Chapter 23 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 23

Question 1

Type: MCSA

The nurse is evaluating the activity tolerance of a 9-month-old with iron deficiency anemia. Which finding indicates that the infant is not tolerating activity?

1. Heart rate of 138

2. Increased alertness

3. Respiratory rate less than 40 with activity

4. Muscle weakness

Correct Answer: 4

Rationale 1: Iron deficiency anemia can result in less oxygen reaching the cells and tissues, causing activity intolerance. An indication that a 9-month-old child is not tolerating activity and that iron deficiency anemia is worsening would be the presence of muscle weakness during activity. A heart rate of 138, increased alertness, and a respiratory rate of less than 40 with activity are all signs that iron deficiency anemia is resolving and activity tolerance is improving.

Rationale 2: Iron deficiency anemia can result in less oxygen reaching the cells and tissues, causing activity intolerance. An indication that a 9-month-old child is not tolerating activity and that iron deficiency anemia is worsening would be the presence of muscle weakness during activity. A heart rate of 138, increased alertness, and a respiratory rate of less than 40 with activity are all signs that iron deficiency anemia is resolving and activity tolerance is improving.

Rationale 3: Iron deficiency anemia can result in less oxygen reaching the cells and tissues, causing activity intolerance. An indication that a 9-month-old child is not tolerating activity and that iron deficiency anemia is worsening would be the presence of muscle weakness during activity. A heart rate of 138, increased alertness, and a respiratory rate of less than 40 with activity are all signs that iron deficiency anemia is resolving and activity tolerance is improving.

Rationale 4: Iron deficiency anemia can result in less oxygen reaching the cells and tissues, causing activity intolerance. An indication that a 9-month-old child is not tolerating activity and that iron deficiency anemia is worsening would be the presence of muscle weakness during activity. A heart rate of 138, increased alertness, and a respiratory rate of less than 40 with activity are all signs that iron deficiency anemia is resolving and activity tolerance is improving.

Global Rationale: Iron deficiency anemia can result in less oxygen reaching the cells and tissues, causing activity intolerance. An indication that a 9-month-old child is not tolerating activity and that iron deficiency anemia is worsening would be the presence of muscle weakness during activity. A heart rate of 138, increased alertness, and a respiratory rate of less than 40 with activity are all signs that iron deficiency anemia is resolving and activity tolerance is improving.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation 

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 23.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

Question 2

Type: MCSA

Which action by the parents demonstrates an understanding of the nurses teaching with regard to prevention of iron-deficient anemia?

1. Feeding their infant with a formula that is not iron fortified

2. Starting iron-fortified infant cereal at 4 to 6 months of age

3. Introducing cows milk at 6 months of age

4. Limiting vitamin C consumption after 1 year of age

Correct Answer: 2

Rationale 1: Starting iron-fortified infant cereal at 4 to 6 months of age is recommended for prevention of iron deficiency in children. Infants who are not breast-fed should get iron-fortified formula. Cows milk should not be introduced until 12 months of age. Vitamin C should be started at 6 to 9 months of age and continued, because foods rich in vitamin C improve iron absorption.

Rationale 2: Starting iron-fortified infant cereal at 4 to 6 months of age is recommended for prevention of iron deficiency in children. Infants who are not breast-fed should get iron-fortified formula. Cows milk should not be introduced until 12 months of age. Vitamin C should be started at 6 to 9 months of age and continued, because foods rich in vitamin C improve iron absorption.

Rationale 3: Starting iron-fortified infant cereal at 4 to 6 months of age is recommended for prevention of iron deficiency in children. Infants who are not breast-fed should get iron-fortified formula. Cows milk should not be introduced until 12 months of age. Vitamin C should be started at 6 to 9 months of age and continued, because foods rich in vitamin C improve iron absorption.

Rationale 4: Starting iron-fortified infant cereal at 4 to 6 months of age is recommended for prevention of iron deficiency in children. Infants who are not breast-fed should get iron-fortified formula. Cows milk should not be introduced until 12 months of age. Vitamin C should be started at 6 to 9 months of age and continued, because foods rich in vitamin C improve iron absorption.

Global Rationale: Starting iron-fortified infant cereal at 4 to 6 months of age is recommended for prevention of iron deficiency in children. Infants who are not breast-fed should get iron-fortified formula. Cows milk should not be introduced until 12 months of age. Vitamin C should be started at 6 to 9 months of age and continued, because foods rich in vitamin C improve iron absorption.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 23.5 Plan the nursing management and collaborative care of a child with a hematologic disorder.

Question 3

Type: MCSA

A child is diagnosed with sickle cell disease. The parents are unsure how their child contracted the disease. Which explanation by the nurse is the most appropriate?

1. Both the mother and the father have the sickle cell trait.

2. The mother has the trait, but the father doesnt.

3. The father has the trait, but the mother doesnt.

4. The mother has sickle cell disease, but the father doesnt have the disease or the trait.

Correct Answer: 1

Rationale 1: Sickle cell disease is an autosomal recessive disorder; both parents must have the trait in order for a child to have the disease.

Rationale 2: Sickle cell disease is an autosomal recessive disorder; both parents must have the trait in order for a child to have the disease.

Rationale 3: Sickle cell disease is an autosomal recessive disorder; both parents must have the trait in order for a child to have the disease.

Rationale 4: Sickle cell disease is an autosomal recessive disorder; both parents must have the trait in order for a child to have the disease.

Global Rationale: Sickle cell disease is an autosomal recessive disorder; both parents must have the trait in order for a child to have the disease.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 23.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

Question 4

Type: MCSA

The charge nurse on a pediatric unit is making a room assignment for a school-age child diagnosed with sickle cell disease, who is in splenic sequestration crisis. Which room assignment is most appropriate for this client?

1. Semiprivate room

2. Reverse-isolation room

3. Contact-isolation room

4. Private room

Correct Answer: 4

Rationale 1: Splenic sequestration can be life-threatening, and there is profound anemia. The child does not need an isolation room but should not be placed in a room with any child who may have an infectious illness. The private room is appropriate for this child.

Rationale 2: Splenic sequestration can be life-threatening, and there is profound anemia. The child does not need an isolation room but should not be placed in a room with any child who may have an infectious illness. The private room is appropriate for this child.

Rationale 3: Splenic sequestration can be life-threatening, and there is profound anemia. The child does not need an isolation room but should not be placed in a room with any child who may have an infectious illness. The private room is appropriate for this child.

Rationale 4: Splenic sequestration can be life-threatening, and there is profound anemia. The child does not need an isolation room but should not be placed in a room with any child who may have an infectious illness. The private room is appropriate for this child.

Global Rationale: Splenic sequestration can be life-threatening, and there is profound anemia. The child does not need an isolation room but should not be placed in a room with any child who may have an infectious illness. The private room is appropriate for this child.

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 23.5 Plan the nursing management and collaborative care of a child with a hematologic disorder.

Question 5

Type: MCSA

The nurse is providing care for an adolescent client who is experiencing pain related to a sickle cell crisis. Which medication does the nurse prepare to administer to this client?

1. Morphine sulfate

2. Meperidine

3. Acetaminophen

4. Ibuprofen

Correct Answer: 1

Rationale 1: The pain during a sickling crisis is severe, and morphine is needed for pain control around the clock or by patient-controlled analgesia (PCA). Meperidine is not used for pain control for clients with sickle cell pain crisis because it could cause seizures. Acetaminophen or ibuprofen is used for mild pain and would not be effective for the severe pain experienced by a child in sickle cell pain crisis.

Rationale 2: The pain during a sickling crisis is severe, and morphine is needed for pain control around the clock or by patient-controlled analgesia (PCA). Meperidine is not used for pain control for clients with sickle cell pain crisis because it could cause seizures. Acetaminophen or ibuprofen is used for mild pain and would not be effective for the severe pain experienced by a child in sickle cell pain crisis.

Rationale 3: The pain during a sickling crisis is severe, and morphine is needed for pain control around the clock or by patient-controlled analgesia (PCA). Meperidine is not used for pain control for clients with sickle cell pain crisis because it could cause seizures. Acetaminophen or ibuprofen is used for mild pain and would not be effective for the severe pain experienced by a child in sickle cell pain crisis.

Rationale 4: The pain during a sickling crisis is severe, and morphine is needed for pain control around the clock or by patient-controlled analgesia (PCA). Meperidine is not used for pain control for clients with sickle cell pain crisis because it could cause seizures. Acetaminophen or ibuprofen is used for mild pain and would not be effective for the severe pain experienced by a child in sickle cell pain crisis.

Global Rationale: The pain during a sickling crisis is severe, and morphine is needed for pain control around the clock or by patient-controlled analgesia (PCA). Meperidine is not used for pain control for clients with sickle cell pain crisis because it could cause seizures. Acetaminophen or ibuprofen is used for mild pain and would not be effective for the severe pain experienced by a child in sickle cell pain crisis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 04. Plan nursing care for the child with a chronic disorder of red blood cells.

Question 6

Type: MCMA

The nurse is teaching parents how to prevent a sickle cell crisis in the child with sickle cell disease. Which precipitating factors to a sickle cell crisis will the nurse include in the explanation?

Standard Text: Select all that apply.

1. Fever

2. Dehydration

3. Regular exercise

4. Altitude

5. Increased fluid intake

Correct Answer: 1,2,4

Rationale 1: Fever, dehydration, and altitude are precipitating factors contributing to a sickle cell crisis. Regular exercise and increased fluid intake are recommended activities for a child with sickle cell disease and will not contribute to a sickle cell crisis.

Rationale 2: Fever, dehydration, and altitude are precipitating factors contributing to a sickle cell crisis. Regular exercise and increased fluid intake are recommended activities for a child with sickle cell disease and will not contribute to a sickle cell crisis.

Rationale 3: Fever, dehydration, and altitude are precipitating factors contributing to a sickle cell crisis. Regular exercise and increased fluid intake are recommended activities for a child with sickle cell disease and will not contribute to a sickle cell crisis.

Rationale 4: Fever, dehydration, and altitude are precipitating factors contributing to a sickle cell crisis. Regular exercise and increased fluid intake are recommended activities for a child with sickle cell disease and will not contribute to a sickle cell crisis.

Rationale 5: Fever, dehydration, and altitude are precipitating factors contributing to a sickle cell crisis. Regular exercise and increased fluid intake are recommended activities for a child with sickle cell disease and will not contribute to a sickle cell crisis.

Global Rationale: Fever, dehydration, and altitude are precipitating factors contributing to a sickle cell crisis. Regular exercise and increased fluid intake are recommended activities for a child with sickle cell disease and will not contribute to a sickle cell crisis.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 23.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

Question 7

Type: MCSA

The nurse is administering packed red blood cells to a child with sickle cell disease (SCD). The nurse is monitoring for a transfusion reaction and knows it is most likely to occur during which time frame?

1. Six hours after the transfusion is given

2. Within the first 20 minutes of administration of the transfusion

3. At the end of the administration of the transfusion

4. Never; children with SCD do not have reactions.

Correct Answer: 2

Rationale 1: Blood reactions can occur as soon as the blood transfusion begins or within the first 20 minutes. The nurse should remain with the child for the first 20 minutes of the transfusion.

Rationale 2: Blood reactions can occur as soon as the blood transfusion begins or within the first 20 minutes. The nurse should remain with the child for the first 20 minutes of the transfusion.

Rationale 3: Blood reactions can occur as soon as the blood transfusion begins or within the first 20 minutes. The nurse should remain with the child for the first 20 minutes of the transfusion.

Rationale 4: Blood reactions can occur as soon as the blood transfusion begins or within the first 20 minutes. The nurse should remain with the child for the first 20 minutes of the transfusion.

Global Rationale: Blood reactions can occur as soon as the blood transfusion begins or within the first 20 minutes. The nurse should remain with the child for the first 20 minutes of the transfusion.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 23.5 Plan the nursing management and collaborative care of a child with a hematologic disorder.

Question 8

Type: MCSA

A child who has beta-thalassemia is receiving numerous blood transfusions. The child is also receiving deferoxamine (Desferal) therapy. The parents ask how the deferoxamine will help their child. Which rationale does the nurse use when responding to the parents?

1. It prevents blood transfusion reactions.

2. It stimulates red blood cell production.

3. It provides vitamin supplementation.

4. It prevents iron overload.

Correct Answer: 4

Rationale 1: Iron overload can be a side effect of a hypertransfusion therapy. Deferoxamine (Desferal) is an iron-chelating drug, which binds excess iron so it can be excreted by the kidneys. It does not prevent blood-transfusion reactions, stimulate red blood cell production, or provide vitamin supplementation.

Rationale 2: Iron overload can be a side effect of a hypertransfusion therapy. Deferoxamine (Desferal) is an iron-chelating drug, which binds excess iron so it can be excreted by the kidneys. It does not prevent blood-transfusion reactions, stimulate red blood cell production, or provide vitamin supplementation.

Rationale 3: Iron overload can be a side effect of a hypertransfusion therapy. Deferoxamine (Desferal) is an iron-chelating drug, which binds excess iron so it can be excreted by the kidneys. It does not prevent blood-transfusion reactions, stimulate red blood cell production, or provide vitamin supplementation.

Rationale 4: Iron overload can be a side effect of a hypertransfusion therapy. Deferoxamine (Desferal) is an iron-chelating drug, which binds excess iron so it can be excreted by the kidneys. It does not prevent blood-transfusion reactions, stimulate red blood cell production, or provide vitamin supplementation.

Global Rationale: Iron overload can be a side effect of a hypertransfusion therapy. Deferoxamine (Desferal) is an iron-chelating drug, which binds excess iron so it can be excreted by the kidneys. It does not prevent blood-transfusion reactions, stimulate red blood cell production, or provide vitamin supplementation.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 23.5 Plan the nursing management and collaborative care of a child with a hematologic disorder.

Question 9

Type: MCSA

A child recently diagnosed with aplastic anemia is being prepared for discharge. When planning support for the family, which service should the nurse plan to include in the discharge plan?

1. Referrals to support groups and social services

2. Short-term support

3. Genetic counseling

4. Nutrition counseling

Correct Answer: 1

Rationale 1: Families require support in dealing with a child who has a life-threatening disease. They should be referred to support groups for counseling, if indicated, and to social services. The support will be long term in nature. Aplastic anemia is not a genetically transmitted disease. Nutrition counseling is not a priority and may or may not be needed with aplastic anemia.

Rationale 2: Families require support in dealing with a child who has a life-threatening disease. They should be referred to support groups for counseling, if indicated, and to social services. The support will be long term in nature. Aplastic anemia is not a genetically transmitted disease. Nutrition counseling is not a priority and may or may not be needed with aplastic anemia.

Rationale 3: Families require support in dealing with a child who has a life-threatening disease. They should be referred to support groups for counseling, if indicated, and to social services. The support will be long term in nature. Aplastic anemia is not a genetically transmitted disease. Nutrition counseling is not a priority and may or may not be needed with aplastic anemia.

Rationale 4: Families require support in dealing with a child who has a life-threatening disease. They should be referred to support groups for counseling, if indicated, and to social services. The support will be long term in nature. Aplastic anemia is not a genetically transmitted disease. Nutrition counseling is not a priority and may or may not be needed with aplastic anemia.

Global Rationale: Families require support in dealing with a child who has a life-threatening disease. They should be referred to support groups for counseling, if indicated, and to social services. The support will be long term in nature. Aplastic anemia is not a genetically transmitted disease. Nutrition counseling is not a priority and may or may not be needed with aplastic anemia.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 23.5 Plan the nursing management and collaborative care of a child with a hematologic disorder.

Question 10

Type: MCSA

A school-age child with hemophilia falls on the playground and goes to the nurses office with superficial bleeding above the knee. Which action by the nurse is the most appropriate?

1. Apply a warm, moist pack to the area.

2. Perform some passive range of motion to the affected leg.

3. Apply pressure to the area for at least 15 minutes.

4. Keep the affected extremity in a dependent position.

Correct Answer: 3

Rationale 1: If a hemophiliac child experiences a bleeding episode, superficial bleeding should be controlled by applying pressure to the area for at least 15 minutes. Ice should be applied, not heat. The extremity should be immobilized and elevated, so passive range of motion and keeping the extremity in a dependent position would not be appropriate interventions at this time.

Rationale 2: If a hemophiliac child experiences a bleeding episode, superficial bleeding should be controlled by applying pressure to the area for at least 15 minutes. Ice should be applied, not heat. The extremity should be immobilized and elevated, so passive range of motion and keeping the extremity in a dependent position would not be appropriate interventions at this time.

Rationale 3: If a hemophiliac child experiences a bleeding episode, superficial bleeding should be controlled by applying pressure to the area for at least 15 minutes. Ice should be applied, not heat. The extremity should be immobilized and elevated, so passive range of motion and keeping the extremity in a dependent position would not be appropriate interventions at this time.

Rationale 4: If a hemophiliac child experiences a bleeding episode, superficial bleeding should be controlled by applying pressure to the area for at least 15 minutes. Ice should be applied, not heat. The extremity should be immobilized and elevated, so passive range of motion and keeping the extremity in a dependent position would not be appropriate interventions at this time.

Global Rationale: If a hemophiliac child experiences a bleeding episode, superficial bleeding should be controlled by applying pressure to the area for at least 15 minutes. Ice should be applied, not heat. The extremity should be immobilized and elevated, so passive range of motion and keeping the extremity in a dependent position would not be appropriate interventions at this time.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 23.5 Plan the nursing management and collaborative care of a child with a hematologic disorder.

.

Question 11

Type: MCSA

A child diagnosed with hemophilia plans on participating in a bicycling club. Which recommendation by the nurse is the most appropriate?

1. Consider a swim club instead of the bicycling club.

2. Wear kneepads, elbow pads, and a helmet while bicycling.

3. Participate only in the social activities of the club.

4. Not join the club.

Correct Answer: 2

Rationale 1: Children with hemophilia should be encouraged to participate in noncontact sports activities. Bicycling is an excellent option and is recommended along with swimming. The child should always use kneepads, elbow pads, and a helmet when participating in a physical sport. Participating only in the social aspects of the club would not encourage physical activity. Discouraging a child from joining a club would not foster growth and development.

Rationale 2: Children with hemophilia should be encouraged to participate in noncontact sports activities. Bicycling is an excellent option and is recommended along with swimming. The child should always use kneepads, elbow pads, and a helmet when participating in a physical sport. Participating only in the social aspects of the club would not encourage physical activity. Discouraging a child from joining a club would not foster growth and development.

Rationale 3: Children with hemophilia should be encouraged to participate in noncontact sports activities. Bicycling is an excellent option and is recommended along with swimming. The child should always use kneepads, elbow pads, and a helmet when participating in a physical sport. Participating only in the social aspects of the club would not encourage physical activity. Discouraging a child from joining a club would not foster growth and development.

Rationale 4: Children with hemophilia should be encouraged to participate in noncontact sports activities. Bicycling is an excellent option and is recommended along with swimming. The child should always use kneepads, elbow pads, and a helmet when participating in a physical sport. Participating only in the social aspects of the club would not encourage physical activity. Discouraging a child from joining a club would not foster growth and development.

Global Rationale: Children with hemophilia should be encouraged to participate in noncontact sports activities. Bicycling is an excellent option and is recommended along with swimming. The child should always use kneepads, elbow pads, and a helmet when participating in a physical sport. Participating only in the social aspects of the club would not encourage physical activity. Discouraging a child from joining a club would not foster growth and development.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 23.5 Plan the nursing management and collaborative care of a child with a hematologic disorder.

Question 12

Type: MCSA

The nurse is caring for a child with disseminated intravascular coagulation (DIC). Which nursing intervention is a priority for this child?

1. Frequent ambulation

2. Maintenance of skin integrity

3. Monitoring of fluid restriction

4. Preparation for x-ray procedures

Correct Answer: 2

Rationale 1: Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should be placed on bed rest. Fluids need to be monitored but will not be restricted, and DIC is not diagnosed with x-ray examination but by serum lab studies.

Rationale 2: Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should be placed on bed rest. Fluids need to be monitored but will not be restricted, and DIC is not diagnosed with x-ray examination but by serum lab studies.

Rationale 3: Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should be placed on bed rest. Fluids need to be monitored but will not be restricted, and DIC is not diagnosed with x-ray examination but by serum lab studies.

Rationale 4: Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should be placed on bed rest. Fluids need to be monitored but will not be restricted, and DIC is not diagnosed with x-ray examination but by serum lab studies.

Global Rationale: Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should be placed on bed rest. Fluids need to be monitored but will not be restricted, and DIC is not diagnosed with x-ray examination but by serum lab studies.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 23.5 Plan the nursing management and collaborative care of a child with a hematologic disorder.

Question 13

Type: MCSA

The nurse is providing care to a school-age client diagnosed with idiopathic thrombocytopenic purpura (ITP). Which nursing diagnosis is the priority for this client?

1. Risk for Injury

2. Ineffective Breathing Pattern

3. Nausea

4. Fluid-Volume Deficit.

Correct Answer: 1

Rationale 1: ITP is the most common bleeding disorder in children, so risk for injury (bleeding) is the priority nursing diagnosis. The disease process does not usually cause ineffective breathing patterns, nausea, or fluid-volume deficits.

Rationale 2: ITP is the most common bleeding disorder in children, so risk for injury (bleeding) is the priority nursing diagnosis. The disease process does not usually cause ineffective breathing patterns, nausea, or fluid-volume deficits.

Rationale 3: ITP is the most common bleeding disorder in children, so risk for injury (bleeding) is the priority nursing diagnosis. The disease process does not usually cause ineffective breathing patterns, nausea, or fluid-volume deficits.

Rationale 4: ITP is the most common bleeding disorder in children, so risk for injury (bleeding) is the priority nursing diagnosis. The disease process does not usually cause ineffective breathing patterns, nausea, or fluid-volume deficits.

Global Rationale: ITP is the most common bleeding disorder in children, so risk for injury (bleeding) is the priority nursing diagnosis. The disease process does not usually cause ineffective breathing patterns, nausea, or fluid-volume deficits.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 23.4 Discuss the pathophysiology and clinical manifestations of the major bleeding disorders affecting the pediatric population.

Question 14

Type: MCSA

A child with meningococcemia is being admitted to the pediatric intensive-care unit. Which room assignment is the most appropriate for this child?

1. Semiprivate room

2. Private room, but not in isolation

3. Private room, in protective isolation

4. Private room, in respiratory isolation

Correct Answer: 4

Rationale 1: Meningococcemia follows an infection with Neisseria meningitidis. N. meningitidis is transmitted through airborne droplets; thus, the child should be placed in a private room in respiratory isolation. A private room with protective isolation (child is essentially kept in a bubble) would not be appropriate.

Rationale 2: Meningococcemia follows an infection with Neisseria meningitidis. N. meningitidis is transmitted through airborne droplets; thus, the child should be placed in a private room in respiratory isolation. A private room with protective isolation (child is essentially kept in a bubble) would not be appropriate.

Rationale 3: Meningococcemia follows an infection with Neisseria meningitidis. N. meningitidis is transmitted through airborne droplets; thus, the child should be placed in a private room in respiratory isolation. A private room with protective isolation (child is essentially kept in a bubble) would not be appropriate.

Rationale 4: Meningococcemia follows an infection with Neisseria meningitidis. N. meningitidis is transmitted through airborne droplets; thus, the child should be placed in a private room in respiratory isolation. A private room with protective isolation (child is essentially kept in a bubble) would not be appropriate.

Global Rationale: Meningococcemia follows an infection with Neisseria meningitidis. N. meningitidis is transmitted through airborne droplets; thus, the child should be placed in a private room in respiratory isolation. A private room with protective isolation (child is essentially kept in a bubble) would not be appropriate.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 23.5 Plan the nursing management and collaborative care of a child with a hematologic disorder.

Question 15

Type: MCMA

A child who has undergone a hematopoietic stem cell transplantation (HSCT) is ready for discharge. Which items will the nurse include in the discharge teaching for this child and family?

Standard Text: Select all that apply.

1. Recognize the signs of graft-versus-host disease.

2. Return the child to school within six weeks.

3. Practice good handwashing.

4. Avoid obtaining influenza vaccinations.

5. Avoid live plants and fresh vegetables.

Correct Answer: 1,3,5

Rationale 1: A child who is preparing for discharge after a HSCT will require specific interventions to decrease the risk of contracting communicable illnesses. Appropriate teaching points include: recognizing the signs of graft-versus-host disease; practicing good handwashing; and avoiding live plants and fresh vegetables. The child will require home schooling for 6 to 12 months. The child and family members should be encouraged to obtain yearly influenza vaccinations.

Rationale 2: A child who is preparing for discharge after a HSCT will require specific interventions to decrease the risk of contracting communicable illnesses. Appropriate teaching points include: recognizing the signs of graft-versus-host disease; practicing good handwashing; and avoiding live plants and fresh vegetables. The child will require home schooling for 6 to 12 months. The child and family members should be encouraged to obtain yearly influenza vaccinations.

Rationale 3: A child who is preparing for discharge after a HSCT will require specific interventions to decrease the risk of contracting communicable illnesses. Appropriate teaching points include: recognizing the signs of graft-versus-host disease; practicing good handwashing; and avoiding live plants and fresh vegetables. The child will require home schooling for 6 to 12 months. The child and family members should be encouraged to obtain yearly influenza vaccinations.

Rationale 4: A child who is preparing for discharge after a HSCT will require specific interventions to decrease the risk of contracting communicable illnesses. Appropriate teaching points include: recognizing the signs of graft-versus-host disease; practicing good handwashing; and avoiding live plants and fresh vegetables. The child will require home schooling for 6 to 12 months. The child and family members should be encouraged to obtain yearly influenza vaccinations.

Rationale 5: A child who is preparing for discharge after a HSCT will require specific interventions to decrease the risk of contracting communicable illnesses. Appropriate teaching points include: recognizing the signs of graft-versus-host disease; practicing good handwashing; and avoiding live plants and fresh vegetables. The child will require home schooling for 6 to 12 months. The child and family members should be encouraged to obtain yearly influenza vaccinations.

Global Rationale: A child who is preparing for discharge after a HSCT will require specific interventions to decrease the risk of contracting communicable illnesses. Appropriate teaching points include: recognizing the signs of graft-versus-host disease; practicing good handwashing; and avoiding live plants and fresh vegetables. The child will require home schooling for 6 to 12 months. The child and family members should be encouraged to obtain yearly influenza vaccinations.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 23.6 Prioritize nursing interventions for a child receiving hematopoietic stem cell transplantation (HSCT).

Question 16

Type: MCSA

The nurse is caring for a child who is in a sickle cell crisis and has severe pain. Which nursing intervention is the most appropriate for this child?

1. Giving comfort measures, such as back rubs

2. Suggesting diversional activities, such as coloring

3. Administering pain medication

4. Preparing the child for painful procedures

Correct Answer: 3

Rationale 1: Severe pain requires administration of pain medication for pain relief. Comfort measures and diversional activities are not effective against severe pain in children. Comfort measures should be given to every child and can be used after pain medication is given. A child in severe pain is not capable of participating in or enjoying diversional activities. Preparing the child for painful procedures is not appropriate when the child is already in pain.

Rationale 2: Severe pain requires administration of pain medication for pain relief. Comfort measures and diversional activities are not effective against severe pain in children. Comfort measures should be given to every child and can be used after pain medication is given. A child in severe pain is not capable of participating in or enjoying diversional activities. Preparing the child for painful procedures is not appropriate when the child is already in pain.

Rationale 3: Severe pain requires administration of pain medication for pain relief. Comfort measures and diversional activities are not effective against severe pain in children. Comfort measures should be given to every child and can be used after pain medication is given. A child in severe pain is not capable of participating in or enjoying diversional activities. Preparing the child for painful procedures is not appropriate when the child is already in pain.

Rationale 4: Severe pain requires administration of pain medication for pain relief. Comfort measures and diversional activities are not effective against severe pain in children. Comfort measures should be given to every child and can be used after pain medication is given. A child in severe pain is not capable of participating in or enjoying diversional activities. Preparing the child for painful procedures is not appropriate when the child is already in pain.

Global Rationale: Severe pain requires administration of pain medication for pain relief. Comfort measures and diversional activities are not effective against severe pain in children. Comfort measures should be given to every child and can be used after pain medication is given. A child in severe pain is not capable of participating in or enjoying diversional activities. Preparing the child for painful procedures is not appropriate when the child is already in pain.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 23.5 Plan the nursing management and collaborative care of a child with a hematologic disorder.

Question 17

Type: MCMA

The nurse is providing an educational session for parents with children diagnosed with iron deficiency anemia. Which statements will the nurse include educate about the normal functions of red blood cells?

Standard Text: Select all that apply.

1. Red blood cells transport oxygen from the lungs to the tissue.

2. Red blood cells carbon dioxide to the lungs.

3. Red blood cells protect the body against bacterial invaders.

4. Red blood cells form hemostatic plugs to stop bleeding.

5. Red blood cells are responsible for psychosocial development.

Correct Answer: 

Rationale 1: The normal function of red blood cells includes transporting oxygen from the lungs to the tissue and transporting carbon dioxide to the lungs. White blood cells protect the body against bacterial invaders. Platelets form hemostatic plugs to stop bleeding. Red blood cells are not directly responsible for psychosocial development.

Rationale 2: The normal function of red blood cells includes transporting oxygen from the lungs to the tissue and transporting carbon dioxide to the lungs. White blood cells protect the body against bacterial invaders. Platelets form hemostatic plugs to stop bleeding. Red blood cells are not directly responsible for psychosocial development.

Rationale 3: The normal function of red blood cells includes transporting oxygen from the lungs to the tissue and transporting carbon dioxide to the lungs. White blood cells protect the body against bacterial invaders. Platelets form hemostatic plugs to stop bleeding. Red blood cells are not directly responsible for psychosocial development.

Rationale 4: The normal function of red blood cells includes transporting oxygen from the lungs to the tissue and transporting carbon dioxide to the lungs. White blood cells protect the body against bacterial invaders. Platelets form hemostatic plugs to stop bleeding. Red blood cells are not directly responsible for psychosocial development.

Rationale 5: The normal function of red blood cells includes transporting oxygen from the lungs to the tissue and transporting carbon dioxide to the lungs. White blood cells protect the body against bacterial invaders. Platelets form hemostatic plugs to stop bleeding. Red blood cells are not directly responsible for psychosocial development.

Global Rationale: The normal function of red blood cells includes transporting oxygen from the lungs to the tissueand transporting carbon dioxide to the lungs. White blood cells protect the body against bacterial invaders. Platelets form hemostatic plugs to stop bleeding. Red blood cells are not directly responsible for psychosocial development.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 23.1: Describe the function of red blood cells, white blood cells, and platelets.

Question 18

Type: MCMA

The nurse is providing care to a school-age client with neutropenia. Which clinical manifestations does the nurse anticipate when assessing this client?

Standard Text: Select all that apply.

1. Fever

2. Fatigue

3. Tachycardia

4. Hypertension

5. Tachypnea

Correct Answer: 1,2,3,5

Rationale 1: A school-age client who is diagnosed with neutropenia, or a decrease in white blood cells, will likely exhibit fever, fatigue, tachycardia, and tachypnea (as a result of congestive heart failure). The nurse would not anticipate that the client will exhibit hypertension as a result of the diagnosis.

Rationale 2: A school-age client who is diagnosed with neutropenia, or a decrease in white blood cells, will likely exhibit fever, fatigue, tachycardia, and tachypnea (as a result of congestive heart failure). The nurse would not anticipate that the client will exhibit hypertension as a result of the diagnosis.

Rationale 3: A school-age client who is diagnosed with neutropenia, or a decrease in white blood cells, will likely exhibit fever, fatigue, tachycardia, and tachypnea (as a result of congestive heart failure). The nurse would not anticipate that the client will exhibit hypertension as a result of the diagnosis.

Rationale 4: A school-age client who is diagnosed with neutropenia, or a decrease in white blood cells, will likely exhibit fever, fatigue, tachycardia, and tachypnea (as a result of congestive heart failure). The nurse would not anticipate that the client will exhibit hypertension as a result of the diagnosis.

Rationale 5: A school-age client who is diagnosed with neutropenia, or a decrease in white blood cells, will likely exhibit fever, fatigue, tachycardia, and tachypnea (as a result of congestive heart failure). The nurse would not anticipate that the client will exhibit hypertension as a result of the diagnosis.

Global Rationale: A school-age client who is diagnosed with neutropenia, or a decrease in white blood cells, will likely exhibit fever, fatigue, tachycardia, and tachypnea (as a result of congestive heart failure). The nurse would not anticipate that the client will exhibit hypertension as a result of the diagnosis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 23.3: Discuss the pathophysiology and clinical manifestations of the selected disorders of white blood cells affecting the pediatric population.

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

Copyright 2015 by Pearson Education, Inc.

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