1.
2. Drain cleaner almost always contains lye, which can burn the mouth, pharynx, and esophagus on ingestion. The nurse would be prepared to assist with a tracheostomy, which may be necessary because of swelling around the area of the larynx. An emetic is contraindicated because, as the substance burns on ingestion, so too would it burn when vomiting. Addi- tionally, the mucosa becomes necrotic and vomiting could lead to perforations. Gastric lavage is contrain- dicated because the mucosa is burned from the inges- tion of the caustic lye, causing necrosis. Gastric lavage also could lead to perforation of the necrotic mucosa.Insertion of an indwelling urinary (Foley) catheter would be indicated after the measures to remove the caustic substance have been started.
CN: Reduction of risk potential;
CL: Apply
2.
3. As the burn from the lye ingestion heals, scar tissue develops and can lead to esophageal strictures, a common complication of lye inges- tion. Tracheal stenosis would occur if the child had vomited and aspirated. Tracheal varices do not commonly occur after the ingestion of lye or other substances. Although very rare, esophageal diver- ticula may occur. Diverticula are commonly found in the colon of adults.CN: Physiological adaptation;
CL: Analyze
3.
4. Administer activated charcoal.
1. Draw acetaminophen serum levels.
3. Administer acetylcysteine (Acetadote IV).
2. Attempt to determine the exact time and amount of drug ingested.
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The Client with Celiac Disease
10.
2. Celiac disease is a disorder involving intolerance to the protein gluten, which is found in wheat, rye, oats, and barley. The stools of a child with celiac disease are characteristically malodorous, pale, large (bulky), and soft (loose). Excessive fl atus is common, and bouts of diarrhea may occur. Dark urine is commonly associated with concentrated urine, such as when a child has dehydration. The belly of a child with celiac disease, a malabsorption disorder, typically is protuberant. A small belly may be associated with a child who is thin. Short stature is not associated with this malabsorption disorder.CN: Physiological adaptation;
CL: Analyze
11.
2. The intestines of a child with celiac disease fi ll with accumulated undigested food and fl atus, causing the characteristic protuberant abdomen.Celiac disease is not usually associated with any liver dysfunction, including poor liver functioning leading to liver enlargement. Tender inguinal lymph nodes are often associated with an infection. Periorbital edema, swelling around the eyes, is associated with nephritis.
CN: Physiological adaptation;
CL: Analyze
12.
3. Damage to intestinal mucosa in celiac dis- ease is caused by gliadin, a part of the protein found in wheat, rye, barley, and oats. Foods containing these grains must be eliminated entirely from the diet of children with celiac disease. Foods contain- ing rice and corn are a good substitute. Although an adequate intake of milk is important for any child, children with celiac disease do not need an increased milk intake.CN: Physiological adaptation;
CL: Evaluate
13.
1, 2, 3. Children with celiac disease should avoid foods containing the protein gluten, which is found in wheat, oats, rye, and barley grains. Chil- dren are allowed to eat foods containing rice or corn.Labels need to be read carefully since these glutens are used as fi llers in many food items including many types of chocolate candy and hot dogs.
CN: Reduction of risk potential;
CL: Evaluate
14.
3. The child with celiac disease should not eat foods containing wheat, oats, rye, or barley.Foods containing rice, such as Rice Chex cereal, or corn are appropriate. Because Cheerios are made from oats, this cereal should be avoided. Pancakes and waffl es are made from fl our that typically is derived from wheat and therefore should be avoided.
CN: Physiological adaptation;
CL: Synthesize recommended for this age group, so more nutritional
information would need to be obtained. Temper tan- trums are characteristic of 18-month-old children as they try to assert themselves. Determining whether the child is smaller than other children the same age requires measuring height and weight and plot- ting them on growth charts. In addition, inadequate growth could be a result of numerous causes, such as genetics, chronic illness, or chronic drug use (e.g., prednisone).
CN: Physiological adaptation;
CL: Evaluate
7.
3. Healthy People 2010 has set a goal of eliminating blood lead levels of greater than 10 mcg/dL in children age 1 to 5 years of age. The CDC recommends that the treatment for children with lead levels between 10 and 14 mcg/dL should include family lead education, follow-up testing, and a social service consultation if needed. Wait- ing 6 months for a follow-up screening is too long because the effects of lead are irreversible.Oral chelation therapy is not begun until levels approach 45 mcg/dL. There is no such thing as a
“normal” lead level because there is no benefi cial action in the body.
CN: Safety and infection control;
CL: Synthesize
8.
3. The most serious and irreversible conse- quence of lead poisoning is mental retardation due to neurologic changes. It can be expected if lead poisoning is long-standing and goes untreated. Lead poisoning also affects the hematologic and renal systems. Cirrhosis is the end stage of several chronic liver diseases, such as biliary atresia and hepati- tis. Lead poisoning is not associated with stunted growth. Chronic illnesses, such as cystic fi brosis, cause slowing of the growth velocity. Heart failure is associated with congenital heart disease and rheu- matic fever.CN: Physiological adaptation;
CL: Apply
9.
4. Most of the pathologic effects of lead poisoning are reversible as long as the problem is diagnosed early. The most serious effects are those on the central nervous system (e.g., brain damage, mental retardation, behavior changes), not prob- lems with the law. However, because of screening programs, many children with lead poisoning are diagnosed and treated early. As a result, little if any brain damage occurs thatwould require children to receive special schooling.
CN: Physiological adaptation;
CL: Synthesize
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20.
3. PKU is caused by an inborn error ofmetabolism. It is an autosomal recessive disorder that inhibits the conversion of phenylalanine to tyrosine.
A form of Down syndrome, trisomy 21, is an example of a disorder caused by chromosomal translocation.
Cri du chat is an example of a disorder caused by chromosomal deletion. Hemophilia A is an example of a disorder caused by an X-linked recessive gene.
CN: Physiological adaptation; CL: Apply
21.
4. Although it is not known how long diet therapy must continue for children with PKU, many experts suggest continuing it indefi nitely because of academic diffi culties and lower intelligence quotients in older children who have stopped the restrictive diet. For women it is necessary to resume the diet before conception to lower the phenylala- nine levels in the fetus and prevent complications.CN: Physiological adaptation;
CL: Synthesize
22.
2. PKU is considered a chronic illness.Parents typically grieve about the loss of health in their child affl icted with a chronic disease. Many times, they repeat questions, as though trying to deny what is really happening. This type of behav- ior represents an attempt to integrate the experi- ence and their feelings with their self-image as they pass through the grieving process. Asking for detailed explanations, testing the competence of health workers, and expressing impatience with health workers may explain the parents’ behavior, but viewing the behavior as a part of the grieving process is the most plausible explanation.
CN: Psychosocial adaptation;
CL: Analyze
The Client with Colic
23.
2. Information on the crying pattern of the infant is most helpful in confi rming the diagnosis of colic. Typically the colic attack begins abruptly, with the infant crying loudly and continuously, possibly for hours. The attack may end when the child becomes exhausted. The child also may attain some relief after passing stool or fl atus. Often, in an attempt to alleviate the infant’s crying, parents try to feed the infant, resulting in overfeeding leading to discomfort and distention. Asking about the type of formula, sleep position, or position for burping will not provide suffi cient information to confi rm the diagnosis of colic. However, the nurse can obtain additional information after determining the nature of the crying pattern.CN: Physiological adaptation;
CL: Analyze
15.
4. Most children with celiac disease have a lifelong sensitivity to gluten, which requires that they maintain some type of diet restriction for the rest of their lives.CN: Physiological adaptation;
CL: Synthesize
The Client with Phenylketonuria
16.
3. PKU is an autosomal recessive disorder involving the absence of an enzyme needed to metabolize the essential amino acid, phenylala- nine, to tyrosine. To ensure reliable results, the neonate must have ingested suffi cient protein, such as breast milk or formula, for at least 24 hours.Testing the infant before that time, excessive vomit- ing, or poor intake can yield false-negative results.
The infant does not need to fast 4 hours before the test. A loading dose of glucose water does not affect test values.
CN: Reduction of risk potential;
CL: Evaluate
17.
1. The goal of care is to prevent men- tal retardation by adjusting the diet to meet the infant’s nutritional needs for optimal growth.The diet needs to be started as soon as the infant is diagnosed, ideally within a few days of birth.
Serum phenylalanine level should be maintained between 3 and 7 mg/100 mL. Signifi cant brain damage usually occurs if the serum phenylalanine level exceeds 10 to 15 mg/100 mL. If the level drops below 2 mg/100 mL, the body begins to catabolize its protein stores, causing growth retardation.
CN: Physiological adaptation; CL: Create
18.
1. Foods with low phenylalanine levels include vegetables, fruits, and juices. Foods high in phenylalanine include meats and dairy prod- ucts, which must be restricted or eliminated.Colas contain more phenylalanine than the fruits listed.
CN: Physiological adaptation;
CL: Analyze
19.
1, 2, 3. Children with PKU lack an enzyme to metabolize phenylalanine and convert it to tyrosine.Treatment is dietary management to control the amount of phenylalanine ingested. Foods with low phenylalanine levels include fruits, most vegetables, and cereals. High-protein foods have high levels of phenylalanine and include meats and dairy products.
CN: Reduction of risk potential;
CL: Create
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28.
4. A 3-day diet history is the best way to accurately assess the child’s intake. Children under age 1 year should not drink cow’s milk because of the risk of allergy. Children over age 1 year should drink whole milk because skim milk and 2% milk do not contain all the essential fatty acids needed by young children. It is unknown at this time how much formula the child is actually taking, but an infant should not have more than 6 oz of juice per day and additional water is usually not necessary.If an infant is taking no more than 32 oz of formula per day and is eating some baby food and cereal, additional fl uids and frequent feeding should not be necessary.
CN: Health promotion and maintenance;
CL: Synthesize
29.
2. The most accurate way to determine whether an adolescent has a problem with obesity is to calculate the body mass index (BMI). The BMI indicates a relationship between height and weight.Numbers obtained through calculation are then applied to a BMI table for interpretation. A food diary will provide information on what the ado- lescent is eating but does not provide information about obesity. A 4-hour diet history will not provide suffi cient information about the client’s typical eat- ing patterns over time. Measuring skinfold thick- ness with skinfold calipers is a common method used to assess obesity. The skinfold thickness test, which determines the amount of subcutaneous fat, determines obesity more accurately than does a height and weight chart. However, it is not the most accurate method and is not routinely performed by nurses.
CN: Health promotion and maintenance;
CL: Analyze
30.
1. The most common complication of ado- lescent obesity is its persistence into adulthood.The incidence of gastrointestinal and orthopedic problems, such as Legg-Calvé-Perthes disease and genu valgum (knock knees), is greater for obese ado- lescents; however, they are not the most common complication. Although psychosocial problems do occur, they are not the most common complication.
CN: Reduction of risk potential;
CL: Apply
31.
1. Decreasing the amount of formula given as the infant begins to take solids helps prevent excess caloric intake. Because the infant is receiving calories from the solid foods, the formula no longer needs to provide the infant’s total caloric require- ments. Mixing vegetables with formula or breast milk does not allow the child to become accustomed to new textures or tastes. Solid foods should be given with a spoon, not in a bottle. Using a bottle24.
1. Infants with colic usually pass normal stools, typically soft and yellowish. Frequent watery stools might indicate diarrhea. Ribbon-like stools are suggestive of a narrowing of the colon or rectum.Foul-smelling stools by themselves are related to diet. When other symptoms such as large size and protuberant abdomen are present, malabsorption may be possible.
CN: Physiological adaptation;
CL: Analyze
25.
2. The nurse needs to provide the parents with support because of the infant’s crying. The parents are stressed and need to be encouraged to get out of the house and arrange for some free time.Although infants need lots of attention and care for the fi rst few months, they do not need the mother’s undivided attention. Comparing colic with other problems is inappropriate. Parents have the right to be upset. Although colic usually disappears sponta- neously by age 3 months, the nurse should not make any guarantees.
CN: Psychosocial adaptation;
CL: Synthesize
26.
4. Infants with colic should be burped fre- quently during and after the feeding. Much of the discomfort of colic appears to be associated with the presence of air in the stomach and intestines.Frequent burping helps to relieve the air. Infants with colic should be held fairly upright while being fed, to help air rise. The preferred position for burp- ing the infant with colic is to hold the infant at the mother’s shoulder so that the infant’s abdomen lies on the shoulder. This position causes more pressure to be exerted on the infant’s abdomen, leading to a more forceful burp. The child should be placed in an infant seat after feedings.
CN: Physiological adaptation;
CL: Evaluate
The Client with Obesity
27.
1. Children ages 2 to 20 years of age with a BMI-for-age at the 90th percentile are considered at risk for being overweight. If no other risk factors are present, the family should receive dietary counseling to slow the child’s weight gain until an appropriate height for weight is attained. Without intervention, the child may become overweight. A physician who specializes in pediatric weight loss should be con- sidered when the child is overweight and has com- plicating factors. Commercial diet programs alone do not include the necessary monitoring for children, thus are rarely appropriate.CN: Management of care ; CL: Synthesize
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34.
1. Lactose intolerance is not an allergy.Rather, it is caused by the lack of the digestive enzyme lactase. This enzyme, found in the intes- tines, is necessary for the digestion of lactose, the primary carbohydrate in cow’s milk. Protein and fat digestion are not affected.
CN: Physiological adaptation;
CL: Evaluate
35.
4. People who are lactose-intolerant usually are able to tolerate dairy products in which lactose has been fermented, such as yogurt, cheese, and buttermilk. Pudding, ice cream, and creamed soups contain lactose that has not been fermented.CN: Physiological adaptation;
CL: Evaluate
36.
1. Mothers of infants with a cow’s milk allergy can continue to breast-feed if they eliminate cow’s milk from their diet. It is important to encourage mothers to continue to breast-feed because breast milk is usually the least allergenic and most easily digested food for an infant. In addition, the infant is able to obtain protein through the mother’s milk. If the mother stops breast-feeding, then a predigested protein hydrolysate formula would be the fi rst choice.An iron-fortifi ed formula is a cow’s milk-based formula. A soy-based formula is not used because approximately 20% of infants with cow’s milk sen- sitivity are also sensitive to soy. Solid foods are not introduced until the infant is 4 to 6 months of age.
CN: Basic care and comfort;
CL: Synthesize
The Client with Failure to Thrive
37.
The nasogastric tube should reside in the stom- ach. The site placement can be verifi ed by inserting 3 to 5 mL of air in the tube and auscultating the infant’s abdomen for the sound of air. The nurse should then aspirate the injected air and a small amount of stomach contents and then test the contents for acidity.CN: Safety and infection control;
CL: Apply with food allows the infant to ingest more food than
is needed. Also, the infant needs to learn to eat from a spoon. A small-bowled spoon is recommended for infants because infants have a tendency to push food out with the tongue. The small-bowled spoon helps in placing the food at the back of the infant’s tongue when feeding.
CN: Basic care and comfort; CL: Create
32.
1. Infants generally do not overeat unless they are urged to do so. Parents should watch for clues indicating that the infant is full—for example, stopping sucking and pushing the nipple out of the mouth. Bottle-feeding instead of breast-feeding is more likely to lead to excessive caloric intake.A demand schedule, rather than a regulated sched- ule, allows the infant to regulate intake according to individual needs. Normally, giving an infant a regular supplementation of water is unnecessary;
the infant’s sucking needs can be met by providing a pacifi er. Adding more water to the formula than as directed decreases the caloric intake and also places the infant at risk for hyponatremia due to decreased sodium and increased water intake.
CN: Basic care and comfort;
CL: Synthesize
The Client with Food Sensitivity
33.
1. Administer the child’s epinephrine (Epipen).
3. Position to facilitate breathing.
2. Assess vital signs.
5. Notify the parents.
4. Send someone to activate the Emergency Management Systems (EMS)
The child is exhibiting signs of anaphylaxis. The principles of emergency management involve acti- vating EMS when an emergency is fi rst realized. The nurse then follows the priorities of Airway, Breath- ing, Circulation (A, B, C). The epinephrine should then be given to reduce airway constriction. The child should be assisted into the most comfortable position to facilitate breathing, usually with the head elevated. Then nurse can take the child’s vital signs to assess circulation. Lastly, the nurse should notify the family.
CN: Physiological adaptation;
CL: Synthesize
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