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Focus on Child Health Exam.
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Focus on Child Health Exam.Focus on Child Health Exam
1.
An HIV-positive woman delivers an infant. The pediatrician prescribes testing for the newborn,
and the nurse prepares for which action?
A. Ask the laboratory to perform virologic testing Correct
B. Obtain blood from the umbilical cord to send to the laboratory
C. Perform a heelstick to obtain a specimen for a Western blot assay
D. Perform a fingerstick to obtain a specimen for an enzyme-linked immunosorbent
assay (ELISA)
Rationale: Traditional HIV antibody measurement by ELISA or Western-blot assay is not
accurate in infants younger than 18 months because of the persistence of maternal antibodies.
Because of the potential for maternal contamination during delivery, umbilical cord blood
should not be used for testing. HIV-exposed infants should undergo virologic testing within 48
hours of birth and follow-up testing, depending on the initial results.
Test-Taking Strategy: Focus on the subject, newborn infant exposed to HIV. Recalling that the
ELISA and Western blot assay are not accurate in an infant younger than 18 months will assist
you in eliminating these options. Next eliminate the option involving cord blood, knowing that
such blood could be contaminated.
Review: tests for HIV in newborn
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Child Health—Infectious Diseases
Giddens Concepts: Immunity, Infection
HESI Concepts: Immunity, Infection
Awarded 98.0 points out of 98.0 possible points.
2.
A nurse providing home care instructions to a mother of a HIV-positive child discusses
measures to prevent transmission of the virus. Which statement by the mother indicates a need
for further instruction?
A. “I won’t let my children share toothbrushes.”
B. “I’ll wash up blood spills with soap and hot water and allow them to
air dry.” Correct
C. “I’ll wash my hands with soap and water if I touch any blood from my child.”
D. “I’ll rinse bloodstained clothing with hydrogen peroxide and then wash it as
usual.”
Rationale: The correct method of cleaning up blood spills is to wash the area with soap and
water, rinse with bleach, and let the area air dry. The remaining statements by the mother reflect
correct measures to prevent transmission of the virus.
Test-Taking Strategy: Focus on the subject, transmission of HIV virus. Note the strategic
words “need for further instruction,” which indicates a negative event query and the need to
select the incorrect statement. Recalling that blood spills must be cleaned with a 1:10
,Focus on Child Health Exam.
bleach/water solution will direct you to the correct option.
Review: home care measures for HIV
Level of Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Child Health—Infectious Diseases
Giddens Concepts: Client Education, Infection
HESI Concepts: Infection, Teaching and Learning/Patient Education
Awarded 98.0 points out of 98.0 possible points.
3.
A child has been in the hospital for several days for treatment of severe vomiting related to his
HIV-positive status. Which assessment finding is the best indication that the child’s condition is
improving?
A. No lesions in the mouth and throat
B. Weight increase of 1 lb (0.45 kg) over 3 days Correct
C. Temperature change from 100.2° F to 99.2° F (37.3°C)
D. Capillary refill slowing from 2 seconds to 3 seconds
Rationale: Vomiting results in fluid volume deficit. The most accurate method of evaluating
fluid volume increase (the desired outcome) is weight. A temperature decrease is not reflective
of fluid volume increase. Increasing capillary refill time is indicative of a fluid volume
decrease, not an increase. The absence of mouth ulcers would allow the child to drink without
pain but does not reflect a fluid volume increase.
Test-Taking Strategy: Note the data in the question and the strategic word best, and
remember that the child is experiencing severe vomiting. Use the process of elimination and
focus on the subject, an assessment finding indicating fluid volume increase. The correct option
is the only one related to fluid volume.
Review: child with HIV and severe vomiting
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Child Health—Infectious Diseases
Giddens Concepts: Fluid and Electrolytes, Evidence
HESI Concepts: Evidence-Based Practice/Evidence, Fluids and Electrolytes
Awarded 98.0 points out of 98.0 possible points.
4.
A girl with systemic lupus erythematosus (SLE) wants to go to the beach with her friends on the
day after their junior prom. The girl asks the nurse for guidance regarding sun exposure. The
nurse should provide which information to the girl?
A. She cannot be exposed to any sunlight at all
B. She must bring a beach umbrella and remain under it all day
C. Waterproof sunscreen with a minimum sun protection factor (SPF) of 15 is
a necessity Correct
,Focus on Child Health Exam.
D. It is all right to go to the beach as long as she wears sunglasses, a sun hat, and
clothes that cover her entire body
Rationale: SLE, a chronic multi-system autoimmune disease characterized by inflammation of
the connective tissue, varies in severity and is marked by remissions and exacerbations.
Although the origin of SLE is not known, genetic, environmental, hormonal, and immune
response factors are likely responsible. These factors include exposure to sun and other UV
light, stress, fatigue, viruses, bacteria, certain medications, and some food additives. Avoiding
triggers that set off exacerbation is essential, so wearing appropriate sunscreen is a necessity.
The sunscreen should contain an SPF higher than 15 and should be waterproof. The remaining
options present incorrect information.
Test-Taking Strategy: Focus on the subject, girl with SLE. Eliminate the options that
are comparable or alike in that they indicate that exposure to sunlight must be avoided. Also,
noting the close-ended words “cannot” and “must” will help you eliminate these options.
Review: preventing exacerbation of SLE
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Safety
Giddens Concepts: Client Education, Immunity
HESI Concepts: Immunmity, Teaching and Learning/Patient Education
Awarded 98.0 points out of 98.0 possible points.
5.
A nurse is monitoring a school-age child who is being treated for dehydration. The nurse notes
that the child’s urine output has been 1 mL/kg/hr over the past 3 hours and that the specific
gravity of the urine is 1.020. Which is the appropriate nursing action?
A. Contact the pediatrician
B. Document the findings Correct
C. Encourage the child to drink more fluids
D. Increase the rate of flow of the intravenous (IV) solution
Rationale: The appropriate nursing action is for the nurse to document the findings, because
they are normal. Urine output of less than 2 to 3 mL/kg/hr in infants and toddlers, 1 to 2
mL/kg/hr in preschoolers and young school-age children, and 0.5 to 1 mL/kg/hr in school-age
children or adolescents indicates dehydration. A specific gravity of the urine above 1.020 may
indicate dehydration.
Test-Taking Strategy: Focus on the subject, child with dehydration. Note the data in the
question, and the strategic word “appropriate”. This indicates the best action by the nurse.
Eliminate the options that indicate the need to implement additional treatment. Additionally,
note that these options indicate increasing fluid intake. Remember also that the nurse would not
increase the rate of IV fluids without a pediatrician’s prescription to do so.
Review: urine output and specific gravity in school-age child
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
, Focus on Child Health Exam.
Content Area: Fluids and Electrolytes
Giddens Concepts: Clinical Judgment, Fluid and Electrolytes
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluid and Electrolytes
Awarded 98.0 points out of 98.0 possible points.
6.
Intravenous potassium chloride (KCL) in 0.9% sodium chloride solution has been prescribed
for a child who is severely dehydrated. Before administering the solution, the nurse must take
which priority action?
A. Check urine output Correct
B. Evaluate skin turgor
C. Measure capillary refill
D. Obtain the child’s blood pressure
Rationale: The nurse’s priority action is to check the child’s urine output. Potassium chloride
is not administered if the urine output is not adequate. If the child is anuric, potassium will be
retained, causing an increased potassium level. Although skin turgor, capillary refill, and blood
pressure may be checked, they are not essential assessments in this situation.
Test-Taking Strategy: Focus on the subject, severely dehydrated child to receive intravenous
solution of KCL. Note the strategic word“priority.” Eliminate the options that refer to clinical
signs/symptoms of dehydration — skin turgor and capillary refill. Focus on what the question is
asking about the administration of a particular solution.
Review: IV potassium chloride
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Intravenous Therapy
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety
Awarded 98.0 points out of 98.0 possible points.
7.
A nurse is monitoring a 3-year-old with diarrhea for signs/symptoms of dehydration. The child
now weighs 42 lb (19 kg), a decrease from his weight of 44 lb (20 kg) 24 hours ago. In addition
to dry mucous membranes and lack of tears, what assessment finding would the nurse find?
A. Decreased heart rate
B. Bilateral 1+ pedal pulses Correct
C. Increased blood pressure
D. Urine output of 80 mL in the last 3 hours
Rationale: The assessment finding the nurse would expect to find in the child with dehydration
is a bilateral 1+ pedal pulse that is difficult to palpate, weak, and thready. The minimum urine
output for a child is 1 mL/kg/hour. The child weighs 42 lb, or 19 kg, so 80 mL in the last 4
hours is within the minimum range. A child with dehydration will have a rapid, weak, thready
pulse. Blood pressure may be decreased in moderate and severe dehydration, but it is a late sign
of hypovolemia.
Test-Taking Strategy: Focus on the subject, signs/symptoms of dehydration. Thinking about
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