Final Exam

The temperature of an adolescent who is unconscious is 105° F. The PRIORITY nursing action is to: A continue to monitor temperature. B. initiate a pain assessment. C. apply a hypothermia blanket. D. administer acetaminophen or ibuprofen.

C apply a hypothermia blanket. The temperature needs to be monitored, but it also needs to be lowered. This should be ongoing; lowering the body temperature is the priority action. Brain damage can occur at temperatures this high. It is extremely important to institute temperature-lowering interventions, such as hypothermia blankets and tepid water baths. Antipyretics are not useful in cases of hyperthermia.

The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome? (Select all that apply.) A. Palpable distal pulse B. Capillary refill to extremity less than 3 seconds C. Severe pain not relieved by analgesics D. Tingling of extremity E. Inability to move extremit

C,D,E

The nurse is especially concerned to assess for adequate respiratory function in which of the following disease processes? Select all that apply: a) Spina bifida occulta b) Duchene muscular dystrophy c) Spinal Muscular Atrophy d) Brachial plexus injury e) Cerebral Palsy

B,C,E

A 6-year-old child born with a myelomeningocele has a neurogenic bladder. The parents have been performing clean intermittent catheterization. What should the nurse recommend? A. Teach the child to do self-catheterization. B. Teach the child appropriate bladder control. C. Continue having the parents do the catheterization. D. Encourage the family to consider urinary diversion

A. Teach the child to do self-catheterization.

The health care provider has ordered both tetanus immunoglobulin (TIG) and tetanus toxoid for a child suffering from tetanus. Which is the most accurate method of administration? A. Orally or intravenously at two different times by the nurse B. Intramuscularly using separate syringes at separate sites C. Intramuscularly using the same syringe at different times D. In the same syringe at a single site via the intramuscular rout

B TIG and tetanus toxoid are administered via the intramuscular route in separate syringes and at separate sites.

The nurse is monitoring a 7-year-old child post-surgical resection of an infratentorial brain tumor. Which vital sign findings indicate Cushing's triad? a. Increased temperature, tachycardia, tachypnea b. Decreased temperature, bradycardia, bradypnea c. Bradycardia, hypertension, irregular respirations d. Bradycardia, hypotension, tachypnea

C Cushing's triad is a hallmark sign of increased intracranial pressure (ICP). The triad includes bradycardia, hypertension, and irregular respirations. Increased or decreased temperature is not a sign of Cushing's triad.

A baby was born 2 hours ago by Cesarean section. The newborn has a myelomeningocele with the sac intact and has been placed in an incubator. The nurse, when planning care for the baby, should focus on potential for: A. Disuse syndrome B. Infection C. Fluid volume deficit D. Decreased cardiac output

(B) RATIONALE(A) Varying degrees of neurological involvement affecting the lower musculoskeletal system occur; however, this is not a life-threatening problem.(B) There is potential for infection spreading into the CNS through the meningeal sac, which could be life threatening.(C) Electrolyte imbalance is not a problem.(D) Renal complications often occur, but cardiac complications would not occur from myelomeningocele

A 14-year-old with osteogenesis imperfecta (OI) is confined to a wheelchair. Which nursing interventions will promote normal development? Select all that apply. 1. Encourage participation in groups with teens who have disabilities or chronic illness. 2. Encourage decorating the wheelchair with stickers 3. Encourage transfer of primary care to an adult provider at age 18 years. 4. Allow the teen to view the radiographs. 5. Help the teen set realistic goals for the future. 6. Discourage discussion of sexuality, as the child is not likely to date.

1,2,4,5,

When planning a rehabilitative approach for a child with osteogenesis imperfect (OI), the nurse should prevent which of the following? Select all that apply. 1. Positional contractures and deformities. 2. Bone infection. 3. Muscle weakness. 4. Osteoporosis. 5. Misalignment of lower extremity joints.

1,3,4,5

An infant is born with a sac protruding through the spine, containing cerebrospinal fluid (CSF), a portion of the meninges, and nerve roots. This condition is referred to as: 1. Meningocele. 2. Myelomeningocele. 3. Spina bifida occulta. 4. Anencephaly.

2. Myelomeningocele.

Which diagnostic exam does the nurse know will best aid in the diagnosis of Duchenne muscular dystrophy? 1) EEG 2) CT Scan 3) MRI 4) EMG

4

The nurse is assessing a child with increased intracranial pressure. On assessment, the nurse notes that the child is now exhibiting decerebrate posturing. The nurse should modify the client's plan of care based on which interpretation of the client's change? 1.An insignificant finding 2.An improvement in condition 3.Decreasing intracranial pressure 4.Deteriorating neurological function

4 The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants health care provider notification. The remaining options are inaccurate interpretations.

The nurse is evaluating the laboratory results on cerebral spinal fluid (CSF) from a 3-year-old child with bacterial meningitis. Which findings confirm bacterial meningitis? (Select all that apply.) a. Elevated white blood cell (WBC) count b. Decreased glucose c. Normal protein d. Elevated red blood cell (RBC) count

A,B The cerebrospinal fluid analysis in bacterial meningitis shows elevated WBC count, decreased glucose, and increased protein content. There should not be RBCs evident in the CSF fluid.

Which assessment findings should the nurse note in a school-age child with Duchenne's muscular dystrophy (DMD) (Select all that apply)? a. Lordosis b. Gower's sign c. Kyphosis d. Scoliosis e. Waddling gait

A,B,E

Which of the following symptoms would the nurse expect to possibly see in the child with Duchenne muscular dystrophy? Select all that apply a) Protuberant belly b) Diminished intelligence c) Walking on the toes or balls of feet d) Gower's sign e) Spinal curvatures

A,C,D,E

A mother whose 7-year-old child has been placed in a cast for a fractured right arm reports that he will not stop crying even after taking acetaminophen with codeine. He also will not straighten the fingers on his right arm. The nurse tells the mother to a. Take him to the emergency department. b. Put ice on the injury. c. Avoid letting him get so tired. d. Wait another hour; if he is still crying, call back.

ANS: A A Unrelieved pain and the child's inability to extend his fingers are signs of compartmental syndrome, which requires immediate attention.B Placing ice on the extremity is an inappropriate action for the symptoms.C This is an inappropriate response to give to a mother who is concerned about herchild.D A child who has signs and symptoms of compartmental syndrome should be seenimmediately. Waiting an hour could compromise the recovery of the child.

Which clinical manifestations would suggest hydrocephalus in a neonate? a. Bulging fontanel and dilated scalp veins b. Closed fontanel and high-pitched cry c. Constant low-pitched cry and restlessness d. Depressed fontanel and decreased blood pressure

Answer: A

A 3-year-old child is status post shunt revision for hydrocephaly. Part of the discharge teaching plan for the parents is signs of shunt malformation. Which signs are of shunt malformation? (Select all that apply.) A. Personality change B. Bulging anterior fontanel C. Vomiting D. Dizziness E. Fever

Answer: A,C,E

An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should be included in the child's postoperative care (Select all that apply)? a. Observe closely for signs of infection. b. Pump the shunt reservoir to maintain patency. c. Administer sedation to decrease irritability. d. Maintain Trendelenburg position to decrease pressure on the shunt. e. Maintain an accurate record of intake and output. f. Monitor for abdominal distention.

Answer: A,E,F

The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. An important part of the discussion with the parents is that A. parental protection is essential until the child reaches adulthood. B. mental retardation is to be expected with hydrocephalus. C. shunt malfunction or infection requires immediate treatment. D. most usual childhood activities must be restricted.

Answer: C

What is a nursing intervention to reduce the risk of increasing intracranial pressure (ICP) in an unconscious child?

Avoid activities that cause pain or crying

4. The nurse is caring for a neonate with suspected meningitis. Which clinicalmanifestations should the nurse prepare to assess if meningitis is confirmed? (Select all that apply.) a. Headache b. Photophobia c. Bulging anterior fontanel d. Weak cry e. Poor muscle tone

C,D,E Assessment findings in a neonate with meningitis include bulging anterior fontanel, weak cry, and poormuscle tone. Headache and photophobia are signs seen in an older child.DIF: Cognitive Level: Understand REF: p. 890TOP: Integrated Process: Nursing Process: AssessmentMSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

The nurse is caring for a child with an epidural hematoma. The nurse should assess for what signs that can indicate Cushing triad? (Select all that apply.) a. Fever b. Flushing c. Bradycardia d. Systemic hypertension e. Respiratory depression

C,D,E Cushing triad (systemic hypertension, bradycardia, and respiratory depression) is a late sign of impending brainstem herniation. Fever or flushing does not occur with Cushing triad.

What most accurately describes bowel function in children born with a myelomeningocele? A. Incontinence cannot be prevented. B. Enemas and laxatives are contraindicated. C. Some degree of fecal continence can usually be achieved. D. A colostomy is usually required by the time the child reaches adolescence.

C. Some degree of fecal continence can usually be achieved.

intracranial pressure can indicate...?

Cushing triad?

The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like her oldest son did when he was an infant. The nurse should base her response on which statement? a. Meningitis rarely occurs during infancy. b. Often a genetic predisposition to meningitis is found. c. Vaccination to prevent all types of meningitis is now available. d. Vaccination to prevent Haemophilus influenzae type B meningitis has decreased the frequency of this disease in children.

D H. influenzae type B meningitis has been virtually eradicated in areas of the world where the vaccine is administered routinely. Bacterial meningitis remains a serious illness in children. It is significant because of the residual damage caused by undiagnosed and untreated or inadequately treated cases. The leading causes of neonatal meningitis are the group B streptococci and Escherichia coli organisms. Meningitis is an extension of a variety of bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of the potential causative organisms.

The nurse is caring for a 10-year-old child who has an acute head injury, has a pediatric Glasgow Coma Scale score of 9, and is unconscious. What intervention should the nurse include in the child's care plan?

Elevate the head of the bed 15 to 30 degrees with the head maintained in midline. Nursing activities for children with head trauma and increased intracranial pressure (ICP) include elevating the head of the bed 15 to 30 degrees and maintaining the head in a midline position. The nurse should try to maintain a quiet, nonstimulating environment for a child with increased ICP. Chest percussion and suctioning should be performed judiciously because they can elevate ICP. Range of motion should be passive and nontherapeutic touch should be avoided because both of these activities can increase ICP.

_____________ in a Duchenne muscular dystrophy patient indicated heart muscle weakening, a serious complicating of this disorder.

Tachycardia

Which child is at the highest risk for osteomyelitis? a female 13 year old who likes playing soccer b. a male 10 year old with the flu c. a female 4 month old who was small for gestational age d. a male preschooler who likes climbing trees

d. a male preschooler who likes climbing trees

The nurse is caring for an unconscious 6-year-old who has had a severe closed-headinjury and notes the following changes: heart rate has dropped from 120 to 55, bloodpressure has increased from 110/44 to 195/62, and respirations are becoming moreirregular. Which should the nurse do first after calling the physician? 1. Call for additional help, and prepare to administer mannitol. 2. Continue to monitor the patient's vital signs, and prepare to administer a bolus ofisotonic fluids. 3. Call for additional help, and prepare to administer an antihypertensive. 4. Continue to monitor the patient, and administer supplemental oxygen.

1. Call for additional help, and prepare to administer mannitol.

A parent of a newborn diagnosed with myelomeningocele asks what is a common long-term complication? The nurse's best response is: 1. Learning disabilities. 2. Urinary tract infections. 3. Hydrocephalus. 4. Decubitus ulcers and skin breakdown.

2 Urinary tract infections are the most common complication of myelome - ningocele. Nearly all children with myelomeningocele have a neurogenic bladder that leads to incomplete emptying of the bladder and subsequent urinary tract infections. Frequent catheterization also increases the risk of urinary tract infection.

A patient is hospitalized for initiation of regional antibiotic perfusion for acute osteomyelitis of the right femur. Which intervention will be included in the plan of care? a. Frequent weight-bearing exercise b. Immobilization of the right leg c. Avoid administration of NSAIDs d. Support right leg in a flexed position

Answer: B Rationale: Immobilization of the affected leg helps to decrease pain and reduce the risk for pathologic fractures. Weight-bearing exercise increases the risk for pathologic fractures. NSAIDs are frequently prescribed to treat pain. Flexion of the affected limb is avoided to prevent contractures.Cognitive Level: Application Text Reference: pp. 1670-1671Nursing Process: Planning NCLEX: Physiological Integrity

The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. What is the major priority of nursing care? A. Initiate isolation precautions as soon as the diagnosis is confirmed. B. Initiate isolation precautions as soon as the causative agent is identified. C. Administer antibiotic therapy as soon as it is ordered. D. Administer sedatives and analgesics on a preventive schedule to manage pain.

C Initiation of antibiotic therapy is the priority action. Antibiotics are begun as soon as possible to prevent death and to avoid resultant disabilities.Isolation should be instituted as soon as a diagnosis is anticipated and should remain in effect until bacterial or viral origin is determined. If bacterial meningitis is ruled out, then isolation precautions can be discontinued.Isolation should be instituted as soon as a diagnosis is anticipated and should remain in effect until bacterial or viral origin is determined. If bacterial meningitis is ruled out, then isolation precautions can be discontinued.Initiation of antibiotics is the priority nursing intervention. Pain should be managed on an as-needed basis.

A newborn baby is diagnosed with a myelomeningocele. The nurse measures his head circumference daily to assess for the development of what complication? A. Hydrocele B. Hordeolum C. Hypsarrhythmia D. Hydrocephalus

D RATIONALE(A) This is fluid in the tunica vaginalis testes and is not associated with myelomeningocele.(B) This is a stye and not a complication of myelomeningocele.(C) This occurs in infantile spasms and is not a complication of myelomeningocele.(D) There is greater production than absorption of cerebrospinal fluid in the ventricular system, which is a complication associated with myelomeningocele.

What is the most important nursing intervention to identify and minimize compartment syndrome? A. Apply BP cuff above the cast. B. Treat pain with minimum amount needed to control it. C. Elevate arm at least 30 min/hr. D. Perform frequent neurovascular checks.

D. Perform frequent neurovascular checks.

What nursing intervention is appropriate when caring for an unconscious child?

Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema. Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema. Narcotics and sedatives should be used as necessary to reduce pain and anxiety, which can increase ICP. The child's position should be changed frequently to avoid complications such as pneumonia and skin breakdown. Antipyretics are the method of choice for fever reduction.

The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. How should the nurse interpret this?

Neurosurgical emergency The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. One fixed and dilated pupil is not suggestive of brain death. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain.

The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. The nurse's response is based on the understanding that: A bone fragment has injured the nerve supply in the area b. An injured artery causes impaired arterial perfusion through the compartment c. Bleeding and swelling cause increased pressure in an area that cannot expand d. The fascia expands with injury, causing pressure on underlying nerves and muscles

c. Bleeding and swelling cause increased pressure in an area that cannot expand

Therapeutic management of a child with tetanus includes the administration of: a. Nonsteroidal antiinflammatory drugs (NSAIDs) to reduce inflammation. b. Muscle stimulants to counteract muscle weakness. c. Bronchodilators to prevent respiratory complications. d. Antibiotics to control bacterial proliferation at the site of injury.

d. Antibiotics to control bacterial proliferation at the site of injury. Antibiotics are administered to control the proliferation of the vegetative forms of the organism at the site of infection. Tetanus toxin acts at the myoneural junction to produce muscular stiffness and lowers the threshold for reflex excitability. NSAIDs are not routinely used. Sedatives or muscle relaxants are used to help reduce titanic spasm and prevent seizures. Respiratory status is carefully evaluated for any signs of distress because muscle relaxants, opioids, and sedatives that may be prescribed may cause respiratory depression. Bronchodilators would not be used unless specifically indicated.

The Glasgow Coma Scale consists of an assessment of a. Pupil reactivity and motor response b. Eye opening and verbal and motor responses c. Level of consciousness and verbal response d. ICP and level of consciousness

ANS: B Feedback A Pupil reactivity is not a part of the Glasgow Coma Scale but is included in thepediatric coma scale. B The Glasgow Coma Scale assesses eye opening, and verbal and motor responses. C Level of consciousness is not a part of the Glasgow Coma Scale. D Intracranial pressure and level of consciousness are not part of the GlasgowComa Scale.

A nurse prepares to care for a patient diagnosed with athetoid, or dyskinetic, cerebral palsy. Which of the following does the nurse expect to see? Select all that apply: 1) Hypertonicity of affected extremities 2) Drooling 3) Worsening of symptoms when the child gets stressed 4) Worm-like writhing 5) Exaggerated deep tendon reflexes

2,3,4 Others are characteristic of spastic cerebral palsy. The infant may also appear limp or flaccid with the face, neck, and tongue possibly affected.

The nurse is performing an assessment on a child with a head injury. The nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. What should the nurse document that the child is experiencing? 1.Decorticate posturing 2.Decerebrate posturing 3.Flexion of the arms and legs 4.Normal expected positioning after head injury

1.Decorticate posturing Decorticate posturing is an abnormal flexion of the upper extremities and an extension of the lower extremities with possible plantar flexion of the feet. Decerebrate posturing is an abnormal extension of the upper extremities with internal rotation of the upper arms and wrists and an extension of the lower extremities with some internal rotation.

A nurse admits a child who has a history of cerebral palsy. Which assessment finding by the nurse is most concerning? 1) The mother reports the child had a seizure 5 hours ago. 2) The child has a fever of 100.3. 3) The child is standing on his toes. 4) The mother reports the child's twisting movements seem to have worsened since arriving at the clinic.

2 The child has a fever of 100.3. (Respiratory issues!! :O) This fever could indicate aspiration pneumonia, and this needs to be investigated further immediately with questioning of coughing, respiratory difficulty, or sputum production. Seizures are common with cerebral palsy. The child's symptoms have likely worsened because of the stress due to a clinic visit. Standing on the toes or scooting on the back (instead of crawling on the abdomen) are both commonly seen in a patient with cerebral palsy.

When counseling the parents of a child with osteogenesis imperfecta (OI), the nurse should include which of the following? Select all that apply. 1. Discourage future children because the condition is inherited. 2. Provide education about the child's physical limitations. 3. Give the parents a letter signed by the primary care provider explaining OI. 4. Provide information on contacting the Osteogenesis Imperfecta Foundation. 5. Encourage the parents to treat the child like their other children. 6. Encourage use of calcium to decrease risk of fractures.

2,3,4

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. Which assessment finding should the nurse expect if this type of posturing is present? 1.Flexion of the upper extremities and extension of the lower extremities. 2.Unilateral or bilateral postural change in which the extremities are rigid. 3.Abnormal extension of the upper and lower extremities with some internal rotation. 4.Arms are adducted with fists clenched, and the legs are flaccid with external rotation

3 Decerebrate (extension) posturing is an abnormal extension of the upper extremities, with internal rotation of the upper arm and wrist and extension of the lower extremities with some internal rotation. Decorticate posturing involves flexion of the upper extremities and extension of the lower extremities. The remaining two options are incorrect and not characteristics of decerebrate posturing.

You are the nurse working at a pediatrics clinic in Miami. You are assessing four amazingly awesome patients today. Which assessment finding concerns the nurse the most? A) The patient diagnosed with Duchenne Muscular Dystrophy demonstrating Gower's sign, waddling gait, and tachycardia B) The patient with cerebral palsy with scoliosis who is need of bracing C) The patient with myelomeningocele whose urine is cloudy and smells foul D) The patient with a brachial plexus injury who has an absent Moro's reflex

A

The nurse is planning care for a school-age child with bacterial meningitis. Which nursing intervention should be included? A. Keep environmental stimuli to a minimum. B. Avoid giving pain medications that could dull the sensorium. C. Measure the head circumference to assess developing complications. D. Have the child move the head side to side at least every 2 hours.

A Children with meningitis are sensitive to noise, bright lights, and other external stimuli because of the irritation on the meningeal nerves. The nurse should keep the room as quiet as possible with a minimum of external stimuli, including lighting.After consultation with the practitioner, pain medications can be used on an as-needed basis. A school-age child will have closed sutures; therefore, the head circumference cannot change. The head circumference is not relevant to a child of this age.The child is placed in a side-lying position, with the head of the bed slightly elevated. The nurse should avoid measures such as lifting the child's head that increase discomfort and put tension on the neck.

Prior to surgery for a myelomeningocele, the nurse would place the baby in which of the following positions? A. Prone B. Right side C. Left side D. Dorsal

A RATIONALE(A) This position minimizes the tension on the sac and reduces the potential for trauma to the area.(B, C) A side-lying position puts pressure on the sac with potential for leaks or breaks.(D) This would cause trauma to the sac and cause it to leak or break.

The nurse anticipates which of the following orders for the patient with Duchenne Muscular Dystrophy? Select all that apply: A) Prednisone B) Calcium supplements C) Bedrest D) Botulinum Toxin E) Chest percussion

A,B,E Corticosteroids are thought to help slow the progression of the disease. Calcium supplements are provided to help with the long-term effects of osteoporosis caused by the corticosteroids. Chest percussion can help remove excess secretions from the respiratory tract that the patient may be too weak to expel by themselves. Bedrest or use of botulinum toxin would not be recommended for this patient.

When infants are seen for fractures, which nursing intervention is a priority? a. No intervention is necessary. It is not uncommon for infants to fracture bones. b. Assess the family's safety practices. Fractures in infants usually result from falls. c. Assess for child abuse. Fractures in infants are often nonaccidental. d. Assess for genetic factors.

ANS: C Fractures in infancy are not common.B Infants should be cared for in a safe environment and should not be falling.C Fractures in infants warrant further investigation to rule out child abuse.Fractures in children younger than 1 year are unusual because of thecartilaginous quality of the skeleton; a large amount of force is necessary tofracture their bones.D Fractures in infancy are usually nonaccidental rather than related to a geneticfactor.

A patient is being discharged after 2 weeks of IV antibiotic therapy for acute osteomyelitis in the left leg. Which information will be included in the discharge teaching? a. The reason for taking oral antibiotics for 7 to 10 days after discharge b. The need for daily aerobic exercise to help maintain muscle strength c. How to monitor and care for the long-term IV catheter site d. How to apply warm packs safely to the leg to reduce pain

Answer: C Rationale: The patient will be on IV antibiotics for several months, and the patient will need to recognize signs of infection at the IV site and how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.

A painful condition that results when pressure within the muscles builds to dangerous levels is called _____________ This prevents nourishment from reaching nerve and muscle cells. A. Neurovascular impairment B. Compartment syndrome C. Bone demineralization D. Greenstick fracture

B. Compartment syndrome

You are the nurse taking care of the infant just diagnosed with cerebral palsy. The mother of the child asks you, "What does this mean for my child?" What is the best response by the nurse? A) This means that your child will gradually lose more and more muscle mass until eventually they will be unable to sustain their respiratory function B) This is a disorder related to how your child was born. Most likely they sustained injury during the birthing process C) There really is no specific way to tell how this disease will affect your child other than it will affect the muscle tone and control in some way. D) Why are you asking me? I ain't no doctor!

C Cerebral Palsy is a term used to describe a range of nonspecific clinical symptoms characterized by abnormal motor pattern and postures caused by nonprogressive abnormal brain function.

The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. In the discussion the nurse should include that: A. parental protection is essential until the child reaches adulthood. B. cognitive impairment is to be expected with hydrocephalus C. shunt malfunction or infection requires immediate treatment. D. most usual childhood activities must be restricted.

C Limits should be appropriate to the developmental age of the child. Except for contact sports, the child will have few restrictions. Cognitive impairment depends on the extent of damage before the shunt was placed. Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately if present. Limits should be appropriate to the developmental age of the child. Except for contact sports, the child will have few restrictions.)

Appropriate nursing interventions for a newborn's myelomeningocele sac prior to surgery include using sterile technique and: A. Leaving the sac open to air B. Applying petrolatum to cover the sac C. Applying moist saline dressings D. Applying dry dressings

C RATIONALE (A) The sac should be kept moist. Leaving the sac open to air, especially in an incubator, has a drying effect.(B) Prolonged use of ointments can cause breakdown of the tissue.(C) The sac should be kept moist to maintain the integrity of the sac prior to surgery.(D) A dry dressing may be irritating to the sac.

What is important when caring for a child with myelomeningocele in the preoperative stage? A. Place the child on one side to decrease pressure on the spinal cord. B. Apply a heat lamp to facilitate drying and toughening of the sac. C. Keep the skin clean and dry to prevent irritation from diarrheal stools. D. Measure the head circumference and examine the fontanels for signs that might indicate developing hydrocephalus.

D. Measure the head circumference and examine the fontanels for signs that might indicate developing hydrocephalus.

A neural tube defect that is not visible externally in the lumbosacral area would be called A. meningocele. B. myelomeningocele. C. spina bifida cystica. D. spina bifida occulta.

D. spina bifida occulta.

An 18-month-old child is brought to the emergency department after being found unconscious in the family pool. What does the nurse identify as the primary problem in drowning incidents? 1. slow onset hypothermia 2. hypoxia 3. electrolyte imbalance

2. Hypoxia Hypoxia is the primary problem because it results in global cell damage, with different cells tolerating variable lengths of anoxia. Neurons sustain irreversible damage after 4 to 6 minutes of submersion. Severe neurologic damage occurs from hypoxia in 3 to 6 minutes. Aspiration of fluid does occur, resulting in pulmonary edema, atelectasis, airway spasm, and pneumonitis, which complicate the anoxia. Hypothermia occurs rapidly, except in hot tubs. Electrolyte imbalances do result, but they are not a major cause of morbidity and mortality.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?1.Flaccid paralysis of all extremities 2.Adduction of the arms at the shoulders 3.Rigid extension and pronation of the arms and legs 4.Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3 Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.

The nurse is caring for a child with a head injury. The nurse observes decerebrate posturing. What is the nurse's best action? 1.Document the finding. 2.Complete a head-to-toe examination. 3.Notify the health care provider. 4.Inform the family of the improved status.

3 Decorticate posturing indicates a lesion in the cerebral hemisphere or disruption of the corticospinal tracts. Decerebrate posturing indicates damage in the diencephalon, midbrain, or pons. The progression from flexion to extension posturing usually indicates deteriorating neurological function, not improvement, and warrants physician notification. A focused neurological examination is priority at this time, not a complete head to toe.

The nurse is caring for a 2-year-old girl who is unconscious but stable following a car accident. Her parents are staying at the bedside most of the time. An appropriate nursing intervention is to: A. suggest that the parents go home until she is alert enough to know that they are present. B. use ointment on her lips but do not attempt to cleanse her teeth until swallowing returns. C.encourage the parents to hold, talk, and sing to her as they usually would. D. position her with proper body alignment and head of bed lowered 15 degrees.

C.encourage the parents to hold, talk, and sing to her as they usually would. This is not recommended. The daughter may be able to hear that they are present. Oral care is essential in the unconscious child. Mouth care should be done at least twice daily. The parents should be encouraged to interact with their daughter. Senses of hearing and tactile perception may be intact, and stimulation of these senses is important. The head of the bed should be elevated, not lowered.

What nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious child? A. Suctioning child frequently B. Providing environmental stimulation C. Turning head side to side every hour D. Avoiding activities that cause pain or crying

D. Avoiding activities that cause pain or crying Suctioning is a distressing procedure. In addition the resultant decrease in carbon dioxide can increase ICP. Environmental stimulation should be minimized. The child's head should not be turned side to side. If the jugular vein is compressed, ICP can rise. Nursing interventions should focus on assessment and interventions to minimize pain. These activities can cause the intracranial pressure to increase.