in this process. Explaining that the parents can visit at any time promotes bonding only if they do visit with, talk to, and hold the newborn.
Asking the parents to help monitor intake and output at this time may be too anxiety-producing, thus interfering with bonding. Helping the parents plan for the infant’s discharge involves them in the newborn’s care and is important. However, it is not the fi rst step in the development of bonding.
CN: Psychosocial adaptation;
CL: Synthesize
The Client with Pyloric Stenosis
23.
3. The vomitus of an infant with hypertro- phic pyloric stenosis contains gastric contents, mucus, and streaks of blood. The vomitus does not contain bile or stool because the pyloric constriction is proximal to the ampulla of Vater.CN: Physiological adaptation;
CL: Analyze
15.
4. When initiating oral feedings after surgical repair of a TEF, it is best to follow a plan of care in conjunction with observation of the infant’s needs and behavior. When the infant’s needs and behavior are overlooked, plans are likely to be unsatisfactory and are more likely to meet the nurse’s needs rather than the infant’s needs. After a surgical procedure, infants initially tolerate small amounts of fl uids offered more frequently better than larger amounts offered less often. Smaller amounts cause less bloat- ing as the infant becomes used to feeding again.Although infants accept feedings more readily from their mother or from someone who feeds the infant repeatedly, the priority is to meet the infant’s nutri- tional needs based on the infant’s behavior.
CN: Basic care and comfort; CL: Create