RNSG 2201 EXAM 5 RNSG 2201.

RNSG 2201 EXAM 5 RNSG 2201. EXAM # 5 RNSG 2201 CH. 23, 24, 25, 26 Chapter 23: The Child with Fluid and Electrolyte Imbalance MULTIPLE CHOICE 1. What substance is released from the posterior pituitary gland and promotes water retention in the renal system? a. Renin b. Aldosterone c. Angiotensin d. Antidiuretic hormone (ADH) ANS: D ADH is released in response to increased osmolality and decreased volume of intravascular fluid; it promotes water retention in the renal system by increasing the permeability of renal tubules to water. Renin release is stimulated by diminished blood flow to the kidneys. Aldosterone is secreted by the adrenal cortex. It enhances sodium reabsorption in renal tubules, promoting osmotic reabsorption of water. Renin reacts with a plasma globulin to generate angiotensin, which is a powerful vasoconstrictor. Angiotensin also stimulates the release of aldosterone. 2. Nurses should be alert for increased fluid requirements in which circumstance? a. Fever b. Mechanical ventilation c. Congestive heart failure d. Increased intracranial pressure ANS: A Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. The mechanically ventilated child has decreased fluid requirements. Congestive heart failure is a case of fluid overload in children. Increased intracranial pressure does not lead to increased fluid requirements in children. 3. What factor predisposes an infant to fluid imbalances? a. Decreased surface area b. Lower metabolic rate c. Immature kidney functioning d. Decreased daily exchange of extracellular fluid ANS: C The infants kidneys are functionally immature at birth and are inefficient in excreting waste products of metabolism. Infants have a relatively high body surface area (BSA) compared with adults. This allows a higher loss of fluid to the environment. A higher metabolic rate is present as a result of the higher BSA in relation to active metabolic tissue. The higher metabolic rate increases heat production, which results in greater insensible water loss. Infants have a greater exchange of extracellular fluid, leaving them with a reduced fluid reserve in conditions of dehydration. 4. What is the required number of milliliters of fluid needed per day for a 14-kg child? a. 800 b. 1000 c. 1200 d. 1400 ANS: C For the first 10 kg of body weight, a child requires 100 ml/kg. For each additional kilogram of body weight, an extra 50 ml is needed. 10 kg 100 ml/kg/day = 1000 ml 4 kg 50 ml/kg/day = 200 ml 1000 ml + 200 ml = 1200 ml/day Eight hundred to 1000 ml is too little; 1400 ml is too much. 5. An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation? a. Water excess b. Sodium excess c. Water depletion d. Potassium excess ANS: C These clinical manifestations indicate water depletion or dehydration. Edema and weight gain occur with water excess or overhydration. Sodium or potassium excess would not cause these symptoms. 6. Clinical manifestations of sodium excess (hypernatremia) include which signs or symptoms? a. Hyperreflexia b. Abdominal cramps c. Cardiac dysrhythmias d. Dry, sticky mucous membranes ANS: D Dry, sticky mucous membranes are associated with hypernatremia. Hyperreflexia is associated with hyperkalemia. Abdominal cramps, weakness, dizziness, nausea, and apprehension are associated hyponatremia. Cardiac dysrhythmias are associated with hypokalemia. 7. What laboratory finding should the nurse expect in a child with an excess of water? a. Decreased hematocrit b. High serum osmolality c. High urine specific gravity d. Increased blood urea nitrogen ANS: A The excess water in the circulatory system results in hemodilution. The laboratory results show a falsely decreased hematocrit. Laboratory analysis of blood that is hemodiluted reveals decreased serum osmolality and blood urea nitrogen. The urine specific gravity is variable relative to the childs ability to correct the fluid imbalance. 8. What clinical manifestation(s) is associated with calcium depletion (hypocalcemia)? a. Nausea, vomiting b. Weakness, fatigue c. Muscle hypotonicity d. Neuromuscular irritability ANS: D Neuromuscular irritability is a clinical manifestation of hypocalcemia. Nausea and vomiting occur with hypercalcemia and hypernatremia. Weakness, fatigue, and muscle hypotonicity are clinical manifestations of hypercalcemia. 9. What type of dehydration occurs when the electrolyte deficit exceeds the water deficit? a. Isotonic dehydration b. Hypotonic dehydration c. Hypertonic dehydration d. Hyperosmotic dehydration ANS: B Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Hyperosmotic dehydration is another term for hypertonic dehydration. 10. What amount of fluid loss occurs with moderate dehydration? a. 50 ml/kg b. 50 to 90 ml/kg c. 5% total body weight d. 15% total body weight ANS: B Moderate dehydration is defined as a fluid loss of between 50 and 90 ml/kg. Mild dehydration is defined as a fluid loss of less than 50 ml/kg. Weight loss up to 5% is considered mild dehydration. Weight loss over 15% is severe dehydration. 11. Physiologically, the child compensates for fluid volume losses by which mechanism? a. Inhibition of aldosterone secretion b. Hemoconcentration to reduce cardiac workload c. Fluid shift from interstitial space to intravascular space d. Vasodilation of peripheral arterioles to increase perfusion ANS: C Compensatory mechanisms attempt to maintain fluid volume. Initially, interstitial fluid moves into the intravascular compartment to maintain blood volume. Aldosterone is released to promote sodium retention and conserve water in the kidneys. Hemoconcentration results from the fluid volume loss. With less circulating volume, tachycardia results. Vasoconstriction of peripheral arterioles occurs to help maintain blood pressure. 12. Ongoing fluid losses can overwhelm the childs ability to compensate, resulting in shock. What early clinical sign precedes shock? a. Tachycardia b. Slow respirations c. Warm, flushed skin d. Decreased blood pressure ANS: A Shock is preceded by tachycardia and signs of poor tissue perfusion and decreased pulse oximetry values. Respirations are increased as the child attempts to compensate. As a result of the poor peripheral circulation, the child has skin that is cool and mottled with decreased capillary refilling after blanching. In children, lowered blood pressure is a late sign and may accompany the onset of cardiovascular collapse. 13. The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant? a. Weight loss and decreased heart rate b. Capillary refill of less than 2 seconds and no tears c. Increased skin elasticity and sunken anterior fontanel d. Dry mucous membranes and generally ill appearance ANS: D A good predictor of a fluid deficit of at least 5% is any two four factors: capillary refill of more than 2 seconds, absent tears, dry mucous membranes, and ill general appearance. Weight loss is associated with fluid deficit, but the degree needs to be quantified. Heart rate is usually elevated. Skin elasticity is decreased, not increased. The anterior fontanel is depressed. 14. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication? a. Oliguria b. Weight loss c. Irritability and seizures d. Muscle weakness and cardiac dysrhythmias ANS: C Irritability, somnolence, headache, vomiting, diarrhea, and generalized seizures are manifestations of water intoxication. Urinary output is increased as the child attempts to maintain fluid balance. Weight gain is usually associated with water intoxication. Muscle weakness and cardiac dysrhythmias are not associated with water intoxication. 15. What physiologic state(s) produces the clinical manifestations of nervous system stimulation and excitement, such as overexcitability, nervousness, and tetany? a. Metabolic acidosis b. Respiratory alkalosis c. Metabolic and respiratory acidosis d. Metabolic and respiratory alkalosis ANS: D The major symptoms and signs of alkalosis include nervous system stimulation and excitement, including overexcitability, nervousness, tingling sensations, and tetany that may progress to seizures. Acidosis (both metabolic and respiratory) has clinical signs of depression of the central nervous system, such as lethargy, diminished mental capacity, delirium, stupor, and coma. Respiratory alkalosis has the same symptoms and signs as metabolic alkalosis. 16. What is an approximate method of estimating output for a child who is not toilet trained? a. Have parents estimate output. b. Weigh diapers after each void. c. Place a urine collection device on the child. d. Have the child sit on a potty chair 30 minutes after eating. ANS: B Weighing diapers will provide an estimate of urinary output. Each 1 g of weight is equivalent to 1 ml of urine. Having parents estimate output would be inaccurate. It is difficult to estimate how much fluid is in a diaper. The urine collection device would irritate the childs skin. It would be difficult for a toddler who is not toilet trained to sit on a potty chair 30 minutes after eating. 17. The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The superficial veins on his hand and arm are not readily visible. What intervention should increase the visibility of these veins? a. Gently tap over the site. b. Apply a cold compress to the site. c. Raise the extremity above the level of the body. d. Use a rubber band as a tourniquet for 5 minutes. ANS: A Gently tapping the site can sometimes cause the veins to be more visible. This is done before the skin is prepared. Warm compresses (not cold) may be useful. The extremity is held in a dependent position. A tourniquet may be helpful, but if too tight, it could cause the vein to burst when punctured. Five minutes is too long. 18. When caring for a child with an intravenous (IV) infusion, what is an appropriate nursing action? a. Change the insertion site every 24 hours. b. Check the insertion site frequently for signs of infiltration. c. Use a macrodropper to facilitate reaching the prescribed flow rate. d. Avoid restraining the child to prevent undue emotional stress. ANS: B The nursing responsibility for IV therapy is to calculate the amount to be infused in a given length of time; set the infusion rate; and monitor the apparatus frequently, at least every 1 to 2 hours, to make certain that the desired rate is maintained, the integrity of the system remains intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the infusion does not stop. Insertion sites do not need to be changed every 24 hours unless a problem is found with the site. This exposes the child to significant trauma. A minidropper (60 drops/ml) is the recommended IV tubing in pediatric patients. Intravenous sites should be protected. This may require soft restraints on the child. 19. The nurse determines that a childs intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action? a. Stop the infusion and apply ice. b. End the infusion and notify the practitioner. c. Slow the infusion rate and notify the practitioner. d. Discontinue the infusion and apply warm compresses. ANS: B A vesicant causes cellular damage when even minute amounts escape into the tissue. The intravenous infusion is immediately stopped, the extremity is elevated, the practitioner is notified, and the treatment protocol is initiated. The applying of heat or ice depends on the fluid that has extravasated. The catheter is left in place until it is no longer needed. 20. Several types of long-term central venous access devices are used. What is a benefit of using an implanted port (e.g., Port-a-Cath)? a. You do not need to pierce the skin for access. b. It is easy to use for self-administered infusions. c. The patient does not need to limit regular physical activity, including swimming. d. The catheter cannot dislodge from the port even if the child plays with the port site. ANS: C No limitations on physical activity are needed. The child is able to participate in all regular physical activities, including bathing, showering, and swimming. The skin over the device is pierced with a Huber needle to access. Long-term central venous access devices are difficult to use for self-administration. The port is placed under the skin. If the child manipulates the device and plays with the actual port, the catheter can be dislodged. 21. The nurse is teaching the family of a child with a long-term central venous access device about signs and symptoms of bacteremia. What finding indicates the presence of bacteremia? a. Hypertension b. Pain at the entry site c. Fever and general malaise d. Redness and swelling at the entry site ANS: C Fever, chills, general malaise, and an ill appearance can be signs of bacteremia and require immediate intervention. Hypotension would be indicative of sepsis and possible impending cardiovascular collapse. Pain, redness, and swelling at the entry site indicate local infection. 22. What flush solution is recommended for intravenous catheters larger than 24 gauge? a. Saline b. Heparin c. Alteplase d. Heparin and saline combination ANS: A The recommended solution for flushing venous access devices is saline. The turbulent flow flush with saline is effective for catheters larger than 24 gauge. The use of heparin does not increase the longevity of the venous access device. In 24-gauge catheters, heparin may offer an advantage. Alteplase is used for treating catheter- related occlusions in children. The heparin and saline combination does not offer any advantage over saline or heparin individually. 23. The nurse is teaching a parent of a 10-year-old child who will be discharged with a venous access device (VAD). What statement by the parent indicates a correct understanding of the teaching? a. I should have my child wear a protective vest when my child wants to participate in contact sports. b. I should apply pressure to the entry site to the vein, not the exit site, if the VAD is accidentally removed. c. I can expect my child to have feelings of general malaise for 1 week after the VAD is inserted. d. I should give my child a sponge bath for the first 2 weeks after the VAD is inserted; then I can allow my child to take a bath. ANS: B The parents of a child with a VAD should be taught to apply pressure to the entry site to the vein, not the exit site, if the VAD is accidentally removed. The child should not participate in contact sports, even with a protective vest, to prevent the VAD from becoming dislodged. General malaise is a sign of an infection, not an expected finding after insertion of the VAD. The child can shower or take a bath after insertion of the VAD; the child does not need a sponge bath for any length of time. 24. What type of diarrhea is associated with an inflammation of the mucosa and submucosa in the ileum and colon caused by infectious agents? a. Osmotic b. Secretory c. Cytotoxic d. Dysenteric ANS: D Dysenteric diarrhea is associated with an inflammation of the mucosa and submucosa in the ileum and colon caused by infectious agents such as Campylobacter, Salmonella, or Shigella organisms. Edema, mucosal bleeding, and leukocyte infiltration occur. Osmotic diarrhea occurs when the intestine cannot absorb nutrients or electrolytes. It is commonly seen in malabsorption syndromes such as lactose intolerance. Secretory diarrhea is usually a result of bacterial enterotoxins that stimulate fluid and electrolyte secretion from the mucosal crypt cells, the principal secretory cells of the small intestine. Cytotoxic diarrhea is characterized by the viral destruction of the villi of the small intestine. This results in a smaller intestinal surface area, with a decreased capacity for fluid and electrolyte absorption. 25. What condition is often associated with severe diarrhea? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: A Metabolic acidosis results from the increased absorption of short-chain fatty acids produced in the colon. There is an increase in lactic acid from tissue hypoxia secondary to hypovolemia. Bicarbonate is lost through the stool. Ketosis results from fat metabolism when glycogen stores are depleted. Metabolic alkalosis and respiratory alkalosis do not occur from severe diarrhea. 26. What organism is a parasite that causes acute diarrhea? a. Shigella organisms b. Salmonella organisms c. Giardia lamblia d. Escherichia coli ANS: C G. lamblia is a parasite that represents 10% of nondysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens. 27. A school-age child with diarrhea has been rehydrated. The nurse is discussing the childs diet with the family. What food or beverage should be tolerated best? a. Clear fluids b. Carbonated drinks c. Applesauce and milk d. Easily digested foods ANS: D Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness. Clear fluids (e.g., fruit juices and gelatin) and carbonated drinks have high carbohydrate content and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. In some children, lactose intolerance will develop with diarrhea, and cows milk should be avoided in the recovery stage. 28. A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solutions (ORS). The childs mother calls the clinic nurse because he is also occasionally vomiting. The nurse should recommend which intervention? a. Bring the child to the hospital for intravenous fluids. b. Alternate giving ORS and carbonated drinks. c. Continue to give ORS frequently in small amounts. d. Keep child NPO (nothing by mouth) for 8 hours and resume ORS if vomiting has subsided. ANS: C Children who are vomiting should be given ORS at frequent intervals and in small amounts. Intravenous fluids are not indicated for mild dehydration. Carbonated beverages are high in carbohydrates and are not recommended for the treatment of diarrhea and vomiting. The child is not kept NPO because this would cause additional fluid losses. 29. A 7-year-old child with acute diarrhea has been rehydrated with oral rehydration solution (ORS). The nurse should recommend that the childs diet be advanced to what kind of diet? a. Regular diet b. Clear liquids c. High carbohydrate diet d. BRAT (bananas, rice, applesauce, and toast or tea) diet ANS: A It is appropriate to advance to a regular diet after ORS has been used to rehydrate the child. Clear liquids are not appropriate for hydration or afterward. A high carbohydrate diet may contribute to loose stools because of the low electrolyte content and high osmolality. The BRAT diet has little nutritional value and is high in carbohydrates. 30. What is the most frequent cause of hypovolemic shock in children? a. Sepsis b. Blood loss c. Anaphylaxis d. Heart failure ANS: B Blood loss is the most frequent cause of hypovolemic shock in children. Sepsis causes septic shock, which is overwhelming sepsis and circulating bacterial toxins. Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Heart failure contributes to hypervolemia, not hypovolemia. 31. What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy? a. Neurogenic shock b. Cardiogenic shock c. Hypovolemic shock d. Anaphylactic shock ANS: D Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission after a spinal cord injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure. 32. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock? a. Thirst b. Irritability c. Apprehension d. Confusion and somnolence ANS: D Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock. 33. The nurse suspects shock in a child 1 day after surgery. What should be the initial nursing action? a. Place the child on a cardiac monitor. b. Obtain arterial blood gases. c. Provide supplemental oxygen. d. Put the child in the Trendelenburg position. ANS: C The initial nursing action for a patient in shock is to establish ventilatory support. Oxygen is provided, and the nurse carefully observes for signs of respiratory failure, which indicates a need for intubation. Cardiac monitoring would be indicated to assess the childs status further, but ventilatory support comes first. Oxygen saturation monitoring should be begun. Arterial blood gases would be indicated if alternative methods of monitoring oxygen therapy were not available. The Trendelenburg position is not indicated and is detrimental to the child. The head-down position increases intracranial pressure and decreases diaphragmatic excursion and lung volume. 34. What explains physiologically the edema formation that occurs with burns? a. Vasoconstriction b. Reduced capillary permeability c. Increased capillary permeability d. Diminished hydrostatic pressure within capillaries ANS: C With a major burn, capillary permeability increases, allowing plasma proteins, fluids, and electrolytes to be lost into the interstitial space, causing edema. Maximum edema in a small wound occurs about 8 to 12 hours after injury. In larger injuries, the maximum edema may not occur until 18 to 24 hours later. Vasodilation occurs, causing an increase in hydrostatic pressure. 35. What is a systemic response to severe burns in a child? a. Metabolic alkalosis b. Decreased metabolic rate c. Increased renal plasma flow d. Abrupt drop in cardiac output ANS: D The initial physiologic response to a burn injury is a dramatic change in circulation. A precipitous drop in cardiac output precedes any change in circulating blood or plasma volumes. A circulating myocardial depressant factor associated with severe burn injury is thought to be the cause. Metabolic acidosis usually occurs secondary to the disruption of the bodys buffering action resulting from fluid shifting to extravascular space. There is a greatly accelerated metabolic rate in burn patients, supported by protein and lipid breakdown. With the loss of circulating volume, there is decreased renal blood flow and depressed glomerular filtration. 36. A child is admitted with extensive burns. The nurse notes burns on the childs lips and singed nasal hairs. The nurse should suspect what condition in the child? a. A chemical burn b. A hot-water scald c. An electrical burn d. An inhalation injury ANS: D Evidence of an inhalation injury includes burns of the face and lips, singed nasal hairs, and laryngeal edema. Clinical manifestations may be delayed for up to 24 hours. Chemical burns, electrical burns, and burns associated with hot-water scalds would not produce singed nasal hair. 37. What is the most immediate threat to life in children with thermal injuries? a. Shock b. Anemia c. Local infection d. Systemic sepsis ANS: A The immediate threat to life in children with thermal injuries is airway compromise and profound shock. Anemia is not of immediate concern. During the healing phase, local infection or sepsis is the primary complication. 38. After the acute stage and during the healing process, what is the primary complication from burn injury? a. Shock b. Asphyxia c. Infection d. Renal shutdown ANS: C During the healing phase, local infection or sepsis is the primary complication. Respiratory problems, primarily airway compromise, and shock are the primary complications during the acute stage of burn injury. Renal shutdown is not a complication of the burn injury but may be a result of the profound shock. 39. What sign is one of the first to indicate overwhelming sepsis in a child with burn injuries? a. Seizures b. Bradycardia c. Disorientation d. Decreased blood pressure ANS: C Disorientation in the burn patient is one of the first signs of overwhelming sepsis and may indicate inadequate hydration. Seizures, bradycardia, and decreased blood pressure are not initial manifestations of overwhelming sepsis. 40. A toddler sustains a minor burn on the hand from hot coffee. What is the first action in treating this burn? a. Apply burn ointment. b. Put ice on the burned area. c. Cover the hand with gauze dressing. d. Hold the hand under cool running water. ANS: D In minor burns, the best method to stop the burning process is to hold the burned area under cool running water. Ointments are not applied to a new burn; the ointment will contribute to the burning. Ice is not recommended. Gauze dressings do not stop the burning process. 41. What finding is the most reliable guide to the adequacy of fluid replacement for a small child with burns? a. Absence of thirst b. Falling hematocrit c. Increased seepage from burn wound d. Urinary output of 1 to 2 ml/kg of body weight/hr ANS: D Replacement fluid therapy is delivered to provide a urinary output of 30 ml/hr in older children or 1 to 2 ml/kg of body weight/hr for children weighing less than 30 kg (66 lb). Thirst is the result of a complex set of interactions and is not a reliable indicator of hydration. Thirst occurs late in dehydration. A falling hematocrit would be indicative of hemodilution. This may reflect fluid shifts and may not accurately represent fluid replacement therapy. Increased seepage from a burn wound would be indicative of increased output, not adequate hydration. 42. What is the purpose of a high-protein diet for a child with major burns? a. Promote growth b. Improve appetite c. Minimize protein breakdown d. Diminish risk of stress-induced hyperglycemia ANS: C Initially after major burns, there is a hypometabolic phase, which lasts for 2 or 3 days. A hypermetabolic phase follows, characterized by increased body temperature, oxygen and glucose consumption, carbon dioxide production, glycogenolysis, proteolysis, and lipolysis. This response continues for up to 9 months. A diet high in protein and calories is necessary. Healing, not growth, is the primary consideration. Many children have poor appetites, and supplementation is necessary. Hypoglycemia, not hyperglycemia, can occur from the stress of burn injury because the liver glycogen stores are rapidly depleted. 43. Fentanyl and midazolam (Versed) are given before dbridement of a childs burn wounds. What is the purpose of using these medications? a. Facilitate healing b. Provide pain relief c. Minimize risk of infection d. Decrease amount of dbridement needed ANS: B Partial-thickness burns require dbridement of devitalized tissue to promote healing. The procedure is painful and requires analgesia and sedation before the procedure. Fentanyl and midazolam provide excellent intravenous sedation and analgesia to control procedural pain in children with burns. 44. Hydrotherapy is required to treat a child with extensive partial-thickness burn wounds. What is the purpose of hydrotherapy? a. Provide pain relief b. Debride the wounds c. Destroy bacteria on the skin d. Increase peripheral blood flow ANS: B Soaking in a tub or showering once or twice a day acts to loosen and remove sloughing tissue, exudate, and topical medications. The hydrotherapy cleanses the wound and the entire body and helps maintain range of motion. Appropriate pain medications are necessary. Dressing changes are extremely painful. The total bacterial count of the skin is reduced by the hydrotherapy, but this is not the primary goal. There may be an increase in peripheral blood flow, but the primary purpose is for wound debridement. 45. What is the nursing action related to the applying of biologic or synthetic skin coverings for a child with partial-thickness burns of both legs? a. Splint the legs to prevent movement. b. Observe wounds for signs of infection. c. Monitor closely for manifestations of shock. d. Examine dressings for indications of bleeding. ANS: B When applied early to a superficial partial-thickness injury, biologic dressings stimulate epithelial growth and faster wound healing. If the dressing covers areas of heavy microbial contamination, infection occurs beneath the dressing. In the case of partial-thickness burns, such infection may convert the wound to a full-thickness injury. Infection is the primary concern when biologic dressings are used. 46. What is an effective strategy to reduce the stress of burn dressing procedures? a. Involve the child and give choices as feasible. b. Explain to the child why analgesics cannot be used. c. Reassure the child that dressing changes are not painful. d. Encourage the child to master stress with controlled passivity. ANS: A Children who have an understanding of the procedure and some perceived control demonstrate less maladaptive behavior. They respond well to participating in decisions and should be given as many choices as possible. Analgesia and sedation can and should be used. The dressing change procedure is very painful and stressful. Misinformation should not be given to the child. Encouraging the child to master stress with controlled passivity is not a positive coping strategy. 47. What consideration is important for the nurse when changing dressings and applying topical medication to a childs abdomen and leg burns? a. Apply topical medication with clean hands. b. Wash hands and forearms before and after dressing change. c. If dressings have adhered to the wound, soak in hot water before removal. d. Apply dressing so that movement is limited during the healing process. ANS: B Frequent hand and forearm washing is the single most important element of the infection-control program. Topical medications should be applied with a tongue blade or gloved hand. Dressings that have adhered to the wound can be removed with tepid water or normal saline. Dressings are applied with sufficient tension to remain in place but not so tightly as to impair circulation or limit motion. 48. What is a strategy used to minimize scarring with burn injury in a child? a. Applying of drying agents on skin b. Use of loose-fitting garments over healing areas c. Limitation of period without pressure to areas of scarring d. Immobilization of extremities while healing is occurring ANS: C Uniform pressure to the scar decreases the blood supply and forces the collagen into a more normal alignment. When pressure is removed, blood supply to the scar is immediately increased; therefore, periods without pressure should be brief to avoid nourishment of the hypertrophic tissue. Moisturizing agents are used with massage to help stretch tissue and prevent contractures. Compression garments, not loose-fitting garments, are indicated. Range of motion exercises are done to minimize contractures. 49. Prevention of burn injury is important anticipatory guidance. In the infant and toddler period, which mode is the most common cause of burn? a. Matches b. Electrical cords c. Hot liquids in the kitchen d. Microwave-heated foods ANS: C Infants and toddlers are most commonly injured by hot liquids in the kitchen and bathroom. This often occurs as a result of inadequate supervision of this curious and energetic age group. Matches and lighters are seen as toys by young children and should be kept out of reach. Older toddlers and preschool children are at risk of chewing on electrical cords and placing objects in outlets. Microwave-heated fluids and foods can become superheated, resulting in oral burns. 50. The nurse is teaching a group of female adolescents about toxic shock syndrome and the use of tampons. What statement by a participant indicates a need for additional teaching? a. I can alternate using a tampon and a sanitary napkin. b. I should wash my hands before inserting a tampon. c. I can use a superabsorbent tampon for more than 6 hours. d. I should call my health care provider if I suddenly develop a rash that looks like sunburn. ANS: C Teaching female adolescents about the association between toxic shock syndrome and the use of tampons is important. The teaching should include not using superabsorbent tampons; not leaving the tampon in for longer than 4 to 6 hours; alternating the use of tampons with sanitary napkins; washing hands before inserting a tampon to decrease the chance of introducing pathogens; and informing a health care provider if a sudden high fever, vomiting, muscle pain, dizziness, or a rash that looks like a sunburn appears. 51. The nurse is caring for an 18-month-old child with rotavirus. What clinical manifestations should the nurse expect to observe? a. Severe abdominal cramping and bloody diarrhea b. Mild fever and vomiting followed by onset of watery stools c. Colicky abdominal pain and vomiting d. High fever, diarrhea, and lethargy ANS: B Rotavirus is one of the most common pathogens that cause gastroenteritis in children younger than the age of 2 years. Clinical manifestations include mild to moderate fever and vomiting followed by the onset of watery stools. The fever and vomiting usually abate in 1 or 2 days, but the diarrhea persists for 5 to 7 days. Severe abdominal cramping and bloody diarrhea are seen with Escherichia coli infection; colicky abdominal pain and vomiting are seen with salmonella infection; and high fever, diarrhea, and lethargy are seen with infection by Salmonella typhi. MULTIPLE RESPONSE 1. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.) a. Tachypnea b. Oliguria c. Confusion d. Pale extremities e. Hypotension f. Thready pulse ANS: A, B, C, D As shock progresses, perfusion in the microcirculation becomes marginal despite compensatory adjustments, and the signs are more obvious. Signs include tachypnea, oliguria, confusion, and pale extremities, as well as decreased skin turgor and poor capillary filling. Hypotension and a thready pulse are clinical manifestations of irreversible shock. 2. In what condition should the nurse be alert for altered fluid requirements in children? (Select all that apply.) a. Oliguric renal failure b. Increased intracranial pressure c. Mechanical ventilation d. Compensated hypotension e. Tetralogy of Fallot f. Type 1 diabetes mellitus ANS: A, B, C The nurse should recognize that conditions such as oliguric renal failure, increased intracranial pressure, and mechanical ventilation can cause an increase or a decrease in fluid requirements. Conditions such as hypotension, tetralogy of Fallot, and diabetes mellitus (type 1) do not cause an alteration in fluid requirements. 3. What clinical manifestations should be observed in a 2-year-old child with hypotonic dehydration? (Select all that apply.) a. Thick, doughy feel to the skin b. Slightly moist mucous membranes c. Absent tears d. Very rapid pulse e. Hyperirritability ANS: B, C, D Clinical manifestations of hypotonic dehydration include slightly moist mucous membranes, absent tears, and a very rapid pulse. A thick, doughy feel to the skin and hyperirritability are signs of hypertonic dehydration. 4. The nurse is caring for a child with hypokalemia. The nurse evaluates the child for which signs and symptoms of hypokalemia? (Select all that apply.) a. Twitching b. Hypotension c. Hyperreflexia d. Muscle weakness e. Cardiac arrhythmias ANS: B, D, E Signs and symptoms of hypokalemia are hypotension, muscle weakness, and cardiac arrhythmias. Twitching and hyperreflexia are signs of hyperkalemia. 5. The nurse is caring for a child with hypercalcemia. The nurse evaluates the child for which signs and symptoms of hypercalcemia? (Select all that apply.) a. Tetany b. Anorexia c. Constipation d. Laryngospasm e. Muscle hypotonicity ANS: B, C, E Signs and symptoms of hypercalcemia are anorexia, constipation, and muscle hypotonicity. Tetany and laryngospasm are signs of hypocalcemia. 6. The nurse is caring for a child with hypernatremia. The nurse evaluates the child for which signs and symptoms of hypernatremia? (Select all that apply.) a. Apathy b. Lethargy c. Oliguria d. Intense thirst e. Dry, sticky mucus ANS: B, C, E Signs and symptoms of hypernatremia are nausea; oliguria; and dry, sticky mucus. Apathy and lethargy are signs of hyponatremia. COMPLETION 1. A health care provider prescribes dopamine (Intropin), 5 mcg/kg/min in a continuous intravenous (IV) infusion for a child in shock. The child weighs 25 kg. The medication is available as dopamine 400 mg in 250 ml. The nurse prepares to calculate the rate. How many milliliters per hour will the nurse set the IV infusion pump to deliver 5 mcg/kg/min? Fill in the blank. Round to one decimal place. ANS:4.7 ml/hr 2. A health care provider prescribes diphenhydramine (Benadryl), 1 mg/kg PO every 4 to 6 hours as needed for pruritus to a child with a mild cutaneous anaphylactic reaction. The child weighs 5 kg. The medication label states: Diphenhydramine 12.5 mg/5 ml. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number. ANS: 2 ml 3. A health care provider prescribes nitroprusside (Nipride), 1 mcg/kg/min in a continuous intravenous (IV) infusion for a child in shock. The child weighs 20 kg. The medication is available as nitroprusside 50 mg in 250 ml. The nurse prepares to calculate the rate. How many milliliters per hour will the nurse set the IV infusion pump to deliver 1 mcg/kg/min? Fill in the blank. Record your answer in a whole number. ANS: 6 ml/hr 4. A health care provider prescribes midazolam (Versed) syrup 0.5 mg/kg per mouth (PO) 30 minutes before a burn wound dressing change on a child. The medication label states: Versed 2 mg/1 ml. The child weighs 8 kg. The nurse prepares to administer the dose. How many milliliters will the nurse prepare to administer the dose? Fill in the blank. Record your answer in a whole number. ANS: 2 ml MATCHING Match the type of skin graft to its definition. a. Allografts- Skin that is obtained from genetically different members of the same species who are free of disease b. Xenografts- Skin that is obtained from members of a different species, primarily pigskin c. Autografts- Tissue obtained from undamaged areas of the patients own body d. Isografts- Histocompatible tissue obtained from genetically identical individuals 1. Tissue obtained from undamaged areas of the patients own body- c. Autografts 2. Histocompatible tissue obtained from genetically identical individuals- d. Isografts 3. Skin that is obtained from genetically different members of the same species who are free of disease- a. Allografts 4. Skin that is obtained from members of a different species, primarily pigskin- b. Xenografts Chapter 24: The Child with Renal Dysfunction MULTIPLE CHOICE 1. Urinary tract anomalies are frequently associated with what irregularities in fetal development? a. Myelomeningocele b. Cardiovascular anomalies c. Malformed or low-set ears d. Defects in lower extremities ANS: C Although unexplained, there is a frequent association between malformed or low-set ears and urinary tract anomalies. During the newborn examination, the nurse should have a high suspicion about urinary tract structure and function if ear anomalies are present. Children who have myelomeningocele may have impaired urinary tract function secondary to the neural defect. When other congenital defects are present, there is an increased likelihood of other issues with other body systems. Cardiac and extremity defects do not have a strong association with renal anomalies. 2. What urine test result is considered abnormal? a. pH 4.0 b. WBC 1 or 2 cells/ml c. Protein level absent d. Specific gravity 1.020 ANS: A The expected pH ranges from 4.8 to 7.8. A pH of 4.0 can be indicative of urinary tract infection or metabolic alkalosis or acidosis. Less than 1 or 2 white blood cells per milliliter is the expected range. The absence of protein is expected. The presence of protein can be indicative of glomerular disease. A specific gravity of 1.020 is within the anticipated range of 1.001 to 1.030. Specific gravity reflects level of hydration in addition to renal disorders and hormonal control such as antidiuretic hormone. 3. What diagnostic test allows visualization of renal parenchyma and renal pelvis without exposure to external-beam radiation or radioactive isotopes? a. Renal ultrasonography b. Computed tomography c. Intravenous pyelography d. Voiding cystourethrography ANS: A The transmission of ultrasonic waves through the renal parenchyma allows visualization of the renal parenchyma and renal pelvis without exposure to external- beam radiation or radioactive isotopes. Computed tomography uses external radiation, and sometimes contrast media are used. Intravenous pyelography uses contrast medium and external radiation for radiography. Contrast medium is injected into the bladder through the urethral opening. External radiation for radiography is used before, during, and after voiding in voiding cystourethrography. 4. What name is given to inflammation of the bladder? a. Cystitis b. Urethritis c. Urosepsis d. Bacteriuria ANS: A Cystitis is an inflammation of the bladder. Urethritis is an inflammation of the urethra. Urosepsis is a febrile urinary tract infection with systemic signs of bacterial infection. Bacteriuria is the presence of bacteria in the urine. 5. The nurse is teaching a client to prevent future urinary tract infections (UTIs). What factor is most important to emphasize as the potential cause? a. Poor hygiene b. Constipation c. Urinary stasis d. Congenital anomalies ANS: C Urinary stasis is the single most important host factor that influences the development of UTIs. Urine is usually sterile but at body temperature provides an excellent growth medium for bacteria. Poor hygiene can be a contributing cause, especially in females because their short urethras predispose them to UTIs. Urinary stasis then provides a growth medium for the bacteria. Intermittent constipation contributes to urinary stasis. A full rectum displaces the bladder and posterior urethra in the fixed and limited space of the bony pelvis, causing obstruction, incomplete micturition, and urinary stasis. Congenital anomalies can contribute to UTIs, but urinary stasis is the primary factor in many cases. 6. A girl, age 5 1/2 years, has been sent to the school nurse for urinary incontinence three times in the past 2 days. The nurse should recommend to her parent that the first action is to have the child evaluated for what condition? a. School phobia b. Glomerulonephritis c. Urinary tract infection (UTI) d. Attention deficit hyperactivity disorder (ADHD) ANS: C Girls between the ages of 2 and 6 years are considered high risk for UTIs. This child is showing signs of a UTI, including incontinence in a toilet-trained child and possible urinary frequency or urgency. A physiologic cause should be ruled out before psychosocial factors are investigated. Glomerulonephritis usually manifests with decreased urinary output and fluid retention. ADHD can contribute to urinary incontinence because the child is distracted, but the first manifestation was incontinence, not distractibility. 7. What recommendation should the nurse make to prevent urinary tract infections (UTIs) in young girls? a. Avoid public toilet facilities. b. Limit long baths as much as possible. c. Cleanse the perineum with water after voiding. d. Ensure clear liquid intake of 2 L/day. ANS: D Adequate fluid intake minimizes urinary stasis. The recommended fluid intake is 50 ml/kg or 100 ml/lb per day. The average 5- to 6-year-old weighs approximately 18 kg (40 lb), so she should drink 2 L/day of fluid. There is no evidence that using public toilet facilities increases UTIs. Long baths are not associated with increased UTIs. Proper hand washing and perineal cleansing are important, but no evidence exists that these decrease UTIs in young girls. 8. In teaching the parent of a newly diagnosed 2-year-old child with pyelonephritis related to vesicoureteral reflux (VUR), the nurse should include which information? a. Limit fluids to reduce reflux. b. Give cranberry juice twice a day. c. Have siblings examined for VUR. d. Surgery is indicated to reverse scarring. ANS: C Siblings are at high risk for VUR. The incidence of reflux in siblings is approximately 36%. The other children should be screened for early detection and to potentially reduce scarring. Fluids are not reduced. The efficacy of cranberry juice in reducing infection in children has not been established. Surgery may be necessary for higher grades of VUR, but the scarring is not reversible. 9. What pathologic process is believed to be responsible for the development of postinfectious glomerulonephritis? a. Infarction of renal vessels b. Immune complex formation and glomerular deposition c. Bacterial endotoxin deposition on and destruction of glomeruli d. Embolization of glomeruli by bacteria and fibrin from endocardial vegetation ANS: B After a streptococcal infection, antibodies are formed, and immune-complex reaction occurs. The immune complexes are trapped in the glomerular capillary loop. Infarction of renal vessels occurs in renal involvement in sickle cell disease. Bacterial endotoxin deposition on and destruction of glomeruli is not a mechanism for postinfectious glomerulonephritis. Embolization of glomeruli by bacteria and fibrin from endocardial vegetation is the pathology of renal involvement with bacterial endocarditis. 10. The nurse notes that a child has lost 3.6 kg (8 lb) after 4 days of hospitalization for acute glomerulonephritis. What is the most likely cause of this weight loss? a. Poor appetite b. Reduction of edema c. Restriction to bed rest d. Increased potassium intake ANS: B This amount of weight loss in this period is a result of the improvement of renal function and mobilization of edema fluid. Poor appetite and bed rest would not result in a weight loss of 8 lb in 4 days. Foods with substantial amounts of potassium are avoided until renal function is normalized. 11. What measure of fluid balance status is most useful in a child with acute glomerulonephritis? a. Proteinuria b. Daily weight c. Specific gravity d. Intake and output ANS: B A record of daily weight is the most useful means to assess fluid balance and should be kept for children treated at home or in the hospital. Proteinuria does not provide information about fluid balance. Specific gravity does not accurately reflect fluid balance in acute glomerulonephritis. If fluid is being retained, the excess fluid will not be included. Also proteinuria and hematuria affect specific gravity. Intake and output can be useful but are not considered as accurate as daily weights. In children who are not toilet trained, measuring output is more difficult. 12. The parent of a child hospitalized with acute glomerulonephritis asks the nurse why blood pressure readings are being taken so often. What knowledge should influence the nurses reply? a. The antibiotic therapy contributes to labile blood pressure values. b. Hypotension leading to sudden shock can develop at any time. c. Acute hypertension is a concern that requires monitoring. d. Blood pressure fluctuations indicate that the condition has become chronic. ANS: C Blood pressure monitoring is essential to identify acute hypertension, which is treated aggressively. Antibiotic therapy is usually not indicated for glomerulonephritis. Hypertension, not hypotension, is a concern in glomerulonephritis. Blood pressure control is essential to prevent further renal damage. Blood pressure fluctuations do not provide information about the chronicity of the disease. 13. What laboratory finding, in conjunction with the presenting symptoms, indicates minimal change nephrotic syndrome? a. Low specific gravity b. Decreased hemoglobin c. Normal platelet count d. Reduced serum albumin ANS: D Total serum protein concentrations are reduced, with the albumin fractions significantly reduced. Specific gravity is high and proportionate to the amount of protein in the urine. Hemoglobin and hematocrit are usually normal or elevated. The platelet count is elevated as a result of hemoconcentration. 14. What is the primary objective of care for the child with minimal change nephrotic syndrome (MCNS)? a. Reduce blood pressure. b. Lower serum protein levels. c. Minimize excretion of urinary protein. d. Increase the ability of tissue to retain fluid. ANS: C The objectives of therapy for the child with MCNS include reducing the excretion of urinary protein, reducing fluid retention, preventing infection, and minimizing complications associated with therapy. Blood pressure is usually not elevated in minimal change nephrotic syndrome. Serum protein levels are already reduced as part of the disease process. This needs to be reversed. The tissue is already retaining fluid as part of the edema. The goal of therapy is to reduce edema. 15. A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. What nursing goal is appropriate for this child? a. Stimulate appetite. b. Detect evidence of edema. c. Minimize risk of infection. d. Promote adherence to the antibiotic regimen. ANS: C High-dose steroid therapy has an immunosuppressant effect. These children are particularly vulnerable to upper respiratory tract infections. A priority nursing goal is to minimize the risk of infection by protecting the child from contact with infectious individuals. Appetite is increased with prednisone therapy. The amount of edema should be monitored as part of the disease process, not necessarily related to the administration of prednisone. Antibiotics would not be used as prophylaxis. 16. The nurse is teaching a child experiencing severe edema associated with minimal change nephrotic syndrome about his diet. The nurse should discuss what dietary need? a. Consuming a regular diet b. Increasing protein c. Restricting fluids d. Decreasing calories ANS: C During the edematous stage of active nephrosis, the child has restricted fluid and sodium intake. As the edema subsides, the child is placed on a diet with increased salt and fluids. A regular diet is not indicated. There is no evidence that a diet high in protein is beneficial or has an effect on the course of the disease. Calories sufficient for growth and tissue healing are essential. With the child having little appetite and the fluid and salt restrictions, achieving adequate nutrition is difficult. 17. A child is admitted for minimal change nephrotic syndrome (MCNS). The nurse recognizes that the childs prognosis is related to what factor? a. Admission blood pressure b. Creatinine clearance c. Amount of protein in urine d. Response to steroid therapy ANS: D Corticosteroids are the drugs of choice for MCNS. If the child has not responded to therapy within 28 days of daily steroid administration, the likelihood of subsequent response decreases. Blood pressure is normal or low in MCNS. It is not correlated with prognosis. Creatinine clearance is not correlated with prognosis. The presence of significant proteinuria is used for diagnosis. It is not predictive of prognosis. 18. A 12-year-old child is injured in a bicycle accident. When considering the possibility of renal trauma, the nurse should consider what factor? a. Flank pain rarely occurs in children with renal injuries. b. Few nonpenetrating injuries cause renal trauma in children. c. Kidneys are immobile, well protected, and rarely injured in children. d. The amount of hematuria is not a reliable indicator of the seriousness of renal injury. ANS: D Hematuria is consistently present with renal trauma. It does not provide a reliable indicator of the seriousness of the renal injury. Flank pain results from bleeding around the kidney. Most injuries that cause renal trauma in children are of the nonpenetrating or blunt type and usually involve falls, athletic injuries, and motor vehicle accidents. In children, the kidneys are more mobile, and the outer borders are less protected than in adults. 19. What condition is the most common cause of acute renal failure in children? a. Pyelonephritis b. Tubular destruction c. Severe dehydration d. Upper tract obstruction ANS: C The most common cause of acute renal failure in children is dehydration or other causes of poor perfusion that may respond to restoration of fluid volume. Pyelonephritis and tubular destruction are not common causes of acute renal failure. Obstructive uropathy may cause acute renal failure, but it is not the most common cause. 20. A child is admitted in acute renal failure (ARF). Therapeutic management to rapidly provoke a flow of urine includes the administration of what medication? a. Propranolol (Inderal) b. Calcium gluconate c. Mannitol (Osmitrol) or furosemide (Lasix) (or both) d. Sodium, chloride, and potassium ANS: C In ARF, if hydration is adequate, mannitol or furosemide (or both) is administered to provoke a flow of urine. If glomerular function is intact, an osmotic diuresis will occur. Propranolol is a beta-blocker; it will not produce a rapid flow of urine in ARF. Calcium gluconate is administered for its protective cardiac effect when hyperkalemia exists. It does not affect diuresis. Electrolyte measurements must be done before administration of sodium, chloride, or potassium. These substances are not given unless there are other large, ongoing losses. In the absence of urine production, potassium levels may be elevated, and additional potassium can cause cardiac dysrhythmias. 21. What major complication is associated with a child with chronic renal failure? a. Hypokalemia b. Metabolic alkalosis c. Water and sodium retention d. Excessive excretion of blood urea nitrogen ANS: C Chronic renal failure leads to water and sodium retention, which contributes to edema and vascular congestion. Hyperkalemia, metabolic acidosis, and retention of blood urea nitrogen are complications of chronic renal failure. 22. What diet is most appropriate for the child with chronic renal failure (CRF)? a. Low in protein b. Low in vitamin D c. Low in phosphorus d. Supplemented with vitamins A, E, and K ANS: C Dietary phosphorus may need to be restricted by limiting protein and milk intake. Substances that bind phosphorus are given with meals to prevent its absorption, which enables a more liberal intake of phosphorus-containing protein. Protein is limited to the recommended daily allowance for the childs age. Further restriction is thought to negatively affect growth and neurodevelopment. Vitamin D therapy is administered in children with CRF to increase calcium absorption. Supplementation of vitamins A, E, and K, beyond normal dietary intake, is not advised in children with CRF. These fat-soluble vitamins can accumulate. 23. What nursing consideration is most important when caring for a child with end-stage renal disease (ESRD)? a. Children with ESRD usually adapt well to minor inconveniences of treatment. b. Children with ESRD require extensive support until they outgrow the condition. c. Multiple stresses are placed on children with ESRD and their families until the illness is cured. d. Multiple stresses are placed on children with ESRD and their families because childrens lives are maintained by drugs and artificial means. ANS: D Stressors on the family are often overwhelming because of the progressive deterioration. The child progresses from renal insufficiency to uremia to dialysis and transplantation, each of which requires intensive therapy and supportive care. The treatment of ESRD is intense and requires multiple examinations, dietary restrictions, and medications. Adherence to the regimen is often difficult for children and families because of the progressive nature of the renal failure. ESRD has an unrelenting course that has no known cure. Children do not outgrow the renal failure. 24. The nurse is caring for an adolescent who has just started dialysis. The child always seems angry, hostile, or depressed. The nurse should recognize that this is most likely related to what underlying cause? a. Physiologic manifestations of renal disease b. The fact that adolescents have few coping mechanisms c. Neurologic manifestations that occur with dialysis d. Resentment of the control and enforced dependence imposed by dialysis ANS: D Older children and adolescents need to feel in control. Dialysis forces the adolescent into a dependent relationship, which results in these behaviors. Being angry, hostile, or depressed are functions of the age of the child, not neurologic or physiologic manifestations of the dialysis. 25. What statement is an advantage of peritoneal dialysis compared with hemodialysis? a. Protein loss is less extensive. b. Dietary limitations are not necessary. c. It is easy to learn and safe to perform. d. It is needed less frequently than hemodialysis. ANS: C Peritoneal dialysis is the preferred form of dialysis for parents, infants, and children who wish to remain independent. Parents and older children can perform the treatments themselves. Protein loss is not significantly different. The dietary limitations are necessary, but they are not as stringent as those for hemodialysis. Treatments are needed more frequently but can be done at home. 26. What statement is descriptive of renal transplantation in children? a. It is an acceptable means of treatment after age 10 years. b. Children can receive kidneys only from other children. c. It is the preferred means of renal replacement therapy in children. d. The decision for transplantation is difficult because a relatively normal lifestyle is not possible. ANS: C Renal transplantation offers the opportunity for a relatively normal life and is the preferred means of renal replacement therapy in end-stage renal disease. It can be done in children as young as age 6 months. Both children and adults can serve as donors for renal transplant purposes. Renal transplantation affords the child a more normal lifestyle than dependence on dialysis. 27. The nurse is conducting discharge teaching with the parent of a 7-year-old child with minimal change nephrotic syndrome (MCNS). What statement by the parent indicates a correct understanding of the teaching? a. My child needs to stay home from school for at least 1 more month. b. I should not add additional salt to any of my childs meals. c. My child will not be able to participate in contact sports while receiving corticosteroid therapy. d. I should measure my childs urine after each void and report the 24-hour amount to the health care provider. ANS: B Children with MCNS can be treated at home after the initial phase with appropriate discharge instructions, including a salt restriction of no additional salt to the childs meals. The child may return to school but should avoid exposure to infected playmates. Participation in contact sports is not affected by corticosteroid therapy. The parent does not need to measure the childs urine on a daily basis but may be instructed to test for albumin. 28. What is the narrowing of preputial opening of foreskin called? a. Chordee b. Phimosis c. Epispadias d. Hypospadias ANS: B Phimosis is the narrowing or stenosis of the preputial opening of the foreskin. Chordee is the ventral curvature of the penis. Epispadias is the meatal opening on the dorsal surface of the penis. Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis. 29. Identification and treatment of cryptorchid testes should be done by age 2 years. What is an important consideration? a. Medical therapy is not effective after this age. b. Treatment is necessary to maintain the ability to be fertile when older. c. The younger child can tolerate the extensive surgery needed. d. Sexual reassignment may be necessary if treatment is not successful. ANS: B The longer the testis is exposed to higher body heat, the greater the likelihood of damage. To preserve fertility, surgery should be done at an early age. Surgical intervention is the treatment of choice. Simple orchiopexy is usually performed as an outpatient procedure. The surgical procedure restores the testes to the scrotum. This helps the boy to have both testes in the scrotum by school age. Sexual reassignment is not indicated when the testes are not descended. 30. Congenital defects of the genitourinary tract, such as hypospadias, are usually repaired as early as possible to accomplish what? a. Minimize separation anxiety. b. Prevent urinary complications. c. Increase acceptance of hospitalization. d. Promote development of normal body image. ANS: D Promoting development of normal body image is extremely important. Surgery involving sexual organs can be upsetting to children, especially preschoolers, who fear mutilation and castration. Proper preprocedure preparation can facilitate coping with these issues. Preventing urinary complications is important for defects that affect function, but for all external defects, repair should be done as soon as possible. 31. The parents of a 2-year-old boy who had a repair of exstrophy of the bladder at birth ask when they can begin toilet training their son. The nurse replies based on what knowledge? a. Most boys in the United States can be toilet trained at age 3 years. b. Training can begin when he has sufficient bladder capacity. c. Additional surgery may be necessary to achieve continence. d. They should begin now because he will require additional time. ANS: C After repair of the bladder exstrophy, the childs bladder is allowed to increase capacity. Several surgical procedures may be necessary to create a urethral sphincter mechanism to aid in urination and ejaculation. With the lack of a urinary sphincter, toilet training is unlikely. The child cannot hold the urine in the bladder. Bladder capacity is one component of continence. A functional sphincter is also needed. 32. An infant has been diagnosed with bladder obstruction. What do symptoms of this disorder include? a. Renal colic b. Strong urinary stream c. Urinary tract infections d. Posturination dribbling ANS: D Symptoms of bladder obstruction include poor force of urinary stream, intermittency of voided stream, feelings of incomplete bladder emptying, and posturination dribbling. They may also include urinary frequency, nocturia, nocturnal enuresis, and urgency. Renal colic is a symptom of upper urinary tract obstruction. Children with bladder obstruction have a weak urinary stream. Urinary tract infections are not associated with bladder obstruction. 33. The parents of a child born with ambiguous genitalia tell the nurse that family and friends are asking what caused the baby to be this way. Tests are being done to assist in gender assignment. What should the nurses intervention include? a. Explain the disorder so they can explain it to others. b. Help parents understand that this is a minor problem. c. Suggest that parents avoid family and friends until the gender is assigned. d. Encourage parents not to worry while the tests are being done. ANS: A Explaining the disorder to parents so they can explain it to others is the most therapeutic approach while the parents awa