Question 1

The nurse is working with a school district to ensure students do not develop food-borne illnesses. Which intervention should the nurse emphasize that supports the 2020 National Health Goals regarding food preparation?

A) Refrigerate foods promptly.
B) Provide fresh fruits and vegetables.
C) Ensure all students are appropriately immunized.
D) Examine the number of students who contract food-borne illnesses.

Refrigerate foods promptly.

Accepted Answer

Unsafe food preparation is an area that could be reduced in incidence if people knew more about it and took active interventions to reduce its occurrence or spread. The 2020 National Health Goals addressing these include reducing infections caused by key pathogens transmitted commonly through food and increasing the proportion of consumers who follow key food safety practices of "Chill: refrigerate promptly." Nurses can help the nation achieve the goal by counseling parents about safe food preparation and serving as consultants to those responsible for food preparation.

Question 2

The nurse is caring for an infant recovering from surgery for pyloric stenosis. Which nursing diagnosis should the nurse use to guide care during the immediate postoperative period?&#10;A) Anxiety related to new feeding method used postoperatively&#10;B) Ineffective tissue perfusion related to pressure on heart chambers&#10;C) Excess fluid volume related to increased fluid intake prescribed postoperatively&#10;D) Risk for infection of incision line, related to disruption of skin barrier during surgery

Accepted Answer

Because the incision line for a pyloric stenosis repair is near the diaper area, the child is at risk for developing a surgical infection. The diagnosis risk for infection of incision line is the most appropriate during the immediate postoperative period. Anxiety might be appropriate after the immediate postoperative period has passed. There is no enough information to determine if the infant is being given excessive fluid or if the infant is experiencing ineffective tissue perfusion.

Question 3

The mother of a 3-month-old infant is distraught because the child vomits after every feeding. After an assessment, the nurse determines that the infant is experiencing regurgitation and not vomiting. What did the nurse assess in the infant? (Select all that apply.)

A) Slight sour smell
B) Occurs after a feeding
C) Accompanied by prolonged crying
D) Runs out of the mouth with no force
E) Volume amount similar to entire stomach contents

Slight sour smell
Occurs after a feeding
Runs out of the mouth with no force

Accepted Answer

Evidence of regurgitation includes a slightly sour smell to the emesis, occurs after a feeding, and runs out of the mouth without any force. Evidence of vomiting would be infant distress by prolonged crying and a large volume similar to that of entire stomach contents.

Question 4

A preschool-age child has been experiencing severe vomiting for over 24 hours. The child's respiratory rate is currently 10 breaths/min. On which health problem will the nurse focus when caring for this child?

A) Overhydration
B) Metabolic acidosis
C) Metabolic alkalosis
D) Hypertonic dehydration

Accepted Answer

With vomiting, a great deal of hydrochloric acid is lost. When Cl^- ions are lost this way, the body has to decrease the number of H⁺ ions present so the number of positive and negative charges remains balanced. This causes the child to develop alkalosis. The lungs attempt to conserve carbon dioxide and water by slowing respirations. Overhydration generally occurs in children who are receiving IV fluid, ingestion of large quantities of tap water, or through the use of tap water enemas. Metabolic acidosis is more closely associated with diarrhea. Hypertonic dehydration occurs when water is lost in a greater proportion than electrolytes. This might occur in a child with nausea, fever, and profuse diarrhea.

Question 5

A 1-month-old infant is diagnosed with gastroesophageal reflux. Which intervention should the nurse teach the mother to help with the symptoms of this disorder?&#10;A) Hold in a horizontal position while feeding.&#10;B) Place on the back immediately after feeding.&#10;C) Feed with formula thickened with rice cereal.&#10;D) Administer prescribed medications before each feeding.

Accepted Answer

The traditional treatment of gastroesophageal reflux is to feed infants a formula thickened with rice cereal. The baby should be held in an upright position and then kept upright in an infant chair for 1 hour after feeding so gravity can help prevent reflux.
Medication for gastroesophageal reflux is prescribed daily and not before each feeding.

Question 6

A 2-month-old infant experiencing severe diarrhea is prescribed intravenous fluid replacement. Before adding potassium to this solution, which assessment should the nurse make?&#10;A) Is voiding&#10;B) Is sleeping&#10;C) Is crying with tears&#10;D) Hands are restrained

Accepted Answer

Although infants usually have a potassium depletion, potassium is not given until it is established the child is not in renal failure because giving potassium IV when the body has no outlet for excessive potassium can lead to excessively high potassium levels and heart block. Before this initial IV fluid is changed to a potassium solution, the nurse needs to be certain that the infant has voided, which is proof that the kidneys are functioning. The nurse does not need to ensure that the child is sleeping, crying with tears, or has the hands restrained.

Question 7

During the assessment of a preschool-age child, the nurse notes that the child's tongue is tender and there are cracks in the corners of the child's mouth. Which vitamin deficiency does the nurse suspect this child is experiencing?

A) Vitamin A
B) Vitamin B₁
C) Vitamin C
D) Vitamin D

Accepted Answer

A vitamin A deficiency is caused by a lack of yellow vegetables in the diet. Manifestations of this deficiency include a tender tongue and cracks at the corners of the mouth. Manifestations of a vitamin B₁ deficiency include beriberi, diarrhea, and vomiting. Manifestations of a vitamin C deficiency include muscle tenderness and petechiae. Manifestations of a vitamin D deficiency include poor muscle tone, delayed tooth formation, poor bone formation, swelling of the wrists and cartilage of ribs, bowed legs, and muscle spasms.

Question 8

The nurse is advising a group of new parents on how to care for their infant at home if the baby develops mild diarrhea. Which statement indicates that teaching has been effective?&#10;A) &#34;I should offer milk after each episode of diarrhea.&#34;&#10;B) &#34;I should take the baby's temperature and call my physician.&#34;&#10;C) &#34;I could give Kaopectate as long as I follow the directions on the bottle.&#34;&#10;D) &#34;I should offer Pedialyte after 1 hour and frequently thereafter to prevent dehydration.&#34;

Accepted Answer

Mild diarrhea is not considered serious and at the end of approximately 1 hour, parents can begin to offer an oral rehydration solution such as Pedialyte in small amounts.
Infants may develop a temporary lactase deficiency after diarrhea that leads to lactose intolerance. With this, a child cannot take formula or breast milk without new diarrhea beginning. Parents should alert their health care provider if they feel this is happening as the infant will need to be introduced to a lactose-free formula initially before being returned to the usual formula or to breast milk. An elevated temperature is seen in severe diarrhea. The parents should be cautioned to contact their health care provider prior to initiating over-the-counter drugs such as kaolin and pectin (Kaopectate) to halt diarrhea because toxic levels of these can occur quickly.

Question 9

The nurse suspects that an infant is experiencing intussusception. What did the nurse assess in this infant? (Select all that apply.)&#10;A) Crying as if in severe pain&#10;B) Pulse rate of 78 beats/min and irregular&#10;C) Sudden drawing up of the legs&#10;D) Vomit that looks like currant jelly&#10;E) Leg drawing up and crying repeats every 15 minutes

Accepted Answer

With intussusception, the infant will suddenly draw up the legs and cry as if in severe pain. After the peristaltic wave that caused the discomfort passes, the infant is symptom free but in approximately 15 minutes the same pattern repeats. After approximately 12 hours, blood can appear in the vomitus and looks like "currant jelly." A slow pulse rate is not typically assessed in an infant with intussusception.

Question 10

A school-aged child with Crohn's disease will receive enteral nutrition for the next 6 weeks. What should the nurse counsel the parents to do to support this child's needs?&#10;A) Provide the feeding during regular meal times.&#10;B) Encourage the child to stay with the family during routine meal times.&#10;C) Suggest the child stay in the bedroom during routine meal times with the family.&#10;D) Explain that this might be a permanent method to have nutrition going forward.

Accepted Answer

When nutrition is supplied by enteral solutions, the enteral infusion should be provided during the night. Removing the tube during the day can make feedings more tolerable. Meal time provides social stimulation so the parents should encourage the child to spend time with the family during routine meal times. The feedings should not be provided during regular meal times. Having the child stay in the bedroom during meal times with the family will not support the child's socialization needs. There is no way of knowing if enteral feedings will be a permanent method for this child to obtain nutrition going forward.

Question 11

An adolescent patient is diagnosed with hepatitis A. Which problem should the nurse consider when planning the care for this patient?&#10;A) The patient will develop hypothermia.&#10;B) The patient will become easily fatigued.&#10;C) The patient's urine will be dark and infectious.&#10;D) The patient will be very irritable and perhaps require sedation.

Accepted Answer

The answer of An adolescent patient is diagnosed with hepatitis...

Question 12

A 14-year-old child is brought into the emergency room with manifestations consistent with a ruptured appendix. What is the first action that the nurse should take in the care of this child?&#10;A) Apply oxygen.&#10;B) Position flat in bed.&#10;C) Place in the semi-Fowler's position.&#10;D) Insert an indwelling urinary catheter.

Accepted Answer

The answer of A 14-year-old child is brought into the...

Question 13

The nurse is evaluating teaching provided to the mother of a child with celiac disease. Which type of breakfast indicates that instruction has been effective?&#10;A) Eggs and orange juice&#10;B) Oat cereal and skim milk&#10;C) Wheat toast and grape jelly&#10;D) Rye toast and peanut butter

Accepted Answer

The answer of The nurse is evaluating teaching provided to...

Deck 45: Nursing Care of a Family When a Child Has a Gastrointestinal Disorder