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What is the best response
to a parent who asks the nurse whether her 5-month-old infant can have cow’s
- “Infants younger than 12
- months need iron-rich formula to get the iron they need.”
- Rationale:Infants younger than 12
- months need iron-fortified formula or breast milk. Infants who drink cow’s milk
- do not get adequate iron and are at risk for iron deficiency anemia.
An assessment of a 7-month-old infant with a hemoglobin level of
6.5 mg/dL is likely to reveal an infant who is
- Lethargic, pale, and
- Rationale:Pallor, lethargy,
- irritability, and tachycardia are clinical manifestations of iron deficiency
- anemia. A child with a hemoglobin level of 6.5 mg/dL has anemia
A child with a hemoglobin
level of 6.5 mg/dL has _____.
What action is not appropriate for a 14-month-old child with iron
- Allowing the infant to
- drink the iron supplement from a small medicine cup
- Rationale:Iron supplements should be
- administered through a straw or by a medicine dropper placed at the back of the
- mouth because iron temporarily stains the teeth.
An accurate description of
- Decreased oxygen-carrying
- capacity of blood
- Rationale: Anemia is a condition in
- which the number of red blood cells or hemoglobin concentration is reduced
- below the normal values for age. This results in a decreased oxygen-carrying
- capacity of blood.
What is true about the genetic transmission of sickle cell
- Both parents must carry the
- sickle cell trait.
- Rationale: An autosomal recessive
- pattern of inheritance means that both parents must be carriers of the sickle
- cell trait
A condition in which the
normal adult hemoglobin is partly or completely replaced by abnormal hemoglobin
is known as
- Sickle cell anemia
- Rationale: Sickle cell anemia is one
- of a group of diseases collectively called hemoglobinopathies, in which normal
- adult hemoglobin is replaced by an abnormal hemoglobin
What are the nursing
priorities for a child with sickle cell disease in vaso-occlusive crisis?
- Hydration and pain
- Rationale: Hydration and pain
- management decrease the cells’ oxygen demands and prevent sickling.
What describes the pathologic
changes of sickle cell anemia?
- Increased red blood cell
- destruction occurs.
- Rationale: The clinical features of
- sickle cell anemia are primarily the result of increased red blood cell
- destruction and obstruction caused by the sickle-shaped red blood cells.
manifestation should the nurse expect when a child with sickle cell anemia
experiences an acute vaso-occlusive crisis?
- Painful swelling of hands
- and feet; painful joints
- Rationale: A vaso-occlusive crisis is
- characterized by severe pain in the area of involvement. If in the extremities,
- painful swelling of the hands and feet is seen; if in the abdomen, severe pain
- resembles that of acute surgical abdomen; and if in the head, stroke and visual
- disturbances occur.
What should the discharge
plan for a school-age child with sickle cell disease include?
- Administering penicillin
- daily as ordered
- Rationale: Children with sickle cell
- disease are at a high risk for pneumococcal infections and should receive
- long-term penicillin therapy and preventive immunizations.
How should the nurse
respond when asked by the mother of a child with beta-thalassemia why the child
is receiving deferoxamine?
- “To eliminate excessive
- iron being stored in the organs.”
- Rationale: Multiple transfusions
- result in hemosiderosis. Deferoxamine is given to chelate iron and prevent
- organ damage.
Which statement best
describes beta-thalassemia major (Cooley anemia)?
- Increased incidence occurs
- in families of Mediterranean extraction.
- Rationale: Individuals who live near
- the Mediterranean Sea and their descendants have the highest incidence of
An overproduction of red
cells occurs. Although numerous, the red cells are relatively unstable.
- beta-thalassemia major
- (Cooley anemia)
What is the priority
nursing intervention for a child hospitalized with hemarthrosis resulting from
- Immobilization and
- elevation of the affected joint
- Rationale: Immobilization and
- elevation of the joint will prevent further injury until bleeding is resolved.
What is descriptive of most cases of hemophilia?
- X-linked recessive
- inherited disorder in which a blood-clotting factor is deficient
- Rationale: The inheritance pattern in
- 80% of all of the cases of hemophilia is X-linked recessive. The two most
- common forms of the disorder are factor VIII deficiency, hemophilia A or
- classic hemophilia; and factor IX deficiency, hemophilia B or Christmas
The mother of a child with
hemophilia asks the nurse how long her child will need to be treated for
hemophilia. What is the best response to this question?
- “Hemophilia is a lifelong
- blood disorder.”
- Rationale: Hemophilia is a lifelong
- hereditary blood disorder with no cure. Prevention by avoiding activities that
- induce bleeding and by treatment is lifelong. The management of hemophilia is
- highly individual and depends on the severity of the illness.
In teaching family members
about their child’s von Willebrand disease, what is the priority outcome for
the child that the nurse should discuss?
- Prevention of injury
- Rationale: Hemorrhage as a result of
- injury is the child’s greatest threat to life.
The treatment of von
Willebrand disease is ___________, which is administered
intranasally or intravenously.
desmopressin acetate (DDAVP)
A child who has been in
good health has a platelet count of 45,000/mm3, petechiae, and
excessive bruising that covers the body. The nurse is aware that these signs
are clinical manifestations of
- Immune thrombocytopenic
- purpura (ITP)
- Rationale: Excessive bruising and
- petechiae, especially involving the mucous membranes and gums in a child who is
- otherwise healthy, are the clinical manifestations of ITP, resulting from
- decreased platelets. The etiology of ITP is unknown, but it is considered to be
- an autoimmune process.
The clinical manifestations
of _________ are pallor, lethargy, headache, fainting, and a history
of upper respiratory infection.
The clinical manifestations
of __________ are bleeding from the gums or nose, prolonged
bleeding from cuts, and excessive bleeding after surgery or trauma.
von Willebrand disease
Bleeding is the clinical
manifestation of ________ and results from a deficiency of normal factor
activity necessary to produce blood clotting.
What is the priority in the
discharge plan for a child with immune thrombocytopenic purpura (ITP)?
- Establishing a safe,
- age-appropriate home environment
- Rationale: Prevention of injury is a
- priority concern for a child with ITP.
ITP (immune thrombocytopenic purpura ) is associated with __________.immune thrombocytopenic purpura
low platelet levels
What is a priority
intervention in planning care for the child with disseminated intravascular
- Management in the intensive
- care unit
- Rationale: The child with DIC is
- seriously ill and needs to be monitored in an intensive care unit.
_____ typically develops in a
child who is already hospitalized.
- DIC disseminated intravascular
What is the nurse’s best
response to a parent with questions about how her child’s blood disorder will
- “What did the physician
- tell you?”
- Rationale: Providing the parent an
- opportunity to express what she was told by the physician allows the nurse to
- assess the parent’s understanding and provide further information
The nurse is caring for a
child with aplastic anemia. What nursing diagnoses are appropriate? Select all
- -Risk for Infection related to inadequate secondary defenses or immunosuppression
- -Ineffective Protection related to thrombocytopenia
- -Ineffective Tissue Perfusion related to anemia
- Rationale: These are appropriate
- nursing diagnosis for the nurse planning care for a child with aplastic anemia.
- Aplastic anemia is a condition in which the bone marrow ceases production of
- the cells it normally manufactures, resulting in pancytopenia. The child will
- have varying degrees of the disease depending on how low the values are for
- absolute neutrophil count (affecting the body’s response to infection),
- platelet count (putting the child at risk for bleeding), and absolute
- reticulocyte count (causing the child to have anemia).
__________________ is an appropriate nursing diagnosis for sickle cell anemia for
the child in vaso-occlusive crisis.
Acute pain related to vaso-occlusion
_______________ is an appropriate diagnosis for von Willebrand
Ineffective protection related to abnormal clotting
The nurse is caring for a
child with iron-deficiency anemia. What should the nurse expect to find when
reviewing the results of the complete blood count (CBC)? Select all that apply.
- -Low hemoglobin levels
- -Low reticulocyte count
- -Decreased MCV levels
- Rationale: The results of the complete
- blood count in a child with iron-deficiency anemia will show low hemoglobin
- levels (6 to 11 g/dL) and microcytic, hypochromic RBCs; this manifests as
- decreased MCV and decreased mean cell hemoglobin. The reticulocyte count is usually
- slightly elevated or normal.
A nurse is teaching home
care instructions to parents of a child with sickle cell disease. Which
instructions should the nurse include? Select all that apply.
- Administer penicillin as ordered.
- Avoid cold and extreme heat.
- Provide for adequate rest periods.
- Rationale: Parents should be taught to
- avoid cold, which can increase sickling, and extreme heat, which can cause
- dehydration. Adequate rest periods should be provided. Penicillin should be
- administered daily as ordered. The use of aspirin should
- be avoided; acetaminophen or ibuprofen should be used as an alternative. Fluids
- should be encouraged and an increase in fluid intake is encouraged in hot
- weather or when there are other risks for dehydration.
A syndrome that leads to
the deposition of platelets and fibrinogen plugs in the vasculature and the
simultaneous depletion of platelets and clotting factor proteins is commonly
known as DIC or _____________________.
- disseminated intravascular
- The pathophysiology of DIC
- is complicated and not easily understood because both extreme bleeding and
- clotting occur at the same time.
The nurse is evaluating lab results to determine if her patient is
experiencing a diagnosis of DIC. The nurse should anticipate the following
results: increased red blood cell count, low platelet counts, and an increased
fibrinogen level. Is this statement true or false?
- The results indicate a
- decreased red blood cell count, low platelets, red blood cell fragments,
- prolonged prothrombin time, and a decreased fibrinogen level with an increased
Which statement is accurate
concerning a child’s musculoskeletal system and how it may be different from an
- Because soft tissues are
- resilient in children, dislocations and sprains are less common than in adults.
- Rationale: Because soft tissues are
- resilient in children, dislocations and sprains are less common than in adults.
- This is an accurate statement.
When infants are seen for
fractures, which nursing intervention is a priority?
- Assess for child abuse.
- Fractures in infants are often nonaccidental.
- Rationale: Fractures in infants
- warrant further investigation to rule out child abuse. Fractures in children
- younger than 1 year are unusual because of the cartilaginous quality of the
- skeleton; a large amount of force is necessary to fracture their bones.
Which nursing intervention
is appropriate to assess for neurovascular competency in a child who fell off
the monkey bars at school and hurt his arm?
- The skin color,
- temperature, movement, sensation, and capillary refill of the extremity
- Rationale: A neurovascular evaluation
- includes assessing skin color and temperature, ability to move the affected
- extremity, degree of sensation experienced, and speed of capillary refill in
- the extremity.
A mother whose 7-year-old
child has been placed in a cast for a fractured right arm reports that he will
not stop crying even after taking acetaminophen with codeine. He also will not
straighten the fingers on his right arm. The nurse tells the mother to
- Take him to the emergency department.
- Rationale: Unrelieved pain and the
- child’s inability to extend his fingers are signs of compartmental syndrome,
- which requires immediate attention.
A 4-year-old child with a long leg cast complains of “fire” in his cast. The nurse should
- Notify the physician immediately.
- Rationale: A burning sensation under
- the cast is an indication of tissue ischemia. It may be an early indication of
- serious neurovascular compromise, such as compartmental syndrome, that requires
- immediate attention.
When a child with a musculoskeletal
injury on the foot is assessed, what is most indicative of a fracture?
- The inability of the child to bear weight
- Rationale: An inability to bear weight
- on the affected extremity is indicative of a more serious injury. With a
- fracture, general manifestations include pain or tenderness at the site, immobility or decreased range of motion, deformity of the extremity, edema, and inability to bear weight.
A child with osteomyelitis asks the nurse, “What is a ‘sed’ rate?” What is the best response for
- “It tells us how you are responding to the treatment.”
- Rationale: The erythrocyte sedimentation rate (ESR) indicates the presence of inflammation and infectious process and is one of the best indicators of the child’s response to treatment.
Which interaction is part of the discharge plan for a school-age child with osteomyelitis who is receiving home antibiotic therapy?
- Arrange for tutoring and school work
- Rationale: Promoting optimal growth and development in the school-age child is important. It is important to continue school work and arrange for tutoring if indicated.
During a 14-year-old’s physical examination, the nurse identifies that he plays soccer and football and is complaining of knee pain when he rises from a squatting position, and difficulty with weight bearing. The nurse should suspect
- Osgood-Schlatter disease
- Rationale: Knee pain and tenderness
- aggravated by activity that requires kneeling, running, climbing stairs, and rising from a squatting position is highly significant for Osgood-Schlatter disease. The cause is believed to be related to repetitive stress from sports-related activities combined with overuse of immature muscles and tendons.
______________causes progressive generalized weakness and muscle wasting.
Duchenne muscular dystrophy
Preexisting pain, favoring the affected limb, erythema, and tenderness are associated with __________.
Pain on activity that decreases with rest is indicative of _______________.