Chapter 24: The Child with Fluid and Electrolyte Imbalance My Nursing Test Banks

Chapter 24: The Child with Fluid and Electrolyte Imbalance

MULTIPLE CHOICE

1. What substance is released from the posterior pituitary gland and promotes water retention in the renal system?

a.

Renin

b.

Aldosterone

c.

Angiotensin

d.

Antidiuretic hormone (ADH)

ANS: D

ADH is released in response to increased osmolality and decreased volume of intravascular fluid; it promotes water retention in the renal system by increasing the permeability of renal tubules to water. Renin release is stimulated by diminished blood flow to the kidneys. Aldosterone is secreted by the adrenal cortex. It enhances sodium reabsorption in renal tubules, promoting osmotic reabsorption of water. Renin reacts with a plasma globulin to generate angiotensin, which is a powerful vasoconstrictor. Angiotensin also stimulates the release of aldosterone.

DIF: Cognitive Level: Understanding REF: p. 947

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2. Nurses should be alert for increased fluid requirements in which circumstance?

a.

Fever

b.

Mechanical ventilation

c.

Congestive heart failure

d.

Increased intracranial pressure

ANS: A

Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. The mechanically ventilated child has decreased fluid requirements. Congestive heart failure is a case of fluid overload in children. Increased intracranial pressure does not lead to increased fluid requirements in children.

DIF: Cognitive Level: Understanding REF: p. 948

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

3. What factor predisposes an infant to fluid imbalances?

a.

Decreased surface area

b.

Lower metabolic rate

c.

Immature kidney functioning

d.

Decreased daily exchange of extracellular fluid

ANS: C

The infants kidneys are functionally immature at birth and are inefficient in excreting waste products of metabolism. Infants have a relatively high body surface area (BSA) compared with adults. This allows a higher loss of fluid to the environment. A higher metabolic rate is present as a result of the higher BSA in relation to active metabolic tissue. The higher metabolic rate increases heat production, which results in greater insensible water loss. Infants have a greater exchange of extracellular fluid, leaving them with a reduced fluid reserve in conditions of dehydration.

DIF: Cognitive Level: Understanding REF: p. 948

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

4. What is the required number of milliliters of fluid needed per day for a 14-kg child?

a.

800

b.

1000

c.

1200

d.

1400

ANS: C

For the first 10 kg of body weight, a child requires 100 ml/kg. For each additional kilogram of body weight, an extra 50 ml is needed.

10 kg 100 ml/kg/day = 1000 ml

4 kg 50 ml/kg/day = 200 ml

1000 ml + 200 ml = 1200 ml/day

Eight hundred to 1000 ml is too little; 1400 ml is too much.

DIF: Cognitive Level: Applying REF: p. 952

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

5. An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation?

a.

Water excess

b.

Sodium excess

c.

Water depletion

d.

Potassium excess

ANS: C

These clinical manifestations indicate water depletion or dehydration. Edema and weight gain occur with water excess or overhydration. Sodium or potassium excess would not cause these symptoms.

DIF: Cognitive Level: Analyzing REF: p. 949

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

6. Clinical manifestations of sodium excess (hypernatremia) include which signs or symptoms?

a.

Hyperreflexia

b.

Abdominal cramps

c.

Cardiac dysrhythmias

d.

Dry, sticky mucous membranes

ANS: D

Dry, sticky mucous membranes are associated with hypernatremia. Hyperreflexia is associated with hyperkalemia. Abdominal cramps, weakness, dizziness, nausea, and apprehension are associated hyponatremia. Cardiac dysrhythmias are associated with hypokalemia.

DIF: Cognitive Level: Understanding REF: p. 950

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

7. What laboratory finding should the nurse expect in a child with an excess of water?

a.

Decreased hematocrit

b.

High serum osmolality

c.

High urine specific gravity

d.

Increased blood urea nitrogen

ANS: A

The excess water in the circulatory system results in hemodilution. The laboratory results show a falsely decreased hematocrit. Laboratory analysis of blood that is hemodiluted reveals decreased serum osmolality and blood urea nitrogen. The urine specific gravity is variable relative to the childs ability to correct the fluid imbalance.

DIF: Cognitive Level: Understanding REF: p. 949

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

8. What clinical manifestation(s) is associated with calcium depletion (hypocalcemia)?

a.

Nausea, vomiting

b.

Weakness, fatigue

c.

Muscle hypotonicity

d.

Neuromuscular irritability

ANS: D

Neuromuscular irritability is a clinical manifestation of hypocalcemia. Nausea and vomiting occur with hypercalcemia and hypernatremia. Weakness, fatigue, and muscle hypotonicity are clinical manifestations of hypercalcemia.

DIF: Cognitive Level: Understanding REF: p. 951

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

9. What type of dehydration occurs when the electrolyte deficit exceeds the water deficit?

a.

Isotonic dehydration

b.

Hypotonic dehydration

c.

Hypertonic dehydration

d.

Hyperosmotic dehydration

ANS: B

Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Hyperosmotic dehydration is another term for hypertonic dehydration.

DIF: Cognitive Level: Understanding REF: p. 952

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

10. What amount of fluid loss occurs with moderate dehydration?

a.

<50 ml/kg

b.

50 to 90 ml/kg

c.

<5% total body weight

d.

>15% total body weight

ANS: B

Moderate dehydration is defined as a fluid loss of between 50 and 90 ml/kg. Mild dehydration is defined as a fluid loss of less than 50 ml/kg. Weight loss up to 5% is considered mild dehydration. Weight loss over 15% is severe dehydration.

DIF: Cognitive Level: Understanding REF: p. 952

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

11. Physiologically, the child compensates for fluid volume losses by which mechanism?

a.

Inhibition of aldosterone secretion

b.

Hemoconcentration to reduce cardiac workload

c.

Fluid shift from interstitial space to intravascular space

d.

Vasodilation of peripheral arterioles to increase perfusion

ANS: C

Compensatory mechanisms attempt to maintain fluid volume. Initially, interstitial fluid moves into the intravascular compartment to maintain blood volume. Aldosterone is released to promote sodium retention and conserve water in the kidneys. Hemoconcentration results from the fluid volume loss. With less circulating volume, tachycardia results. Vasoconstriction of peripheral arterioles occurs to help maintain blood pressure.

DIF: Cognitive Level: Understanding REF: p. 952

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

12. Ongoing fluid losses can overwhelm the childs ability to compensate, resulting in shock. What early clinical sign precedes shock?

a.

Tachycardia

b.

Slow respirations

c.

Warm, flushed skin

d.

Decreased blood pressure

ANS: A

Shock is preceded by tachycardia and signs of poor tissue perfusion and decreased pulse oximetry values. Respirations are increased as the child attempts to compensate. As a result of the poor peripheral circulation, the child has skin that is cool and mottled with decreased capillary refilling after blanching. In children, lowered blood pressure is a late sign and may accompany the onset of cardiovascular collapse.

DIF: Cognitive Level: Understanding REF: p. 952

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

13. The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant?

a.

Weight loss and decreased heart rate

b.

Capillary refill of less than 2 seconds and no tears

c.

Increased skin elasticity and sunken anterior fontanel

d.

Dry mucous membranes and generally ill appearance

ANS: D

A good predictor of a fluid deficit of at least 5% is any two four factors: capillary refill of more than 2 seconds, absent tears, dry mucous membranes, and ill general appearance. Weight loss is associated with fluid deficit, but the degree needs to be quantified. Heart rate is usually elevated. Skin elasticity is decreased, not increased. The anterior fontanel is depressed.

DIF: Cognitive Level: Applying REF: p. 957

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

14. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?

a.

Oliguria

b.

Weight loss

c.

Irritability and seizures

d.

Muscle weakness and cardiac dysrhythmias

ANS: C

Irritability, somnolence, headache, vomiting, diarrhea, and generalized seizures are manifestations of water intoxication. Urinary output is increased as the child attempts to maintain fluid balance. Weight gain is usually associated with water intoxication. Muscle weakness and cardiac dysrhythmias are not associated with water intoxication.

DIF: Cognitive Level: Understanding REF: p. 985

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

15. What physiologic state(s) produces the clinical manifestations of nervous system stimulation and excitement, such as overexcitability, nervousness, and tetany?

a.

Metabolic acidosis

b.

Respiratory alkalosis

c.

Metabolic and respiratory acidosis

d.

Metabolic and respiratory alkalosis

ANS: D

The major symptoms and signs of alkalosis include nervous system stimulation and excitement, including overexcitability, nervousness, tingling sensations, and tetany that may progress to seizures. Acidosis (both metabolic and respiratory) has clinical signs of depression of the central nervous system, such as lethargy, diminished mental capacity, delirium, stupor, and coma. Respiratory alkalosis has the same symptoms and signs as metabolic alkalosis.

DIF: Cognitive Level: Analysis REF: p. 962 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

16. What is an approximate method of estimating output for a child who is not toilet trained?

a.

Have parents estimate output.

b.

Weigh diapers after each void.

c.

Place a urine collection device on the child.

d.

Have the child sit on a potty chair 30 minutes after eating.

ANS: B

Weighing diapers will provide an estimate of urinary output. Each 1 g of weight is equivalent to 1 ml of urine. Having parents estimate output would be inaccurate. It is difficult to estimate how much fluid is in a diaper. The urine collection device would irritate the childs skin. It would be difficult for a toddler who is not toilet trained to sit on a potty chair 30 minutes after eating.

DIF: Cognitive Level: Applying REF: p. 957

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

17. The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The superficial veins on his hand and arm are not readily visible. What intervention should increase the visibility of these veins?

a.

Gently tap over the site.

b.

Apply a cold compress to the site.

c.

Raise the extremity above the level of the body.

d.

Use a rubber band as a tourniquet for 5 minutes.

ANS: A

Gently tapping the site can sometimes cause the veins to be more visible. This is done before the skin is prepared. Warm compresses (not cold) may be useful. The extremity is held in a dependent position. A tourniquet may be helpful, but if too tight, it could cause the vein to burst when punctured. Five minutes is too long.

DIF: Cognitive Level: Applying REF: p. 961

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

18. When caring for a child with an intravenous (IV) infusion, what is an appropriate nursing action?

a.

Change the insertion site every 24 hours.

b.

Check the insertion site frequently for signs of infiltration.

c.

Use a macrodropper to facilitate reaching the prescribed flow rate.

d.

Avoid restraining the child to prevent undue emotional stress.

ANS: B

The nursing responsibility for IV therapy is to calculate the amount to be infused in a given length of time; set the infusion rate; and monitor the apparatus frequently, at least every 1 to 2 hours, to make certain that the desired rate is maintained, the integrity of the system remains intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the infusion does not stop. Insertion sites do not need to be changed every 24 hours unless a problem is found with the site. This exposes the child to significant trauma. A minidropper (60 drops/ml) is the recommended IV tubing in pediatric patients. Intravenous sites should be protected. This may require soft restraints on the child.

DIF: Cognitive Level: Applying REF: p. 961

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

19. The nurse determines that a childs intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action?

a.

Stop the infusion and apply ice.

b.

End the infusion and notify the practitioner.

c.

Slow the infusion rate and notify the practitioner.

d.

Discontinue the infusion and apply warm compresses.

ANS: B

A vesicant causes cellular damage when even minute amounts escape into the tissue. The intravenous infusion is immediately stopped, the extremity is elevated, the practitioner is notified, and the treatment protocol is initiated. The applying of heat or ice depends on the fluid that has extravasated. The catheter is left in place until it is no longer needed.

DIF: Cognitive Level: Applying REF: p. 972

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

20. Several types of long-term central venous access devices are used. What is a benefit of using an implanted port (e.g., Port-a-Cath)?

a.

You do not need to pierce the skin for access.

b.

It is easy to use for self-administered infusions.

c.

The patient does not need to limit regular physical activity, including swimming.

d.

The catheter cannot dislodge from the port even if the child plays with the port site.

ANS: C

No limitations on physical activity are needed. The child is able to participate in all regular physical activities, including bathing, showering, and swimming. The skin over the device is pierced with a Huber needle to access. Long-term central venous access devices are difficult to use for self-administration. The port is placed under the skin. If the child manipulates the device and plays with the actual port, the catheter can be dislodged.

DIF: Cognitive Level: Applying REF: p. 979 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

21. The nurse is teaching the family of a child with a long-term central venous access device about signs and symptoms of bacteremia. What finding indicates the presence of bacteremia?

a.

Hypertension

b.

Pain at the entry site

c.

Fever and general malaise

d.

Redness and swelling at the entry site

ANS: C

Fever, chills, general malaise, and an ill appearance can be signs of bacteremia and require immediate intervention. Hypotension would be indicative of sepsis and possible impending cardiovascular collapse. Pain, redness, and swelling at the entry site indicate local infection.

DIF: Cognitive Level: Applying REF: p. 979

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

22. What flush solution is recommended for intravenous catheters larger than 24 gauge?

a.

Saline

b.

Heparin

c.

Alteplase

d.

Heparin and saline combination

ANS: A

The recommended solution for flushing venous access devices is saline. The turbulent flow flush with saline is effective for catheters larger than 24 gauge. The use of heparin does not increase the longevity of the venous access device. In 24-gauge catheters, heparin may offer an advantage. Alteplase is used for treating catheter-related occlusions in children. The heparin and saline combination does not offer any advantage over saline or heparin individually.

DIF: Cognitive Level: Applying REF: p. 977

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

23. The nurse is teaching a parent of a 10-year-old child who will be discharged with a venous access device (VAD). What statement by the parent indicates a correct understanding of the teaching?

a.

I should have my child wear a protective vest when my child wants to participate in contact sports.

b.

I should apply pressure to the entry site to the vein, not the exit site, if the VAD is accidentally removed.

c.

I can expect my child to have feelings of general malaise for 1 week after the VAD is inserted.

d.

I should give my child a sponge bath for the first 2 weeks after the VAD is inserted; then I can allow my child to take a bath.

ANS: B

The parents of a child with a VAD should be taught to apply pressure to the entry site to the vein, not the exit site, if the VAD is accidentally removed. The child should not participate in contact sports, even with a protective vest, to prevent the VAD from becoming dislodged. General malaise is a sign of an infection, not an expected finding after insertion of the VAD. The child can shower or take a bath after insertion of the VAD; the child does not need a sponge bath for any length of time.

DIF: Cognitive Level: Analyzing REF: p. 979

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

24. What type of diarrhea is associated with an inflammation of the mucosa and submucosa in the ileum and colon caused by infectious agents?

a.

Osmotic

b.

Secretory

c.

Cytotoxic

d.

Dysenteric

ANS: D

Dysenteric diarrhea is associated with an inflammation of the mucosa and submucosa in the ileum and colon caused by infectious agents such as Campylobacter, Salmonella, or Shigella organisms. Edema, mucosal bleeding, and leukocyte infiltration occur. Osmotic diarrhea occurs when the intestine cannot absorb nutrients or electrolytes. It is commonly seen in malabsorption syndromes such as lactose intolerance. Secretory diarrhea is usually a result of bacterial enterotoxins that stimulate fluid and electrolyte secretion from the mucosal crypt cells, the principal secretory cells of the small intestine. Cytotoxic diarrhea is characterized by the viral destruction of the villi of the small intestine. This results in a smaller intestinal surface area, with a decreased capacity for fluid and electrolyte absorption.

DIF: Cognitive Level: Understanding REF: p. 952

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

25. What condition is often associated with severe diarrhea?

a.

Metabolic acidosis

b.

Metabolic alkalosis

c.

Respiratory acidosis

d.

Respiratory alkalosis

ANS: A

Metabolic acidosis results from the increased absorption of short-chain fatty acids produced in the colon. There is an increase in lactic acid from tissue hypoxia secondary to hypovolemia. Bicarbonate is lost through the stool. Ketosis results from fat metabolism when glycogen stores are depleted. Metabolic alkalosis and respiratory alkalosis do not occur from severe diarrhea.

DIF: Cognitive Level: Understanding REF: p. 952

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

26. What organism is a parasite that causes acute diarrhea?

a.

Shigella organisms

b.

Salmonella organisms

c.

Giardia lamblia

d.

Escherichia coli

ANS: C

G. lamblia is a parasite that represents 10% of nondysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens.

DIF: Cognitive Level: Understanding REF: p. 948

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

27. A school-age child with diarrhea has been rehydrated. The nurse is discussing the childs diet with the family. What food or beverage should be tolerated best?

a.

Clear fluids

b.

Carbonated drinks

c.

Applesauce and milk

d.

Easily digested foods

ANS: D

Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness. Clear fluids (e.g., fruit juices and gelatin) and carbonated drinks have high carbohydrate content and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. In some children, lactose intolerance will develop with diarrhea, and cows milk should be avoided in the recovery stage.

DIF: Cognitive Level: Applying REF: p. 988

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

28. A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solutions (ORS). The childs mother calls the clinic nurse because he is also occasionally vomiting. The nurse should recommend which intervention?

a.

Bring the child to the hospital for intravenous fluids.

b.

Alternate giving ORS and carbonated drinks.

c.

Continue to give ORS frequently in small amounts.

d.

Keep child NPO (nothing by mouth) for 8 hours and resume ORS if vomiting has subsided.

ANS: C

Children who are vomiting should be given ORS at frequent intervals and in small amounts. Intravenous fluids are not indicated for mild dehydration. Carbonated beverages are high in carbohydrates and are not recommended for the treatment of diarrhea and vomiting. The child is not kept NPO because this would cause additional fluid losses.

DIF: Cognitive Level: Implementation REF: p. 954

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

29. A 7-year-old child with acute diarrhea has been rehydrated with oral rehydration solution (ORS). The nurse should recommend that the childs diet be advanced to what kind of diet?

a.

Regular diet

b.

Clear liquids

c.

High carbohydrate diet

d.

BRAT (bananas, rice, applesauce, and toast or tea) diet

ANS: A

It is appropriate to advance to a regular diet after ORS has been used to rehydrate the child. Clear liquids are not appropriate for hydration or afterward. A high carbohydrate diet may contribute to loose stools because of the low electrolyte content and high osmolality. The BRAT diet has little nutritional value and is high in carbohydrates.

DIF: Cognitive Level: Implementation REF: p. 954 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

30. What is the most frequent cause of hypovolemic shock in children?

a.

Sepsis

b.

Blood loss

c.

Anaphylaxis

d.

Heart failure

ANS: B

Blood loss is the most frequent cause of hypovolemic shock in children. Sepsis causes septic shock, which is overwhelming sepsis and circulating bacterial toxins. Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Heart failure contributes to hypervolemia, not hypovolemia.

DIF: Cognitive Level: Understanding REF: p. 959

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

31. What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?

a.

Neurogenic shock

b.

Cardiogenic shock

c.

Hypovolemic shock

d.

Anaphylactic shock

ANS: D

Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission after a spinal cord injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure.

DIF: Cognitive Level: Understanding REF: p. 959

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

32. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock?

a.

Thirst

b.

Irritability

c.

Apprehension

d.

Confusion and somnolence

ANS: D

Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock.

DIF: Cognitive Level: Understanding REF: p. 960

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

33. The nurse suspects shock in a child 1 day after surgery. What should be the initial nursing action?

a.

Place the child on a cardiac monitor.

b.

Obtain arterial blood gases.

c.

Provide supplemental oxygen.

d.

Put the child in the Trendelenburg position.

ANS: C

The initial nursing action for a patient in shock is to establish ventilatory support. Oxygen is provided, and the nurse carefully observes for signs of respiratory failure, which indicates a need for intubation. Cardiac monitoring would be indicated to assess the childs status further, but ventilatory support comes first. Oxygen saturation monitoring should be begun. Arterial blood gases would be indicated if alternative methods of monitoring oxygen therapy were not available. The Trendelenburg position is not indicated and is detrimental to the child. The head-down position increases intracranial pressure and decreases diaphragmatic excursion and lung volume.

DIF: Cognitive Level: Understanding REF: p. 961

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

34. What explains physiologically the edema formation that occurs with burns?

a.

Vasoconstriction

b.

Reduced capillary permeability

c.

Increased capillary permeability

d.

Diminished hydrostatic pressure within capillaries

ANS: C

With a major burn, capillary permeability increases, allowing plasma proteins, fluids, and electrolytes to be lost into the interstitial space, causing edema. Maximum edema in a small wound occurs about 8 to 12 hours after injury. In larger injuries, the maximum edema may not occur until 18 to 24 hours later. Vasodilation occurs, causing an increase in hydrostatic pressure.

DIF: Cognitive Level: Analyzing REF: p. 963

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

35. What is a systemic response to severe burns in a child?

a.

Metabolic alkalosis

b.

Decreased metabolic rate

c.

Increased renal plasma flow

d.

Abrupt drop in cardiac output

ANS: D

The initial physiologic response to a burn injury is a dramatic change in circulation. A precipitous drop in cardiac output precedes any change in circulating blood or plasma volumes. A circulating myocardial depressant factor associated with severe burn injury is thought to be the cause. Metabolic acidosis usually occurs secondary to the disruption of the bodys buffering action resulting from fluid shifting to extravascular space. There is a greatly accelerated metabolic rate in burn patients, supported by protein and lipid breakdown. With the loss of circulating volume, there is decreased renal blood flow and depressed glomerular filtration.

DIF: Cognitive Level: Understanding REF: p. 975

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

36. A child is admitted with extensive burns. The nurse notes burns on the childs lips and singed nasal hairs. The nurse should suspect what condition in the child?

a.

A chemical burn

b.

A hot-water scald

c.

An electrical burn

d.

An inhalation injury

ANS: D

Evidence of an inhalation injury includes burns of the face and lips, singed nasal hairs, and laryngeal edema. Clinical manifestations may be delayed for up to 24 hours. Chemical burns, electrical burns, and burns associated with hot-water scalds would not produce singed nasal hair.

DIF: Cognitive Level: Analyzing REF: p. 993

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

37. What is the most immediate threat to life in children with thermal injuries?

a.

Shock

b.

Anemia

c.

Local infection

d.

Systemic sepsis

ANS: A

The immediate threat to life in children with thermal injuries is airway compromise and profound shock. Anemia is not of immediate concern. During the healing phase, local infection or sepsis is the primary complication.

DIF: Cognitive Level: Analyzing REF: p. 972

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

38. After the acute stage and during the healing process, what is the primary complication from burn injury?

a.

Shock

b.

Asphyxia

c.

Infection

d.

Renal shutdown

ANS: C

During the healing phase, local infection or sepsis is the primary complication. Respiratory problems, primarily airway compromise, and shock are the primary complications during the acute stage of burn injury. Renal shutdown is not a complication of the burn injury but may be a result of the profound shock.

DIF: Cognitive Level: Analyzing REF: p. 975

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

39. What sign is one of the first to indicate overwhelming sepsis in a child with burn injuries?

a.

Seizures

b.

Bradycardia

c.

Disorientation

d.

Decreased blood pressure

ANS: C

Disorientation in the burn patient is one of the first signs of overwhelming sepsis and may indicate inadequate hydration. Seizures, bradycardia, and decreased blood pressure are not initial manifestations of overwhelming sepsis.

DIF: Cognitive Level: Understanding REF: p. 976

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

40. A toddler sustains a minor burn on the hand from hot coffee. What is the first action in treating this burn?

a.

Apply burn ointment.

b.

Put ice on the burned area.

c.

Cover the hand with gauze dressing.

d.

Hold the hand under cool running water.

ANS: D

In minor burns, the best method to stop the burning process is to hold the burned area under cool running water. Ointments are not applied to a new burn; the ointment will contribute to the burning. Ice is not recommended. Gauze dressings do not stop the burning process.

DIF: Cognitive Level: Applying REF: p. 977

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

41. What finding is the most reliable guide to the adequacy of fluid replacement for a small child with burns?

a.

Absence of thirst

b.

Falling hematocrit

c.

Increased seepage from burn wound

d.

Urinary output of 1 to 2 ml/kg of body weight/hr

ANS: D

Replacement fluid therapy is delivered to provide a urinary output of 30 ml/hr in older children or 1 to 2 ml/kg of body weight/hr for children weighing less than 30 kg (66 lb). Thirst is the result of a complex set of interactions and is not a reliable indicator of hydration. Thirst occurs late in dehydration. A falling hematocrit would be indicative of hemodilution. This may reflect fluid shifts and may not accurately represent fluid replacement therapy. Increased seepage from a burn wound would be indicative of increased output, not adequate hydration.

DIF: Cognitive Level: Applying REF: p. 978 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

42. What is the purpose of a high-protein diet for a child with major burns?

a.

Promote growth

b.

Improve appetite

c.

Minimize protein breakdown

d.

Diminish risk of stress-induced hyperglycemia

ANS: C

Initially after major burns, there is a hypometabolic phase, which lasts for 2 or 3 days. A hypermetabolic phase follows, characterized by increased body temperature, oxygen and glucose consumption, carbon dioxide production, glycogenolysis, proteolysis, and lipolysis. This response continues for up to 9 months. A diet high in protein and calories is necessary. Healing, not growth, is the primary consideration. Many children have poor appetites, and supplementation is necessary. Hypoglycemia, not hyperglycemia, can occur from the stress of burn injury because the liver glycogen stores are rapidly depleted.

DIF: Cognitive Level: Applying REF: p. 979 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

43. Fentanyl and midazolam (Versed) are given before dbridement of a childs burn wounds. What is the purpose of using these medications?

a.

Facilitate healing

b.

Provide pain relief

c.

Minimize risk of infection

d.

Decrease amount of dbridement needed

ANS: B

Partial-thickness burns require dbridement of devitalized tissue to promote healing. The procedure is painful and requires analgesia and sedation before the procedure. Fentanyl and midazolam provide excellent intravenous sedation and analgesia to control procedural pain in children with burns.

DIF: Cognitive Level: Analyzing REF: p. 980

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

44. Hydrotherapy is required to treat a child with extensive partial-thickness burn wounds. What is the purpose of hydrotherapy?

a.

Provide pain relief

b.

Dbride the wounds

c.

Destroy bacteria on the skin

d.

Increase peripheral blood flow

ANS: B

Soaking in a tub or showering once or twice a day acts to loosen and remove sloughing tissue, exudate, and topical medications. The hydrotherapy cleanses the wound and the entire body and helps maintain range of motion. Appropriate pain medications are necessary. Dressing changes are extremely painful. The total bacterial count of the skin is reduced by the hydrotherapy, but this is not the primary goal. There may be an increase in peripheral blood flow, but the primary purpose is for wound dbridement.

DIF: Cognitive Level: Applying REF: p. 980

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

45. What is the nursing action related to the applying of biologic or synthetic skin coverings for a child with partial-thickness burns of both legs?

a.

Splint the legs to prevent movement.

b.

Observe wounds for signs of infection.

c.

Monitor closely for manifestations of shock.

d.

Examine dressings for indications of bleeding.

ANS: B

When applied early to a superficial partial-thickness injury, biologic dressings stimulate epithelial growth and faster wound healing. If the dressing covers areas of heavy microbial contamination, infection occurs beneath the dressing. In the case of partial-thickness burns, such infection may convert the wound to a full-thickness injury. Infection is the primary concern when biologic dressings are used.

DIF: Cognitive Level: Applying REF: p. 982

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

46. What is an effective strategy to reduce the stress of burn dressing procedures?

a.

Involve the child and give choices as feasible.

b.

Explain to the child why analgesics cannot be used.

c.

Reassure the child that dressing changes are not painful.

d.

Encourage the child to master stress with controlled passivity.

ANS: A

Children who have an understanding of the procedure and some perceived control demonstrate less maladaptive behavior. They respond well to participating in decisions and should be given as many choices as possible. Analgesia and sedation can and should be used. The dressing change procedure is very painful and stressful. Misinformation should not be given to the child. Encouraging the child to master stress with controlled passivity is not a positive coping strategy.

DIF: Cognitive Level: Applying REF: p. 988 TOP: Nursing Process: Planning

MSC: Client Needs: Psychosocial Integrity

47. What consideration is important for the nurse when changing dressings and applying topical medication to a childs abdomen and leg burns?

a.

Apply topical medication with clean hands.

b.

Wash hands and forearms before and after dressing change.

c.

If dressings have adhered to the wound, soak in hot water before removal.

d.

Apply dressing so that movement is limited during the healing process.

ANS: B

Frequent hand and forearm washing is the single most important element of the infection-control program. Topical medications should be applied with a tongue blade or gloved hand. Dressings that have adhered to the wound can be removed with tepid water or normal saline. Dressings are applied with sufficient tension to remain in place but not so tightly as to impair circulation or limit motion.

DIF: Cognitive Level: Analyzing REF: p. 988

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

48. What is a strategy used to minimize scarring with burn injury in a child?

a.

Applying of drying agents on skin

b.

Use of loose-fitting garments over healing areas

c.

Limitation of period without pressure to areas of scarring

d.

Immobilization of extremities while healing is occurring

ANS: C

Uniform pressure to the scar decreases the blood supply and forces the collagen into a more normal alignment. When pressure is removed, blood supply to the scar is immediately increased; therefore, periods without pressure should be brief to avoid nourishment of the hypertrophic tissue. Moisturizing agents are used with massage to help stretch tissue and prevent contractures. Compression garments, not loose-fitting garments, are indicated. Range of motion exercises are done to minimize contractures.

DIF: Cognitive Level: Analyzing REF: p. 989

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

49. Prevention of burn injury is important anticipatory guidance. In the infant and toddler period, which mode is the most common cause of burn?

a.

Matches

b.

Electrical cords

c.

Hot liquids in the kitchen

d.

Microwave-heated foods

ANS: C

Infants and toddlers are most commonly injured by hot liquids in the kitchen and bathroom. This often occurs as a result of inadequate supervision of this curious and energetic age group. Matches and lighters are seen as toys by young children and should be kept out of reach. Older toddlers and preschool children are at risk of chewing on electrical cords and placing objects in outlets. Microwave-heated fluids and foods can become superheated, resulting in oral burns.

DIF: Cognitive Level: Analyzing REF: p. 992 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

50. The nurse is teaching a group of female adolescents about toxic shock syndrome and the use of tampons. What statement by a participant indicates a need for additional teaching?

a.

I can alternate using a tampon and a sanitary napkin.

b.

I should wash my hands before inserting a tampon.

c.

I can use a superabsorbent tampon for more than 6 hours.

d.

I should call my health care provider if I suddenly develop a rash that looks like sunburn.

ANS: C

Teaching female adolescents about the association between toxic shock syndrome and the use of tampons is important. The teaching should include not using superabsorbent tampons; not leaving the tampon in for longer than 4 to 6 hours; alternating the use of tampons with sanitary napkins; washing hands before inserting a tampon to decrease the chance of introducing pathogens; and informing a health care provider if a sudden high fever, vomiting, muscle pain, dizziness, or a rash that looks like a sunburn appears.

DIF: Cognitive Level: Applying REF: p. 958

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

51. The nurse is caring for an 18-month-old child with rotavirus. What clinical manifestations should the nurse expect to observe?

a.

Severe abdominal cramping and bloody diarrhea

b.

Mild fever and vomiting followed by onset of watery stools

c.

Colicky abdominal pain and vomiting

d.

High fever, diarrhea, and lethargy

ANS: B

Rotavirus is one of the most common pathogens that cause gastroenteritis in children younger than the age of 2 years. Clinical manifestations include mild to moderate fever and vomiting followed by the onset of watery stools. The fever and vomiting usually abate in 1 or 2 days, but the diarrhea persists for 5 to 7 days. Severe abdominal cramping and bloody diarrhea are seen with Escherichia coli infection; colicky abdominal pain and vomiting are seen with salmonella infection; and high fever, diarrhea, and lethargy are seen with infection by Salmonella typhi.

DIF: Cognitive Level: Applying REF: p. 954

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

MULTIPLE RESPONSE

1. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)

a.

Tachypnea

b.

Oliguria

c.

Confusion

d.

Pale extremities

e.

Hypotension

f.

Thready pulse

ANS: A, B, C, D

As shock progresses, perfusion in the microcirculation becomes marginal despite compensatory adjustments, and the signs are more obvious. Signs include tachypnea, oliguria, confusion, and pale extremities, as well as decreased skin turgor and poor capillary filling. Hypotension and a thready pulse are clinical manifestations of irreversible shock.

DIF: Cognitive Level: Applying REF: p. 960

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2. In what condition should the nurse be alert for altered fluid requirements in children? (Select all that apply.)

a.

Oliguric renal failure

b.

Increased intracranial pressure

c.

Mechanical ventilation

d.

Compensated hypotension

e.

Tetralogy of Fallot

f.

Type 1 diabetes mellitus

ANS: A, B, C

The nurse should recognize that conditions such as oliguric renal failure, increased intracranial pressure, and mechanical ventilation can cause an increase or a decrease in fluid requirements. Conditions such as hypotension, tetralogy of Fallot, and diabetes mellitus (type 1) do not cause an alteration in fluid requirements.

DIF: Cognitive Level: Applying REF: p. 946

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

3. What clinical manifestations should be observed in a 2-year-old child with hypotonic dehydration? (Select all that apply.)

a.

Thick, doughy feel to the skin

b.

Slightly moist mucous membranes

c.

Absent tears

d.

Very rapid pulse

e.

Hyperirritability

ANS: B, C, D

Clinical manifestations of hypotonic dehydration include slightly moist mucous membranes, absent tears, and a very rapid pulse. A thick, doughy feel to the skin and hyperirritability are signs of hypertonic dehydration.

DIF: Cognitive Level: Applying REF: p. 952

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

4. The nurse is caring for a child with hypokalemia. The nurse evaluates the child for which signs and symptoms of hypokalemia? (Select all that apply.)

a.

Twitching

b.

Hypotension

c.

Hyperreflexia

d.

Muscle weakness

e.

Cardiac arrhythmias

ANS: B, D, E

Signs and symptoms of hypokalemia are hypotension, muscle weakness, and cardiac arrhythmias. Twitching and hyperreflexia are signs of hyperkalemia.

DIF: Cognitive Level: Applying REF: p. 950 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

5. The nurse is caring for a child with hypercalcemia. The nurse evaluates the child for which signs and symptoms of hypercalcemia? (Select all that apply.)

a.

Tetany

b.

Anorexia

c.

Constipation

d.

Laryngospasm

e.

Muscle hypotonicity

ANS: B, C, E

Signs and symptoms of hypercalcemia are anorexia, constipation, and muscle hypotonicity. Tetany and laryngospasm are signs of hypocalcemia.

DIF: Cognitive Level: Applying REF: p. 951 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

6. The nurse is caring for a child with hypernatremia. The nurse evaluates the child for which signs and symptoms of hypernatremia? (Select all that apply.)

a.

Apathy

b.

Lethargy

c.

Oliguria

d.

Intense thirst

e.

Dry, sticky mucos

ANS: B, C, E

Signs and symptoms of hypernatremia are nausea; oliguria; and dry, sticky mucos. Apathy and lethargy are signs of hyponatremia.

DIF: Cognitive Level: Applying REF: p. 950 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

COMPLETION

1. A health care provider prescribes dopamine (Intropin), 5 mcg/kg/min in a continuous intravenous (IV) infusion for a child in shock. The child weighs 25 kg. The medication is available as dopamine 400 mg in 250 ml. The nurse prepares to calculate the rate. How many milliliters per hour will the nurse set the IV infusion pump to deliver 5 mcg/kg/min? Fill in the blank. Round to one decimal place.

________________

ANS:

4.7

Follow the formula for dosage calculation.

5 kg 60

_________________ = Pump rate ml/hr

Drug concentration

The patient weighs 10 kg, and the drug is available as 400 mg in 250 ml.

Calculate the drug concentration.

400 1000

___________ = 1600 mcg/ml

250

Then calculate the infusion rate.

5 25 60

_____________________ = 4.6875 ml/hr = rounded to 4.7 ml/hr

1600

DIF: Cognitive Level: Applying REF: p. 962

TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

2. A health care provider prescribes diphenhydramine (Benadryl), 1 mg/kg PO every 4 to 6 hours as needed for pruritus to a child with a mild cutaneous anaphylactic reaction. The child weighs 5 kg. The medication label states: Diphenhydramine 12.5 mg/5 ml. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number.

________________

ANS:

2

Follow the formula for dosage calculation.

Multiply 1 mg 5 kg to get the dose = 5 mg

Desired

Volume = ml per dose

Available

5 mg

5 mL = 2 mL

12.5 mg

DIF: Cognitive Level: Applying REF: p. 966

TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

3. A health care provider prescribes nitroprusside (Nipride), 1 mcg/kg/min in a continuous intravenous (IV) infusion for a child in shock. The child weighs 20 kg. The medication is available as nitroprusside 50 mg in 250 ml. The nurse prepares to calculate the rate. How many milliliters per hour will the nurse set the IV infusion pump to deliver 1 mcg/kg/min? Fill in the blank. Record your answer in a whole number.

________________

ANS:

6

Follow the formula for dosage calculation.

1 kg 60

_________________ = Pump rate ml/hr

Drug concentration

The patient weighs 20 kg and the drug is available as 50 mg in 250 ml.

Calculate the drug concentration.

50 1000

___________ = 200 mcg/ml

250

Then calculate the infusion rate.

1 20 60

_____________________ = 6 ml/hr

200

DIF: Cognitive Level: Applying REF: p. 964

TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

4. A health care provider prescribes midazolam (Versed) syrup 0.5 mg/kg per mouth (PO) 30 minutes before a burn wound dressing change on a child. The medication label states: Versed 2 mg/1 ml. The child weighs 8 kg. The nurse prepares to administer the dose. How many milliliters will the nurse prepare to administer the dose? Fill in the blank. Record your answer in a whole number.

________________

ANS:

2

Follow the formula for dosage calculation.

Multiply 0.5 mg 8 kg to get the dose = 4 mg

Desired

Volume = ml per dose

Available

4 mg

1 ml = 2 ml

2 mg

DIF: Cognitive Level: Applying REF: p. 980

TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

MATCHING

Match the type of skin graft to its definition.

a.

Allografts

b.

Xenografts

c.

Autografts

d.

Isografts

1. Tissue obtained from undamaged areas of the patients own body

2. Histocompatible tissue obtained from genetically identical individuals

3. Skin that is obtained from genetically different members of the same species who are free of disease

4. Skin that is obtained from members of a different species, primarily pigskin

1. ANS: C DIF: Cognitive Level: Understanding REF: p. 982

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2. ANS: D DIF: Cognitive Level: Understanding REF: p. 982

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

3. ANS: A DIF: Cognitive Level: Understanding REF: p. 982

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

4. ANS: B DIF: Cognitive Level: Understanding REF: p. 982

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

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