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Flashcards in Chapter 23 Deck (20):

What clinical manifestation would the nurse expect when a pneumothorax occurs in a neonate who is undergoing mechanical ventilation?
a. Barrel chest
b. Wheezing
c. Thermal instability
d. Nasal flaring and retractions

Ans: D
Nasal flaring, retractions, and grunting are signs of respiratory distress in a neonate.
Barrel chest develops with chronic obstructive pulmonary disease, not with acute pneumothorax.
Wheezing has a greater association with bronchopulmonary dysplasia or an obstruction in the airways than with an acute pneumothorax.
An acute pneumothorax would not affect the neonate's thermal stability.


The nurse is interviewing the parents of a 4-month-old infant brought to the hospital emergency department. The infant is dead on arrival, and no attempt at resuscitation is made. The parents state that the baby was found in the crib with a blanket over the head, lying face down in bloody fluid from the nose and mouth. The parents indicate no problems when the infant was placed in the crib asleep. Which of the following causes of death does the nurse suspect?
a. Suffocation
b. Child abuse
c. Infantile apnea
d. Sudden infant death syndrome (SIDS)

Ans: D
Death is consistent with the appearance of SIDS. The infant is usually found in a disheveled bed; with blankets over the head; huddled into a corner and clutching the sheets; with frothy, blood-tinged fluid in the mouth and nose; and lying face down. The diaper is also usually full of stool, indicating a cataclysmic type of death.
Although the child was found under the blanket, the other findings are consistent with SIDS.
The findings as reported are consistent with SIDS, not child abuse.
The history and physical findings are consistent with SIDS, not infantile apnea.


Apnea of infancy has been diagnosed in an infant scheduled for discharge with home monitoring. Part of the infant’s discharge teaching plan should include?
a. Cardiopulmonary resuscitation (CPR)
b. Administration of intravenous (IV) fluids
c. Foreign airway obstruction removal using the Heimlich maneuver
d. Advice that the infant not be left with caretakers other than the parents

Ans: A
CPR is essential for all parents and caregivers to know, especially when an infant has a history of apnea of infancy that is being monitored at home.
Most likely, the child will not be receiving home IV therapy as part of the discharge care.
The Heimlich maneuver is used to intervene when a child or an adult is experiencing a choking episode. It would not be necessary for the parents to learn the maneuver at this time. (Back slaps and chest thrusts are used on the responsive infant for choking.)
The parents should arrange for other caregivers to help when possible. There is no reason that the infant cannot be left with capable and trained individuals. Anyone caring for the infant will need to be taught to use equipment and how to perform CPR.


The most appropriate time to perform bronchial postural drainage is
a. immediately before all aerosol therapy.
b. before meals and at bedtime.
c. immediately on arising and at bedtime.
d. thirty minutes after meals and at bedtime

Ans: B
The most effective time for bronchial drainage is before meals and before bedtime to prevent the interaction of excessive amounts of mucus and food intake, thereby increasing the risk of vomiting.
Bronchial drainage is more effective after other respiratory therapies such as bronchodilator or nebulizer treatments. These treatments open the airways, facilitating the movement of mucus with the positioning of bronchial drainage.
Bronchial drainage should be done three or four times each day to be effective.
When bronchial drainage is completed after meals, it may cause the child to vomit.


A humidified atmosphere is recommended for a young child with an upper respiratory tract infection because it
a. liquefies secretions.
b. improves oxygenation.
c. promotes ventilation.
d. soothes inflamed mucous membrane.

Ans: D
Humidified inspired air soothes the membranes inflamed by the infection and dry air.
The size of the droplets in humidified air is too large to liquefy secretions.
No additional oxygen is provided with humidified air.
The humidity has no effect on ventilation.


It is important that a child with acute streptococcal pharyngitis be treated with antibiotics to prevent
a. otitis media.
b. diabetes insipidus.
c. nephrotic syndrome.
d. acute rheumatic fever.

Ans: D
Children with group A β-hemolytic streptococci (GABHS) infection are at risk for acute rheumatic fever and acute glomerulonephritis.
Otitis media is not a complication of acute streptococcal pharyngitis.
Diabetes insipidus is not a complication of acute streptococcal pharyngitis.
Children who have had acute streptococcal pharyngitis are at risk for acute glomerulonephritis, not nephrotic syndrome.


The most appropriate nursing intervention for a child following a tonsillectomy is to
a. watch for continuous swallowing.
b. encourage gargling to reduce discomfort.
c. position the child on the back for sleeping.
d. apply warm compresses to the throat.

Ans: A
Frequent swallowing is the most obvious early sign of bleeding from the operative site in a child who has had a tonsillectomy.
Gargling should be avoided after a tonsillectomy because of potential trauma to the suture line.
The child should be positioned on the side or abdomen to facilitate drainage after a tonsillectomy.
Ice collars and cold liquids are encouraged for the child who has had a tonsillectomy. Cold therapy soothes and anesthetizes the area, decreasing the pain. Heat or warmth would increase the risk of bleeding.


A 4-year-old child is brought to the emergency department. The child has a "froglike" croaking sound on inspiration, is agitated, and is drooling. The child insists on sitting upright. The priority action by the nurse is to
a. examine the child's oropharynx and report the assessment to the healthcare provider.
b. make the child lie down and rest quietly.
c. auscultate the child's lungs and make preparations for placement in a mist tent.
d. notify the healthcare provider immediately and be prepared to assist with a tracheostomy or intubation.

Ans: D
Sitting upright, drooling, agitation, and a froglike cough are indicative of epiglottitis. This is a medical emergency, and tracheostomy or intubation may be necessary.
Examination of the oropharynx may cause total obstruction and should not be done when a child manifests signs indicating potential epiglottitis.
The child assumes a tripod position to facilitate breathing. Forcing the child to lie down will increase the respiratory distress and anxiety.
Interventions should be planned once the diagnosis of epiglottitis has been made or ruled out.


The mother of a 20-month-old tells the nurse that the child has a barking cough at night. The child’s temperature is 37ºC (98.6ºF). The mother states the child is not having difficulty breathing. The nurse suspects croup and should recommend
a. controlling the fever with acetaminophen (Tylenol) and call the primary care provider if the cough gets worse tonight.
b. trying a cool-mist vaporizer at night and watching for signs of difficulty breathing.
c. trying over-the-counter cough medicine and coming to the clinic tomorrow if there is no improvement.
d. bringing the child to the hospital to be admitted and to be observed for impending epiglottitis.

Ans: B
Because the child is not having difficulty breathing, the nurse should teach the parents the signs of respiratory distress and tell them to come to the emergency department if they develop. Cool mist is recommended to provide relief because this therapy will assist in opening up the child's airways.
The child does not have a temperature and, therefore, does not need management with acetaminophen.
Cough suppressants are not indicated by symptom, and the American Pediatrics Association no longer recommends over-the-counter cough medicines for children under the age of 2 years.
A barking cough is characteristic of laryngotracheobronchitis, not epiglottitis.


An infant with a congenital heart defect is receiving palivizumab (Synagis). Based on the nurse’s knowledge of medication, the purpose of this medication is to
a. prevent respiratory syncytial virus (RSV) infection.
b. make isolation of the infant with RSV unnecessary.
c. prevent secondary bacterial infection.
d. decrease toxicity of antiviral agents.

Ans: A
Palivizumab is a monoclonal antibody specifically used in the prevention of RSV. Monthly administration is expected to prevent infection with RSV.
The goal of this drug is prevention of RSV. It will not affect the need to isolate the child if RSV develops.
Palivizumab is specific to RSV, not bacterial infections.
Palivizumab will have no effect on antiviral agents.


A child with asthma is having pulmonary function tests. What explains the purpose of the peak expiratory flow rate (PEFR)?
a. Confirms the diagnosis of asthma
b. Determines the cause of asthma
c. Identifies the "triggers" of asthma
d. Assesses the severity of asthma

Ans: D
The PEFR measures the maximum amount of air that can be forcefully exhaled in 1 minute. This can provide an objective measure of pulmonary function when compared with the child's baseline.
The diagnosis of asthma is made on the basis of clinical manifestations, history, and physical examination, not pulmonary function tests such as the PEFR.
The cause of asthma is inflammation, bronchospasm, and obstruction, which are not identified by the PEFR.
Some of the triggers of asthma are identified with allergy testing, not with the PEFR.


A 4-year-old boy needs to use a metered-dose inhaler to treat asthma. He cannot coordinate the breathing to use it effectively. The nurse should suggest that he use a
a. spacer.
b. nebulizer.
c. peak expiratory flow meter.
d. trial of chest physiotherapy.

Ans: A
The medication in a metered-dose inhaler is sprayed into the spacer. The child can then inhale the medication without having to coordinate the spraying and breathing.
A nebulizer is a mechanism to administer medications, but it cannot be used with metered-dose inhalers.
Peak expiratory flow meters measure pulmonary function but are not related to medication administration.
Chest physiotherapy is unrelated to medication administration.


One of the goals for children with asthma is to prevent respiratory tract infection because infections
a. lessen effectiveness of medications.
b. encourage exercise-induced asthma.
c. increase sensitivity to allergens.
d. can trigger an episode or aggravate asthmatic state.

Ans: D
Respiratory tract infections can trigger an asthmatic attack. An annual influenza vaccine is recommended. All respiratory equipment should be kept clean.
Respiratory tract infection affects the asthma, not the medications.
Exercise-induced asthma is caused by vigorous activity, not a respiratory tract infection.
Sensitivity to allergens is independent of respiratory tract infection.


Cystic fibrosis may affect one system or multiple systems of the body. What is the primary factor responsible for possible multiple clinical manifestations?
a. Atrophic changes in the mucosal wall of the intestines
b. Hypoactivity of the autonomic nervous system
c. Hyperactivity of the apocrine glands
d. Mechanical obstruction caused by increased viscosity of exocrine gland secretions

Ans: D
Children with cystic fibrosis have thick exocrine gland secretions. The viscous secretions obstruct small passages in organs such as the lungs and pancreas.
Thick mucous secretions are the probable cause of the multiple body system involvement, not atrophic changes in the intestinal mucosal walls.
There is an identified autonomic nervous system anomaly, but it is not hypoactivity.
The apocrine, or sweat, glands are not hyperactive. The child loses a greater amount of salt due to abnormal chloride movement.


The parent of a child with cystic fibrosis calls the clinic nurse to report that the child has developed tachypnea, tachycardia, dyspnea, pallor, and cyanosis. The nurse should tell the parent to bring the child to the clinic because these symptoms are suggestive of
a. pneumothorax.
b. bronchodilation.
c. carbon dioxide retention.
d. increased viscosity of sputum.

Ans: A
The child is exhibiting signs of increasing respiratory distress suggestive of a pneumothorax. The child needs to be seen as soon as possible.
Bronchodilation would not produce the described symptoms.
Carbon dioxide retention would not produce the described symptoms.
The increased viscosity of sputum is characteristic of cystic fibrosis. The change in respiratory status is potentially due to a pneumothorax.


Because the absorption of fat-soluble vitamins is decreased in cystic fibrosis, which vitamin supplementation is necessary?
a. C, D
b. A, E, K
c. A, D, E, K
d. C, folic acid

Ans: C
A, D, E, and K are the fat-soluble vitamins, which need to be supplemented in higher doses for the child with cystic fibrosis.
C is not one of the fat-soluble vitamins.
D also needs to be supplemented in children with cystic fibrosis.
C and folic acid are not fat-soluble vitamins.


An immediate intervention to teach parents for when an infant chokes on a piece of food would be to
a. have infant lie quietly while a call is placed for emergency help.
b. position infant in a head-down, face-down position and administer five quick back slaps.
c. administer mouth-to-mouth resuscitation.
d. give some water by a cup to relieve the obstruction.

Ans: B
Positioning the infant head and face down while administering five quick blows between the shoulder blades is the correct initial sequence of actions for an infant with an obstructed airway.
The infant needs to receive treatment immediately. Emergency help is called after attempting to remove the obstruction.
Mouth-to-mouth resuscitation should not be used. This may push the object further into the child's respiratory system.
If the child is obstructed, the water will not be able to pass. This will increase the risk of aspiration.


The school nurse is called to the cafeteria because a child "has eaten something he is allergic to." The child is in severe respiratory distress. The first action by the nurse is to
a. determine what the child has eaten.
b. administer diphenhydramine (Benadryl) PO stat.
c. move the child to the nurse's office or hallway.
d. have someone call for an ambulance and paramedic rescue squad or 9-1-1.

Ans: D
Because the child is in severe respiratory distress, the nurse should have someone call for a rescue squad or 9-1-1.
Because severe respiratory distress is occurring, treatment of the response is indicated. What the child has eaten can be determined later.
Diphenhydramine by mouth will not be effective for this type of emergency allergic reaction.
The child should not be moved, unless the child is currently in a place that puts him or her at greater hazard.


Asthma is classified into four categories: mild intermittent, mild persistent, moderate persistent, and severe persistent. Clinical features used to determine these categories include (Select all that apply)
a. lung function.
b. associated allergies.
c. frequency of symptoms.
d. frequency and severity of exacerbations.

Ans: A, C, D


A 5-year-old child is brought the Emergency Department with abrupt onset of sore throat, pain with swallowing, fever, and sitting upright and forward. Acute epiglottitis is suspected. What are the most appropriate nursing interventions? (Select all that apply.)
a. Vital signs
b. Throat culture
c. Medical history
d. Assessment of breath sounds
e. Emergency airway equipment readily available

Ans: A, C, D, E