Chapter 20 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 20

Question 1

Type: MCSA

A child is showing signs of acute respiratory distress. Which position will the nurse place this child?

1. Upright

2. Side-lying

3. Flat

4. In semi-Fowlers

Correct Answer: 1

Rationale 1: Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowlers (head up slightly) do not allow for as optimal chest expansion as the upright position.

Rationale 2: Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowlers (head up slightly) do not allow for as optimal chest expansion as the upright position.

Rationale 3: Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowlers (head up slightly) do not allow for as optimal chest expansion as the upright position.

Rationale 4: Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowlers (head up slightly) do not allow for as optimal chest expansion as the upright position.

Global Rationale: Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowlers (head up slightly) do not allow for as optimal chest expansion as the upright position.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 20.6 Create a nursing care plan for a child with a common acute respiratory condition.

Question 2

Type: MCSA

A nurse delegates the task of neonatal vital-sign assessment to a nurse technician. Which instruction will the nurse give to the technician prior to assign care?

1. Report any neonate using abdominal muscles to breathe.

2. Report any neonate with apnea for 10 seconds.

3. Count respirations for 15 seconds and multiply by 4 to get the rate for 1 minute.

4. Report any neonate with a breathing pause that lasts 20 seconds or longer.

Correct Answer: 4

Rationale 1: The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea and could lead to an apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is called periodic breathing and is a normal pattern for a neonate. Respirations should be counted for 1 minute, not 15 seconds. It is normal for neonates to use abdominal muscles for breathing.

Rationale 2: The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea and could lead to an apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is called periodic breathing and is a normal pattern for a neonate. Respirations should be counted for 1 minute, not 15 seconds. It is normal for neonates to use abdominal muscles for breathing.

Rationale 3: The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea and could lead to an apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is called periodic breathing and is a normal pattern for a neonate. Respirations should be counted for 1 minute, not 15 seconds. It is normal for neonates to use abdominal muscles for breathing.

Rationale 4: The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea and could lead to an apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is called periodic breathing and is a normal pattern for a neonate. Respirations should be counted for 1 minute, not 15 seconds. It is normal for neonates to use abdominal muscles for breathing.

Global Rationale: The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea and could lead to an apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is called periodic breathing and is a normal pattern for a neonate. Respirations should be counted for 1 minute, not 15 seconds. It is normal for neonates to use abdominal muscles for breathing.

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 20.2 Contrast the different respiratory conditions and injuries that can cause respiratory distress in infants and children.

Question 3

Type: MCSA

A child is admitted to the hospital with the diagnosis of laryngotracheobronchitis (LTB). Which nursing intervention is the priority for this child?

1. Administer nebulized epinephrine and oral or IM dexamethasone.

2. Administer antibiotics and assist with possible intubation.

3. Swab the throat for a throat culture.

4. Obtain a sputum specimen.

Correct Answer: 1

Rationale 1: Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.

Rationale 2: Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.

Rationale 3: Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.

Rationale 4: Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.

Global Rationale: Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 20.6 Create a nursing care plan for a child with a common acute respiratory condition.

Question 4

Type: MCSA

The nurse is teaching a group of mothers of infants about the benefits of immunization. Which immunization will the nurse teach to the mothers that can assist in preventing the life-threatening disease epiglottitis?

1. Measles, mumps, and rubella (MMR)

2. Haemophilus influenzae type B (HIB)

3. Hepatitis B

4. Polio

Correct Answer: 2

Rationale 1: The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Rationale 2: The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Rationale 3: The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Rationale 4: The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Global Rationale: The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 20.2 Contrast the different respiratory conditions and injuries that can cause respiratory distress in infants and children.

Question 5

Type: MCSA

A nurse is assessing a neonate. Which assessment finding indicates that the neonates respiratory status is worsening?

1. Acrocyanosis

2. Arterial CO2 of 40

3. Periorbital edema

4. Grunting respirations with nasal flaring

Correct Answer: 4

Rationale 1: Grunting respirations with nasal flaring indicates respiratory status is becoming worse. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate. CO2 of 40 is within a normal range. Periorbital edema does not necessarily mean deterioration in respiratory status.

Rationale 2: Grunting respirations with nasal flaring indicates respiratory status is becoming worse. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate. CO2 of 40 is within a normal range. Periorbital edema does not necessarily mean deterioration in respiratory status.

Rationale 3: Grunting respirations with nasal flaring indicates respiratory status is becoming worse. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate. CO2 of 40 is within a normal range. Periorbital edema does not necessarily mean deterioration in respiratory status.

Rationale 4: Grunting respirations with nasal flaring indicates respiratory status is becoming worse. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate. CO2 of 40 is within a normal range. Periorbital edema does not necessarily mean deterioration in respiratory status.

Global Rationale: Grunting respirations with nasal flaring indicates respiratory status is becoming worse. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate. CO2 of 40 is within a normal range. Periorbital edema does not necessarily mean deterioration in respiratory status.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 20.8 Perform a nursing assessment of the child with an acute lung injury.

Question 6

Type: MCSA

Which nursing diagnosis is most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)?

1. Activity Intolerance

2. Decreased Cardiac Output

3. Pain, Acute

4. Tissue Perfusion, Ineffective (peripheral)

Correct Answer: 1

Rationale 1: Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.

Rationale 2: Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.

Rationale 3: Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.

Rationale 4: Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.

Global Rationale: Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 20.2 Contrast the different respiratory conditions and injuries that can cause respiratory distress in infants and children.

Question 7

Type: MCSA

A child is admitted to the hospital with pneumonia. The childs oximetry reading is 88 percent upon admission to the pediatric floor. Which is the priority nursing intervention for this child?

1. Obtain a blood sample to send to the lab for electrolyte analysis.

2. Begin oxygen per nasal cannula.

3. Medicate for pain.

4. Begin administration of intravenous fluids.

Correct Answer: 2

Rationale 1: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the childs oxygenation status has been addressed.

Rationale 2: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the childs oxygenation status has been addressed.

Rationale 3: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the childs oxygenation status has been addressed.

Rationale 4: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the childs oxygenation status has been addressed.

Global Rationale: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the childs oxygenation status has been addressed.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 20.4 Assess the childs respiratory status and analyze the need for oxygen supplementation.

Question 8

Type: MCSA

The practitioner changes the medications for the child with asthma to salmeterol (Serevent). The mother asks the nurse what this drug will do. The nurse explains that salmeterol (Serevent) is used to treat asthma because the drug produces which characteristic?

1. Decreases inflammation

2. Decreases mucous production

3. Controls allergic rhinitis

4. Dilates the bronchioles

Correct Answer: 4

Rationale 1: Salmeterol (Serevent) is a long-acting beta2-agonist that acts by bronchodilating. Steroids are anti-inflammatory, anticholinergics decrease mucous production, and antihistamines control allergic rhinitis.

Rationale 2: Salmeterol (Serevent) is a long-acting beta2-agonist that acts by bronchodilating. Steroids are anti-inflammatory, anticholinergics decrease mucous production, and antihistamines control allergic rhinitis.

Rationale 3: Salmeterol (Serevent) is a long-acting beta2-agonist that acts by bronchodilating. Steroids are anti-inflammatory, anticholinergics decrease mucous production, and antihistamines control allergic rhinitis.

Rationale 4: Salmeterol (Serevent) is a long-acting beta2-agonist that acts by bronchodilating. Steroids are anti-inflammatory, anticholinergics decrease mucous production, and antihistamines control allergic rhinitis.

Global Rationale: Salmeterol (Serevent) is a long-acting beta2-agonist that acts by bronchodilating. Steroids are anti-inflammatory, anticholinergics decrease mucous production, and antihistamines control allergic rhinitis.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 20.6 Create a nursing care plan for a child with a common acute respiratory condition.

Question 9

Type: MCSA

Following parental teaching, the nurse is evaluating the parents understanding of environmental control for their childs asthma management. Which statement by the parents indicates appropriate understanding of the teaching?

1. We will replace the carpet in our childs bedroom with tile.

2. Were glad the dog can continue to sleep in our childs room.

3. Well be sure to use the fireplace often to keep the house warm in the winter.

4. Well keep the plants in our childs room dusted.

Correct Answer: 1

Rationale 1: Control of dust in the childs bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

Rationale 2: Control of dust in the childs bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

Rationale 3: Control of dust in the childs bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

Rationale 4: Control of dust in the childs bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

Global Rationale: Control of dust in the childs bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 20.6 Create a nursing care plan for a child with a common acute respiratory condition.

Question 10

Type: MCSA

A newborn is suspected of having cystic fibrosis. As the child is being prepared for transfer to a pediatric hospital, the mother asks the nurse which symptoms made the practitioner suspect cystic fibrosis. Which response by the nurse is the most appropriate?

1. Steatorrheic stools

2. Constipation

3. Meconium ileus

4. Rectal prolapse

Correct Answer: 3

Rationale 1: Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child.

Rationale 2: Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child.

Rationale 3: Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child.

Rationale 4: Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child.

Global Rationale: Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 20.2 Contrast the different respiratory conditions and injuries that can cause respiratory distress in infants and children.

Question 11

Type: MCSA

The nurse is teaching the parents of a newly diagnosed cystic fibrosis patient how to administer the pancreatic enzymes. How often will the nurse teach the parents to administer the enzymes?

1. Two times per day

2. With meals and snacks

3. Every 6 hours around the clock

4. Four times per day

Correct Answer: 2

Rationale 1: Pancreatic enzymes are administered with meals and large snacks. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Rationale 2: Pancreatic enzymes are administered with meals and large snacks. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Rationale 3: Pancreatic enzymes are administered with meals and large snacks. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Rationale 4: Pancreatic enzymes are administered with meals and large snacks. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Global Rationale: Pancreatic enzymes are administered with meals and large snacks. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 20.6 Create a nursing care plan for a child with a common acute respiratory condition.

Question 12

Type: FIB

A child with asthma will be receiving an oral dose of prednisone. The order reads prednisone 2 mg/kg per day. The child weighs 50 lbs. The child will receive ____ milligrams daily. (Round the answer.)

Standard Text: Round the answer to the nearest whole number.

Correct Answer: 45.5 = 46

Rationale: 22.7 2 = 45.5 (46)

Global Rationale: 22.7 2 = 45.5 (46)

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 07. Plan the nursing care for the child with a chronic respiratory condition.

Question 13

Type: MCSA

Parents of a child admitted with respiratory distress are concerned because the child wont lie down and wants to sit in a chair leaning forward. Which response by the nurse is the most appropriate?

1. This helps the child feel in control of his situation.

2. The child needs to be encouraged to lie flat in bed.

3. This position helps keep the airway open.

4. This confirms the child has asthma.

Correct Answer: 3

Rationale 1: Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward. Lying flat in bed will increase the respiratory distress. This position does not confirm asthma.

Rationale 2: Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward. Lying flat in bed will increase the respiratory distress. This position does not confirm asthma.

Rationale 3: Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward. Lying flat in bed will increase the respiratory distress. This position does not confirm asthma.

Rationale 4: Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward. Lying flat in bed will increase the respiratory distress. This position does not confirm asthma.

Global Rationale: Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward. Lying flat in bed will increase the respiratory distress. This position does not confirm asthma.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 20.6 Create a nursing care plan for a child with a common acute respiratory condition.

Question 14

Type: MCSA

A child is prescribed rifampicin for treatment of tuberculosis. For which length of time will the nurse tell the parents that this child must remain on the medication?

1. 2 months

2. 4 months

3. 6 months

4. 8 months

Correct Answer: 3

Rationale 1: Active and latent TB are treated with isoniazid, rifampicin, pyrazinamide, and ethambutol. Therapy for active TB usually involves a 6-month regimen consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol for the first 2 months and isoniazid and rifampicin for the remaining 4 months. Therefore, the child will remain on rifampicin for a total of 6 months.

Rationale 2: Active and latent TB are treated with isoniazid, rifampicin, pyrazinamide, and ethambutol. Therapy for active TB usually involves a 6-month regimen consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol for the first 2 months and isoniazid and rifampicin for the remaining 4 months. Therefore, the child will remain on rifampicin for a total of 6 months.

Rationale 3: Active and latent TB are treated with isoniazid, rifampicin, pyrazinamide, and ethambutol. Therapy for active TB usually involves a 6-month regimen consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol for the first 2 months and isoniazid and rifampicin for the remaining 4 months. Therefore, the child will remain on rifampicin for a total of 6 months.

Rationale 4: Active and latent TB are treated with isoniazid, rifampicin, pyrazinamide, and ethambutol. Therapy for active TB usually involves a 6-month regimen consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol for the first 2 months and isoniazid and rifampicin for the remaining 4 months. Therefore, the child will remain on rifampicin for a total of 6 months.

Global Rationale: Active and latent TB are treated with isoniazid, rifampicin, pyrazinamide, and ethambutol. Therapy for active TB usually involves a 6-month regimen consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol for the first 2 months and isoniazid and rifampicin for the remaining 4 months. Therefore, the child will remain on rifampicin for a total of 6 months.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 20.6 Create a nursing care plan for a child with a common acute respiratory condition.

Question 15

Type: MCMA

The nurse is providing care to an infant who is diagnosed with bronchiolitis. Which breath sounds indicate the infant is experiencing respiratory distress?

Standard Text: Select all that apply.

1. Tachypnea

2. Wheezing

3. Grunting

4. Retractions

5. Eupnea

Correct Answer: 1,2,3

Rationale 1: Wheezing and grunting are adventitious respiratory sounds that indicates respiratory distress in the neonate. Tachypnea is the term used to indicate a respiratory rate of greater than 60 breaths per minute in an infant. While this does indicate respiratory distress, tachynpea is not a type of breath sound. Retractions, or the use of accessory muscles, are indicative of respiratory distress in the neonate, but this is not a type of breath sound. Eupnea is the medical term for normal breathing.

Rationale 2: Wheezing and grunting are adventitious respiratory sounds that indicates respiratory distress in the neonate. Tachypnea is the term used to indicate a respiratory rate of greater than 60 breaths per minute in an infant. While this does indicate respiratory distress, tachynpea is not a type of breath sound. Retractions, or the use of accessory muscles, are indicative of respiratory distress in the neonate, but this is not a type of breath sound. Eupnea is the medical term for normal breathing.

Rationale 3: Wheezing and grunting are adventitious respiratory sounds that indicates respiratory distress in the neonate. Tachypnea is the term used to indicate a respiratory rate of greater than 60 breaths per minute in an infant. While this does indicate respiratory distress, tachynpea is not a type of breath sound. Retractions, or the use of accessory muscles, are indicative of respiratory distress in the neonate, but this is not a type of breath sound. Eupnea is the medical term for normal breathing.

Rationale 4: Wheezing and grunting are adventitious respiratory sounds that indicates respiratory distress in the neonate. Tachypnea is the term used to indicate a respiratory rate of greater than 60 breaths per minute in an infant. While this does indicate respiratory distress, tachynpea is not a type of breath sound. Retractions, or the use of accessory muscles, are indicative of respiratory distress in the neonate, but this is not a type of breath sound. Eupnea is the medical term for normal breathing.

Rationale 5: Wheezing and grunting are adventitious respiratory sounds that indicates respiratory distress in the neonate. Tachypnea is the term used to indicate a respiratory rate of greater than 60 breaths per minute in an infant. While this does indicate respiratory distress, tachynpea is not a type of breath sound. Retractions, or the use of accessory muscles, are indicative of respiratory distress in the neonate, but this is not a type of breath sound. Eupnea is the medical term for normal breathing.

Global Rationale: Wheezing and grunting are adventitious respiratory sounds that indicates respiratory distress in the neonate. Tachypnea is the term used to indicate a respiratory rate of greater than 60 breaths per minute in an infant. While this does indicate respiratory distress, tachynpea is not a type of breath sound. Retractions, or the use of accessory muscles, are indicative of respiratory distress in the neonate, but this is not a type of breath sound. Eupnea is the medical term for normal breathing.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Phyiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 20.3 Explain the visual and auditory observations made to assess a childs respiratory effort or work of breathing.

Question 16

Type: MCMA

The nurse educator is teaching a group of nursing students how to perform a respiratory assessment for a newborn in the newborn intensive care unit (NICU) diagnosed with respiratory distress syndrome (RDS). Which normal characteristics of the newborns respiratory system increase the risk for obstruction?

Standard Text: Select all that apply.

1. Shorter and narrower airway

2. Higher trachea

3. Bronchial branching at different angles

4. Inadequate smooth muscle bundles

5. Diaphragmatic breather

Correct Answer: 1,2,3

Rationale 1: Normal characteristics of the pediatric respiratory system that increase the risk for obstruction include a shorter and narrower airway, a higher trachea, and a different angle for bronchial branching. Inadequate smooth muscle bundles and being diaphragmatic breathers are characteristics that do not increase the risk of obstruction.

Rationale 2: Normal characteristics of the pediatric respiratory system that increase the risk for obstruction include a shorter and narrower airway, a higher trachea, and a different angle for bronchial branching. Inadequate smooth muscle bundles and being diaphragmatic breathers are characteristics that do not increase the risk of obstruction.

Rationale 3: Normal characteristics of the pediatric respiratory system that increase the risk for obstruction include a shorter and narrower airway, a higher trachea, and a different angle for bronchial branching. Inadequate smooth muscle bundles and being diaphragmatic breathers are characteristics that do not increase the risk of obstruction.

Rationale 4: Normal characteristics of the pediatric respiratory system that increase the risk for obstruction include a shorter and narrower airway, a higher trachea, and a different angle for bronchial branching. Inadequate smooth muscle bundles and being diaphragmatic breathers are characteristics that do not increase the risk of obstruction.

Rationale 5: Normal characteristics of the pediatric respiratory system that increase the risk for obstruction include a shorter and narrower airway, a higher trachea, and a different angle for bronchial branching. Inadequate smooth muscle bundles and being diaphragmatic breathers are characteristics that do not increase the risk of obstruction.

Global Rationale: Normal characteristics of the pediatric respiratory system that increase the risk for obstruction include a shorter and narrower airway, a higher trachea, and a different angle for bronchial branching. Inadequate smooth muscle bundles and being diaphragmatic breathers are characteristics that do not increase the risk of obstruction.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Phyiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 20.1 Describe unique characteristics of the pediatric respiratory system anatomy and physiology and apply that information to the care of children with respiratory conditions.

Question 17

Type: MCMA

A school nurse is planning care for a school-age child recently diagnosed with asthma. Which items will the school nurse include in the plan of care at the school?

Standard Text: Select all that apply.

1. Maintain a log of quick-relief medication administration.

2. Call the parents if quick-relief medications work appropriately.

3. Assess for symptoms of exercise-induced bronchospasm.

4. Coordinate education of the childs teachers.

5. Conduct a support group for all children with asthma.

Correct Answer: 1,3,4,5

Rationale 1: Appropriate interventions for the school nurse to include in the plan of care include: keeping a log of the quick-relief medications administered; assessing the child for exercise-induced bronchospasms and reporting, if needed; coordinating education of the childs teachers; and conducting a support group for all children in the school with asthma. The nurse would only call the parents if the quick-relief mediation was not effective in treating the childs symptoms.

Rationale 2: Appropriate interventions for the school nurse to include in the plan of care include: keeping a log of the quick-relief medications administered; assessing the child for exercise-induced bronchospasms and reporting, if needed; coordinating education of the childs teachers; and conducting a support group for all children in the school with asthma. The nurse would only call the parents if the quick-relief mediation was not effective in treating the childs symptoms.

Rationale 3: Appropriate interventions for the school nurse to include in the plan of care include: keeping a log of the quick-relief medications administered; assessing the child for exercise-induced bronchospasms and reporting, if needed; coordinating education of the childs teachers; and conducting a support group for all children in the school with asthma. The nurse would only call the parents if the quick-relief mediation was not effective in treating the childs symptoms.

Rationale 4: Appropriate interventions for the school nurse to include in the plan of care include: keeping a log of the quick-relief medications administered; assessing the child for exercise-induced bronchospasms and reporting, if needed; coordinating education of the childs teachers; and conducting a support group for all children in the school with asthma. The nurse would only call the parents if the quick-relief mediation was not effective in treating the childs symptoms.

Rationale 5: Appropriate interventions for the school nurse to include in the plan of care include: keeping a log of the quick-relief medications administered; assessing the child for exercise-induced bronchospasms and reporting, if needed; coordinating education of the childs teachers; and conducting a support group for all children in the school with asthma. The nurse would only call the parents if the quick-relief mediation was not effective in treating the childs symptoms.

Global Rationale: Appropriate interventions for the school nurse to include in the plan of care include: keeping a log of the quick-relief medications administered; assessing the child for exercise-induced bronchospasms and reporting, if needed; coordinating education of the childs teachers; and conducting a support group for all children in the school with asthma. The nurse would only call the parents if the quick-relief mediation was not effective in treating the childs symptoms.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Phyiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 20.7 Develop a school-based nursing care plan for the child with asthma.

 

Question 18

Type: MCSA

The nurse is providing care to an infant in the emergency department. Upon assessment, the infant is noted to have to be experiencing tachypnea, wheezing, retractions, and nasal flaring. The infant is irritability and the parents state the infant has had poor fluid intake for two days. Pulse ox reading is currently at 85% on room air. The infants blood gas is pending. Which diagnosis does the nurse anticipate for this infant?

1. Bronchitis

2. Bronchiolitis

3. Pneumonia

4. Active pulmonary tuberculosis

Correct Answer: 2

Rationale 1: The nurse anticipates the infant will be diagnosed with bronchiolitis. Symptoms of bronchiolitis include mild respiratory symptoms that progress to tachypnea, wheezing, retractions, nasal flaring, irritability, poor fluid intake, hypoxia, cyanosis, and decreased mental status. Symptoms of bronchitis include a dry hacking cough, increases in severity at night, painful chest and ribs. Symptoms of pneumonia include initial rhinitis and cough, followed by fever, crackles, wheezes, dyspnea, tachypnea, restlessness, diminished breath sounds. Symptoms of active pulmonary tuberculosis include persistent cough, decreased appetite, weight loss or failure to gain weight, low-grade fever, night sweats, chills, enlarged lymph nodes.

Rationale 2: The nurse anticipates the infant will be diagnosed with bronchiolitis. Symptoms of bronchiolitis include mild respiratory symptoms that progress to tachypnea, wheezing, retractions, nasal flaring, irritability, poor fluid intake, hypoxia, cyanosis, and decreased mental status. Symptoms of bronchitis include a dry hacking cough, increases in severity at night, painful chest and ribs. Symptoms of pneumonia include initial rhinitis and cough, followed by fever, crackles, wheezes, dyspnea, tachypnea, restlessness, diminished breath sounds. Symptoms of active pulmonary tuberculosis include persistent cough, decreased appetite, weight loss or failure to gain weight, low-grade fever, night sweats, chills, enlarged lymph nodes.

Rationale 3: The nurse anticipates the infant will be diagnosed with bronchiolitis. Symptoms of bronchiolitis include mild respiratory symptoms that progress to tachypnea, wheezing, retractions, nasal flaring, irritability, poor fluid intake, hypoxia, cyanosis, and decreased mental status. Symptoms of bronchitis include a dry hacking cough, increases in severity at night, painful chest and ribs. Symptoms of pneumonia include initial rhinitis and cough, followed by fever, crackles, wheezes, dyspnea, tachypnea, restlessness, diminished breath sounds. Symptoms of active pulmonary tuberculosis include persistent cough, decreased appetite, weight loss or failure to gain weight, low-grade fever, night sweats, chills, enlarged lymph nodes..

Rationale 4: The nurse anticipates the infant will be diagnosed with bronchiolitis. Symptoms of bronchiolitis include mild respiratory symptoms that progress to tachypnea, wheezing, retractions, nasal flaring, irritability, poor fluid intake, hypoxia, cyanosis, and decreased mental status. Symptoms of bronchitis include a dry hacking cough, increases in severity at night, painful chest and ribs. Symptoms of pneumonia include initial rhinitis and cough, followed by fever, crackles, wheezes, dyspnea, tachypnea, restlessness, diminished breath sounds. Symptoms of active pulmonary tuberculosis include persistent cough, decreased appetite, weight loss or failure to gain weight, low-grade fever, night sweats, chills, enlarged lymph nodes.

Global Rationale: The nurse anticipates the infant will be diagnosed with bronchiolitis. Symptoms of bronchiolitis include mild respiratory symptoms that progress to tachypnea, wheezing, retractions, nasal flaring, irritability, poor fluid intake, hypoxia, cyanosis, and decreased mental status. Symptoms of bronchitis include a dry hacking cough, increases in severity at night, painful chest and ribs. Symptoms of pneumonia include initial rhinitis and cough, followed by fever, crackles, wheezes, dyspnea, tachypnea, restlessness, diminished breath sounds. Symptoms of active pulmonary tuberculosis include persistent cough, decreased appetite, weight loss or failure to gain weight, low-grade fever, night sweats, chills, enlarged lymph nodes.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Phyiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 20.5 Distinguish between conditions of the lower respiratory tract that cause illness in children.

Question 19

Type: MCMA

The nurse is assessing a school-age client who experienced blunt force trauma to the chest when an airbag deployed following a motor vehicle crash. Which areas of assessment are essential for this client?

Standard Text: Select all that apply.

1. Monitor responsiveness and behavior.

2. Monitor SpO2.

3. Auscultate the lungs for crackles, wheezes, decreased breath sounds.

4. Document input and output.

5. Note changes in voice quality or coughing.

Correct Answer: 1,2,3,4

Rationale 1: The areas of assessment that are essential for this client include: monitoring for responsive and behavior in order to detect hypoxia and the potential for airway obstruction; monitoring SpO2 frequently to identify changes indicating deterioration in condition; auscultating the lungs for crackles, wheezes, decreased breath sound; and noting changes in voice quality or coughing. Documenting input and output is not a priority for this client.

Rationale 2: The areas of assessment that are essential for this client include: monitoring for responsive and behavior in order to detect hypoxia and the potential for airway obstruction; monitoring SpO2 frequently to identify changes indicating deterioration in condition; auscultating the lungs for crackles, wheezes, decreased breath sound; and noting changes in voice quality or coughing. Documenting input and output is not a priority for this client.

Rationale 3: The areas of assessment that are essential for this client include: monitoring for responsive and behavior in order to detect hypoxia and the potential for airway obstruction; monitoring SpO2 frequently to identify changes indicating deterioration in condition; auscultating the lungs for crackles, wheezes, decreased breath sound; and noting changes in voice quality or coughing. Documenting input and output is not a priority for this client.

Rationale 4: The areas of assessment that are essential for this client include: monitoring for responsive and behavior in order to detect hypoxia and the potential for airway obstruction; monitoring SpO2 frequently to identify changes indicating deterioration in condition; auscultating the lungs for crackles, wheezes, decreased breath sound; and noting changes in voice quality or coughing. Documenting input and output is not a priority for this client.

Rationale 5: The areas of assessment that are essential for this client include: monitoring for responsive and behavior in order to detect hypoxia and the potential for airway obstruction; monitoring SpO2 frequently to identify changes indicating deterioration in condition; auscultating the lungs for crackles, wheezes, decreased breath sound; and noting changes in voice quality or coughing. Documenting input and output is not a priority for this client.

Global Rationale: The areas of assessment that are essential for this client include: monitoring for responsive and behavior in order to detect hypoxia and the potential for airway obstruction; monitoring SpO2 frequently to identify changes indicating deterioration in condition; auscultating the lungs for crackles, wheezes, decreased breath sound; and noting changes in voice quality or coughing. Documenting input and output is not a priority for this client.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Phyiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 20.8 Perform a nursing assessment of the child with an acute lung injury.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 6th Ed. Test Bank

Copyright 2015 by Pearson Education, Inc.

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