CHAPTER 21: FLUID AND ELECTROLYTE ALTERATIONS My Nursing Test Banks

CHAPTER 21: FLUID AND ELECTROLYTE ALTERATIONS

MULTIPLE CHOICE

1.Which of the following statements represents a true difference between the fluids and electrolytes of a child compared to those of an adult?

a.

Water constitutes a smaller percent of the body weight of children.

b.

A smaller percent of the body weight is in the extracellular compartment in children.

c.

Infants and children have a relatively greater body surface area than adults.

d.

Infants and children have a lower basal metabolic rate than adults.

ANS: C

Feedback

A

Incorrect: Water constitutes a higher percent of the body weight of children than adults.

B

Incorrect: A larger percent of the body weight is in the extracellular compartment in children.

C

Correct: Infants and children have a relatively greater body surface area than adults.

D

Incorrect: Infants and children have a higher basal metabolic rate than adults.

PTS:1REF:p. 656 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Knowledge

2.Children reach adult water distribution percentages in the body by the time the child is how old?

a.

1 year

c.

5 years

b.

3 years

d.

8 years

ANS: C

Feedback

A

Incorrect: Children do not reach adult water distribution percentages in the body by the time they are 1 year old.

B

Incorrect: Children do not reach adult water distribution percentages in the body by the time they are 3 years old.

C

Correct: Children reach adult water distribution percentages in the body by the time they are 5 years old.

D

Incorrect: Children do not reach adult water distribution percentages in the body by the time they are 8 years old.

PTS:1REF:p. 656 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Knowledge

3.What percentage of an infants body water is located in extracellular spaces?

a.

20%

c.

40%

b.

30%

d.

50%

ANS: C

Feedback

A

Incorrect: Twenty percent of an infants body water is not located in extracellular spaces.

B

Incorrect: Thirty percent of an infants body water is not located in extracellular spaces.

C

Correct: Forty percent of an infants body water is located in extracellular spaces.

D

Incorrect: Fifty percent of an infants body water is not located in extracellular spaces.

PTS:1REF:p. 656 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Knowledge

4.Which of the following substances is the predominant component of extracellular fluid?

a.

saline

c.

proteins

b.

potassium

d.

phosphate

ANS: A

Feedback

A

Correct: Saline is the predominant component of extracellular fluid because it contains large amounts of sodium, chloride, and bicarbonate.

B

Incorrect: Potassium is not the predominant component of extracellular fluid. It is the predominant component of intracellular fluid.

C

Incorrect: Proteins are not the predominant component of extracellular fluid.

D

Incorrect: Phosphate is not the predominant component of extracellular fluid.

PTS: 1 REF: p. 656 Electrolyte Imbalances OBJ: Cognitive Level: Knowledge

5.Regulation of homeostatic changes associated with fluids and electrolytes in infants and young children is much slower than in adults because of childrens:

a.

proportionately smaller stomach and intestines

b.

immature kidneys and buffering systems

c.

differences in the chemical composition of the body

d.

immature nervous systems

ANS: B

Feedback

A

Incorrect: The proportionately smaller stomach and intestines in infants and young children are not a factor in the regulation of homeostatic changes associated with fluids and electrolytes.

B

Correct: Regulation of homeostatic changes associated with fluids and electrolytes in infants and young children is much slower than in adults because of childrens immature kidneys and buffering systems. Children need more water to excrete a given amount of solute.

C

Incorrect: Differences in the chemical composition of the body of children compared with adults are not a factor in the regulation of homeostatic changes associated with fluids and electrolytes.

D

Incorrect: Immature nervous systems of infants and children are not a factor in the regulation of homeostatic changes associated with fluids and electrolytes.

PTS:1REF:p. 657 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Comprehension

6.Insensible water loss per unit of body weight is:

a.

less in children and infants compared to adults

b.

about the same in infants and children compared to adults

c.

higher in infants and children

d.

significantly higher in infants and children

ANS: C

Feedback

A

Incorrect: Insensible water loss per unit of body weight is not less in children and infants compared to adults.

B

Incorrect: Insensible water loss per unit of body weight is not about the same in children and infants compared to adults.

C

Correct: Insensible water loss per unit of body weight is higher in children and infants compared to adults.

D

Incorrect: Insensible water loss per unit of body weight is not significantly higher in children and infants compared to adults.

PTS:1REF:p. 658 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Comprehension

7.When solutes flow from an area of higher concentration to an area of lower concentration until equilibrium is reached, given that pressures on either side of the membrane are equal, the movement of the solute across the membrane does so by:

a.

filtration

c.

diffusion

b.

osmosis

d.

transference

ANS: C

Feedback

A

Incorrect: Filtration is the movement of a solute based on the force exerted by the weight of the solution. The fluid containing the solute will move from an area of greater pressure to an area of lesser pressure.

B

Incorrect: Osmosis is the movement of water across a semipermeable membrane from a solution that has a lower solute concentration to one that has a higher solute concentration.

C

Correct: When solutes flow from an area of higher concentration to an area of lower concentration until equilibrium is reached, given that pressures on either side of the membrane are equal, the movement of the solute across the membrane does so by diffusion.

D

Incorrect: Transference is not related to the movement of fluids or solutes.

PTS:1REF:p. 657 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Comprehension

8.Which of the following types of pressure is a force caused by the amount of plasma proteins in the vascular system and which holds the fluids in the capillaries?

a.

oncotic

c.

protein

b.

osmotic

d.

filtration

ANS: A

Feedback

A

Correct: Oncotic pressure, which is caused by the amount of plasma proteins in the vascular system, holds fluids in the capillaries.

B

Incorrect: Osmotic pressure is a force within the capillary beds that tends to pull water into the capillaries.

C

Incorrect: Protein is not a type of pressure caused by the amount of plasma proteins in the vascular system and which holds the fluids in the capillaries.

D

Incorrect: Filtration is the movement of a solute based on the force exerted by the weight of the solution.

PTS:1REF:p. 657 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Comprehension

9.Which kind of pressure is a force within the capillary beds that tends to pull water into the capillaries?

a.

oncotic

c.

hydrostatic

b.

osmotic

d.

filtration

ANS: B

Feedback

A

Incorrect: Oncotic pressure, which is caused by the amount of plasma proteins in the vascular system, holds fluids in the capillaries.

B

Correct: Osmotic pressure is a force within the capillary beds that tends to pull water into the capillaries.

C

Incorrect: Hydrostatic pressure is the pressure of blood against the capillary walls generated by the contraction of the heart.

D

Incorrect: Filtration is the movement of a solute based on the force exerted by the weight of the solution.

PTS:1REF:p. 657 Anatomy and Physiology

OBJ: Cognitive Level: Comprehension

10.Which of the following is the pressure of blood against the capillary walls generated by the contraction of the heart?

a.

oncotic

c.

hydrostatic

b.

osmotic

d.

filtration

ANS: C

Feedback

A

Incorrect: Oncotic pressure, which is caused by the amount of plasma proteins in the vascular system, holds fluids in the capillaries.

B

Incorrect: Osmotic pressure is a force within the capillary beds that tends to pull water into the capillaries.

C

Correct: Hydrostatic pressure is the pressure of blood against the capillary walls generated by the contraction of the heart.

D

Incorrect: Filtration is the movement of a solute based on the force exerted by the weight of the solution.

PTS:1REF:p. 657 Electrolyte Imbalances

OBJ: Cognitive Level: Comprehension

11.When the nurse takes a blood pressure reading, the nurse is measuring which of the following kinds of pressure?

a.

hydrostatic

c.

velocity

b.

viscosity

d.

osmotic

ANS: A

Feedback

A

Correct: When the nurse takes a blood pressure reading, the nurse is measuring hydrostatic pressure.

B

Incorrect: When the nurse takes a blood pressure reading, the nurse is not measuring viscosity pressure.

C

Incorrect: When the nurse takes a blood pressure reading, the nurse is not measuring velocity pressure.

D

Incorrect: When the nurse takes a blood pressure reading, the nurse is not measuring osmotic pressure.

PTS:1REF:p. 657 Anatomy and Physiology

OBJ: Cognitive Level: Comprehension

12.The formula for calculating daily fluid requirements for an infant weighing less than 10 kilograms is:

a.

10 milliliters per kilogram

c.

50 milliliters per kilogram

b.

25 milliliters per kilogram

d.

100 milliliters per kilogram

ANS: D

Feedback

A

Incorrect: The formula for calculating daily fluid requirements for an infant weighing less than 10 kilograms is not 10 milliliters per kilogram.

B

Incorrect: The formula for calculating daily fluid requirements for an infant weighing less than 10 kilograms is not 25 milliliters per kilogram.

C

Incorrect: The formula for calculating daily fluid requirements for an infant weighing less than 10 kilograms is not 50 milliliters per kilogram.

D

Correct: The formula for calculating daily fluid requirements for an infant weighing less than 10 kilograms is 100 milliliters per kilogram.

PTS:1REF:p. 658 Anatomy and Physiology

OBJ: Cognitive Level: Comprehension

13.What is the daily fluid requirement for an infant weighing 5 kilograms?

a.

250 milliliters

c.

1 liter

b.

500 milliliters

d.

1-1/2 liters

ANS: B

Feedback

A

Incorrect: The daily fluid requirement for an infant weighing 5 kilograms is not 250 milliliters.

B

Correct: The daily fluid requirement for an infant weighing 5 kilograms is 500 milliliters. The formula is 100ml/kg so an infant weighing 5 kg requires 500 milliliters.

C

Incorrect: The daily fluid requirement for an infant weighing 5 kilograms is not 1 liter.

D

Incorrect: The daily fluid requirement for an infant weighing 5 kilograms is not 1-1/2 liters.

PTS:1REF:p. 658 Anatomy and Physiology

OBJ: Cognitive Level: Application

14.You are the nurse calculating the minimum acceptable urine output per hour for an infant who weighs 5 kilograms (kg). Which of the following amounts in cubic centimeters (cc) would you find to be acceptable?

a.

4-9

c.

16-22

b.

10-15

d.

25-30

ANS: B

Feedback

A

Incorrect: The minimum acceptable urine output per hour for an infant who weighs 5 kilograms is not >4-9 cc.

B

Correct: The minimum acceptable urine output per hour for an infant who weighs 5 kilograms is >10-15 cc. The formula for calculating minimum urine output for infants is >2-3 ml/kg/hr.

C

Incorrect: The minimum acceptable urine output per hour for an infant who weighs 5 kilograms is not >16-22 cc.

D

Incorrect: The minimum acceptable urine output per hour for an infant who weighs 5 kilograms is not >25-30 cc.

PTS:1REF:p. 658 Anatomy and Physiology

OBJ: Cognitive Level: Application

15.The normal minimum urine output for older school-aged and adolescent children is how many milliliters per kilogram per hour?

a.

5-10

c.

1-2

b.

2-3

d.

0.5-1

ANS: D

Feedback

A

Incorrect: The normal minimum urine output for older school-aged and adolescent children is not > 5-10 milliliters per kilogram per hour.

B

Incorrect: The normal minimum urine output for older school-aged and adolescent children is not > 2-3 milliliters per kilogram per hour.

C

Incorrect: The normal minimum urine output for older school-aged and adolescent children is not > 1-2 milliliters per kilogram per hour.

D

Correct: The normal minimum urine output for older school-aged and adolescent children is > 0.5-1 milliliters per kilogram per hour.

PTS:1REF:p. 658 Anatomy and Physiology

OBJ: Cognitive Level: Application

16.Which of the following is the electrolyte responsible for establishing and maintaining the osmolarity and volume of the extracellular fluid?

a.

calcium

c.

sodium

b.

potassium

d.

phosphate

ANS: C

Feedback

A

Incorrect: The electrolyte calcium is not responsible for establishing and maintaining the osmolarity and volume of the extracellular fluid.

B

Incorrect: The electrolyte potassium is not responsible for establishing and maintaining the osmolarity and volume of the extracellular fluid.

C

Correct: The electrolyte sodium is responsible for establishing and maintaining the osmolarity and volume of the extracellular fluid.

D

Incorrect: The electrolyte phosphate is not responsible for establishing and maintaining the osmolarity and volume of the extracellular fluid

PTS: 1 REF: p. 658 Electrolyte Imbalances OBJ: Cognitive Level: Knowledge

17.The nurse coming on duty gets a laboratory report on an assigned child, and the serum sodium level is reported as 133 milliequivalents per liter (mEq/L). The nurse would expect this client with a 133 mEq/L sodium level to:

a.

be experiencing headache, muscle weakness, and abdominal cramps

b.

have flushed skin, an elevated temperature, and intense thirst

c.

have a slow pulse rate, decreased respirations, and elevated blood pressure

d.

appear perfectly normal because this is a normal serum sodium level for a child

ANS: A

Feedback

A

Correct: The nurse would expect this client with a 133 mEq/L sodium level to be experiencing headache, muscle weakness, and abdominal cramps. Normal sodium level for a child is 135-148 mEq/L so this client has hyponatremia or low serum sodium level.

B

Incorrect: Flushed skin, an elevated temperature, and intense thirst are symptoms of hypernatremia or increased serum sodium level.

C

Incorrect: The nurse would not expect this client with a 133 mEq/L sodium level to have a slow pulse rate, decreased respirations, and elevated blood pressure.

D

Incorrect: The nurse would not expect this client with a 133 mEq/L sodium level to appear perfectly normal because this is a normal serum sodium level for a child. This is a low serum sodium level.

PTS:1REF:p. 658 Electrolyte Imbalances

OBJ: Cognitive Level: Application

18.When the nurse finds that a child has a sodium level of more than 145 milliequivalents per liter, the nurse would most expect to see:

a.

diarrhea and vomiting

c.

moist mucous membranes

b.

dry mucous membranes and thirst

d.

subnormal temperature

ANS: B

Feedback

A

Incorrect: A child with a sodium level of more than 145 milliequivalents per liter indicates an increased serum sodium level (hypernatremia), and the nurse would not most expect to see diarrhea and vomiting.

B

Correct: The nurse would most expect to see dry mucous membranes and thirst in this child because water is pulled out of the cells into the extracellular spaces, resulting in an intracellular fluid deficit.

C

Incorrect: The nurse would not most expect to see moist mucous membranes, but rather dry mucous membranes.

D

Incorrect: The nurse would not most expect to see a subnormal temperature, but rather an elevated temperature.

PTS:1REF:p. 660 Electrolyte Imbalances

OBJ: Cognitive Level: Application

19.The difference between the intracellular and the extracellular level of potassium determines the:

a.

pulse pressure of an individual

c.

excitability of neurons and muscles

b.

viscosity of the blood

d.

amount of edema a person has

ANS: C

Feedback

A

Incorrect: The difference between the intracellular and the extracellular level of potassium does not determine the pulse pressure of an individual. Pulse pressure is the difference between the systolic and diastolic pressures.

B

Incorrect: The difference between the intracellular and the extracellular level of potassium doe not determine the viscosity of the blood.

C

Correct: The difference between the intracellular and the extracellular level of potassium determines the excitability of neurons and muscles.

D

Incorrect: The difference between the intracellular and the extracellular level of potassium doe not determine the amount of edema a person has.

PTS:1REF:p. 660 Electrolyte Imbalances

OBJ: Cognitive Level: Comprehension

20.You are the nurse assigned to care for a child on the pediatric unit. The lab calls with a potassium level of slightly over 5 milliequivalents per liter. This report comes just as you note a widened QRS complex on the electrocardiogram (EKG). From this information, you realize this:

a.

child has a slightly elevated potassium level and you should leave the pediatrician a note

b.

could lead to cardiac arrest if not treated quickly

c.

is a normal lab report and a slight deviation from a normal EKG

d.

should be called to the attention of the oncoming nurse at the end-of-shift report

ANS: B

Feedback

A

Incorrect: The child with a slightly elevated potassium level and a widened QRS complex on the electrocardiogram (EKG) can develop a cardiac arrest. It is not appropriate to leave the pediatrician a note. The physician should be called immediately with these lab results, so intervention can occur.

B

Correct: When a child has a potassium level of slightly over 5 milliequivalents per liter and a widened QRS complex on the electrocardiogram (EKG), you realize this could lead to cardiac arrest if not treated quickly. This child has hyperkalemia. An elevated serum potassium level can cause cardiac irritability and ventricular fibrillation. If not treated, this situation will lead to cardiac arrest.

C

Incorrect: As a nurse you realize this is not a normal lab report nor a slight deviation from a normal EKG.

D

Incorrect: As the nurse you realize this situation should not wait to be\ called to the attention of the oncoming nurse at the end-of-shift report. The physician needs to be contacted immediately.

PTS:1REF:p. 661 Electrolyte Imbalances

OBJ: Cognitive Level: Application

21.You would expect to see hypokalemia in which of the following conditions?

a.

tissue necrosis

c.

rapid infusion of IV potassium

b.

renal failure

d.

loss of gastric or intestinal fluids

ANS: D

Feedback

A

Incorrect: You would not expect to see hypokalemia with tissue necrosis. Tissue necrosis is seen with hyperkalemia.

B

Incorrect: You would not expect to see hypokalemia with renal failure. This is seen with hyperkalemia.

C

Incorrect: You would not expect to see hypokalemia with rapid infusion of IV potassium. This is seen with hyperkalemia

D

Correct: You would expect to see hypokalemia with a loss of gastric or intestinal fluids.

PTS:1REF:p. 663 Electrolyte Imbalances

OBJ: Cognitive Level: Comprehension

22.In which of the following ways does the concentration of hydrogen ions affect the movement of potassium ions into or out of cells, if at all?

a.

Hydrogen ions have no effect on the movement of potassium ions.

b.

Decreased hydrogen concentration will move potassium out of the bloodstream into the cells.

c.

Decreased hydrogen concentration will move potassium from the cells into the bloodstream.

d.

Increased hydrogen concentration will move potassium from the bloodstream into the cells.

ANS: B

Feedback

A

Incorrect: The concentration of hydrogen ions does have an effect on the movement of potassium ions.

B

Correct: The concentration of hydrogen ions affect the movement of potassium ions into or out of cells. Decreased hydrogen concentration will move potassium out of the bloodstream into the cells. Increased hydrogen concentration will move potassium from the intracellular to the intravascular spaces.

C

Incorrect: Decreased hydrogen concentration will not move potassium from the cells into the bloodstream. It does just the opposite.

D

Incorrect: Increased hydrogen concentration will not move potassium from the bloodstream into the cells.

PTS:1REF:p. 656 Electrolyte Imbalances

OBJ: Cognitive Level: Comprehension

23.The nurse assesses a child and finds the child to have hypotonic muscles, decreased respirations, and to be irritable. Looking at the lab work, the nurse will likely find:

a.

hypernatremia and hypochloremia

c.

hypocalcemia and hypernatremia

b.

hypercalcemia and hyperchloremia

d.

hyponatremia and hypochloremia

ANS: D

Feedback

A

Incorrect: Looking at the lab work, the nurse will not likely find hypernatremia and hypochloremia. The childs symptoms occur with hypochloremia; therefore, this should be accompanied by hyponatremia.

B

Incorrect: Looking at the lab work, the nurse will not likely find hypercalcemia and hyperchloremia. Hypercalcemia and hypochloremia (not hyperchloremia) are manifested by muscle hypotonicity, bradycardia, and weakness and fatigue.

C

Incorrect: Looking at the lab work, the nurse will not likely find hypocalcemia and hypernatremia. Hypocalcemia is manifested by neuromuscular irritability, tetany, and laryngospasm. Hypernatremia is characterized by intense thirst, elevated temperature, and dry, sticky mucous membranes.

D

Correct: The nurse assesses a child and finds the child to have hypotonic muscles, decreased respirations, and to be irritable. Looking at the lab work, the nurse will likely find hyponatremia and hypochloremia. A child with a decreased chloride level will exhibit these symptoms. Chloride levels usually parallel sodium levels, meaning if the sodium level is decreasing, chloride levels will decrease and vice versa.

PTS:1REF:p. 658 Electrolyte Imbalances

OBJ: Cognitive Level: Comprehension

24.Acid-base metabolism of the body is controlled by the:

a.

respiratory system retaining or releasing carbon dioxide

b.

electrolytes at a cellular membrane level

c.

digestive system and the release or retention of stomach acid

d.

circulatory system through osmotic and oncotic pressure

ANS: A

Feedback

A

Correct: Acid-base metabolism of the body is controlled by the respiratory system retaining or releasing carbon dioxide.

B

Incorrect: Acid-base metabolism of the body is not controlled by the electrolytes at a cellular membrane level.

C

Incorrect: Acid-base metabolism of the body is not controlled by the digestive system and the release or retention of stomach acid.

D

Incorrect: Acid-base metabolism of the body is not controlled by the circulatory system through osmotic and oncotic pressure.

PTS:1REF:p. 661 Electrolyte Imbalances

OBJ: Cognitive Level: Comprehension

25.When there are pH changes caused by respiratory problems or a buildup of metabolic acids, compensation will take place by what method?

a.

the kidneys controlling hydrogen ion and bicarbonate levels in the blood

b.

the baroreceptors in the aortic arch of the heart regulating electrolytes

c.

the hormone negative feedback system of the hypothalamic-pituitary-adrenal system

d.

regulation of hydrogen and bicarbonate by neurotransmitters in the limbic system

ANS: A

Feedback

A

Correct: When there are pH changes caused by respiratory problems or a buildup of metabolic acids, compensation will take place by the kidneys controlling hydrogen ion and bicarbonate levels in the blood.

B

Incorrect: When there are pH changes caused by respiratory problems or a buildup of metabolic acids, compensation will not take place by the baroreceptors in the aortic arch of the heart regulating electrolytes.

C

Incorrect: When there are pH changes caused by respiratory problems or a buildup of metabolic acids, compensation will not take place by the hormone negative feedback system of the hypothalamic-pituitary-adrenal system.

D

Incorrect: When there are pH changes caused by respiratory problems or a buildup of metabolic acids, compensation will not take place by regulation of hydrogen and bicarbonate by neurotransmitters in the limbic system.

PTS:1REF:p. 662 Acid-Base Balance and Imbalance

OBJ: Cognitive Level: Application

26.The nurse is working with a child who has a drug overdose. Respirations are decreased and shallow. Arterial blood gases show the childs pH is decreased and the pCO2 is elevated. The nurse realizes that this child is in:

a.

respiratory alkalosis

c.

metabolic alkalosis

b.

respiratory acidosis

d.

metabolic acidosis

ANS: B

Feedback

A

Incorrect: The nurse realizes that this child is in not in respiratory alkalosis.

B

Correct: The nurse is working with a child who has a drug overdose. Respirations are decreased and shallow. Arterial blood gases show the childs pH is decreased and the pCO2 is elevated. The nurse realizes that this child is in respiratory acidosis. Respiratory acidosis can be caused by any condition that decreases a childs respiratory effort. Slowed or shallow respirations will result in a build up of carbon dioxide, which combined with water forms carbonic acid and leads to acidosis.

C

Incorrect: The nurse realizes that this child is in not in metabolic alkalosis.

D

Incorrect: The nurse realizes that this child is in not in metabolic acidosis.

PTS:1REF:p. 662 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Application

27.The nurse is assigned to an adolescent who is admitted with out-of-control diabetes. There are high levels of ketones in the urine. The child has Kussmauls respirations and is confused and somewhat lethargic. The nurse knows that this child is in:

a.

respiratory alkalosis

c.

metabolic acidosis

b.

respiratory acidosis

d.

metabolic alkalosis

ANS: C

Feedback

A

Incorrect: The nurse knows that this child is not in respiratory alkalosis.

B

Incorrect: The nurse knows that this child is\ not in respiratory acidosis.

C

Correct: The nurse is assigned to an adolescent who is admitted with out-of-control diabetes. There are high levels of ketones in the urine. The child has Kussmauls respirations and is confused and somewhat lethargic. The nurse knows that this child is in metabolic acidosis. Metabolic acidosis is commonly caused by an increase of ketone bodies in the blood and urine, as seen in diabetic ketoacidosis. The child is confused, lethargic, and tachycardic. The body compensates by increasing the depth and rate of respirations.

D

Incorrect: The nurse knows that this child is not in metabolic alkalosis.

PTS:1REF:p. 662 Electrolyte Imbalances

OBJ: Cognitive Level: Application

28.A child is more susceptible to dehydration states than adults because children:

a.

forget to drink enough water unless their parents remind them

b.

have diarrhea and vomiting more often than adults

c.

have a larger portion of the total body fluid in extracellular spaces

d.

dont regulate their intake of salt and potassium as well as adults do

ANS: C

Feedback

A

Incorrect: A child is not more susceptible to dehydration states than adults because children forget to drink enough water unless their parents remind them.

B

Incorrect: A child is not more susceptible to dehydration states than adults because children have diarrhea and vomiting more often than adults.

C

Correct: A child is more susceptible to dehydration states than adults because children have a larger portion of the total body fluid in extracellular spaces. During illness states (vomiting, diarrhea, or hemorrhage), fluid that is located in the extracellular compartment is lost first.

D

Incorrect: A child is not more susceptible to dehydration states than adults because they dont regulate their intake of salt and potassium as well as adults do.

PTS:1REF:p. 656 Electrolyte Imbalances

OBJ: Cognitive Level: Application

29.One type of dehydration in children is isotonic dehydration, which occurs then:

a.

the loss of sodium exceeds water loss and serum sodium levels are low

b.

extracellular sodium is at the same level as intracellular sodium

c.

the muscle tone and skin tone remain stable while the child is dehydrated

d.

the loss of sodium and water are equal and the serum sodium level remains normal

ANS: D

Feedback

A

Incorrect: One type of dehydration in children is isotonic dehydration, which does not occur then the loss of sodium exceeds water loss and serum sodium levels are low.

B

Incorrect: One type of dehydration in children is isotonic dehydration, which does not occur then extracellular sodium is at the same level as intracellular sodium.

C

Incorrect: One type of dehydration in children is isotonic dehydration, which does not occur then the muscle tone and skin tone remain stable while the child is dehydrated.

D

Correct: One type of dehydration in children is isotonic dehydration, which occurs then the loss of sodium and water are equal and the serum sodium level remains normal.

PTS:1REF:p. 665 Acid-Base Balance and Imbalance

OBJ: Cognitive Level: Comprehension

30.The nurse is working with a child who has a diagnosis of gastroenteritis. The child becomes dehydrated, has serum sodium of 125 milliequivalents per liter, and goes into shock. After corrective measures to restore the childs electrolyte balance and hydration status, the nurse realizes that this child had which of the following types of dehydration?

a.

isotonic

c.

hypertonic

b.

hypotonic

d.

idiopathic

ANS: B

Feedback

A

Incorrect: The nurse realizes that this child did not have isotonic dehydration.

B

Correct: The nurse is working with a child who has a diagnosis of gastroenteritis. The child becomes dehydrated, has serum sodium of 125 milliequivalents per liter, and goes into shock. After corrective measures to restore the childs electrolyte balance and hydration status, the nurse realizes that this child had hypotonic dehydration. Hypotonic dehydration occurs then there is a sodium loss greater than the water loss, resulting in a serum sodium level below 130 milliequivalents per liter. The child can go into shock.

C

Incorrect: The nurse realizes that this child did not have isotonic dehydration.

D

Incorrect: There is not a type of dehydration called idiopathic dehydration. Idiopathic means without a known cause.

PTS:1REF:p. 665 Acid-Base Balance and Imbalance

OBJ: Cognitive Level: Application

31.Hypertonic dehydration occurs in which of the following conditions?

a.

the vascular space loses fluid and particles in equal proportions

b.

with vomiting and diarrhea or in severe blood loss

c.

then the vascular space loses more fluid than particles

d.

then the vascular space loses a greater portion of particles than fluid

ANS: C

Feedback

A

Incorrect: Hypertonic dehydration does not occur then the vascular space loses fluid and particles in equal proportions.

B

Incorrect: Hypertonic dehydration does not occur with vomiting and diarrhea or in severe blood loss.

C

Correct: Hypertonic dehydration occurs then the vascular space loses more fluid than particles.

D

Incorrect: Hypertonic dehydration does not occur then the vascular space loses a greater portion of particles than fluid.

PTS:1REF:p. 665 Acid-Base Balance and Imbalance

OBJ: Cognitive Level: Comprehension

32.Which of the following methods is the most reliable method of diagnosing dehydration in children?

a.

specific gravity of urine

c.

skin turgor

b.

blood pressure changes

d.

weight loss

ANS: D

Feedback

A

Incorrect: Specific gravity of urine is not the most reliable method of diagnosing dehydration in children.

B

Incorrect: Blood pressure changes are not the most reliable method of diagnosing dehydration in children.

C

Incorrect: Skin turgor is not the most reliable method of diagnosing dehydration in children.

D

Correct: Weight loss is the most reliable method of diagnosing dehydration in children.

PTS:1REF:p. 670 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Comprehension

33.Classical symptoms of impending shock in a child who is dehydrated are:

a.

decreased skin elasticity, flat fontanel, decreased urine output

b.

azotemia, rapid thready pulse, mottled skin, low blood pressure

c.

dusky and grayish skin color, increased weak pulse, depressed fontanel

d.

decreased tears, oliguria, depressed fontanel, slightly increased pulse

ANS: B

Feedback

A

Incorrect: Classical symptoms of impending shock in a child who is dehydrated are not decreased skin elasticity, flat fontanel, decreased urine output. These are symptoms of mild dehydration.

B

Correct: Classical symptoms of impending shock in a child who is dehydrated are azotemia, rapid thready pulse, mottled skin, low blood pressure. These are symptoms of severe dehydration.

C

Incorrect: Classical symptoms of impending shock in a child who is dehydrated are not dusky and grayish skin color, increased weak pulse, depressed fontanel. These are symptoms of moderate dehydration.

D

Incorrect: Classical symptoms of impending shock in a child who is dehydrated are not decreased tears, oliguria, depressed fontanel, slightly increased pulse. These are additional symptoms of moderate dehydration.

PTS:1REF:p. 669 Dehydration and Hypovolemia

OBJ: Cognitive Level: Application

34.The nurse is working with a child who is dehydrated. When the nurse weighs the child and compares the weight obtained with the childs weight prior to the illness, there has been an 8% weight loss. This weight loss means that this childs dehydration is:

a.

mild

c.

severe

b.

moderate

d.

life-threatening

ANS: B

Feedback

A

Incorrect: This weight loss means that this childs dehydration is not mild.

B

Correct: The nurse is working with a child who is dehydrated. When the nurse weighs the child and compares the weight obtained with the childs weight prior to the illness, there has been an 8% weight loss. This weight loss means that this childs dehydration is moderate.

C

Incorrect: This weight loss means that this childs dehydration is not severe.

D

Incorrect: This weight loss means that this childs dehydration is not life-threatening.

PTS:1REF:p. 672 Dehydration and Hypovolemia

OBJ: Cognitive Level: Application

35.Children with an internal hemorrhage such as bleeding into the thoracic or peritoneal cavity will have the same signs and symptoms of hypovolemic shock as a child with an external hemorrhage, except for one difference, which is:

a.

weight loss with external hemorrhage and no weight loss with internal hemorrhage

b.

decreased urine loss with external hemorrhage and no decreased urine loss with internal hemorrhage

c.

bradycardia with external hemorrhage and tachycardia with internal hemorrhage

d.

decreased blood pressure with external hemorrhage and no decrease with internal hemorrhage

ANS: A

Feedback

A

Correct: Children with an internal hemorrhage such as bleeding into the thoracic or peritoneal cavity will have the same signs and symptoms of hypovolemic shock as a child with an external hemorrhage, except for one difference, which is weight loss with external hemorrhage and no weight loss with internal hemorrhage.

B

Incorrect: Signs and symptoms common to both internal hemorrhage and hypovolemic shock include hypotension, bradycardia, weak peripheral pulses, and decreased urine output.

C

Incorrect: Signs and symptoms common to both internal hemorrhage and hypovolemic shock include hypotension, bradycardia, weak peripheral pulses, and decreased urine output.

D

Incorrect: Signs and symptoms common to both internal hemorrhage and hypovolemic shock include hypotension, bradycardia, weak peripheral pulses, and decreased urine output.

PTS:1REF:p. 668 Dehydration and Hypovolemia

OBJ: Cognitive Level: Application

36.The nurse is working as a volunteer on a health care team serving in a clinic in a village in a third world country. Several children come to the clinic in a mild or moderate state of dehydration. Which of the following solutions or liquids would be best for rehydrating the dehydrated children?

a.

Gatorade

c.

Pedialyte

b.

fruit juices

d.

athletic drinks

ANS: C

Feedback

A

Incorrect: Gatorade would not be best for rehydrating the dehydrated children because it has a high-carbohydrate content, low electrolyte concentrations, and a high osmolality.

B

Incorrect: Fruit juices would not be best for rehydrating the dehydrated children for the same reasons Gatorade is not appropriate.

C

Correct: The nurse is working as a volunteer on a health care team serving in a clinic in a village in a third world country. Several children come to the clinic in a mild or moderate state of dehydration. Pedialyte would be best for rehydrating the dehydrated children. Rehydration solutions should contain glucose, sodium, potassium, and bicarbonate. Glucose must be present for the intestines to absorb sodium chloride.

D

Incorrect: Athletic drinks would not be best for rehydrating the dehydrated children for the same reasons Gatorade is not appropriate.

PTS:1REF:p. 668 Dehydration and Hypovolemia

OBJ: Cognitive Level: Application

37.The nurse will read the label to determine the contents of any solution before using it for rehydration because solutions must contain which of the following substances in order for the intestines to absorb sodium chloride?

a.

carbohydrate

c.

phosphate

b.

glucose

d.

aluminum

ANS: B

Feedback

A

Incorrect: Rehydration solutions do not need to contain carbohydrates in order for the intestines to absorb sodium chloride.

B

Correct: The nurse will read the label to determine the contents of any solution before using it for rehydration because solutions must contain glucose in order for the intestines to absorb sodium chloride.

C

Incorrect: Rehydration solutions do not need to contain phosphate in order for the intestines to absorb sodium chloride.

D

Incorrect: Rehydration solutions do not need to contain aluminum in order for the intestines to absorb sodium chloride.

PTS:1REF:p. 667 Dehydration and Hypovolemia

OBJ: Cognitive Level: Application

38.The nurse is assessing a 5-year-old child. In checking the heart rate, the nurse finds an increase of 25 beats then the child changes from a lying to a standing position. This increase in heart rate is indicative of:

a.

hypovolemia

c.

normal findings

b.

hypervolemia

d.

left-sided heart failure

ANS: A

Feedback

A

Correct: The nurse is assessing a 5-year-old child. In checking the heart rate, the nurse finds an increase of 25 beats then the child changes from a lying to a standing position. This increase in heart rate is indicative of hypovolemia. A postural change in heart rate is a useful cue in assessing fluid status in children over 4 years of age.

B

Incorrect: This increase in heart rate is not indicative of hypervolemia.

C

Incorrect: This increase in heart rate is not indicative of normal findings.

D

Incorrect: This increase in heart rate is not indicative of left-sided heart failure.

PTS:1REF:p. 679 Acute Gastroenteritis

OBJ: Cognitive Level: Application

39.The nurse is assessing a child who is dehydrated. The child begins to cry, but there are no tears. The nurse knows that the loss of the ability to produce tears indicates a fluid loss of at least what percent of the childs body weight?

a.

1%

c.

8%

b.

5%

d.

10%

ANS: B

Feedback

A

Incorrect: The nurse knows that the loss of the ability to produce tears does not indicate a fluid loss of at least 1 percent of the childs body weight.

B

Correct: The nurse is assessing a child who is dehydrated. The child begins to cry, but there are no tears. The nurse knows that the loss of the ability to produce tears indicates a fluid loss of at least 5 percent of the childs body weight

C

Incorrect: The nurse knows that the loss of the ability to produce tears does not indicate a fluid loss of at least 8 percent of the childs body weight.

D

Incorrect: The nurse knows that the loss of the ability to produce tears does not indicate a fluid loss of at least 10 percent of the childs body weight.

PTS:1REF:p. 664 Dehydration and Hypovolemia

OBJ: Cognitive Level: Comprehension

40.The nurse is preparing to administer intravenous fluids containing potassium for a child who is dehydrated. Which of the following is the most important thing for the nurse to check before administering the potassium?

a.

Respirations are over 14.

b.

The child does not have a low-grade fever.

c.

There is no nausea present; give medication if nausea is present.

d.

The child is able to void at least 1 to 2 milliliters per kilogram per hour.

ANS: D

Feedback

A

Incorrect: Before administering intravenous fluids containing potassium, the most important thing for the nurse to check is not if respirations are over 14.

B

Incorrect: Before administering intravenous fluids containing potassium, the most important thing for the nurse to check is not that the child does not have a low-grade fever.

C

Incorrect: Before administering intravenous fluids containing potassium, the most important thing for the nurse to check is not that there is no nausea present. Potassium is not given to treat nausea.

D

Correct: The nurse is preparing to administer intravenous fluids containing potassium for a child who is dehydrated. The most important thing for the nurse to check before administering the potassium if that the child is able to void at least 1 to 2 milliliters per kilogram per hour. Children who are dehydrated are oliguric and can become anuric. These children will not be able to excrete electrolytes that are in an IV solution and cause elevated serum potassium. An elevated serum potassium can cause cardiac irritability and ventricular fibrillation.

PTS:1REF:p. 670 Dehydration and Hypovolemia

OBJ: Cognitive Level: Application

41.The nurse has instructed caregivers on how to care for a dehydrated child at home. The nurse has included instructions on how to decide then the child is doing well and then the caregivers should contact a health professional. The nurse would instruct the family to contact a health professional then which of the following occurs?

a.

The childs urine output decreases.

c.

The child complains of nausea.

b.

The child is more mentally alert.

d.

There is any pain.

ANS: A

Feedback

A

Correct: The nurse would instruct the family to contact a health professional then the childs urine output decreases, if there is no improvement after 4 hours of rehydration fluid, if the child cannot retain fluids, and if there is a change in mental alertness.

B

Incorrect: The nurse would not instruct the family to contact a health professional then the child is more mentally alert. Instead the family should contact a health professional then there is a change in the childs mental alertness, such as a decrease.

C

Incorrect: The nurse would not instruct the family to contact a health professional if the child complains of nausea.

D

Incorrect: The nurse would not instruct the family to contact a health professional if there is any pain.

PTS:1REF:p. 670 Dehydration and Hypovolemia

OBJ: Cognitive Level: Application

42.The majority of cases of acute gastroenteritis in children under 2 years old in the United States are caused by:

a.

Shigella

c.

Salmonella

b.

rotavirus

d.

Giardia

ANS: B

Feedback

A

Incorrect: The majority of cases of acute gastroenteritis in children under 2 years old in the United States are not caused by Shigella.

B

Correct: The majority of cases of acute gastroenteritis in children under 2 years old in the United States are caused by rotavirus.

C

Incorrect: The majority of cases of acute gastroenteritis in children under 2 years old in the United States are not caused by Salmonella.

D

Incorrect: The majority of cases of acute gastroenteritis in children under 2 years old in the United States are caused by Giardia.

PTS:1REF:p. 670 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Comprehension

43.The causes of acute gastroenteritis include viruses, bacteria, and parasites. Which of the following is a parasitic cause of gastroenteritis?

a.

Shigella

c.

Yersinia

b.

Escherichia coli

d.

Giardia lamblia

ANS: D

Feedback

A

Incorrect: A parasitic cause of gastroenteritis is not Shigella. This is a bacterium.

B

Incorrect: A parasitic cause of gastroenteritis is not Escherichia coli. This is also a bacterium.

C

Incorrect: A parasitic cause of gastroenteritis is not Yersinia. This is a bacterium.

D

Correct: The causes of acute gastroenteritis include viruses, bacteria, and parasites. A parasitic cause of gastroenteritis is Giardia lamblia.

PTS:1REF:p. 671 Acid-Base Balance and Imbalance

OBJ: Cognitive Level: Comprehension

44.When the family of a child with acute gastroenteritis asks about giving their child a diet of bananas, rice, applesauce, and toast or tea, the best response by the nurse would be:

a.

This would be a good diet because it is easily digested; however, the toast needs to be soaked in tea to soften it.

b.

This diet needs to be modified slightly to include either the applesauce or the bananas but not both.

c.

Do not use this diet, because it is low in energy, protein, and fat.

d.

Avoid this diet, because it is low in glucose, sodium, and potassium.

ANS: C

Feedback

A

Incorrect: When a family asks about giving their child who has acute gastroenteritis a diet of bananas, rice, applesauce, and toast or tea, the best response by the nurse would not be This would be a good diet because it is easily digested; however, the toast needs to be soaked in tea to soften it.

B

Incorrect: When a family asks about giving their child who has acute gastroenteritis a diet of bananas, rice, applesauce, and toast or tea, the best response by the nurse would not be This diet needs to be modified slightly to include either the applesauce or the bananas but not both.

C

Correct: When the family of a child with acute gastroenteritis asks about giving their child a diet of bananas, rice, applesauce, and toast or tea, the best response by the nurse would be Do not use this diet, because it is low in energy, protein, and fat.

D

Incorrect: When a family asks about giving their child who has acute gastroenteritis a diet of bananas, rice, applesauce, and toast or tea, the best response by the nurse would not be Avoid this diet, because it is low in glucose, sodium, and potassium.

PTS:1REF:p. 672 Dehydration and Hypovolemia

OBJ: Cognitive Level: Application

45.The care plan for a baby with gastroenteritis includes a nursing diagnosis of Impaired skin integrity related to irritation from frequent stools. Which of the following interventions by the nurse would be the best intervention?

a.

Clean the diaper area with commercial baby wipes after each stool.

b.

Keep the diaper area covered and avoid airing the diaper area.

c.

Clean the diaper area with water and mild soap after each stool.

d.

Do not use any diaper cream to coat the skin.

ANS: C

Feedback

A

Incorrect: The best intervention by the nurse would not be to clean the diaper area with commercial baby wipes after each stool. Commercial baby wipes contain alcohol and may cause further irritation.

B

Incorrect: The best intervention by the nurse would not be to keep the diaper area covered and avoid airing the diaper area. Leaving the diaper area open to air as often as possible promotes healing.

C

Correct: The care plan for a baby with gastroenteritis includes a nursing diagnosis of Impaired skin integrity related to irritation from frequent stools. The best intervention by the nurse would be to clean the diaper area with water and mild soap after each stool in order to remove diarrheal stool, which is acidic and very irritating to the perineum.

D

Incorrect: The best intervention by the nurse would not be to avoid use any diaper cream to coat the skin. Instead applying creams and ointments provide a protective barrier from frequent stools.

PTS:1REF:p. 672 Dehydration and Hypovolemia

OBJ: Cognitive Level: Application

46.The nurse is assessing a child who is on bed rest to see if the child has edema. If the child has edema, there is the nurse most likely to find it upon assessment?

a.

ankles

c.

periorbital areas

b.

sacral areas

d.

hands

ANS: B

Feedback

A

Incorrect: If the child who is on bedrest has edema, the nurse would not most likely find it in the ankles. If the child is ambulatory, dependent edema will be evident in the ankles.

B

Correct: The nurse is assessing a child who is on bed rest to see if the child has edema. If the child has edema, the nurse most likely will find it in the sacral area upon assessment.

C

Incorrect: If the child who is on bedrest has edema, the nurse would not most likely find it in the periorbital areas. In most cases, edema in children is manifested initially periorbitally or dependently.

D

Incorrect: If the child who is on bedrest has edema, the nurse would not most likely find it in the hands.

PTS:1REF:p. 675 Dehydration and Hypovolemia

OBJ: Cognitive Level: Application

47.When the nurse is trying to treat a childs edema that is due to an allergic reaction, the nurse can reduce blood hydrostatic pressure by decreasing capillary blood flow with which of the following interventions?

a.

warm compresses

c.

restriction of fluid

b.

cold compresses

d.

restriction of sodium

ANS: B

Feedback

A

Incorrect: When the nurse is trying to treat a childs edema that is due to an allergic reaction, the nurse can reduce blood hydrostatic pressure through decreasing capillary blood flow by applying cold compresses.

B

Correct: When the nurse is trying to treat a childs edema that is due to an allergic reaction, the nurse can reduce blood hydrostatic pressure through decreasing capillary blood flow not by applying warm compresses. Warm compresses will increase capillary blood flow by dilating the capillaries.

C

Incorrect: Restriction of fluids will not reduce blood hydrostatic pressure by decreasing capillary blood flow.

D

Incorrect: Restriction of sodium would only be appropriate if the edema resulted from sodium retention by the kidneys. That is not the case with an allergic reaction

PTS:1REF:p. 675 Acute Gastroenteritis

OBJ: Cognitive Level: Application

48.The nurse is caring for a child who is receiving a diuretic for edema. Which of the following interventions is the most important intervention by the nurse?

a.

Monitor blood electrolytes for potassium depletion.

b.

Elevate the limbs on pillows to facilitate reabsorption.

c.

Elevate the head of the bed.

d.

Measure the abdomen daily.

ANS: A

Feedback

A

Correct: The nurse is caring for a child who is receiving a diuretic for edema. The most important intervention by the nurse is to monitor blood electrolytes for potassium depletion.

B

Incorrect: The most important intervention by the nurse is not to elevate the limbs on pillows to facilitate reabsorption. Although this is an important aspect of nursing management, it is not the priority intervention since this child is receiving diuretics.

C

Incorrect: Elevating the head of the bed would be an important nursing action if the child had pulmonary edema.

D

Incorrect: Measuring the abdomen daily would be an important intervention only is the child has an edematous abdomen.

PTS:1REF:p. 676 Acute Gastroenteritis

OBJ: Cognitive Level: Application

49.The nurse is assessing a child who has significant edema. The nurse finds an increasing respiratory rate and some rales. Which of the following nursing interventions would be best?

a.

Place the child in a semi-Fowlers position.

b.

Elevate the head of the bed.

c.

Place shock blocks under the foot of the bed.

d.

Elevate the childs legs on pillows.

ANS: B

Feedback

A

Incorrect: The nurse is assessing a child who has significant edema. The nurse finds an increasing respiratory rate and some rales. The best nursing intervention would not be to place the child in a semi-Fowlers position.

B

Correct: The nurse is assessing a child who has significant edema. The nurse finds an increasing respiratory rate and some rales. The best nursing intervention would be to elevate the head of the bed because these signs often reflect pulmonary edema.

C

Incorrect: The best nursing intervention would not be to place shock blocks under the foot of the bed for the child with pulmonary edema.

D

Incorrect: The best nursing intervention would not be to elevate the childs legs on pillows.

PTS:1REF:p. 675 Acute Gastroenteritis

OBJ: Cognitive Level: Application

50.Which type of burn is most common in children?

a.

electrical

c.

radiation

b.

chemical

d.

thermal

ANS: D

Feedback

A

Incorrect: Electrical burn is not the most common type of burn in children.

B

Incorrect: Chemical burn is not the most common type of burn in children.

C

Incorrect: Radiation burn is not the most common type of burn in children.

D

Correct: Thermal burn is the most common type of burn in children. The majority of burn injuries in children are related to scalds which are thermal burns.

PTS: 1 REF: p. 676 Acute Gastroenteritis OBJ: Cognitive Level: Knowledge

51.Which of the following statements best describes full thickness burns?

a.

They usually heal within 5 to 10 days without scarring.

b.

They are essentially the same as a first-degree burn and are very painful.

c.

They involve the epidermis, dermis, and extend into subcutaneous tissues.

d.

The skin is moist, bright red, painful, and extremely sensitive to cold air.

ANS: C

Feedback

A

Incorrect: Full thickness burns do not usually heal within 5 to 10 days without scarring. This describes a superficial or 1st degree burn.

B

Incorrect: Full thickness burns are essentially the same as a first-degree burn and are very painful.

C

Correct: Full thickness burns involve the epidermis, dermis, and extend into subcutaneous tissues.

D

Incorrect: In full thickness burns the skin is not moist, bright red, painful, and extremely sensitive to cold air. This describes a partial thickness or 2nd degree burn.

PTS:1REF:p. 676 Acute Gastroenteritis

OBJ: Cognitive Level: Comprehension

52.The extent of burns in children are normally assessed and expressed in:

a.

percentages of total body surface area (TBSA)

b.

terms of how deep the deepest burns are

c.

the severity of the burns on a 1 to 5 burn scale

d.

the amount of body surface that is unburned

ANS: A

Feedback

A

Correct: The extent of burns in children are normally assessed and expressed in percentages of total body surface area (TBSA).

B

Incorrect: The extent of burns in children are not normally assessed and expressed in terms of how deep the deepest burns are.

C

Incorrect: The extent of burns in children are not normally assessed and expressed according to the severity of the burns on a 1 to 5 burn scale.

D

Incorrect: The extent of burns in children are normally assessed and expressed in terms of the amount of body surface that is unburned.

PTS:1REF:p. 680 Edema

OBJ: Cognitive Level: Comprehension

53.If burns are severe enough, the child will require fluid replacement. Which of the following fluids is most often used as replacement?

a.

dextrose 5% in water

c.

normal saline solution

b.

one-half strength normal saline

d.

lactated Ringers solution

ANS: D

Feedback

A

Incorrect: If burns are severe enough, the child will require fluid replacement. Dextrose 5% in water is not most often used as replacement.

B

Incorrect: If burns are severe enough, the child will require fluid replacement. One-half strength normal saline is not most often used as replacement.

C

Incorrect: If burns are severe enough, the child will require fluid replacement. Normal saline solution is not most often used as replacement.

D

Correct: If burns are severe enough, the child will require fluid replacement. Lactated Ringers solution is most often used as replacement.

PTS:1REF:p. 681 Acute Gastroenteritis

OBJ: Cognitive Level: Comprehension

54.Fluid resuscitation for burn victims is based on formulas; however, the adequacy of the amount is based on:

a.

skin turgor of the unburned area of skin and how normal or abnormal it is

b.

thirst levels of the victims by self-assessment

c.

urine output of 1-2 milliliters per kilogram per hour, stable vital signs, alertness, and orientation

d.

amount of weeping taking place in the area of the burns

ANS: C

Feedback

A

Incorrect: Fluid resuscitation for burn victims is based on formulas; however, the adequacy of the amount is not based on skin turgor of the unburned area of skin and how normal or abnormal it is.

B

Incorrect: Fluid resuscitation for burn victims is based on formulas; however, the adequacy of the amount is not based on thirst levels of the victims by self-assessment.

C

Correct: Fluid resuscitation for burn victims is based on formulas; however, the adequacy of the amount is based on urine output of 1-2 milliliters per kilogram per hour, stable vital signs, alertness, and orientation.

D

Incorrect: Fluid resuscitation for burn victims is based on formulas; however, the adequacy of the amount is not based on amount of weeping taking place in the area of the burns.

PTS:1REF:p. 681 Edema

OBJ: Cognitive Level: Application

55.Nurses have been found to have a tendency to undermedicate children with severe burns due to:

a.

a fear of hurting the children with a needle

b.

a fear of causing the children to be addicted

c.

an unrealistic fear of causing respiratory depression

d.

a perception that pain is experienced to a lesser extent than actually exists

ANS: C

Feedback

A

Incorrect: Nurses have been found to have a tendency to undermedicate children with severe burns but not due to a fear of hurting the children with a needle.

B

Incorrect: Nurses have been found to have a tendency to undermedicate children with severe burns but not due to a fear of causing the children to be addicted.

C

Correct: Nurses have been found to have a tendency to undermedicate children with severe burns due to an unrealistic fear of causing respiratory depression.

D

Incorrect: Nurses have been found to have a tendency to undermedicate children with severe burns but not due to a perception that pain is experienced to a lesser extent than actually exists.

PTS:1REF:p. 682 Edema

OBJ: Cognitive Level: Comprehension

56.The nurse working with children with severe burns who are in pain and anxious will best help the child by:

a.

touching the child even if this hurts

b.

holding the hands 2-5 inches from the clients body

c.

taking as much time as necessary then having to touch the child

d.

not touching the child and staying at least 2 feet away then possible

ANS: B

Feedback

A

Incorrect: The nurse working with children with severe burns who are in pain and anxious will not best help the child by touching the child even if this hurts. Touching the child causes discomfort and additional pain and is not therapeutic.

B

Correct: The nurse working with children with severe burns who are in pain and anxious will best help the child by holding the hands 2-5 inches from the clients body. Therapeutic touch can be implemented by holding the childs hands and is based on the assumption that the human energy field extends beyond the skin.

C

Incorrect: The nurse working with children with severe burns who are in pain and anxious will not best help the child by taking as much time as necessary then having to touch the child. Touching the child causes discomfort and additional pain and is not therapeutic.

D

Incorrect: The nurse working with children with severe burns who are in pain and anxious will not best help the child by not touching the child and staying at least 2 feet away then possible. By staying at least 2 feet away then possible is not therapeutic and may contribute to the childs feeling of isolation and concerns about how he or she looks.

PTS:1REF:p. 681 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Application

57.For hydrotherapy and debridement of a childs burn wound, the nurse will most help the child by:

a.

medicating the child first

c.

asking the parents to leave

b.

moving swiftly and getting it done

d.

explaining the procedure fully

ANS: A

Feedback

A

Correct: For hydrotherapy and debridement of a childs burn wound, the nurse will most help the child by medicating the child first. Hydrotherapy and debridement procedures are very painful and scary for all burn clients. Medication is essential prior to the procedures.

B

Incorrect: For hydrotherapy and debridement of a childs burn wound, the nurse will not most help the child by moving swiftly and getting it done.

C

Incorrect: For hydrotherapy and debridement of a childs burn wound, the nurse will not most help the child by asking the parents to leave. It is helpful if parents can be present to comfort and distract the child.

D

Incorrect: Children who have an understanding of the procedure to be performed demonstrate less maladaptive behavior. However, medicating the child with adequate analgesia before the procedures will help most.

PTS:1REF:p. 682 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Application

58.Hydrotherapy before the debridement of a wound is done to soften tissue and to:

a.

get rid of dead skin so debridement will be faster

b.

make the area sterile

c.

soothe the nerves in the area

d.

improve circulation to the wound

ANS: D

Feedback

A

Incorrect: Hydrotherapy before the debridement of a wound is done to soften tissue, but not to get rid of dead skin so debridement will be faster.

B

Incorrect: Hydrotherapy before the debridement of a wound is done to soften tissue, but not to make the area sterile.

C

Incorrect: Hydrotherapy before the debridement of a wound is done to soften tissue, but not to soothe the nerves in the area.

D

Correct: Hydrotherapy before the debridement of a wound is done to soften tissue and to improve circulation to the wound.

PTS:1REF:p. 682 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Application

59.Skin grafts made from cadaver skin are called:

a.

homografts

c.

c-grafts

b.

heterografts

d.

humano grafts

ANS: A

Feedback

A

Correct: Skin grafts made from cadaver skin are called homografts.

B

Incorrect: Skin grafts made from cadaver skin are not called heterografts.

C

Incorrect: Skin grafts made from cadaver skin are not called c-grafts.

D

Incorrect: Skin grafts made from cadaver skin are not called humano grafts.

PTS:1REF:p. 683 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Knowledge

60.The nurse caring for clients with severe burns that have required grafts will expect which of the following types of grafts to be more likely to be replaced every day or every other day?

a.

cadaver skin

c.

nylon

b.

pig skin

d.

nonnylon synthetics

ANS: B

Feedback

A

Incorrect: The nurse caring for clients with severe burns that have required grafts will not expect cadaver skin grafts to be more likely to be replaced every day or every other day.

B

Correct: The nurse caring for clients with severe burns that have required grafts will expect pig skin grafts to be more likely to be replaced every day or every other day.

C

Incorrect: The nurse caring for clients with severe burns that have required grafts will not expect nylon grafts to be more likely to be replaced every day or every other day.

D

Incorrect: The nurse caring for clients with severe burns that have required grafts will not expect nonnylon synthetics grafts to be more likely to be replaced every day or every other day.

PTS:1REF:p. 683 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Comprehension

61.The parents of a child who has suffered serious burns and is scheduled for temporary grafts asks the nurse to explain why the child needs temporary grafts instead of permanent ones. Which of the following is the nurses best answer?

a.

The temporary graft gives the tissue area time to rest and recover from the burn before the work of accepting a permanent graft.

b.

The temporary graft allows for a quick skin cover while the surgeon studies just what type of permanent graft to use.

c.

Temporary grafts provide an educated guess as to how difficult it will be to get the permanent graft to take.

d.

Temporary grafts promote formation of granulation tissue, which has to be present before a person can be permanently grafted.

ANS: D

Feedback

A

Incorrect: The nurses best answer is not The temporary graft gives the tissue area time to rest and recover from the burn before the work of accepting a permanent graft.

B

Incorrect: The nurses best answer is not The temporary graft allows for a quick skin cover while the surgeon studies just what type of permanent graft to use.

C

Incorrect: The nurses best answer is not The temporary graft allows for a quick skin cover while the surgeon studies just what type of permanent graft to use.

D

Correct: The parents of a child who has suffered serious burns and is scheduled for temporary grafts asks the nurse to explain why the child needs temporary grafts instead of permanent ones. The nurses best answer is Temporary grafts promote formation of granulation tissue, which has to be present before a person can be permanently grafted.

PTS:1REF:p. 683 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Application

62.Cultured epithelial autografts are used only in children with more than which of the following percent of total body surface area burned?

a.

25%

c.

60%

b.

40%

d.

80%

ANS: D

Feedback

A

Incorrect: Cultured epithelial autografts are not used in children with more than 25 percent of total body surface area burned.

B

Incorrect: Cultured epithelial autografts are not used in children with more than 40 percent of total body surface area burned.

C

Incorrect: Cultured epithelial autografts are not used in children with more than 60 percent of total body surface area burned.

D

Correct: Cultured epithelial autografts are used only in children with more than 80 percent of total body surface area burned.

PTS:1REF:p. 683 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Comprehension

63.The nurse is working with a child who has had skin grafts that are now healed. The nurse realizes that for several months the child will need which of the following to prevent complications?

a.

antibiotics

c.

skin stimulation

b.

hydrotherapy

d.

pressure dressings

ANS: D

Feedback

A

Incorrect: The child will not need to receive antibiotics for several months after a skin graft has healed. Once the graft has healed, the risk of infection is eliminated.

B

Incorrect: The child will not need hydrotherapy for several months after a skin graft has healed. Hydrotherapy is used along with debridement which occurs before skin grafting.

C

Incorrect: Skin stimulation is not needed after a graft has healed.

D

Correct: The nurse is working with a child who has had skin grafts that are now healed. The nurse realizes that for several months the child will need to wear pressure dressings to prevent the formation of contractures and minimize scarring.

PTS:1REF:p. 683 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Application

64.When the nurse develops a care plan for a child with severe burns, the nurse will most likely include which of the following interventions?

a.

Perform active range-of-motion exercises using familiar toys or objects and passive range- of-motion exercises at least three times a day.

b.

Encourage bed rest without any more movement than is absolutely necessary.

c.

Allow the child to choose the amount of movement he or she is comfortable with, and do not push the child to perform exercises.

d.

Maintain joints in a position that is somewhat flexed.

ANS: A

Feedback

A

Correct: When the nurse develops a care plan for a child with severe burns, the nurse will most likely include performing active range-of-motion exercises using familiar toys or objects and passive range- of-motion exercises at least three times a day.

B

Incorrect: For a child with severe burns, the nurse will not most likely encourage bed rest without any more movement than is absolutely necessary. The goal is to prevent contractures and loss of function, and bed rest would do promote these complications.

C

Incorrect: Children are reluctant to move then\ it causes pain, and they are likely to assume a position of comfort. However, the most comfortable position is often one that encourages contractures and loss of function. Therefore, the nurse would not allow the child to choose the amount of movement he or she is comfortable with. Instead the nurse would push the child to perform exercises.

D

Incorrect: Joints should be maintained in maximal extension, not flexion, using splints if necessary in order to maintain joint mobility.

PTS:1REF:p. 684 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Application

65.The nurse working with a child with severe burns instructs the family about the dietary needs of the child explaining that the child needs a diet:

a.

high in carbohydrates and fat

b.

high in calories, protein, vitamin A, and vitamin C

c.

that consists of strained baby foods

d.

high in bulk, fruit, and vegetables

ANS: B

Feedback

A

Incorrect: The child does not need a diet high in carbohydrates and fat

B

Correct: The nurse working with a child with severe burns instructs the family that the child needs a diet high in calories, protein, vitamin A, and vitamin C. Burns increase metabolism significantly. So the child will need two to three times the normal amount of calories. Because of the hypermetabolic state, protein breakdown increases, requiring extra protein to maintain weight and muscle function. Increased amounts of vitamins A and C help replace the losses from the changes in metabolism.

C

Incorrect: The child does not need a diet that consists of strained baby foods. Many burned children are able to eat and do not require strained baby foods. If a child is unable to eat or has a poor appetite, enteral feedings are often administered.

D

Incorrect: The child does not need a diet high in bulk, fruit, and vegetables. Such a diet would not supply the extra calories and protein.

PTS:1REF:p. 685 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Application

66.The nurse is working with a child with severe burns who is not eating much. What strategy will the nurse most likely use to get the child to eat more?

a.

Explain how eating more helps a person get well quicker.

b.

Offer rewards for eating more.

c.

Serve food more often.

d.

Have other children or family members eat with this child.

ANS: D

Feedback

A

Incorrect: The strategy of explaining how eating more helps a person get well quicker will not most likely get the child to eat more. Children with burns often lack an appetite.

B

Incorrect: The strategy of offering rewards for eating more will not most likely get the child to eat more. Children with burns often lack an appetite.

C

Incorrect: Serving food more often will not most likely get the child to eat more.

D

Correct: The nurse is working with a child with severe burns who is not eating much. The strategy the nurse will most likely use to get the child to eat more is to encourage them to have their meals with family members or other children.

PTS:1REF:p. 685 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Application

67.Which of the following is most important in doing discharge teaching to prepare the family to care for the child who is recovering from severe burns?

a.

Procedures must be done even when painful, because the burns wont heal properly if the procedures are not done.

b.

Wait until the child is pain free before doing any painful procedures, even if you have to postpone procedures for a day.

c.

Measure and record the childs weight at the same time each day for several months.

d.

Prepare and feed the child food that is on the list of suggested dietary meals, and dont deviate from this list.

ANS: A

Feedback

A

Correct: It is most important in doing discharge teaching for the child who is recovering from severe burns to teach the family that procedures must be done even then painful, because the burns wont heal properly if the procedures are not done. Caregivers need encouragement and support to perform these procedures because most have difficulty inflicting pain on their child.

B

Incorrect: It is not appropriate to teach the family to wait until the child is pain free before doing any painful procedures, even if they have to postpone procedures for a day.

C

Incorrect: Although measuring and recording the childs weight at the same time each day for several months may be an aspect of discharge teaching, it is not the most important.

D

Incorrect: It is inappropriate to teach the family to prepare and feed the child food that is on the list of suggested dietary meals, and not to deviate from this list. Children recovering from severe burns should be offered foods they like to stimulate their appetite.

PTS:1REF:p. 685 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Application

MULTIPLE RESPONSE

1.Which of the following intravenous fluids would be considered isotonic solutions? Select all that apply.

a.

dextrose 5% in 0.45% normal saline

c.

Ringers lactate

b.

normal saline

d.

dextrose 5% in water

ANS: B, C, D

Feedback

Correct

Normal saline is an isotonic solution.

Ringers lactate is an isotonic solution.

Dextrose 5% in water is an isotonic solution.

Incorrect

Dextrose 5% in 0.45% normal saline is a hypertonic solution.

PTS:1REF:p. 658 Fluid and Electrolyte Alterations

OBJ: Cognitive Level: Comprehension

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