Chapter 24: The Child with Hematologic or Immunologic Dysfunction
Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
MULTIPLE CHOICE
1. Which child should the nurse document as being anemic?
a. 7-year-old child with a hemoglobin of 11.5 g/dl
b. 3-year-old child with a hemoglobin of 12 g/dl
c. 14-year-old child with a hemoglobin of 10 g/dl
d. 1-year-old child with a hemoglobin of 13 g/dl
ANS: D
Anemia is a condition in which the number of red blood cells, or hemoglobin concentration, is reduced below the normal values for
age. Anemia is defined as a hemoglobin level below 10 or 11 g/dl. The child with a hemoglobin of 10 g/dl would be considered
anemic. The normal hemoglobin for a child after 2 years of age is 11.5 to 15.5 g/dl.
DIF: Cognitive Level: Understand
REF: p. 789
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Several blood tests are ordered for a preschool child with severe anemia. The child is crying and upset because of memories of the
venipuncture done at the clinic 2 days ago. What should the nurse explain?
a. The venipuncture discomfort is very brief
b. Only one venipuncture will be needed
c. A topical application of local anesthetic can eliminate venipuncture pain
d. Most blood tests on children require only a finger puncture because a small
amount of blood is needed
ANS: C
Preschool children are concerned with both pain and the loss of blood. When preparing the child for venipuncture, the nurse will
use a topical anesthetic to eliminate any pain. This is a traumatic experience for preschool children. They are concerned about their
bodily integrity. A local anesthetic should be used, and a bandage should be applied to maintain bodily integrity. The nurse should
not promise one attempt in case multiple attempts are required. Both finger punctures and venipunctures are traumatic for children.
Both require preparation.
DIF: Cognitive Level: Apply
REF: p. 789
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. The nurse is planning activity for a 4-year-old child with anemia. Which activity should the nurse plan for this child?
a. Game of “hide and seek” in the children’s outdoor play area
b. Participation in dance activities in the playroom
c. Puppet play in the child’s room
d. A walk down to the hospital lobby
ANS: C
Because the basic pathologic process in anemia is a decrease in oxygen-carrying capacity, an important nursing responsibility is to
assess the child’s energy level and minimize excess demands. The child’s level of tolerance for activities of daily living and play is
assessed, and adjustments are made to allow as much self-care as possible without undue exertion. Puppet play in the child’s room
would not be overly tiring. Hide and seek, dancing, and walking to the lobby would not conserve the anemic child’s energy.
DIF: Cognitive Level: Apply
REF: p. 789
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
4. The nurse is teaching parents about the importance of iron in a toddler’s diet. Which explains why iron-deficiency anemia is
common during toddlerhood?
a. Milk is a poor source of iron.
b. Iron cannot be stored during fetal development.
c. Fetal iron stores are depleted by age 1 month.
d. Dietary iron cannot be started until age 12 months.
ANS: A
Children between the ages of 12 and 36 months are at risk for anemia because cow’s milk is a major component of their diet and it
is a poor source of iron. Iron is stored during fetal development, but the amount stored depends on maternal iron stores. Fetal iron
stores are usually depleted by age 5 to 6 months. Dietary iron can be introduced by breastfeeding, iron-fortified formula, and
cereals during the first 12 months of life.
DIF: Cognitive Level: Understand
REF: p. 789
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Copyright © 2017, Elsevier Inc. All Rights Reserved.
1
5. The nurse is teaching parents of an infant about the causes of iron-deficiency anemia. Which statement best describes
iron-deficiency anemia in infants?
a. It is caused by depression of the hematopoietic system.
b. It is easily diagnosed because of an infant’s emaciated appearance.
c. Clinical manifestations are similar regardless of the cause of the anemia.
d. Clinical manifestations result from a decreased intake of milk and the preterm
addition of solid foods.
ANS: C
In iron-deficiency anemia, the child’s clinical appearance is a result of the anemia, not the underlying cause. Usually the
hematopoietic system is not depressed in iron-deficiency anemia. The bone marrow produces red cells that are smaller and contain
less hemoglobin than normal red cells. Children who are iron deficient from drinking excessive quantities of milk are usually pale
and overweight. They are receiving sufficient calories, but are deficient in essential nutrients. The clinical manifestations result
from decreased intake of iron-fortified solid foods and an excessive intake of milk.
DIF: Cognitive Level: Apply
REF: p. 789
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. Which should the nurse include when teaching the mother of a 9-month-old infant about administering liquid iron preparations?
a. They should be given with meals.
b. They should be stopped immediately if nausea and vomiting occur.
c. Adequate dosage will turn the stools a tarry green color.
d. Allow preparation to mix with saliva and bathe the teeth before swallowing.
ANS: C
The nurse should prepare the mother for the anticipated change in the child’s stools. If the iron dose is adequate, the stools will
become a tarry green color. The lack of the color change may indicate insufficient iron. The iron should be given in two divided
doses between meals when the presence of free hydrochloric acid is greatest. Iron is absorbed best in an acidic environment.
Vomiting and diarrhea may occur with iron administration. If these occur, the iron should be given with meals, and the dosage
reduced, then gradually increased as the child develops tolerance. Liquid preparations of iron stain the teeth. They should be
administered through a straw and the mouth rinsed after administration.
DIF: Cognitive Level: Apply
REF: p. 789
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
7. Iron dextran is ordered for a young child with severe iron-deficiency anemia. What nursing considerations should be included?
a. Administer with meals
b. Administer between meals
c. Inject deeply into a large muscle
d. Massage injection site for 5 minutes after administration of drug
ANS: C
Iron dextran is a parenteral form of iron. When administered intramuscularly, it must be injected into a large muscle. Iron dextran is
for intramuscular or intravenous (IV) administration. The site should not be massaged to prevent leakage, potential irritation, and
staining of the skin.
DIF: Cognitive Level: Apply
REF: p. 790
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
8. The nurse is recommending how to prevent iron-deficiency anemia in a healthy, term, breastfed infant. Which should be suggested?
a. Iron (ferrous sulfate) drops after age 1 month
b. Iron-fortified commercial formula by age 4 to 6 months
c. Iron-fortified infant cereal by age 2 months
d. Iron-fortified infant cereal by age 4 to 6 months
ANS: D
Breast milk supplies inadequate iron for growth and development after age 5 months. Supplementation is necessary at this time.
The mother can supplement the breastfeeding with iron-fortified infant cereal. Iron supplementation or the introduction of solid
foods in a breastfed baby is not indicated. Providing iron-fortified commercial formula by age 4 to 6 months should be done only if
the mother is choosing to discontinue breastfeeding.
DIF: Cognitive Level: Apply
REF: p. 789
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
Copyright © 2017, Elsevier Inc. All Rights Reserved.
2
9. Parents of a child with sickle cell anemia ask the nurse, “What happens to the hemoglobin in sickle cell anemia?” Which statement
by the nurse explains the disease process?
a. Normal adult hemoglobin is replaced by abnormal hemoglobin.
b. There is a lack of cellular hemoglobin being produced.
c. There is a deficiency in the production of globulin chains.
d. The size and depth of the hemoglobin are affected.
ANS: A
Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is
replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being produced. Thalassemia major refers to a
variety of inherited disorders characterized by deficiencies in production of certain globulin chains. Iron-deficiency anemia affects
the size, depth, and color of hemoglobin.
DIF: Cognitive Level: Apply
REF: p. 791
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. When both parents have sickle cell trait, which is the chance their children will have sickle cell anemia?
a. 25%
b. 50%
c. 75%
d. 100%
ANS: A
Sickle cell anemia is inherited in an autosomal recessive pattern. If both parents have sickle cell trait (one copy of the sickle cell
gene), then for each pregnancy, a 25% chance exists that their child will be affected with sickle cell disease. With each pregnancy,
a 50% chance exists that the child will have sickle cell trait. Percentages of 75% and 100% are too high for the children of parents
who have sickle cell trait.
DIF: Cognitive Level: Analyze
REF: p. 791
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
11. The nurse is conducting a staff in-service on sickle cell anemia. Which describes the pathologic changes of sickle cell anemia?
a. Sickle-shaped cells carry excess oxygen.
b. Sickle-shaped cells decrease blood viscosity.
c. Increased red blood cell destruction occurs.
d. Decreased adhesion of sickle-shaped cells occurs.
ANS: C
The clinical features of sickle cell anemia are primarily the result of increased red blood cell destruction and obstruction caused by
the sickle-shaped red blood cells. Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in
conditions of low oxygen tension. When the sickle cells change shape, they increase the viscosity in the area where they are
involved in the microcirculation. Increased adhesion and entanglement of cells occurs.
DIF: Cognitive Level: Apply
REF: p. 791
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
12. Which clinical manifestation should the nurse expect when a child with sickle cell anemia experiences an acute vasoocclusive
crisis?
a. Circulatory collapse
b. Cardiomegaly, systolic murmurs
c. Hepatomegaly, intrahepatic cholestasis
d. Painful swelling of hands and feet; painful joints
ANS: D
A vasoocclusive crisis is characterized by severe pain in the area of involvement. If in the extremities, painful swelling of the hands
and feet is seen; if in the abdomen, severe pain resembles that of acute surgical abdomen; and if in the head, stroke and visual
disturbances occur. Circulatory collapse results from sequestration crises. Cardiomegaly, systolic murmurs, hepatomegaly, and
intrahepatic cholestasis result from chronic vasoocclusive phenomena.
DIF: Cognitive Level: Understand
REF: p. 791
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. Why is meperidine (Demerol) not recommended for children in sickle cell crisis?
a. May induce seizures
b. Is easily addictive
c. Not adequate for pain relief
d. Given by intramuscular injection
ANS: A
A metabolite of meperidine, normeperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and
generalized seizures when it accumulates with repetitive dosing. Patients with sickle cell disease are particularly at r isk for
normeperidine-induced seizures. Meperidine is no more addictive than other narcotic agents. Meperidine is adequate for pain relief.
It is available for IV infusion.
DIF: Cognitive Level: Understand
REF: p. 795
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
Copyright © 2017, Elsevier Inc. All Rights Reserved.
3
14. A school-age child is admitted in vasoocclusive sickle cell crisis. What should be included in the child’s care?
a. Correction of acidosis
b. Adequate hydration and pain management
c. Pain management and administration of heparin
d. Adequate oxygenation and replacement of factor VIII
ANS: B
The management of crises includes adequate hydration, minimization of energy expenditures, pain management, electrolyte
replacement, and blood component therapy if indicated. Hydration and pain control are two of the major goals of therapy. The
acidosis will be corrected as the crisis is treated. Heparin and factor VIII are not indicated in the treatment of vasoocclusive sickle
cell crisis. Oxygen may prevent further sickling, but it is not effective in reversing sickling because it cannot reach the clogged
blood vessels.
DIF: Cognitive Level: Apply
REF: p. 796
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
15. The parents of a child hospitalized with sickle cell anemia tell the nurse that they are concerned about narcotic analgesics causing
addiction. Which is appropriate for the nurse to explain about narcotic analgesics?
a. Are often ordered but not usually needed
b. Rarely cause addiction because they are medically indicated
c. Are given as a last resort because of the threat of addiction
d. Are used only if other measures, such as ice packs, are ineffective
ANS: B
The pain of sickle cell anemia is best treated by a multidisciplinary approach. Mild to moderate pain can be controlled by ibuprofen
and acetaminophen. When narcotics are indicated, they are titrated to effect and are given around the clock. Patient-controlled
analgesia reinforces the patient’s role and responsibility in managing the pain and provides flexibility in dealing with pain. Few, if
any, patients who receive opioids for severe pain become behaviorally addicted to the drug. Narcotics are often used because of the
severe nature of the pain of vasoocclusive crisis. Ice is contraindicated because of its vasoconstrictive effects.
DIF: Cognitive Level: Apply
REF: p. 796
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
16. Which statement best describes β-thalassemia major (Cooley anemia)?
a. All formed elements of the blood are depressed.
b. Inadequate numbers of red blood cells are present.
c. Increased incidence occurs in families of Mediterranean extraction.
d. Increased incidence occurs in persons of West African descent.
ANS: C
Individuals who live near the Mediterranean Sea and their descendants have the highest incidence of thalassemia. An
overproduction of red cells occurs. Although numerous, the red cells are relatively unstable. Sickle cell disease is common in
persons of West African descent.
DIF: Cognitive Level: Understand
REF: p. 799
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
17. Chelation therapy is begun on a child with β-thalassemia major. What is the purpose of this therapy?
a. Treat the disease
b. Eliminate excess iron
c. Decrease risk of hypoxia
d. Manage nausea and vomiting
ANS: B
A complication of the frequent blood transfusions in thalassemia is iron overload. Chelation therapy with deferoxamine (an
iron-chelating agent) is given with oral supplements of vitamin C to increase iron excretion. Chelation therapy treats the side effect
of the disease management. Decreasing the risk of hypoxia and managing nausea and vomiting are not the purposes of chelation
therapy.
DIF: Cognitive Level: Understand
REF: p. 799
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
18. In which of the conditions are all the formed elements of the blood simultaneously depressed?
a. Aplastic anemia
b. Sickle cell anemia
c. Thalassemia major
d. Iron-deficiency anemia
ANS: A
Aplastic anemia refers to a bone marrow–failure condition in which the formed elements of the blood are simultaneously
depressed. Sickle cell anemia is a hemoglobinopathy in which normal adult hemoglobin is partly or completely replaced by
abnormal sickle hemoglobin. Thalassemia major is a group of blood disorders characterized by deficiency in the production rate of
specific hemoglobin globin chains. Iron-deficiency anemia results in a decreased amount of circulating red cells.
DIF: Cognitive Level: Understand
REF: p. 800
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Copyright © 2017, Elsevier Inc. All Rights Reserved.
4
19. What is a possible cause of acquired aplastic anemia in children?
a. Drugs
b. Injury
c. Deficient diet
d. Congenital defect
ANS: A
Drugs, such as chemotherapeutic agents and several antibiotics (e.g., chloramphenicol), can cause aplastic anemia. Injury, deficient
diet, and congenital defect are not causative agents in acquired aplastic anemia.
DIF: Cognitive Level: Understand
REF: p. 800
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
20. Parents of a hemophiliac child ask the nurse, “Can you describe hemophilia to us?” Which response by the nurse is descriptive of
most cases of hemophilia?
a. Autosomal dominant disorder causing deficiency in a factor involved in the
blood-clotting reaction
b. X-linked recessive inherited disorder causing deficiency of platelets and
prolonged bleeding
c. X-linked recessive inherited disorder in which a blood-clotting factor is deficient
d. Y-linked recessive inherited disorder in which the red blood cells become
moon-shaped
ANS: C
The inheritance pattern in 80% of all of the cases of hemophilia is X-linked recessive. The two most common forms of the disorder
are factor VIII deficiency, hemophilia A or classic hemophilia; and factor IX deficiency, hemophilia B or Christmas disease. The
inheritance pattern is X-linked recessive. The disorder involves coagulation factors, not platelets, and does not involve red cells or
the Y chromosomes.
DIF: Cognitive Level: Understand
REF: p. 801
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
21. The nurse is conducting a staff in-service on childhood blood disorders. Which describes the pathology of idiopathic
thrombocytopenic purpura?
a. Bone marrow failure in which all elements are suppressed
b. Deficiency in the production rate of globin chains
c. Diffuse fibrin deposition in the microvasculature
d. An excessive destruction of platelets
ANS: D
Idiopathic thrombocytopenic purpura is an acquired hemorrhagic disorder characterized by an excessive destruction of platelets,
discolorations caused by petechiae beneath the skin, and a normal bone marrow. Aplastic anemia refers to a bone marrow–failure
condition in which the formed elements of the blood are simultaneously depressed. Thalassemia major is a group of blood disorders
characterized by deficiency in the production rate of specific hemoglobin globin chains. Disseminated intravascular coagulation is
characterized by diffuse fibrin deposition in the microvasculature, consumption of coagulation factors, and endogenous generation
of thrombin and plasma.
DIF: Cognitive Level: Understand
REF: p. 804
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. Which is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4+ T cells?
a. Wiskott-Aldrich syndrome
b. Idiopathic thrombocytopenic purpura
c. Acquired immunodeficiency syndrome (AIDS)
d. Severe combined immunodeficiency disease
ANS: C
AIDS is caused by the human immunodeficiency virus (HIV), which primarily attacks the CD4+ T cells. Wiskott-Aldrich
syndrome, idiopathic thrombocytopenic purpura, and severe combined immunodeficiency disease are not viral illnesses.
DIF: Cognitive Level: Remember
REF: p. 806
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
23. A young child with human immunodeficiency virus (HIV) is receiving several antiretroviral drugs. What is the purpose of these
drugs?
a. Cure the disease
b. Delay disease progression
c. Prevent spread of disease
d. Treat Pneumocystis carinii pneumonia
ANS: B
Although not a cure, these antiviral drugs can suppress viral replication, preventing further deterioration of the immune system and
delaying disease progression. At this time, cure is not possible. These drugs do not prevent the spread of the disease. P. carinii
prophylaxis is accomplished with antibiotics.
DIF: Cognitive Level: Understand
REF: p. 806
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
Copyright © 2017, Elsevier Inc. All Rights Reserved.
5
24. Which immunization should be given with caution to children infected with human immunodeficiency virus (HIV)?
a. Influenza
b. Varicella
c. Pneumococcal
d. Inactivated poliovirus (IPV)
ANS: B
The children should be carefully evaluated before being given live viral vaccines such as varicella, measles, mumps, and rubella.
The child must be immunocompetent and not have contact with other severely immunocompromised individuals. Influenza,
pneumococcal, and inactivated poliovirus (IPV) are not live vaccines.
DIF: Cognitive Level: Apply
REF: p. 806
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
25. The nurse is planning care for an adolescent with AIDS. Which is the priority nursing goal?
a. Preventing infection
b. Preventing secondary cancers
c. Restoring immunologic defenses
d. Identifying source of infection
ANS: A
Because the child is immunocompromised in association with HIV infection, the prevention of infection is paramount. Although
certain precautions are justified in limiting exposure to infection, these must be balanced with the concern for the child’s normal
developmental needs. Preventing secondary cancers is not currently possible. Current drug therapy is affecting the disease
progression; although not a cure, these drugs can suppress viral replication, preventing further deterioration. Case finding is not a
priority nursing goal.
DIF: Cognitive Level: Apply
REF: p. 806
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
26. The school nurse is informed that a child with human immunodeficiency virus (HIV) will be attending school soon. Which is an
important nursing intervention?
a. Carefully follow universal precautions.
b. Determine how the child became infected.
c. Inform the parents of the other children.
d. Reassure other children that they will not become infected.
ANS: A
Universal precautions are necessary to prevent further transmission of the disease. It is not the role of the nurse to determine how
the child became infected. Informing the parents of other children and reassuring children that they will not become infected is a
violation of the child’s right to privacy.
DIF: Cognitive Level: Apply
REF: p. 807
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
27. The nurse is conducting a staff in-service on inherited childhood blood disorders. Which statement describes severe combined
immunodeficiency syndrome (SCIDS)?
a. There is a deficit in both the humoral and cellular immunity with this disease.
b. Production of red blood cells is affected with this disease.
c. Adult hemoglobin is replaced by abnormal hemoglobin in this disease.
d. There is a deficiency of T and B lymphocyte production with this disease.
ANS: A
Severe combined immunodeficiency syndrome (SCIDS) is a genetic disorder that results in deficits of both humoral and cellular
immunity. Wiskott-Aldrich is an X-linked recessive disorder with selected deficiencies of T and B lymphocytes. Fanconi syndrome
is a hereditary disorder of red cell production. Sickle cell disease is characterized by the replacement of adult hemoglobin with an
abnormal hemoglobin S.
DIF: Cognitive Level: Understand
REF: p. 809
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
28. Several complications can occur when a child receives a blood transfusion. Which is an immediate sign or symptom of an air
embolus?
a. Chills and shaking
b. Nausea and vomiting
c. Irregular heart rate
d. Sudden difficulty in breathing
ANS: D
Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Air emboli should be avoided by
carefully flushing all tubing of air before connecting to patient. Chills, shaking, nausea, and vomiting are associated with hemolytic
reactions. Irregular heart rate is associated with electrolyte disturbances and hypothermia.
DIF: Cognitive Level: Understand
REF: p. 810
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Copyright © 2017, Elsevier Inc. All Rights Reserved.
6
29. An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed precordial pain, dyspnea, distended
neck veins, slight cyanosis, and a dry cough. Of what are these manifestations most suggestive?
a. Air emboli
b. Allergic reaction
c. Hemolytic reaction
d. Circulatory overload
ANS: D
The signs of circulatory overload include distended neck veins, hypertension, crackles, dry cough, cyanosis, and precordial pain.
Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Allergic reactions are manifested
by urticaria, pruritus, flushing, asthmatic wheezing, and laryngeal edema. Hemolytic reactions are characterized by chills, shaking,
fever, pain at infusion site, nausea, vomiting, tightness in chest, flank pain, red or black urine, and progressive signs of shock and
renal failure.
DIF: Cognitive Level: Apply
REF: p. 811
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
30. The nurse is reviewing first aid with a group of school nurses. Which statement made by a participant indicates a correct
understanding of the information?
a. “If a child loses a tooth due to injury, I should place the tooth in warm milk.”
b. “If a child has recurrent abdominal pain, I should send him or her back to class
until the end of the day.”
c. “If a child has a chemical burn to the eye, I should irrigate the eye with normal
saline.”
d. “If a child has a nosebleed, I should have the child sit up and lean forward.”
ANS: D
If a child has a nosebleed, the child should lean forward, not lie down. A tooth should be placed in cold milk or saliva for
transporting to a dentist. Recurrent abdominal pain is a physiologic problem and requires further evaluation. If a chemical burn
occurs in the eye, the eye should be irrigated with water for 20 minutes.
DIF: Cognitive Level: Apply
REF: p. 805
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. The nurse is planning care for a school-age child admitted to the hospital with hemophilia. Which interventions should the nurse
plan to implement for this child? (Select all that apply.)
a. Finger sticks for blood work instead of venipunctures
b. Avoidance of IM injections
c. Acetaminophen (Tylenol) for mild pain control
d. Soft tooth brush for dental hygiene
e. Administration of packed red blood cells
ANS: B, C, D
Nurses should take special precautions when caring for a child with hemophilia to prevent the use of procedures that may cause
bleeding, such as IM injections. The subcutaneous route is substituted for IM injections whenever possible. Venipunctures for
blood samples are usually preferred for these children. There is usually less bleeding after the venipuncture than after finger or heel
punctures. Neither aspirin nor any aspirin-containing compound should be used. Acetaminophen is a suitable aspirin substitute,
especially for controlling mild pain. A soft toothbrush is recommended for dental hygiene to prevent bleeding from the gums.
Packed red blood cells are not administered. The primary therapy for hemophilia is replacement of the missing clotting factor. The
products available are factor VIII concentrates.
DIF: Cognitive Level: Apply
REF: p. 806
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. Parents of a school-age child with hemophilia ask the nurse, “Which sports are recommended for children with hemophilia?”
Which sports should the nurse recommend? (Select all that apply.)
a. Soccer
b. Swimming
c. Basketball
d. Golf
e. Bowling
ANS: B, D, E
Because almost all persons with hemophilia are boys, the physical limitations in regard to active sports may be a difficult
adjustment, and activity restrictions must be tempered with sensitivity to the child’s emotional and physical needs. Use of
protective equipment, such as padding and helmets, is particularly important, and noncontact sports, especially swimming, walking,
jogging, tennis, golf, fishing, and bowling, are encouraged. Contact sports such as soccer and basketball are not recommended.
DIF: Cognitive Level: Apply
REF: p. 801
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
Copyright © 2017, Elsevier Inc. All Rights Reserved.
7
3. Which should the nurse teach about prevention of sickle cell crises to parents of a preschool child with sickle cell disease? (Select
all that apply.)
a. Limit fluids at bedtime.
b. Notify the health care provider if a fever of 38.5° C (101.3° F) or greater occurs.
c. Give penicillin as prescribed.
d. Use ice packs to decrease the discomfort of vasoocclusive pain in the legs.
e. Notify the health care provider if your child begins to develop symptoms of a
cold.
ANS: B, C, E
The most important issues to teach the family of a child with sickle cell anemia are to (1) seek early intervention for problems, such
as a fever of 38.5° C (101.3° F) or greater; (2) give penicillin as ordered; (3) recognize signs and symptoms of splenic
sequestration, as well as respiratory problems that can lead to hypoxia; and (4) treat the child normally. The nurse emphasizes the
importance of adequate hydration to prevent sickling and to delay the adhesion–stasis–thrombosis–ischemia cycle. It is not
sufficient to advise parents to “force fluids” or “encourage drinking.” They need specific instructions on how many daily glasses or
bottles of fluid are required. Many foods are also a source of fluid, particularly soups, flavored ice pops, ice cream, sherbet, gelatin,
and puddings. Increased fluids combined with impaired kidney function result in the problem of enuresis. Parents who are unaware
of this fact frequently use the usual measures to discourage bedwetting, such as limiting fluids at night. Enuresis is treated as a
complication of the disease, such as joint pain or some other symptom, to alleviate parental pressure on the child. Ice should not be
used during a vasoocclusive pain crisis because it vasoconstricts and impairs circulation even more.
DIF: Cognitive Level: Apply
REF: p. 797
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
OTHER
1. The nurse has initiated a blood transfusion on a preschool child. The child begins to exhibit signs of a transfusion reaction. Place in
order the interventions the nurse should implement sequencing from the highest priority to the lowest. Provide the answer using
lowercase letters separated by commas (e.g., a, b, c, d).
a. Take the vital signs.
b. Stop the transfusion.
c. Notify the practitioner.
d. Maintain a patent IV line with normal saline.
ANS:
b, a, d, c
If a blood transfusion reaction of any type is suspected, stop the transfusion, take vital signs, maintain a patent IV line with normal
saline and new tubing, notify the practitioner, and do not restart the transfusion until the child’s condition has been medically
evaluated.
DIF: Cognitive Level: Apply
REF: p. 811
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
Copyright © 2017, Elsevier Inc. All Rights Reserved.
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