The Child with Health Problems of the Urinary System 269
Answers, Rationales, and Test 4. 3. When an anomaly is found in one system,
Taking Strategies
The answers and rationales for each question follow
below, along with keys ( ) to the client need
(CN) and cognitive level (CL) for each question. Use
these keys to further develop your test-taking skills.
For additional information about test-taking skills
and strategies for answering questions, refer to pages
10–21, and pages 25–26 in Part 1 of this book.
The Client with Cryptorchidism
1. 4. Normally the testes descend by 1 year of age;
failure to do so may indicate a problem with patency
or a hormonal imbalance. By age 4 weeks, descent
may not have occurred. However, telling the father
that lack of descent is not a cause for worry is inappro-
priate and uncaring. Additionally, a statement such as
this may be false reassurance. By acknowledging the
father’s concern, the nurse indicates acceptance of his
feelings. If the testes have not descended, then they
will not be palpable in the scrotal sac. Surgery is not
discussed until after a full assessment is completed.
CN: Health promotion and maintenance;
CL: Synthesize
2. 3. A cold environment can cause the testes
to retract. Cold and touch stimulate the cremasteric
reflex, which causes a normal retraction of the testes
toward the body. Therefore, the nurse should warm
the hands and make sure that the environment also
is warm. Checking the diaper for urination provides
information about the infant’s voiding and urinary
function, not information about the testes. Giving
the infant a pacifier may help to calm the infant
and possibly make the examination easier, but the
concern here is with the temperature of the environ-
ment. Tapping on the inguinal ring would not be
helpful in assessing the infant.
CN: Health promotion and maintenance;
CL: Synthesize
3. 2. The nurse needs more information about
the father’s perceptions and feelings before provid-
ing any information or taking action. Determining
the exact nature of the father’s concern rather than
making an assumption about it is essential. There-
fore, the nurse should identify what is observed
and ask the father how he is feeling. Telling the
father that everything will be fine or not to worry
is inappropriate and provides false reassurance. It
also devalues the father’s concern. Later on it may
be appropriate for the father to talk to a parent of a
child with the same problem for support.
CN: Psychosocial adaptation;
CL: Synthesize
Billings_Part 2_Chap 2_Test 6.indd 269
such as the genitourinary system, that system
requires a more focused assessment to reveal other
conditions that also may be occurring. A bulging in
the inguinal area may suggest an inguinal hernia.
Also, hydrocele or an upper urinary tract anomaly
may occur on the same side as the undescended tes-
tis. A neuromuscular problem, not a genitourinary
problem such as undescended testes, would most
likely be the cause of abnormal lower extremity
reflexes. A history of frequent emesis may be caused
by pyloric stenosis or viral gastroenteritis. Poor
weight gain might suggest a metabolic or feeding
problem.
CN: Health promotion and maintenance;
CL: Analyze
5. 1. A trial of human chorionic gonadotrophin
may be given to stimulate descent of the affected tes-
tis. A trial of adrenocorticotropic hormone will not
cause the testis to descend. The cremasteric reflex
results in the testis being drawn up, the opposite of
the intended effect. Application of warmth, such as
warm baths, although soothing and relaxing for the
infant, would have little or no effect on stimulating
the testis to descend.
CN: Pharmacological and parenteral
therapies; CL: Apply
6. 2. Preoperative teaching would be directed at
the parents, because the child is too young to under-
stand the teaching. Telling the child that his penis
and scrotum will be “fixed,” telling the child he will
not see incisions after surgery, and using a doll to
illustrate the surgery are appropriate interventions
for a preschool-age child.
CN: Psychosocial adaptation;
CL: Create
7. 3. Because the incidence of testicular cancer
is increased in adulthood among children who have
had undescended testes, it is extremely important to
teach the adolescent how to perform the testicular
self-examination monthly. The undescended tes-
ticle is removed to reduce the risk of cancer in that
testicle. Removal of a testis would not necessarily
make the adolescent sterile because the other tes-
ticle remains. Although discussing the adolescent’s
future plans is important, it is not the priority at
this time. Because the adolescent has been dealing
with the situation for a long time, the need for a
sports physical at this time should not be a cause of
emotional distress requiring a lot of psychological
support.
CN: Health promotion and maintenance;
CL: Synthesize
8/7/2010 10:03:42 AM
 270 The Nursing Care of Children
The Client with Hydrocele
8. 3. A hydrocele is a collection of fluid in the
tunica vaginalis of the testicle or along the spermatic
cord that results from a patent processus vaginalis.
Failure of the upper part of the processus vaginalis to
atrophy allows the accumulation of fluid in the tes-
ticle and peritoneal cavity, causing an inguinal hernia.
CN: Physiological adaptation; CL: Apply
9. 3. A hydrocele is a collection of fluid in the
tunica vaginalis of the testicle or along the spermatic
cord that results from a patent processus vaginalis.
Because scrotal size is decreasing, the fluid is being
absorbed. Elevation of the infant’s bottom, mas-
sage, or keeping the infant quiet or in an infant seat
would have no effect in promoting fluid reabsorp-
tion in hydrocele.
CN: Physiological adaptation;
CL: Evaluate
10. 4. Some swelling and bruising are normal post-
operatively. By assessing the area with the mother, the
nurse is conveying acceptance of the mother’s con-
cern. In addition, the nurse needs to inspect the area
to determine if what the mother is describing is accu-
rate. Doing so also provides an opportunity for teach-
ing. Aspirin is not usually prescribed for children
because of the link between aspirin and Reye’s syn-
drome. Acetaminophen is commonly administered
for fever or pain relief. Asking the mother to wait in
the child’s room ignores the mother’s concerns. There
is no need to notify the doctor at this time.
CN: Psychosocial adaptation;
CL: Synthesize
The Client with Hypospadias
11. 2. The condition in which the urethral open-
ing is on the ventral side of the penis or below the
glans penis is referred to as hypospadias. Chordee
refers to a ventral curvature of the penis that results
from a fibrous band of tissue that has replaced
normal tissue. Circumcision is delayed because the
foreskin, which is removed with a circumcision,
often is used to reconstruct the urethra. The chordee
is corrected when the hypospadias is repaired. Cir-
cumcision is performed at the same time. Urethral
meatal stenosis, which can occur in circumcised
infants, results from meatal ulceration, possibly
leading to urinary obstruction. It is not associated
with hypospadias or circumcision. The infant is not
too small to have a circumcision, which is com-
monly performed on the first or second day of life.
CN: Reduction of risk potential;
CL: Apply
Billings_Part 2_Chap 2_Test 6.indd 270
12. In hypospadias, the urethral opening is on
the ventral side of the penis.
CN: Physiological adaptation; CL: Apply
13. 2. The preferred time for surgery is between the
ages of 6 and 18 months, before the child develops cas-
tration and body image anxiety. Children learn early
on about society’s emphasis on the importance of geni-
tals. Pain is different for each child and is not related
to the preferred time for repair of the hypospadias or
chordee. Although the child will probably not remem-
ber the experience, this is not the basis for having the
surgery at this age. If the condition is not repaired, the
child will have difficulty with toilet training because
urine is not eliminated through the tip of the penis.
CN: Physiological adaptation; CL: Apply
14. 1. The parents should keep the penis as dry
as possible until the stent is removed. Soaking in a
tub bath is not recommended. Children this age typ-
ically go home voiding directly into a diaper. Infants
may be started on juice at 6 months of age. Parents
are advised to keep their child well hydrated after a
hypospadius repair. Therefore, there is no reason to
avoid juice. Cleaning the tip of the penis 3 times a
day may cause unnecessary irritation.
CN: Safety and infection control;
CL: Synthesize
15. 2. The main purpose of the urethral catheter
is to maintain patency of the reconstructed urethra.
The catheter prevents the new tissue inside the
urethra from healing on itself. However, the urethral
catheter can cause bladder spasms. Recently, stents
have been used instead of catheters. The urethral
catheter will have no effect on the child’s pain level.
In fact, because bladder spasms are associated with
its use, the child’s complaints of pain may actually
increase. Urine output can be measured through the
suprapubic catheter because it provides an alterna-
tive route for urinary elimination, thus keeping the
bladder empty and pressure-free.
CN: Reduction of risk potential;
CL: Evaluate
8/7/2010 10:03:43 AM
 The Child with Health Problems of the Urinary System
16. 2. A dusky blue color at the tip of the penis
may indicate a problem with circulation, and the
nurse should notify the surgeon. Following surgery,
it is normal for the penis to be swollen and pink.
The penis may be misshapen and is unlikely to look
normal even after reconstruction.
CN: Physiological adaptation;
CL: Analyze
17. 4. The most important consideration for a
successful outcome of this surgery is maintenance
of the catheters or stents. A 12-month-old infant
likes to explore his environment but must be pre-
vented from manipulating his dressings or catheters
through the use of soft restraints. Allowing the
infant to become familiar with the dressings will not
prevent him from pulling at them. After surgery the
child is allowed limited activity, possibly with sit-
ting in the parent’s lap. A 12-month-old infant may
or may not be walking. If he is, most likely he will
be clumsy and possibly injure himself. Although
increasing fluids is important, 2,500 mL/day is an
excessive amount for a 12-month-old. Fluid require-
ments would be 115 mL/kg.
CN: Physiological adaptation;
CL: Create
18. 3. A normal white blood cell count in a
urinalysis is 1 to 2 cells/mL. A white blood cell
count of 25 per high-powered field indicates a
urinary tract infection. A urine specific gravity of
1.017 is within the normal range of 1.002 to 1.030.
After urologic surgery, it is not unusual for a small
number of red blood cells to appear in the urine.
The child’s urine pH is within the normal range of
4.6 to 8.
CN: Reduction of risk potential;
CL: Analyze
The Client with Urinary
Tract Infection
19. 3. 2% lidocaine lubricants have been found
to significantly reduce the pain of urinary catheter
insertion in children. If the unit does not have a
standing protocol to use the lubricant, the nurse
should request an order. A sedative would carry
with it additional risks that could be avoided
with the use of other methods to reduce pain. The
parents should be encouraged to hold the child
in addition to other pain relief methods. Frequent
urination would make the use of topical anesthet-
ics that must be left in place for a period of time
impractical.
CN: Basic care and comfort;
CL: Synthesize
Billings_Part 2_Chap 2_Test 6.indd 271
271
20. 2. Sulfonamides have been associated with
severe adverse reactions. A blistering rash may be a
sign of Stevens-Johnson syndrome, a severe allergic
reaction that manifests as skin lesions. This reaction
is life threatening and requires immediate attention.
Lotion should not be applied to skin with blisters.
Bactrim may cause photosensitivity, but this usually
appears as a mild red rash, not blisters. Increasing
the child’s fluid intake may help the urinary tract
infection, but does not address the rash.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
21. 1. Abdominal pain frequently accompanies
urinary tract infection in children 2 years of age and
older. Other associated signs and symptoms include
decreased appetite, vomiting, fever, and irritability.
The presence of swollen lymph glands (lymphade-
nopathy) is unrelated to urinary tract infections.
Lymphadenopathy is associated with a systemic
infection or possibly cancer. Skin rash is associated
with exposure to allergens or irritants (e.g., poison
ivy or harsh soaps); prolonged contact with urine
(e.g., diaper dermatitis); or illnesses such as measles,
rheumatic fever, or juvenile rheumatoid arthritis.
Flank or back pain is associated with urinary tract
infection in children older than 2 years of age and in
adults.
CN: Physiological adaptation;
CL: Analyze
22. 2. To ensure appropriate psychosocial
development, a child needs to have normal patterns
maintained as much as possible during illness. It is
tempting to give ill children special treatment and
to relax discipline. However, family routines and
discipline should be kept as normal as possible. The
child needs to know the limits to ensure feelings
of security. When they are ill, children commonly
attempt to stretch the rules and limits. If this occurs,
returning to the previous well-behavior patterns will
take time.
CN: Health promotion and maintenance;
CL: Synthesize
23. 1. The reason that urinary tract infections
are a problem in children with vesicoureteral reflux
is that urine flows back up the ureter, past the
incompetent valve, and back into the bladder after
the child has finished voiding. This incomplete
emptying of the bladder results in stasis of urine,
providing a good medium for bacterial growth and
subsequent infection. Vesicoureteral reflux does not
cause bladder spasms or painful urination. How-
ever, the child may experience painful urination
with a urinary tract infection.
CN: Physiological adaptation; CL: Apply
8/7/2010 10:03:44 AM
 272 The Nursing Care of Children
The Client with Glomerulonephritis
24. 2. An adolescent with acute glomerulone-
phritis has a high urine specific gravity related to
oliguria caused by inflammation of the glomeruli.
The client will have periorbital edema, but not
the generalized edema that occurs in nephrotic
syndrome. In glomerulonephritis, there is some
albumin in the urine, but there are large amounts
of red blood cells, giving the urine a brown color.
The urine in glomerulonephritis is scanty, averag-
ing about 400 mL in 24 hours, which leads to fluid
volume excess and hypertension.
CN: Physiological adaptation;
CL: Synthesize
25. 3. The best selection of food would include
no added salt or salty food. Because sodium cannot
be excreted due to the oliguria and to avoid increas-
ing the hypertension, a low-salt diet is recom-
mended. Most canned foods have sodium added as
a preservative. Hamburger, ham, hot dogs, canned
peas, canned carrots, corn chips, pickles, and milk
are high in sodium.
CN: Health promotion and maintenance;
CL: Synthesize
26. 2. Hypertension occurs with acute glomeru-
lonephritis. The symptoms of headache and blurred
vision may indicate an elevated blood pressure.
Hypertension in acute glomerulonephritis occurs
due to the inability of the kidneys to remove fluid
and sodium; the fluid is reabsorbed, causing fluid
volume excess. The nurse must verify that these
symptoms are due to hypertension. Calling the phy-
sician before confirming the cause of the symptoms
would not assist the physician in his treatment.
Putting the client to bed may help treat an elevated
blood pressure, but first the nurse must establish
that high blood pressure is the cause of the symp-
toms. Administering Tylenol for high blood pressure
is not recommended.
CN: Physiological adaptation;
CL: Synthesize
27. 3. Most likely, the nurse suspects that the
child is exhibiting signs and symptoms of glomeru-
lonephritis, such as periorbital edema and fever.
Other signs and symptoms include loss of appetite,
dark-colored urine, pallor, headaches, and abdomi-
nal pain. To confirm this suspicion, the nurse would
ask about the child’s urinary elimination patterns.
Typically the child with glomerulonephritis expe-
riences a decrease in urine output. Asking about
any recent sore throat would provide additional
information to confirm the suspicion of glom-
erulonephritis, because the most common type is
acute poststreptococcal glomerulonephritis, which
Billings_Part 2_Chap 2_Test 6.indd 272
follows a strep throat by 10 to 14 days. Frequently,
the children have only mild cold symptoms and do
not realize they have a streptococcal infection. Ask-
ing whether the child plays with friends as usual
is important and gives the nurse information about
how the child feels in general. However, this is a
general question that would be appropriate to ask
later on in the history. Although asking the mother
about the color of the child’s urine is important,
the nurse needs to determine whether there is any
change in the child’s urinary output first.
CN: Physiological adaptation;
CL: Analyze
28. 3. The child with acute poststreptococcal
glomerulonephritis experiences a problem with
renal function that ultimately affects fluid balance.
Because weight is the best indicator of fluid bal-
ance, obtaining daily weights would be the highest
priority.
CN: Physiological adaptation;
CL: Analyze
29. 2. The most appropriate and effective choice
would be ice chips, because they help moisten the
mouth and lips while keeping fluid intake low.
However, ice chips must still be counted as intake
with the fluid restriction. Sweet beverages, such as
diet cola or lemonade, commonly increase thirst.
Tap water effectively relieves thirst but does not
help keep fluid intake low.
CN: Physiological adaptation;
CL: Synthesize
30. 4. The best choice would be fruits such
as strawberries and kiwi because they are low in
sodium and potassium. Typically, diet is related
to the stage and severity of the disease. In children
with uncomplicated disease, a regular diet is offered
but sodium is usually restricted. In children with
hypertension and edema, moderate restriction of
sodium is instituted. Pizza and cola, hamburgers
and fries, and ice cream are high in sodium and
should be avoided. Children with oliguria usually
also have potassium restricted. Therefore, foods
such as bananas and oranges would be avoided.
CN: Physiological adaptation;
CL: Evaluate
31. 1. Generally, school-age children enjoy activi-
ties with their peers first, then family members,
and lastly younger children. School-age children
like to be busy but also to accomplish something.
This helps to meet their task of industry versus
inferiority, feeling good about what they are able to
accomplish.
CN: Health promotion and maintenance;
CL: Create
8/7/2010 10:03:45 AM
 The Child with Health Problems of the Urinary System
32. 1. The nurse should assess the child’s
neurologic status, because hypertensive encephalop-
athy is a major potential complication of the acute
phase of glomerulonephritis. Seizure precautions
also should be instituted. Hypertensive encephalop-
athy can result in transient loss of vision, hemipare-
sis, disorientation, and grand mal seizures. Encour-
aging the child to drink more water is inappropriate
because the child has had a low urine output for
14 hours. Typically, in this situation, fluids would
be restricted. Although a low-sodium diet is encour-
aged, it is not the priority action at this time. Ini-
tially, bed rest, not ambulation, is advocated during
the acute phase of glomerulonephritis.
CN: Reduction of risk potential;
CL: Synthesize
33. 3. Children recovering from glomerulonephritis
need to avoid exposure to all types of infections. Glom-
erulonephritis is caused by group A beta-hemolytic
streptococcus, a common cause of sore throat. As
the child recovers, he or she may be susceptible to a
recurrence if exposed to the organism again. During
convalescence from glomerulonephritis, fluid and
dietary restrictions are no longer indicated because
the kidneys are now functioning normally. There is no
need for the parents to assess the child’s vital signs.
CN: Physiological adaptation;
CL: Synthesize
34. 2. The nurse would expect a person with a
normal GFR to have approximately equal inputs and
outputs. Chronic renal failure has five stages. In stage I
the glomerular filtration rate (GFR) is approximately
≥90 mL/minute/1.73 m2. In stage II the GFR decreases
to approximately 60 to 89 mL/minute/1.73 m2. The
decreased urine output may indicate worsening
disease and should be reported. Assessing the client’s
intake and output is still important, but notifying the
provider is the priority. Fluids are restricted based on
decreased sodium. Clients are encouraged to drink to
thirst. Therefore, there is not enough information to
suggest increasing or restricting fluids.
CN: Physiological adaptation;
CL: Synthesize
The Client with Nephrotic Syndrome
35. 2, 3. Adverse effects of steroid therapy include
edema of the face and trunk, increased susceptibility
to infection, gastric and intestinal mucosal bleed-
ing, sodium and water retention, and hypertension.
Urinary output is decreased due to the retention of
sodium. Bleeding gums do not result from steroids.
Steroid therapy does not cause vision problems.
CN: Pharmacological and parenteral
therapies; CL: Create
Billings_Part 2_Chap 2_Test 6.indd 273
273
36. 3. The National Institute of Health has
established blood pressure standards for gender, age,
and height. Reading at or above the 95th percentile
are considered indicative of hypertension. Here,
both the systolic and diastolic readings are at the
95th percentile for a boy who is at the 75th percentile
for height. This blood pressure may be a side effect
of the medication or part of the disease process
and needs to be reported. The charts do not define
hypotension. Readings below the 90th percentile
are considered normal. Blood pressures at the 90th
percentile, but below the 95th are considered prehy-
pertension. Blood pressures at the 99th percentile are
considered stage II hypertension and are most likely
to need antihypertensive medications.
CN: Reduction of risk potential;
CL: Analyze
37. 1. Children with nephrotic syndrome usually
require sodium restriction. Because potato chips
and bologna are high in sodium, the mother’s state-
ment about finding something else reflects under-
standing of this need. Although fluid intake is not
restricted in children with nephrotic syndrome, 4 L
is an excessive amount for a toddler. The typical
fluid requirement for a toddler is 115 mL/kg. Surgi-
cal intervention and antibiotic therapy are not parts
of the treatment plan for nephrotic syndrome.
CN: Physiological adaptation;
CL: Evaluate
38. 4. The best indicator of fluid balance is
weight. Therefore, daily weight measurements help
determine fluid losses and gains. Although limiting
visitors to 2 to 3 hours per day or maintaining strict
bed rest would help to ensure that the child gets
adequate rest, this is unrelated to the child’s fluid
balance. In nephrotic syndrome, urine is tested for
protein, not specific gravity.
CN: Physiological adaptation;
CL: Synthesize
39. 2. The child’s swollen eyes are caused by
fluid accumulation. Elevating the head of the bed
allows gravity to increase the downward flow of flu-
ids in the body, away from the face. Applying cool
compresses or eye drops, or limiting television, may
be comforting but will not relieve the swelling.
CN: Physiological adaptation;
CL: Synthesize
40. 1. Fluid accumulates in the abdomen and
interstitial spaces owing to hydrostatic pressure
changes. Increased abdominal fluid is evidenced by
an increase in abdominal girth. Therefore, decreased
abdominal girth is a sign of reduced fluid in the
third spaces and tissues. When fluid accumulates in
the abdomen and interstitial spaces, the child does
not feel hungry and does not eat well. Although
8/7/2010 10:03:45 AM
 274 The Nursing Care of Children
increased caloric intake may indicate decreased
intestinal edema, it is not the best and most accurate
indicator of fluid retention. Increased respiratory
rate may be an indication of increasing fluid in the
abdomen (ascites) causing pressure on the dia-
phragm. Heart rate usually stays in the normal range
even with excessive fluid volume.
CN: Physiological adaptation;
CL: Evaluate
41. 4. Placing soft cloth between opposing skin
surfaces absorbs moisture and keeps the area dry,
thus preventing any further breakdown. The child
with nephrotic syndrome and severe edema is usu-
ally maintained on bed rest. Therefore, ambulation
is not appropriate. Applying lotion or powder to
edematous surfaces that touch increases moisture
and can lead to maceration, causing further break-
down.
CN: Basic care and comfort;
CL: Synthesize
42. 11.3 mg
25 lb × 2.2 = 11.3 kg
11.3 kg × 2 mg = 22.7 mg/day
22.7 mg × 2 = 11.3 mg per dose
CN: Pharmacological and parenteral
therapies; CL: Apply
43. 2. A child recovering from nephrotic syn-
drome should be protected from infection. Therefore,
the nurse would teach the parents to keep the child
away from others with an infection. Because pain is
not associated with this disorder, pain medication
typically is not needed. The physician should be
notified if urine output decreases, not increases. In
children recovering from nephrotic syndrome, there
is no reason to administer acetaminophen daily.
CN: Reduction of risk potential;
CL: Synthesize
The Client with Acute or Chronic
Renal Failure
44. 3. A client who has had a ruptured appen-
dix may have peritoneal scarring that may alter the
effectiveness of treatment. Living a long distance
from a medical facility is typically a reason to select
peritoneal dialysis. Attending a large school is not a
problem, but the school nurse needs to be included
as part of the health care team. Typically the treat-
ment schedule can be planned to allow for uninter-
rupted sleep at night.
CN: Management of care; CL: Create
Billings_Part 2_Chap 2_Test 6.indd 274
45. 3. Until it heals, the catheter exit site is
particularly vulnerable to invasion by pathogenic
organisms. Therefore, the site must be monitored
for signs of infection. An occlusive dressing is not
needed because there is no danger of air being sucked
in or out of the peritoneal space. Furthermore, the
catheter used is designed with a cuff, so that the
skin grows around the catheter, sealing off the area.
Site care may be done at any time, but the child may
experience abdominal discomfort if the peritoneal
space is dry during site care. Holding the catheter
taut or pulling on it may cause irritation of the skin at
the exit site, which could lead to infection.
CN: Safety and infection control;
CL: Synthesize
46. 4. With minimal or absent kidney function,
the serum phosphate level rises, and the ionized cal-
cium level falls in response. This causes increased
secretion of parathyroid hormone, which releases
calcium from the bones. Therefore, the intake of
foods high in phosphorus is restricted. Because
renal failure results in decreased erythropoietin
production, an increase in ascorbic acid intake is
needed. Because magnesium is minimally affected
by renal failure, its intake need not be restricted.
CN: Physiological adaptation; CL: Apply
47. 4. Demonstration of desire to do the dressing
changes and manage medications implies compli-
ance with the medical regimen and acceptance of
the condition, thereby indicating a positive self-
image. Diffuse somatic symptoms could indicate
anxiety or problems with coping, with a nega-
tive effect on self-concept. Insistence on choosing
restricted foods implies that the adolescent has
not accepted the diagnosis and is noncompliant,
possibly indicating a negative self-concept. Social
withdrawal from activities may indicate depression,
possibly negatively affecting the self-concept.
CN: Physiological adaptation;
CL: Evaluate
48. 2. The child with acute renal failure needs
extra calories to reduce tissue catabolism, metabolic
acidosis, and uremia. Using a high-fat and carbo-
hydrate diet helps to supply the necessary extra
calories. If the child is able to tolerate oral foods,
concentrated food sources that are high in carbo-
hydrate and fat but low in protein, potassium, and
sodium may be provided.
CN: Physiological adaptation; CL: Apply
49. 3. For an adolescent, body image is a major
concern. The presence of an abdominal catheter can
greatly affect the client’s body image. The adolescent
needs opportunities to discuss feelings about altered
body image due to the catheter. Adolescents need to
be with their peers and to maintain social activities
8/7/2010 10:03:46 AM
 The Child with Health Problems of the Urinary System
and contacts in order to meet the developmental tasks
for this age group. The adolescent client may choose
to confide in friends for both psychological health and
physical safety. Because peers are most important to
adolescents, they will confide in their peers before
confiding in family members. Another major develop-
mental need of the adolescent is achieving indepen-
dence. Relying on the parents would interfere with
the adolescent’s ability to do so.
CN: Psychosocial adaptation; CL: Create
50. 4. Tissue swelling, pain, redness, and exu-
date indicate infection. Dialysate leakage is associ-
ated with improper catheter function, incomplete
healing at the insertion site, or excessive instillation
of dialysate. Granulation tissue indicates healing
around the exit site, not infection. Increased time for
drainage may indicate that the tube is kinked, sug-
gesting an obstruction.
CN: Reduction of risk potential;
CL: Analyze
51. 1. Normally, dialysate drainage return should
be clear. With peritonitis, large numbers of bacteria,
white blood cells, and fibrin cause the dialysate to
appear cloudy. Abdominal distention is unrelated
to peritonitis. However, it might suggest an obstruc-
tion. Weight gain and shortness of breath are associ-
ated with fluid excess, not infection.
CN: Physiological adaptation;
CL: Evaluate
52. 4. With edema, pallor can occur owing
to hemodilution as intestinal fluid moves to the
vascular space. The child would exhibit pulmo-
nary crackles secondary to pulmonary congestion
and edema. Dialysate outflow would decrease, not
increase, as the body attempts to conserve fluid. The
child’s blood pressure would be increased because
of excessive fluid volume.
CN: Physiological adaptation;
CL: Analyze
53. 1. Accumulation of hard stool in the bowel
can cause the distended intestine to block the holes
of the catheter. Consequently, the dialysate can-
not flow freely through the catheter. Decreasing the
dialysate infusion may make the dialysis less effec-
tive. Altering fluid, electrolyte, and waste product
removal can cause fluid and electrolyte imbalance
and increased levels of blood urea nitrogen and cre-
atinine. Incorporating the increased times into the
dialysis may make the dialysis less effective because
fewer cycles can be scheduled. Shoulder pain,
which may occur occasionally, can be caused by air
in the peritoneal space and diaphragmatic irritation.
However, it is unrelated to inflow and drain times.
CN: Physiological adaptation;
CL: Synthesize
Billings_Part 2_Chap 2_Test 6.indd 275
275
54. 4. Regulation of the diet is the most effective
means, besides dialysis, for reducing renal excre-
tion. Dietary phosphorus is restricted, which
reduces the protein load on the kidneys. Clients are
also given substances to bind phosphorus in the
intestines to prevent absorption. Limited protein
in the diet should include foods high in essential
amino acids. Foods high in fat and carbohydrate are
used to increase caloric intake. Sodium and water
may not be restricted because of the continual loss
of sodium and water through the dialysate. Iron-rich
foods are commonly high in protein.
CN: Physiological adaptation;
CL: Evaluate
The Client with Wilms’ Tumor
55. 3. When a client receiving chemotherapy
develops neutropenia, eating uncooked fruits and
vegetables may pose a health risk due to possible
bacterial contamination. All other foods are either
cooked or pasteurized and would not produce a
health risk.
CN: Safety and infection control;
CL: Apply
56. 2. The abdomen of the child with Wilms’
tumor should not be palpated because of the danger
of disseminating tumor cells. Techniques such as
measuring the occipitofrontal circumference (which
is done in children younger than 18 months of age
because the anterior fontanel closes between 12 to
18 months of age), upright positioning, and measur-
ing chest circumference are not necessarily con-
traindicated; however, the child with Wilms’ tumor
should always be handled gently and carefully.
CN: Physiological adaptation;
CL: Analyze
57. 1. A stage II tumor is one that extends beyond
the kidney but is completely resected. The tumor
staging is verified during surgery to maximize treat-
ment protocols. The following criteria for staging are
commonly used: stage I, tumor is limited to the kid-
ney and completely resected; stage II, tumor extends
beyond the kidney but is completely resected; stage
III, residual nonhematogenous tumor is confined
to the abdomen; stage IV, hematogenous metastasis
occurs, with deposits beyond stage III (lung, bone
and brain, liver); stage V, bilateral renal involvement
is present at diagnosis.
CN: Physiological adaptation;
CL: Evaluate
58. 3. The child who has undergone abdominal
surgery is usually placed in a semi-Fowler’s posi-
tion to facilitate draining of abdominal contents
8/7/2010 10:03:47 AM
 276 The Nursing Care of Children
and promote pulmonary expansion. The modified
Trendelenburg position is used for clients in
shock. The Sims’ position is likely to be uncom-
fortable for this child because of the large trans-
abdominal incision. The supine position, without
the head elevated, puts the child at increased risk
for aspiration.
CN: Reduction of risk potential;
CL: Synthesize
59. 1. Children who have undergone abdominal
surgery are at risk for intestinal obstruction from a
dynamic ileus. Indications of intestinal obstruction
include abdominal distention, decreased or absent
bowel sounds, and vomiting. Later signs of intesti-
nal obstruction include tachycardia, fever, hypoten-
sion, increased respirations, shock, and decreased
urinary output.
CN: Reduction of risk potential;
CL: Analyze
60. 3. Because the child has only one kidney,
measures should be recommended to prevent
urinary tract infection and injury to the remaining
kidney. Severe pain and dependent edema are not
associated with surgery for Wilms’ tumor. Dietary
sodium is not restricted because function in the
remaining kidney is not impaired.
CN: Reduction of risk potential;
CL: Create
Managing Care Quality and Safety
61. 4. There are many problems with this medi-
cation order. The abbreviation QOD is on the Joint
Commission’s “do not use list.” The abbreviation
D/C may also be interpreted as “discontinue” or
“discharge.” The prescriber should have specifi-
cally stated when to start the lower dose because the
Billings_Part 2_Chap 2_Test 6.indd 276
nurse could reason beginning the medication that
day, the next, or even the day after that. The only
safe thing to do is call for clarification.
CN: Safety and infection control;
CL: Synthesize
62. 3. The charge nurse should assure the parent
that it is okay to use CIC and discuss the conversa-
tion with the nurse. It is possible that the nurse
was unaware of current research findings or unit
policies. The charge nurse should also determine
if the parent has the supplies and space to clean
the catheters. If not, the procedure may need to be
modified to use a new catheter each time, but the
insertion principles would not change. Parents are
frequently taught how to do CIC while a child is
in the hospital. Therefore, the rationale that it now
becomes unsafe, or that sterile technique is needed,
is faulty. Switching nurses will not solve the under-
lying problem.
CN: Management of care; CL: Synthesize
63. 3. The U.S. Department of Health and Human
Services has an Internet-based family health history
tool that can make sharing a client’s health history
easier. This is particularly helpful because it can
be accessed by the client from a variety of loca-
tions. Access to a well-constructed e-history will
facilitate care if the adolescent becomes ill while at
college. Because the client is 18, legally the nurse
cannot transfer the records to the school without
permission. Also, the adolescent may need to seek
treatment in facilities other than the health cen-
ter. Instructing the adolescent to always carry the
nephrologist’s phone number is not bad advice, but
compliance may vary and there is no guarantee the
provider will be available in all instances. Telling
the parent that the son must learn to manage his
own disease does not address the parent’s concern.
CN: Management of care; CL: Synthesize
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