55.
A 3-year-old child receiving chemotherapy after surgery for a Wilms’ tumor has developed neu- tropenia. The parent is trying to encourage the child to eat by bringing extra foods to the room. Which food would not be appropriate for this child?■ 1. Fudge.
■ 2. French fries.
■ 3. Fresh strawberries.
■ 4. A milk shake.
56.
When assessing a 2-year-old child with Wilms’ tumor, the nurse should avoid?■ 1. Measuring the child’s chest circumference.
■ 2. Palpating the child’s abdomen.
■ 3. Placing the child in an upright position.
■ 4. Measuring the child’s occipitofrontal circumference.
57.
Which statement by the mother of a child with Wilms’ tumor tells the nurse that the mother understands what stage II tumor means?■ 1. “The tumor has extended beyond the kidney but was completely removed.”
■ 2. “Although the tumor was in the kidney, it has spread to the lung, liver, and bone.”
■ 3. “The tumor has extended outside the kidney to the lungs and the liver.”
■ 4. “The tumor was solely located in the kidney but it was totally removed.”
58.
A child diagnosed with Wilms’ tumor under- goes successful surgery for removal of the diseased kidney. When the child returns to the room, the nurse should place the child in which position?■ 1. Modifi ed Trendelenburg.
■ 2. Sims’.
■ 3. Semi-Fowler’s.
■ 4. Supine.
59.
After a child undergoes nephrectomy for a Wilms’ tumor, the nurse should assess the child postoperatively for which early sign of a complication?■ 1. Increased abdominal distention.
■ 2. Elevated blood pressure.
■ 3. Increased respiratory rate.
■ 4. Increased urine output.
60.
When developing the discharge plan for a child who had a nephrectomy for a Wilms’ tumor, the nurse identifi es outcomes to prevent damage to the child’s remaining kidney and accomplish which of the following?■ 1. Minimize pain.
■ 2. Prevent dependent edema.
■ 3. Prevent urinary tract infection.
■ 4. Minimize sodium intake.
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4.
3. When an anomaly is found in one system, such as the genitourinary system, that system requires a more focused assessment to reveal other conditions that also may be occurring. A bulging in the inguinal area may suggest an inguinal hernia.Also, hydrocele or an upper urinary tract anomaly may occur on the same side as the undescended tes- tis. A neuromuscular problem, not a genitourinary problem such as undescended testes, would most likely be the cause of abnormal lower extremity refl exes. A history of frequent emesis may be caused by pyloric stenosis or viral gastroenteritis. Poor weight gain might suggest a metabolic or feeding problem.
CN: Health promotion and maintenance;
CL: Analyze
5.
1. A trial of human chorionic gonadotrophin may be given to stimulate descent of the affected tes- tis. A trial of adrenocorticotropic hormone will not cause the testis to descend. The cremasteric refl ex results in the testis being drawn up, the opposite of the intended effect. Application of warmth, such as warm baths, although soothing and relaxing for the infant, would have little or no effect on stimulating the testis to descend.CN: Pharmacological and parenteral therapies; CL: Apply
6.
2. Preoperative teaching would be directed at the parents, because the child is too young to under- stand the teaching. Telling the child that his penis and scrotum will be “fi xed,” telling the child he will not see incisions after surgery, and using a doll to illustrate the surgery are appropriate interventions for a preschool-age child.CN: Psychosocial adaptation;
CL: Create
7.
3. Because the incidence of testicular cancer is increased in adulthood among children who have had undescended testes, it is extremely important to teach the adolescent how to perform the testicular self-examination monthly. The undescended tes- ticle is removed to reduce the risk of cancer in that testicle. Removal of a testis would not necessarily make the adolescent sterile because the other tes- ticle remains. Although discussing the adolescent’s future plans is important, it is not the priority at this time. Because the adolescent has been dealing with the situation for a long time, the need for a sports physical at this time should not be a cause of emotional distress requiring a lot of psychological support.CN: Health promotion and maintenance;
CL: Synthesize
Answers, 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 Cryptorchidism
1.
4. Normally the testes descend by 1 year of age;failure to do so may indicate a problem with patency or a hormonal imbalance. By age 4 weeks, descent may not have occurred. However, telling the father that lack of descent is not a cause for worry is inappro- priate and uncaring. Additionally, a statement such as this may be false reassurance. By acknowledging the father’s concern, the nurse indicates acceptance of his feelings. If the testes have not descended, then they will not be palpable in the scrotal sac. Surgery is not discussed until after a full assessment is completed.
CN: Health promotion and maintenance;
CL: Synthesize
2.
3. A cold environment can cause the testes to retract. Cold and touch stimulate the cremasteric refl ex, which causes a normal retraction of the testes toward the body. Therefore, the nurse should warm the hands and make sure that the environment also is warm. Checking the diaper for urination provides information about the infant’s voiding and urinary function, not information about the testes. Giving the infant a pacifi er may help to calm the infant and possibly make the examination easier, but the concern here is with the temperature of the environ- ment. Tapping on the inguinal ring would not be helpful in assessing the infant.CN: Health promotion and maintenance;
CL: Synthesize
3.
2. The nurse needs more information about the father’s perceptions and feelings before provid- ing any information or taking action. Determining the exact nature of the father’s concern rather than making an assumption about it is essential. There- fore, the nurse should identify what is observed and ask the father how he is feeling. Telling the father that everything will be fi ne or not to worry is inappropriate and provides false reassurance. It also devalues the father’s concern. Later on it may be appropriate for the father to talk to a parent of a child with the same problem for support.CN: Psychosocial adaptation;
CL: Synthesize
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12.
In hypospadias, the urethral opening is on the ventral side of the penis.CN: Physiological adaptation; CL: Apply
13.
2. The preferred time for surgery is between the ages of 6 and 18 months, before the child develops cas- tration and body image anxiety. Children learn early on about society’s emphasis on the importance of geni- tals. Pain is different for each child and is not related to the preferred time for repair of the hypospadias or chordee. Although the child will probably not remem- ber the experience, this is not the basis for having the surgery at this age. If the condition is not repaired, the child will have diffi culty with toilet training because urine is not eliminated through the tip of the penis.CN: Physiological adaptation; CL: Apply
14.
1. The parents should keep the penis as dry as possible until the stent is removed. Soaking in a tub bath is not recommended. Children this age typ- ically go home voiding directly into a diaper. Infants may be started on juice at 6 months of age. Parents are advised to keep their child well hydrated after a hypospadius repair. Therefore, there is no reason to avoid juice. Cleaning the tip of the penis 3 times a day may cause unnecessary irritation.CN: Safety and infection control;
CL: Synthesize
15.
2. The main purpose of the urethral catheter is to maintain patency of the reconstructed urethra.The catheter prevents the new tissue inside the urethra from healing on itself. However, the urethral catheter can cause bladder spasms. Recently, stents have been used instead of catheters. The urethral catheter will have no effect on the child’s pain level.
In fact, because bladder spasms are associated with its use, the child’s complaints of pain may actually increase. Urine output can be measured through the suprapubic catheter because it provides an alterna- tive route for urinary elimination, thus keeping the bladder empty and pressure-free.
CN: Reduction of risk potential;
CL: Evaluate
The Client with Hydrocele
8.
3. A hydrocele is a collection of fl uid in the tunica vaginalis of the testicle or along the spermatic cord that results from a patent processus vaginalis.Failure of the upper part of the processus vaginalis to atrophy allows the accumulation of fl uid in the tes- ticle and peritoneal cavity, causing an inguinal hernia.
CN: Physiological adaptation; CL: Apply
9.
3. A hydrocele is a collection of fl uid in the tunica vaginalis of the testicle or along the spermatic cord that results from a patent processus vaginalis.Because scrotal size is decreasing, the fl uid is being absorbed. Elevation of the infant’s bottom, mas- sage, or keeping the infant quiet or in an infant seat would have no effect in promoting fl uid reabsorp- tion in hydrocele.
CN: Physiological adaptation;
CL: Evaluate
10.
4. Some swelling and bruising are normal post- operatively. By assessing the area with the mother, the nurse is conveying acceptance of the mother’s con- cern. In addition, the nurse needs to inspect the area to determine if what the mother is describing is accu- rate. Doing so also provides an opportunity for teach- ing. Aspirin is not usually prescribed for children because of the link between aspirin and Reye’s syn- drome. Acetaminophen is commonly administered for fever or pain relief. Asking the mother to wait in the child’s room ignores the mother’s concerns. There is no need to notify the doctor at this time.CN: Psychosocial adaptation;
CL: Synthesize
The Client with Hypospadias
11.
2. The condition in which the urethral open- ing is on the ventral side of the penis or below the glans penis is referred to as hypospadias. Chordee refers to a ventral curvature of the penis that results from a fi brous band of tissue that has replaced normal tissue. Circumcision is delayed because the foreskin, which is removed with a circumcision, often is used to reconstruct the urethra. The chordee is corrected when the hypospadias is repaired. Cir- cumcision is performed at the same time. Urethral meatal stenosis, which can occur in circumcised infants, results from meatal ulceration, possibly leading to urinary obstruction. It is not associated with hypospadias or circumcision. The infant is not too small to have a circumcision, which is com- monly performed on the fi rst or second day of life.CN: Reduction of risk potential;
CL: Apply
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20.
2. Sulfonamides have been associated with severe adverse reactions. A blistering rash may be a sign of Stevens-Johnson syndrome, a severe allergic reaction that manifests as skin lesions. This reaction is life threatening and requires immediate attention.Lotion should not be applied to skin with blisters.
Bactrim may cause photosensitivity, but this usually appears as a mild red rash, not blisters. Increasing the child’s fl uid intake may help the urinary tract infection, but does not address the rash.
CN: Pharmacological and parenteral therapies; CL: Synthesize
21.
1. Abdominal pain frequently accompanies urinary tract infection in children 2 years of age and older. Other associated signs and symptoms include decreased appetite, vomiting, fever, and irritability.The presence of swollen lymph glands (lymphade- nopathy) is unrelated to urinary tract infections.
Lymphadenopathy is associated with a systemic infection or possibly cancer. Skin rash is associated with exposure to allergens or irritants (e.g., poison ivy or harsh soaps); prolonged contact with urine (e.g., diaper dermatitis); or illnesses such as measles, rheumatic fever, or juvenile rheumatoid arthritis.
Flank or back pain is associated with urinary tract infection in children older than 2 years of age and in adults.
CN: Physiological adaptation;
CL: Analyze
22.
2. To ensure appropriate psychosocialdevelopment, a child needs to have normal patterns maintained as much as possible during illness. It is tempting to give ill children special treatment and to relax discipline. However, family routines and discipline should be kept as normal as possible. The child needs to know the limits to ensure feelings of security. When they are ill, children commonly attempt to stretch the rules and limits. If this occurs, returning to the previous well-behavior patterns will take time.
CN: Health promotion and maintenance;
CL: Synthesize
23.
1. The reason that urinary tract infections are a problem in children with vesicoureteral refl ux is that urine fl ows back up the ureter, past the incompetent valve, and back into the bladder after the child has fi nished voiding. This incomplete emptying of the bladder results in stasis of urine, providing a good medium for bacterial growth and subsequent infection. Vesicoureteral refl ux does not cause bladder spasms or painful urination. How- ever, the child may experience painful urination with a urinary tract infection.CN: Physiological adaptation; CL: Apply
16.
2. A dusky blue color at the tip of the penis may indicate a problem with circulation, and the nurse should notify the surgeon. Following surgery, it is normal for the penis to be swollen and pink.The penis may be misshapen and is unlikely to look normal even after reconstruction.
CN: Physiological adaptation;
CL: Analyze
17.
4. The most important consideration for a successful outcome of this surgery is maintenance of the catheters or stents. A 12-month-old infant likes to explore his environment but must be pre- vented from manipulating his dressings or catheters through the use of soft restraints. Allowing the infant to become familiar with the dressings will not prevent him from pulling at them. After surgery the child is allowed limited activity, possibly with sit- ting in the parent’s lap. A 12-month-old infant may or may not be walking. If he is, most likely he will be clumsy and possibly injure himself. Although increasing fl uids is important, 2,500 mL/day is an excessive amount for a 12-month-old. Fluid require- ments would be 115 mL/kg.CN: Physiological adaptation;
CL: Create
18.
3. A normal white blood cell count in a urinalysis is 1 to 2 cells/mL. A white blood cell count of 25 per high-powered fi eld indicates a urinary tract infection. A urine specifi c gravity of 1.017 is within the normal range of 1.002 to 1.030.After urologic surgery, it is not unusual for a small number of red blood cells to appear in the urine.
The child’s urine pH is within the normal range of 4.6 to 8.
CN: Reduction of risk potential;
CL: Analyze
The Client with Urinary Tract Infection
19.
3. 2% lidocaine lubricants have been found to signifi cantly reduce the pain of urinary catheter insertion in children. If the unit does not have a standing protocol to use the lubricant, the nurse should request an order. A sedative would carry with it additional risks that could be avoided with the use of other methods to reduce pain. The parents should be encouraged to hold the child in addition to other pain relief methods. Frequent urination would make the use of topical anesthet- ics that must be left in place for a period of time impractical.CN: Basic care and comfort;
CL: Synthesize
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follows a strep throat by 10 to 14 days. Frequently, the children have only mild cold symptoms and do not realize they have a streptococcal infection. Ask- ing whether the child plays with friends as usual is important and gives the nurse information about how the child feels in general. However, this is a general question that would be appropriate to ask later on in the history. Although asking the mother about the color of the child’s urine is important, the nurse needs to determine whether there is any change in the child’s urinary output fi rst.
CN: Physiological adaptation;
CL: Analyze
28.
3. The child with acute poststreptococcal glomerulonephritis experiences a problem with renal function that ultimately affects fl uid balance.Because weight is the best indicator of fl uid bal- ance, obtaining daily weights would be the highest priority.
CN: Physiological adaptation;
CL: Analyze
29.
2. The most appropriate and effective choice would be ice chips, because they help moisten the mouth and lips while keeping fl uid intake low.However, ice chips must still be counted as intake with the fl uid restriction. Sweet beverages, such as diet cola or lemonade, commonly increase thirst.
Tap water effectively relieves thirst but does not help keep fl uid intake low.
CN: Physiological adaptation;
CL: Synthesize
30.
4. The best choice would be fruits such as strawberries and kiwi because they are low in sodium and potassium. Typically, diet is related to the stage and severity of the disease. In children with uncomplicated disease, a regular diet is offered but sodium is usually restricted. In children with hypertension and edema, moderate restriction of sodium is instituted. Pizza and cola, hamburgers and fries, and ice cream are high in sodium and should be avoided. Children with oliguria usually also have potassium restricted. Therefore, foods such as bananas and oranges would be avoided.CN: Physiological adaptation;
CL: Evaluate
31.
1. Generally, school-age children enjoy activi- ties with their peers fi rst, then family members, and lastly younger children. School-age children like to be busy but also to accomplish something.This helps to meet their task of industry versus inferiority, feeling good about what they are able to accomplish.
CN: Health promotion and maintenance;
CL: Create
The Client with Glomerulonephritis
24.
2. An adolescent with acute glomerulone- phritis has a high urine specifi c gravity related to oliguria caused by infl ammation of the glomeruli.The client will have periorbital edema, but not the generalized edema that occurs in nephrotic syndrome. In glomerulonephritis, there is some albumin in the urine, but there are large amounts of red blood cells, giving the urine a brown color.
The urine in glomerulonephritis is scanty, averag- ing about 400 mL in 24 hours, which leads to fl uid volume excess and hypertension.
CN: Physiological adaptation;
CL: Synthesize
25.
3. The best selection of food would include no added salt or salty food. Because sodium cannot be excreted due to the oliguria and to avoid increas- ing the hypertension, a low-salt diet is recom- mended. Most canned foods have sodium added as a preservative. Hamburger, ham, hot dogs, canned peas, canned carrots, corn chips, pickles, and milk are high in sodium.CN: Health promotion and maintenance;
CL: Synthesize
26.
2. Hypertension occurs with acute glomeru- lonephritis. The symptoms of headache and blurred vision may indicate an elevated blood pressure.Hypertension in acute glomerulonephritis occurs due to the inability of the kidneys to remove fl uid and sodium; the fl uid is reabsorbed, causing fl uid volume excess. The nurse must verify that these symptoms are due to hypertension. Calling the phy- sician before confi rming the cause of the symptoms would not assist the physician in his treatment.
Putting the client to bed may help treat an elevated blood pressure, but fi rst the nurse must establish that high blood pressure is the cause of the symp- toms. Administering Tylenol for high blood pressure is not recommended.
CN: Physiological adaptation;
CL: Synthesize
27.
3. Most likely, the nurse suspects that the child is exhibiting signs and symptoms of glomeru- lonephritis, such as periorbital edema and fever.Other signs and symptoms include loss of appetite, dark-colored urine, pallor, headaches, and abdomi- nal pain. To confi rm this suspicion, the nurse would ask about the child’s urinary elimination patterns.
Typically the child with glomerulonephritis expe- riences a decrease in urine output. Asking about any recent sore throat would provide additional information to confi rm the suspicion of glom- erulonephritis, because the most common type is acute poststreptococcal glomerulonephritis, which
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