Exam 4
The nurse is preparing an adolescent girl for an instrumentation procedure to treat scoliosis. Which of the following should the nurse include? a. Nasogastric intubation and urinary catheter may be required. b. Ambulation will not be allowed for up to 3 months. c. Surgery eliminates the need for casting and bracing. d. Discomfort can be controlled with nonpharmacologic methods.
ANS: A Harrington instrumentation is a surgical procedure. Nasogastric intubation and urinary catheterization may be required.
3. The nurse is evaluating the laboratory results on cerebral spinal fluid (CSF) from a 3- year-old child with bacterial meningitis. Which findings confirm bacterial meningitis? (Select all that apply.) a. Elevated white blood cell (WBC) count b. Decreased glucose c. Normal protein d. Elevated red blood cell (RBC) count
...ANS: A, B The cerebrospinal fluid analysis in bacterial meningitis shows elevated WBC count, decreased glucose, and increased protein content. There should not be RBCs evident in the CSF fluid. DIF: Cognitive Level: Analyze REF: p. 890 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
Which of the following can result from the bone demineralization associated with immobility? a. Osteoporosis b. Urinary retention c. Pooling of blood d. Susceptibility to infection
ANS: A Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi.
Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which action? a. Avoid using any latex product. b. Use only nonallergenic latex products. c. Administer medication for long-term desensitization. d. Teach family about long-term management of asthma.
ANS: A Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment. There are no nonallergenic latex products. At this time, desensitization is not an option. The child does not have asthma. The parents must be taught about allergy and the risk of anaphylaxis.
An adolescent is scheduled for a leg amputation in 2 days for treatment of osteosarcoma. The nurse's approach should include which of the following? a. Answer questions with straightforward honesty. b. Avoid discussing the seriousness of the condition. c. Explain that although the amputation is difficult, it will cure the cancer. d. Assist adolescent in accepting the amputation as better than a long course of chemotherapy.
ANS: A Honesty is essential to gain the child's cooperation and trust. The diagnosis of cancer should not be disguised with falsehoods. The adolescent should be prepared for the surgery so he or she has time to reflect on the diagnosis and subsequent treatment. This allows questions to be answered.
The nurse is conducting a staff in-service on common problems associated with myelomeningocele. Which common problem is associated with this defect? a. Hydrocephalus b. Craniosynostosis c. Biliary atresia d. Esophageal atresia
ANS: A Hydrocephalus is a frequently associated anomaly in 80% to 90% of children. Craniosynostosis is the premature closing of the cranial sutures and is not associated with myelomeningocele. Biliary and esophageal atresia is not associated with myelomeningocele.
The nurse is planning a staff in-service on childhood spastic cerebral palsy. Spastic cerebral palsy is characterized by: a. hypertonicity and poor control of posture, balance, and coordinated motion. b. athetosis and dystonic movements. c. wide-based gait and poor performance of rapid, repetitive movements. d. tremors and lack of active movement.
ANS: A Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic cerebral palsy. Athetosis and dystonic movements are part of the classification of dyskinetic (athetoid) cerebral palsy. Wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic cerebral palsy. Tremors and lack of active movement may indicate other neurologic disorders.
Which of the following terms is used to describe a type of fracture that does not produce a break in the skin? a. Simple b. Compound c. Complicated d. Comminuted
ANS: A If a fracture does not produce a break in the skin, it is called a simple, or closed, fracture.
The nurse is teaching a group of nursing students about newborns born with the congenital defect of myelomeningocele. Which common problem is associated with this defect? a. Neurogenic bladder b. Mental retardation c. Respiratory compromise d. Cranioschisis
ANS: A Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder dysfunction among children. Risk of mental retardation is minimized through early intervention and management of hydrocephalus. Respiratory compromise is not a common problem in myelomeningocele. Cranioschisis is a skull defect through which various tissues protrude. It is not associated with myelomeningocele.
Osteosarcoma is the most common bone cancer in children. Where are most of the primary tumor sites? a. Femur b. Humerus c. Pelvis d. Tibia
ANS: A Osteosarcoma is the most frequently encountered malignant bone cancer in children. The peak incidence is between ages 10 and 25 years. More than half occur in the femur.
A 4-year-old child has just been diagnosed with pseudohypertrophic (Duchenne) muscular dystrophy. The management plan should include which action? a. Recommend genetic counseling. b. Explain that the disease is easily treated. c. Suggest ways to limit use of muscles. d. Assist family in finding a nursing facility to provide his care.
ANS: A Pseudohypertrophic (Duchenne) muscular dystrophy is inherited as an X-linked recessive gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring. No effective treatment exists at this time for childhood muscular dystrophy. Maintaining optimal function of all muscles for as long as possible is the primary goal. It has been found that children who remain as active as possible are able to avoid wheelchair confinement for a longer time. Assisting the family in finding a nursing facility to provide his care is inappropriate at the time of diagnosis. When the child becomes increasingly incapacitated, the family may consider home-based care, a skilled nursing facility, or respite care to provide the necessary care.
2. Immobilization causes which of the following effects on metabolism? a. Hypocalcemia b. Decreased metabolic rate c. Positive nitrogen balance d. Increased production of stress hormones
ANS: B Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased food intake
A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. Which of the following should the nurse suggest to remove this material? a. Soak in a bathtub. b. Vigorously scrub leg. c. Apply powder to absorb material. d. Carefully pick material off leg.
ANS: A Simple soaking in the bathtub is usually sufficient for the removal of the desquamated skin and sebaceous secretions. It may take several days to eliminate the accumulation completely.
A young girl has just injured her ankle at school. In addition to calling the child's parents, the most appropriate, immediate action by the school nurse is which of the following? a. Apply ice. b. Observe for edema and discoloration. c. Encourage child to assume a position of comfort. d. Obtain parental permission for administration of acetaminophen or aspirin.
ANS: A Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be rested, be elevated, and have compression applied.
Four-year-old David is placed in Buck extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses that the skin of his right foot is pale with an absence of pulse. What should the nurse do first? a. Notify the practitioner of the changes noted. b. Give the child medication to relieve the pain. c. Reposition the child and notify physician. d. Chart the observations and check the extremity again in 15 minutes.
ANS: A The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner.
The nurse in the neonatal intensive care unit is caring for an infant with myelomeningocele scheduled for surgical repair in the morning. Which early signs of infection should the nurse monitor on this infant? (Select all that apply.) a. Temperature instability b. Irritability c. Lethargy d. Bradycardia e. Hypertension
ANS: A, B, C The nurse should observe an infant with unrepaired myelomeningocele for early signs of infection, such as temperature instability (axillary), irritability, and lethargy. Bradycardia and hypertension are not early signs of infection in infants.
Which of the following is most descriptive of the therapeutic management of osteosarcoma? a. Treatment usually consists of surgery and chemotherapy. b. Amputation of affected extremity is rarely necessary. c. Intensive irradiation is the primary treatment. d. Bone marrow transplantation offers the best chance of long-term survival.
ANS: A The optimal therapy for osteosarcoma is a combination of surgery and chemotherapy.
Immobilization causes which of the following effects on the cardiovascular system? a. Venous stasis b. Increased vasopressor mechanism c. Normal distribution of blood volume d. Increased efficiency of orthostatic neurovascular reflexes
ANS: A The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi.
The nurse is conducting discharge teaching to parents of a preschool child with myelomeningocele, repaired at birth, being discharged from the hospital after a urinary tract infection (UTI). Which should the nurse include in the discharge instructions related to management of the child's genitourinary function? (Select all that apply.) a. Continue to perform the clean intermittent catheterizations (CIC) at home. b. Administer the oxybutynin chloride (Ditropan) as prescribed. c. Reduce fluid intake in the afternoon and evening hours. d. Monitor for signs of a recurrent urinary tract infection. e. Administer furosemide (Lasix) as prescribed.
ANS: A, B, D Discharge teaching to prevent renal complications in a child with myelomeningocele include: (1) regular urologic care with prompt and vigorous treatment of infections; (2) a method of regular emptying of the bladder, such as clean intermittent catheterization (CIC) taught to and performed by parents and self-catheterization taught to children; (3) medications to improve bladder storage and continence, such as oxybutynin chloride (Ditropan) and tolterodine (Detrol). Fluids should not be limited and Lasix is not used to improve renal function for children with myelomeningocele.
Which assessment findings should the nurse note in a school-age child with Duchenne muscular dystrophy (DMD)? (Select all that apply.) a. Lordosis b. Gower sign c. Kyphosis d. Scoliosis e. Waddling gait
ANS: A, B, E Difficulties in running, riding a bicycle, and climbing stairs are usually the first symptoms noted in Duchenne muscular dystrophy. Typically, affected boys have a waddling gait and lordosis, fall frequently, and develop a characteristic manner of rising from a squatting or sitting position on the floor (Gower sign). Lordosis occurs as a result of weakened pelvic muscles, and the waddling gait is a result of weakness in the gluteus medius and maximus muscles. Kyphosis and scoliosis are not assessment findings with DMD.
A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Nursing care for this child includes which action(s)? (Select all that apply.) a. Monitoring and maintaining systemic blood pressure b. Administering corticosteroids c. Minimizing environmental stimuli d. Discussing long-term care issues with the family e. Monitoring for respiratory complications
ANS: A, B, E Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury. Corticosteroids are administered to minimize the inflammation present with the injury. It is not necessary to minimize environmental stimuli for this type of injury. Discussing long-term care issues with the family is inappropriate. The family is focusing on the recovery of their child. It will not be known until the rehabilitation period how much function the child may recover.
2. An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should be included in the child's postoperative care? (Select all that apply.) a. Observe closely for signs of infection. b. Pump the shunt reservoir to maintain patency. c. Administer sedation to decrease irritability. d. Maintain Trendelenburg position to decrease pressure on the shunt. e. Maintain an accurate record of intake and output. f. Monitor for abdominal distention.
ANS: A, E, F Infection is a major complication of ventriculoperitoneal shunts. Observation for signs of infection is a priority nursing intervention. Intake and output should be measured carefully. Abdominal distention could be a sign of peritonitis or a postoperative ileus. Pumping of the shunt may cause obstruction or other problems and should not be performed unless indicated by the neurosurgeon. Pain management rather than sedation should be the goal of therapy. The child is kept flat to avoid too rapid a reduction of intracranial fluid. DIF: Cognitive Level: Apply REF: p. 877 TOP: Integrated Process: Nursing Process: Assessment
Which of the following is an advantage to using a fiberglass cast instead of a plaster of Paris cast? a. Cheaper b. Dries rapidly c. Molds closely to body parts d. Smooth exterior
ANS: B A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which takes 10 to 72 hours to dry.
The nurse is caring for an infant with myelomeningocele scheduled for surgical closure in the morning. Which interventions should the nurse plan for the care of the myelomeningocele sac? a. Open to air b. Covered with a sterile moist nonadherent dressing c. Reinforcement of the original dressing if drainage noted d. A diaper secured over the dressing
ANS: B Before surgical closure, the myelomeningocele is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. The moistening solution is usually sterile normal saline. Dressings are changed frequently (every 2 to 4 hours), and the sac is closely inspected for leaks, abrasions, irritation, and any signs of infection. The sac must be carefully cleansed if it becomes soiled or contaminated. The original dressing would not be reinforced but changed as needed. A diaper is not placed over the dressing because stool contamination can occur.
Kristin, age 10 years, sustained a fracture in the epiphyseal plate of her right fibula when she fell out of a tree. When discussing this injury with her parents, the nurse should consider which of the following? a. Healing is usually delayed in this type of fracture. b. Bone growth can be affected by this type of fracture. c. This is an unusual fracture site in young children. d. This type of fracture is inconsistent with a fall.
ANS: B Detection of epiphyseal injuries is sometimes difficult, but fractures involving the epiphysis or epiphyseal plate present special problems in determining whether bone growth will be affected.
The nurse is caring for a neonate born with a myelomeningocele. Surgery to repair the defect is scheduled the next day. The most appropriate way to position and feed this neonate is which position? a. Prone and tube-fed b. Prone, head turned to side, and nipple-fed c. Supine in an infant carrier and nipple-fed d. Supine, with defect supported with rolled blankets, and nipple-fed
ANS: B In the prone position, feeding is a problem. The infant's head is turned to one side for feeding. If the child is able to nipple-feed, tube feeding is not needed. Before surgery, the infant is kept in the prone position to minimize tension on the sac and risk of trauma.
How much folic acid is recommended for women of childbearing age? a. 1.0 mg b. 0.4 mg c. 1.5 mg d. 2.0 mg
ANS: B It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age will prevent 50% to 70% of cases of neural tube defects; 1.0 mg is too low a dose; 1.5 to 2.0 mg are not the recommended dosages of folic acid.
An appropriate nursing intervention when caring for a child in traction would be which of the following? a. Remove adhesive traction straps daily to prevent skin breakdown. b. Assess for tightness, weakness, or contractures in uninvolved joints and muscles. c. Provide active range-of-motion exercises to affected extremity three times a day. d. Keep child in one position to maintain good alignment.
ANS: B Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles.
The nurse is admitting a school-age child with suspected Guillain-Barré syndrome (GBS). Which is a priority in the care for this child? a. Monitoring intake and output b. Assessing respiratory efforts c. Placing on a telemetry monitor d. Obtaining laboratory studies
ANS: B Treatment of GBS is primarily supportive. In the acute phase, patients are hospitalized because respiratory and pharyngeal involvement may require assisted ventilation, sometimes with a temporary tracheotomy. Treatment modalities include aggressive ventilatory support in the event of respiratory compromise, intravenous (IV) administration of immunoglobulin (IVIG), and sometimes steroids; plasmapheresis and immunosuppressive drugs may also be used. Intake and output, telemetry monitoring and obtaining laboratory studies may be part of the plan of care but are not the priority.
An adolescent is in traction. The purpose of the traction is to fatigue the muscle and reduce muscle spasm so that the bones can be realigned. Nursing actions should include which of the following? a. Maintain continuous traction until muscle spasm ceases. b. Maintain continuous traction to prevent muscle from contracting. c. Release traction every hour to allow muscle to briefly regain its contractibility. d. Release traction once every 8 hours to allow muscle to briefly regain its contractibility.
ANS: B When the muscles are stretched, muscle spasm ceases and permits realignment of the bone ends. The continued maintenance of traction is important during this phase because releasing the traction allows the muscle's normal contracting ability to again cause of malpositioning of the bone ends.
Which should the nurse expect to find in the cerebral spinal fluid (CSF) results of a child with Guillain-Barré syndrome (GBS)? (Select all that apply.) a. Decreased protein concentration b. Normal glucose c. Fewer than 10 white blood cells (WBCs/mm3) d. Elevated red blood cell (RBC) count
ANS: B, C Diagnosis of GBS is based on clinical manifestations, CSF analysis, and EMG findings. CSF analysis reveals an abnormally elevated protein concentration, normal glucose, and fewer than 10 WBCs/mm3. CSF fluid should not contain RBCs.
5. The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased intracranial pressure (ICP) in an infant? (Select all that apply.) a. Tachycardia b. Alteration in pupil size and reactivity c. Increased motor response d. Extension or flexion posturing e. Cheyne-Stokes respirations
ANS: B, D, E Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes respirations. DIF: Cognitive Level: Analyze REF: p. 872 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
When does idiopathic scoliosis become most noticeable? a. Newborn period b. When child starts to walk c. During preadolescent growth spurt d. Adolescence
ANS: C Idiopathic scoliosis is most noticeable during the preadolescent growth spurt.
The nurse is teaching a family how to care for their infant in a Pavlik harness to treat developmental dysplasia of the hip. Which of the following should be included? a. Apply lotion or powder to minimize skin irritation. b. Remove harness several times a day to prevent contractures. c. Return to clinic every 1 to 2 weeks. d. Place diaper over harness, preferably using a superabsorbent disposable diaper that is relatively thin.
ANS: C Infants have a rapid growth pattern. The child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments.
Which of the following is the primary method of treating osteomyelitis? a. Joint replacement b. Bracing and casting c. Intravenous antibiotic therapy d. Long-term corticosteroid therapy
ANS: C Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus aureus. The treatment of choice is antibiotics.
Which of the following types of traction uses skin traction on the lower leg and a padded sling under the knee? a. Dunlop b. Bryant c. Russell d. Buck extension
ANS: C Russell traction uses skin traction on the lower leg and a padded sling under the knee. The combination of longitudinal and perpendicular traction allows realignment of the lower extremity and immobilizes the hips and knees in a flexed position.
Which clinical manifestations in an infant would be suggestive of spinal muscular atrophy (Werdnig-Hoffmann disease)? a. Hyperactive deep tendon reflexes b. Hypertonicity c. Lying in the frog position d. Motor deficits on one side of body
ANS: C The infant lies in the frog position with the legs externally rotated, abducted, and flexed at knees. The deep tendon reflexes are absent. The child has hypotonia and inactivity as the most prominent features. The motor deficits are bilateral.
A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, the nurse should explain that: a. traction is tried first. b. surgical intervention is needed. c. frequent, serial casting is tried first. d. children outgrow this condition when they learn to walk.
ANS: C Serial casting is begun shortly after birth before discharge from nursery. Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy.
A home care nurse is caring for an adolescent with a T1 spinal cord injury. The adolescent suddenly becomes flushed, hypertensive, and diaphoretic. Which intervention should the nurse perform first? a. Place the adolescent in a flat right side-lying position. b. Place a cool washcloth on the adolescent's forehead and continue to monitor the blood pressure. c. Implement a standing prescription to empty the bladder with a sterile in and out Foley catheter. d. Take a full set of vital signs and notify the health care provider.
ANS: C The adolescent is experiencing an autonomic dysreflexia episode. The paralytic nature of autonomic function is replaced by autonomic dysreflexia, especially when the lesions are above the mid-thoracic level. This autonomic phenomenon is caused by visceral distention or irritation, particularly of the bowel or bladder. Sensory impulses are triggered and travel to the cord lesion, where they are blocked, which causes activation of sympathetic reflex action with disturbed central inhibitory control. Excessive sympathetic activity is manifested by a flushing face, sweating forehead, pupillary constriction, marked hypertension, headache, and bradycardia. The precipitating stimulus may be merely a full bladder or rectum or other internal or external sensory input. It can be a catastrophic event unless the irritation is relieved. Placing a cool washcloth on the adolescent's forehead, continuing to monitor blood pressure and vital signs, and notifying the healthcare provider would not reverse the sympathetic reflex situation.
An important nursing consideration when caring for a child with JIA would be which of the following? a. Apply ice packs to relieve stiffness and pain. b. Administer acetaminophen to reduce inflammation. c. Teach child and family correct administration of medications. d. Encourage range-of-motion exercises during periods of inflammation.
ANS: C The management of JIA is primarily pharmacologic. The family should be instructed regarding administration of medications and the value of regular schedule of administration to maintain a satisfactory blood level in the body. They need to know that NSAIDs should not be given on an empty stomach and to be alert for signs of toxicity.
The nurse is reviewing prenatal vitamin supplements with an expectant client. Which supplement should be included in the teaching? a. Vitamin A throughout pregnancy b. Multivitamin preparations as soon as pregnancy is suspected c. Folic acid for all women of childbearing age d. Folic acid during the first and second trimesters of pregnancy
ANS: C The widespread use of folic acid among women of childbearing age has decreased the incidence of spina bifida significantly. Vitamin A is not related to the prevention of spina bifida. Folic acid supplementation is recommended for the preconception period and during the pregnancy. Only 42% of women actually follow these guidelines.
The nurse is admitting a child with Werdnig-Hoffmann disease (spinal muscular atrophy type 1). Which signs and symptoms are associated with this disease? a. Spinal muscular atrophy b. Neural atrophy of muscles c. Progressive weakness and wasting of skeletal muscle d. Pseudohypertrophy of certain muscle groups
ANS: C Werdnig-Hoffmann disease (spinal muscular atrophy type 1) is the most common paralytic form of floppy infant syndrome (congenital hypotonia). It is characterized by progressive weakness and wasting of skeletal muscle caused by degeneration of anterior horn cells. Kugelberg-Welander disease is a juvenile spinal muscular atrophy with a later onset. Charcot-Marie-Tooth disease is a form of progressive neural atrophy of muscles supplied by the peroneal nerves. Progressive weakness is found of the distal muscles of the arms and feet. Duchenne muscular dystrophy is characterized by muscles, especially in the calves, thighs, and upper arms, which become enlarged from fatty infiltration and feel unusually firm or woody on palpation. The term pseudohypertrophy is derived from this muscular enlargement.
4. The nurse is caring for a neonate with suspected meningitis. Which clinical manifestations should the nurse prepare to assess if meningitis is confirmed? (Select all that apply.) a. Headache b. Photophobia c. Bulging anterior fontanel d. Weak cry e. Poor muscle tone
ANS: C, D, E Assessment findings in a neonate with meningitis include bulging anterior fontanel, weak cry, and poor muscle tone. Headache and photophobia are signs seen in an older child. DIF: Cognitive Level: Understand REF: p. 890 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse is preparing to admit a newborn with myelomeningocele to the neonatal intensive care nursery. Which describes this newborn's defect? a. Fissure in the spinal column that leaves the meninges and the spinal cord exposed b. Herniation of the brain and meninges through a defect in the skull c. Hernial protrusion of a saclike cyst of meninges with spinal fluid but no neural elements d. Visible defect with an external saclike protrusion containing meninges, spinal fluid, and nerves
ANS: D A myelomeningocele is a visible defect with an external saclike protrusion, containing meninges, spinal fluid, and nerves. Rachischisis is a fissure in the spinal column that leaves the meninges and the spinal cord exposed. Encephalocele is a herniation of brain and meninges through a defect in the skull, producing a fluid-filled sac. Meningocele is a hernial protrusion of a saclike cyst of meninges with spinal fluid, but no neural elements.
The parents of a child with cerebral palsy ask the nurse whether any drugs can decrease their child's spasticity. The nurse's response should be based on which statement? a. Anticonvulsant medications are sometimes useful for controlling spasticity. b. Medications that would be useful in reducing spasticity are too toxic for use with children. c. Many different medications can be highly effective in controlling spasticity. d. Implantation of a pump to deliver medication into the intrathecal space to decrease spasticity has recently become available.
ANS: D Baclofen, given intrathecally, is best suited for children with severe spasticity that interferes with activities of daily living and ambulation. Anticonvulsant medications are used when seizures occur in children with cerebral palsy. The intrathecal route decreases the side effects of the drugs that reduce spasticity. Few medications are currently available for the control of spasticity.
Which of the following is a type of skin traction with legs in an extended position? a. Dunlop b. Bryant c. Russell d. Buck extension
ANS: D Buck extension traction is a type of skin traction with the legs in an extended position. It is used primarily for short-term immobilization, preoperatively with dislocated hips, for correcting contractures, or for bone deformities such as Legg-Calvé-Perthes disease.
The nurse is conducting reflex testing on infants at a well-child clinic. Which reflex finding should be reported as abnormal and considered as a possible sign of cerebral palsy? a. Tonic neck reflex at 5 months of age b. Absent Moro reflex at 8 months of age c. Moro reflex at 3 months of age d. Extensor reflex at 7 months of age
ANS: D Establishing a diagnosis of cerebral palsy (CP) may be confirmed with the persistence of primitive reflexes: (1) either the asymmetric tonic neck reflex or persistent Moro reflex (beyond 4 months of age) and (2) the crossed extensor reflex. The tonic neck reflex normally disappears between 4 and 6 months of age. The crossed extensor reflex, which normally disappears by 4 months, is elicited by applying a noxious stimulus to the sole of one foot with the knee extended. Normally, the contralateral foot responds with extensor, abduction, and then adduction movements. The possibility of CP is suggested if these reflexes occur after 4 months.
Which of the following would cause a nurse to suspect that an infection has developed under a cast? a. Complaint of paresthesia b. Cold toes c. Increased respirations d. "Hot spots" felt on cast surface
ANS: D If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so that a window can be made in the cast to observe the site.
Which of the following terms is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine? a. Scoliosis b. Ankylosis c. Lordosis d. Kyphosis
ANS: D Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine.
Which of the following medications is usually tried first when a child is diagnosed with juvenile idiopathic arthritis (JIA)? a. Aspirin b. Corticosteroids c. Cytotoxic drugs such as methotrexate d. Nonsteroidal antiinflammatory drugs (NSAIDs)
ANS: D NSAIDs are the first drugs used in JIA. Naproxen, ibuprofen, and tolmetin are approved for use in children.
Therapeutic management of a child with tetanus includes the administration of: a. nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation. b. muscle stimulants to counteract muscle weakness. c. bronchodilators to prevent respiratory complications. d. tetanus immunoglobulin therapy.
ANS: D Tetanus immunoglobulin therapy, to neutralize toxins, is the most specific therapy for tetanus. Tetanus toxin acts at the myoneural junction to produce muscular stiffness and lowers the threshold for reflex excitability. NSAIDs are not routinely used. Sedatives or muscle relaxants are used to help reduce titanic spasm and prevent seizures. Respiratory status is carefully evaluated for any signs of distress because muscle relaxants, opioids, and sedatives that may be prescribed may cause respiratory depression. Bronchodilators would not be used unless specifically indicated.
A 4 year old is newly diagnosed with Legg-Calvé-Perthes disease. Nursing considerations include which of the following? a. Encourage normal activity for as long as is possible. b. Explain the cause of the disease to the child and family. c. Prepare child and family for long-term, permanent disabilities. d. Teach family the care and management of the corrective appliance.
ANS: D The family needs to learn the purpose, function, application, and care of the corrective device and the importance of compliance to achieve the desired outcome
The nurse is teaching the parents of a 7-year-old child who has just had a cast applied for a fractured arm with the wrist and elbow immobilized. Which of the following instructions should be included in the teaching? a. Swelling of the fingers is to be expected for the next 48 hours. b. Immobilize the shoulder to decrease pain in the arm. c. Allow the affected limb to hang down for 1 hour each day. d. Elevate casted arm when resting and when sitting up.
ANS: D The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return.
The nurse is caring for an intubated infant with botulism in the pediatric intensive care unit. Which health care provider prescriptions should the nurse clarify with the health care provider before implementing? a. Administer 250 mg botulism immune globulin intravenously (BIG-IV) one time. b. Provide total parenteral nutrition (TPN) at 25 ml/hr intravenously. c. Titrate oxygen to keep pulse oximetry saturations greater than 92. d. Administer gentamicin sulfate (Garamycin) 10 mg per intravenous piggyback every 12 hours.
ANS: D The nurse should clarify the administration of an aminoglycoside antibiotic. Antibiotic therapy is not part of the management of infant botulism because the botulinum toxin is an intracellular molecule, and antibiotics would not be effective; aminoglycosides in particular should not be administered because they may potentiate the blocking effects of the neurotoxin. Treatment consists of immediate administration of botulism immune globulin intravenously (BIG-IV) without delaying for laboratory diagnosis. Early administration of BIG-IV neutralizes the toxin and stops the progression of the disease. The human-derived botulism antitoxin (BIG-IV) has been evaluated and is now available nationwide for use only in infant botulism. Approximately 50% of affected infants require intubation and mechanical ventilation; therefore, respiratory support is crucial, as is nutritional support because these infants are unable to feed.
Which of the following is a physiologic effect of immobilization on children? a. Metabolic rate increases. b. Increased joint mobility can lead to contractures in a short time. c. Bone calcium increases, releasing excess calcium into the body (hypercalcemia). d. Venous stasis can lead to thrombi or emboli formation.
ANS: D The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi.
The nurse is talking to a parent with a child who has a latex allergy. Which statement by the parent would indicate a correct understanding of the teaching? a. "My child will have an allergic reaction if he comes in contact with yeast products." b. "My child may have an upset stomach if he eats a food made with wheat or barley." c. "My child will probably develop an allergy to peanuts." d. "My child should not eat bananas or kiwis."
ANS: D There are cross-reactions between latex allergies and a number of foods such as bananas, avocados, kiwi, and chestnuts. Children with a latex allergy will not develop allergies to other food products such as yeast, wheat, barley, or peanuts.
18. A child is unconscious after a motor vehicle accident. The watery discharge from the nose tests positive for glucose. What does this finding suggest? a. Diabetic coma b. Brainstem injury c. Upper respiratory tract infection d. Leaking of cerebrospinal fluid (CSF)
ANS: D Watery discharge from the nose that is positive for glucose suggests leaking of CSF from a skull fracture and is not associated with diabetes or respiratory tract infection. The fluid is probably CSF from a skull fracture and does not signify whether the brainstem is involved. DIF: Cognitive Level: Apply REF: p. 906 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse uses the palms of the hands when handling a wet cast for which of the following reasons? a. To assess dryness of the cast b. To facilitate easy turning c. To keep the patient's limb balanced d. To avoid indenting the cast
ANS: D Wet casts should be handled by the palms of the hands, not the fingers, to avoid creating pressure points.
17. An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed. The nurse should suspect which type of head injury? a. Brainstem b. Skull fracture c. Subdural hemorrhage d. Epidural hemorrhage
a. Brainstem ANS: A Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are consistent with a brainstem injury. Skull fracture, subdural hemorrhage, and epidural hemorrhage are not consistent with brainstem injuries. DIF: Cognitive Level: Understand REF: p. 887 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
38. Which clinical manifestations would suggest hydrocephalus in a neonate? a. Bulging fontanel and dilated scalp veins b. Closed fontanel and high-pitched cry c. Constant low-pitched cry and restlessness d. Depressed fontanel and decreased blood pressure
a. Bulging fontanel and dilated scalp veins ANS: A Bulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. Closed fontanel and high-pitched cry, constant low-pitched cry and restlessness, and depressed fontanel and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation. DIF: Cognitive Level: Analyze REF: p. 906 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
9. Which is the priority nursing intervention for an unconscious child after a fall? a. Establish adequate airway. b. Perform neurologic assessment. c. Monitor intracranial pressure. d. Determine whether a neck injury is present.
a. Establish adequate airway. ANS: A Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishment of an adequate airway is always the first priority. A neurologic assessment and determination of whether a neck injury is present will be performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after airway, breathing, and circulation are maintained. DIF: Cognitive Level: Apply REF: p. 879 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. Which drug should the nurse expect to administer to a preschool child who has increased intracranial pressure (ICP) resulting from cerebral edema? a. Mannitol (Osmitrol) b. Epinephrine hydrochloride (Adrenalin) c. Atropine sulfate (Atropine) d. Sodium bicarbonate (Sodium bicarbonate)
a. Mannitol (Osmitrol) ANS: A For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used most frequently for rapid reduction. Epinephrine hydrochloride, atropine sulfate, and sodium bicarbonate are not used to decrease ICP. DIF: Cognitive Level: Apply REF: p. 879 TOP: Integrated Process: Nursing Process: Implementation
28. When caring for the child with Reye syndrome, what is the priority nursing intervention? a. Monitor intake and output b. Prevent skin breakdown c. Observe for petechiae d. Do range-of-motion exercises
a. Monitor intake and output ANS: A Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema. Preventing skin breakdown, observing for petechiae, and doing range-of-motion exercises are important interventions in the care of a critically ill or comatose child. Careful monitoring of intake and output is a priority. DIF: Cognitive Level: Apply REF: p. 895 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
6. The nurse is taking care of a child who is alert but showing signs of increased intracranial pressure. Which test is contraindicated in this case? a. Oculovestibular response b. Doll's head maneuver c. Funduscopic examination for papilledema d. Assessment of pyramidal tract lesions
a. Oculovestibular response ANS: A The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a comatose child. The caloric test is painful and is never performed on a child who is awake or one who has a ruptured tympanic membrane. Doll's head maneuver, funduscopic examination for papilledema, and assessment of pyramidal tract lesions can be performed on children who are awake. DIF: Cognitive Level: Analyze REF: p. 887 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
19. A toddler fell out of a second-story window. She had a brief loss of consciousness and vomited four times. Since admission, she has been alert and oriented. Her mother asks why a computed tomography (CT) scan is required when she "seems fine." Which explanation should the nurse give? a. Your child may have a brain injury and the CT can rule one out. b. The CT needs to be done because of your child's age. c. Your child may start to have seizures and a baseline CT should be done. d. Your child probably has a skull fracture and the CT can confirm this diagnosis.
a. Your child may have a brain injury and the CT can rule one out. ANS: A The child's history of the fall, brief loss of consciousness, and vomiting four times necessitates evaluation of a potential brain injury. The severity of a head injury may not be apparent on clinical examination but will be detectable on a CT scan. The need for the CT scan is related to the injury and symptoms, not the child's age. The CT scan is necessary to determine whether a brain injury has occurred. DIF: Cognitive Level: Apply REF: p. 876 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
You are working with a pediatric nurse who has just transferred to the pediatric clinic. You are role-playing phone triage related to a child with a head injury. You ascertain that the nurse needs more teaching based on what response? a. "After initial physical exam, if there was no loss of consciousness with the head injury, the child can be observed at home." b. "If there is a language barrier, written instructions can be given, followed by discharge." c. "Another physical exam should take place in 1 or 2 days." d. "Parents should call the doctor if their child has any of these signs: blurred vision, walking unsteadily, or is hard to awaken."
b. "If there is a language barrier, written instructions can be given, followed by discharge."
7. The nurse is preparing a school-age child for computed tomography (CT scan) to assess cerebral function. The nurse should include which statement in preparing the child? a. "Pain medication will be given." b. "The scan will not hurt." c. "You will be able to move once the equipment is in place." d. "Unfortunately, no one can remain in the room with you during the test."
b. "The scan will not hurt." ANS: B For CT scans, the child must be immobilized. It is important to emphasize to the child that at no time is the procedure painful. Pain medication is not required; however, sedation is sometimes necessary. Someone is able to remain with the child during the procedure. DIF: Cognitive Level: Apply REF: p. 876 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance
2. The nurse has received report on four children. Which child should the nurse assess first? a. A school-age child in a coma with stable vital signs b. A preschool child with a head injury and decreasing level of consciousness c. An adolescent admitted after a motor vehicle accident is oriented to person and place d. A toddler in a persistent vegetative state with a low-grade fever
b. A preschool child with a head injury and decreasing level of consciousness ANS: B The nurse should assess the child with a head injury and decreasing level of consciousness first (LOC). Assessment of LOC remains the earliest indicator of improvement or deterioration in neurologic status. The next child the nurse should assess is a toddler in a persistent vegetative state with a low-grade fever. The school-age child in a coma with stable vital signs and the adolescent admitted to the hospital who is oriented to his surroundings would be of least worry to the nurse. DIF: Cognitive Level: Apply REF: p. 873 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
14. Which statement best describes a subdural hematoma? a. Bleeding occurs between the dura and the skull. b. Bleeding occurs between the dura and the cerebrum. c. Bleeding is generally arterial, and brain compression occurs rapidly. d. The hematoma commonly occurs in the parietotemporal region.
b. Bleeding occurs between the dura and the cerebrum. ANS: B A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region. DIF: Cognitive Level: Understand REF: p. 883 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
13. The nurse is teaching nursing students about childhood fractures. Which describes a compound skull fracture? a. Involves the basilar portion of the occipital bone b. Bone is exposed through the skin c. Traumatic separations of the cranial sutures d. Bone is pushed inward, causing pressure on the brain
b. Bone is exposed through the skin ANS: B A compound fracture has the bone exposed through the skin. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. Diastatic skull fractures are traumatic separations of the cranial sutures. A depressed fracture has the bone pushed inward, causing pressure on the brain. DIF: Cognitive Level: Understand REF: p. 883 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
21. A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The child's level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. What is the most appropriate nursing action? a. Discuss with parents the child's previous experiences with pain b. Discuss with practitioner what analgesia can be safely administered c. Explain that analgesia is contraindicated with a head injury d. Explain that analgesia is unnecessary when child is not fully awake and alert
b. Discuss with practitioner what analgesia can be safely administered ANS: B A key nursing role is to provide sedation and analgesia for the child. Consultation with the appropriate practitioner is necessary to avoid conflict between the necessity to monitor the child's neurologic status and the promotion of comfort and relief of anxiety. Information on the child's previous experiences with pain should be obtained as part of the assessment, but because of the severity of injury, analgesia should be provided as soon as possible. Analgesia can be safely used in individuals who have sustained head injuries and can decrease anxiety and resultant increased ICP. DIF: Cognitive Level: Apply REF: p. 905 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
25. What are the vector reservoirs for agents causing viral encephalitis in the United States? a. Tarantula spiders b. Mosquitoes c. Carnivorous wild animals d. Domestic and wild animals
b. Mosquitoes ANS: B Viral encephalitis, not attributable to a childhood viral disease, is usually transmitted by mosquitoes. The vector reservoir for most agents pathogenic for humans and detected in the United States are mosquitoes and ticks; therefore, most cases of encephalitis appear during the hot summer months. Tarantula spiders, carnivorous wild animals, and domestic and wild animals are not reservoirs for the agents that cause viral encephalitis. DIF: Cognitive Level: Understand REF: p. 890 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. How should the nurse interpret these findings? a. Eye trauma b. Neurosurgical emergency c. Severe brainstem damage d. Indication of brain death
b. Neurosurgical emergency ANS: B The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or bilateral fixed pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain. One fixed and dilated pupil is not suggestive of brain death. DIF: Cognitive Level: Analyze REF: p. 875 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
27. When taking the history of a child hospitalized with Reye syndrome, the nurse should not be surprised that a week ago the child had recovered from: a. measles. b. varicella. c. meningitis. d. hepatitis.
b. varicella. ANS: B Most cases of Reye syndrome follow a common viral illness such as varicella or influenza. Measles, meningitis, and hepatitis are not associated with Reye syndrome. DIF: Cognitive Level: Understand REF: p. 895 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. Which statement made by the mother indicates a correct understanding of the teaching? a. "I should expect my child to have a few episodes of vomiting." b. "If I notice sleep disturbances, I should contact the physician immediately." c. "I should expect my child to have some behavioral changes after the accident." d. "If I notice diplopia, I will have my child rest for 1 hour."
c. "I should expect my child to have some behavioral changes after the accident." ANS: C The parents are advised of probable posttraumatic symptoms that may be expected. These include behavioral changes and sleep disturbances. If the child has these clinical signs, they should be immediately reported for evaluation. Sleep disturbances are to be expected. DIF: Cognitive Level: Apply REF: p. 883 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
1. The nurse has documented that a child's level of consciousness is obtunded. Which describes this level of consciousness? a. Slow response to vigorous and repeated stimulation b. Impaired decision making c. Arousable with stimulation d. Confusion regarding time and place
c. Arousable with stimulation ANS: C Obtunded describes a level of consciousness in which the child is arousable with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion regarding time and place. DIF: Cognitive Level: Understand REF: p. 874 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
8. Which neurologic diagnostic test gives a visualized horizontal and vertical cross-section of the brain at any axis? a. Nuclear brain scan b. Echoencephalography c. CT scan d. Magnetic resonance imaging (MRI)
c. CT scan ANS: C A CT scan provides a visualization of the horizontal and vertical cross-sections of the brain at any axis. A nuclear brain scan uses a radioisotope that accumulates where the blood-brain barrier is defective. Echoencephalography identifies shifts in midline structures of the brain as a result of intracranial lesions. MRI permits visualization of morphologic features of target structures and permits tissue discrimination that is unavailable with any other techniques. DIF: Cognitive Level: Understand REF: p. 877 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
12. The nurse is planning care for an 8-year-old child with a concussion. Which is descriptive of a concussion? a. Petechial hemorrhages cause amnesia. b. Visible bruising and tearing of cerebral tissue occur. c. It is a transient and reversible neuronal dysfunction. d. A slight lesion develops remotely from the site of trauma.
c. It is a transient and reversible neuronal dysfunction. ANS: C A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of awareness and responsiveness resulting from trauma to the head. Petechial hemorrhages along the superficial aspects of the brain along the point of impact are a type of contusion, but are not necessarily associated with amnesia. A contusion is visible bruising and tearing of cerebral tissue. Contrecoup is a lesion that develops remote from the site of trauma as a result of an acceleration-deceleration injury. DIF: Cognitive Level: Understand REF: p. 883 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. What is an appropriate nursing intervention when caring for an unconscious child? a. Change the child's position infrequently to minimize the chance of increased ICP b. Avoid using narcotics or sedatives to provide comfort and pain relief c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema d. Give tepid sponge baths to reduce fever because antipyretics are contraindicated
c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema ANS: C Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema. The child's position should be changed frequently to avoid complications such as pneumonia and skin breakdown. Narcotics and sedatives should be used as necessary to reduce pain and discomfort, which can increase ICP. Antipyretics are the method of choice for fever reduction. DIF: Cognitive Level: Apply REF: p. 879 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
As the nurse assigned to a child diagnosed with bacterial meningitis, you know that: a. The child will not need to be placed in isolation because antibiotics have been started. b. Enteric precautions will remain in place for up to 48 hours. c. Respiratory isolation will remain in place for 24 hours after antibiotics are started. d. Due to headache, the child will want the head of the bed elevated with two pillows.
c. Respiratory isolation will remain in place for 24 hours after antibiotics are started.
16. A 10-year-old boy on a bicycle has been hit by a car in front of the school. The school nurse immediately assesses airway, breathing, and circulation. What is the next nursing action? a. Place on side b. Take blood pressure c. Stabilize neck and spine d. Check scalp and back for bleeding
c. Stabilize neck and spine ANS: C After determining that the child is breathing and has adequate circulation, the next action is to stabilize the neck and spine to prevent any additional trauma. The child's position should not be changed until the neck and spine are stabilized. Blood pressure is a later assessment. Less urgent, but an important assessment, is inspection of the scalp for bleeding. DIF: Cognitive Level: Apply REF: p. 886 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
3. The nurse is performing a Glasgow Coma Scale on a school-age child with a head injury. The child opens eyes spontaneously, obeys commands, and is oriented to person, time, and place. Which is the score the nurse should record? a. 8 b. 11 c. 13 d. 15
d. 15 ANS: D The Glasgow Coma Scale (GCS) consists of a three-part assessment: eye opening, verbal response, and motor response. Numeric values of 1 through 5 are assigned to the levels of response in each category. The sum of these numeric values provides an objective measure of the patient's level of consciousness (LOC). A person with an unaltered LOC would score the highest, 15. The child who opens eyes spontaneously, obeys commands, and is oriented is scored at a 15. DIF: Cognitive Level: Understand REF: p. 873 TOP: Integrated Process: Nursing Process: Assessment
26. What is beneficial in reducing the risk of Reye syndrome? a. Immunization against the disease b. Medical attention for all head injuries c. Prompt treatment of bacterial meningitis d. Avoidance of aspirin to treat fever associated with influenza
d. Avoidance of aspirin to treat fever associated with influenza ANS: D Although the etiology of Reye syndrome is obscure, most cases follow a common viral illness, either varicella or influenza. A potential association exists between aspirin therapy and the development of Reye syndrome, so use of aspirin is avoided. No immunization currently exists for Reye syndrome. Reye syndrome is not correlated with head injuries or bacterial meningitis. DIF: Cognitive Level: Understand REF: p. 895 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
You are the nurse assigned to care for a child with a basilar skull fracture. Your most important nursing observation is change in level of consciousness (LOC). You will be highly alert for: a. Alterations in vital signs that often appear before alterations in consciousness or focal neurologic signs b. Bleeding from the ear, which is indicative of an anterior basal skull fracture c. Seizures, which are relatively uncommon in children at the time of head injury d. Changes in posturing, such as any signs of extension or flexion posturing, unusual response to stimuli, and random versus purposeful movement
d. Changes in posturing, such as any signs of extension or flexion posturing, unusual response to stimuli, and random versus purposeful movement
You are caring for a child with hydrocephalus who is postoperative from a shunt revision. Which assessment finding is your priority for increased intracranial pressure (ICP)? a. Nausea and refusal to eat postoperatively b. Complaint of a headache c. Irritability and wanting to sleep d. Decrease in heart rate over the last hour
d. Decrease in heart rate over the last hour
1. Which are clinical manifestations of increased intracranial pressure (ICP) in infants? (Select all that apply.) a. Low-pitched cry b. Sunken fontanel c. Diplopia and blurred vision d. Irritability e. Distended scalp veins f. Increased blood pressure
d. Irritability e. Distended scalp veins ANS: D, E Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP in infants. Diplopia and blurred vision are indicative of elevated ICP in CHILDREN. A HIGH-pitched cry and a tense or BULGING fontanel are characteristics of increased ICP. Increased blood pressure, common in adults, is rarely seen in children. DIF: Cognitive Level: Understand REF: p. 872 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
15. When should the nurse recommend medical attention for a child with a slight head injury? a. Experiences sleepiness b. Vomits c. Has a headache d. Is confused or has abnormal behavior
d. Is confused or has abnormal behavior ANS: D Medical attention should be sought if the child exhibits confusion or abnormal behavior, loses consciousness, has amnesia, has fluid leaking from the nose or ears, complains of blurred vision, or has an unsteady gait. Sleepiness alone does not require evaluation. If the child is difficult to arouse from sleep, medical attention should be obtained. Vomiting more than three times requires medical attention. Severe or worsening headache or one that interferes with sleep should be evaluated. DIF: Cognitive Level: Apply REF: p. 883 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
20. The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. Which is the most essential part of the nursing assessment to detect early signs of a worsening condition? a. Posturing b. Vital signs c. Focal neurologic signs d. Level of consciousness
d. Level of consciousness ANS: D The most important nursing observation is assessment of the child's level of consciousness. Alterations in consciousness appear earlier in the progression of an injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic damage. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes. DIF: Cognitive Level: Analyze REF: p. 886 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
5. The nurse is caring for a child with severe head trauma after a car accident. Which is an ominous sign that often precedes death? a. Papilledema b. Delirium c. Doll's head maneuver d. Periodic and irregular breathing
d. Periodic and irregular breathing ANS: D Periodic or irregular breathing is an ominous sign of brainstem (especially medullary) dysfunction that often precedes complete apnea. Papilledema is edema and inflammation of optic nerve. It is commonly a sign of increased intracranial pressure Delirium is a state of mental confusion and excitement marked by disorientation for time and place. The doll's head maneuver is a test for brainstem or oculomotor nerve dysfunction. DIF: Cognitive Level: Understand REF: p. 880 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
24. The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like her oldest son did when he was an infant. The nurse should base her response on which statement? a. Meningitis rarely occurs during infancy. b. Often a genetic predisposition to meningitis is found. c. Vaccination to prevent all types of meningitis is now available. d. Vaccination to prevent Haemophilus influenzae type B meningitis has decreased the frequency of this disease in children.
d. Vaccination to prevent Haemophilus influenzae type B meningitis has decreased the frequency of this disease in children. ANS: D H. influenzae type B meningitis has been virtually eradicated in areas of the world where the vaccine is administered routinely. Bacterial meningitis remains a serious illness in children. It is significant because of the residual damage caused by undiagnosed and untreated or inadequately treated cases. The leading causes of neonatal meningitis are the group B streptococci and Escherichia coli organisms. Meningitis is an extension of a variety of bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of the potential causative organisms. DIF: Cognitive Level: Apply REF: p. 890 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
37. Children taking phenobarbital (phenobarbital sodium) and/or phenytoin (Dilantin) may experience a deficiency of: a. calcium. b. vitamin C. c. fat-soluble vitamins. d. vitamin D and folic acid.
d. vitamin D and folic acid. ANS: D Deficiencies of vitamin D and folic acid have been reported in children taking phenobarbital and phenytoin. Calcium, vitamin C, and fat-soluble vitamin deficiencies are not associated with phenobarbital or phenytoin. DIF: Cognitive Level: Understand REF: p. 905 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
