Chapter 22 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 22

Question 1

Type: MCSA

A nurse begins an infusion of intravenous immune globulin (IVIG) to a child who has combined immunodeficiency disease. Which assessment finding indicates that the nurse should stop the infusion?

1. A mild headache

2. Clear yellow urine

3. Severe shaking, chills, and fever

4. Complaints of being thirsty

Correct Answer: 3

Rationale 1: Hypersensitivity reaction can be seen with IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction. A mild headache is an adverse side effect of IVIG but not a severe reaction. Thirst is not an indication of a reaction. Voiding clear yellow urine is a normal finding.

Rationale 2: Hypersensitivity reaction can be seen with IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction. A mild headache is an adverse side effect of IVIG but not a severe reaction. Thirst is not an indication of a reaction. Voiding clear yellow urine is a normal finding.

Rationale 3: Hypersensitivity reaction can be seen with IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction. A mild headache is an adverse side effect of IVIG but not a severe reaction. Thirst is not an indication of a reaction. Voiding clear yellow urine is a normal finding.

Rationale 4: Hypersensitivity reaction can be seen with IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction. A mild headache is an adverse side effect of IVIG but not a severe reaction. Thirst is not an indication of a reaction. Voiding clear yellow urine is a normal finding.

Global Rationale: Hypersensitivity reaction can be seen with IVIG. The infusion should be started slowly and increased if there is no reaction. Shaking, chills, and fever can indicate a reaction. A mild headache is an adverse side effect of IVIG but not a severe reaction. Thirst is not an indication of a reaction. Voiding clear yellow urine is a normal finding.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 22.1 Describe the structure and function of the immune system and apply that knowledge to the care of children with immunologic disorders.

Question 2

Type: MCSA

A nurse is administering an intramuscular vaccination to an infant diagnosed with WiskottAldrich syndrome (WAS). Which reaction is the infant more at risk for due to the diagnosis of WAS?

1. Pain at injection site

2. Bleeding at injection site

3. Redness and swelling at injection site

4. Mild rash at injection site

Correct Answer: 2

Rationale 1: WiskottAldrich syndrome is characterized by thrombocytopenia, with bleeding tendencies appearing during the neonatal period. The syndrome would not put the child at higher risk for pain, redness, swelling, or rash at the injection site.

Rationale 2: WiskottAldrich syndrome is characterized by thrombocytopenia, with bleeding tendencies appearing during the neonatal period. The syndrome would not put the child at higher risk for pain, redness, swelling, or rash at the injection site.

Rationale 3: WiskottAldrich syndrome is characterized by thrombocytopenia, with bleeding tendencies appearing during the neonatal period. The syndrome would not put the child at higher risk for pain, redness, swelling, or rash at the injection site.

Rationale 4: WiskottAldrich syndrome is characterized by thrombocytopenia, with bleeding tendencies appearing during the neonatal period. The syndrome would not put the child at higher risk for pain, redness, swelling, or rash at the injection site.

Global Rationale: WiskottAldrich syndrome is characterized by thrombocytopenia, with bleeding tendencies appearing during the neonatal period. The syndrome would not put the child at higher risk for pain, redness, swelling, or rash at the injection site.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 22.1 Describe the structure and function of the immune system and apply that knowledge to the care of children with immunologic disorders.

Question 3

Type: MCSA

A nurse is planning care for a child with human immunodeficiency virus (HIV). Which nursing diagnosis is the highest priority for this child?

1. Risk for Infection

2. Risk for Fluid-Volume Deficit

3. Ineffective Thermoregulation

4. Ineffective Tissue Perfusion, Peripheral

Correct Answer: 1

Rationale 1: A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Fluid-Volume Deficit, Ineffective Thermoregulation, and Ineffective Tissue Perfusion, Peripheral would not be priority problems with this disease process.

Rationale 2: A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Fluid-Volume Deficit, Ineffective Thermoregulation, and Ineffective Tissue Perfusion, Peripheral would not be priority problems with this disease process.

Rationale 3: A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Fluid-Volume Deficit, Ineffective Thermoregulation, and Ineffective Tissue Perfusion, Peripheral would not be priority problems with this disease process.

Rationale 4: A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Fluid-Volume Deficit, Ineffective Thermoregulation, and Ineffective Tissue Perfusion, Peripheral would not be priority problems with this disease process.

Global Rationale: A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Fluid-Volume Deficit, Ineffective Thermoregulation, and Ineffective Tissue Perfusion, Peripheral would not be priority problems with this disease process.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 22.3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV infection).

Question 4

Type: MCSA

A child is prescribed Didanosine (Videx), a nucleoside reverse transcriptase inhibitor, for human immunodeficiency virus (HIV). Which lab value will the nurse monitor closely for this child?

1. Potassium

2. Sodium

3. Red blood cell count

4. Glucose

Correct Answer: 3

Rationale 1: Didanosine (Videx) causes bone-marrow suppression with resulting anemia. Red blood cell counts are monitored at least monthly for changes. Potassium and sodium are electrolytes, and glucose is a laboratory test for checking diabetes. Didanosine (Videx) does not affect these values.

Rationale 2: Didanosine (Videx) causes bone-marrow suppression with resulting anemia. Red blood cell counts are monitored at least monthly for changes. Potassium and sodium are electrolytes, and glucose is a laboratory test for checking diabetes. Didanosine (Videx) does not affect these values.

Rationale 3: Didanosine (Videx) causes bone-marrow suppression with resulting anemia. Red blood cell counts are monitored at least monthly for changes. Potassium and sodium are electrolytes, and glucose is a laboratory test for checking diabetes. Didanosine (Videx) does not affect these values.

Rationale 4: Didanosine (Videx) causes bone-marrow suppression with resulting anemia. Red blood cell counts are monitored at least monthly for changes. Potassium and sodium are electrolytes, and glucose is a laboratory test for checking diabetes. Didanosine (Videx) does not affect these values.

Global Rationale: Didanosine (Videx) causes bone-marrow suppression with resulting anemia. Red blood cell counts are monitored at least monthly for changes. Potassium and sodium are electrolytes, and glucose is a laboratory test for checking diabetes. Didanosine (Videx) does not affect these values.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 22.3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV infection).

Question 5

Type: FIB

A child with human immunodeficiency virus is started on sulfamethoxazole and trimethoprim (Bactrim) for Pneumocystis carinii pneumonia (PCP) prophylaxis. The recommended dose is based on the trimethoprim (TMP) component and is 1520 mg TMP/kg/day in divided doses every 68 hours. The child weighs 6.8 kg. The highest dose of TMP the child can receive a day is ____.

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

Correct Answer: 136

Rationale: 6.8 kg (the childs weight) is multiplied by 20 mg. This yields the answer, which is 136 mg a day.

Global Rationale: 6.8 kg (the childs weight) is multiplied by 20 mg. This yields the answer, which is 136 mg a day.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 22.3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV infection).

Question 6

Type: MCSA

The nurse is providing care to a preschool-age client who is diagnosed with acquired immune deficiency syndrome (AIDS). In planning the clients care, which vaccine is inappropriate for the client to receive?

1. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)

2. Haemophilus influenzae type B (HIB conjugate vaccine)

3. Varicella vaccine

4. Hepatitis B vaccine (Hep B)

Correct Answer: 3

Rationale 1: A child with an immune disorder should not be immunized with a live varicella vaccine because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines and should be given on schedule.

Rationale 2: A child with an immune disorder should not be immunized with a live varicella vaccine because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines and should be given on schedule.

Rationale 3: A child with an immune disorder should not be immunized with a live varicella vaccine because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines and should be given on schedule.

Rationale 4: A child with an immune disorder should not be immunized with a live varicella vaccine because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines and should be given on schedule.

Global Rationale: A child with an immune disorder should not be immunized with a live varicella vaccine because of the risk of contracting the disease. DTaP, HIB, and hepatitis B vaccinations are not live vaccines and should be given on schedule.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 22.3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV infection).

Question 7

Type: MCSA

A child with human immunodeficiency virus (HIV) also has oral candidiasis. Which type of mouth care solution will the nurse teach the child to use?

1. Normal saline

2. Listerine

3. Scope

4. Viscous lidocaine

Correct Answer: 1

Rationale 1: The mouth care should be with a nonalcohol base. Normal saline can keep the childs lips and mouth moist. Listerine and Scope are commercial mouth rinses that can have an alcohol base and cause drying of the membranes. Viscous lidocaine causes numbing and could depress the gag reflex in a younger child.

Rationale 2: The mouth care should be with a nonalcohol base. Normal saline can keep the childs lips and mouth moist. Listerine and Scope are commercial mouth rinses that can have an alcohol base and cause drying of the membranes. Viscous lidocaine causes numbing and could depress the gag reflex in a younger child.

Rationale 3: The mouth care should be with a nonalcohol base. Normal saline can keep the childs lips and mouth moist. Listerine and Scope are commercial mouth rinses that can have an alcohol base and cause drying of the membranes. Viscous lidocaine causes numbing and could depress the gag reflex in a younger child.

Rationale 4: The mouth care should be with a nonalcohol base. Normal saline can keep the childs lips and mouth moist. Listerine and Scope are commercial mouth rinses that can have an alcohol base and cause drying of the membranes. Viscous lidocaine causes numbing and could depress the gag reflex in a younger child.

Global Rationale: The mouth care should be with a nonalcohol base. Normal saline can keep the childs lips and mouth moist. Listerine and Scope are commercial mouth rinses that can have an alcohol base and cause drying of the membranes. Viscous lidocaine causes numbing and could depress the gag reflex in a younger child.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 22.3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV infection).

Question 8

Type: MCSA

The nurse is providing care to an adolescent client diagnosed with systemic lupus erythematosus (SLE). Which action by the client indicates acceptance of body changes associated with SLE?

1. She refuses to attend school.

2. She doesnt want to attend any social functions.

3. She discusses the body changes with a peer.

4. She discusses the body changes with healthcare personnel only.

Correct Answer: 3

Rationale 1: Peer interaction is important to the teen. Being able to discuss the changes to her body with a peer indicates acceptance of the change in body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to body-image changes. Refusing to go to school or not going to social functions indicates nonacceptance of the changes to body image.

Rationale 2: Peer interaction is important to the teen. Being able to discuss the changes to her body with a peer indicates acceptance of the change in body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to body-image changes. Refusing to go to school or not going to social functions indicates nonacceptance of the changes to body image.

Rationale 3: Peer interaction is important to the teen. Being able to discuss the changes to her body with a peer indicates acceptance of the change in body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to body-image changes. Refusing to go to school or not going to social functions indicates nonacceptance of the changes to body image.

Rationale 4: Peer interaction is important to the teen. Being able to discuss the changes to her body with a peer indicates acceptance of the change in body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to body-image changes. Refusing to go to school or not going to social functions indicates nonacceptance of the changes to body image.

Global Rationale: Peer interaction is important to the teen. Being able to discuss the changes to her body with a peer indicates acceptance of the change in body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to body-image changes. Refusing to go to school or not going to social functions indicates nonacceptance of the changes to body image.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 22.4 Plan nursing care for the child with an autoimmune condition such as systemic lupus erythematosus or juvenile arthritis.

Question 9

Type: MCSA

A school-age child diagnosed with rheumatoid arthritis asks the nurse to recommend an exercise activity. Which activity is most appropriate for this child?

1. Softball

2. Football

3. Swimming

4. Basketball

Correct Answer: 3

Rationale 1: Swimming helps to exercise all of the extremities without putting undue stress on joints. Softball, football, and basketball could exacerbate joint discomfort.

Rationale 2: Swimming helps to exercise all of the extremities without putting undue stress on joints. Softball, football, and basketball could exacerbate joint discomfort.

Rationale 3: Swimming helps to exercise all of the extremities without putting undue stress on joints. Softball, football, and basketball could exacerbate joint discomfort.

Rationale 4: Swimming helps to exercise all of the extremities without putting undue stress on joints. Softball, football, and basketball could exacerbate joint discomfort.

Global Rationale: Swimming helps to exercise all of the extremities without putting undue stress on joints. Softball, football, and basketball could exacerbate joint discomfort.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 22.4 Plan nursing care for the child with an autoimmune condition such as systemic lupus erythematosus or juvenile arthritis.

Question 10

Type: MCSA

The nurse is caring for an adolescent client diagnosed with rheumatoid arthritis. Which nonpharmacological measure to reduce joint pain is most appropriate for the nurse to recommend to this client?

1. Moist heat

2. Elevation of extremity

3. Massage

4. Immobilization

Correct Answer: 1

Rationale 1: Moist heat can promote relief of pain and decrease joint stiffness. Elevation of extremity would not have an effect on reducing pain in rheumatoid arthritis. Massage of extremities should be avoided because of a potential risk for emboli. Immobilization can lead to contractures, and range of motion to the involved joint should be maintained.

Rationale 2: Moist heat can promote relief of pain and decrease joint stiffness. Elevation of extremity would not have an effect on reducing pain in rheumatoid arthritis. Massage of extremities should be avoided because of a potential risk for emboli. Immobilization can lead to contractures, and range of motion to the involved joint should be maintained.

Rationale 3: Moist heat can promote relief of pain and decrease joint stiffness. Elevation of extremity would not have an effect on reducing pain in rheumatoid arthritis. Massage of extremities should be avoided because of a potential risk for emboli. Immobilization can lead to contractures, and range of motion to the involved joint should be maintained.

Rationale 4: Moist heat can promote relief of pain and decrease joint stiffness. Elevation of extremity would not have an effect on reducing pain in rheumatoid arthritis. Massage of extremities should be avoided because of a potential risk for emboli. Immobilization can lead to contractures, and range of motion to the involved joint should be maintained.

Global Rationale: Moist heat can promote relief of pain and decrease joint stiffness. Elevation of extremity would not have an effect on reducing pain in rheumatoid arthritis. Massage of extremities should be avoided because of a potential risk for emboli. Immobilization can lead to contractures, and range of motion to the involved joint should be maintained.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 22.4 Plan nursing care for the child with an autoimmune condition such as systemic lupus erythematosus or juvenile arthritis.

Question 11

Type: MCSA

The nurse is providing discharge teaching to a school-age client who was recently diagnosed with a latex allergy. Which product will the nurse educate the client and family to avoid?

1. Plastic bottles

2. Footballs

3. Chewing gum

4. Paper bags

Correct Answer: 3

Rationale 1: When a child is diagnosed with a latex allergy, it is essential for the nurse to educate both the child and the family regarding sources of latex within the home and the community. The child and family should be educated to avoid chewing gum as it contains latex. The other items do not contain latex and do not pose a risk for this child in the community.

Rationale 2: When a child is diagnosed with a latex allergy, it is essential for the nurse to educate both the child and the family regarding sources of latex within the home and the community. The child and family should be educated to avoid chewing gum as it contains latex. The other items do not contain latex and do not pose a risk for this child in the community.

Rationale 3: When a child is diagnosed with a latex allergy, it is essential for the nurse to educate both the child and the family regarding sources of latex within the home and the community. The child and family should be educated to avoid chewing gum as it contains latex. The other items do not contain latex and do not pose a risk for this child in the community.

Rationale 4: When a child is diagnosed with a latex allergy, it is essential for the nurse to educate both the child and the family regarding sources of latex within the home and the community. The child and family should be educated to avoid chewing gum as it contains latex. The other items do not contain latex and do not pose a risk for this child in the community.

Global Rationale: When a child is diagnosed with a latex allergy, it is essential for the nurse to educate both the child and the family regarding sources of latex within the home and the community. The child and family should be educated to avoid chewing gum as it contains latex. The other items do not contain latex and do not pose a risk for this child in the community.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 22.5 Identify exposure prevention measures for the child with latex allergy.

Question 12

Type: MCSA

An HIV-positive mother states she is relieved after the birth of her child to hear that the child is HIV-negative. Which response by the nurse is the most appropriate?

1. Symptoms could still appear over the next 2 years.

2. You took good care of yourself, so your child did not get HIV.

3. We will assess for signs of pneumonia to be sure.

4. The test will be repeated in 1 week to verify the negative status.

Correct Answer: 1

Rationale 1: Symptoms of HIV could still manifest within the first 2 years. An infant is retested 12 months after the initial negative result. The HIV-positive mother can infect the newborn regardless of how well she takes care of herself once she is HIV-positive. There is no reason to assess for signs of pneumonia if the newborn is HIV-negative.

Rationale 2: Symptoms of HIV could still manifest within the first 2 years. An infant is retested in 12 months after the initial negative result. The HIV-positive mother can infect the newborn regardless of how well she takes care of herself once she is HIV-positive. There is no reason to assess for signs of pneumonia if the newborn is HIV-negative.

Rationale 3: Symptoms of HIV could still manifest within the first 2 years. An infant is retested in 12 months after the initial negative result. The HIV-positive mother can infect the newborn regardless of how well she takes care of herself once she is HIV-positive. There is no reason to assess for signs of pneumonia if the newborn is HIV-negative.

Rationale 4: Symptoms of HIV could still manifest within the first 2 years. An infant is retested in 12 months after the initial negative result. The HIV-positive mother can infect the newborn regardless of how well she takes care of herself once she is HIV-positive. There is no reason to assess for signs of pneumonia if the newborn is HIV-negative.

Global Rationale: Symptoms of HIV could still manifest within the first 2 years. An infant is retested 12 months after the initial negative result. The HIV-positive mother can infect the newborn regardless of how well she takes care of herself once she is HIV-positive. There is no reason to assess for signs of pneumonia if the newborn is HIV-negative.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 22.3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV infection).

Question 13

Type: MCSA

Parents of a child who experienced a moderately severe allergic reaction after eating peanuts ask the nurse what they can do to help if it happens again. Which response by the nurse is the most appropriate?

1. If it happens again, I will teach you what to do.

2. You should have an antihistamine like Benadryl with you at all times.

3. We can start a desensitization process to take the allergy away.

4. I will teach you how to use an EpiPen.

Correct Answer: 4

Rationale 1: An EpiPen is the appropriate treatment if this reaction occurs again. Benadryl is fine, but most likely is not strong enough in light of the serious reaction the child had. Desensitization is not the appropriate instruction at this time. Telling the parents that they will be taught if it happens again is brushing off the seriousness of the situation.

Rationale 2: An EpiPen is the appropriate treatment if this reaction occurs again. Benadryl is fine, but most likely is not strong enough in light of the serious reaction the child had. Desensitization is not the appropriate instruction at this time. Telling the parents that they will be taught if it happens again is brushing off the seriousness of the situation.

Rationale 3: An EpiPen is the appropriate treatment if this reaction occurs again. Benadryl is fine, but most likely is not strong enough in light of the serious reaction the child had. Desensitization is not the appropriate instruction at this time. Telling the parents that they will be taught if it happens again is brushing off the seriousness of the situation.

Rationale 4: An EpiPen is the appropriate treatment if this reaction occurs again. Benadryl is fine, but most likely is not strong enough in light of the serious reaction the child had. Desensitization is not the appropriate instruction at this time. Telling the parents that they will be taught if it happens again is brushing off the seriousness of the situation.

Global Rationale: An EpiPen is the appropriate treatment if this reaction occurs again. Benadryl is fine, but most likely is not strong enough in light of the serious reaction the child had. Desensitization is not the appropriate instruction at this time. Telling the parents that they will be taught if it happens again is brushing off the seriousness of the situation.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 22.6 Determine nursing interventions and prevention measures for the child experiencing hypersensitivity reactions.

Question 14

Type: MCMA

A preschool-age child has just had a moderate reaction to latex. When teaching the parents about latex allergy, the nurse should inform the parents of what common household items that contain latex?

Standard Text: Select all that apply.

1. Rubber bands

2. Sneakers

3. Toothbrushes

4. Big Wheel tricycle

5. Water toys

Correct Answer: 1,2,3,5

Rationale 1: Rubber bands, sneakers, toothbrushes, and water toys are household items that might contain latex. A Big Wheel tricycle is plastic and does not contain latex.

Rationale 2: Rubber bands, sneakers, toothbrushes, and water toys are household items that might contain latex. A Big Wheel tricycle is plastic and does not contain latex.

Rationale 3: Rubber bands, sneakers, and toothbrushes are household items that might contain latex. A Big Wheel tricycle is plastic.

Rationale 4: Rubber bands, sneakers, and toothbrushes are household items that might contain latex. A Big Wheel tricycle is plastic.

Rationale 5: Rubber bands, sneakers, and toothbrushes are household items that might contain latex. A Big Wheel tricycle is plastic.

Global Rationale: Rubber bands, sneakers, and toothbrushes are household items that might contain latex. A Big Wheel tricycle is plastic.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 22.5 Identify exposure prevention measures for the child with latex allergy.

Question 15

Type: MCSA

A child comes to the clinic for an assessment 20 days postbone marrow transplant. Which system should receive the highest priority during the nursing assessment?

1. Integumentary

2. Gastrointestinal

3. Respiratory

4. Cardiovascular

Correct Answer: 1

Rationale 1: The skin is most commonly affected in graft-versus-host disease after a transplant. A pruritic, macular papular rash and a blistering, burning sensation can occur. The other systems are important to assess, but are not the highest priority.

Rationale 2: The skin is most commonly affected in graft-versus-host disease after a transplant. A pruritic, macular papular rash and a blistering, burning sensation can occur. The other systems are important to assess, but are not the highest priority.

Rationale 3: The skin is most commonly affected in graft-versus-host disease after a transplant. A pruritic, macular papular rash and a blistering, burning sensation can occur. The other systems are important to assess, but are not the highest priority.

Rationale 4: The skin is most commonly affected in graft-versus-host disease after a transplant. A pruritic, macular papular rash and a blistering, burning sensation can occur. The other systems are important to assess, but are not the highest priority.

Global Rationale: The skin is most commonly affected in graft-versus-host disease after a transplant. A pruritic, macular papular rash and a blistering, burning sensation can occur. The other systems are important to assess, but are not the highest priority.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 22.1 Describe the structure and function of the immune system and apply that knowledge to the care of children with immunologic disorders.

Question 16

Type: MCMA

The nurse is providing care to a school-age client with a documented immunodeficiency who is admitted to the general pediatric unit for intravenous medication administration. Which interventions are appropriate for this client?

Standard Text: Select all that apply.

1. Institute droplet precautions.

2. Place in a positive-pressure room.

3. Avoid live vaccines.

4. Perform frequent handwashing.

5. Recommend fresh fruits brought in by the family.

Correct Answer: 2,3,4

Rationale 1: Pediatric clients with documented immunodeficiency require specific interventions to decrease their risk for developing infections while in the hospital environment. Appropriate interventions for this client include a positive-pressure room, avoiding live vaccines, and meticulous handwashing from staff and visitors. This client would require standard precautions, not droplet precautions. Because of the risk of infection with fresh fruit, the family would not be allowed to bring this to the client during their hospital stay.

Rationale 2: Pediatric clients with documented immunodeficiency require specific interventions to decrease their risk for developing infections while in the hospital environment. Appropriate interventions for this client include a positive-pressure room, avoiding live vaccines, and meticulous handwashing from staff and visitors. This client would require standard precautions, not droplet precautions. Because of the risk of infection with fresh fruit, the family would not be allowed to bring this to the client during their hospital stay.

Rationale 3: Pediatric clients with documented immunodeficiency require specific interventions to decrease their risk for developing infections while in the hospital environment. Appropriate interventions for this client include a positive-pressure room, avoiding live vaccines, and meticulous handwashing from staff and visitors. This client would require standard precautions, not droplet precautions. Because of the risk of infection with fresh fruit, the family would not be allowed to bring this to the client during their hospital stay.

Rationale 4: Pediatric clients with documented immunodeficiency require specific interventions to decrease their risk for developing infections while in the hospital environment. Appropriate interventions for this client include a positive-pressure room, avoiding live vaccines, and meticulous handwashing from staff and visitors. This client would require standard precautions, not droplet precautions. Because of the risk of infection with fresh fruit, the family would not be allowed to bring this to the client during their hospital stay.

Rationale 5: Pediatric clients with documented immunodeficiency require specific interventions to decrease their risk for developing infections while in the hospital environment. Appropriate interventions for this client include a positive-pressure room, avoiding live vaccines, and meticulous handwashing from staff and visitors. This client would require standard precautions, not droplet precautions. Because of the risk of infection with fresh fruit, the family would not be allowed to bring this to the client during their hospital stay.

Global Rationale: Pediatric clients with documented immunodeficiency require specific interventions to decrease their risk for developing infections while in the hospital environment. Appropriate interventions for this client include a positive-pressure room, avoiding live vaccines, and meticulous handwashing from staff and visitors. This client would require standard precautions, not droplet precautions. Because of the risk of infection with fresh fruit, the family would not be allowed to bring this to the client during their hospital stay.

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 22.2 Summarize infection control measures needed for children with an immunodeficiency.

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

Copyright 2015 by Pearson Education, Inc.

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