Chapter 19: The Child with a Gastrointestinal Alteration My Nursing Test Banks

Chapter 19: The Child with a Gastrointestinal Alteration

Test Bank

MULTIPLE CHOICE

1. Which is the best nursing response to a mother asking about the cause of her infants bilateral cleft lip?

a.

Did you have trouble with this pregnancy?

b.

Do you know of anyone in your or the fathers family born with cleft lip or palate problems?

c.

This defect is associated with intrauterine infection during the second trimester.

d.

Was your husband in the military and involved in chemical warfare?

ANS: B

Cleft lip and palate result from embryonic failure resulting from multiple genetic and environmental factors. A genetic pattern or familial risk seems to exist. A troublesome pregnancy has not been associated with bilateral cleft lip. The defect occurred at approximately 6 to 8 weeks of gestation. Second-trimester intrauterine infection is not a known cause of bilateral cleft lip. Chemical warfare is not significantly associated with bilateral cleft lip and palate.

DIF: Cognitive Level: Application REF: p. 413

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

2. Which nursing intervention is most helpful to parents of a neonate with bilateral cleft lip?

a.

Assure the parents that the correction will be immediate and uncomplicated.

b.

Show the parents before-and-after pictures of an infant whose cleft lip has been successfully repaired.

c.

Teach the parents about long-term enteral feedings.

d.

Refer the parents to a community agency that addresses this problem.

ANS: B

Showing the parents pictures of successful lip repair promotes bonding and enhances coping ability. Correction is usually done around 4 weeks but may be done as early as 2 to 3 days after birth. The infant with a bilateral cleft lip can be fed orally using a compressible, longer nipple, and by making a larger hole in the nipple. Long-term enteral feedings are not usually indicated. A community agency referral is not appropriate at this time and may not be indicated long term.

DIF: Cognitive Level: Application REF: p. 415

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

3. The postoperative care plan for an infant with surgical repair of a cleft lip includes which intervention?

a.

A clear liquid diet for 72 hours

b.

Nasogastric feedings until the sutures are removed

c.

Elbow restraints to keep the infants fingers away from the mouth

d.

Rinsing the mouth after every feeding

ANS: C

Keeping the infants hands away from the incision reduces potential complications at the surgical site. The infants diet is advanced from clear liquid to soft foods within 48 hours of surgery. After surgery, the infant can resume preoperative feeding techniques. Rinsing the mouth after feeding is an inappropriate intervention. Feeding a small amount of water after feedings will help keep the mouth clean. A cleft lip repair site should be cleansed with a wet sterile cotton swab after feedings.

DIF: Cognitive Level: Application REF: p. 415

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

4. A nurse is teaching a group of parents about tracheoesophageal fistula. Which statement, made by the nurse, is accurate about tracheoesophageal fistula (TEF)?

a.

This defect results from an embryonal failure of the foregut to differentiate into the trachea and esophagus.

b.

It is a fistula between the esophagus and stomach that results in the oral intake being refluxed and aspirated.

c.

An extra connection between the esophagus and trachea develops because of genetic abnormalities.

d.

The defect occurs in the second trimester of pregnancy.

ANS: A

When the foregut does not differentiate into the trachea and esophagus during the fourth to fifth week of gestation, a TEF occurs. TEF is an abnormal connection between the esophagus and trachea. There is no connection between the trachea and esophagus in normal fetal development. Tracheoesophageal fistula occurs early in pregnancy during the fourth to fifth week of gestation.

DIF: Cognitive Level: Application REF: p. 414

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

5. Which maternal assessment is related to the infants diagnosis of TEF?

a.

Maternal age more than 40 years

b.

First term pregnancy for the mother

c.

Maternal history of polyhydramnios

d.

Complicated pregnancy

ANS: C

A maternal history of polyhydramnios is associated with TEF. Advanced maternal age is not a risk factor for TEF. The first term pregnancy is not a risk factor for an infant with TEF. Complicated pregnancy is not a risk factor for TEF.

DIF: Cognitive Level: Comprehension REF: p. 414

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

6. What clinical manifestation should a nurse should be alert for when a diagnosis of esophageal atresia is suspected?

a.

A radiograph in the prenatal period indicates abnormal development.

b.

It is visually identified at the time of delivery.

c.

A nasogastric tube fails to pass at birth.

d.

The infant has a low birth weight.

ANS: C

Atresia is suspected when a nasogastric tube fails to pass 10 to 11 centimeters beyond the gum line. Abdominal radiographs will confirm the diagnosis. Prenatal radiographs do not provide a definitive diagnosis. The defect is not externally visible. Bronchoscopy and endoscopy can be used to identify this defect. Infants with esophageal atresia may have been born prematurely and with a low birth weight, but neither is suggestive of the presence of an esophageal atresia.

DIF: Cognitive Level: Comprehension REF: p. 414

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

7. The nurse admits an infant with vomiting and the diagnosis of hypertrophic pyloric stenosis. Which metabolic alteration should the nurse plan to assess for with this infant?

a.

Metabolic alkalosis

b.

Metabolic acidosis

c.

Respiratory acidosis

d.

Respiratory alkalosis

ANS: A

Frequent projectile vomiting, characteristic of pyloric stenosis, results in a loss of nonvolatile acids that decreases hydrogen ion concentration. This results in an excess of bicarbonate that increases arterial pH above 7.45 (metabolic alkalosis). Metabolic acidosis, respiratory acidosis, and respiratory alkalosis do not result from vomiting.

DIF: Cognitive Level: Application REF: p. 436

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

8. What is the most important information to be included in the discharge planning for an infant with gastroesophageal reflux?

a.

Teach the parents to position the infant on the left side.

b.

Reinforce the parents knowledge of the infants developmental needs.

c.

Teach the parents how to do infant cardiopulmonary resuscitation (CPR).

d.

Have the parents keep an accurate record of intake and output.

ANS: C

Risk of aspiration is a priority nursing diagnosis for the infant with gastroesophageal reflux. The parents must be taught infant CPR. Correct positioning minimizes aspiration. The correct position for the infant is on the right side after feeding and supine for sleeping. Knowledge of developmental needs should be included in discharge planning for all hospitalized infants but is not the most important in this case. Keeping a record of intake and output is not a priority and may not be necessary.

DIF: Cognitive Level: Application REF: pp. 423-424

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

9. Which information does the nurse include when teaching the parents of a 5-week-old infant about pyloromyotomy?

a.

The infant will be in the hospital for a week.

b.

The surgical procedure is routine and no big deal.

c.

The prognosis for complete correction with surgery is good.

d.

They will need to ask the physician about home care nursing.

ANS: C

Pyloromyotomy is the definitive treatment for pyloric stenosis. Prognosis is good with few complications. These comments reassure parents. The infant will remain in the hospital for a day or two postoperatively. Although the prognosis for surgical correction is good, telling the parents that surgery is no big deal minimizes the infants condition. Home care nursing is not necessary after pyloromyotomy.

DIF: Cognitive Level: Application REF: p. 437

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

10. A nurse has admitted a child to the hospital with a diagnosis of rule out peptic ulcer disease. Which test will the nurse expect to be ordered to confirm the diagnosis of a peptic ulcer?

a.

A 24-hour dietary history

b.

A positive Hematest result on a stool sample

c.

A fiberoptic upper endoscopy

d.

An abdominal ultrasound

ANS: C

Endoscopy provides direct visualization of the stomach lining and confirms the diagnosis of peptic ulcer. Dietary history may yield information suggestive of a peptic ulcer, but the diagnosis is confirmed through endoscopy. Blood in the stool indicates a gastrointestinal abnormality, but it does not conclusively confirm a diagnosis of peptic ulcer. An abdominal ultrasound is used to rule out other gastrointestinal alterations such as gallstones, tumor, or mechanical obstruction.

DIF: Cognitive Level: Comprehension REF: p. 427

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

11. What should the nurse teach a school-age child and his parents about the management of ulcer disease?

a.

Eat a bland, low-fiber diet in small frequent meals.

b.

Eat three balanced meals a day with no snacking between meals.

c.

The child needs to eat alone to avoid stress.

d.

Do not give antacids 1 hour before or after antiulcer medications.

ANS: D

Antacids can interfere with antiulcer medication if given less than 1 hour before or after antiulcer medications. A bland diet is not indicated for ulcer disease. The diet should be a regular diet that is low in caffeine, and the child should eat a meal or snack every 2 to 3 hours. Eating alone is not indicated.

DIF: Cognitive Level: Application REF: p. 428

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

12. Which prescribed formula should the nurse plan to provide for an infant with lactose intolerance?

a.

Isomil

b.

Enfamil

c.

Similac

d.

Good Start

ANS: A

The treatment for lactose intolerance is removal of lactose from the diet. Formulas that do not contain lactose (Isomil, Nursoy, Nutramigen, Prosobee, and other soy-based formulas) may be given to the infant suspected of having lactose intolerance. Enfamil, Similac, and Good Start are all milk-based formulas.

DIF: Cognitive Level: Application REF: p. 443

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

13. Which dietary foods high in calcium should the nurse encourage a lactose intolerant child to eat?

a.

Yogurt

b.

Green leafy vegetables

c.

Cheese

d.

Rice

ANS: B

The child between 1 and 10 years requires a minimum of 800 milligrams of calcium daily. Because high-calcium dairy products containing lactose are restricted from the childs diet, alternate sources such as egg yolk, green leafy vegetables, dried beans, and cauliflower must be provided to prevent hypocalcemia. Yogurt and cheese contain lactose. Rice is not high in calcium.

DIF: Cognitive Level: Application REF: p. 443

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

14. Which food choice by a parent of a 2-year-old child with celiac disease indicates a need for further teaching?

a.

Oatmeal

b.

Rice cake

c.

Corn muffin

d.

Meat patty

ANS: A

The child with celiac disease is unable to fully digest gluten, the protein found in wheat, barley, rye, and oats. Oatmeal contains gluten and is not an appropriate food selection. Rice is an appropriate choice because it does not contain gluten. Corn is digestible because it does not contain gluten. Meats do not contain gluten and can be included in the diet of a child with celiac disease.

DIF: Cognitive Level: Comprehension REF: p. 445

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

15. Which assessment finding should the nurse expect in an infant with Hirschsprungs disease?

a.

Currant jelly stools

b.

Constipation with passage of foul-smelling, ribbon-like stools

c.

Foul-smelling, fatty stools

d.

Diarrhea

ANS: B

Constipation results from the absence of ganglion cells in the rectum and colon and is present since the neonatal period with passage of frequent foul-smelling, ribbon-like, or pellet-like stools. Currant jelly stools are associated with intussusception. Foul-smelling, fatty stools are associated with cystic fibrosis and celiac disease. Diarrhea is not typically associated with Hirschsprungs disease but may result from impaction.

DIF: Cognitive Level: Comprehension REF: p. 441

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

16. Which would be an expected outcome for the parents of a child with encopresis?

a.

The parents will give the child an enema daily for 34 months.

b.

The parents will develop a plan to achieve control over incontinence.

c.

The parents will have the child launder soiled clothes.

d.

The parents will supply the child with a low-fiber diet.

ANS: B

Parents of the child with encopresis often feel guilty and believe that encopresis is willful on the part of the child. The family functions effectively by openly discussing problems and developing a plan to achieve control over incontinence. Stool softeners or laxatives, along with dietary changes, are typically used to treat encopresis. Enemas are indicated when a fecal impaction is present. Having the child launder soiled clothes is a punishment and will increase the childs shame and embarrassment. The child should not be punished for an action that is not willful. Increasing fiber in the diet and fluid intake results in greater bulk in the stool, making it easier to pass.

DIF: Cognitive Level: Analysis REF: p. 425

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

17. Which intervention should be included in the nurses plan of care for a 7-year-old child with encopresis who has cleared the initial impaction?

a.

Have the child sit on the toilet 30 minutes when he gets up in the morning and at bedtime.

b.

Increase sugar in the childs diet to promote bowel elimination.

c.

Use a Fleet enema daily.

d.

Give the child a choice of beverage to mix with a laxative.

ANS: D

Offering realistic choices is helpful in meeting the school-age childs sense of control. To facilitate bowel elimination, the child should sit on the toilet for 5 to 10 minutes after breakfast and dinner. Decreasing the amount of sugar in the diet will help keep stools soft. Daily Fleet enemas can result in hypernatremia and hyperphosphatemia and are used only during periods of fecal impaction.

DIF: Cognitive Level: Application REF: p. 425

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

18. A nurse is assisting a child with inflammatory bowel disease to choose items from the dietary menu. Which dietary item should be avoided because it is high in residue?

a.

Eggs

b.

Cheese

c.

Grapes

d.

Jello

ANS: C

Fruits with skins or seeds should be avoided because they are high in residue. Cooked or canned fruits and vegetables without skins are allowed. Eggs, cheese, and Jello would be allowed on a low residue diet.

DIF: Cognitive Level: Application REF: p. 433|p. 435

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

19. What is an expected outcome for the child with irritable bowel disease?

a.

Decreasing symptoms

b.

Adherence to a low-fiber diet

c.

Increasing milk products in the diet

d.

Adapting the lifestyle to the lifelong problems

ANS: A

Management of irritable bowel disease is aimed at identifying and decreasing exposure to triggers and decreasing bowel spasms, which will decrease symptoms. Management includes maintenance of a healthy, well-balanced, moderate-fiber, lower-fat diet. A moderate amount of fiber in the diet is indicated for the child with irritable bowel disease. No modification in dairy products is necessary unless the child is lactose intolerant. Irritable bowel syndrome is typically self-limiting and resolves by age 20 years.

DIF: Cognitive Level: Comprehension REF: p. 434

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

20. An infant has been admitted to the Neonatal Intensive Care Unit (NICU) with a congenital gastroschisis. Which intervention should the nurse perform first upon admission to the unit?

a.

Place the infant flat and prone.

b.

Cover the defect with sterile warm, moist gauze and wrap with plastic.

c.

Begin a gestational age assessment.

d.

Wrap the infant in a warm blanket and allow the father to hold the infant briefly.

ANS: B

Gastroschisis is the protrusion of intraabdominal contents through a defect in the abdominal wall lateral to the umbilical ring. There is no peritoneal sac. The defect should be immediately wrapped in warm, moist, sterile gauze and covered with plastic to keep moist. The infant cannot be placed prone as more damage could occur to the defect. Movement of the infant should be minimized so gestational age assessment and parental holding would be done after the infant is stabilized.

DIF: Cognitive Level: Application REF: p. 422

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

21. What is an appropriate statement for the nurse to make to parents of a child who has had a barium enema to correct an intussusception?

a.

I will call the physician when the baby passes his first stool.

b.

I am going to dilate the anal sphincter with a gloved finger to help the baby pass the barium.

c.

I would like you to save all the soiled diapers so I can inspect them.

d.

Add cereal to the babys formula to help him pass the barium.

ANS: C

The nurse needs to inspect diapers after a barium enema because it is important to document the passage of barium and note the characteristics of the stool. The physician does not need to be notified when the infant passes the first stool. Dilating the anal sphincter is not appropriate for the child after a barium enema. After reduction, the infant is given clear liquids and the diet is gradually increased.

DIF: Cognitive Level: Application REF: p. 439

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

22. Which is the best response for the nurse to make to parents who ask why their infant has a nasogastric tube to intermittent suction after abdominal surgery?

a.

The nasogastric tube decompresses the abdomen and decreases vomiting.

b.

We can keep a more accurate measure of intake and output with the nasogastric tube.

c.

The tube is used to decrease postoperative diarrhea.

d.

Believe it or not, the nasogastric tube makes the baby more comfortable after surgery.

ANS: A

The nasogastric tube provides decompression and decreases vomiting. A nursing responsibility when a patient has a nasogastric tube is measurement of accurate intake and output, but this is not why nasogastric tubes are inserted. Nasogastric tube placement does not decrease diarrhea. The presence of a nasogastric tube can be perceived as a discomfort by the patient.

DIF: Cognitive Level: Application REF: p. 439

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

23. Which stool characteristic should the nurse expect to assess with a child diagnosed with intussusception?

a.

Ribbon-like stools

b.

Hard stools positive for guaiac

c.

Currant jelly stools

d.

Loose, foul-smelling stools

ANS: C

Pressure on the bowel from obstruction leads to passage of currant jelly stools. Ribbon-like stools are characteristic of Hirschsprungs disease. With intussusception, passage of bloody mucus stools occurs. Stools will not be hard. Loose, foul-smelling stools may indicate infectious gastroenteritis.

DIF: Cognitive Level: Comprehension REF: p. 439

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

24. Which is a priority concern for a 14-year-old child with inflammatory bowel disease?

a.

Compliance with antidiarrheal medication therapy

b.

Long-term complications

c.

Dealing with the embarrassment and stress of diarrhea

d.

Home schooling

ANS: C

Embarrassment and stress from chronic diarrhea are real concerns for the adolescent with inflammatory bowel disease. Antidiarrheal medications are not typically ordered for a child with inflammatory bowel disease. Long-term complications are not a priority concern for the adolescent with inflammatory bowel disease. Exacerbations may interfere with school attendance, but home schooling is not a usual consideration for the adolescent with inflammatory bowel disease.

DIF: Cognitive Level: Comprehension REF: p. 434

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

25. A nurse is conducting a teaching session to adolescents about Crohns disease. Which statement, made by the nurse, is the most accurate?

a.

Crohns disease is responsive to dietary modifications.

b.

Crohns disease can occur anywhere in the gastrointestinal tract.

c.

Edema usually accompanies this disease.

d.

Symptoms of Crohns disease usually disappear by late adolescence.

ANS: B

Crohns disease can occur anywhere in the GI tract from the mouth to the anus and is most common in the terminal ileum. Maintaining a low-fiber, low-residue, and milk-free diet may give the child some relief; however, strict restrictions may not alleviate symptoms. Diarrhea and malabsorption from Crohns disease cause weight loss, anorexia, dehydration, and growth failure. Edema does not accompany this disease. Crohns disease is a long-term health problem. Symptoms do not typically disappear by adolescence.

DIF: Cognitive Level: Application REF: p. 433

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

26. A child is admitted to the pediatric floor for appendicitis. Which assessment finding will the nurse monitor that indicates the appendix has ruptured?

a.

Abdominal pain shifts from the left to the right side.

b.

Vomiting and diarrhea become more intense.

c.

Elevated temperature decreases to normal.

d.

Abdominal pain is relieved.

ANS: D

Abdominal pain is relieved when appendix rupture occurs. Pain in the right lower quadrant is suggestive of appendicitis. Abdominal pain does not shift from one side to the other. The child with appendicitis may have vomiting and diarrhea. A rupture does not intensify symptoms. Because peritonitis is associated with a ruptured appendix, the temperature would be elevated in the presence of infection.

DIF: Cognitive Level: Analysis REF: p. 432

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

27. What is the most important action to prevent the spread of gastroenteritis in a daycare setting?

a.

Administering prophylactic medications to children and staff

b.

Frequent hand washing

c.

Having parents bring food from home

d.

Directing the staff to wear gloves at all times

ANS: B

Hand washing is the most the important measure to prevent the spread of infectious diarrhea. Prophylactic medications are not helpful in preventing gastroenteritis. Bringing food from home will not prevent the spread of infectious diarrhea. Gloves should be worn when changing diapers, soiled clothing, or linens. They do not need to be worn for interactions that do not involve contact with secretions.

DIF: Cognitive Level: Comprehension REF: p. 431

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

28. What is an expected outcome for a 1-month-old infant with biliary atresia?

a.

Correction of the defect with the Kasai procedure

b.

Adequate nutrition and age-appropriate growth and development

c.

Increased blood pressure and adherence to a salt-free diet

d.

Adequate protein intake

ANS: B

Adequate nutrition, preventing skin breakdown, adequate growth and development, and family education and support are expected outcomes in an infant with biliary atresia. The goal of the Kasai procedure is to allow for adequate growth until a transplant can be done. It is not a curative procedure. Although blood pressure typically is elevated, a modified salt diet is appropriate. Protein intake may need to be restricted to avoid hepatic encephalopathy.

DIF: Cognitive Level: Comprehension REF: p. 449

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

29. Which assessment findings would be significant for a child with cirrhosis?

a.

Weight loss

b.

Change in level of consciousness

c.

Soft, smooth skin

d.

Pallor and cyanosis

ANS: B

The child with cirrhosis must be assessed for encephalopathy, which is characterized by a change in level of consciousness. Encephalopathy can result from a buildup of ammonia in the blood from the incomplete breakdown of protein. One complication of cirrhosis is ascites. The child needs to be assessed for increasing abdominal girth and edema. A child who is retaining fluid will not exhibit weight loss. Biliary obstruction can lead to intense pruritus. The skin will be irritated from frequent scratching. A skin assessment would likely reveal jaundice. Pallor and cyanosis are associated with a cardiac problem.

DIF: Cognitive Level: Analysis REF: p. 451

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

30. Which nursing diagnosis has the highest priority for the child with celiac disease?

a.

Pain related to chronic constipation

b.

Altered growth and development related to obesity

c.

Fluid volume excess related to celiac crisis

d.

Imbalanced nutrition: Less than body requirements related to malabsorption

ANS: D

Imbalanced nutrition: Less than body requirements related to malabsorption is the highest priority nursing diagnosis because celiac disease causes gluten enteropathy, a malabsorption condition. The pain associated with celiac disease is associated with diarrhea, not constipation. Celiac disease causes altered growth and development associated with malnutrition, not obesity. Celiac crisis causes fluid volume deficit.

DIF: Cognitive Level: Comprehension REF: p. 445

OBJ: Nursing Process Step: Nursing Diagnosis MSC: Physiological Integrity

31. The nurse notes on assessment that a 1-year-old child is underweight, with abdominal distention, thin legs and arms, and foul-smelling stools. The nurse suspects failure to thrive associated with which condition?

a.

Celiac disease

b.

Intussusception

c.

Irritable bowel syndrome

d.

Imperforate anus

ANS: A

These are classic symptoms of celiac disease. Intussusception is not associated with failure to thrive or underweight, thin legs and arms, and foul-smelling stools. Stools are like currant jelly. Irritable bowel syndrome is characterized by diarrhea and pain, and the child does not typically have thin legs and arms. Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum. Symptoms are evident in early infancy.

DIF: Cognitive Level: Analysis REF: p. 445

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

32. A 10-year-old boy is admitted to the hospital with a diagnosis of appendicitis. He is nauseated, febrile, and complaining of severe abdominal pain radiating to the right lower quadrant. During a routine nursing check, he states that his stomach doesnt hurt anymore. The nurse should suspect that:

a.

he is anxious about surgery.

b.

his appendix has ruptured.

c.

he does not communicate effectively about pain.

d.

his nausea and vomiting have decreased, thereby relieving his abdominal pain.

ANS: B

A classic symptom indicating appendix rupture is the sudden relief of pain. The boy may be anxious, but this will not cause his pain to disappear. There is no evidence to substantiate the assumption that he does not communicate effectively about pain. His nausea and vomiting have not decreased, nor will this affect his abdominal pain.

DIF: Cognitive Level: Comprehension REF: pp. 431-432

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

33. The nurse caring for a child with suspected appendicitis should question which physician prescriptions?

a.

Keep patient NPO.

b.

Start IV of D5/0.45 normal saline at 60 mL/hr.

c.

Apply K-pad to abdomen prn for pain.

d.

Obtain CBC on admission to the nursing unit.

ANS: C

A K-pad (moist heat device) is contraindicated for suspected appendicitis because it may contribute to the rupture of the appendix. NPO status is appropriate for the potential appendectomy client. An IV is appropriate both as a preoperative intervention and to compensate for the short-term NPO status. Because appendicitis is frequently reflected in an elevated WBC, laboratory data are needed.

DIF: Cognitive Level: Analysis REF: pp. 431-432

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

34. Which order should the nurse question when caring for a child after surgery for Hirschsprungs disease?

a.

Monitor rectal temperature every 4 hours and report an elevation greater than 38.5 C.

b.

Assess stools after surgery.

c.

Keep the child NPO until bowel sounds return.

d.

Maintain IV fluids at an ordered rate.

ANS: A

Rectal temperatures should not be taken after this surgery. Rectal temperatures are generally not the route of choice for children because of the routes traumatic nature. Assessing stools after surgery is an appropriate intervention postoperatively. Stools should be soft and formed. Keeping the child NPO until bowel sounds return is an appropriate intervention postoperatively. Maintaining IV fluids at an ordered rate is an appropriate postoperative order.

DIF: Cognitive Level: Analysis REF: p. 442

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

35. Which diagnosis has the highest priority for the child with irritable bowel syndrome?

a.

Alteration in nutrition: Less than body requirements related to malabsorption

b.

Altered growth and development related to inadequate nutrition

c.

Pain related to hyperperistalsis

d.

Constipation related to maldigestion

ANS: C

Diffuse abdominal pain unrelated to activity or meals is a common clinical manifestation of irritable bowel syndrome. Normal physical growth and development usually occur with this disorder. Constipation may occur with irritable bowel syndrome, usually alternating with diarrhea.

DIF: Cognitive Level: Application REF: p. 434

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

36. A 7-year-old child is admitted to the hospital with severe abdominal pain, bloody currant jelly diarrhea, and fever. What is his probable diagnosis?

a.

Hirschsprungs disease

b.

Celiac disease

c.

Ruptured appendix

d.

Intussusception

ANS: D

Severe abdominal pain, bloody currant jelly diarrhea, and fever are common clinical manifestations of intussusception. Hirschsprungs disease usually manifests as bowel obstruction. Severe abdominal pain, bloody currant jelly diarrhea, and fever are not common symptoms of celiac disease. Although a child with a ruptured appendix will probably be febrile, the other symptoms are not indicative of a ruptured appendix.

DIF: Cognitive Level: Analysis REF: p. 439

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

37. Which goal has the highest priority for a child with malabsorption associated with lactose intolerance?

a.

The child will experience no abdominal spasms.

b.

The child will not experience constipation associated with malabsorption syndrome.

c.

The child will not experience diarrhea associated with malabsorption syndrome.

d.

The child will receive adequate nutrition as evidenced by a weight gain of 1 kg/day.

ANS: C

The highest priority goal is that the child will not experience diarrhea associated with malabsorption syndrome; this goal is correct for a child with malabsorption associated with lactose intolerance. A child usually has abdominal cramping, pain, and distention rather than spasms. The child usually has diarrhea, not constipation. One kilogram a day is too much weight gain with no time parameters.

DIF: Cognitive Level: Application REF: p. 443

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

38. What would be an appropriate meal for a school-age child with celiac disease?

a.

Baked chicken and cornbread

b.

Hot dog and bun

c.

Bean with barley soup and rice cakes

d.

Cheeseburger on rye bread

ANS: A

Children with celiac disease must eliminate all wheat, rye, barley, oats, and hydrolyzed vegetable proteins from their diet. Cornbread does not contain glutens. Most buns, barley, and rye bread contain glutens.

DIF: Cognitive Level: Application REF: p. 445

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

39. What should the nurse stress in a teaching plan for the mother of an 11-year-old boy with ulcerative colitis?

a.

Preventing the spread of illness to others

b.

Nutritional guidance and preventing constipation

c.

Teaching daily use of enemas

d.

Coping with stress and adjusting to a chronic illness

ANS: D

Coping with the stress of a chronic illness and the clinical manifestations associated with ulcerative colitis (diarrhea, pain) are important teaching foci. Ulcerative colitis is not infectious. Although nutritional guidance is a priority teaching focus, diarrhea is a problem with ulcerative colitis, not constipation. Teaching daily use of enemas is not part of the therapeutic plan of care.

DIF: Cognitive Level: Application REF: pp. 435-436

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

40. An infant with Hirschsprungs disease has a temporary colostomy. Which statement by the infants mother indicates she understands how to care for the infants colostomy at home?

a.

I need to be careful to check the skin around the colostomy for breakdown and be sure I keep it clean.

b.

Ill call my home health nurse if the colostomy bag needs to be changed.

c.

Ill call the doctor if I notice that the colostomy stoma is pink.

d.

Ill have my mother help me with the care of the colostomy.

ANS: A

Preventing skin breakdown is a priority concern when caring for a colostomy. The mother should be taught the basics of colostomy care, including how to change the appliance. The colostomy stoma should be pink in color, not pale or discolored. There is no evidence that her mother knows how to care for a colostomy.

DIF: Cognitive Level: Application REF: p. 442

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

41. Careful hand washing before and after contact can prevent the spread of _____ in day care and school settings.

a.

irritable bowel syndrome

b.

ulcerative colitis

c.

hepatic cirrhosis

d.

hepatitis A

ANS: D

Hepatitis A is spread person to person, by the fecal-oral route and through contaminated food or water. Good hand washing is critical in preventing its spread. The virus can survive on contaminated objects for weeks. Irritable bowel syndrome is the result of increased intestinal motility and is not contagious. Ulcerative colitis and cirrhosis are not infectious.

DIF: Cognitive Level: Application REF: p. 447

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

MULTIPLE RESPONSE

1. Which interventions should a nurse implement when caring for a child with hepatitis? Select all that apply.

a.

Provide a well-balanced low-fat diet.

b.

Schedule play time in the playroom with other children.

c.

Teach parents not to administer any over-the-counter medications.

d.

Arrange for home schooling as the child will not be able to return to school.

e.

Instruct parents on the importance of good hand washing.

ANS: A, C, E

The child with hepatitis should be placed on a well-balanced low-fat diet. Parents should be taught to not give over-the-counter medications because of impaired liver function. Hand hygiene is the most important preventive measure for the spread of hepatitis. The child will be in contact isolation in the hospital so play time with other hospitalized children is not scheduled. The child will be on contact isolation for at least 1 week after the onset of jaundice, but after that period, will be allowed to return to school.

DIF: Cognitive Level: Application REF: p. 432|pp. 448-449

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

2. The nurse is providing home care instructions to the parents of an infant being discharged after repair of a bilateral cleft lip. Which instructions should the nurse include? Select all that apply.

a.

Acetaminophen (Tylenol) should not be given to your infant.

b.

Feed your infant in an upright position.

c.

Place your infant prone for a period of time each day.

d.

Burp your child frequently during feedings.

e.

Apply antibiotic ointment to the lip as prescribed.

ANS: B, D, E

After cleft lip surgery the parents are taught to feed the infant in an upright position to decrease the chance of choking. The parents are taught to burp the infant frequently during feedings because excess air is often swallowed. Parents are taught to cleanse the suture line area with a cotton swab using a rolling motion and apply antibiotic ointment with the same technique. Tylenol is used for pain and the child should never be placed prone as that can damage the suture line.

DIF: Cognitive Level: Application REF: p. 414

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

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