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1. A child is admitted to the hospital with a diagnosis of Wilm's tumor, stage II. Which of the following statements most accurately describes this stage?
2. A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Note: More than one answer may be correct.
3. Which of the following conditions most commonly causes acute glomerulonephritis?
4. An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?
5. A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?
6. A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?
7. Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct?
8. A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions?
9. A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?
10. A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?
11. Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?
12. An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?
13. An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?
14. The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?
15. A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse LEAST likely to find in an abusing parent?
16. A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?
17. A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?
18. A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child's symptoms?
19. A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Note: More than one answer may be correct.
20. A child has recently been diagnosed with Duchenne's muscular dystrophy. The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?
The staging of Wilm's tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual nonhematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.
2. A, B, and C
Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark "tea colored" urine caused by large amounts of red blood cells. There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis.
Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.
A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.
Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.
Family history of heart disease is an inherited risk factor that is not subject to life style change. Having a first degree relative with heart disease has been shown to significantly increase risk. Overweight and smoking are risk factors that are subject to life style change and can reduce risk significantly. Advancing age increases risk of atherosclerosis but is not a hereditary factor.
7. A, C, and D
Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.
Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. Walking barefoot is not advised, as foot protection is important to avoid trauma that may lead to serious infection. Heating pads can cause injury, which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician.
Raynaud's disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis.
In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Myocardial infarction and atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure due to fluid overload. There is no reason to suspect an anxiety disorder in this patient. Though anxiety is a possible cause of her symptoms, the seriousness of pulmonary embolism demands that it be considered first.
Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment demands that it be instituted as soon as possible, often before the cause of stroke has been determined. Air embolus is not a concern. Thrombolytic therapy does not lead to expansion of the clot, but to resolution, which is the intended effect.
In torticollis, the sternocleidomastoid muscle is contracted, limiting range of motion of the neck and causing the chin to point to the opposing side. In craniosynostosis one of the cranial sutures, often the sagittal, closes prematurely, causing the head to grow in an abnormal shape. Plagiocephaly refers to the flattening of one side of the head, caused by the infant being placed supine in the same position over time. Hydrocephalus is caused by a build-up of cerebrospinal fluid in the brain resulting in large head size.
Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. Swimming is not a likely cause. The condition is usually self-limited, responding to ice, rest, and analgesics. Continued participation will worsen the condition and the symptoms.
A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Choices A, B, and C are not part of the routine adolescent exam.
The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. These parents also have a high incidence of low self-esteem, unemployment, unstable financial situation, and single status.
Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Half of children with the disorder recover without joint deformity, and about a third will continue with symptoms into adulthood. Physical activity is an integral part of therapy.
Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Parental presence is important for the adjustment of the child but not for the administration of medication.
The child's refusal to walk, combined with swelling of the limb is suspicious for fracture. Toddlers will often continue to walk on a muscle that is bruised or strained. The radius is found in the lower arm and is not relevant to this question. Toddlers rarely feign injury to be carried, and swelling indicates a physical injury.
19. A, B, D
Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones.
The recessive Duchenne's gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier.
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