Chapter 25: The Child With a Respiratory or Cardiovascular Disorder My Nursing Test Banks

Chapter 25: The Child With a Respiratory or Cardiovascular Disorder

Elsevier items and derived items 2007 by Saunders, an imprint of Elsevier Inc.

MULTIPLE CHOICE

1. The nurse tells the parents of a child who has a positive throat culture for group A hemolytic streptococcus that the treatment most likely will be:

a.

Acetaminophen and plenty of fluids

b.

Oral penicillin for 10 days

c.

Penicillin until his sore throat is gone

d.

Streptococcus immunization

ANS: B

When a throat culture is positive for group A beta-hemolytic streptococcus, penicillin is administered for 10 days even if symptoms are alleviated before the medication is finished.

DIF: Cognitive Level: Application REF: 575 OBJ: 27

TOP: Acute Pharyngitis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

2. The initial intervention that the nurse would suggest to the parents of a child experiencing laryngeal spasm is to:

a.

Take the child outside in the cool air.

b.

Bring the child directly to the emergency department.

c.

Put the child in the bathroom with a hot shower running.

d.

Have the child drink plenty of fluids.

ANS: C

The child experiencing laryngeal spasm should be placed in a high-humidity environment such as the bathroom with a hot shower running. The humidity liquefies secretions and reduces spasm.

DIF: Cognitive Level: Analysis: Physiological Adaptation REF: 576

OBJ: 8 TOP: Croup Syndromes

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

3. The nurse would observe a child for frequent swallowing following a tonsillectomy and adenoidectomy (T & A) because this is indicative of:

a.

Bleeding from the surgical site

b.

Pain at the incision area

c.

Sore throat from postnasal drip

d.

Potential vomiting

ANS: A

Hemorrhage is the most common postoperative complication. Blood trickling down the back of the childs throat could cause frequent swallowing.

DIF: Cognitive Level: Comprehension REF: 579 OBJ: 19

TOP: Tonsillitis and Adenoiditis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk

4. The best choice for fluid replacement that the nurse can offer a child who has just had a tonsillectomy is:

a.

Popsicle

b.

Chocolate milk

c.

Orange juice

d.

Cola drink

ANS: A

Small amounts of clear liquids can be offered to the child. Synthetic fruit juices are not as irritating as natural juices. A popsicle is usually well-tolerated.

DIF: Cognitive Level: Analysis REF: 581 OBJ: 19

TOP: Tonsillitis and Adenoiditis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

5. The 4-month-old child in the emergency department shows extreme dyspnea, a croaking inspiration, and excessive drooling. Based on these observations alone, the nurses initial intervention would be to:

a.

Sit the child upright and notify the physician.

b.

Start oxygen by mask and keep the child flat.

c.

Apply a cold compress to the throat.

d.

Assess the back of the throat for obstruction.

ANS: A

These are the classic signs of epiglottitis. If epiglottitis is suspected, the nurse should not examine the back of the throat because laryngospasm may occur followed by respiratory arrest. The child should be made as comfortable as possible and the physician should be summoned. Epiglottitis is a medical emergency.

DIF: Cognitive Level: Analysis REF: 576 OBJ: 12

TOP: Epiglottitis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

6. The nurse, auscultating the breath sounds of a child hospitalized for an acute asthma attack, would expect to find:

a.

Fine crackles

b.

Coarse rhonchi

c.

Expiratory wheezing

d.

Decreased breath sounds at lung bases

ANS: C

The child experiencing an acute asthma attack will wheeze as air moves in and out of the narrowed airways. The expiratory wheeze is most pronounced.

DIF: Cognitive Level: Knowledge REF: 582 OBJ: 13, 14

TOP: Asthma KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. The nurse caring for a child experiencing an acute asthma attack would include:

a.

Offering plenty of fluids, particularly carbonated beverages

b.

Placing the child in a humidified cool mist tent with oxygen

c.

Administering sedatives as ordered to decrease anxiety

d.

Positioning the child with arms resting on the overbed table

ANS: D

This position is comfortable and allows maximum use of the accessory muscles for breathing. Sedatives would mask symptoms of increasing air hunger. Carbonated beverages are contraindicated in persons with dyspnea.

DIF: Cognitive Level: Comprehension REF: 583 OBJ: 14

TOP: Asthma KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

8. The nurse explains to the parent of a child with exercise-induced asthma that Cromolyn, an antiinflammatory drug, should be inhaled:

a.

Before exercise to prevent attacks

b.

At the initial onset of the attack

c.

During the attack to relieve symptoms

d.

As often as 4 times a day

ANS: A

Antiinflammatory inhalants are taken before exercise to prevent attacks. These drugs can do nothing for the attack in progress. They are meant to be used as prophylactic therapies.

DIF: Cognitive Level: Analysis REF: 584 OBJ: 14, 15

TOP: Asthma KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

9. The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got this disease, because no one in their families has CF. The nurses response is based on the understanding that with CF:

a.

Only one parent carries the CF gene.

b.

Both parents are carriers of the CF gene.

c.

The inheritance pattern is multifactorial.

d.

The result is probably a genetic mutation.

ANS: B

Cystic fibrosis is an inherited disease. Both parents must be carriers of the CF gene for the child to have the disease.

DIF: Cognitive Level: Analysis REF: 587 OBJ: 20

TOP: Cystic Fibrosis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

10. The statement indicating that the childs parents understand how to perform respiratory therapy is:

a.

We do her postural drainage before the aerosol therapy.

b.

We give her respiratory treatments when she is coughing a lot.

c.

We give the aerosol followed by postural drainage before meals.

d.

She needs respiratory therapy everyday when she has an infection.

ANS: C

Postural drainage for the child with CF is done following nebulization. Therapy is best scheduled before meals or at least 1 hour after eating to prevent vomiting.

DIF: Cognitive Level: Analysis REF: 589 OBJ: 20

TOP: Cystic Fibrosis KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

11. To facilitate digestion and absorption of nutrients, the nurse teaches the child with cystic fibrosis that she needs to take:

a.

Pancreatic enzymes

b.

Water-soluble minerals

c.

Fat-soluble vitamins

d.

Salt supplements

ANS: A

An oral pancreatic enzyme is given to the child with every meal and with snacks to replace the pancreatic enzymes that the childs body cannot produce.

DIF: Cognitive Level: Knowledge REF: 594 OBJ: 20

TOP: Cystic Fibrosis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. The nurse would advise a mother to clear the nostrils when her infant has a cold by:

a.

Clearing the nasal passages after the infant has a feeding

b.

Using over-the-counter nose drops to clear passages

c.

Removing nasal secretions with a bulb syringe

d.

Instilling saline nose drops after clearing away secretions

ANS: C

The nasal passages can be cleared by instilling a few drops of saline into the nose and then suctioning the secretions with a bulb syringe.

DIF: Cognitive Level: Application REF: 574 OBJ: N/A

TOP: Nasopharyngitis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13. The nurse offers a variety of fluids to compensate for the fluid loss through dyspnea. Appropriate fluids would be:

a.

Room temperature water

b.

Carbonated beverages

c.

Iced fruit juice

d.

Cold milk

ANS: A

Room temperature fluids are the best. Carbonated and iced beverages increase spasm Milk stimulates mucus production.

DIF: Cognitive Level: Analysis REF: 585 OBJ: 14

TOP: Asthma KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

14. The asthmatic child who has been taking theophylline complains of stomach ache and tachycardia and is sweating profusely. The nurse recognizes these symptoms as:

a.

Severe asthma attack

b.

Allergic response to theophylline

c.

Onset of bronchitis

d.

Drug toxicity

ANS: D

The symptoms described are the signs of theophylline toxicity.

DIF: Cognitive Level: Analysis REF: 584 OBJ: 13

TOP: Asthma KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

15. The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). Significant information would be to:

a.

Wrap the infant snugly for rest periods.

b.

Position the infant prone for sleep.

c.

Sit the baby up in an infant seat.

d.

Place infants on their back or side for sleep.

ANS: D

The American Academy of Pediatrics recommends that all healthy infants be placed in the supine or side-lying position on a firm mattress to prevent SIDS.

DIF: Cognitive Level: Application REF: 595 OBJ: 16

TOP: Sudden Infant Death Syndrome KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

16. An infant is hospitalized with RSV bronchiolitis. The priority nursing diagnosis is:

a.

Fatigue related to increased work of breathing

b.

Ineffective breathing pattern related to airway inflammation and increased secretions

c.

Risk for fluid volume deficit related to tachypnea and decreased oral intake

d.

Fear/anxiety related to dyspnea and hospitalization

ANS: B

An ineffective breathing pattern is the priority nursing diagnosis for an infant hospitalized with RSV infection.

DIF: Cognitive Level: Analysis REF: 577 OBJ: 9

TOP: Respiratory Syncytial Virus

KEY: Nursing Process Step: Nursing Diagnosis

MSC: NCLEX: Physiological Integrity

17. The nurse explains that a ventricular septal defect will:

a.

Allow blood to shunt left to right, causing increased pulmonary flow and no cyanosis

b.

Allow right-to-left shunt, causing decreased pulmonary flow and cyanosis

c.

Allow no shunting because of high pressure in the left ventricle

d.

Allow increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume

ANS: A

Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis.

DIF: Cognitive Level: Analysis REF: 598 OBJ: 22

TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. The assessment that would lead the nurse to suspect that a newborn infant has a ventricular septal defect, is:

a.

A loud, harsh murmur with a systolic tremor

b.

Cyanosis when crying

c.

Blood pressure higher in the arms than in the legs

d.

A machinery-like murmur

ANS: A

A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal defect.

DIF: Cognitive Level: Analysis: Physiological Adaptation REF: 599

OBJ: 22 TOP: Congenital Heart Disease

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. The finding the nurse would expect when measuring blood pressure on all four extremities of a child with coarctation of the aorta is:

a.

Blood pressure is higher on the right side.

b.

Blood pressure is higher on the left side.

c.

Blood pressure is lower in the arms than in the legs.

d.

Blood pressure is lower in the legs than in the arms.

ANS: D

The characteristic symptoms of coarctation of the aorta are a marked difference in blood pressure and pulses between the upper and lower extremities. Pressure is increased proximal to the defect and decreased distal to the coarctation.

DIF: Cognitive Level: Analysis REF: 599 OBJ: 22

TOP: Congenital Heart Disease KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. The nurse is caring for a toddler with acute laryngotracheobronchitis. The assessment finding that would indicate the child is experiencing increased respiratory obstruction is:

a.

Restlessness

b.

Tachycardia

c.

Brassy cough

d.

Expiratory wheezing

ANS: C

Restlessness is a primary sign of increased respiratory obstruction.

DIF: Cognitive Level: Analysis REF: 576 OBJ: 5

TOP: Acute Croup KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

21. When a father asks why his child with tetralogy of Fallot seems to favor a squatting position, the nurse would explain that squatting:

a.

Increases the return of venous blood back to the heart

b.

Decreases arterial blood flow away from the heart

c.

Is a common resting position when a child is tachycardic

d.

Increases the workload of the heart

ANS: A

The squatting position allows the child to breathe more easily because systemic venous return is increased.

DIF: Cognitive Level: Analysis REF: 600 OBJ: 22

TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

22. An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). The nurse understands dyspnea occurs because:

a.

Blood is circulated through the lungs again, causing pulmonary circulatory congestion.

b.

Blood is shunted past the pulmonary circulation, causing pulmonary hypoxia.

c.

Blood is shunted past cardiac arteries, causing myocardial hypoxia.

d.

Blood is circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the heart.

ANS: A

When PDA is present, oxygenated blood recycles through the lungs, overburdening the pulmonary circulation.

DIF: Cognitive Level: Analysis: Physiological Adaptation REF: 599

OBJ: 22 TOP: Congenital Heart Disease

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

23. An appropriate nursing action related to the administration of Lanoxin to an infant would be:

a.

Counting the apical rate for 30 seconds before administering the medication

b.

Withholding a dose if the apical heart rate is less than 100 beats/min

c.

Repeating a dose if the child vomits within 30 minutes of the previous dose

d.

Checking respiratory rate and blood pressure before each dose

ANS: B

As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and the physician is notified.

DIF: Cognitive Level: Application REF: 603 OBJ: 23

TOP: Congestive Heart Failure KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

24. A child develops carditis from rheumatic fever. The nurse knows that the areas of the heart affected by carditis are:

a.

The coronary arteries

b.

The heart muscle and the mitral valve

c.

The aortic and pulmonic valves

d.

The contractility of the ventricles

ANS: B

The tissues that cover the heart and heart valves are affected. The heart muscle may be involved and the mitral valve is frequently involved.

DIF: Cognitive Level: Knowledge REF: 604 OBJ: 26

TOP: Rheumatic Fever KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

25. The comment made by a parent of a 1-month-old that would alert the nurse about the presence of a congenital heart defect is:

a.

He is always hungry.

b.

He tires out during feedings.

c.

He is fussy for several hours every day.

d.

He sleeps all the time.

ANS: B

Fatigue during feeding or activity is common to most infants with congenital cardiac problems.

DIF: Cognitive Level: Analysis REF: 596 OBJ: 23

TOP: Congenital Heart Disease KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

26. The nurse is caring for a child with a diagnosis of Kawasaki disease. The childs parent asks the nurse, How does Kawasaki disease affect my childs heart and blood vessels? The nurses response is based on the understanding that:

a.

Inflammation weakens blood vessels, leading to aneurism.

b.

Increased lipid levels lead to the development of atherosclerosis.

c.

Untreated disease causes mitral valve stenosis.

d.

Altered blood flow increases cardiac workload with resulting heart failure.

ANS: A

Inflammation of vessels weakens the walls of the vessels and often results in aneurysm.

DIF: Cognitive Level: Analysis REF: 607 OBJ: N/A

TOP: Kawasaki Disease KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. The nurse can determine the parent understood the instructions when he states:

a.

If the baby turns blue, I will hold him over my shoulder with his knees bent up toward his chest.

b.

If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body.

c.

If the baby turns blue, I will immediately put the baby upright in an infant seat.

d.

If the baby turns blue, I will put the baby in a squatting position.

ANS: A

In the event of a paroxysmal hypercyanotic or tet spell, the infant should be placed in a knee-chest position.

DIF: Cognitive Level: Application REF: 600 OBJ: 22

TOP: Tetralogy of Fallot KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

28. The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, Why do my childs fingertips look like that? The nurse bases a response on the understanding that clubbing occurs as a result of:

a.

Untreated congestive heart failure

b.

A left-to-right shunting of blood

c.

Decreased cardiac output

d.

Chronic hypoxia

ANS: D

Clubbing of the fingers develops in response to chronic hypoxia.

DIF: Cognitive Level: Analysis REF: 604 OBJ: 22

TOP: Tetralogy of Fallot KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

29. A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever?

a.

Subcutaneous nodules and fever

b.

Painful, tender joints and carditis

c.

Erythema marginatum and arthralgia

d.

Chorea and elevated sedimentation rate

ANS: B

The presence of two major Jones criteria would indicate a high probability of rheumatic fever.

DIF: Cognitive Level: Analysis REF: 604, Box 25-3

OBJ: 26 TOP: Rheumatic Fever

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

30. An infant with congestive heart failure is receiving Lanoxin. The nurse recognizes signs of digoxin toxicity, which are:

a.

Restlessness

b.

Decreased respiratory rate

c.

Increased urinary output

d.

Vomiting

ANS: D

Symptoms of digoxin toxicity include the following: nausea, vomiting, anorexia, irregularity in pulse rate and rhythm, and a sudden change in pulse.

DIF: Cognitive Level: Analysis REF: 604 OBJ: 23

TOP: Congestive Heart Failure KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. The nurse describes the allergic salute as a cluster of signs related to chronic allergy, which are:

Select all that apply.

a.

Mouth breathing

b.

Transverse nasal crease

c.

Dark circles under the eyes

d.

Productive cough

e.

Reddened conjunctiva

ANS: A, B, C, E

The allergic salute does not include a productive cough.

DIF: Cognitive Level: Comprehension REF: 582 OBJ: 10

TOP: Allergic Salute KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse would suggest to the parents of an asthmatic child to encourage participation in such activities as:

Select all that apply.

a.

Swimming

b.

Gymnastics

c.

Baseball

d.

Basketball

e.

Tennis

ANS: A, B, C

Sports that require bursts of energy rather than long-term output of energy are suitable pursuits for asthmatics. Swimming, gymnastics, and baseball fit this criterion.

DIF: Cognitive Level: Application REF: 585 OBJ: 13

TOP: Sports Activities Suitable for Asthmatics

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

1. The nurse explains that the ____________________ can sense the oxygen concentration in the blood and can signal the brainstem to increase respiration.

ANS: chemoreceptors

DIF: Cognitive Level: Comprehension REF: 573 OBJ: 3

TOP: Chemoreceptors KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

NOT: Rationale: Chemoreceptors can sense the oxygen concentration of the blood and can signal the brainstem to increase and deepen respirations in order to keep an adequate supply of oxygen in the circulating volume.

2. After the 3-month-old child with respiratory syncytial virus is given a protocol of antiviral medications, the nurse explains that routine immunizations will need to be delayed for ____________________ months.

ANS: 9

DIF: Cognitive Level: Application REF: 578 OBJ: 9

TOP: Syncytial Virus KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

NOT: Rationale: After a protocol of antiviral medications, the routine immunizations should be delayed because the antiviral medications affect the integrity of the immunizations.

3. The nurse reviews for the client drugs such Accolate and Zyflo, which are _______________ _______________; they are capable of blocking the inflammatory response as well as providing bronchodilation.

ANS: leukotriene modifiers

DIF: Cognitive Level: Comprehension REF: 585 OBJ: 14

TOP: Leukotriene Modifiers KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

NOT: Rationale: The leukotriene modifiers are capable of blocking the inflammatory response and can also provide bronchodilation.

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