Derm, CV, Neuro NCLEX Practice Questions

16. A nurse is planning care for a 12-year-old with rheumatic fever. The nurse should teach the parents to: ■ 1. Observe the child closely. ■ 2. Allow the child to participate in activities that will not tire him. ■ 3. Provide for adequate periods of rest between activities. ■ 4. Encourage someone in the family to be with the child 24 hours a day.

3. The nurse should teach the parents to provide for sufficient periods of rest to decrease the client's cardiac workload. The client's condition does not warrant close observation unless cardiac complications develop. The child's activity level will be based on the results of the sedimentation rate, c-reactive protein, heart rate, and cardiac function. The family does not need to be with the client 24 hours a day unless carditis develops and his condition deteriorates.

The physician orders carbamazapine extended release (Tegretol-XR) for a client with a cerebral palsy who also has a seizure disorder. The client has a gastrostomy feeding tube, and carbamazapine is on the hospital's "no crush" list. In order to administer the medication, the nurse should: ■ 1. Cut the medication into four pieces that can be placed in the feeding tube. ■ 2. Dissolve the medication in 30 mL's of juice. ■ 3. Ask the pharmacist for an oral suspension. ■ 4. Contact the primary care provider to change the order.

4. The coating on an extended release medication helps assure slow absorption of the medication. If the nurse crushes the medication, the medication may enter the client's system too quickly and result in toxic levels. The only appropriate action is to contact the prescriber and ask that the order be changed. Cutting the medication or trying to dissolve a whole tablet would have similar results as crushing it. Carbamazapine comes as an oral suspension, but it is not extended release. Therefore, an order would be needed to address dosing if switching to this form.

76. When making rounds on the pediatric neurology unit, the nurse manager notes that when giving I.V. medications many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After discussing the problem with the staff educator which intervention would be the most effective way to improve the nursing practice? ■ 1. Create a poster presentation on the topic with a required post test. ■ 2. Send a group email discussing the importance of clamping the device first. ■ 3. Ask each nurse if they are aware that their practice is not current. ■ 4. Post an evidence-based article on the unit.

1. A poster presentation is an eye-catching way to disseminate information that can be used to educate nurses on all shifts. The addition of the post test will verify that the poster information has been received. Because of the large volume of emails the typical employee receives, information sent this way may be overlooked. If several nurses are observed not using the most current practice, it is quite possible many more do not understand it. Thus, a larger scale plan is needed. Posting an article will not alone assure that the information is read.

15. A 13-year-old has been admitted with a diagnosis of rheumatic fever and is on bed rest. He complains of a sore throat. His joints are painful and swollen. He has a red rash on his trunk and is experiencing aimless movements of his extremities. Use the chart below to determine what the nurse should do first. ■ 1. Report the heart rate to the physician. ■ 2. Apply lotion to the rash. ■ 3. Splint the joints to relieve the pain. ■ 4. Request an order for medication to treat the elevated temperature.

1. The child's heart rate of 150 bpm is significantly above its rate at the time of his admission. The nurse must notify the physician. The increase in heart rate may indicate carditis, a possible complication of rheumatic fever that can cause serious and life-long effects on the heart. The physician will intervene with medication and cardiac monitoring. While lotion may soothe the itching, the most important action for the nurse is to notify the physician of the increased heart rate. Splinting will not help the inflammation that is causing the painful joints. The painful joints migrate and will subside with time. The temperature is not elevated at this time, and does not require intervention.

17. When developing the plan of care for a child diagnosed with phenylketonuria (PKU), the nurse should establish which of the following goals? ■ 1. Meeting the child's nutritional needs for optimal growth. ■ 2. Ensuring that the special diet is started at age 3 weeks. ■ 3. Maintaining serum phenylalanine level higher than 12 mg/100 mL. ■ 4. Maintaining serum phenylalanine level lower than 2 mg/100 mL.

1. The goal of care is to prevent mental retardation by adjusting the diet to meet the infant's nutritional needs for optimal growth. The diet needs to be started as soon as the infant is diagnosed, ideally within a few days of birth. Serum phenylalanine level should be maintained between 3 and 7 mg/100 mL. Significant brain damage usually occurs if the serum phenylalanine level exceeds 10 to 15 mg/100 mL. If the level drops below 2 mg/100 mL, the body begins to catabolize its protein stores, causing growth retardation.

16. An 11-year-old child has been diagnosed with Grave's disease and is to start drug therapy. Which of the following instructions should the nurse include in the teaching plan for the child's mother and teacher? ■ 1. Continue with the same amount of schoolwork and homework. ■ 2. Understand that mood swings are rare with this disorder. ■ 3. Limit the amount of food that is offered to the child. ■ 4. Provide the child with a calm, nonstimulating environment.

16. 4. Because it takes approximately 2 weeks before the response to drug treatment occurs, much of the child's care focuses on managing the child's physical symptoms. Signs and symptoms of the disorder include inability to sit still or concentrate, increased appetite with weight loss, emotional lability, and fatigue. Nursing care is directed toward ensuring that the mother and teacher know how to handle the child, suggesting a shortened school day, a nonstimulating environment, and decreased stress and workload. The child should be encouraged to eat a well-balanced diet.

15. Before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is irritable, lethargic, and difficult to feed. To maintain the infant's nutritional status, which of the following actions would be most appropriate? ■ 1. Feeding the infant just before doing any procedures. ■ 2. Giving the infant small, frequent feedings. ■ 3. Feeding the infant in a horizontal position. ■ 4. Scheduling the feedings for every 6 hours.

2. An infant with hydrocephalus is difficult to feed because of poor sucking, lethargy, and vomiting, which are associated with increased intracranial pressure. Small, frequent feedings given at times when the infant is relaxed and calm are tolerated best. Feeding an infant before any procedure is inappropriate because the stress of the procedure may lead to vomiting. Ideally, the infant should be held in a slightly vertical position when feeding to prevent backflow of formula into the eustachian tubes and subsequent development of ear infections. Most infants are fed on demand every 3 to 4 hours.

30. The charge nurse on the pediatric floor has assigned a 6-year-old girl of Arab-American ethnicity with newly diagnosed type 1 diabetes and an 8-year-old girl recovering from ketoacidosis to the same semi-private room. The 6-year-old's mother is upset because the parent staying with the other child is the father. The nurse should: ■ 1. Explain to the parents that this room arrangement facilitates teaching. ■ 2. Reassign the children to different rooms. ■ 3. Offer the Arab-American parent another place to sleep. ■ 4. Refer the parent to the customer service representative.

2. Arab-Americans most frequently practice Islam. Sleeping in the same room with a person of the opposite sex most likely would be viewed as a violation of their faith. If at all possible, the charge nurse should reassign the family to a different room. While it makes sense to have two clients with similar educational needs in the same room, it is likely that the arrangement would be sufficiently distressing enough to create a learning barrier. Offering the mother another place to sleep deprives the child of her parent at night. The customer service representative would only need to be involved if it became impossible to accommodate the mother's needs.

23. When developing the plan of care for a newly admitted 2-year-old child with the diagnosis of Kawasaki disease, which of the following should be the priority? ■ 1. Taking vital signs every 6 hours. ■ 2. Monitoring intake and output every hour. ■ 3. Minimizing skin discomfort. ■ 4. Providing passive range-of-motion exercises.

2. Cardiac status must be monitored carefully in the initial phase of KD because the child is at high risk for congestive heart failure (CHF). Therefore, the nurse needs to assess the child frequently for signs of CHF, which would include respiratory distress and decreased urine output. Vital signs would be obtained more often than every 6 hours because of the risk of CHF. Although minimizing skin discomfort would be important, it is does not take priority over monitoring the child's hourly intake and output. Passive range-of-motion exercises would be done if the child develops arthritis.

19. Which of the following outcomes indicates that the activity restriction necessary for a 7-year-old child with rheumatic fever during the acute phase has been effective? ■ 1. Joints demonstrate absence of permanent injury. ■ 2. The resting heart rate is between 60 and 100 bpm. ■ 3. The child exhibits a decrease in chorea movements. ■ 4. The subcutaneous nodules over the joints are no longer palpable

2. During the acute phase of rheumatic fever, the heart is inflamed and every effort is made to reduce the work of the heart. Bedrest with limited activity is necessary to prevent heart failure. Therefore, the most reliable indicator that activity restriction has been effective is a resting heart rate between 60 and 100 bpm, normal for a 7-year-old child. No permanent damage to the joints occurs with rheumatic fever. The chorea movements associated with rheumatic fever are self-limited and usually disappear in 1 to 3 months. They are unrelated to activity restrictions. Subcutaneous nodules that occur over joint surfaces also resolve over time with no treatment. Therefore, they are not appropriate for evaluating the effectiveness of activity restrictions.

10. Which of the following would be most appropriate to institute when a school-age child with burns becomes angry and combative when it is time to change the dressings and apply mafenide acetate (Sulfamylon)? ■ 1. Ensure parental support during the dressing changes. ■ 2. Allow the child to assist in removing the dressings and applying the cream. ■ 3. Give the child permission to cry during the procedure. ■ 4. Allow the child to schedule the time for dressing changes.

2. Expressions of anger and combativeness are often the result of loss of control and a feeling of powerlessness. Some control over the situation is regained by allowing the child to participate in care. Although having parental support during the dressing changes may be helpful, this action does nothing to allow the child control. Giving the child permission to cry may help with verbalizing feelings, but doing so does nothing to provide the child with control over the situation. Although allowing the child to determine the time for dressing changes may provide a sense of control over the situation, doing so is inappropriate because the dressing changes need to be performed as ordered to ensure effectiveness and healing.

22. Even though several teaching sessions have been documented in the client's health record, the mother asks the nurse again what caused her child's phenylketonuria (PKU). Which of the following statements would best reflect the nurse's interpretation of why the mother keeps asking for information that she has already received? ■ 1. Because the child's condition is chronic, parents commonly want very detailed explanations about the causes of and treatments for their child's disease. ■ 2. Parents of a chronically ill child commonly require a long time to work through the grieving process for their child's disease. ■ 3. Parents commonly test health workers' knowledge about the causes of and treatments for their child's disease. ■ 4. Parents commonly deal with their guilt about possibly causing their child's disease by asking challenging questions.

2. PKU is considered a chronic illness. Parents typically grieve about the loss of health in their child afflicted with a chronic disease. Many times, they repeat questions, as though trying to deny what is really happening. This type of behavior represents an attempt to integrate the experience and their feelings with their self-image as they pass through the grieving process. Asking for detailed explanations, testing the competence of health workers, and expressing impatience with health workers may explain the parents' behavior, but viewing the behavior as a part of the grieving process is the most plausible explanation.

31. After teaching the parents of a child with febrile seizures about methods to lower temperature other than using medication, which of the following statements indicates successful teaching? ■ 1. "We'll add extra blankets when he complains of being cold." ■ 2. "We'll wrap him in a blanket if he starts shivering." ■ 3. "We'll make the bath water cold enough to make him shiver." ■ 4. "We'll use a solution of half alcohol and half water when sponging him."

2. Shivering, the body's defense against rapid temperature decrease, results in an increase in body temperature. Therefore the parents need to take measures to stop the shivering (and the resulting increase in body temperature) by increasing the room temperature or the temperature of the child's immediate environment (such as with blankets) until the shivering stops. Then, attempts are made to lower the temperature more slowly. Shivering does not necessarily correlate with being cold. Alcohol, a toxic substance, can be absorbed through the skin. Its use is to be avoided.

17. A student with type 1 diabetes tells the nurse she is feeling light-headed. The student's blood sugar is 60 mg/dL. Using the 15-15 rule, the nurse should: ■ 1. Give 15 mL of juice and give another 15 mL in 15 minutes. ■ 2. Give 15 g of carbohydrate and retest the blood sugar in 15 minutes. ■ 3. Give 15 g of carbohydrate and 15 g of protein. ■ 4. Give 15 oz of juice and retest in 15 minutes

2. The 15-15 rule is a general guideline for treating hypoglycemia where the client consumes 15 g of carbohydrate and repeats testing the blood sugar in 15 minutes. Fifteen grams of carbohydrate equals 60 calories and is roughly equal to ½ cup of juice or soda, 6 to 8 lifesavers, or a tablespoon of honey or sugar. The general recommendation is if the blood sugar is still low, the client may repeat the sequence. Fifteen milliliters of juice would only provide 15 calories. This would not be sufficient carbohydrates to treat the hypoglycemia. Protein does not treat insulin-related hypoglycemia; however a protein-starch snack may be offered after the blood glucose improves. Fifteen ounces of juice would be almost 4 times the recommended 4 oz of juice

26. The nurse talks to an adolescent about how she can tell her friends about her new diagnosis of diabetes. Which of the following behaviors by the adolescent indicates that the adolescent has responded positively to the discussion? ■ 1. She asks the nurse for material on diabetes for a school paper. ■ 2. She introduces the nurse to her friends as "the one who taught me all about my diabetes." ■ 3. She says, "I'll try to tell my friends, but they'll probably quit hanging out with me." ■ 4. She asks her friends what they think about someone who has a lifelong illness.

2. The ability to talk about her diabetes indicates that the adolescent feels good enough about herself to share her problem with her peers. Asking for reference material does not specifically indicate that the client's self-esteem has improved or that she has accepted her diagnosis. Saying that her friends will probably desert her if she tells them about the illness indicates that the adolescent still needs to work on her self-esteem and her feelings about the disease. Asking her friends what they think of someone with a lifelong illness would not indicate that the nurse's interventions targeted toward improving self-esteem have been successful. Rather, this statement demonstrates the adolescent's uncertainty about herself

5. A 5-year-old child brought to the clinic with several superficial sores on the front of the left leg is diagnosed with impetigo. Which of the following instructions should the nurse give the parent? ■ 1. Wash the child's legs gently three times per day with a mild soap. ■ 2. Cover the sores with loose gauze. ■ 3. Allow the child to go back to school after 24 hours of treatment. ■ 4. Have the child return to the clinic the next week for a follow-up examination.

3. Impetigo involving several superficial lesions is usually treated topically, including washing the affected areas, removing crusts, and applying antibiotic ointment several times a day. The child can return to day care or school after being treated for 24 hours. The lesions do not need to be covered, they can remain open to the air. There is no need for follow-up unless the lesions have not resolved or have become more severe.

7. During a developmental screening, the nurse finds that a 3-year-old child with cerebral palsy has arrested social and language development. The nurse tells the family: ■ 1. "This is a sign the cerebral palsy is progressing." ■ 2. "Your child has reached his maximum language abilities." ■ 3. "I need to refer you for more developmental testing." ■ 4. "We need to modify your therapy plan."

3. It is important to identify primary developmental delays in children with cerebral palsy and to prevent secondary and tertiary delays. The arrested development is worrisome and requires further investigation. It is possible the lack of development indicates hearing loss or may be a sign of autism. The brain damage caused by cerebral palsy is not progressive. The brain of a young child is quite plastic; assuming the child's development has peaked at age 3 would be a serious mistake. The therapy plan will need to be modified, but a better understanding of the underlying problem will lead to the greatest chance of creating a successful therapy plan.

17. Which action should the nurse take when providing postoperative nursing care to a child after insertion of a ventriculoperitoneal shunt? ■ 1. Administer narcotics for pain control. ■ 2. Check the urine for glucose and protein. ■ 3. Monitoring for increased temperature. ■ 4. Test cerebrospinal fluid leakage for protein.

3. Monitoring the temperature allows the nurse to assess for infection, the most common and most hazardous postoperative complication after ventroperitoneal shunt placement. Typically, pain after insertion of a ventriculoperitoneal shunt is mild, requiring the use of mild analgesics. Usually narcotics are not administered because they alter the level of consciousness, making assessment of cerebral function difficult. Neither proteinuria nor glycosuria is associated with shunt placement. Cerebrospinal fluid leakage commonly occurs with head injury. It is not usually associated with shunt placement.

28. A nurse is developing a plan of care with the parents of a 6-year-old girl diagnosed with a seizure disorder. To promote growth and development, the nurse should instruct the parents that: ■ 1. The child will need activity limitation and will be unable to perform as well as her peers. ■ 2. There is potential for a learning disability and the child may need tutoring to reach her grade level. ■ 3. The child will likely have normal intelligence and be able to attend regular school. ■ 4. There will be problems associated with social stigma and parents should consider home schooling.

3. Most children who develop seizures after infancy are intellectually normal. A child with a seizure disorder needs the same experiences and opportunities to develop intellectual, emotional, and social abilities as any other child. Activity limitation is not needed. Learning disabilities are not associated with seizures. The child is able to attend public school, and social stigma is a rarity.

14. An adolescent is to receive radioactive iodine for Graves' diseases. Which statement by the client reflects the need for more teaching? ■ 1. "I plan to talk on Facebook since I have to keep several feet from my friends for 3 days." ■ 2. "Taking radioactive iodine will not affect my ability to have children in the future." ■ 3. "The advantage of radioactive iodine is that I will not need future medication for my disease." ■ 4. "I should try to use a separate bathroom from the rest of my family for several days."

3. Most clients will need lifelong thyroid replacement after treatments with radioactive iodine. Most clients are treated as outpatients. To reduce the risk of exposure to radioactivity to others, clients are advised to avoid public places for at least 1 day and maintain a prudent distance from others for 2 to 3 days. Additionally, clients are advised to avoid close contact with pregnant women and children for 5 to 11 days. The use of radioiodine to treat Graves' disease has not been found to affect long-term fertility. Clients are taught not to share food, utensils, and towels. Use of a private bathroom is desirable. Clients are also instructed to flush the toilet more than one time after each use.

25. A 16-month-old child diagnosed with Kawasaki disease (KD) is very irritable, refuses to eat, and exhibits peeling skin on the hands and feet. The nurse should do which of the following first? ■ 1. Apply lotion to the hands and feet. ■ 2. Offer foods the toddler likes. ■ 3. Place the toddler in a quiet environment. ■ 4. Encourage the parents to get some rest.

3. One of the characteristics of children with KD is irritability. They are often inconsolable. Placing the child in a quiet environment may help quiet the child and reduce the workload of the heart. Although peeling of the skin occurs with KD, the child's irritability takes priority over applying lotion to the hands and feet. Children with KD usually are not hungry and do not eat well regardless of what is served. There is no indication that the parents need rest. Additionally, in this situation, the child takes priority over the parents.

When preparing to obtain a neonatal screening test for phenylketonuria (PKU), the neonate must have received which of the following to ensure reliable results? ■ 1. A feeding of an iron-rich formula. ■ 2. Nothing by mouth for 4 hours before the test. ■ 3. Initial formula or breast milk at least 24 hours before the test. ■ 4. A feeding of glucose water.

3. PKU is an autosomal recessive disorder involving the absence of an enzyme needed to metabolize the essential amino acid, phenylalanine, to tyrosine. To ensure reliable results, the neonate must have ingested sufficient protein, such as breast milk or formula, for at least 24 hours. Testing the infant before that time, excessive vomiting, or poor intake can yield false-negative results. The infant does not need to fast 4 hours before the test. A loading dose of glucose water does not affect test values.

20. When teaching the mother of a child diagnosed with phenylketonuria (PKU) about its transmission, the nurse should use knowledge of which of the following as the basis for the discussion? ■ 1. Chromosome translocation. ■ 2. Chromosome deletion. ■ 3. Autosomal recessive gene. ■ 4. X-linked recessive gene.

3. PKU is caused by an inborn error of metabolism. It is an autosomal recessive disorder that inhibits the conversion of phenylalanine to tyrosine. A form of Down syndrome, trisomy 21, is an example of a disorder caused by chromosomal translocation. Cri du chat is an example of a disorder caused by chromosomal deletion. Hemophilia A is an example of a disorder caused by an X-linked recessive gene.

32. An adolescent girl with a seizure disorder controlled with phenytoin (Dilantin) and carbamazepine (Tegretol) asks the nurse about getting married and having children. Which of the following responses by the nurse would be most appropriate? ■ 1. "You probably shouldn't consider having children until your seizures are cured." ■ 2. "Your children won't necessarily have an increased risk of seizure disorder." ■ 3. "When you decide to have children, talk to the doctor about changing your medication." ■ 4. "Women who have seizure disorders commonly have a difficult time conceiving."

3. Phenytoin sodium (Dilantin) is a known teratogenic agent, causing numerous fetal problems. Therefore the adolescent should be advised to talk to the doctor about changing the medication. Additionally, anticonvulsant requirements usually increase during pregnancy. Seizures can be controlled but cannot be cured. There is a familial tendency for seizure disorders. Seizure disorders and infertility are not related.

38. A preschooler with pneumonococci meningitis is receiving intravenous antibiotic therapy. When discontinuing the intravenous therapy, the nurse allows the child to apply a dressing to the area where the needle is removed. The nurse's rationale for doing so is based on the interpretation that a child in this age-group has a need to accomplish which of the following? ■ 1. Trust those caring for her. ■ 2. Find diversional activities. ■ 3. Protect the image of an intact body. ■ 4. Relieve the anxiety of separation from home.

3. Preschool-age children worry about having an intact body and become fearful of any threat to body integrity. Allowing the child to participate in required care helps protect her image of an intact body. Development of trust is the task typically associated with infancy. Additionally, allowing the child to apply a dressing over the intravenous insertion site is unrelated to the development of trust. Finding diversional activities is not a priority need for a child in this age group. Separation anxiety is more common in toddlers than in preschoolers.

27. When developing the teaching plan for the mother and a child with insulin-dependent diabetes about sick-day management, which of the following instructions should the nurse include? ■ 1. Adhere to the same schedule and type and amount of insulin. ■ 2. Immediately call the physician for information about what to do. ■ 3. Adjust insulin based on more frequent testing of blood glucose levels. ■ 4. Take the child to the emergency department for immediate care.

3. Sick-day management requires more frequent monitoring of the child's blood glucose to evaluate for changes associated with a decreased intake and absorption of food, commonly associated with illness. Based on the child's glucose levels, insulin adjustments may be needed. In this case, regular insulin is used. Adhering to the same schedule, type, and amount of insulin is inappropriate because the child's ability to take in food and absorb nutrients can change rapidly. Typically, the child and parents are provided with specific instructions about sick-day management rules. Commonly the physician will prescribe adjustments to insulin (e.g., on a sliding scale) based on the child's blood glucose levels. Therefore, calling the physician to report that the child is ill and ask what to do is inappropriate. However, the parents do need to notify the physician should any problems arise with management of the child's blood glucose levels. The child who can tolerate oral feedings of simple sugars can be kept at home as long as the parents monitor the child's blood glucose levels frequently for changes.

34. The parents of an 18-year-old preparing to enter college ask if their daughter should have the meningococcal (MCV4) vaccine. The nurse should tell the parents: ■ 1. "It is only necessary to have the vaccine if your daughter will be living in a dormitory." ■ 2. "Yes, we recommend the vaccine, but it needs to be given as a series of three injections." ■ 3. "Let's review your records. The vaccine may have already been given a few years ago." ■ 4. "We highly recommend this vaccine, but we will need to do a pregnancy screening first."

3. The current recommendation is that the MCV4 vaccine be given at the earliest opportunity after the age of 11. Therefore, it is quite possible that the client received the vaccine at a previous visit and did not remember. On a college campus, students living in dormitories are at highest risk, but because it is difficult to target that group colleges may elect to require proof of vaccination for all incoming students. Other risk factors should also be considered, such as if the student plans to travel abroad. The vaccination is typically given as a single injection, but sometimes a second dose is recommended based on risk factors. The MCV4 is not a live vaccine. It may be given during pregnancy if the client is at risk.

9. The nurse judges that the mother understands the term cerebral palsy when she describes it as a term applied to impaired movement resulting from which of the following? ■ 1. Injury to the cerebrum caused by viral infection. ■ 2. Malformed blood vessels in the ventricles caused by inheritance. ■ 3. Nonprogressive brain damage caused by injury. ■ 4. Inflammatory brain disease caused by metabolic imbalances.

3. The term cerebral palsy (CP) refers to a group of nonprogressive disorders of upper motor neuron impairment that result in motor dysfunction due to injury. In addition, a child may have speech or ocular difficulties, seizures, hyperactivity, or cognitive impairment. The condition of congenital malformed blood vessels in the ventricles is known as arteriovenous malformations. Viral infection and metabolic imbalances do not cause CP.

7. A 10-year-old has just spilled hot liquid on his arm, and a 4-inch area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do? ■ 1. Keep the child warm. ■ 2. Cover the burned area with an antibiotic cream. ■ 3. Apply cool water to the burned area. ■ 4. Call 911 to transport the child to the hospital.

3. To prevent further injury to the skin, the mother should apply cool water to the burn site. Doing so causes vasoconstriction, retards further damage to tissues, and decreases fluid loss. Keeping the child warm promotes vasodilation, increases fluid loss, and decreases blood pressure and, thus, circulation to the area. Applying ointment to the burn is contraindicated because it does not allow healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or chilling. If only the arm is burned, a call to 911 for emergency care is not necessary, but the mother should seek health care services immediately.

16. A 4-year-old child with hydrocephalus is scheduled to have a ventroperitoneal shunt in the right side of the head. When developing the child's postoperative plan of care, the nurse should place the preschooler in which of the following positions immediately after surgery? ■ 1. On the right side, with the foot of the bed elevated. ■ 2. On the left side, with the head of the bed elevated. ■ 3. Prone, with the head of the bed elevated. ■ 4. Supine, with the head of the bed flat.

4. For at least the fi rst 24 hours after insertion of a ventriculoperitoneal shunt, the child is positioned supine with the head of the bed flat to prevent too rapid a decrease in cerebrospinal fluid pressure. Although elevating the head increases cerebrospinal fluid drainage and reduces intracranial pressure, a rapid reduction in the size of the ventricles can cause subdural hematoma. Positioning on the operative or right side is avoided because it places pressure on the shunt valve, possibly blocking desired drainage of the cerebrospinal fluid. Elevating the foot of the bed could increase intracranial pressure. With continued increased intracranial pressure, the child would be positioned with the head of the bed elevated to allow gravity to aid drainage. The child should be kept off the nonoperative side (side opposite the shunt), or the left side, to help prevent rapid decompression leading to a cerebral hematoma.

18. An overweight adolescent has been diagnosed with type 2 diabetes. To increase the client's self-efficacy to manage their disease, the nurse should: ■ 1. Provide the client with a written daily food and exercise plan. ■ 2. Discuss eliminating junk food in the home with the parents. ■ 3. Arrange for the school nurse to weigh the child weekly. ■ 4. Utilize a peer with type 2 diabetes to role model lifestyle changes

4. Self-efficacy, or the belief that one can act in a way to produce a desired outcome, can be promoted through the observation of role models. Peers are particularly effective role models because clients can more readily identify with them and believe they are capable of similar behaviors. Providing a written plan alone does not promote self-efficacy. Having parents eliminate junk food and having the school nurse weigh the adolescent can be part of the plan, but these actions do not empower the client.

8. A child diagnosed with tetralogy of Fallot becomes upset, crying and thrashing around when a blood specimen is obtained. The child's color becomes blue and the respiratory rate increases to 44 breaths/minute. Which of the following actions should the nurse do first? ■ 1. Obtain an order for sedation for the child. ■ 2. Assess for an irregular heart rate and rhythm. ■ 3. Explain to the child that it will only hurt for a short time. ■ 4. Place the child in a knee-to-chest position

4. The child is experiencing a tet or hypoxic episode. Therefore the nurse should place the child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from the lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of Fallot. As a result, the blood then entering the systemic circulation has a higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position in the crib, or the mother learns to put the infant over her shoulder while holding the child in a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may need a sedative. Once the child is in the position, the nurse may assess for an irregular heart rate and rhythm. Explaining to the child that it will only hurt for a short time does nothing to alleviate the hypoxia.

12. When developing the discharge plan for the parents of an infant who has undergone a myelomeningocele repair, what information is most important for the nurse to include? ■ 1. A list of available hospital services. ■ 2. Schedule for daily home health care. ■ 3. Chaplain referral for psychological support. ■ 4. Daily care required by the infant.

4. The most important aspect of the discharge plan is to ensure that the parents understand what the daily care of their infant involves and to provide teaching related to carrying out this daily care. In addition to the routine care required by the infant, care also may include physical therapy to the lower extremities. Providing a list of available hospital services may be helpful to the parents, but it is not the most important aspect to include in the discharge plan. Usually, home health care is not needed because the parents are able to care for their child. A referral for counseling is initiated whenever the need arises, not just at discharge.

23. When developing a teaching plan for the parents of a child with Down syndrome, the nurse focuses on activities to increase which of the following for the parents? ■ 1. Affection for their child. ■ 2. Responsibility for their child's welfare. ■ 3. Understanding of their child's disability. ■ 4. Confidence in their ability to care for their child.

4. When teaching the parents of a child with Down syndrome, activities should focus on increasing the parents' confidence in their ability to care for the child. The parents must continue to work daily with their child. Most parents feel affection and a sense of responsibility for their child regardless of the child's limitations. Parents usually understand the child's disability on the cognitive level but have difficulty accepting it on the emotional level. As the parents' confidence in their caring abilities increases, their understanding of the child's disability also increases on all levels.

7. The parents of an infant with myelomeningocele ask the nurse about their child's future mental ability. What is the nurse's best response? ■ 1. "About one-third are mentally retarded, but it's too early to tell about your child." ■ 2. "About two-thirds are significantly retarded, and you'll know soon if this will occur." ■ 3. "Your child will probably be of normal intelligence since he demonstrates signs of it now." ■ 4. "You'll need to talk with the doctor about that, but you can ask later."

1. Approximately one-third of infants diagnosed with myelomeningocele are mentally retarded, but the degree of retardation is variable and it is difficult to predict intellectual functioning in neonates. The parents are asking for an answer now and should not be told to talk with the physician later.

17. A 12-year-old with rheumatic fever has a history of long-term aspirin use. Which statement by the client indicates that the nurse should notify the health care provider? ■ 1. "I hear ringing in my ears." ■ 2. "Is it alright to put lotion on my itchy skin?" ■ 3. "My stomach hurts after I take that medicine." ■ 4. "These pills make me cough."

1. Tinnitus is an adverse effect of prolonged aspirin therapy and the child should be examined by a health care provider for hearing loss. Itchy skin commonly accompanies the rash associated with rheumatic fever and the nurse can encourage lotion use. The nurse teaches clients to take aspirin with food or milk to avoid abdominal discomfort. The nurse can also address the fact that coughing after ingesting aspirin can be caused by inadequate fluid intake during administration.

20. A nurse is assessing a child who is mildly mentally retarded. The best indication of how a mentally retarded child is progressing can be obtained by observing him: ■ 1. At school with his teacher. ■ 2. At home with his family. ■ 3. In the clinic with his mother. ■ 4. Playing soccer with his friends.

1. Watching the child relate to his teacher and school work is the best indication of how he is progressing. School involves interacting with a person who is not a relative and in a situation that is not totally familiar. Observing the client in situations with family and friends shows social relationships but does not indicate how the child is learning new intellectual skills.

31. A 10-year old child is admitted to the hospital with complications related to chickenpox. The nurse should do which of the following to prevent the transmission of the infection to other children on the unit? Select all that apply. ■ 1. Place the child on contact isolation. ■ 2. Wear a gown, mask, and gloves before entering the room. ■ 3. Place the child in a room with a 10-year-old who has had chickenpox. ■ 4. Place the child in a negative air-flow room. ■ 5. Maintain isolation until lesions have disappeared.

2, 4. Gowns, mask, and gloves are needed before the nurse or anyone can enter the room of a client who has chickenpox because the varicella virus is spread by air, droplets, and contact. It is very contagious so a negative-airflow room is recommended. Contact isolation only includes a gown and gloves. Because varicella is spread by air and contact, a private room is needed. The child should remain in isolation until all lesions have crusted.

10. After surgical repair of a myelomeningocele, which position should the nurse use to prevent musculoskeletal deformity in the infant? ■ 1. Placing the feet in flexion. ■ 2. Allowing the hips to be abducted. ■ 3. Maintaining knees in the neutral position. ■ 4. Placing the legs in adduction.

2. Because of the potential for hip dislocation, the neonate's legs should be slightly abducted, hips maintained in slight to moderate abduction, and feet maintained in a neutral position. The infant's knees are flexed to help maintain the hips in abduction.

37. When interviewing the parents of a 2-yearold child, a history of which of the following illnesses should lead the nurse to suspect pneumococcal meningitis? ■ 1. Bladder infection. ■ 2. Middle ear infection. ■ 3. Fractured clavicle. ■ 4. Septic arthritis.

2. Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the body by vascular dissemination from a middle ear infection. The meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumococcus. A chronically draining ear is also frequently found. Bladder infections commonly are caused by Escherichia coli, unrelated to the development of pneumococcal meningitis. Pneumococcal meningitis is unrelated to a fractured clavicle or to septic arthritis, which is commonly caused by Staphylococcus aureus, group A streptococci, or Haemophilus influenzae.

116. A mother tells a nurse that her child has been exposed to roseola. After teaching the mother about the illness, which of the following, if stated by the mother as the most characteristic sign of roseola, indicates successful teaching? ■ 1. Fever and sore throat. ■ 2. Normal temperature followed by a low-grade fever. ■ 3. High fever followed by a drop and then a rash. ■ 4. Coldlike signs and symptoms and a rash.

3. Children with roseola have a high fever for 3 days, which drops suddenly. Then a nonpruritic rash appears, typically lasting for 1 to 2 days. High fever followed by a rash is a characteristic sign. Associated symptoms include cold symptoms, cough, and lymphadenopathy.

15. A nurse is making an initial visit to a family with a 3-year-old child with early Duchenne's muscular dystrophy. Which of the following findings is expected when assessing this child? ■ 1. Contractures of the large joints. ■ 2. Enlarged calf muscles. ■ 3. Difficulty riding a tricycle. ■ 4. Small, weak muscles.

3. Usually the first clinical manifestations of Duchenne's muscular dystrophy include difficulty with typical age-appropriate physical activities such as running, riding a bicycle, and climbing stairs. Contractures of the large joints typically occur much later in the disease process. Occasionally enlarged calves may be noted, but they are not typical findings in a child with Duchenne's muscular dystrophy. Muscular atrophy and development of small, weak muscles are later signs.

10. When assessing the development of a 15-month-old child with cerebral palsy, which of the following milestones should the nurse expect a toddler of this age to have achieved? ■ 1. Walking up steps. ■ 2. Using a spoon. ■ 3. Copying a circle. ■ 4. Putting a block in cup.

4. Delay in achieving developmental milestones is a characteristic of children with cerebral palsy. Ninety percent of 15-month-old children can put a block in a cup. Walking up steps typically is accomplished at 18 to 24 months. A child usually is able to use a spoon at 18 months. The ability to copy a circle is achieved at approximately 3 to 4 years of age.

30. Which of the following statements obtained from the nursing history of a toddler should alert the nurse to suspect that the child has had a febrile seizure? ■ 1. The child has had a low-grade fever for several weeks. ■ 2. The family history is negative for convulsions. ■ 3. The seizure resulted in respiratory arrest. ■ 4. The seizure occurred when the child had a respiratory infection.

4. Most febrile seizures occur in the presence of an upper respiratory infection, otitis media, or tonsillitis. Febrile seizures typically occur during a temperature rise rather than after prolonged fever. There appears to be increased susceptibility to febrile seizures within families. Infrequently, febrile seizures may lead to respiratory arrest.

19. The nurse teaches the mother of a young child with Duchenne's muscular dystrophy about the disease and its management. Which of the following statements by the mother indicates successful teaching? ■ 1. "My son will probably be unable to walk independently by the time he is 9 to 11 years old." ■ 2. "Muscle relaxants are effective for some children; I hope they can help my son." ■ 3. "When my son is a little older, he can have surgery to improve his ability to walk." ■ 4. "I need to help my son be as active as possible to prevent progression of the disease."

1. Muscular dystrophy is a progressive disease. Children who are affected by this disease usually are unable to walk independently by age 9 to 11 years. There is no effective treatment for childhood muscular dystrophy. Although children who remain active are able to avoid wheelchair confinement for a longer period, activity does not prevent disease progression.

A child who is admitted after having suffered trauma has also been exposed to varicella. Which of the following should the nurse institute for infection control? ■ 1. Airborne precautions. ■ 2. Droplet precautions. ■ 3. Contact precautions. ■ 4. Indirect contact precautions.

1. Children with varicella or suspected varicella should be treated under airborne precautions in addition to standard precautions. Varicella is transmitted by airborne nuclei. Droplet precautions are indicated for conditions, such as pertussis, meningococcal pneumonia, and rubella. Contact precautions are indicated for conditions, such as draining major abscesses, acute viral conjunctivitis, and Clostridium difficile gastroenteritis. Indirect contact is not a method of controlling infection. Rather it is a mode of transmission involving contamination via some intermediate object, such as an instrument, needle, or dressing, or by hands that are not washed or gloves that are not changed between clients.

14. The mother of a child with Duchenne's muscular dystrophy asks about the chance that her next child will have the disease. The nurse responds based on the understanding of which of the following? ■ 1. Sons have a 50% chance of being affected. ■ 2. Daughters have a 1 in 4 chance of being carriers. ■ 3. Each child has a 1 in 4 chance of developing the disease. ■ 4. Each child has a 50% chance of being a carrier.

1. Duchenne's muscular dystrophy is an X-linked recessive disorder. The gene is transmitted through female carriers to affected sons 50% of the time. Daughters have a 50% chance of being carriers.

13. The nurse assesses the family's ability to cope with the child's cerebral palsy. Which action should alert the nurse to the possibility of their inability to cope with the disease? ■ 1. Limiting interaction with extended family and friends. ■ 2. Learning measures to meet the child's physical needs. ■ 3. Requesting teaching about cerebral palsy in general. ■ 4. Not seeking financial help to pay for medical bills.

1. Limited interaction or lack of interaction with friends and family may lead the nurse to suspect a possible problem with the family's ability to cope with others' reactions and responses to a child with cerebral palsy. Learning measures to meet the child's physical needs demonstrates some understanding and acceptance of the disease. Requesting teaching about the disease suggests curiosity or a desire for understanding, thus demonstrating the family dealing with the situation. Although not seeking financial help to pay for medical bills may be problem, it does not indicate the type of response the family is having to the child's problems.

2. When positioning a neonate with an unrepaired myelomeningocele, which of the following positions is most appropriate? ■ 1. Supine with the hips at 90-degree flexion. ■ 2. Right side-lying position with the knees flexed. ■ 3. Prone with hips in abduction. ■ 4. Supine in semi-Fowler's position with chest and abdomen elevated.

3. Before surgery, the infant is kept flat in the prone position to decrease tension on the sac. This allows for optimal positioning of the hips, knees, and feet because orthopedic problems are common. The supine position is unacceptable because it causes pressure on the defect. Flexing the knees when side lying will increase tension on the sac, as will placing the infant in semi-Fowler's position, even though the chest and abdomen are elevated.

11. When caring for an infant who has undergone surgical repair of a myelomeningocele, which of the following should the nurse report to the surgeon? ■ 1. Seizures and vomiting. ■ 2. Frontal bossing and sunset eyes. ■ 3. Increased head circumference and bulging fontanel. ■ 4. Irritability and shrill cry.

3. In a neonate with open cranial sutures, increasing head circumference is the predominant and earliest sign of increased intracranial pressure and the nurse should report this to the surgeon. Bulging fontanels also are seen. However, some neonates may exhibit bulging fontanels without head enlargement. Seizures and vomiting are associated with hydrocephalus, but most often these are seen in an older child with closed cranial sutures. Shortly after increasing head circumference and bulging fontanels occur, other signs and symptoms, such as frontal bossing or enlargement with depressed eyes and the sunset sign (sclera visible above the iris), may develop. Although irritability is an early sign, a brief, shrill cry is a later sign of increasing intracranial pressure associated with the development of hydrocephalus.

18. When interacting with the mother of a child who has Duchenne's muscular dystrophy, the nurse observes behavior indicating that the mother may feel guilty about her child's condition. The nurse interprets this behavior as guilt stemming from which of the following? ■ 1. The terminal nature of the disease. ■ 2. The dependent behavior of the child. ■ 3. The genetic mode of transmission. ■ 4. The sudden onset of the disease.

3. The guilt that mothers of children with muscular dystrophy commonly experience usually results from the fact that the disease is genetic and the mother transmitted the defective gene. Although many children die from the disease, the disease is considered chronic and progressive. As the disease progresses, the child becomes more dependent. However, guilt typically stems from the knowledge that the mother transmitted the disease to her son rather than the dependency of the child. The disease onset is usually gradual, not sudden.

12. The mother asks the nurse whether her child with hemiparesis due to spastic cerebral palsy will be able to walk normally because he can pull himself to a standing position. Which of the following responses by the nurse would be most appropriate? ■ 1. "Ask the doctor what he thinks at your next appointment." ■ 2. "Maybe, maybe not. How old were you when you first walked?" ■ 3. "It's difficult to predict, but his ability to bear weight is a positive factor." ■ 4. "If he really wants to walk, and works hard, he probably will eventually."

3. The nurse needs to respond honestly to the mother. Most children with hemiparesis due to spastic cerebral palsy are able to walk because the motor deficit is usually greater in the upper extremity. There is no need to refer the mother to the physician. The age at which the mother walked may be important to elicit, but this does not influence when the child will walk. The will to walk is important, but without neurologic stability the child may be unable to do so.

11. The parent of a child with spastic cerebral palsy and a communication disorder tells the nurse, "He seems so restless. I think he is in pain." The nurse should: ■ 1. Assess the child for pain using the Faces, Legs, Activity, Cry, Consolability (FLACC) scale. ■ 2. Assess the child using the pediatric FACES scale. ■ 3. Administer the pain medication which is ordered to be given as needed and assess the response. ■ 4. Notify the primary care provider of the change in behavior.

3. The parent is the child's primary care provider and may be very in tune to subtle changes in the child's behavior. If the parent thinks the child is in pain, it is very likely to be so. The nurse should administer the pain medication and evaluate if the medication affected the child's behavior. The FLACC scale may be difficult to interpret when the child has spasticity. The FACES scale requires self report. The physician should be contacted regarding the change in behavior only if other available interventions are unsuccessful.

17. When developing the plan of care for a child with early Duchenne's muscular dystrophy, which of the following nursing goals is the priority? ■ 1. Encouraging early wheelchair use. ■ 2. Fostering social interactions. ■ 3. Maintaining function of unaffected muscles. ■ 4. Prevent circulatory impairment.

3. The primary nursing goal is to maintain function in unaffected muscles for as long as possible. There is no effective treatment for childhood muscular dystrophy. Children who remain active are able to forestall being confined in wheelchair. Remaining active also minimizes the risk for social isolation. Preventing rather than encouraging wheelchair use by maintaining function for as long as possible is an appropriate nursing goal. Children with muscular dystrophy become socially isolated as their condition deteriorates and they can no longer keep up with friends. Maintaining function helps prevent social isolation. Circulatory impairment is not associated with muscular dystrophy.

3. The nurse is teaching the parents of a child with myelomeningocele how to prevent urinary tract infections. What should the care plan include for this child? Select all that apply. ■ 1. Provide meticulous skin care. ■ 2. Use the Crede's maneuver to empty the bladder. ■ 3. Encourage frequent emptying of the bladder. ■ 4. Assure adequate fluid intake. ■ 5. Use tight-fitting diapers around the meatus.

2, 3, 4. Prevention of urinary tract infections includes adequate fluid intake, urine acidification, frequent emptying of the bladder including the use of the Crede's maneuver if needed. While the nurse should keep the skin clean and dry, this will not prevent urinary tract infections. Keeping urine close to the meatus with a tight-fitting diaper would increase the risk for infection.

3. When teaching the parents of a child with a ventricular septal defect who is scheduled for a cardiac catheterization, the nurse explains that this procedure involves the use of which of the following? ■ 1. Ultra-high-frequency sound waves. ■ 2. Catheter placed in the right femoral vein. ■ 3. Cutdown procedure to place a catheter. ■ 4. General anesthesia.

2. In children, cardiac catheterization usually involves a right-sided approach because septal defects permit entry into the left side of the heart. The catheter is usually inserted into the femoral vein through a percutaneous puncture. Echocardiography involves the use of ultra-high frequency sound waves. A cutdown procedure is rarely used. The catheterization is usually performed under local, not general, anesthesia with sedation.

24. A nurse is teaching an 8-year-old with diabetes and her parents about managing diabetes during illness. The nurse determines the parents understand the instruction when they indicate that, when the child is ill, they will provide: ■ 1. More calories. ■ 2. More insulin. ■ 3. Less insulin. ■ 4. Less protein and fat.

2. The child needs more insulin during an illness, because the cells becomes more insulin resistant during illness and need more insulin to achieve a normal blood glucose level. During an acute illness, simple carbohydrates and fluids are usually tolerated best.

18. Which of the following should the nurse expect to include in the plan of care for a child who is diagnosed with rheumatic fever and carditis and admitted to the hospital? ■ 1. Ensuring continuous parental presence at the child's bedside. ■ 2. Providing the child with periods of rest. ■ 3. Encouraging participation in age-appropriate activities. ■ 4. Advising the child to eat as much as possible

2. The nurse should encourage and plan to provide periods of rest for the child with rheumatic fever and carditis to allow the heart to rest. The parents should be made to feel that they can come and go as they need to. The child is not in critical condition, so the parents do not need to be present at the child's bedside continuously. The child should be allowed to participate in nonstrenuous activities that avoid overtaxing the heart, thus allowing the heart time to rest. There is no reason to encourage the child to eat as much as possible; in fact, overeating should be discouraged because it taxes the heart muscle.

10. When assessing a child after heart surgery to correct tetralogy of Fallot, which of the following should alert the nurse to suspect a low cardiac output? ■ 1. Bounding pulses and mottled skin. ■ 2. Altered level of consciousness and thready pulse. ■ 3. Capillary refill of 2 seconds and blood pressure of 96/67 mm Hg. ■ 4. Extremities warm to the touch and pale skin.

2. With a low cardiac output and subsequent poor tissue perfusion, signs and symptoms would include pale, cool extremities; cyanosis; weak, thready pulses; delayed capillary refill; and decrease in level of consciousness.

13. Which of the following statements by the mother of an infant with a repaired upper lumbar myelomeningocele indicates that she understands the nurse's teaching at the time of discharge? ■ 1. "I can apply a heating pad to his lower back." ■ 2. "I'll be sure to keep him away from other children." ■ 3. "I will call the doctor if his urine has a funny smell." ■ 4. "I will prop him on pillows to keep him from rolling over."

3. Children with a myelomeningocele are prone to urinary tract infections (UTI) and foul smelling urine is one symptom of a UTI. Because of the level of defect, the child may be insensitive to pressure or heat. Using a heating pad may lead to thermal injury because the child may not be able to sense if the pad is too hot. Keeping the child away from other children is unnecessary and can retard social development. Using pillows as props increases the risk of sudden infant death syndrome.

19. Which foods would the nurse teach the parents of a child with phenylketonuria (PKU) to avoid? Select all that apply. ■ 1. Hamburger. ■ 2. Hot dog. ■ 3. Ice cream. ■ 4. Juice. ■ 5. Cereal.

1, 2, 3. Children with PKU lack an enzyme to metabolize phenylalanine and convert it to tyrosine. Treatment is dietary management to control the amount of phenylalanine ingested. Foods with low phenylalanine levels include fruits, most vegetables, and cereals. High-protein foods have high levels of phenylalanine and include meats and dairy products.

22. The nurse discusses with the parents how best to raise the IQ of their child with Down syndrome. Which of the following would be most appropriate? ■ 1. Serving hearty, nutritious meals. ■ 2. Giving vasodilator medications as prescribed. ■ 3. Letting the child play with more able children. ■ 4. Providing stimulating, nonthreatening life experiences.

4. Nonthreatening experiences that are stimulating and interesting to the child have been observed to help raise IQ. Practices such as serving nutritious meals or letting the child play with more able children have not been supported by research as beneficial in increasing intelligence. Vasodilator medications act to increase oxygenation to the tissues, including the brain. However, these medications do not increase the child's IQ.

18. When taking a diet history from the mother of a 7-year-old child with phenylketonuria, a report of an intake of which of the following foods should cause the nurse to gather additional information? ■ 1. Cola. ■ 2. Carrots. ■ 3. Orange juice. ■ 4. Bananas.

1. Foods with low phenylalanine levels include vegetables, fruits, and juices. Foods high in phenylalanine include meats and dairy products, which must be restricted or eliminated. Colas contain more phenylalanine than the fruits listed.

19. A 7-year-old has been diagnosed as mentally retarded. Which of the parents' expectations for their child is realistic? Select all that apply. ■ 1. Difficulty learning. ■ 2. An IQ below 70. ■ 3. Deficits in adaptive behavior. ■ 4. Normal intellectual capacity. ■ 5. Behavioral problems.

1, 2, 3. The definition of mental retardation includes deficits in intellectual functioning and behavior. The child's IQ will be 70 or less and he will have difficult learning. The client cannot adapt to situations in a manner consistent with children with higher IQs. The client does not have a normal intellectual capacity to learn and develop from his experiences. The client may have behavioral problems but these are not considered a result of mental retardation.

Discharge teaching for a 3-month-old infant with a cardiac defect who is to receive digoxin (Lanoxin) should include which of the following? Select all that apply. ■ 1. Give the medication at regular intervals. ■ 2. Mix the medication with a small volume of breast milk or formula. ■ 3. Repeat the dose one time if the child vomits immediately after administration. ■ 4. Notify the primary care provider of poor feeding or vomiting. ■ 5. Make up any missed doses as soon as realized. ■ 6. Notify the primary care provider if more than 2 consecutive doses are missed. ■ 7. Keep medication in a safe place, preferably a locked cabinet. ■ 8. Induce vomiting if there is an accidental overdose.

1, 4, 6, 7. To achieve optimal therapeutic levels, digoxin should be given at regular intervals without variation, usually every 12 hours. Vomiting and poor feeding are signs of toxicity. If more than two consecutive doses are missed, interventions may be needed to assure therapeutic drug levels. Accidental ingestion of digoxin may be life-threatening and parents should be advised on safe storage practices. The medication should not be mixed with any other fluid as refusal may result in inaccurate intake of the medication. Taking make-up doses, or taking the medication at times other than scheduled, may adversely affect serum levels. Parents should be advised to call poison control in the case of any accidental medication overdose

6. The mother of an infant with myelomeningocele asks if her baby is likely to have any other defects. The nurse responds based on the understanding that myelomeningocele is commonly associated with which disorder? ■ 1. Excessive cerebrospinal fluid within the cranial cavity. ■ 2. Abnormally small head. ■ 3. Congenital absence of the cranial vault. ■ 4. Overriding of the cranial sutures.

1. Excessive cerebrospinal fluid in the cranial cavity, called hydrocephalus, is the most common anomaly associated with myelomeningocele. Microencephaly, an abnormally small head, is associated with maternal exposure to rubella or cytomegalovirus. Anencephaly, a congenital absence of the cranial vault, is a different type of neural tube defect. Overriding of the sutures, possibly a normal finding after a vaginal delivery, is not associated with myelomeningocele.

12. As part of the preoperative teaching for the family of a child undergoing a tetralogy of Fallot repair, the nurse tells the family upon returning to the pediatric floor that the child may: ■ 1. Be placed on a reduced sodium diet. ■ 2. Have an activity restriction for several days. ■ 3. Be assigned to an isolation room. ■ 4. Have visits limited to a select few.

1. Because of the hemodynamic changes that occur with open heart surgery repair, particularly with septal defects, transient congestive heart failure may develop. Therefore, the child's sodium intake typically is restricted to 2 to 3 g/day. Activity restrictions are inappropriate. Typically the child is encouraged to walk the halls and unit. Risk for infection after the repair is the same as any postoperative client, therefore isolation is not necessary. The child may be placed in a room with other children who are not contagious. Visitors are not restricted unless the pediatric unit has restrictive visiting policies.

11. A child has had open heart surgery to repair a tetralogy of Fallot with a patch. The nurse should instruct the parents to: ■ 1. Notify all health care providers before invasive procedures for the next 6 months. ■ 2. Maintain adequate hydration of at least 10 glasses of water a day. ■ 3. Provide for frequent rest periods and naps during the first 4 weeks. ■ 4. Restrict the ingestion of bananas and citrus fruit.

1. Children who have undergone open heart surgery with a patch are at risk for infection, especially subacute bacterial endocarditis (SBE), for the first 6 months following surgery. The newest evidence-based guidelines suggest once the patch has epithelialized, these precautions are no longer necessary. Therefore, parents are instructed about SBE precautions including the need to notify providers before invasive procedures so antibiotics can be prescribed for that time period. Having the child drink a very large amount of water may lead to fluid overload. Children gear their rest schedule to their activities making it unnecessary to schedule frequent rest periods. Bananas and citrus fruit are high in potassium, but there is no evidence provided that the child has an elevated serum potassium requiring restriction.

6. An 18-month-old with a congenital heart defect is to receive digoxin twice a day. The nurse should instruct the parents about which of the following? ■ 1. Digoxin enables the heart to pump more effectively with a slower and more regular rhythm. ■ 2. Signs of toxicity include loss of appetite, vomiting, increased pulse, and visual disturbances. ■ 3. Digoxin is absorbed better if taken with meals. ■ 4. If the child vomits within 15 minutes of administration, the dosage should be repeated.

1. Digoxin's effect is to slow the rate of the electrical conduction through the heart and increase the strength of the heart's contraction. Signs of toxicity include anorexia and decreased heart rate. Digoxin should be taken 1 hour before meals or 2 hours after meals in order to obtain better absorption of the drug. If the child vomits within 15 minutes of administration, the dose should not be repeated because it is not known how much of the medication has been absorbed.

12. After teaching the mother of a child with severe burns about the importance of specific nutritional support in burn management, which of the following, if chosen by the mother from the child's diet menu, indicates the need for further instruction? ■ 1. Bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks. ■ 2. Cheeseburger, cottage cheese and pineapple salad, chocolate milk, and a brownie. ■ 3. Chicken nuggets, orange and grapefruit sections, and a vanilla milkshake. ■ 4. Beef, bean, and cheese burrito; a banana; fruit-flavored yogurt; and skim milk.

1. Hypoproteinemia is common after severe burns. The child's diet should be high in protein to compensate for protein loss and to promote tissue healing. The child will also require a diet that is high in calories and rich in iron. The menu of bacon, lettuce, and tomato sandwich; milk; and celery sticks is lacking in sufficient protein and calories.

23. An 8-year-old with diabetes is placed on neutral protamine Hagedorn (NPH) and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. The snack will: ■ 1. Help her regain lost weight. ■ 2. Provide carbohydrates for immediate use. ■ 3. Prevent late night hypoglycemia. ■ 4. Help her stay on her diet.

3. NPH insulin peaks in 6 to 8 hours, which would occur during sleep. A bedtime snack is needed to prevent late night hypoglycemia. The snack is not given to help regain weight. Milk contains fat and protein which cause delayed absorption into the blood stream and maintains the blood glucose level at night when the NPH insulin will peak. The snack is not used to provide carbohydrates for immediate use because NPH insulin, unlike regular insulin, does not peak immediately. The snack has nothing to do with a diet.

9. Prior to surgery, a nurse is positioning a neonate with a myelomeningocele. The nurse should position the neonate in which of the following ways? Select all that apply. ■ 1. Place the neonate in a prone position. ■ 2. Keep a diaper over the sac. ■ 3. Allow the neonate's feet to hang over the mattress edge. ■ 4. Use a foam pad to maintain hip adduction. ■ 5. Use a soft pad over the mattress.

1, 3, 5. Prior to surgery, the neonate with a myelomeningocele should be placed in a prone position. The feet can hang over the edge of the mattress to prevent foot deformities. The neonate should rest on a soft surface to reduce pressure on the skin; the nurse can use a fleece pad or foam over the mattress. The meningeal sac should not be covered. The hips should be maintained in abduction using a diaper roll or small pillow.

32. The mother of an 8-year-old with diabetes tells the nurse that she does not want the school to know about her daughter's condition. The nurse should reply: ■ 1. "I think that would be a good idea." ■ 2. "What is it that concerns you about having the school know about your daughter's condition?" ■ 3. "It would be fine not to tell your daughter's friends, but the teacher must know." ■ 4. "In order to keep your daughter safe, it is necessary for all adults in the school to know her condition."

2. The nurse's first response should be to obtain more information about the mother's concerns. It is true that the child may have a diabetic reaction anywhere at school, and it is advisable that her teacher, classmates, and other adults know about her diabetes in order to help her; however, it is ultimately the client and her parents who will make the decision about informing the school. The nurse can facilitate a dialogue that will help the mother reach this decision. Dictating to the mother does not explain any rationale for the necessity of the information.

40. A hospitalized preschooler with meningitis who is to be discharged becomes angry when the discharge is delayed. Which of the following play activities would be most appropriate at this time? ■ 1. Reading the child a story. ■ 2. Painting with watercolors. ■ 3. Pounding on a pegboard. ■ 4. Stacking a tower of blocks.

3. The child is angry and needs a positive outlet for expression of feelings. An emotionally tense child with pent-up hostilities needs a physical activity that will release energy and frustration. Pounding on a pegboard offers this opportunity. Listening to a story does not allow the child to express emotions. It also places the child in a passive role and does not allow the child to deal with feelings in a healthy and positive way. Activities such as painting and stacking a tower of blocks require concentration and fine movements, which could add to frustration. However, if the child then knocks the tower over, doing so may help to dispel some of the anger.

18. A nurse evaluates discharge teaching as successful when the parents of a school-age child with a ventriculoperitoneal shunt insertion identify which sign as signaling a blocked shunt? ■ 1. Decreased urine output with stable intake. ■ 2. Tense fontanel and increased head circumference. ■ 3. Elevated temperature and reddened incisional site. ■ 4. Irritability and increasing difficulty with eating.

4. In a school-age child, irritability, lethargy, vomiting, difficulty with eating, and decreased level of consciousness are signs of increased intracranial pressure caused by a blocked shunt. Decreased urine output with stable fluid intake indicates fluid loss from a source other than the kidneys. A tense fontanel and increased head circumference would be signs of a blocked shunt in an infant. Elevated temperature and redness around incisions might suggest an infection.

29. The parents of a child with occasional generalized seizures want to send the child to summer camp. The parents contact the nurse for advice on planning for the camping experience. Which of the following activities should the nurse and family decide the child should avoid? ■ 1. Rock climbing. ■ 2. Hiking. ■ 3. Swimming. ■ 4. Tennis.

1. A child who has generalized seizures should not participate in activities that are potentially hazardous. Even if accompanied by a responsible adult, the child could be seriously injured if a seizure were to occur during rock climbing. Someone also should accompany the child during activities in the water. At summer camp, hiking and swimming would occur most commonly as group activities, so someone should be with the child. Tennis would be considered an appropriate, nonhazardous activity for a child with generalized seizures.

36. Which sign should lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? ■ 1. Hemorrhagic skin rash. ■ 2. Edema. ■ 3. Cyanosis. ■ 4. Dyspnea on exertion.

1. Disseminated intravascular coagulation is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition. Heparin therapy is often used to interrupt the clotting process. Edema would suggest a fluid volume excess. Cyanosis would indicate decreased tissue oxygenation. Dyspnea on exertion would suggest respiratory problems, such as pulmonary edema.

20. Which of the following initial physical findings indicate the development of carditis in a child with rheumatic fever? ■ 1. Heart murmur. ■ 2. Low blood pressure. ■ 3. Irregular pulse. ■ 4. Anterior chest wall pain.

1. In rheumatic fever, the connective tissue of the heart becomes inflamed, leading to carditis. The most common signs of carditis are heart murmurs, tachycardia during rest, cardiac enlargement, and changes in the electrical conductivity of the heart. Heart murmurs are present in about 75% of all clients during the first week of carditis and in 85% of clients by the third week. Signs of carditis do not include hypotension or chest pain. The client may have a rapid pulse, but it is usually not irregular

24. A child with Kawasaki disease is receiving low dose aspirin. The mother calls the clinic and states that the child has been exposed to influenza. Which recommendations should the nurse make? Select all that apply. ■ 1. Increase fluid intake. ■ 2. Stop the aspirin. ■ 3. Keep the child home from school. ■ 4. Watch for fever. ■ 5. Weigh the child daily

2, 4. Aspirin needs to be stopped because of its possible link to Reye's syndrome. Additionally, the parents need to watch for signs and symptoms of influenza. Children with influenza frequently present with fever, cold symptoms, and gastrointestinal symptoms. Increasing the child's fluid intake and weighing the child daily are not needed at this time because the child is not ill. Keeping the child home from school is not necessary, because the child is not ill and has already been exposed.

33. When teaching an adolescent with a seizure disorder who is receiving valproic acid (Depakene), which sign or symptom should the nurse instruct the client to report to the health care provider? ■ 1. Three episodes of diarrhea. ■ 2. Loss of appetite. ■ 3. Jaundice. ■ 4. Sore throat.

3. A toxic effect of valproic acid (Depakene) is liver toxicity, which may manifest with jaundice and abdominal pain. If jaundice occurs, the client needs to notify the health care provider as soon as possible. Diarrhea and sore throat are not common side effects of this drug. Increased appetite is common with this drug.

4. The nurse reports to the physician signs of increased intracranial pressure in an infant with a myelomeningocele who has which of the following? ■ 1. Minimal lower extremity movement. ■ 2. A high-pitched cry. ■ 3. Overflow voiding only. ■ 4. A fontanel that bulges with crying.

2. A Chiari malformation obstructs the flow of cerebral spinal fluid resulting in hydrocephalus. This is a common problem in infants with myelomeningocele and will require surgical intervention with a shunt. A high-pitched cry is one sign of increased intracranial pressure that may indicate the presence of a Chiari malformation and requires further evaluation. Minimal movement of the lower extremities is an expected finding associated with spinal cord damage. Overflow voiding comes from a neurogenic bladder, not increased intracranial pressure. It is normal for the fontanel to bulge with crying.

26. Which of the following should the nurse include when completing discharge instructions for the parents of a 12-month-old child diagnosed with Kawasaki disease (KD) and being discharged to home? ■ 1. Offer the child extra fluids every 2 hours for 2 weeks. ■ 2. Take the child's temperature daily for several days. ■ 3. Check the child's blood pressure daily until the follow-up appointment. ■ 4. Call the physician if the irritability lasts for 2 more weeks.

2. The child's temperature should be taken daily for several days after discharge, because recurrent fever may develop. Offering the child fluids every 2 hours is not necessary. Doing so increases the child's risk for CHF. Checking the child's blood pressure at home usually is not included as part of the discharge instructions because, by the time of discharge, the child is considered stable and the risk for cardiac problems is minimal. Most children with KD recover fully. Irritability may last for 2 months after discharge.

11. A 5-year-old child with burns on the trunk and arms has no appetite. The nurse and mother develop a plan of care to stimulate the child's appetite. Which of the following suggestions made by the mother would indicate that she needs additional teaching? ■ 1. Deciding that she will feed the child herself. ■ 2. Withholding dessert and treats unless meals are eaten. ■ 3. Offering the child finger foods that the child likes. ■ 4. Serving smaller and more frequent meals.

2. Withholding certain foods until the child complies is punitive and rarely successful. Allowing the mother to feed the child, serving smaller and more frequent meals, and offering finger foods are all acceptable interventions for a 5-year-old child. This is true whether the child is well or ill.

13. When caring for a child with moderate burns from the waist down, which of the following should the nurse do when positioning the child? ■ 1. Place the child in a position of comfort. ■ 2. Allow the child to lie on the abdomen. ■ 3. Ensure the application of leg splints. ■ 4. Have the child flex the hips and knees.

3. A child with moderate burns is at high risk for contractures. A position of comfort would encourage contracture formation. Therefore, splints need to be applied to maintain proper positioning and joint function, thereby preventing contractures and loss of function. Allowing the child to lie on the abdomen or with hips and knees flexed often encourages contracture formation.

21. A newborn diagnosed with phenylketonuria (PKU) is placed on a milk substitute, Lofenalac. The mother asks the nurse how long her infant will be taking this. Which of the following responses would be most appropriate? ■ 1. "Until the infant is taking solid foods well." ■ 2. "Until the child has stopped growing." ■ 3. "Until the phenylalanine level remains below normal for 6 months." ■ 4. "Probably for a long time, but it's not definitely known."

4. Although it is not known how long diet therapy must continue for children with PKU, many experts suggest continuing it indefinitely because of academic difficulties and lower intelligence quotients in older children who have stopped the restrictive diet. For women it is necessary to resume the diet before conception to lower the phenylalanine levels in the fetus and prevent complications.

1. Parents bring a 10-month-old boy born with myelomeningocele and hydrocephalus with a ventriculoperitoneal shunt to the emergency department. His symptoms include vomiting, poor feeding, lethargy, and irritability. What interventions by the nurse are appropriate? Select all that apply. ■ 1. Weigh the child. ■ 2. Listen to bowel sounds. ■ 3. Palpate the anterior fontanel. ■ 4. Obtain vital signs. ■ 5. Assess pitch and quality of the child's cry.

2, 3, 4, 5. Common shunt complications are obstruction, infection, and disconnection of the tubing. The signs presented by the child indicate increased intracranial pressure from a shunt malformation, which could be caused by an infection, such as peritonitis or meningitis. By listening to bowel sounds, the nurse will note if peritonitis might be a possibility. Palpating the fontanel would indicate increased intracranial pressure if it were bulging and taut. Obtaining vital signs would assess for signs of infection, such as elevated temperature or, possibly, Cushing's triad (elevated blood pressure, slow pulse, and depressed respirations). A high-pitched cry is a sign of increased intracranial pressure. Weighing the child at this time would not be a priority, nor would it add to identifying the cause of the signs and symptoms.

21. The primary health care provider orders pulse assessments through the night for a 12-year old child with rheumatic fever who has a daytime heart rate of 120. The nurse explains to the mother that this is to evaluate if the elevated heart rate is caused by: ■ 1. The morning digitalis. ■ 2. Normal activity during waking hours. ■ 3. A warmer daytime environment. ■ 4. Normal variations in day and evening hours.

2. An above-average pulse rate that is out of proportion to the degree of activity is an early sign of heart failure in a client with rheumatic fever. The sleeping pulse is used to determine whether the mild tachycardia persists during sleep (inactivity) or whether it is a result of daytime activities. The environmental temperature would need to be quite warmer before it could influence the heart rate. Digitalis lowers the heart rate, so the rate would be decreased during the daytime.

26. What should be part of the nurse's teaching plan for a child with epilepsy being discharged on a regimen of diphenylhydantoin (Dilantin)? ■ 1. Drinking plenty of fluids. ■ 2. Brushing teeth after each meal. ■ 3. Having someone be with the child during waking hours. ■ 4. Reporting signs of infection.

2. Diphenylhydantoin (Dilantin) can cause gingival hyperplasia. Children taking Dilantin should brush their teeth after every meal and at bedtime, and visit their dentist on a regular basis. Drinking plenty of fluids is not required while taking Dilantin. A child on Dilantin does not need to be observed during waking hours because the seizures should be under control. Infections do not occur with an increased incidence in clients receiving Dilantin.

2. A 4-year-old has been scheduled for a cardiac catheterization. To help prepare the family the nurse should: ■ 1. Advise the family to bring the child to the hospital for a tour a week in advance. ■ 2. Explain that the child will need a large bandage after the procedure. ■ 3. Discourage bringing favorite toys that might become associated with pain. ■ 4. Explain that the child may get up as soon as the vital signs are stable.

2. The catheter insertion site will be covered with a bandage. This is important for preschool children to know as they are very concerned about bodily harm. The best time to prepare a preschool child for an invasive procedure is the night before. Bringing a favorite toy to the hospital will help decrease the child's anxiety. To prevent bleeding, the child will be expected to keep the extremity straight for 4 to 6 hours after the procedure, either in bed or on the parent's lap.

13. After surgery to correct a tetralogy of Fallot, the child's parents express concern to the nurse that their 4-year-old child wants to be held more frequently than usual. The nurse recommends: ■ 1. Introducing a new skill. ■ 2. Play therapy. ■ 3. Encouraging the behavior. ■ 4. Having the volunteer hold the child.

2. The child is exhibiting regression. During periods of stress, children frequently revert to behaviors that were comforting in earlier developmental stages; play therapy is one way to help the child cope with the stress. Teaching a new skill most likely would add more stress. Parents should be instructed to praise positive behaviors and ignore regressive behaviors rather than calling attention to them through encouragement or discouragement. Having someone else hold the child does not encourage coping with the stress or promoting appropriate development.

4. After the nurse teaches the mother of a child with atopic dermatitis how to bathe her child, which of the following statements by the mother indicates effective teaching? ■ 1. "I let my child play in the tub for 30 minutes every night." ■ 2. "My child loves the bubble bath I put in the tub." ■ 3. "When my child gets out of the tub I just pat the skin dry." ■ 4. "I make sure my child has a bath every night."

3. Atopic dermatitis is a chronic pruritic dermatitis that usually begins in infancy. Many of the children diagnosed with it have a family history of eczema, allergies, or asthma. Atopic dermatitis is best treated with hydrating the skin, controlling the pruritus, and preventing secondary infection. Patting the skin dry removes less natural skin moisturizer and thus maintains skin hydration. Water has a drying effect on the skin. Playing in the tub for 30 minutes each night would deplete the skin of its natural moisturizers, thereby leading to increased pruritus and dry skin. Bubble baths are to be avoided in children with atopic dermatitis because they may act as an irritant, possibly exacerbating the condition. Also, bubble baths deplete the skin of its natural moisturizers. The issue is not whether the child bathes every night. Rather, the goal is to decrease dryness and itching.

19. After 6 months of treatment with diet and exercise, a 12-year-old with type 2 diabetes still has a fasting blood glucose level of 140 mg/dL. The primary care provider has decided to begin metformin (Glucophage). The adolescent asks how the medication works. The nurse should tell the client that the medicine decreases the glucose production and: ■ 1. Replaces natural insulin. ■ 2. Helps the body make more insulin. ■ 3. Increases insulin sensitivity. ■ 4. Decreases carbohydrate adsorption.

3. Metformin is currently approved by the FDA to treat type 2 diabetes in children. The medication decreases glucogenesis in the liver and increases insulin sensitivity in the peripheral tissues. Only insulin can actually replace insulin. This treatment is reserved for clients with type 1 diabetes or those with type 2 who do not respond to diet, exercise, and an oral diabetic agent. Other oral medications used to treat diabetes augments insulin production or decreases carbohydrate absorption, but those medications are primarily used in adults.

15. The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to: ■ 1. Keep their home warmer than usual. ■ 2. Encourage plenty of outdoor activities. ■ 3. Promote interactions with one friend instead of groups. ■ 4. Limit bathing to prevent skin irritation.

3. Children with hyperthyroidism experience emotional labiality that may strain interpersonal relationships. Focusing on one friend is easier than adapting to group dynamics until the child's condition improves. Because of their high metabolic rate, children with hyperthyroidism complain of being too warm. Bright sunshine may be irritating because of disease-related ophthalmopathy. Sweating is common and bathing should be encouraged

4. When developing the discharge teaching plan for the parents of a child who has undergone a cardiac catheterization for ventricular septal defect, which of the following should the nurse expect to include? ■ 1. Restriction of the child's activities for the next 3 weeks. ■ 2. Use of sponge baths until the stitches are removed. ■ 3. Use of prophylactic antibiotics before receiving any dental work. ■ 4. Maintenance of a pressure dressing until a return visit with the physician.

3. Prophylactic antibiotics are suggested for children with heart defects before dental work is done to reduce the risk of bacterial infection. Typically, activities are not restricted after a cardiac catheterization. A percutaneous approach is used to insert the catheter, so stitches are not necessary. Showering or bathing is allowed as usual. The pressure dressing will be removed before the child is discharged.

22. A 14-year-old is using glargine (Lantus) and lispro (Humolog) to manage type I diabetes. The order for sliding scale lispro reads: Lispro subcutaneous give units according to sliding scale: Blood glucose: 70 - 150 mg/dL = 0 units 151-200 mg/dL = 1 unit 201-250 mg/dL = 2 units 251-300 mg/dL = 3 units 301-350 mg/dL = 4 units Call for Blood glucose > 350 In addition give 1 unit for every 15 grams of carbohydrate. The morning blood glucose is 202 mg/dL and the client is going to eat 2 carbohydrate exchanges. The nurse has the client administer how many units of lispro? ______________________units.

4 units. Each carbohydrate food exchange has 15 grams of carbohydrate. Two units are needed to cover the current blood glucose and 2 units are needed to cover the anticipated carbohydrate intake.

73. The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation? ■ 1. Standard precautions. ■ 2. Contact precautions. ■ 3. Airborne precautions. ■ 4. Droplet precautions.

4. Bacterial meningitis is caused by one of three organisms, Haemophilus influenzae type b, Neisseria meningitidis, or Streptococcus pneumoniae. All three organisms may be transmitted through contact with respiratory droplets. These droplets are heavy and typically fall within 3 feet of the client. Droplet precautions require, in addition to standard precautions, that health care providers wear masks when coming into close contact with the client. Standard precautions, previously referred to as universal precautions, are general measures used for all clients. Contact precautions are used when direct or indirect contact with the client causes disease transmission. Gowns and gloves are needed but not masks. Airborne precautions differ from droplet in that the particles are smaller and may stay suspended in the air for longer periods of time. These clients require negative pressure rooms and all heath care workers must wear respirators.

7. Twelve hours after cardiac surgery, the nurse is assessing a 3-year-old who weighs 15 kg. The nurse should notify the surgeon about which of the following clinical finding? ■ 1. A urine output of 60 mL in 4 hours. ■ 2. Strong peripheral pulses in all four extremities. ■ 3. Fluctuations of fluid in the collection chambers of the chest drainage system. ■ 4. Alterations in levels of consciousness.

4. Clinical signs of low cardiac output and poor tissue perfusion include pale, cool extremities, cyanosis or mottled skin, delayed capillary refill, weak, thready pulses, oliguria, and alterations in level of consciousness. An adequate urine output for a child over 1 year should be 1 mL/kg/hour. Therefore 60 mL/4 hr is satisfactory. Strong peripheral pulses indicate adequate cardiac output. Drainage from the chest tube should show fluctuation in the drainage compartment of the chest drainage system. The fluid level normally fluctuates as proof that the apparatus is airtight. On about the third postoperative day, the fluctuation ceases indicating the lungs have fully expanded.

28. An adolescent with insulin-dependent diabetes is being taught the importance of rotating the sites of insulin injections. The nurse should judge that the teaching was successful when the adolescent identifies which of the following as a result of using the same site? ■ 1. Destruction of the fat tissue and poor absorption. ■ 2. Destruction of nerves and painful neuritis. ■ 3. Destruction of the tissue and too-rapid insulin uptake. ■ 4. Development of resistance to insulin and need for increased amounts.

1. Repeated use of the same injection site can result in atrophy of the fat in the subcutaneous tissue and lead to poor insulin absorption. The neuritis that develops from diabetes is related to microvascular changes that occur. Subcutaneous tissue is not destroyed and insulin is not rapidly absorbed. Resistance to insulin is caused by an immune response to the insulin protein.

21. After talking with the parents of a child with Down syndrome, the nurse should help the parents establish which goal? ■ 1. Encouraging self-care skills in the child. ■ 2. Teaching the child something new each day. ■ 3. Encouraging more lenient behavior limits for the child. ■ 4. Achieving age-appropriate social skills.

1. The goal in working with mentally retarded children is to train them to be as independent as possible, focusing on developmental skills. The child may not be capable of learning something new every day but needs to repeat what has been taught previously. Rather than encouraging more lenient behavior limits, the parents need to be strict and consistent when setting limits for the child. Most children with Down syndrome are unable to achieve age-appropriate social skills due to their mental retardation. Rather, they are taught socially appropriate behaviors.

5. When developing the plan of care for an infant diagnosed with myelomeningocele and the parents who have just been informed of the infant's diagnosis, which action should the nurse include as the priority when the parents visit the infant for the first time? ■ 1. Emphasizing the infant's normal and positive features. ■ 2. Encouraging the parents to discuss their fears and concerns. ■ 3. Reinforcing the doctor's explanation of the defect. ■ 4. Having the parents feed their infant.

1. The parents should see the neonate as soon as possible, because the longer they must wait to see the neonate, the more anxiety they will feel. Because the parents are acutely aware of the deficit, the nurse should emphasize the neonate's normal and positive features during the visit. All parents, but especially those with a child who has a disability or defect, need to hear positive comments and comments that reflect how the infant is normal. Although the parents need to discuss their fears and concerns, the priority on the first visit is to emphasize the neonate's normal and positive features. Reinforcing the doctor's explanation of the defect may be necessary later. Reinforcing the explanation at this initial visit emphasizes the defect, not the child. The parents should spend time with or care for the neonate after birth because parent-infant contact is necessary for attachment. The parents cannot feed the neonate before the defect is repaired because the repair typically occurs within 24 hours. The infant will be prone in an isolette or warmed and watched closely. However, the parents can fondle and stroke the neonate.

35. During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? ■ 1. Limiting conversation with the child. ■ 2. Keeping extraneous noise to a minimum. ■ 3. Allowing the child to play in the bathtub. ■ 4. Performing treatments quickly.

2. A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Although treatments need to be completed as quickly as possible to prevent overstressing the child, they should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.

8. After placing an infant with myelomeningocele in an isolette shortly after birth, which indicator should the nurse use as the best way to determine the effectiveness of this intervention? ■ 1. The partial pressure of arterial oxygen remains between 94 and 100 mm Hg. ■ 2. The axillary temperature remains between 97° and 98° F (36.1° and 36.7° C). ■ 3. The bilirubin level remains stable. ■ 4. Weight increases by about 1 oz (28.35 g) per day.

2. The nurse places the neonate with myelomeningocele in an isolette shortly after birth to help to maintain the infant's temperature. Because of the defect, the neonate cannot be bundled in blankets. Therefore, it may be difficult to prevent cold stress. The isolette can be maintained at higher than room temperature, helping to maintain the temperature of a neonate who cannot be dressed or bundled. Body temperature readings, not arterial oxygen levels, are the best indicator. Typically, an infant loses 5% to 10% of body weight before beginning to regain the weight.

9. When teaching a preschool-age child how to perform coughing and deep-breathing exercises before corrective surgery for tetralogy of Fallot, which of the following teaching and learning principles should the nurse address first? ■ 1. Organizing information to be taught in a logical sequence. ■ 2. Arranging to use actual equipment for demonstrations. ■ 3. Building the teaching on the child's current level of knowledge. ■ 4. Presenting the information in order from simplest to most complex

3. Before developing any teaching program for a child, the nurse's first step is to assess the child to determine what is already known. Most older preschool children have some understanding of a condition present since birth. However, the child's interest will soon be lost if familiar material is repeated too often. The nurse can then organize the information in a sequence, because there are several steps to be demonstrated. These exercises do not require the use of equipment. The nurse should judge the amount and complexity of the information to be provided, based on the child's current knowledge and response to teaching

14. A preschooler with a history of repaired lumbar myelomeningocele is in the emergency department with wheezing and skin rash. Which of the following questions should the nurse ask the mother first? ■ 1. "Is your child taking any medications?" ■ 2. "Who brought your child to the emergency department?" ■ 3. "Is your child allergic to bananas or milk products?" ■ 4. "What are you doing to treat your child's skin rash?"

3. Children with myelomeningocele are at high risk for development of latex allergy because of repeated exposure to latex products during surgery and bladder catheterizations. Cross-reactions to food items such as bananas, kiwi, milk products, chestnuts, and avocados also occur. These allergic reactions vary in severity ranging from mild (such as sneezing) to severe anaphylaxis. While the child could have allergies to medications that caused the wheezing, the latex and food allergies are more common. Asking about the skin rash is not a priority when a child is wheezing. Who brought the child to the emergency department is irrelevant at this time.

1. The nurse caring for a 7-year-old child who has undergone a cardiac catheterization 2 hours ago finds the dressing and bed saturated with blood. The nurse should first: ■ 1. Assess the vital signs. ■ 2. Reinforce the dressing. ■ 3. Apply pressure just above the catheter insertion site. ■ 4. Notify the physician.

3. Direct pressure is the first measure that should be used to control bleeding. Taking the vital signs will not control the bleeding. This should be done while another person is being sent to notify the physician. The dressing can be reinforced after the bleeding has been contained.

22. Which of following should the nurse perform to help alleviate a child's joint pain associated with rheumatic fever? ■ 1. Maintaining the joints in an extended position. ■ 2. Applying gentle traction to the child's affected joints. ■ 3. Supporting proper alignment with rolled pillows. ■ 4. Using a bed cradle to avoid the weight of bed linens on joints.

4. For a child with arthritis associated with rheumatic fever, the joints are usually so tender that even the weight of bed linens can cause pain. Use of a bed cradle is recommended to help remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not positioned in extension, to ensure that they remain functional. Applying gentle traction to the joints is not recommended because traction is usually used to relieve muscle spasms, not typically associated with rheumatic fever. Supporting the body in good alignment and changing the client's position are recommended, but these measures are not likely to relieve pain

6. When developing the teaching plan for the mother of a 2-year-old child diagnosed with scabies, which of the following points should the nurse expect to include? ■ 1. The floors of the house should be cleaned with a damp mop. ■ 2. The child should be held frequently. ■ 3. Itching should cease in a few days. ■ 4. The entire family should be treated.

4. Scabies is caused by the scabies mite, Sarcoptes scabiei. The mite burrows into the stratum corneum of the epidermis, where the female deposits eggs and fecal material. These burrows are linear. Scabies is highly contagious. The length of time from infestation to physical symptoms is 30 to 60 days, so everyone in close contact with the child will need to be treated. The bed linens and the child's clothing should be washed in hot water and dried on the hot setting. It is not necessary to damp mop the floors to prevent the spread of scabies. The child should be held minimally until treatment is completed. Family members should wash their hands after contact with the child. Itching lasts for 2 to 3 weeks until the stratum carenum is replaced.

24. The nurse mentions that a group meeting for mothers of mentally retarded children is to be held soon. "Not retarded!" the child's mother angrily blazes, "Exceptional." When responding to this outburst, which of the following replies by the nurse would be most appropriate? ■ 1. "'Retarded' is the commonly used and accepted term." ■ 2. "I'm sorry if I offended you by my thoughtless remark." ■ 3. "No matter what it's called, the condition is still the same, isn't it?" ■ 4. "I'd like to hear more of your thoughts and feelings on that."

4. When responding to a mother who becomes angry when someone calls her child mentally retarded instead of exceptional, the nurse should give the mother a chance to explore her feelings on the subject. Because the mother obviously has difficulty with the term "retarded," stressing the use of this term would cause further angry feelings. Apologizing, trying to use logic, and defending the comment are not effective ways to handle the situation because the mother's feelings need to be addressed.

25. A nurse is assessing an 8-year-old with diabetes who is experiencing hyperglycemia. Which symptom (s) indicate (s) that the hyperglycemia requires immediate intervention? Select all that apply. ■ 1. Weakness. ■ 2. Thirst. ■ 3. Shakiness. ■ 4. Hunger. ■ 5. Headache. ■ 6. Irritability. ■ 7. Dizziness.

1, 2, 7. Weakness, thirst, and dizziness are symptoms related to dehydration caused by excretion of large amounts of glucose and water in the urine. The nurse should notify the physician. Shakiness, hunger, headache, and irritability are related to hypoglycemia and result from the brain and other cells being starved for nutrients.

27. After teaching a group of school teachers about seizures, the teachers role-play a scenario involving a child experiencing a generalized tonic-clonic seizure. Which of the following actions, when performed first, indicates that the nurse's teaching has been successful? ■ 1. Asking the other children what happened before the seizure. ■ 2. Moving the child to the nurse's office for privacy. ■ 3. Removing any nearby objects that could harm the child. ■ 4. Placing a padded tongue blade between the child's teeth.

3. During a generalized tonic-clonic seizure, the first priority is to keep the child safe and protect the child by removing any nearby objects that could cause injury. Although obtaining information about events surrounding the seizure is important, this information can be obtained later, once the child's safety is ensured. During a seizure, the child should not be moved. Although providing privacy is important, the child's safety is the priority. During a seizure, nothing should be forced into the client's mouth because this can cause severe damage to the teeth and mouth.

3. A 9-month-old infant with eczema has lesions that are secondarily infected. Which of the following is most appropriate to help the parents best meet the needs of the child? ■ 1. Preventing siblings from being in close contact. ■ 2. Sending the child to day care as usual. ■ 3. Playing video games for several hours each evening. ■ 4. Playing with the child every day.

4. The parents can best meet the needs of their 9-month-old infant by playing with the child every day. All infants need time with their parents to develop trust and thus attain optimal development. The parents of a child with a chronic problem may need more guidance to meet the child's needs because of the focus on medical problems. The child's lesions are secondarily infected and therefore should not be contagious. Siblings do not need to stay away. Even with lesions that are infected, the child can still attend day care, but the child needs attention from the parents as well. Playing video games for several hours is not appropriate for a 9-month-old infant.