Chapter 23

Question 1

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)

Answer 1

ANS: D. Antidiuretic hormone (ADH)

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.

Question 2

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

Answer 2

ANS: A. Fever

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

Question 3

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

Answer 3

ANS: C. Immature kidney functioning

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.

Question 4

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

Answer 4

ANS: C. 1200

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.

Question 5

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

Answer 5

ANS: C. Water depletion

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.

Question 6

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

Answer 6

ANS: D. Dry, sticky mucous membranes

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.

Question 7

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

Answer 7

ANS: A. Decreased hematocrit

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.

Question 8

8. What clinical manifestation(s) is associated with calcium depletion (hypocalcemia)?
   a. Nausea, vomiting
   b. Weakness, fatigue
   c. Muscle hypotonicity
   d. Neuromuscular irritability

Answer 8

ANS: D. Neuromuscular irritability

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.

Question 9

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

Answer 9

ANS: B. Hypotonic dehydration

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.

Question 10

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

Answer 10

ANS: B. 50 to 90 ml/kg

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.

Question 11

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

Answer 11

ANS: C. Fluid shift from interstitial space to intravascular space

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.

Question 12

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

Answer 12

ANS: A. Tachycardia

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

Question 13

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

Answer 13

ANS: D. Dry mucous membranes and generally ill appearance

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.

Question 14

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

Answer 14

ANS: C. Irritability and seizures

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.

Question 15

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

Answer 15

ANS: D. Metabolic and respiratory alkalosis

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

Question 16

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.

Answer 16

ANS: B. Weigh diapers after each void.

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

Question 17

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.

Answer 17

ANS: A. Gently tap over the site.

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.

Question 18

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

Answer 18

ANS: B. Check the insertion site frequently for signs of infiltration.

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.

Question 19

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.

Answer 19

ANS: B. End the infusion and notify the practitioner.

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.

Question 20

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.

Answer 20

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

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

Question 21

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

Answer 21

ANS: C. Fever and general malaise

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

Question 22

22. What flush solution is recommended for intravenous catheters larger than 24 gauge?
    a. Saline
    b. Heparin
    c. Alteplase
    d. Heparin and saline combination

Answer 22

ANS: A. Saline

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 catheterrelated occlusions in children. The heparin and saline combination does not offer any advantage over saline or
heparin individually.

Question 23

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.

Answer 23

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

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.

Question 24

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

Answer 24

ANS: D. Dysenteric

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.

Question 25

25. What condition is often associated with severe diarrhea? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

Answer 25

ANS: A. Metabolic acidosis 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.

Question 26

26. What organism is a parasite that causes acute diarrhea? a. Shigella organisms b. Salmonella organisms c. Giardia lamblia d. Escherichia coli

Answer 26

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

Question 27

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

Answer 27

ANS: D. Easily digested foods 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.

Question 28

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.

Answer 28

ANS: C. Continue to give ORS frequently in small amounts. 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.

Question 29

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

Answer 29

ANS: A. Regular diet 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

Question 30

30. What is the most frequent cause of hypovolemic shock in children? a. Sepsis b. Blood loss c. Anaphylaxis d. Heart failure

Answer 30

ANS: B. Blood loss 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.

Question 31

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

Answer 31

ANS: D. Anaphylactic shock 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.

Question 32

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

Answer 32

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

Question 33

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.

Answer 33

ANS: C. Provide supplemental oxygen 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

Question 34

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

Answer 34

ANS: C. Increased capillary permeability 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.

Question 35

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

Answer 35

ANS: D. Abrupt drop in cardiac output 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.

Question 36

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

Answer 36

ANS: D. An inhalation injury 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.

Question 37

37. What is the most immediate threat to life in children with thermal injuries? a. Shock b. Anemia c. Local infection d. Systemic sepsis

Answer 37

ANS: A. Shock 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.

Question 38

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

Answer 38

ANS: C. Infection 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.

Question 39

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

Answer 39

ANS: C. Disorientation 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.

Question 40

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.

Answer 40

ANS: D. Hold the hand under cool running water. 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.

Question 41

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

Answer 41

ANS: D. Urinary output of 1 to 2 ml/kg of body weight/hr 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.

Question 42

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

Answer 42

ANS: C. Minimize protein breakdown 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.

Question 43

43. Fentanyl and midazolam (Versed) are given before debridement 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

Answer 43

ANS: B. Provide pain relief 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.

Question 44

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

Answer 44

ANS: B Dbride the wounds 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.

Question 45

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.

Answer 45

ANS: B. Observe wounds for signs of infection. 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.

Question 46

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.

Answer 46

ANS: A. Involve the child and give choices as feasible. 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.

Question 47

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.

Answer 47

ANS: B. Wash hands and forearms before and after dressing change. 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 ap

Question 48

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

Answer 48

ANS: C. Limitation of period without pressure to areas of scarring 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.

Question 49

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

Answer 49

ANS: C. Hot liquids in the kitchen 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.

Question 50

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.

Answer 50

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

Question 51

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

Answer 51

ANS: B. Mild fever and vomiting followed by onset of watery stools 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.