Exam 9 Women and Children Chapter35, (Adult Health 41, 42, 43)
Institute droplet precautions in addition to standard precautions. 35
A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which intervention should the nurse take initially? Institute droplet precautions in addition to standard precautions. Encourage the mother to hold and comfort the infant. Educate the family about preventing bacterial meningitis. Palpate the child's fontanels (fontanelles).
The child will attain the highest level of functioning for his/her mental age. 35
A nurse is developing a plan of care for a child who has congenital infantile glaucoma. Which of these outcomes should receive priority in the plan? The child's communication skills will improve. The child will learn basic safety rules. The child will attain the highest level of functioning for his/her mental age. The child will develop skills to meet self-care needs within his/her ability.
use of the affected eye promotes vision development. 35
The nurse will help parents of a child with amblyopia understand that occluding vision in the unaffected eye is therapeutic because: occlusion relieves eye strain in the affected eye. use of the affected eye promotes vision development. the pain of amblyopia is relieved in both eyes. pupil size in the affected eye will increase.
=Allow the child to see the nurse prior to touching or completing any assessments or procedures. 35
The nurse in the acute care setting is caring for a child with deafness. Which nursing intervention is appropriate for this child? =Touch the child gently on the shoulder to let the child know you are present in the room. =Allow the child to see the nurse prior to touching or completing any assessments or procedures. =Encourage the parents to stay with the child to allow for easier communication for the nursing staff.
Allow the child to see the nurse prior to touching or completing any assessments or procedures. 35
The nurse in the acute care setting is caring for a child with deafness. Which nursing intervention is appropriate for this child? Touch the child gently on the shoulder to let the child know you are present in the room. Allow the child to sleep in the dark in order to hear better at night. Allow the child to see the nurse prior to touching or completing any assessments or procedures. Encourage the parents to stay with the child to allow for easier communication for the nursing staff.
Amblyopia 35
The nurse is screening a 4-year-old girl for vision problems. What problem could result in loss of vision? Amblyopia Exotropia Diplopia Nystagmus
encouraging the child to keep his hands away from his eyes 35
The nurse is teaching the family of a 6-year-old boy with allergic conjunctivitis how to minimize his exposure to allergens. What action would the nurse anticipate as being most difficult for the family to implement? washing the child's hands and face when returning from outdoors rinsing the child's eyelids with a clean washcloth and cool water making sure the child showers and shampoos before bedtime
rubbing the eyes difficulty reading the blackboard squinting 35
What symptom(s) in an 8-year-old child will alert the nurse to screen for myopia? Select all that apply. rubbing the eyes difficulty reading the blackboard profuse watering of the eyes squinting difficulty differentiating color
Lack of depth perception (stereopsis) 35
In examining the vision of a 9-year-old girl, the nurse notices that she frequently reaches either too far or not far enough when attempting to take an object from the nurse's hand. Which condition does the nurse suspect? Lack of depth perception (stereopsis) Lack of accommodation Diplopia Refractive error
Projectile vomiting 35 Projectile vomiting is an early sign of increased intracranial pressure. Bradycardia, Cheyne-Stokes respirations, and fixed dilated pupils are late signs of increased intracranial pressure.
What finding would lead the nurse to suspect that a child is beginning to develop increased intracranial pressure? Bradycardia Cheyne-Stokes respirations Fixed, dilated pupils Projectile vomiting
down and back. 35
A nursing instructor is working with a student caring for an 18-month-old client. In order to ascertain that the tympanic membrane is optimally visualized, the faculty will assess that the student pulls the pinna of the ear: down and forward. up and back. down and forward. down and back.
"What happened just before the seizures? 35
The emergency room nurse is taking a history of a 1-year-old child whose parent said that she had a "fit" at home. Which inquiry would be best to start with? "Were there any jerky movements?" "What happened just before the seizures?" "How did you treat the child afterwards?" "Was the child unconscious?"
high-pitched cry and nuchal rigidity 35
The nurse is caring for a 12-month-old infant diagnosed with Haemophilus influenzae meningitis. Which clinical manifestation would likely have been noted in this child? high-pitched cry and nuchal rigidity shaking the head and pulling the ear severe vomiting and confusion body stiffening and loss of consciousness
administering antibiotics as soon as they're available 35
The nurse is caring for a 20-month-old girl with equivocal bacterial otitis media, a severe earache, and a temperature of 39°C (102.2°F). Which intervention would the nurse expect to implement? administering antibiotics as soon as they're available obtaining a culture of fluid from the middle ear determining if the girl's balance is shaky when walking administering antivirals to ensure broad coverage of all organisms
Sunlight is "too bright" 35
A 16-year-old boy reports to the school nurse with headaches and a stiff neck. Which sign or symptom would alert the nurse that the child may have bacterial meningitis? Fixed and dilated pupils Frequent urination Sunset eyes Sunlight is "too bright"
Their child probably will benefit from early schooling to increase ability for self-care. 35
An infant is diagnosed as having cerebral palsy. When planning care, which would the nurse stress to the parents? Their child probably will benefit from early schooling to increase ability for self-care. Administering an anti-acetylcholinergic drug to decrease muscle spasms is crucial. The parent should be tested during future pregnancies to predict similar involvement. The infant's disease will cause progressive brain cell degeneration with age.
Amblyopia 35 lazy eye
A nurse develops a plan of care for a child that includes patching the eye. This plan of care would be most appropriate for which condition? Astigmatism Hyperopia Myopia Amblyopia
It is caused by chronic otitis media or another infection. 35
The nurse is caring for a child who has conductive hearing loss. What is true regarding this type of hearing loss? It is caused by chronic otitis media or another infection. It is caused by maternal rubella. It is generally severe and unresponsive to medical treatment. It is often undetected until the child goes to school.
Administer lorazepam IV as prescribed. 35
The nurse is caring for a school-age child who has been having a continuous seizure for the last 40 minutes. What is the priority action by the nurse? Administer lorazepam IV as prescribed. Perform a glucose finger stick to determine the child's blood sugar level. Administer carbamazepine as prescribed. Observe and document the length of time of the seizure and type of movement observed.
"Our child recently helped clean the basement." 35
The nurse is taking a health history for a 9-year-old child with conjunctivitis. Which statement by the parents leads the nurse to suspect that the child is experiencing allergic conjunctivitis? "Our child recently helped clean the basement." "Our child was exposed to several family members with an infection." "Our child just recovered from an upper respiratory infection." "We have a family history of conjunctivitis."
Bacteria entering through the eustachian tube 35
The nurse is teaching parents of a 6-year-old child about otitis media (OM). What predisposes the child to OM infections? The use of cotton swabs, which can damage the eardrum Eustachian tubes that are long and narrow in children Swimming and other water activities Bacteria entering through the eustachian tube
not smoking in home hand hygiene 35
A family has a 3-year-old child with recurrent ear infections. What health promotion measure(s) will the nurse recommend to reduce the chance of future infections? Select all that apply. breastfeeding not smoking in home hand hygiene no pets in the home daily bathing
"I need to watch for any new bruises or bleeding and let my health care provider know about it." 35 Carbamazepine is an antiseizure medication. It can cause bone marrow depression, so parents need to watch for any signs of bruising, bleed, or infection and notify their health care provider if this happens.
The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching? "I will give the medication to him when I first wake him up in the morning." "This medication may cause him to have trouble sleeping. He may need something else to help him sleep." "I need to watch for any new bruises or bleeding and let my health care provider know about it." "I'm glad to know he will only need this medication for a short time to stop his seizures."
offering vision screening to all students in kindergarten 35
A school nurse knows that most of the students in the community's elementary school have not received routine vision screening because the families live below the federal poverty threshold. What is the most effective method to promote vision screening for this client population? offering vision screening to all students in kindergarten sending information home to families about the importance of vision screening requiring vision screening prior to enrollment in grade 6 providing information about signs and symptoms of vision problems
ensuring the protective eye patch is securely in place 35
The nurse is providing immediate postoperative care for a 3-month-old who had a cataract removed. Which intervention would be the priority? ensuring the protective eye patch is securely in place instructing parents about using protective sunglasses teaching the family how to use antibiotic eye drops explaining to the parents about patching the eye as therapy
Staphylococcus aureus 35
A group of students are reviewing the various causes of bacterial conjunctivitis in children. The students demonstrate understanding of this condition when they identify what as the most common cause? Staphylococcus aureus Streptococcus pneumoniae Haemophilus influenzae Chlamydia trachomatis
Assess the client's respiratory rate. 35
A 10-month-old infant is brought to the emergency department by the parents after they found the infant face down in the bathtub. The parent states, "I just left the bathroom to answer the phone. When I came back, I found my infant." Which nursing action is priority? Assess the client's respiratory rate. Start cardiopulmonary resuscitative measures. Determine how long the client was face down in the water. Apply a heart monitor to the client.
Elevate the mandible to assess airway with the head in a neutral position. 35
A 16-year-old has suffered a thoracic-level spinal injury from a diving accident. To initiate CPR at the poolside, which measure would be most important? Hyperextend the neck to clear the airway prior to mouth-to-mouth resuscitation. Administer cardiopulmonary resuscitation in a prone position. Do not administer CPR after a head injury. Elevate the mandible to assess airway with the head in a neutral position.
"Introducing fluids slowly reduces the risk of vomiting, which can increase intraocular pressure." 35
A 4-month-old child underwent cataract surgery 3 hours ago. The parents ask why they are only allowed to give the child small amounts of fluid now. How does the nurse respond? "Introducing fluids slowly reduces the risk of vomiting, which can increase intraocular pressure." "Introducing fluids slowly prevents aspiration, which would increase the risk of pneumonia." "Introducing fluids slowly allows the bowel time to recover from the anesthetic, which decreases the risk of bowel obstruction." "Introducing fluids slowly reduces the risk of electrolyte imbalances, which can lead to cardiac arrhythmias."
Relieving the child's pain 35
A 5-year-old child is diagnosed with acute otitis media. Which nursing intervention would be priority? Relieving the child's pain Administering a mydriatic Cautioning the child not to pull on the ear Cautioning the child not to blow the nose
"Your child will need to wear the patch for a few days to keep him/her from rubbing or putting pressure on the eye." 35
A 7-month-old is scheduled for surgical correction of strabismus. The child's mother says to the nurse, "I'm glad my child will never have to wear that patch again." Which of these responses would be most appropriate for the nurse to make? "Your child will never need to wear the patch again." "Your child will need to wear the patch for a few days to keep him/her from rubbing or putting pressure on the eye." "Your child will need to wear the patch for several months to keep the eye in alignment." "Your child will have to be in restraints for a week to keep him/her from rubbing the eye."
"The tubes remain in place for 6 to 12 months until they come out by themselves." 35
A child having tympanostomy tubes placed asks, "How and when will the tubes be removed?" What is the nurse's best response? "You will have them replaced every 2 months until you reach age 18." "The tubes remain in place for 6 months and then are dissolved by vinegar." "The tubes remain in place for 6 to 12 months until they come out by themselves." "The tubes are not removed; they grow permanently into place."
"Wake him every 2 hours to check his movement and responses." 35
A child is brought to the emergency department after sustaining a concussion. The child is to be discharged home with his parents. What would the nurse include in the child's discharge instructions? "Expect his headache to get worse initially and then disappear." "Wake him every 2 hours to check his movement and responses." "Call your medical provider if he vomits more than five times." "Any watery fluid draining from his ears is normal."
lethargic unable to lie with hips flexed and straighten the leg out neck hurts 102.4°F (39.1°C) 92% on room air
A nurse in the emergency department (ED) is assessing a 2-year-old male child. The parents state the child "has been very feverish the past few days, and today the child developed a purple rash on the chest. The child is now very sleepy." Click to highlight the findings that will require immediate follow-up. The assessment reveals the child is lethargic but opens eyes and answers yes and no to questions. The child is unable to lie with hips flexed and straighten the leg out , and states their neck hurts when trying to move it. Vital signs: temperature, 102.4°F (39.1°C) ; heart rate, 120 beats/min; blood pressure, 78/45 mm Hg; respirations, 28 breaths/min ; oxygen saturation, 92% on room air .
explaining instructions using simple and specific terms the child understands allowing the child to explore the postoperative equipment with one's hands orienting the child to the hospital room using the child's body parts to refer to the area where the client may have postoperative pain 35
A nurse is developing a plan of care for a child who is admitted to the hospital for surgery. The child is visually impaired. What would be appropriate action(s) for the nurse to include in the child's plan of care? Select all that apply. explaining instructions using simple and specific terms the child understands allowing the child to explore the postoperative equipment with one's hands orienting the child to the hospital room using the child's body parts to refer to the area where the client may have postoperative pain speaking to the child in a voice that is slightly louder than the usual tone of voice
ensure proper oxygenation administer intravenous (IV) or intramuscular (IM) benzodiazepine 35
A nurse on the neurology unit is monitoring an 8-year-old child admitted with seizures. The child experiences a prolonged tonic-clonic seizure. Complete the following sentence(s) by choosing from the lists of options. The nurse should first ______________________________________ +ensure proper oxygenation +insert an airway into the client's mouth +suction the client's airway followed by __________________________________________ +administer an antiepileptic by mouth +do not allow the client to sleep once the seizure has ended + administer intravenous (IV) or intramuscular (IM) benzodiazepine
"About 40% to 50% of children who follow the diet have really good results." "The diet consists of high fat foods." "Protein is limited in this diet." 35 A ketogenic diet has been proven highly effective in 40% to 50% of the children who are started on it. The diet is high fat and low carbohydrate and protein. Bread and pasta are typically high in carbohydrates which are limited in this diet. This diet can be difficult for families to adhere to and incorporate into their lifestyle.
A parent of a child diagnosed with seizures states, "I've heard about a special diet that may control seizures, I think it's called ketogenic. What can you tell me about it?" Which are appropriate responses by the nurse? Select all that apply. "About 40% to 50% of children who follow the diet have really good results." "The diet consists of high fat foods." "Children are encouraged to eat a lot of breads and pasta on this diet." "Most families find this diet is easy to incorporate into their life." "Protein is limited in this diet."
=with impaired vision, children have difficulty interacting with their environment and meeting developmental milestones. 35
A young preschool-age child with impaired visual acuity can be treated with glasses. The parents are reluctant to agree. The nurse explains that: =by treating the child now, the child will be well-adjusted to wearing glasses by kindergarten. =with impaired vision, children have difficulty interacting with their environment and meeting developmental milestones. =because your preschooler is not old enough to learn to read, it would be acceptable to delay their use until kindergarten.
Loss of motor activity accompanied by a blank stare 35
Absence seizures are marked by what clinical manifestation? Brief, sudden onset of increased tone of the extensor muscle Loss of motor activity accompanied by a blank stare Sudden, brief jerks of a muscle group Loss of muscle tone and loss of consciousness
The shorter and wider eustachian tubes of an infant increase the risk 35
After teaching a group of parents about ear infections in children, which statement indicates that the teaching was successful? Infants with congenital deformities have an increased risk for ear infections. Ear infections typically increase as the child gets older. The shorter and wider eustachian tubes of an infant increase the risk. Adenoids shrink as the child grows, allowing more bacteria to enter.
oral antibiotics acetaminophen 35
An 8-month-old child is brought to the clinic by the parents with reports of a cold for the past 3 days and increased crying and irritability today. What does the nurse anticipate in the plan of care for this child, based on the assessment (above)? Select all that apply. oral antibiotics ice applied to outer ear acetaminophen referral for hearing screening oral steroids
A preoperative injection of atropine 35
An infant is born with congenital glaucoma. The infant is scheduled for surgery to relieve this condition at age 2 days. Which prescription should the nurse question for the infant? Nothing by mouth (with intravenous therapy) prior to surgery A preoperative injection of atropine A preoperative antibiotic Arm restraints to be applied after surgery
reduce the pain related to nuchal rigidity. 35
The nurse is caring for a 4-year-old with meningitis. A primary nursing goal would be to: increase stimulation opportunities to prevent coma. provide an opportunity for therapeutic play. reduce the pain related to nuchal rigidity. inspect the teeth for obvious caries.
"I hate to think that I will need to be worried about my child having seizures for the rest of his life." 35 Febrile seizures occur most often in preschool children but can occur as late as 7 years of age. They occur when the child has a rapid rise in temperature and are not associated with the development of seizures later in life. Administering correct dosages of acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures.
The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education? "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully." "I need to set an alarm to wake up and check his temperature during the night when he is sick." "I hate to think that I will need to be worried about my child having seizures for the rest of his life." "When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever."
Initiate an IV of 0.9% NS to run at 250 ml/hr. 35 Rapid administration of IV fluids may increase ICP. An IV rate of 250 ml/hr of normal saline can be considered a rapid infusion. Corticosteroids such as dexamethasone can reduce cerebral edema. Osmotic diuretics, such as mannitol, can reduce pressure. Because of the administration of the osmotic diuretic, indwelling urinary catheters are typically inserted.
The nurse is caring for a child who has suffered a head injury and has had an ICP monitor placed. Which prescription by the health care provider would the nurse question? Place in an indwelling urinary catheter. Administer dexamethasone, dosage determined by the pharmacist. Administer mannitol IV, dosage determined by the pharmacist. Initiate an IV of 0.9% NS to run at 250 ml/hr.
Attempt to place oxygen on the child so they don't become cyanotic. 35
The nurse is caring for a child who is having a seizure. What is the appropriate action by the nurse? Attempt to place oxygen on the child so they don't become cyanotic. Hold the child's arms and legs still so they aren't injured. Attempt to turn the child on their side to prevent aspiration. Place a bite block or oral airway into the child's mouth to prevent biting of the tongue.
increased head circumference pulse rate of 60 beats/min and regular vomiting parent states, "My infant does not act right." 35
The nurse is caring for a hospitalized infant at risk for developing increased intracranial pressure. Which assessment finding(s) would the nurse communicate to the health care provider for further intervention? Select all that apply. increased head circumference pulse rate of 60 beats/min and regular vomiting blood pressure decreased from baseline parent states, "My infant does not act right."
Convulsive activity often occurs in seizures. 35
The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. The nurse will be correct in telling the parent which information in regard to seizures? Seizures are typically outgrown by 4 years of age. Convulsive activity often occurs in seizures. Seizures are typically provoked by pain. The electroencephalogram (EEG) is normal during a seizure.
"Use this information to teach family and friends." 35
The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope? "If he is out of bed, the helmet's on the head." "Bike riding and swimming are just too dangerous." "Use this information to teach family and friends." "You'll always need a monitor in his room."
"We need to raise the volume of our voices significantly so he can hear us." 35
The nurse is educating the parents of a 7-year-old boy who has hearing loss due to otitis media with effusion. Which statement by the parents indicates that further education is needed? "We need to raise the volume of our voices significantly so he can hear us." "We need to make sure we are speaking clearly." "We need to face our son when we are speaking." "Using hand gestures as visual cues should help our child understand a little better."
After the implant surgery our child will have normal hearing. 35
The nurse is educating the parents of an 18-month-old child being prepared to receive cochlear implants. Which statement by the parents requires further teaching? After the implant surgery our child will have normal hearing. We have arranged for speech-language therapy after the implant is activated. Our child will have hearing tests to assess how the implant is working. The cochlear implant must heal and will be activated 2 to 3 weeks after surgery.
use of helmets for bicycle and motorcycle safety practicing good handwashing technique and infection control importance of proper emergency care to protect the head and neck 35 The client's temperature of 102.4°F (39.1°C) indicates a fever. This will require the nurse to follow up to determine the underlying cause for the fever. A purple (purpuric) rash appearing during a febrile state requires follow-up, because it may indicate meningitis. The child reporting a stiff neck may indicate meningeal irritation. The child's inability to straighten the leg when lying flat with hips flexed indicates meningeal irritation; it is referred to as a positive Kernig sign. Lethargy indicates decreased level of consciousness; the nurse should closely monitor the child's level of consciousness. The child's oxygen saturation of 92% on room air indicates decreased oxygen levels.
The nurse is planning a program for a community that focuses on the 2030 National Health Goals for neurologic health. Which topics should the nurse include in this presentation? Select all that apply. ensuring a diet adequate in vitamins and protein use of helmets for bicycle and motorcycle safety learning the signs and symptoms of inflammatory disorders practicing good handwashing technique and infection control importance of proper emergency care to protect the head and neck
Evidence of bleeding will be reabsorbed within 1 to 3 weeks. 35
The nurse is planning care for a school-age child with a black eye. Which outcome would be the most appropriate for this client? The swelling will be reduced in a month. Evidence of bleeding will be reabsorbed within 1 to 3 weeks. The child will have double vision upon waking in the morning. The child will begin wearing corrective lenses after the swelling subsides.
Assess the child's ability to convey information. 35
The nurse is preparing a nursing care plan for a 2-year-old child with hearing impairment. Which intervention will be part of the plan? Assess vision to determine functional capability. Explain botulinum injection procedure and risks. Teach parents to make vinegar and alcohol eardrops. Assess the child's ability to convey information.
head trauma 35
The nurse knows that children have larger heads in relation to the body and a higher center of gravity. When developing a teaching plan for parents, the nurse includes information about an increased risk for which problem? febrile seizures head trauma caput succedaneum posterior plagiocephaly
Hearing loss can be a cause of delayed speech, so we want to assess this and treat both the hearing and the speech delays if needed. 35
The nurse refers a 2-year-old child to a speech-language pathologist because of limited vocabulary and delayed speech. The speech therapy program requires hearing screening to be completed prior to admission into the program. How does the nurse explain the reason for this to the parents? If your child has hearing loss, then the child can receive treatment for hearing instead of speech therapy. Hearing screening allows the speech-language pathologist to determine if the cause of late speech is medical or developmental. Speech therapy is not effective for a child with hearing loss, so we must first rule out hearing loss. Hearing loss can be a cause of delayed speech, so we want to assess this and treat both the hearing and the speech delays if needed.
"Sometimes it is hard to tell if a product contains aspirin." 35
The parent of a 12-year-old child with Reye syndrome approaches the nurse wanting to know how this happened to their child, saying, "I never give my kids aspirin!" Which response by the nurse is appropriate? "Sometimes it is hard to tell if a product contains aspirin." "Do you think that maybe your child took aspirin on their own?" "Do not worry; you are in good hands. We have it under control now." "Aspirin in combination with the virus will make the brain swell and the liver fail."
"What you are describing may be what is called myopia." 35
The parents of an 8-year-old child report that the child's teachers noted the child is having problems seeing the board in school but state they do not understand this since the child is able to read from the computer with no difficulty. Which response from the nurse is most appropriate? "This may signal your child is having difficulty paying attention rather than a visual disorder." "Your child will need to be evaluated for an accommodation disorder." "What you are describing may be what is called myopia." "These reports are consistent with hyperopia."
evaluation of intraocular pressure (IOP) and adherence to the occlusive patch regimen 35
Which measures should receive priority when planning care for the child who is having surgery to remove a cataract? evaluation of intraocular pressure (IOP) and adherence to the occlusive patch regimen prophylactic antibiotic drops regular insertion and removal of contact lenses regular evaluation of the intraocular lens implant
"I will cradle her in my arms after the procedure for at least 30 minutes." 35 During the procedure, typically 3 tubes of cerebrospinal fluid (CSF) are removed for testing. After the procedure, the child is encouraged to lay flat for at least 30 minutes. During that time, the child is also encouraged to drink a glass of water to help prevent cerebral irritation. Even when all proper procedures are followed, some children develop a headache following the test. An analgesic may be given for pain relief.
While caring for a child who will be undergoing a lumbar puncture, the nurse explains the procedure to the infant's mother. Which statement by the mother would indicate a need for further education? "I will cradle her in my arms after the procedure for at least 30 minutes." "During the test, the health care provider will most likely take 3 tubes of spinal fluid to test for several things." "My child may have a headache after the procedure. If she does, she can have something for the pain." "I need to encourage my child to drink at least 1 glass of water after the procedure."