FOCUS ON CHILD HEALTH 1.ID: 5 An HIV-positive woman delivers an infant. The pediatrician prescribes testing for the newborn, and the nurse prepares for which action? A. Ask the laboratory to perform virologic testing Cor
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FOCUS ON CHILD HEALTH 1.ID: 5 An HIV-positive woman delivers an infant. The pediatrician prescribes testing for the newborn, and the nurse prepares for which action? A. Ask the laboratory to perform virologic testing Correct B. Obtain blood from the umbilical cord to send to the laboratory C. Perform a heelstick to obtain a specimen for a Western blot assay D. Perform a fingerstick to obtain a specimen for an enzyme-linked immunosorbent assay (ELISA) Rationale: Traditional HIV antibody measurement by ELISA or Western-blot assay is not accurate in infants younger than 18 months because of the persistence of maternal antibodies. Because of the potential for maternal contamination during delivery, umbilical cord blood should not be used for testing. HIV-exposed infants should undergo virologic testing within 48 hours of birth and follow-up testing, depending on the initial results. Test-Taking Strategy: Focus on the subject, a newborn infant exposed to HIV. Recalling that the ELISA and Western blot assay are not accurate in an infant younger than 18 months will assist you in eliminating these options. Next eliminate the option involving cord blood, knowing that such blood could be contaminated. Review the tests to detect HIV in a newborn infant. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Infectious Diseases Giddens Concepts:Immunity, Infection HESI Concepts: Immunity, Infection References: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 1046). St. Louis: Elsevier. Pagana, K., & Pagana, T. (2013). Mosby’s diagnostic and laboratory tests reference (11th ed., p. 531). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 2.ID: 1 A nurse providing home care instructions to a mother of a HIV-positive child discusses measures to prevent transmission of the virus. Which statement by the mother indicates a need for further instruction? A. “I won’t let my children share toothbrushes.” B. “I’ll wash up blood spills with soap and hot water and allow them to air dry.” Correct C. “I’ll wash my hands with soap and water if I touch any blood from my child.” D. “I’ll rinse bloodstained clothing with hydrogen peroxide and then wash it as usual.” Rationale: The correct method of cleaning up blood spills is to wash the area with soap and water, rinse with bleach, and let the area air dry. The remaining statements by the mother reflect correct measures to prevent transmission of the virus. Test-Taking Strategy: Note the strategic words “need for further instruction,” which indicate a negative event query and the need to select the incorrect statement. Recalling that blood spills must be cleaned with a 1:10 bleach/water solution will direct you to the correct option. Review these home care measures for HIV. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Child Health—Infectious Diseases Giddens Concepts:Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 1053). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points. 3.ID: 4 A child has been in the hospital for several days for treatment of severe vomiting related his HIV-positive status. Which assessment finding is the best indication that the child’s condition is improving? A. No lesions in the mouth and throat B. Weight increase of 1 lb (0.45 kg) over 3 days C. Correct D. Temperature Changed from 100.2° F to 99.2° F (37.3°C) E. F. Capillary refill slowing from 2 seconds to 3 seconds Rationale: Vomiting results in fluid volume deficit. The most accurate method of evaluating fluid volume increase (the desired outcome) is weight. A temperature decrease is not reflective of fluid volume increase. Increasing capillary refill time is indicative of a fluid volume decrease, not an increase. The absence of mouth ulcers would allow the child to drink without pain but does not reflect a fluid volume increase. Test-Taking Strategy: Note the data in the question and the strategic word, best, and remember that the child is experiencing severe vomiting. Use the process of elimination and focus on the subject, an assessment finding indicating fluid volume increase. The correct option is the only one that related to fluid volume. Review the findings that indicate a positive outcome in a child with HIV with severe vomiting. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health—Infectious Diseases Giddens Concepts: Fluid and Electrolytes, Evidence HESI Concepts: Evidence-Based Practice/Evidence, Fluids and Electrolytes Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 1067-1068). St Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 4.ID: 8 A girl with systemic lupus erythematosus (SLE) wants to go to the beach with her friends on the day after their junior prom. The girl asks the nurse for guidance regarding sun exposure. The nurse should provide which information to the girl? A. She cannot be exposed to any sunlight at all B. She must bring a beach umbrella and remain under it all day C. Waterproof sunscreen with a minimum sun protection factor (SPF) of 15 is a necessity Correct D. It is all right to go to the beach as long as she wears sunglasses, a sun hat, and clothes that cover her entire body Rationale: SLE, a chronic multi-system autoimmune disease characterized by inflammation of the connective tissue, varies in severity and is marked by remissions and exacerbations. Although the origin of SLE is not known, genetic, environmental, hormonal, and immune response factors are likely responsible. These factors include exposure to sun and other UV light, stress, fatigue, viruses, bacteria, certain medications, and some food additives. Avoiding triggers that set off exacerbation is essential, so wearing appropriate sunscreen is a necessity. The sunscreen should contain an SPF higher than 15 and should be waterproof. The remaining options present incorrect information. Test-Taking Strategy: Eliminate the options that are comparable or alike in that they indicate that exposure to sunlight must be avoided. Also, noting the close-ended words “cannot” and “must” will help you eliminate these options. Review measures that will help prevent an exacerbation of SLE. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Giddens Concepts: Client Education, Immunity HESI Concepts: Immunmity, Teaching and Learning/Patient Education Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 622, 1610). St Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 5.ID: 5 A nurse is monitoring a school-age child who is being treated for dehydration. The nurse notes that the child’s urine output has been 1 mL/kg/hr over the past 3 hours and that the specific gravity of the urine is 1.020. Which is the appropriate nursing action? A. Contact the pediatrician B. Document the findings Correct C. Encourage the child to drink more fluids D. Increase the rate of flow of the intravenous (IV) solution Rationale: Urine output of less than 2 to 3 mL/kg/hr in infants and toddlers, 1 to 2 mL/kg/hr in preschoolers and young school-age children, and 0.5 to 1 mL/kg/hr in school-age children or adolescents indicates dehydration. A specific gravity of the urine above 1.020 may indicate dehydration. The nurse would document the findings, because they are normal. Test-Taking Strategy: Focus on the data in the question. Eliminate the options that indicate the need to implement additional treatment. Additionally, note that these options indicate increasing fluid intake. Remember also that the nurse would not increase the rate of IV fluids without a pediatrician’s prescription to do so. Review normal findings related to urine output and specific gravity in a school-age child. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fluids and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolytes HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluid and Electrolytes Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 952-953,1002). St Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 6.ID: 4 Intravenous potassium chloride in 0.9% sodium chloride solution has been prescribed for a child who is severely dehydrated. Before administering the solution, the nurse must take which priority action? A. Check urine output Correct B. Evaluate skin turgor C. Measure capillary refill D. Obtain the child’s blood pressure Rationale: Potassium chloride is not administered if the urine output is not adequate. If the child is anuric, potassium will be retained, causing an increased potassium level. Although skin turgor, capillary refill, and blood pressure may be checked, they are not essential assessments in this situation. Test-Taking Strategy: Note the strategic word “priority.” Eliminate the options that refer to clinical signs of dehydration — skin turgor and capillary refill. Focus on what the question is asking about the administration of a particular solution. Review nursing interventions in the administration of IV potassium chloride. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Intravenous Therapy Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 998). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points. 7.ID: 3 A nurse is monitoring a 3-year-old with diarrhea for signs of dehydration. The child now weighs 42 lb (19 kg), a decrease from his weight of 44 lb (20 kg) 24 hours ago. In addition to dry mucous membranes and lack of tears, what assessment finding would the nurse find? A. Decreased heart rate B. Bilateral 1+ pedal pulses Correct C. Increased blood pressure D. Urine output of 80 mL in the last 3 hours Rationale: The minimum urine output for a child is 1 mL/kg/hour. The child weighs 42 lb, or 19 kg, so 80 mL in the last 4 hours is within the minimum range. A child with dehydration will have a rapid, weak, thready pulse. Blood pressure may be decreased in moderate and severe dehydration, but it is a late sign of hypovolemia. A child with dehydration will exhibit 1+ pedal pulses: difficult to palpate, weak, and thready. Test-Taking Strategy: Focus on the subject, signs of dehydration. Thinking about the pathophysiology of dehydration will direct you to the correct option. Review the signs of dehydration in a child. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluids & Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolytes HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluid and Electrolytes Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 998-999). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points. 8.ID: 5 A nurse is assigned to care for a child with diarrhea. Which intervention should the nurse avoid in caring for the child? A. Wearing clean gloves B. Turning the child every 2 hours C. Using protective moisture barriers D. Taking a rectal temperature every 4 hours Correct Rationale: Rectal temperatures are avoided in the child with diarrhea because inserting a thermometer in the rectum stimulates peristalsis and may damage excoriated tissue. Gloves are worn when caring for the child. Clean gloves are sufficient; sterile gloves are not necessary in this situation. The child is turned every 2 hours to reduce pressure on irritated skin and to prevent skin breakdown. Protective moisture barriers, such as creams or ointments, are useful in protecting the skin from diarrhea stools. Test-Taking Strategy: Note the strategic word “avoids,” which indicates a negative event query and the need to select the incorrect intervention. Focusing on the child’s diagnosis and recalling that peristalsis would aggravate the condition will direct you to the correct option. Review nursing interventions in the care of a child with diarrhea. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Gastrointestinal Giddens Concepts: Clinical Judgment, Elimination HESI Concepts: Clinical Decision-Making/Clinical Judgment, Elimination Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. p. 1067). St Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 9.ID: 8 A nurse is providing home care instructions to the mother of a child who has undergone cleft lip repair. Which statements by the mother indicate an understanding of these instructions? Select all that apply. A. “I should put her on her stomach to sleep.” B. “I shouldn’t brush her teeth for 1 to 2 weeks.” Correct C. “I should rinse her mouth with water after feeding her.” Correct D. “I should watch signs of infection like drainage or fever.” Correct E. “I should never use a bulb syringe to clear secretions from her mouth.” Rationale: “I shouldn’t brush her teeth for 1 to 2 weeks,” “I should rinse her mouth with water after feeding her,” and “I should watch for signs of infection like drainage or fever” are all accurate statements. Gentle aspiration of oral secretions may be needed to prevent respiratory complications, and bulb syringes are often sent home with the family for removal of these secretions. After cleft lip repair the child should be kept supine, on the side opposite the repair, or in an infant seat. The prone position could result in contact of the suture line with the bed linens, leading to disruption of the suture line. Test-Taking Strategy: Focus on the subject, an understanding of home care measures. Consider the safety issues related to oral surgery and positioning .............Continued
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