Pediatric HESI unit 4

which assessment finding strongly indicates cerebral injury and warrants further evaluation of an 8 month old client? a. significant head lag b. posterior fontanel closure c. short neck with skinfold between head and shoulders d. head held to one side with chin pointing to opposite side

a

which information would the nurse focus on when teaching a high school student about scoliosis treatment options? a. effect on body image b. least invasive treatment c. continuation with schooling d. maintenance of contact with peers

a

which parent education would the nurse provide regarding the frequency of foot exercises to be performed for an infant who recently had her cast for talipes equinovarus removed? a. with each diaper change b. once a day in morning c. twice a day after a nap d. every 4 hours during day

a

which postop nursing intervention is specifically related to spinal fusion performed in an adolescent with scoliosis? a. log roll every 2 hours b. check the dressing frequently c. supervising deep breathing exercises d. maintain the adolescent in supine for 3 days

a

a child with meningitis suddenly assumes an opisthotonic position. In which position would the nurse position the child? a. side lying b. knee chest c. high fowler d. trendelenburg

a maximal safety and comfort are ensured with the side lying position because the child neck and back are hyperextended

which assessment finding would the nurse recognize as needing intermediate attention in a 2 week old infant? a. tense anterior fontanel b. uncoordinated eye/muscle movement c. larger head circumference than chest circumference d. inability to supper head while in prone position

a tense or bulging anterior fontanel is indicative of increased ICP

which clinical manifestations indicate early symptoms of aspirin poisoning in children? SATA a. hyperactivity b. seizures c. tinnitus d. hyperventilation e. respiratory failure

c d

which play activity is the best choice to suggest to the parent of a school age child with autism? a. holding a cuddly toy b. climbing a jungle gym c. building with small blocks d. riding on a playground merry-go-round

d the rhythmic movement of the mery-go round provides an opportunity for the child to practice spatial and sensory orientation

which parent education would the nurse provide the parent caring for their infant with cerebral palsy? a. focus on cognitive rather than motor skills b. maintain immobility of limbs with splints c. preserve muscle tone to prevent joint contractures d. continue to offer special formula to prevent gagging

c

which position would the nurse use for an infant who will have a lumbar puncture? a. sitting with buttocks at tables edge and head flexed b. prone with head extended over tables edge and extremities swaddled c. lateral recumbent with back at tables edge and head and legs extended d. side lying with back at tables edge and head flexed with knees brought to chin

d

which clinical finding would the nurse recognize as a sign that an infants ICP has increased? a. hypoactive reflexes b. increased pulse rate c. decreased BP d. tension of anterior fontanel

d anterior fontanel would be widened and tense due to increased volume of cerebrospinal fluid the pulse rate would be decreased reflexes hyperactive BP increased

which intervention is a priority when caring for a child who sustained a head injury 12 hours earlier? a. assessing the level of consciousness every hour b. promoting rest by fostering a quiet environment c. asking about the circumstances that led to the injury d. administering the prescribed opioid for complaints of a headache

a. assessing the level of consciousness every hour diminishing level of consciousness is an early indicator of neurological damage, evidence of a subdural hemorrhage may take hours or days to develop.

a parent of a newborn states to the nurse "my baby is constantly crying and irritable. I just cannot take this much longer." which information would the nurse discuss? a. limit setting b. shaken baby syndrome c. developmental milestones d. SIDS

b

which parental statement would the nurse recognize as signs that an infant may need to be evaluated for cerebral palsy? SATA a. baby does not make eye contact b. seems to have a voracious appetite c. able to turn from front to back by 2 months d. ive noticed that this baby clings to me more than the other children of the same age e. all of my other children were sitting alone by this age. this does seem to be anywhere near sitting alone

c e spasticity that causes unintentional turn from front to back neurological problem that commonly recognized when child fails to meet developmental norms

which information would the nurse share with an adolescent girl with a seizure disorder refusing to wear a medical alert bracelet that may help her wear the bracelet? a. hide under long sleeve clothes b. wear the bracelet when engaging in contact sport c. ask friends to wear bracelet like her d. select bracelet similar to bracelet worn by peers

d

which care plan would the nurse implement for a 1 month old infant with hydrocephalus scheduled to have surgery for the insertion of a ventriculoperitoneal shunt? a. maintain satisfactory comfort level to limit crying b. apply bandages to the infants head to protect from injury c. establishing a fixed feeding schedule to ensure appropriate hydration d. providing play objects to maintain age-appropriate stimulation for the child

a preventing crying will avoid sudden increases in intracranial pressure

the nurse is listing the major developmental characteristics of hearing in infants. which characteristics appear for the first time between 24-32 weeks? SATA a. respond to own name b. locating sounds by turned head in curving arc c. locating sound by turning head side to side then looking up or down d. locating sound by turning head to side and looking in same direction e. locating sounds by turning head diagonally and directed toward sound

a b

which clinical manifestation would lead the nurse to contact the HCP regarding the potential development of acute osteomyelitis? SATA a. foot ulcer b. temp of 102 c. erythema of affected area d. tenderness of affected area e. drainage from affected area

b c d

which parent teaching would the nurse provide for a 4 month old infant with spica cast? a. obtain a specialty designed carseat b. keep diapers on to prevent soiling c. be sure to change the infants position every 8 hours d. use bar between infants legs to change position

a

which client finding would the nurse associate with chronic osteomyelitis? SATA a. elevated WBC b. presence of avascular scar tissue c. cold sensation at infection site d. constant bone pain relieved by rest e. elevated erythrocyte sedimentation rate

a b e

A toddler with a repaired myelomeningocele has urinary incontinence and some flaccidity of the lower extremities. What should the nurse teach the parents? a. An ileal bladder will be necessary once the child is of school age. b. An indwelling catheter offers the best hope for bladder management. c. The child will probably require a program of intermittent straight catheterization. d. The child will have to wear diapers for many years because bladder training is a slow process.

c

which is the most important safety measure for the nurse to institute immediately when a 2 year old child has seizures? a. monitoring VS b. padding the side rails of toddler crib c. placing child in side lying position d. bringing suction equipment to bedside

c

which statement by a parent indicates the need for additional education on reyes syndrome? a. aspirin should be avoided in children with viral diseases b. its ok for me to give acetaminophen if have fever c. i should watch for childs skin to turn yellow during recovery from varicella d. i need to seek medical help right away if my child starts vomiting profusely during recovery period for viral illness

c

which education would the nurse provide the parent of an infant who just underwent insertion of a ventriculoperitoneal shunt for hydrocephalus? a. prognosis is excellent. the valve is permanent b. the shunt may need to be replaced as the child grows older c. if brain damage has occurred, it is irreversible even after the first year of life d. hydrocephalus usually is self-limiting by 2 years of age, then the shunt is removed

b

which action would the nurse take after finding a child having a tonic-clonic seizure? a. apply restraints b. administering oxygen c. protecting child from self injury d. inserting plastic airway into child mouth

c

which complication would the nurse recognize as the most serious in an infant with meningitis? a. epilepsy b. blindness c. peripheral circulatory collapse d. communicating hydrocephalus

c

which is the expected monthly increase in head circumference from 4-6 months of age? a. 1 cm b. 2cm c. 0.5cm d. 3.5cm

a

a nurse in the pediatric clinic would be most observant for signs of cerebral palsy in a 6 month old infant in which instance? a. 40 year old mother b. exhibiting moro reflex c. delivered by elective c section d. born at 32 weeks gestation

d

in which location would the nurse expect a preschool age child with reyes syndrome to be admitted? a. isolation room b. presurgical unit c. pediatric floor d. ICU

d

a child recovering from a diagnosis of meningococcal meningitis and appears sad and cries frequently. how would the nurse help the child verbalize her thoughts and feelings? a. by telling the child that she seems sad and upset b. encouraging the parent to speak with child c. showing the child some photos of hospitalized children and having the child tell stories about them d. having the child watch videotapes about sick children and answering any questions that the child might have

a

which safety instruction would the nurse teach a child with diminished sensation in the legs because of cerebral palsy? a. test the temp of water before bath b. tighten brace straps securely before ambulating c. set the lock twice during the night to change position d. look down at the legs when crutch walking to check how they are positioned

a

while in the playroom a school age child exhibits twitching of the right arm and leg that almost immediately progresses to a generalized tonic-clonic seizure with clenched jaws. which action would the nurse take after moving the child to the floor? a. moving objects away b. taking other children to room c. inserting plastic airway into mouth d. positioning large pillow under head

a

which symptoms would the nurse recognize as indicative of increased ICP in 3 year old child? SATA a. vomiting b. headache c. irritability d. tachypnea e. hypotension

a b c

a protruding tongue and crease that transverses the entire width of each palm are characteristic of which congenital condition? a. hypothyroidism b. down syndrome c. turner syndrome d. fetal alcohol syndrome

b

a child is admitted to the pediatric intensive care unit with acute bacterial meningitis. Which intervention would the nurse include in the plan of care? a. offering clear liquids when the child is awake b. checking the child level of consciousness hourly c. assessing the childs BP every 4 hours d. administering the prescribed oral antibiotic medication

b checking LOC is part of the total neurological check, it can reveal increasing ICP as result of cerebral inflammation.

while assessing a 5 year old which clinical finding would the nurse recognize as indicative of verbal response score of 3 on the glasgow coma scale? a. oriented b. confused c. inappropriate words d. incomprehensible sounds

c

which preop goal would the nurse establish while caring for an infant born with myelomeningocele? a. keeping infant sedated b. keep infant infection free c. ensuring maintenence of leg movement d. ensure development of strong sucking reflex

b

the nurse is providing instruction to a parent of a child with flu. Which statement by parent indicates need for further instruction a. ill manage with baby aspirin b. well make sure to get flu shot next year c. providing fluids will help relieve syndromes d. staying home from school will prevent transmission

a

the nurse places a school age child with bacterial maningitis in isolation with droplet precautions. Which is the purpose of these precautions? a. keep away from uninfected people b. infectious process is interrupted as soon as possible c. child is protected from contacting a secondary infection d. prevent development of a hospital acquired infection

a

an 8 year old child is found to have legg-calve perthes disease and will be required to wear an abduction brace 23 hours a day and engage in non-weight bearing actvity. which activity would the nurse teach the parent to do? a. have child transfer to a wheel chair using unaffected leg b. explain that kneeling but not standing on affected leg is permitted c. perform range of motion exercises of lower extremities twice a day d. allow child to use crutches as the 4 point gait is used for walking

a

which assessment finding would the nurse recognize as increasing the risk of developing amblyopia? a. the child is around 6 years of age an has untreated strabismus b. child is 3 years and has uncorrected strabismus c. hirschberg test performed on child shows that the light falls symmetrically within each pupil d. the alternate cover test performed on the child shows the shifting cover from on eye to another causes the eyes to move

a

which parent education would the nurse provide about the frequency of cast changes needed for an infant with talipes equinovarus? a. each week b. once a month c. when cast edges fray d. if cast becomes soiled

a

which parent education would the nurse provide about the preferred carrying position for an infant with cerebral palsy prone to scissoring of the legs? a. astride one of her hips b. strapped in an infant seat c. wrapped tightly in a blanket d. under arm in football hold

a

which clinical finding would indicate possible meningitis in an infant with infected ventriculoperitoneal shunt? SATA a. fever b. lethargy c. stiff neck d. poor feeding e. depressed fontanels

a b c d

which information would the nurse provide to maintain a positive self image during treatment of a 13 year old with idiopathic scoliosis who is upset about the treatment regimen and is worried about being different from peers? a. remind of consequences if he or she refuses treatment b. help investigate appropriate clothing to minimize appearance of the brace c. disregard negative characteristics and focus on positive attitutes d. refer to psychological counseling until treatment program is completed

b

an 8 year old boy is found to have a mild concussion and is to be discharged home. The parent is instructed to check their child for responsiveness every 2 hours and to wake hi for this assessment after he goes to sleep. They call the nurse and say they are afraid to allow him to go to sleep. How would the nurse respond? a. you can bring him to the hospital before bedtime, if you prefer b. if your son becomes difficult to awaken bring him to the hospital. c. theres no need to worry because you son is past the critical period. d. awakening your son throughout the night is no longer necessary

b

which possible cause would the nurse suspect in a client with a head injury who has fixed dilated right pupil responds only to painful stimuli and exhibits flexion posture? a. meningeal irritation b. subdural hemorrhage c. cerebral compression d. medullary compression

c cerebral compression affected pyramidal tracts, resulting in flexion rigidity and cranial nerve injury which cause pupil dilation

which education would the nurse provide the parent of an infant with cerebral palsy to support setting care goals? a. cognitive impairments require special education b. progressive deterioration require future institutionalization c. unknown extent of the disability requires continual adjustments d. diminished immune responses require protection from infection

c infant is too young for specific long term plans, care planning should incorporate the plan to continually reevaluate care plans due to different needs may manifest as the child grows

which assessment would the nurse perform to monitor for a major complication in an infant after surgery to correct a myelomeningoele? a. daily weights b. fluid output every 8 hours c. blood pressure every 12 hours d. daily head circumference measurements

d

which parent education would the nurse provide the parents of an infant recently diagnosed with communicating hydrocephalus?

there is a part of the brain surface that usually absorbs spinal fluid after its production that is not functioning properly

an infant has noncommunicating hydrocephalus, and a ventriculoperitoneal shunt is inserted. which nursing intervention would the nurse implement for the infant furing the initial postop period? a. change dressing when soiled b. offer infant fluids to increase fluid intake c. place infant flat with head on unaffected sie d. encourage parents to hold infant to prevent crying

c

an infant with severe developmental dysplasia of the hip has a hip spica cast applied. which instruction would the nurse give the parents to help prevent a serious complications? a. change diapers frequently b. decrease number of feedings per day c. call PCP is foul smell is detected d. avoid turning the child from prone to supine position

c

the nurse in the ER is assessing a young child with head injury. the child is accompanied by a parent. which observation would prompt the nurse to assess the child for abuse? a. Mongolian spots b. belongs to single parent family c. received care for injuries twice earlier d. child and parent narrate the same story about the injury

c

what should the nurse tell the parent concerning an exercise program for her child diagnosed with idiopathic scoliosis who has a mild structural curve? a. exercise is used in conjunction with a brace b. exercise can be used if the child appears highly motivated c. exercise might exaggerate the curvature if curve is severe d. exercise is needed to correct the curvature without need for brace

a

the nurse is providing care to an infant diagnosed with downs syndrome. which parental statement related to infants growth indicates need for further education? a. baby will have growth deficiencies during infancy b. child will have accelerated growth during adolescent c. likely be overweight by 3 years d. reduced growth in both height and weight

b

the nurse would utilize the glasgow coma scale on a trauma child to complete which assessment? a. patency of airway b. level of consciousness c. breathing abnormalities d. circulatory abnormalities

b

which nursing intervention is the priority for an infant with myelomeningocele before surgical correction? a. minimizing infection b. preventing trauma to site c. monitoring for increasing paralysis d. preventing hypothermia

b

which intervention would the nurse implement for an infant with increased ICP? a. weighing daily before feedings b. elevating head higher than the hips c. checking reflexes at regular interval d. monitoring alertness with frequent stimulation

b elevating the head helps decrease ICP by way of gravity

which assessment finding alerts the nurse to suspect increasing ICP in infant? a. sunken eyes b. projectile vomiting c. depressed fonatanels d. narrowing pulse pressure

b increased ICP exerts pressure on the vomiting center in the brain resulting in projective vomiting

a child sitting on a chair starts having a tonic-clonic seizure. What would be the initial action by the nurse a. trying to open jaw b. placing child on floor c. calling out for assistance from staff d. placing pillow under head

b placing on floor limits danger of falling and striking hand

Which clinical manifestation would the nurse recognize as a sign of neurologic injury when assessing a 7 month old infant injured in an automobile accident? a. babinki reflex b. persistent vomiting c. heart rate of 110 bpm d. temp of 99.6

b vomiting commonly accompanies a head injury because of increased ICP

what is the purpose of placing a child in cervical traction after sustaining a fractured cervical vertebra? a. hyperextending the neck maintains an open airway b. flexing the head prevents stretching of neck muscles c. immobilizing the area minimizes injury to the spinal cord d. aligning the body allows for cerebrospinal fluid to encircle the spinal cord

c

which action would the nurse take to support movement in an adolescent severely injured in a motor vehicle collision with multiple fractures, contusions, and muscle spasms causing refusal to move? a. allowing friends to visit daily b. explaining that some pain is inevitable c. encouraging decision-making regarding care d. setting specific limits regarding this behavior

c

which intervention would be included in the plan of care for a child immediately after the application of a spica cast? a. using the crossbar to turn the child b. logrolling the child until cast is dry c. performing a neurovascular assessment of the legs d. drying the cast with a hairdryer on the cool setting

c

which intervention would the nurse provide to facilitate the drying of a cast recently applied to a child with clubfoot? a. using a blow dryer b. opening the window c. exposing casted extremity d. covering the cast with light sheet

c

which is most important for the nurse to attempt to prevent for a child with juvenile idiopathic arthritis? a. infection b. hemarthrosis c. contracture deformities d. delayed intellectual development

c

which intervention is appropriate for the nurse to teach the parent of a child with Duchenne muscular dystrophy? a. maintain a high calorie diet b. institute seizure precautions c. restrict the use of larger muscles d. perform range of motion exercises

d

which procedure would the nurse use to elevate the head of an infant in a spica cast? a. use a donut head pad b. inserting pillows under the shoulders c. padding the edge of the cast with folded diapers d. raising the entire mattress at the head of the crib

d

which recommendation would the nurse make to the family of a child with juvenile idiopathic arthritis who has difficulty getting ready for school in the morning due to joint pain and stiffness? a. administer acetaminophen before bed b. ice joints in evening c. encourage exercise after waking up d. provide warm moist heat to the affected joints before arising

d

which action would the nurse include in the plan of care for a 3 month old infant with newly placed ventriculloperitoneal shunt? a. keeping infant in prone b. applying moist sterile dressing to incision c. watching for signs of CSF leakage d. teaching parents signs of increased ICP

d because condition may develop is shunt malfunction occurs

which nursing care would the nurse provide for an infant the first 24 hours after surgical placement of a ventriculoperitoneal shunt for hydrcephaus? a. medicating the infant for pain b. placing the infant in high fowlers c. positioning the infant on the side that has the shunt d. monitoring the infant for increasing ICP

d shunt may become obstructed leading to accululation of CSF and increased ICP

the nurse is teaching a group of parents about the bones of toddlers. which information would the nurse include? SATA a. less pliable than those of older persons b. have more cartilage than do those of younger adults c. can better withstand falls than those of older adults d. more susceptible to bone loss than are those of old people e. more susceptible to osteoporosis than those of women

b c

a toddler has just had a cast applied for a fractured wrist. The wrist and elbow are immobilized. Which information would the nurse include in the home care instructions before discharge? SATA a. resume usual activities b. report swelling of fingers c. keep affected shoulder immobilized d. elevate casted arm when child is standing e. lower the casted arm when child is lying down

b d

the nurse anticipates that the family of a child with cerebral palsy is at risk for difficultly parenting issues. which would the nurse conclude is the probable basis for this difficulty? a. lack of social support b. unrealistic expectations c. loss of expected healthy child d. having child with cognitive impairment

c

which assessment finding would the nurse recognize as common in infants with down syndrome? a. bulging fontanels b. stiff lower extremities c. abnormal heart sounds d. unusual pupillary reactions

c cardiac anomalies often accompany genetic problems

the parents of a toddler with right ventriculoperitoneal shunt for the treatment of hydrocephalus are taught about postop positioning. The nurse concludes that they understand the teaching when they state that they will place the toddler in which positon? a. in position that provides most comfort b. on back with small support underneath c. on abdomen with head turned to the left side d. flat on left side with head and back supported

d

which response would the nurse give the mother of an infant with meningitis who is concerned that her toddler at home will feel neglected when she stays at the hospital? a. has anything happened to make you feel that way b. its so important to spend you time here with the baby c. try to divide your time evenly between the two children d. can you arrange with someone to stay here when you are at home?

d

which would the nurse conclude about isolation for the child admitted to the pediatric unit with diagnosis of meninogococcal meningitis a. unnecessary during incubation period b. required for 7-10 days until fever subsides c. unnecessary after diagnosis confirmed d. necessary for 24-72 hours after initiation of antibiotics

d

why would the nurse encourage the parent of a 9 year old child with Legg-Calve-Perthes disease who is on bed rest to look for something creative for the child to do or hobby? a. relieve pain b. stimulate mind c. encourage use of functional joints d. meeting the developmental task of industry

d

which education would the nurse provide a group of parents about preventing reye syndrome in their preschool age children? a. do not give aspirin when your child has a fever b. restrict your childs carb intake when there are signs of a cold c. begin sponge bathing with cold water if your child experiences a high fever d. you may want to have your child immunized with a recently developed vaccine

a

a child who has undergone surgery to revise a ventriculoperitoneal shunt is to be discharged. for which behavior would the nurse advise the parent to call the clinic or seek immediate care? a. appears drowsy after nap and becomes irritable b. talks incessantly regardles of the presence of others c. becomes angry when frustrated and has temper tantrum d. starts arguments with playmates, claiming that the toys are theirs

a drowsiness and irritability are characteristic of increased ICP along with nausea, projectile vomiting, headache, and diminished physical activity

which positon would the nurse use for an infant after the insertion of a ventriculoperitoneal shunt for hydrocephalus? a. supine on unaffected side b. side lying on affected side c. head elevated 45 degree on affected side d. head elevated 90 on unaffected side

a placing the infant in supine will prevent complication from too rapid reduction of ICF

which activities would be encouraged of a child with juvenile idiopathic arthritis to prevent loss of joint function? SATA a. riding a bicycle b. walking to school c. watching videos after school d. swimming in the community pool e. playing computer games after school

a b d

the nurse is caring for a child who has ADD/ADHD. Which change in the childs classroom will be beneficial? SATA a. providing breaks frequently at regular intervals b. writing instructions on the blackboard after verbalization c. increasing amount of classroom assignments and homework d. improving the writing skills of the child compared with computer skills e. scheduling academic subjects for times when the child is under the effect of medication

a b e