Chapter 27: Select all

Question 1

1. The nurse is caring for a child with Kawasaki disease in the acute phase. What clinical manifestations should the nurse expect to observe? (Select all that apply.)
   a. Osler nodes
   b. Cervical lymphadenopathy
   c. Strawberry tongue
   d. Chorea
   e. Erythematous palms
   f. Polyarthritis

Answer 1

ANS: B, C, E

Clinical manifestations of Kawasaki disease in the acute phase include cervical lymphadenopathy, a strawberry tongue, and erythematous palms. Osler nodes are a clinical manifestation of endocarditis. Chorea and polyarthritis are seen in rheumatic fever.

Question 2

2. The nurse is caring for a child after cardiac surgery. What interventions should the nurse implement with regard to chest tubes placed to a water-seal drainage system? (Select all that apply.)
   a. Maintain sterility.
   b. Check for tube patency.
   c. Do not interrupt the water-seal drainage system.
   d. Clamp the chest tube when ambulating the child.
   e. Measure the drainage by emptying the collection chamber every shift.

Answer 2

ANS: A, B, C

Nursing considerations with regard to chest tubes attached to a water-seal drainage system include (1) do not interrupt water-seal drainage unless the chest tube is clamped, (2) check for tube patency (fluctuation in the water-seal chamber), and (3) maintain sterility. The chest tube should not be clamped when ambulating the child and the drainage is measured in the collection chamber, not emptied.

Question 3

3. The nurse is caring for a child with secondary hypertension. What renal disorders are associated with secondary hypertension? (Select all that apply.)
   a. Renal tumor
   b. Hydronephrosis
   c. Vesicoureteral reflux
   d. Glomerulonephritis
   e. Urinary tract infection

Answer 3

ANS: A, B, D

Renal disorders that can cause secondary hypertension include a renal tumor, hydronephrosis, and glomerulonephritis. Vesicoureteral reflux or urinary tract infections do not cause secondary hypertension.

Question 4

4. The nurse is teaching an adolescent with hypertension foods recommended on the DASH diet. What foods should the nurse include in the teaching session? (Select all that apply.)
   a. Green beans
   b. Energy drinks
   c. Low-fat yogurt
   d. Chocolate milk
   e. Whole grain bread

Answer 4

ANS: A, C, E

The DASH diet provides a lower salt diet that has been associated with improvement in BP and is believed to be beneficial for all patients with hypertension. DASH stands for Dietary Approaches to Stop Hypertension. The DASH diet is plentiful in vegetables, fruits, whole grains, and low-fat dairy products and low in sugar and salt. Energy drinks are high in sugar, and chocolate milk is high in fat.

Question 5

5. An adolescent is being placed on an ACE inhibitor. What should the nurse inform the adolescent with regard to this medication? (Select all that apply.)
   a. Stay well hydrated.
   b. Increase intake of potassium.
   c. Avoid rapid position changes.
   d. Take the medication with meals.
   e. Side effects may include a cough.

Answer 5

ANS: A, C, E

The adolescent should be instructed to stay well hydrated and avoid rapid position changes and that side effects may include a cough when on ACE inhibitors. ACE inhibitors do not deplete potassium, and they should be taken 1 hour before meals to increase absorption.

Question 6

6. An adolescent is being placed on a beta-blocker. What should the nurse inform the adolescent with regard to this medication? (Select all that apply.)
   a. Medication may cause fatigue.
   b. Side effects may include impotence.
   c. Side effects may include bradycardia.
   d. Take the medication 1 hour before meals.
   e. Side effects may include peripheral edema.

Answer 6

ANS: A, B, C

The adolescent should be instructed that the medication may cause fatigue, impotence, and bradycardia. The medications should be taken with meals and side effects do not include peripheral edema.

Question 7

7. An adolescent is being placed on a calcium channel blocker. What should the nurse inform the adolescent with regard to this medication? (Select all that apply.)
   a. The medication may cause fatigue.
   b. The medication may increase heart rate.
   c. The medication may cause constipation.
   d. The medication may cause cold extremities.
   e. The medication may cause peripheral edema.

Answer 7

ANS: B, C, E

Calcium channel blockers may cause an increase in heart rate, constipation, and peripheral edema. Beta-blockers can cause fatigue and cold extremities, but calcium channel blockers do not cause these potential side effects.

Question 8

8. The nurse is teaching an adolescent with elevated triglycerides foods that should be decreased. What foods should the nurse include in the teaching? (Select all that apply.)
   a. Avocados
   b. Canola oil
   c. White flour
   d. White rice
   e. Sugary cereals

Answer 8

ANS: C, D, E

If triglycerides are elevated, dietary recommendations include decreasing the intake of foods high in simple carbohydrates such as white flour, white rice, white bread, white pasta, sugary cereals, juice, and soda. Avocados and canola oil have beneficial effects on HDL, which is the good cholesterol.

Question 9

9. What interventions should the nurse anticipate being administered to a child with supraventricular tachycardia (SVT)?
   a. Bed rest
   b. Applying ice to the face
   c. Administration of atropine
   d. Administration of adenosine (Adenocor)
   e. Having the child perform a Valsalva maneuver

Answer 9

ANS: B, D, E

The treatment of SVT depends on the degree of compromise imposed by the dysrhythmia. In some instances, vagal maneuvers, such as applying ice to the face, massaging the carotid artery (on one side of the neck only), or having an older child perform a Valsalva maneuver (e.g., exhaling against a closed glottis, blowing on the thumb as if it were a trumpet for 30 to 60 seconds), can reverse the SVT. When vagal maneuvers fail, adenosine may be used to end the episode of SVT by impairing AV node conduction. IV adenosine is the first-line pharmacologic measure for termination of SVT in infants and children in the emergency setting. Administration of atropine or bed rest will not resolve SVT.