chapter 14 Flashcards
- A father calls the clinic because he found his young daughter squirting Visine eyedrops into her mouth. What is the most appropriate nursing action?
a. Reassure the father that Visine is harmless.
b. Direct him to seek immediate medical treatment.
c. Recommend inducing vomiting with ipecac.
d. Advise him to dilute Visine by giving his daughter several glasses of water to drink
ANS: B Direct him to seek immediate medical treatment.
Visine is a sympathomimetic and if ingested may cause serious consequences. Medical treatment is necessary.
Inducing vomiting is no longer recommended for ingestions. Dilution will not decrease risk.
- The nurse suspects that a child has ingested some type of poison. What clinical manifestation would be most
suggestive that the poison was a corrosive product?
a. Tinnitus
b. Disorientation
c. Stupor, lethargy, and coma
d. Edema of the lips, tongue, and pharynx
ANS: D Edema of the lips, tongue, and pharynx
Edema of the lips, tongue, and pharynx indicates a corrosive ingestion. Tinnitus is indicative of aspirin
ingestion. Corrosives do not act on the central nervous system.
- A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The
nurse taking the call should know that the primary danger is what?
a. Hepatic dysfunction
b. Dehydration secondary to vomiting
c. Esophageal stricture and shock
d. Bronchitis and chemical pneumonia
ANS: D Bronchitis and chemical pneumonia
Lighter fluid is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose, not
hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger. Esophageal stricture is a late
or chronic consequence of hydrocarbon ingestion.
- What is a clinical manifestation of acetaminophen poisoning?
a. Hyperpyrexia
b. Hepatic involvement
c. Severe burning pain in stomach
d. Drooling and inability to clear secretions
ANS: B Hepatic involvement
Hepatic involvement is the third stage of acetaminophen poisoning. Hyperpyrexia is a severe elevation in body
temperature and is not related to acetaminophen poisoning. Acetaminophen does not cause burning pain in
stomach and does not pose an airway threat.
- An awake, alert 4-year-old child has just arrived at the emergency department after an ingestion of aspirin at home. The practitioner has ordered activated charcoal. The nurse administers charcoal in which manner?
a. Giving half of the solution and then repeating the other half in 1 hour
b. Mixing with a flavorful beverage in an opaque container with a straw
c. Serving it in a clear plastic cup so the child can see how much has been drunk
d. Administering it through a nasogastric tube because the child will not drink it because of the taste
ANS: B Mixing with a flavorful beverage in an opaque container with a straw
Although activated charcoal can be mixed with a flavorful sugar-free beverage, it will be black and resemble mud. When it is served in an opaque container, the child will not have any preconceived ideas about its being
distasteful. The ability to see the charcoal solution may affect the childs desire to drink the solution. The child
should be encouraged to drink the solution all at once. The nasogastric tube would be traumatic. It should be
used only in children who cannot be cooperative or those without a gag reflex.
- What is a significant secondary prevention nursing activity for lead poisoning?
a. Chelation therapy
b. Screening children for blood lead levels
c. Removing lead-based paint from older homes
d. Questioning parents about ethnic remedies containing lead
ANS: B Screening children for blood lead levels
Screening children for lead poisoning is an important secondary prevention activity. Screening does not
prevent the initial exposure of the child to lead. It can lead to identification and treatment of children who are
exposed. Chelation therapy is treatment, not prevention. Removing lead-based paints from older homes before
children are affected is primary prevention. Questioning parents about ethnic remedies containing lead is part
of the assessment to determine the potential source of lead.
- What is an important nursing consideration when a child is hospitalized for chelation therapy to treat lead
poisoning?
a. Maintain bed rest.
b. Maintain isolation precautions.
c. Keep an accurate record of intake and output.
d. Institute measures to prevent skeletal fracture.
ANS: C Keep an accurate record of intake and output.
The iron chelates are excreted though the kidneys. Adequate hydration is essential. Periodic measurement of
renal function is done. Bed rest is not necessary. Often the chelation therapy is done on an outpatient basis. Chelation therapy is not infectious or dangerous. Isolation is not indicated. Skeletal weakness does not result
from high levels of lead.
- What is the most common form of child maltreatment?
a. Sexual abuse
b. Child neglect
c. Physical abuse
d. Emotional abuse
ANS: B Child neglect
Child neglect, which is characterized by the failure to provide for the childs basic needs, is the most common
form of child maltreatment. Sexual abuse, physical abuse, and emotional abuse are individually not as common
as neglect.
- A child is admitted with a suspected diagnosis of Munchausen syndrome by proxy (MSBP). What is an
important consideration in the care of this child?
a. Monitoring the parents whenever they are with the child
b. Reassuring the parents that the cause of the disorder will be found
c. Teaching the parents how to obtain necessary specimens
d. Supporting the parents as they cope with diagnosis of a chronic illness
ANS: A Monitoring the parents whenever they are with the child
MSBP refers to an illness that one person fabricates or induces in another. The child must be continuously
observed for development of symptoms to determine the cause. MSBP is caused by an individual harming the
child for the purpose of gaining attention. Nursing staff should obtain all specimens for analyzing. This
minimizes the possibility of the abuser contaminating the sample. The child must be supported through the
diagnosis of MSBP. The abuser must be identified and the child protected from that individual.
- When only one child is abused in a family, the abuse is usually a result of what?
a. The child is the firstborn.
b. The child is the same gender as the abusing parent.
c. The parent abuses the child to avoid showing favoritism
d. The parent is unable to deal with the childs behavioral style.
ANS: D The parent is unable to deal with the childs behavioral style.
The child unintentionally contributes to the abuse. The fit or compatibility between the childs temperament and
the parents ability to deal with that behavior style is an important predictor. Birth order and gender can
contribute to abuse, but there is not a specific birth order or gender relationship that is indicative of abuse. Being the firstborn or the same gender as the abuser is not linked to child abuse. Avoidance of favoritism is not
usually a cause of abuse.
- The parents of a 7-year-old boy tell the nurse that lately he has been cruel to their family pets and actually
caused physical harm. The nurses recommendation should be based on remembering what?
a. This is an expected behavior at this age.
b. This is a warning sign of a serious problem.
c. This is harmless venting of anger and frustration.
d. This is common in children who are physically abused.
ANS: B This is a warning sign of a serious problem.
Cruelty to family pets is not an expected behavior. Hurting animals can be one of the earliest symptoms of a
conduct disorder. Abusing animals does not dissipate violent emotions; rather, the acts may fuel the abusive
behaviors. Referral for evaluation is essential. This behavior may be seen in emotional abuse or neglect, not
physical abuse
- A 3-month-old infant dies shortly after arrival to the emergency department. The infant has subdural and retinal hemorrhages but no external signs of trauma. What should the nurse suspect?
a. Unintentional injury
b. Shaken baby syndrome
c. Congenital neurologic problem
d. Sudden infant death syndrome (SIDS)
ANS: B Shaken baby syndrome
Shaken baby syndrome causes internal bleeding but may have no external signs. Unintentional injury would not cause these injuries. With unintentional injuries, external signs are usually present. Congenital neurologic
problems would usually have signs of abnormal neurologic anatomy. SIDS does not usually have identifiable
injuries.
- What statement is correct about young children who report sexual abuse?
a. They may exhibit various behavioral manifestations.
b. In more than half the cases, the child has fabricated the story.
c. Their stories should not be believed unless other evidence is apparent.
d. They should be able to retell the story the same way to another person.
ANS: A They may exhibit various behavioral manifestations.
Victims of sexual abuse have no typical profile. The child may exhibit various behavioral manifestations, none
of which is diagnostic for sexual abuse. When children report potentially sexually abusive experiences, their
reports need to be taken seriously. Other children in the household also need to be evaluated. In children who
are sexually abused, it is often difficult to identify other evidence. In one study, approximately 96% of children
who were sexually abused had normal genital and anal findings. The ability to retell the story is partly
dependent on the childs cognitive level. Children who repeatedly tell identical stories may have been coached
- What is probably the most important criterion on which to base the decision to report suspected child
abuse?
a. Inappropriate response of child
b. Inappropriate parental concern for the degree of injury
c. Absence of parents for questioning about childs injuries
d. Incompatibility between the history and injury observed
ANS: D Incompatibility between the history and injury observed
Conflicting stories about the accident are the most indicative red flags of abuse. The child or caregiver may
have an inappropriate response, but this is subjective. Parents should be questioned at some point during the
investigation.
- The nurse is caring for a child with suspected ingestion of some type of poison. What action should the
nurse take next after initiating cardiopulmonary resuscitation (CPR)?
a. Empty the mouth of pills, plants, or other material.
b. Question the victim and witness.
c. Place the child in a side-lying position.
d. Call poison control.
ANS: A Empty the mouth of pills, plants, or other material.
Emptying the mouth of any leftover pills, plants, or other ingested material is the next step after assessment
and initiation of CPR if needed. Questioning the victim and witnesses, calling poison control, and placing the
child in a side-lying position are follow-up steps
