IHockenberry & Wilson: Wong’s Essentials of Pediatric Nursing,
8th Edition
Pub Review
Chapter 24: The Child with Gastrointestinal Dysfunction
MULTIPLE CHOICE
1.
Nurses must be alert for increased fluid requirements when a child has which of the
following?
a Fever
.
b Mechanical ventilation
.
c Congestive heart failure
.
d Increased intracranial pressure (ICP)
.
ANS: A
Fever leads to great insensible fluid loss in young children because of increased body surface area
relative to fluid volume.
DIF: Cognitive Level: Comprehension REF: Page 814
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2.
Melena, the passage of black, tarry stools, suggests bleeding from:
perianal or rectal area.
a
.
b hemorrhoids or anal fissures.
.
c upper gastrointestinal (GI) tract.
.
d lower GI tract.
.
ANS: C
Melena is denatured blood from the upper GI tract or bleeding from the right colon.
DIF: Cognitive Level: Comprehension REF: Page 815
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
What type of dehydration is defined as “dehydration that occurs in conditions in which
electrolyte and water deficits are present in approximately balanced proportion”?
a Isotonic dehydration
3.
.
b Hypotonic dehydration
.
c Hypertonic dehydration
.
d All types of dehydration in infants and small children
.
ANS: A
Isotonic dehydration is the correct term for this definition and is the most frequent form of
dehydration in children.
DIF: Cognitive Level: Comprehension REF: Page 816
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4.
Which of the following types of dehydration results from water loss in excess of electrolyte
loss?
a Isotonic dehydration
.
b Isosmotic dehydration
.
c Hypotonic dehydration
.
d Hypertonic dehydration
.
ANS: D
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.
DIF: Cognitive Level: Comprehension REF: Page 816
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
5.
An infant is brought to the emergency department with poor skin turgor, weight loss,
lethargy, and tachycardia. This is suggestive of which of the following?
a Overhydration
.
b Dehydration
.
c Sodium excess
.
d Potassium excess
.
ANS: B
These clinical manifestations indicate dehydration.
DIF: Cognitive Level: Comprehension REF: Page 816
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6.
Acute diarrhea is often caused by which of the following?
Celiac disease
a
.
b Antibiotic therapy
.
c Immunodeficiency
.
d Protein malnutrition
.
ANS: B
Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be
associated with antibiotic therapy.
DIF: Cognitive Level: Comprehension REF: Page 817
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
7.
Which of the following is the viral pathogen that frequently causes acute diarrhea in young
children?
a Giardia organisms
.
b Shigella organisms
.
c Rotavirus
.
d Salmonella organisms
.
ANS: C
Rotavirus is the most frequent viral pathogen that causes diarrhea in young children.
DIF: Cognitive Level: Comprehension REF: Page 818
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8.
Which of the following is a parasite that causes acute diarrhea?
Shigella organisms
a
.
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.
DIF: Cognitive Level: Comprehension REF: Page 820
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9.
A stool specimen from a child with diarrhea shows the presence of neutrophils and red blood
cells. This is most suggestive of which of the following conditions?
a Protein intolerance
.
b Parasitic infection
.
c Fat malabsorption
.
d Bacterial gastroenteritis
.
ANS: D
Neutrophils and red blood cells in stool indicate bacterial gastroenteritis.
DIF: Cognitive Level: Comprehension REF: Page 821
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
10.
Therapeutic management of the child with acute diarrhea and dehydration usually begins
with which of the following?
a Clear liquids
.
b Adsorbents, such as kaolin and pectin
.
c Oral rehydration solution (ORS)
.
d Antidiarrheal medications such as paregoric
.
ANS: C
ORS is the first treatment for acute diarrhea.
DIF: Cognitive Level: Comprehension REF: Page 821
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
11.
A school-age child with diarrhea has been rehydrated. The nurse is discussing the child’s diet
with the family. Which of the following statement by the parent would indicate a correct
understanding of the teaching?
a “I will keep my child on a clear liquid diet for the next 24 hours.”
.
b
.
c
.
d
.
“I should encourage my child to drink carbonated drinks but avoid food for the
next 24 hours.”
“I will offer my child bananas, rice, applesauce, and toast for the next 48 hours.”
“I should have my child eat a normal diet with easily digested foods for the
next 48 hours.”
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.
DIF: Cognitive Level: Application
REF: Page 821 | Page 822
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
12.
A young child is brought to the emergency department with severe dehydration secondary to
acute diarrhea and vomiting. Therapeutic management of this child will begin with:
a intravenous (IV) fluids.
.
b ORS.
.
c clear liquids, 1 to 2 ounces at a time.
.
d administration of antidiarrheal medication.
.
ANS: A
In children with severe dehydration, IV fluids are initiated.
DIF: Cognitive Level: Application
REF: Page 822
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13.
A mother calls the clinic nurse about her 4-year-old son who has acute diarrhea. She has
been giving him the antidiarrheal drug loperamide (Imodium A-D). The nurse’s response should be
based on knowledge that this drug is:
a not indicated.
.
b indicated because it slows intestinal motility.
.
c indicated because it decreases diarrhea.
.
d indicated because it decreases fluid and electrolyte losses.
.
ANS: A
Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea. These
medications have adverse effects and toxicity, such as worsening of the diarrhea because of slowing
of motility and ileus, or a decrease in diarrhea with continuing fluid losses and dehydration.
DIF: Cognitive Level: Analysis
REF: Page 823
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
14.
Constipation has recently become a problem for a school-age girl. She is healthy except for
seasonal allergies, which are now being successfully treated with antihistamines. The nurse should
suspect that the constipation is most likely caused by which of the following?
a Diet
.
b Allergies
.
c Antihistamines
.
d Emotional factors
.
ANS: C
Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids,
antiepileptics, and iron. Because this is the only known change in her habits, the addition of
antihistamines is most likely the cause of the diarrhea.
DIF: Cognitive Level: Comprehension REF: Page 823
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
15.
Which of the following is a high-fiber food that the nurse could recommend for a child with
chronic constipation?
a Popcorn
.
b Pancakes
.
c Muffins
.
d Ripe bananas
.
ANS: A
Popcorn is a high-fiber food.
DIF: Cognitive Level: Comprehension REF: Page 825
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
16.
Therapeutic management of most children with Hirschsprung disease is primarily which of
the following?
a Daily enemas
.
b Low-fiber diet
.
c Permanent colostomy
.
d Surgical removal of affected section of bowel
.
ANS: D
Most children with Hirschsprung disease require surgical rather than medical management. Surgery
is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal
bowel motility and function of the internal anal sphincter.
DIF: Cognitive Level: Comprehension REF: Page 826
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17.
Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease.
The enema solution should be:
a tap water.
.
b normal saline.
.
c oil retention.
.
d phosphate preparation.
.
ANS: B
Isotonic solutions should be used in children. Saline is the solution of choice.
DIF: Cognitive Level: Comprehension REF: Page 826
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
18.
A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary
colostomy will be necessary. The nurse should recognize that preparing this child psychologically
is:
a not necessary because of child’s age.
.
b not necessary because colostomy is temporary.
.
c necessary because it will be an adjustment.
.
d necessary because child must deal with a negative body image.
.
ANS: C
The child’s age dictates the type and extent of psychologic preparation. When a colostomy is
performed, the child who is at least preschool age is told about the procedure and what to expect in
concrete terms, with the use of visual aids.
DIF: Cognitive Level: Application
REF: Page 826
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Psychosocial Integrity: Coping and Adaptation
19.
The nurse is explaining to a parent how to care for a child with vomiting associated with a
viral illness. Which of the following should the nurse include?
a Avoid carbohydrate-containing liquids.
.
b Give nothing by mouth for 24 hours.
.
c Brush teeth or rinse mouth after vomiting.
.
d Give plain water until vomiting ceases for at least 24 hours.
.
ANS: C
It is important to emphasize the need for the child to brush the teeth or rinse the mouth after
vomiting to dilute the hydrochloric acid that comes in contact with the teeth.
DIF: Cognitive Level: Comprehension REF: Page 827
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
20.
A 4-month-old infant has gastroesophageal reflux (GER) but is thriving without other
complications. Which of the following should the nurse suggest to minimize reflux?
a Place in Trendelenburg position after eating.
.
b Thicken formula with rice cereal.
.
c Give continuous nasogastric tube feedings.
.
d Give larger, less frequent feedings.
.
ANS: B
Small, frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per
ounce of formula has been recommended. Milk thickening agents have been shown to decrease the
number of episodes of vomiting and to increase the caloric density of the formula. This may benefit
infants who are underweight as a result of GER disease.
DIF: Cognitive Level: Application
REF: Page 827
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
21.
A histamine-receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is
ordered for an infant with GER. The purpose of this is to:
a
.
b
.
c
.
d
.
prevent reflux.
prevent hematemesis.
reduce gastric acid production.
increase gastric acid production.
ANS: C
The mechanism of action of histamine-receptor antagonists is to reduce the amount of acid present
in gastric contents and perhaps prevent esophagitis.
DIF: Cognitive Level: Comprehension REF: Page 828
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
22.
Which of the following clinical manifestations would be the most suggestive of acute
appendicitis?
a Rebound tenderness
.
b Bright red or dark red rectal bleeding
.
c Abdominal pain that is relieved by eating
.
d Abdominal pain that is most intense at McBurney point
.
ANS: D
Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain localizes to the
right lower quadrant at McBurney point.
DIF: Cognitive Level: Comprehension REF: Page 830
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23.
When caring for a child with probable appendicitis, the nurse should be alert to recognize
that which of the following is a sign of perforation?
a Bradycardia
.
b Anorexia
.
c Sudden relief from pain
.
d Decreased abdominal distention
.
ANS: C
Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation.
DIF: Cognitive Level: Comprehension REF: Page 830
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24.
The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis.
Which of the following is appropriate to relieve the abdominal discomfort?
a Place in Trendelenburg position.
.
b Allow to assume position of comfort.
.
c Apply moist heat to the abdomen.
.
d Administer a saline enema to cleanse bowel.
.
ANS: B
The child should be allowed to take a position of comfort, usually with the legs flexed.
DIF: Cognitive Level: Comprehension REF: Page 831
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
25.
a
.
b
.
c
.
d
.
Which of the following statements is most descriptive of Meckel diverticulum?
It is more common in females than in males.
It is acquired during childhood.
Intestinal bleeding may be mild or profuse.
Medical interventions are usually sufficient to treat the problem.
ANS: C
Bloody stools are often a presenting sign of Meckel diverticulum. It is associated with mild to
profuse intestinal bleeding.
DIF: Cognitive Level: Comprehension REF: Page 832
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
26.
Which of the following is characterized by a chronic inflammatory process that may involve
any part of the GI tract from mouth to anus?
a Crohn disease
.
b Ulcerative colitis
.
c Meckel diverticulum
.
d Irritable bowel syndrome
.
ANS: A
The chronic inflammatory process of Crohn disease involves any part of the GI tract from the mouth
to the anus but most often affects the terminal ileum.
DIF: Cognitive Level: Comprehension REF: Page 834
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27.
a
.
b
.
c
.
d
.
Which of the following is used to treat moderate to severe inflammatory bowel disease?
Antacids
Antibiotics
Corticosteroids
Antidiarrheal medications
ANS: C
Corticosteroids, such as prednisone and prednisolone, are used in short bursts to suppress the
inflammatory response in inflammatory bowel disease.
DIF: Cognitive Level: Comprehension REF: Page 834
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
28.
Bismuth subsalicylate, clarithromycin, and metronidazole are prescribed for a child with a
peptic ulcer to:
a eradicate Helicobacter pylori.
.
b coat gastric mucosa.
.
c treat epigastric pain.
.
d reduce gastric acid production.
.
ANS: A
This combination of drug therapy is effective in the treatment of H. pylori.
DIF: Cognitive Level: Comprehension REF: Page 837
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
29.
Which of the following statements best characterizes hepatitis A?
a
.
b
.
c
.
d
.
Incubation period is 6 weeks to 6 months.
Principal mode of transmission is through the parenteral route.
Onset is usually rapid and acute.
There is a persistent carrier state.
ANS: C
Hepatitis A is the most common form of acute hepatitis in most parts of the world. It is characterized
by a rapid and acute onset.
DIF: Cognitive Level: Comprehension REF: Page 839
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
30.
a
.
b
.
c
.
d
.
Which of the following is now recommended for the immunization of all newborns?
Hepatitis A vaccine
Hepatitis B vaccine
Hepatitis C vaccine
Hepatitis A, B, and C vaccines
ANS: B
Universal vaccination for hepatitis B is now recommended for all newborns.
DIF: Cognitive Level: Comprehension REF: Page 839
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance: Immunizations
31.
a
.
b
.
c
.
d
.
The best chance of survival for a child with cirrhosis is:
liver transplantation.
treatment with corticosteroids.
treatment with immune globulin.
provision of nutritional support.
ANS: A
The only successful treatment for end-stage liver disease and liver failure may be liver
transplantation, which has improved the prognosis for many children with cirrhosis.
DIF:
Cognitive Level: Comprehension
REF: Page 841
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
32.
a
.
b
.
c
.
d
.
Which of the following is the earliest clinical manifestation of biliary atresia?
Jaundice
Vomiting
Hepatomegaly
Absence of stooling
ANS: A
Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in the
sclera, may be present at birth, but is usually not apparent until age 2 to 3 weeks.
DIF: Cognitive Level: Comprehension REF: Page 842
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
33.
A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The
physician explained the plan of therapy and its expected good results. However, the mother refuses
to see or hold her baby. Initial therapeutic approach to the mother should be which of the following?
a Restate what the physician has told her about plastic surgery.
.
b Encourage her to express her feelings.
.
c Emphasize the normalcy of her baby and the baby’s need for mothering.
.
d Recognize that negative feelings toward the child continue throughout childhood.
.
ANS: B
For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must place
emphasize not only the infant’s physical needs but also the parents’ emotional needs. The mother
needs to be able to express her feelings before she can accept her child.
DIF: Cognitive Level: Analysis
REF: Page 845
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity: Coping and Adaptation
34.
Caring for the newborn with a cleft lip and palate before surgical repair includes which of
the following?
a Gastrostomy feedings
.
b Keeping infant in near-horizontal position during feedings
.
c Allowing little or no sucking
.
d Providing satisfaction of sucking needs
.
ANS: D
Using special or modified nipples for feeding techniques helps meet the infant’s sucking needs.
DIF: Cognitive Level: Application
REF: Page 845
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
35.
A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing
interventions should include which of the following?
a Give medication to suppress lactation.
.
b Encourage and help mother to breastfeed.
.
c Teach mother to feed breast milk by gavage.
.
d Recommend use of a breast pump to maintain lactation until infant can suck.
.
ANS: B
The mother who wishes to breastfeed may need encouragement and support because the defect does
present some logistical issues. The nipple must be positioned and stabilized well back in the infant’s
oral cavity so that the tongue action facilitates milk expression.
DIF: Cognitive Level: Comprehension REF: Page 845
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
36.
The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this
infant’s postoperative care include which of the following?
a Arm restraints, postural drainage, mouth irrigations
.
b Cleansing suture line, supine and side-lying positions, arm restraints
.
c Mouth irrigations, prone position, cleansing suture line
.
d Supine and side-lying positions, postural drainage, arm restraints
.
ANS: B
The suture line should be cleansed gently after feeding. The child should be positioned on the back,
on the side, or in an infant seat. Elbows are restrained to prevent the child from accessing the
operative site.
DIF:
Cognitive Level: Analysis
REF: Page 846
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
37.
During the first few days after surgery for cleft lip, the nurse should do which of the
following?
a Leave infant in crib at all times to prevent suture strain.
.
b Keep infant heavily sedated to prevent suture strain.
.
c Remove restraints periodically to cuddle infant.
.
d Alternate position from prone to side lying to supine.
.
ANS: C
Remove restraints periodically, while supervising the infant, to allow him or her to exercise arms
and to provide cuddling and tactile stimulation.
DIF: Cognitive Level: Comprehension REF: Page 846
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
38.
The nurse is caring for a neonate with a suspected tracheoesophageal fistula. Nursing care
should include which of the following?
a Elevate head but give nothing by mouth.
.
b Elevate head for feedings.
.
c Feed glucose water only.
.
d Avoid suctioning unless infant is cyanotic.
.
ANS: A
When a newborn is suspected of having a tracheoesophageal fistula, the most desirable position is
supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that any
source of aspiration be removed at once; oral feedings are withheld.
DIF: Cognitive Level: Analysis
REF: Page 848
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
39.
Which type of hernia has an impaired blood supply to the herniated organ?
a Hiatal hernia
.
b Incarcerated hernia
.
c Omphalocele
.
d Strangulated hernia
.
ANS: D
A strangulated hernia is one in which the blood supply to the herniated organ is impaired.
DIF: Cognitive Level: Comprehension REF: Page 849
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
40.
a
.
b
.
c
.
d
.
Pyloric stenosis can best be described as which of the following?
Dilation of the pylorus
Hypertrophy of the pyloric muscle
Hypotonicity of the pyloric muscle
Reduction of tone in the pyloric muscle
ANS: B
Hypertrophic pyloric stenosis occurs when the circumferential muscle of the pyloric sphincter
becomes thickened, resulting in elongation and narrowing of the pyloric channel.
DIF: Cognitive Level: Comprehension REF: Page 849
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
41.
Which of the following observations made of the exposed abdomen is most indicative of
pyloric stenosis?
a Abdominal rigidity
.
b Substernal retraction
.
c Visible peristalsis
.
d Marked distention of lower abdomen
.
ANS: C
Visible gastric peristaltic waves that move from left to right across the epigastrium are observed in
pyloric stenosis.
DIF: Cognitive Level: Comprehension REF: Page 851
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
42.
The nurse is caring for an infant with suspected pyloric stenosis. Which of the following
clinical manifestations would indicate pyloric stenosis?
a Abdominal rigidity and pain on palpation
.
b Rounded abdomen and hypoactive bowel sounds
.
c Visible peristalsis and weight loss
.
d Distention of lower abdomen and constipation
.
ANS: C
Visible gastric peristaltic waves that move from left to right across the epigastrium and weight loss
are observed in pyloric stenosis.
DIF: Cognitive Level: Application
REF: Page 851
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
43.
a
.
b
.
c
.
d
.
Excessive vomiting can result in which of the following in an infant with pyloric stenosis?
Hyperchloremia
Hypernatremia
Metabolic acidosis
Metabolic alkalosis
ANS: D
Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions.
DIF: Cognitive Level: Comprehension REF: Page 852
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
44.
a
.
b
.
c
.
d
.
Invagination of one segment of bowel within another is called which of the following?
Atresia
Stenosis
Herniation
Intussusception
ANS: D
Intussusception occurs when a proximal section of the bowel telescopes into a more distal segment,
pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and
venous obstruction.
DIF: Cognitive Level: Comprehension REF: Page 852
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
45.
The nurse is caring for a boy with probable intussusception. He had diarrhea before
admission but, while waiting for administration of air pressure to reduce the intussusception, he
passes a normal brown stool. Which of the following is the most appropriate nursing action?
a Notify practitioner.
.
b Measure abdominal girth.
.
c Auscultate for bowel sounds.
.
d Take vital signs, including blood pressure.
.
ANS: A
Passage of a normal brown stool indicates that the intussusception has reduced itself. This is
immediately reported to the practitioner, who may choose to alter the diagnostic-therapeutic care
plan.
DIF: Cognitive Level: Analysis
REF: Page 853
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
46.
Which of the following is an important nursing consideration in the care of a child with
celiac disease?
a Refer to a nutritionist for detailed dietary instructions and education.
.
b Help child and family understand that diet restrictions are usually only temporary.
.
c Teach proper hand washing and standard precautions to prevent disease
. transmission.
d Suggest ways to cope more effectively with stress to minimize symptoms.
.
ANS: A
The main consideration is helping the child adhere to dietary management. Considerable time is
spent explaining to the child and parents about the disease process, the specific role of gluten in
aggravating the condition, and foods that must be restricted. Referral to a nutritionist would help in
this process.
DIF: Cognitive Level: Comprehension REF: Page 856
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
47.
An infant with short bowel syndrome will be discharged home on total parenteral nutrition
(TPN) and gastrostomy feedings. Nursing care should include which of the following?
a
.
b
.
c
.
d
.
Prepare family for impending death.
Teach family signs of central venous catheter infection.
Teach family how to calculate caloric needs.
Secure TPN and gastrostomy tubing under diaper to lessen risk of dislodgment.
ANS: B
During TPN therapy care must be taken to minimize the risk of complications related to the central
venous access device, such as catheter infections, occlusions, or accidental removal. This is an
important part of family teaching.
DIF: Cognitive Level: Comprehension REF: Page 857
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
MULTIPLE RESPONSE
1.
A child who has just had definitive repair of a high rectal malformation is to be discharged.
Which of the following should the nurse address in the discharge preparation of this family? (Select
all that apply.)
a Perineal and wound care
.
b Necessity of firm stools to keep suture line clean
.
c Bowel training beginning as soon as child returns home
.
d Changes in stooling patterns to report to practitioner
.
e Use of diet modification to prevent constipation
.
ANS: A, D, E
Wound care instruction is necessary in a child who is being discharge after surgery. The parents are
taught to notify the practitioner if any signs of an anal stricture or other complications develop.
Constipation is avoided, since a firm stool will place strain on the suture line.
DIF: Cognitive Level: Application
REF: Page 855
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2.
Which of the following is true concerning hepatitis B? (Select all that apply.)
Hepatitis B cannot exist in carrier state.
a
.
b Hepatitis B can be prevented by HBV vaccine.
.
c
.
d
.
e
.
f.
Hepatitis B can be transferred to an infant of a breastfeeding mother.
Onset of hepatitis B is insidious.
Principal mode of transmission for hepatitis B is fecal-oral route.
Immunity to hepatitis B occurs after one attack.
ANS: B, C, D, F
The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is
protective against hepatitis B. Hepatitis B can be transferred to an infant of a breastfeeding mother,
especially if the mother’s nipples are cracked. The onset of hepatitis B is insidious. Immunity
develops after one exposure to hepatitis B.
DIF: Cognitive Level: Application
REF: Page 839
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential