Chapter 22 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 5th Edition Test Bank
Chapter 22

Question 1

Type: MCSA

A nurse has begun an infusion of intravenous immune globulin (IVIG) to a child who has combined immunodeficiency disease. The infusion should be stopped if the child

1. Experiences a mild headache.

2. Voids clear yellow urine.

3. Develops severe shaking, chills, and fever.

4. Complains 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:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 02. Apply knowledge of the immune system to the care of children with immunological disorders.

Question 2

Type: MCSA

A nurse is administering an intramuscular vaccination to an infant who has Wiskott-Aldrich syndrome (WAS). Because of this syndrome, this infant is at higher risk for

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: Wiskott-Aldrich 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: Wiskott-Aldrich 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: Wiskott-Aldrich 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: Wiskott-Aldrich 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:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 02. Apply knowledge of the immune system to the care of children with immunological disorders.

Question 3

Type: MCSA

A nurse is planning care for a child with human immunodeficiency virus (HIV). The highest-priority nursing problem for this child is

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:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 05. Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV).

Question 4

Type: MCSA

A child is receiving Didanosine (Videx), a nucleoside reverse transcriptase inhibitor, for human immunodeficiency virus (HIV). The nurse should monitor the lab value of

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:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 05. Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV).

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:

Correct Answer: 136

Rationale : 6.8 multiplied by 20 mg is 136 mg a day.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV).

Question 6

Type: MCSA

The immunization a child with acquired immune deficiency syndrome (AIDS) should not receive is the

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:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV).

Question 7

Type: MCSA

A child with human immunodeficiency virus (HIV) also has oral candidiasis. Mouth care for a child should be with

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:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV).

Question 8

Type: MCSA

An adolescent has systemic lupus erythematosus (SLE). An action by the adolescent that indicates acceptance of body changes with SLE would be that the teen

1. Refuses to attend school.

2. Doesnt want to attend any social functions.

3. Discusses the body changes with a peer.

4. Discusses the body changes with health-care personnel only.

Correct Answer: 3

Rationale 1: Peer interaction is important to the teen. Being able to discuss the changes to his body with a peer indicates acceptance of the change in body image. Discussing changes only with health-care 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 his body with a peer indicates acceptance of the change in body image. Discussing changes only with health-care 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 his body with a peer indicates acceptance of the change in body image. Discussing changes only with health-care 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 his body with a peer indicates acceptance of the change in body image. Discussing changes only with health-care 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:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 07. Plan nursing care for the child with an autoimmune condition such as systemic lupus erythematosus or juvenile idiopathic arthritis.

Question 9

Type: MCSA

A school-age child with rheumatoid arthritis asks the nurse to recommend an exercise activity. The nurse should recommend

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:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 07. Plan nursing care for the child with an autoimmune condition such as systemic lupus erythematosus or juvenile idiopathic arthritis.

Question 10

Type: MCSA

The nurse is caring for a child with rheumatoid arthritis. A nonpharmacological measure to reduce the joint pain is

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:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 07. Plan nursing care for the child with an autoimmune condition such as systemic lupus erythematosus or juvenile idiopathic arthritis.

Question 11

Type: MCSA

One of the nurse technicians is showing symptoms of latex sensitivity. The nurse should:

1. Send the nurse technician to a department that does not use latex products.

2. Contact the employee health department in the facility and obtain latex-free products for the nurse technician.

3. Wait until Monday to report the problem to the supervisor of the unit.

4. Assign the nurse technician nonclient-care duties.

Correct Answer: 2

Rationale 1: When symptoms of sensitivity to latex occur on exposure, the employee health department of the facility should be contacted and latex-free products should be supplied. The other options are not realistic because the nurse technician may experience exposure on another unit (no hospital unit can be latex free); waiting until Monday does not solve the problem, and assigning the nurse technician nonclient-care duties may not be possible.

Rationale 2: When symptoms of sensitivity to latex occur on exposure, the employee health department of the facility should be contacted and latex-free products should be supplied. The other options are not realistic because the nurse technician may experience exposure on another unit (no hospital unit can be latex free); waiting until Monday does not solve the problem, and assigning the nurse technician nonclient-care duties may not be possible.

Rationale 3: When symptoms of sensitivity to latex occur on exposure, the employee health department of the facility should be contacted and latex-free products should be supplied. The other options are not realistic because the nurse technician may experience exposure on another unit (no hospital unit can be latex free); waiting until Monday does not solve the problem, and assigning the nurse technician nonclient-care duties may not be possible.

Rationale 4: When symptoms of sensitivity to latex occur on exposure, the employee health department of the facility should be contacted and latex-free products should be supplied. The other options are not realistic because the nurse technician may experience exposure on another unit (no hospital unit can be latex free); waiting until Monday does not solve the problem, and assigning the nurse technician nonclient-care duties may not be possible.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 08. Describe 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. The nurse correctly states to the mother that:

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:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 05. Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV).

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. The nurses best response is:

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:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 09. Apply nursing interventions and prevention measures for the child experiencing other hypersensitivity reactions.

Question 14

Type: MCMA

A 4-year-old 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.

Correct Answer: 1,2,3

Rationale 1: Rubber bands, sneakers, and toothbrushes are household items that might contain latex. A Big Wheel tricycle is plastic.

Rationale 2: Rubber bands, sneakers, and toothbrushes are household items that might contain latex. A Big Wheel tricycle is plastic.

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.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 08. Describe 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. The system that should receive the highest priority during the nursing assessment would be the:

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:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 02. Apply knowledge of the immune system to the care of children with immunological disorders.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 5th Ed. Test Bank

Copyright 2012 by Pearson Education, Inc.

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