Peds Exam 3 NCLEX: Cardiac, Musculoskeletal, Neuro

A 7-year-old child has been diagnosed with rheumatic fever. Which of the following physical findings would the nurse expect to assess? 1. Vesicular rash over the face and chest 2. Warm and swollen knees and elbows 3. Palpable mass in the upper right quadrant of the abdomen 4. Yellow pigmentation of the sclera of the eyes

2. Warm and swollen knees and elbows Feedback 1: Erythema marginatum is one of the major manifestations of RF; however, it is not a vesicular rash. It is a well-demarcated macular rash that is seen on the torso and inner surfaces of the extremities. Feedback 2: Polyarthritis, one of the major manifestations of RF, is manifested by warm, swollen, and painful joints

A couple is being discharged from the hospital with their 2-day-old Down syndrome baby. The nurse is providing discharge teaching. The nurse should include in the teaching information regarding which of the following physiological characteristics of the syndrome? 1. Small cerebral ventricles 2. Weak musculature 3. Inability to feel pain 4. Low glomerular filtration rate

2. Weak musculature The nurse should educate the parents regarding the child's weak musculature because the child will be at high risk for a number of problems, including upper respiratory infections, pendulous abdominal muscles, and lumbering gait.

A 10-year-old child is in the hospital on bedrest with a diagnosis of rheumatic fever complicated by carditis. When the nurse responds to the child's call bell, the child states, "I hate this! I want to get up and play!" Which of the following responses is appropriate for the nurse to make at this time? 1. "I know that you are unhappy, but you must stay in bed so that you can get better and go home." 2. "What if we make a deal and I promise to let you get up for 10 minutes every 2 hours if you are very good the rest of the day?" 3. "I am sure that I can get the doctor to let you go to the playroom for 1 to 2 hours this afternoon." 4. "I am so sorry that you are unhappy, but what if I contact the play lady and have her bring you a selection of video games to play with?"

4. "I am so sorry that you are unhappy, but what if I contact the play lady and have her bring you a selection of video games to play with?" It is important for nurses to be honest with children. When a promise is made to a child and not kept, the child often will not trust any future statements the caregiver makes. Feedback 1: Although accurate, the statement is not supportive of the young child's frustration with having to remain on bedrest. There is a much better response. Feedback 2: This response is not appropriate. The activity may be damaging to the child's heart. Feedback 3: This response is not appropriate. The doctor may not allow the child to go to the playroom, even if transported in the hospital bed. The child, then, may not trust the nurse after the promise has been broken. Feedback 4: This is an appropriate statement. The nurse is empathetic and is offering a realistic solution to the child's unhappiness.

A 5-year-old child, diagnosed with a greenstick fracture of the left ulna, is being discharged home from the emergency department in a fiberglass cast. Which of the following actions should the nurse make at this time? 1. Inform the parents to use a hair dryer to facilitate the drying of the cast. 2. Report the suspected child abuse case to the local child abuse agency. 3. Refer the family to a specialist to investigate the etiology for the unusual break. 4. Educate the parents to monitor the temperature and color of the child's left hand.

4. Educate the parents to monitor the temperature and color of the child's left hand. Unless the parents' explanation for the child's injury is questionable, a greenstick fracture should not trigger the nurse to suspect that the child has been physically abused. Greenstick fractures commonly are seen in children. After a cast has been applied, a patient's caregivers should carefully assess the neurovascular status of the extremity distal to the cast.

The nurse is admitting a newly delivered neonate with meningocele into the nursery. Which of the following assessments is priority for the nurse to perform? 1. Assessment of the red reflexes 2. Hard palate assessment 3. Trunk incurvation reflex 4. Head and chest circumferences

4. Head and chest circumferences Over 90% of babies born with meningocele and myelomeningocele will also have hydrocephalus. It is priority, therefore, for the nurse to assess the circumferences to determine whether the baby is suffering from that complication.

A 9-year-old child is in the hospital in skin traction after sustaining a simple fracture of the femur. Which of the following assessments should the nurse make during rounds with the child's orthopedist? The nurse should assess the: (Select all that apply.) 1. child's level of pain. 2. child's bowel sounds. 3. capillary refill of the child's toes. 4. skin under the ace bandage for signs of skin breakdown. 5. wound for signs of redness, edema, ecchymosis, drainage, and approximation.

ANS 1,2,3,4 A simple fracture is an internal fracture that is enclosed in intact skin. Skin traction is applied directly to the skin using ace bandages or other external devices. One of the complications of skin traction is impaired skin integrity. Children who are in traction are confined to the bed. A complication of immobility is impaired elimination secondary to decrease in peristalsis.

A toddler with Kawasaki disease is to receive IV immune globulin. Which of the following actions must the nurse perform? Select all that apply. 1. Discard the immune globulin if it appears cloudy. 2. Check the expiration date of the immune globulin. 3. Secure the arm to the arm board with a clear shield. 4. Document the lot number of the infusion in the child's medical record. 5. Allow the refrigerated immune globulin to warm in the microwave for 1 full minute.

ANS 1,2,3,4 Administering immune globulin requires similar safety practices as those performed when administering blood products. Although no matching of blood type is involved as it is when blood is infused, there is a potential for allergic responses and other signs/symptoms seen in transfusion reactions (e.g., flank pain and elevated temperature). Feedback 1: Immune globulin should be clear with no cloudiness or sediment. If either is present, the solution should be discarded. Feedback 2: It is essential for nurses to check the expiration date of any medication administered to patients. Feedback 3: Toddlers may unintentionally injure an IV site. To maintain its patency, therefore, the arm should be taped to an arm board, and a clear shield should be placed above the site for easy inspection. Feedback 4: The lot number of the immune globulin should be documented in case serious side effects occur. All other bags of that lot number can then be examined and/or destroyed. Feedback 5: If the immune globulin has been refrigerated, it should be warmed. The only safe way to warm the solution, however, is to leave it at room temperature for 30 min. The solution should never be placed in the microwave.

Congenital heart defects have traditionally been divided into acyanotic or cyanotic defects. Based on the nurse's knowledge of congenital heart defects, this system in clinical practice is a) helpful, because it explains the hemodynamics involved. b) helpful, because children with cyanotic defects are easily identified. c) problematic, because cyanosis is rarely present in children. d) problematic, because children with acyanotic heart defects may develop cyanosis.

d) problematic, because children with acyanotic heart defects may develop cyanosis. This classification is problematic. Children with traditionally named acyanotic defects may become cyanotic, and children with traditionally classified cyanotic defects may be pink at times.The classification does not reflect the blood flow within the heart. Cardiac defects are best described by using the actual pathophysiologic process and mechanism.Children with cyanosis may be easily identified, but that does not help with the diagnosis.Cyanosis is present when children have defects where there is mixing of oxygenated blood with unoxygenated blood.

A child with Kawasaki disease is to receive IV immune globulin on day 7 of the illness. A parent asks the nurse, "I am so scared. Will my child be cured after getting the medicine?" Which of the following responses by the nurse is appropriate? 1. "I cannot promise, but children have been shown to have the best results from the medicine when it is given before the 10th day of the illness." 2. "I am sure that your child will be fine. This medicine has been shown to work well for children with Kawasaki disease." 3. "I really do not know. We will find out more when your child has follow up testing in 1 or 2 days." 4. "I know that you are scared, but it is important for you to have faith in your doctors because they are doing all that they can do."

1. "I cannot promise, but children have been shown to have the best results from the medicine when it is given before the 10th day of the illness." Nurses must communicate to parents honestly but with compassion. It is inappropriate to give parents false promises, but to provide them with realistic hope for a successful outcome is appropriate.

A 12-year-old child has been diagnosed with group A strep pharyngitis. The primary health-care provider has ordered penicillin V 500 mg PO tid for 10 days. Which of the following questions is important for the nurse to ask the parents and the child before giving them the prescription? 1. "Is there any reason why you will not be able to take medicine 3 times a day for 10 days?" 2. "Would you rather get 1 shot or take 40 pills?" 3. "Have you ever had strep throat before?" 4. "Do you know of any other children in your school who have recently had sore throats?"

1. "Is there any reason why you will not be able to take medicine 3 times a day for 10 days?" If either the parents or the child indicates an unwillingness or inability to complete the full course of oral antibiotics, the nurse should suggest to the ordering practitioner that it would be best to administer an injection. Because only one injection of penicillin G is needed, the nurse and ordering health-care practitioner can then be assured that the child's infection will be treated adequately.

A nurse is reviewing the results of a genetic analysis performed on a child with Duchenne muscular dystrophy (DMD). Which of the following results would the nurse expect to see? 1. 46 XY, X-linked recessive inheritance 2. 46 XX, autosomal dominant inheritance 3. 46 XY, autosomal recessive inheritance 4. 46 XX, mitochondrial inheritance

1. 46 XY, X-linked recessive inheritance The results of a genetic analysis of a child with DMD will state that the child has 46 chromosomes, is male, and does have an X-linked recessive disease. DMD is a single gene genetic disease that is carried on the X chromosome. As a result, women carry the gene that can then be inherited by their children. Because women carry two X chromosomes, they do not exhibit the disease. Only men, who carry only one X chromosome, exhibit the fatal disease.

A 4-year-old child has had a ventriculoperitoneal shunt in place since birth. The parents called the triage nurse at the child's primary health-care provider and stated that when the child awoke, he complained of a "bad" headache, and he vomited shortly thereafter. Which of the following actions by the nurse is appropriate? 1. Advise the parents to have the child seen in the emergency department. 2. Make an afternoon appointment for the child to see the health-care provider. 3. Tell the parents to give the child electrolyte replacement therapy instead of food. 4. Inform the parents that they should call back if the child also develops diarrhea.

1. Advise the parents to have the child seen in the emergency department. Ventriculoperitoneal (VP) shunts drain the cerebral spinal fluid from the ventricles of the brain in order to maintain normal intracranial pressures. When they malfunction, patients exhibit signs of increased ICP. The child needs to be assessed as an emergency so that the needed shunt revision can be scheduled and performed.

A 9-year-old child with autism spectrum disorder has been admitted to the hospital. Which of the following interventions is important for the nurse to perform during the child's stay? 1. Follow a strict schedule for all medicines and treatments. 2. Take the child to the playroom at least twice a day. 3. Keep all of the room lights on throughout the night. 4. Provide the child with sugar-free juice at snack time

1. Follow a strict schedule for all medicines and treatments. To reduce the stress of hospitalization for children with autism, the nurse must meet the child's needs. Maintaining strict schedules is one of those needs. Autistic children are often obsessive about following schedules.

A 7-month-old child has been diagnosed with cerebral palsy (CP). Which of the following signs/ symptoms would the nurse assess as consistent with the diagnosis? 1. Positive grasp reflex 2. Pigeon chest 3. Harlequin sign 4. Circumoral cyanosis

1. Positive grasp reflex In healthy babies, the neonatal grasp reflex begins to fade at about 3 months of age and is replaced by a voluntary grasp by about 5 months of age. A grasp reflex that does not fade is consistent with a diagnosis of CP.

The nurse is educating the parents of a child who has been diagnosed with febrile seizures. Which of the following actions should the nurse advise the parents is important for them to perform if their child has another seizure? 1. Protect the child's head. 2. Restrain the child's arms and legs. 3. Place a tongue blade in the child's mouth. 4. Administer mouth-to-mouth resuscitation.

1. Protect the child's head. During tonic-clonic seizures, patients are unconscious and are thrashing indiscriminately. In order to prevent the child from experiencing a head injury, his or her head should be protected, but restraining a child's arms and legs may actually result in an injury

A 13-year-old girl, who has been diagnosed with scoliosis, has been ordered to wear a therapeutic brace for 20 hours each day. The nurse identifies which of the following nursing diagnoses for this child? 1. Risk for Disturbed Body Image 2. Bathing Self-care Deficit 3. Risk for Impaired Urinary Elimination 4. Ineffective Breathing Pattern

1. Risk for Disturbed Body Image Adolescent girls are concerned about their bodies and how they appear to others, especially their peers. As a result, many refuse to comply with wearing their braces, especially when they are asked to wear the braces to school.

A baby is preoperative for closure of a myelomeningocele. Which of the following is the baby's priority nursing diagnosis? 1. Risk for Infection 2. Impaired Physical Mobility 3. Risk for Latex Allergy 4. Bowel Incontinence

1. Risk for Infection Although babies born with meningomyelocele are at risk for latex allergy and have both impaired physical mobility of their lower extremities and bowel incontinence, their most significant problem is their risk for infection. The exposed sac is a direct portal for bacterial invasion. The sac must be protected with moist, sterile dressings until it is surgically closed.

A baby with trisomy 21 is admitted to the newborn nursery. The baby should be assessed for which of the following features? 1. Simian crease 2. Polydactyly 3. Harlequin sign 4. Mongolian spots

1. Simian crease It is important to remember that chromosomal syndrome diseases are usually associated with a number of characteristics. In addition to features such as simian creases seen in children with Down syndrome, the babies may exhibit life-threatening anomalies, including cardiac and gastrointestinal defects. Polydactyly is a relatively common birth anomaly that is not directly associated with Down syndrome. Mongolian spots & Harlequin sign are normal variations in neonatal skin color.

The nurse has taken a health history from a school-age child who is being assessed 6 weeks' post-surgery for a benign brain tumor. The nurse should report which of the following findings to the health-care provider? 1. The child states that he fell at school three times last week. 2. The child states that he has had no headaches all week. 3. The child states that he did very well on yesterday's history test. 4. The child states that he has decided to join the school's swim team.

1. The child states that he fell at school three times last week. The child has communicated that he has fallen, which likely is related to poor coordination. Even after a brain tumor has been removed, a number of children will experience long-term complications.

A teenager has been in an automobile accident. The parents are advised that their child has experienced a cerebral contusion. When they ask what that means, the nurse should provide which of the following explanations? 1. "Your child has ruptured a blood vessel between the layers that protect the brain from injury." 2. "Your child has a bruise of the brain tissue." 3. "Your child has a fracture in one part of the skull." 4. "Your child has a great deal of swelling of the part of the brain that is called the brain stem."

2. "Your child has a bruise of the brain tissue." A cerebral contusion is a brain bruise. Although this question refers to a conversation between parents and a nurse, it simply is asking for the definition of a contusion

A 7-year-old child has just had a lumbar puncture in the emergency department for complaints of elevated temperature and a stiff neck. Which of the following cerebral spinal fluid findings would indicate that this child has bacterial meningitis? 1. Markedly lower than normal pressure 2. Glucose 20 mg/dL 3. White blood cell count 3 cells/mm3 4. Clear fluid

2. Glucose 20 mg/dL Low glucose (below 45 mg/dL) is consistent with a diagnosis of bacterial meningitis. Feedback 1: Cerebral spinal fluid pressures are elevated with a diagnosis of bacterial meningitis. Feedback 2: When a child has bacterial meningitis, he or she has bacteria in the cerebral spinal fluid. The bacteria use the glucose for energy. As a result, glucose levels drop. Feedback 3: Elevated white blood cell counts are consistent with a diagnosis of bacterial meningitis (normal is less than 5 cells/mm3). Feedback 4: Cerebral spinal fluid is cloudy with a diagnosis of bacterial meningitis.

A nurse is providing counseling to parents regarding an important action they can take to prevent their children from developing meningitis. Which of the following actions did the nurse suggest? 1. Have children sleep in separate beds during sleepover parties. 2. Have children receive all recommended immunizations. 3. Teach children to wash their hands after toileting and before eating. 4. Teach children to cover their faces with a tissue when they sneeze.

2. Have children receive all recommended immunizations. Many of the vaccinations administered to children immunize children against bacteria that cause meningitis. Immunizations against H. influenzae, N. meningitides, and S. pneumoniae have prevented many children from developing meningitis. Sleeping in separate beds may help to prevent transmission if one child is harboring bacteria that cause meningitis, but it is not the best response.

The nurse, who is admitting a neonate into the well-baby nursery, assesses the following: widely separated sagittal suture and enlarged anterior and posterior fontanels. Which of the following follow-up assessments is most important for the nurse to perform at this time? 1. Tonic neck reflex 2. Head and chest circumferences 3. Ortolani's sign 4. Red reflexes of both eyes

2. Head and chest circumferences Babies with widely separated sagittal sutures and enlarged fontanels may have heads that are larger than normal. The head circumference should be approximately 2 cm larger than the chest circumference. If it is markedly larger, the baby may be developing hydrocephalus.

A 3-year-old child is admitted to the pediatric unit in skeletal traction after fracturing the femur. Which of the following orders should the nurse request from the child's primary health-care practitioner? 1. Liquid diet 2. Jacket restraint when not accompanied by parent 3. Active range of motion exercises of lower extremities 4. Foley catheter

2. Jacket restraint when not accompanied by parent Three-year-old children do not understand the rationale for bedrest and traction following a serious fracture. They often will attempt to get out of bed in order to walk and run. They may also attempt to twist and turn to get out of the traction. A jacket restraint will help to keep the child in the appropriate position in the bed. However, it should never be used as punishment.

A baby, exhibiting no obvious signs of congestive heart failure, has been diagnosed with a small ventricular septal defect. Which of the following information should the nurse explain to the baby's parents? 1. The baby will likely need open-heart surgery within a week. 2. The defect will likely close without therapy. 3. The defect likely developed early in the second trimester. 4. The baby will likely be placed on high-calorie formula.

2. The defect will likely close without therapy. The vast majority of babies with VSDs are discharged from the well-baby nursery and are seen periodically by a cardiologist on an outpatient basis. This can be frightening to the parents who are told that their baby has a hole in his or her heart. It is important, therefore, for the nurse to reassure the parents that most VSDs do close spontaneously. However, the nurse must educate the parents regarding signs of CHF in case the baby does begin to go into cardiac failure.

A baby that was born 5 minutes earlier is tachypneic, tachycardic, and markedly cyanotic. A STAT echocardiogram confirms the presence of a cyanotic congenital cardiac defect. Which of the following defects would be consistent with the assessment findings? 1. Patent ductus arteriosus 2. Transposition of the great vessels 3. Atrial septal defect 4. Ventricular septal defect

2. Transposition of the great vessels Transposition of the great vessels (TGV) is a cyanotic defect. Unless another defect is also present, the defect is incompatible with life. The only cyanotic defect listed is TGV. If the test-taker were not to know that fact, however, he or she could deduce the correct response. Septal defects and PDAs result in left-to-right shunts, resulting in the blood reentering the pulmonary system in which it is oxygenated.

A pediatric nurse is having a discussion with a father whose child has recently been diagnosed with spastic cerebral palsy. Which of the following statements by the nurse is appropriate? 1. "It must be very hard to know that your child's ability to move will decrease over time." 2. "I am sure that it is hard for you to know that your child has this disease, but at least the medicine will treat the underlying problem." 3. "The treatment plan for your child will focus on enabling him to have as normal movements as possible." 4. "The nerve stimulation of your child's legs will enable him to walk on his own when he is older."

3. "The treatment plan for your child will focus on enabling him to have as normal movements as possible." The signs and symptoms of CP result from a hypoxic insult to the brain. The therapeutic interventions are aimed at enabling the child to reach his or her highest potential.

An 8-year-old girl, who is complaining of a "really bad" sore throat and whose temperature is 102.2°F, is seen in the school nurse's office. The nurse has the child lie down in a room away from other children. Which of the following statements is most important for the nurse to convey when calling the child's parents? 1. "Your child is crying and asking for mommy and daddy." 2. "Your child is very uncomfortable with a sore throat." 3. "Your child should be seen by her primary care provider." 4. "Your child may be contagious to the other children."

3. "Your child should be seen by her primary care provider." This is the most important statement. The child may have a group A strep infection that will need to be treated. Anytime a test question includes the word "most," all of the actions in the responses are correct. The examiner, however, is asking the test-taker to pick the one best response to the question. Because any infection caused by group A strep that is untreated may result in the child developing rheumatic fever, the nurse must advise the parents to have their child assessed by the child's primary health-care provider.

A baby with myelomeningocele is admitted to the neonatal intensive care unit. Which of the following signs/symptoms would the nurse expect to see? 1. Hyperreflexia 2. Ptosis 3. Bilateral lower limb paralysis 4. Marked respiratory distress

3. Bilateral lower limb paralysis Babies with myelomeningocele are born with a sac of cerebral spinal fluid and nerves protruding through the skin in the lower back. The nerves to the upper body are unaffected, but the nerves to the lower body are adversely affected. The lower extremities of these babies often are paralyzed.

An adolescent is being admitted to the pediatric intensive care unit following rod placement for a diagnosis of scoliosis. Which of the following assessments is highest priority for the nurse to perform? 1. Pain level 2. Intravenous flow rate 3. Blood loss 4. Electrolyte values

3. Blood loss Blood loss during rod placement for scoliosis can be extensive and can result in impaired perfusion to vital organs (e.g., kidneys).

A child with nonorganic failure to thrive (NOFTT) is being discharged from the hospital. The baby's mother, who is now exhibiting appropriate parenting behaviors, is providing the baby with needed nutritional supplementation. In addition, the mother does which of the following? 1. Puts the baby to bed with a bottle of formula 2. Feeds the baby through an enlarged hole in the nipple 3. Faces a blank wall while feeding the baby 4. Adds rice cereal to the baby's formula

3. Faces a blank wall while feeding the baby Some babies with NOFTT eat poorly because they become distracted by external stimuli and fail to attend to the primary caregiver who is feeding them. By facing a blank wall, distractions are markedly reduced.

The EKG of a child diagnosed with rheumatic fever is shown: After examining the strip, which of the following conclusions would the nurse make? The strip shows evidence of: 1. Atrial fibrillation. 2. Premature ventricular contraction. 3. Prolonged P-R interval. 4. Flattened T wave.

3. Prolonged P-R interval. Although pediatric nurses are not expected to be expert EKG readers, they should be able to identify some characteristic changes. A prolonged P-R interval (i.e., a P-R interval that lasts longer than 0.2 sec) is one of those changes.

A nurse is educating the parents of a child with an atrial septal defect regarding the child's condition. Which of the following information would be appropriate for the nurse to provide? 1. The baby becomes cyanotic because the blood is flowing through a hole from the right side of the heart to the left side of the heart. 2. The baby has a murmur because there is a hole between the aorta and the pulmonary artery. 3. The baby's heart is working harder than a normal heart because some of its blood is reentering the pulmonary system. 4. The baby's heart rate is slowed because of the high number of red blood cells in the blood.

3. The baby's heart is working harder than a normal heart because some of its blood is reentering the pulmonary system. This response is correct. In the case of an ASD and other acyanotic defects, the blood is reentering the pulmonary system as a result of left to right shunting. Left-to-right shunt refers to the path the blood takes through the heart. When there is a hole in the heart—ASD, VSD, or PDA—the blood travels from the left side to the right side simply because the left ventricle is stronger than the right ventricle. Because the blood travels repeatedly into the right ventricle, it enters the pulmonary system repeatedly via the pulmonary artery. In some cyanotic diseases, most notably Tetralogy of Fallot, the blood travels from the right side of the heart to the left side. This occurs in Tetralogy of Fallot because the stenotic pulmonic valve prevents the blood from entering the pulmonary artery. Rather the blood is "shunted" through the overriding aorta, thereby bypassing the lungs.

A 9-year-old child is admitted to the hospital with a primary diagnosis of fractured femur and a secondary diagnosis of intellectual disability. Which of the following patient-care goals is appropriate for the child's nursing diagnosis of Deficient Knowledge related to the medical diagnosis? 1. The child will write a story about a child who has broken a leg. 2. The child will name the bones of the leg and tell the nurse which bone was broken. 3. The child will draw a picture of a child who is in the hospital in traction. 4. The child will complete a science project for school about how traction weights work.

3. The child will draw a picture of a child who is in the hospital in traction. Children with intellectual disabilities are usually able to draw pictures and should be able to draw a picture of a child who is in a hospital in traction. Because a child with an intellectual disability has a developmental age that is likely very different from his or her chronological age, it is very important for the nurse to determine the child's developmental age. The nurse will then be able to alter his or her care appropriately.

A nurse must change the position of an adolescent who is 2 hours' post-op rod placement for a diagnosis of scoliosis. Which of the following actions should the nurse perform? 1. Elevate the head of the bed to thirty degrees 2. Lower the bed into the Trendelenburg position. 3. Turn the child while keeping the child's spine straight. 4. Place a pillow under the knees and keep the child supine.

3. Turn the child while keeping the child's spine straight. To prevent damage to the child's surgical site and spinal cord following rod placement for scoliosis, the child should be log rolled. It usually requires more than one nurse to roll a patient like a log and to keep from bending the child's spine. The bed should remain flat.

The nurse is educating the parents of a child with Duchenne muscular dystrophy (DMD) regarding priority actions that they should take when caring for their child. Which of the following actions should the nurse include during the teaching session? Immediately report to the child's primary health-care provider if the child: 1. has diarrhea. 2. refuses to eat. 3. develops an upper respiratory infection. 4. complains of pain in any limbs.

3. develops an upper respiratory infection. As the child's muscle fibers are replaced by fat cells, he is less and less able to fight upper respiratory infections. The child must be seen by a health-care practitioner so that an aggressive therapy can be instituted.

A child has been diagnosed with febrile seizures. Which of the following information should the nurse include in the parent teaching session? 1. "Whenever your child develops a fever, place him in a warm bath and pour the water over his arms and legs." 2. "Make sure to give your child high dosages of acetaminophen whenever his temperature goes above 104°F." 3. "It is very important that your child have no more seizures to prevent him from experiencing permanent injury to his brain." 4. "It should be comforting to know that most children outgrow the febrile seizures by the time they reach 6 years of age."

4. "It should be comforting to know that most children outgrow the febrile seizures by the time they reach 6 years of age." Febrile seizures usually occur as a child's temperature is rising. It is recommended, therefore, to administer antipyretics as soon as an elevation is noted. When placed in tepid baths, children usually shiver. Shivering actually stimulates the body to raise its temperature.

A nurse is admitting a 7-month-old infant with a diagnosis of neuroblastoma to the pediatric in-patient unit. The infant is the parents' third child. The infant's father asks, "The doctor keeps talking about the genetics of the tumor. What the heck does that mean?" Which of the following responses by the nurse is appropriate? 1. "The doctor wants to determine whether any of your other children is at high risk of developing a neuroblastoma." 2. "The doctor wants to determine whether the genetic code in your baby's tumor is different from the genetic code in the rest of the baby's cells." 3. "The doctor is mandated by law to report to the health department any genetic mutation that is caused by environmental contaminants." 4. "The doctor will be better able to determine how the baby's therapy will work once the exact genetic code of the tumor is identified.

4. "The doctor will be better able to determine how the baby's therapy will work once the exact genetic code of the tumor is identified. The prognosis for children with neuroblastoma is dependent upon the child's age and the exact genetic mutation of the cancer. Although the exact cause of the mutation is unknown, neuroblastoma is a cancer of the peripheral nervous system that originates from embryonic tissue. A small number of neuroblastomas are hereditary and some neuroblastomas are environmental in origin.

A child who is experiencing high fever and neck pain is diagnosed with viral meningitis. Which of the following should the nurse include in the discharge teaching? 1. Keep the child isolated until the temperature returns to normal. 2. Pad the child's bed headboard. 3. Rent a commode for the child to use at home. 4. Administer over-the-counter analgesics as needed.

4. Administer over-the-counter analgesics as needed. Children with meningitis often have headaches. Over-the-counter analgesics are administered for the pain

A child with osteomyelitis is receiving IV gentamycin. The nurse should monitor which of the child's laboratory values to assess for possible toxicity from the medication? 1. Hematocrit 2. Platelet count 3. Serum sodium 4. Blood urea nitrogen

4. Blood urea nitrogen Gentamycin, an aminoglycoside, can cause nephrotoxicity. BUN is one of the renal function tests that should be monitored by the nurse.

A newborn baby is receiving digoxin (Lanoxin) and furosemide (Lasix) for congestive heart failure. Which of the following actions would be appropriate for the nurse to perform? 1. Hold digoxin if the apical heart rate is 170 bpm. 2. Hold digoxin for a digoxin level of 1 ng/mL. 3. Hold both the digoxin and furosemide for a weight increase of 5% in one day. 4. Hold both the digoxin and the furosemide for a potassium 3.2 mEq/L.

4. Hold both the digoxin and the furosemide for a potassium 3.2 mEq/L. A serum potassium level of 3.2 mEq/L is well below the normal for a newborn of 3.7 to 5.9 mEq/L. The nurse should hold both medications and notify the health-care provider who ordered them. Hypokalemia, or a serum potassium level that is lower than normal, places the body at high risk for cardiac arrhythmias. In addition, when digoxin is taken, the potential for the cardiac arrhythmias increases. Furosemide increases the excretion of potassium. It is essential, therefore, that the nurse not administer the medications until the hypokalemia has been reported and action has been taken to return the electrolyte level to normal.

A baby is admitted to the neonatal intensive care unit following closure of a myelomeningocele. Which of the following patient care goals should the nurse include in the nursing care plan? The baby will: 1. maintain supine positioning. 2. have normal elimination patterns. 3. exhibit a normal startle reflex. 4. consume feedings and gain weight.

4. consume feedings and gain weight. Patient-care goals are expectations of patients' behavior. A baby with a meningomyelocele would not be expected to have normal elimination patterns or a normal startle (Moro) reflex because of the nerve damage sustained from the defect. In addition, to prevent injury to the surgical site, the baby must be placed in the prone position. After surgery, the baby would be expected to feed and gain weight.

A child is admitted to the pediatric unit with a diagnosis of meningitis. Which of the following actions should the nurse perform? Select all that apply. 1. Raise the head of the bed. 2. Dim the lights in the room. 3. Place the child on droplet isolation. 4. Administer intravenous antibiotics, as prescribed. 5. Perform passive range-of-motion exercises of the neck.

ANS 1,2,3,4 The bacteria that cause meningitis are transmitted via the respiratory route. The child, therefore, should be placed on droplet isolation. Once the child has been on antibiotics for a full 24 hr or if the culture report is negative for bacteria, he or she no longer needs to remain on isolation. The nurse should refrain from moving the child's neck. The movement is very painful.

A 12-year-old child is being assessed in the emergency department for possible Reye syndrome. The child was diagnosed with influenza by a primary health-care provider 2 weeks earlier. Which of the following findings would the nurse expect to see? Select all that apply. 1. Child's Babinski reflex is positive. 2. Child has had vomiting episodes for the past 24 hr. 3. Child's serum ammonia levels are markedly lower than normal. 4. Child was administered ibuprofen (Advil) when the child had the flu. 5. Child is unusually argumentative and aggressive.

ANS 1,2,4,5 Reye syndrome is seen as a sequela to some viral illnesses, most notably varicella and influenza. It is more likely to occur if a child has received aspirin during the viral illness. Feedback 1: A positive Babinski reflex is seen in children with Reye syndrome. Feedback 2: Vomiting episodes are seen in children with Reye syndrome. Feedback 3: Serum ammonia levels rise with Reye syndrome. Feedback 4: Aspirin is contraindicated when a child has the flu. Feedback 5: Combative behavior, including being argumentative and aggressive, is seen in children with Reye syndrome.

A child who has been diagnosed with chorea has been admitted to the pediatric unit with a diagnosis of rheumatic fever. Immediately prior to admission, the child's throat culture was positive for group A strep. Which of the following actions should the nurse perform when admitting the child? Select all that apply. 1. Cover the headboard with a soft material. 2. Put the child on droplet precautions. 3. Place a tracheostomy tray in the child's room. 4. Have the child perform active range of motion exercises. 5. Assess the child's apical heart rate for one full minute.

ANS 1,2,5 Feedback 1: A child with chorea from RF should be placed on seizure precautions. The headboard should be covered. Feedback 2: The child's throat culture is positive for group A strep. The child should be placed on droplet isolation until he or she has received a full 24 hr of medication. Feedback 3: There is no need to place a trach tray in the child's room. Tracheal occlusion is a rare complication of strep pharyngitis. Feedback 4: It is inappropriate to have the child perform active ROM exercises. The child may have carditis and/or polyarthritis. ROM exercises could aggravate either of the manifestations of the disease. Feedback 5: The nurse should assess the child's apical pulse for 1 full minute to assess whether or not a murmur is present. A murmur would indicate that the child likely has carditis. This is a multiple response item. Each of the items should be reviewed independently to determine which of them is related to the stem of the question. Because the child in the scenario has been diagnosed with RF and has been found to have a positive culture for group A strep, responses 1, 2, and 5 are correct.

A 16-year-old gymnast falls from the uneven parallel bars onto her right arm. The school nurse is called to the scene. The young woman points to her right forearm and states, "It really hurts there." Which of the following actions should the nurse perform at this time? Select all that apply. 1. Apply pressure to the site of point tenderness. 2. Ask the young woman to move the fingers of her right hand. 3. Compare the radial pulses on the right wrist to those on the left wrist. 4. Compare the range of motion of the right wrist to that of the left wrist. 5. Ask the young woman whether her right hand and arm feel differently from the left hand and arm.

ANS 2,3,4,5 After a patient is injured, the nurse should attempt to evaluate the severity of the injury by assessing for the five Ps: severity of the pain, including a specific point of tenderness; pulse distal to the injury; pallor or loss of color distal to the injury; presence of paresthesias distal to the injury; and paralysis of movement distal to the injury. It would be inappropriate to apply pressure to the site of point tenderness.

A nurse suspects that a newly delivered baby has Down syndrome. The nurse noted that the baby exhibited which of the following physiological characteristics? Select all that apply. 1. Elongated face 2. Protruding tongue 3. Large, high-set ears 4. Wide, flat nasal bridge 5. Asymmetric Moro reflex

ANS 2,4 The protruding tongue of the Down syndrome baby is not related to the fact that the tongue is enlarged but rather to the poor muscle tone of the baby. Ear height is determined by drawing and extending an imaginary line from the inner canthus to the outer canthus of the eye. The top of the ear should be found at or slightly above the imaginary line. In Down syndrome babies, the top of the ear falls below the imaginary line.

A child has been diagnosed with Kawasaki disease. Which of the following signs and symptoms would the nurse expect to see? Select all that apply. 1. Diarrhea 2. Vertigo 3. Purpural rash over torso 4. Reddened and crusty eyes 5. Skin peeling from hands and feet

ANS 4,5 Kawasaki disease is diagnosed from a series of signs and symptoms, including prolonged fever, conjunctivitis, strawberry tongue, rash on the palms and soles that desquamates, and cardiac changes. Feedback: Diarrhea, Vertigo, and Purpuric rash is not a classic symptom of Kawasaki disease. . Feedback 4: Children with Kawasaki disease do have conjunctivitis. Feedback 5: The palms and soles of children with Kawasaki do desquamate.

A 3-year-old child is status post shunt revision for hydrocephaly. Part of the discharge teaching plan for the parents is signs of shunt malformation. Which signs are of shunt malformation? Select all that apply. a) Personality change b) Bulging anterior fontanel c) Vomiting d) Dizziness e) Fever

ANS a,c,e Personality change can be a sign of shunt malformation related to increased intracranial pressure.Vomiting can be a sign of shunt malformation related to increased intracranial pressure.Fever can be a sign of shunt malformation and is a very serious complication.The anterior fontanel closes between 12-18 months of age.Dizziness is difficult to assess in a 3-year-old and is not necessarily a sign of shunt malformation.

A nurse is caring for an infant with developmental dysplasia of the hip (DDH). Based on the nurse's knowledge of DDH, which clinical manifestation should the nurse expect to observe? Select all that apply. a) Lordosis b) Negative Babinski sign c) Asymmetric thigh and gluteal folds d) Positive Ortolani and Barlow tests e) Shortening of limb on affected side

ANS c,d,e Asymmetric thigh and gluteal folds are clinical manifestation of DDH and seen from birth to two months.Positive Ortolani and Barlow tests are clinical manifestations of DDH. Ortolani test is the abducting of the thighs to test for hip subluxation or dislocation. Barlow test is the adducting to feel if the femoral head slips out of the socket postolaterally.Shortening of limb on affected side is another clinical manifestation of DDH.Lordosis is the inward curve of the lumbar spine just above the buttocks and is not a clinical manifestation of DDH.A negative Babinski sign is not a clinical manifestation of DDH. It is a neurological reflex.

Which statement is most accurate in describing tetanus? a) Acute infectious disease caused by an exotoxin produced by an anaerobic, gram-positive bacillus b) Inflammatory disease that causes extreme, localized muscle spasm c) Acute infection that causes meningeal inflammation, resulting in symptoms of generalized muscle spasm d) Disease affecting the salivary gland with resultant stiffness of the jaw

a) Acute infectious disease caused by an exotoxin produced by an anaerobic, gram-positive bacillus Tetanus is an acute, preventable disease caused by an exotoxin produced by an anaerobic spore-forming, gram-positive bacillus,

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

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

Which measure is important in managing hypercalcemia in a child who is immobilized? a) Promote adequate hydration b) Change position frequently c) Encourage a diet high in calcium d) Provide a diet high in protein and calories

a) Promote adequate hydration Hydration is extremely important to help remove the excess calcium from the body. This can help prevent hypercalcemia.Changing the child's position frequently will help with managing skin integrity but will not affect calcium levels.The calcium will not be incorporated into bone because of the lack of weight bearing. The child is at risk of developing hypercalcemia.The child's metabolism is slower because of the immobilization. A diet with sufficient calories and nutrients for healing is important.

The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. What is the priority assessment for this child? a) Reactivity of pupils b) Doll's head maneuver c) Oculovestibular response d) Funduscopic examination to identify papilledema

a) Reactivity of pupils Pupil reactivity is an important indication of neurologic health. The pupils should be assessed for no reaction, unilateral reaction, and rate of reactivity.The doll's head maneuver should not be performed if there is a cervical spine injury.Assessing for an oculovestibular response is a painful test that should not be done for a child who is having variable levels of consciousness.Papilledema does not develop for 24 to 48 hours in the course of unconsciousness.

What is a clinical manifestation of increased intracranial pressure (ICP) in infants? a) Shrill, high-pitched cry b) Photophobia c) Pulsating anterior fontanel d) Vomiting and diarrhea

a) Shrill, high-pitched cry A shrill, high-pitched cry is a common clinical manifestation of increased ICP in infants. The characteristic cry occurs secondary to the pressure being placed on the meningeal nerves, causing pain. Photophobia is not indicative of increased ICP in infants.A pulsating anterior fontanel is normal in infants. The infant with increased ICP would be seen with a bulging anterior fontanel.Vomiting is one of the signs of increased ICP in children, but when present with diarrhea, it is more indicative of a gastrointestinal disturbance.

What is an early sign of congestive heart failure that the nurse should recognize? a) Tachypnea b) Bradycardia c) Inability to sweat d) Increased urinary output

a) Tachypnea Tachypnea is one of the early signs of congestive heart failure that should be identified. Tachycardia at rest, dyspnea, retractions, and activity intolerance are other physical signs and symptoms.Tachycardia, not bradycardia, is one of the symptoms suggestive of congestive heart failure.The child may be diaphoretic if experiencing congestive heart failure.There will usually be decreased urinary output in a child experiencing congestive heart failure.

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

a) Teach the child to do self-catheterization. At 6 years of age, this child should have the dexterity to perform the intermittent catheterization. This will give the child more control and mastery over the disability.Bladder control cannot be taught in a child with a neurogenic bladder.School-age children, even as young as 6 years, should be able to begin self-catheterization.A urinary diversion is not necessary for a neurogenic bladder.

Which statement is the most descriptive of rhabdomyosarcoma? a) The most common sites are the head and neck. b) It is a common hereditary neoplasm of childhood. c) It is the most common bone tumor of childhood. d) It is a benign tumor and unusual in children.

a) The most common sites are the head and neck Although striated muscle fibers from which this tumor arises can be found anywhere in the body, the most common sites are the head and neck.Rhabdomyosarcoma is not known to be hereditary.Rhabdomyosarcoma arises from skeletal muscle tissue, not bone.Rhabdomyosarcoma is highly malignant.

The nurse is preparing to give digoxin (Lanoxin) to a 9-month-old infant. The nurse checks the dose; 4 mL of the drug is to be drawn up. Based on the nurse's knowledge of this medication and safe pediatric dosages, the most appropriate action by the nurse is a) do not draw-up dose; suspect dosage error. b) mix dose with juice to disguise its taste. c) check heart rate; administer dose by placing it to the back and side of mouth. d) check heart rate; administer dose by letting infant suck it through a nipple.

a) do not draw-up dose; suspect dosage error Digoxin is often prescribed in micrograms. Rarely is more than 1 mL administered to an infant. As a potentially dangerous drug, digoxin has precise administration guidelines. Some institutions require that digoxin dosages be checked with another professional before administration.The nurse has drawn up too much medication and should not give it to the child.This is a correct procedure, but too much medication is prepared, so it should not be given to the child.This is a correct procedure, but too much medication is prepared, so it should not be given to the child.

The nurse is performing a neurologic assessment of a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes suggest a) neurologic health b) severe brain damage c) decorticate posturing d) decerebrate posturing

a) neurologic health The Moro, tonic neck, and withdrawal reflexes are usually present in infants under 3 to 4 months of age. Therefore, the presence of these reflexes indicates neurologic health.The presence of the Moro, tonic neck, and withdrawal reflexes does not indicate severe brain damage. Decorticate posturing is indicative of severe dysfunction of the cerebral cortex and is not related to the presence of the Moro, tonic neck, or withdrawal reflexes.Decerebrate posturing is indicative of dysfunction at the level of the midbrain and is not related to the presence of the Moro, tonic neck, or withdrawal reflexes.

The nurse is caring for a toddler who has had surgery for a brain tumor. During an assessment, the nurse notes that the child is becoming irritable and the pupils are unequal and sluggish. The most appropriate nursing action is to a) notify the practitioner immediately. b) assess for level of consciousness (LOC). c) observe closely for signs of increased intracranial pressure (ICP). d) administer pain medication and assess for response.

a) notify the practitioner immediately. The worsening of symptoms may indicate that the ICP is increasing. The practitioner should be notified immediately because this is considered a medical emergency.Assessing for the LOC should be done as part of the assessment. The nurse is noting signs of potentially increased ICP as described; therefore, this has already been completed.Pain medication should not be given, because it can often mask the signs of increasing ICP. The priority nursing intervention is to consult with the practitioner immediately.

Which statement is true concerning osteogenesis imperfecta (OI)? a) OI is easily treated. b) OI is an inherited disorder. c) With a later onset, the disease usually runs a more difficult course. d) Braces and exercises are of no therapeutic value.

b) OI is an inherited disorder. OI is an autosomal dominant inherited disorder.OI is a lifelong problem caused by defective bone mineralization, abnormal bone architecture, and increased susceptibility to fracture.OI has a predictable course that is determined by the pathophysiologic processes, not the time of onset. Lightweight braces and splints can help support limbs and fractures.

What is characteristic of fractures in children? a) Fractures rarely occur at the growth plate site because it absorbs shock well. b) Rapidity of healing is inversely related to the child's age. c) Pliable bones of growing children are less porous than those of adults. d) The periosteum of a child's bone is thinner, is weaker, and has less osteogenic potential compared with that of the adult.

b) Rapidity of healing is inversely related to the child's age. Fractures heal in less time in children than in adults. As the child ages, the healing time increases.The cartilage epiphyseal plate is the weakest point of the long bone. Therefore, it is a frequent site of damage and fractures.The periosteum is thickened, and there is a great production of osteoclasts when a bone injury occurs.Bone healing in children is rapid due to the thickened periosteum and generous blood supply.

A 3-year-old has cerebral palsy (CP) and is hospitalized for orthopedic surgery. The child's mother states the child has difficulty swallowing and cannot hold a utensil to self-feed. The child is slightly underweight for height. What is the most appropriate nursing action related to feeding? a) Bottle-feed or tube-feed the child with a specialized formula until sufficient weight is gained. b) Stabilize the child's jaw with one hand (either from a front or side position) to facilitate swallowing. c) Place the child in a well-supported, semireclining position to make use of gravity flow. d) Place the child in a sitting position with the neck hyperextended to make use of gravity flow.

b) Stabilize the child's jaw with one hand (either from a front or side position) to facilitate swallowing. Because the jaw is compromised, more normal control can be achieved if the feeder provides stability. Manual jaw controls assist with head control, correction of neck and trunk hyperextension, and jaw stabilization.The child is too old to be bottle-fed. The neuromuscular compromise of the jaw interferes with the child's ability to eat.The child should be sitting up for meals to prevent aspiration.For swallowing, the neck should not be hyperextended.

The postoperative care of a preschool child who has had a brain tumor removed should include a) recording of colorless drainage as normal on the nurse's notes. b) close supervision of the child while he or she is regaining consciousness. c) positioning the child on the right side in the Trendelenburg position. d) no administration of analgesics.

b) close supervision of the child while he or she is regaining consciousness. The child needs to be observed closely, with careful and frequent assessment of the vital signs and monitoring for signs of increasing intracranial pressure. Any changes should be reported immediately to the practitioner.Colorless drainage may be leakage of cerebrospinal fluid from the incision site. This needs to be reported to the practitioner immediately. The child should not be positioned in the Trendelenburg position postoperatively.Analgesics can be used for postoperative pain as needed.

A child with spina bifida has developed a latex allergy from numerous bladder catheterizations and surgeries. A priority nursing intervention is to a) recommend allergy testing. b) provide a latex-free environment. c) use only powder-free latex gloves. d) limit the use of latex products as much as possible.

b) provide a latex-free environment. The most important nursing intervention is to provide a latex-free environment. From birth on, limitation of exposure to latex is essential in an attempt to minimize sensitization. Latex-free catheters for self-catheterization are available.Allergy testing may expose the child to the allergen and, therefore, is not recommended.The gloves contain latex and will contribute to sensitization. No latex products should be used with children who have latex allergies.Latex products should be avoided at all times.

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

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

A diagnosis of rheumatic fever is being ruled out for a child. Which lab test(s) is/are the most reliable? a) Throat culture b) C-reactive protein (CRP) c) Antistreptolysin-O titer (ASO) titer d) Elevated white blood count (WBC) e) Erythrocyte sedimentation rate (ESR)

c) Antistreptolysin-O titer (ASO) titer The most reliable and best standardized lab for antistreptococcal antibodies is an Antistreptolysin-O (ASO) titer.A throat culture indicates a current streptococcal infection.C-reactive protein (CRP) lab test indicates inflammation.An elevated white blood count (WBC) may indicate a possible infection but does not indicate a causative agent.An erythrocyte sedimentation rate (ESR) indicates inflammation.

What is an important nursing responsibility when a dysrhythmia is suspected? a) order an immediate electrocardiogram. b) Count the radial pulse every 1 minute for five times. c) Count the apical pulse for 1 full minute, and compare the rate with the radial pulse rate. d) Have someone else take the radial pulse simultaneously with the apical pulse.

c) Count the apical pulse for 1 full minute, and compare the rate with the radial pulse rate. This is the nurse's first action. If a dysrhythmia is occurring, the radial pulse rate may be lower than the apical pulse rate.This may be indicated after conferring with the practitioner.The radial pulse rate needs to be compared with the apical pulse rate. It does not need to be counted for 1 minute five times.Only one nurse is needed to carry out this action.

Which statement best describes pseudohypertrophic (Duchenne) muscular dystrophy (DMD)? a) DMD is inherited as an autosomal dominant disorder. b) DMD is characterized by weakness of the proximal muscles of both the pelvic and shoulder girdles. c) DMD is characterized by muscle weakness, usually beginning at about age 3 years. d) The onset of DMD occurs in later childhood and adolescence.

c) DMD is characterized by muscle weakness, usually beginning at about age 3 years. Usually, children with DMD reach the early developmental milestones, but the muscular weakness is usually observed in the third year of life.DMD is inherited as an X-linked recessive disorder.Weakness in a child with DMD is usually first noted in walking. Progressive muscle weakness in other muscle groups then follows. DMD usually develops in the third year of life.

The nurse is caring for a 2-year-old child who is unconscious but stable after a car accident. The child's parents are staying at the bedside most of the time. What is an appropriate nursing intervention? a) Suggest that the parents go home until the child is alert enough to know they are present. b) Use ointment on the lips but do not attempt to cleanse the teeth until swallowing returns. c) Encourage the parents to hold, talk to, and sing to the child as they usually would. d) Position the child with proper body alignment and the head of the bed lowered 15 degrees.

c) Encourage the parents to hold, talk to, and sing to the child as they usually would. The parents should be encouraged to interact with the child. Senses of hearing and tactile perception may be intact, and stimulation is important in the child's recovery.Suggesting that the parents go home until the child is awake is not recommended. The child may be able to hear that they are present, and this stimulation may assist in recovery.Oral care is essential in the unconscious child. Mouth care should be done at least twice daily to prevent oral infections.The head of the bed should be elevated, not lowered, in a child with neurologic involvement.

The temperature of an unconscious adolescent is 105º F (40.5º C). The priority nursing intervention is to a) continue to monitor temperature. b) initiate a pain assessment. c) apply a hypothermia blanket. d) administer aspirin stat.

c) apply a hypothermia blanket. Brain damage can occur at temperatures as high as 105º F (40.5º C). It is extremely important to institute temperature-lowering interventions such as hypothermia blankets and tepid water baths immediately.The temperature needs to be monitored, but lowering the temperature is the priority. Pain assessments should be ongoing, but this is not the priority at this time. Lowering the body temperature is the priority.Aspirin should never be administered to a child, because of the risk of Reye syndrome. Antipyretics, such as acetaminophen or ibuprofen, usually are not effective with temperatures as high as 105º F (40. 5ºC).

A 3-year-old has just returned from surgery in a hip spica cast. The priority nursing intervention is to a) elevate the head of the bed. b) offer sips of water. c) check circulation, sensation, and motion of toes. d) turn the child to the right side, then the left side every 4 hours.

c) check circulation, sensation, and motion of toes. The chief concern is that the extremity may continue to swell. The circulation, sensation, and motion of the toes must be assessed to ensure that the cast does not become a tourniquet and cause complications.Elevating the head of the bed might help with comfort, but it is not a priority. The nurse must be observant to the risk of increased swelling in the extremities.Offering sips of water is acceptable once assessment of the extremities has been completed. The child's position should be changed every 2 hours. Positioning a child with a spica cast is important to prevent injury.

Nursing care of the infant and child with congestive heart failure includes a) force fluids appropriate to age. b) monitor respirations during active periods. c) organize activities to allow for uninterrupted sleep. d) give larger feedings less often to conserve energy.

c) organize activities to allow for uninterrupted sleep. The child needs to be well rested before feeding. The child's needs should be met to minimize crying. The nurse must organize care to decrease energy expenditure.The child in congestive heart failure has an excess of fluid, so forcing fluids is contraindicated.Monitoring of vital signs is appropriate, but minimizing energy expenditure is a priority.The child often cannot tolerate larger feedings; small, frequent feedings should be given to the child in congestive heart failure.

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

c) shunt malfunction or infection requires immediate treatment. Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately if present.Limits should be appropriate to the child's developmental age. Except for contact sports, the child will have few restrictions.The development of mental retardation depends on the extent of damage before the shunt was placed.Limits should be appropriate to the child's developmental age. Except for contact sports, the child will have few restrictions.

A young child is having a seizure that has lasted 35 minutes. There is a loss of consciousness. Based on the nurse's knowledge of seizures, the nurse recognizes this as a) absence seizure. b) generalized seizure. c) status epilepticus. d) simple partial seizure.

c) status epilepticus. Status epilepticus is a generalized seizure that lasts more than 30 minutes. This is considered a medical emergency and requires immediate treatment.Absence seizures are generalized seizures that are characterized by brief losses of consciousness, blank staring, and fluttering of the eyelids.Generalized seizures are the most common form of seizures. They include tonic-clonic (grand mal) seizures and absence (petit mal) seizures. Tonic-clonic seizures have tonic-clonic activity and loss of consciousness and involve both hemispheres of the brain. Simple partial seizures are characterized by varying sensations and motor behaviors.

A child is admitted to the pediatric intensive care unit for a submersion injury. The child's parents express guilt over the submersion injury to the nurse. The most appropriate response by the nurse is a) "You will need to watch your child more closely in the future." b) "Why did you let your child almost drown?" c) "Your child will be fine, so don't worry." d) "Tell me more about your feelings."

d) "Tell me more about your feelings." The nurse needs to be nonjudgmental and provide the parents an opportunity to express their feelings.

What should the nurse recognize as an early clinical sign of compensated shock in a child? a) Confusion b) sleepiness c) Hypotension d) Apprehensiveness

d) Apprehensiveness Apprehensiveness is indicative of compensated shock.Confusion is indicative of uncompensated shock.Sleepiness is not an indication of shock.Hypotension is a symptom of irreversible shock.

What nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious child? a) Suction the child frequently. b) Provide environmental stimulation. c) Turn the head side to side every hour. d) Avoid activities that cause pain or crying.

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

What is a secondary effect when a child experiences decreased muscle strength, tone, and endurance from immobilization? a) Increased metabolism b) Increased venous return c) Increased cardiac output d) Decreased exercise tolerance

d) Decreased exercise tolerance Muscle disuse leads to tissue breakdown and loss of muscle mass or muscle atrophy. It may take weeks or months to recover.Metabolism decreases during periods of immobility.There is decreased venous return due to decreased muscle activity secondary to immobility.There is decreased cardiac output secondary to immobility.

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

d) Measure the head circumference and examine the fontanels for signs that might indicate developing hydrocephalus. Obstructive hydrocephalus is frequently associated with myelomeningocele. Assessment of the fontanels and daily measurements of the head circumference will aid in early detection of associated increased intracranial pressure.Preoperatively, the child is kept in a prone position to decrease tension on the sac and reduce the risk of trauma or sac tearing.The sac must be kept moist. Sterile, moist, nonadherent dressings are placed over the sac as prescribed by the physician.Most infants do not have diarrheal stools. The sac area, though, should be kept clean and dry and out of contact with urine and stools

What is an appropriate nursing intervention when caring for the child with chronic osteomyelitis? a) Provide active range-of-motion exercises of the affected extremity. b) Administer pain medication with meals. c) Encourage frequent ambulation. d) Move and turn the child carefully and gently to minimize pain.

d) Move and turn the child carefully and gently to minimize pain. Osteomyelitis is extremely painful. Movement is carried out only as needed and then carefully and gently.Active range-of-motion exercises are contraindicated until pain has subsided.Pain medication should be administered as needed.Ambulation is contraindicated until pain has subsided.

Which of the following phrases describes a characteristic of most neonatal seizures? a) Generalized seizure b) Tonic-clonic seizure c) Well-organized seizure d) Subtle and barely discernible seizure

d) Subtle and barely discernible seizure Signs of seizures in newborns are subtle. They include symptoms such as lip smacking, tongue thrusting, eye rolling, and arching of the back.The newborn's central nervous system is not sufficiently developed to maintain a generalized seizure.The newborn's central nervous system is not sufficiently developed to maintain a tonic-clonic (generalized) seizure.The newborn's central nervous system is not sufficiently developed to maintain a well-organized seizure.

The nurse is caring for an immobilized preschool child. What is helpful during this period of immobilization? a) Encourage the child to wear pajamas. b) Let the child have few behavioral limitations. c) Keep the child away from other immobilized children if possible. d) Take the child for a "walk" by wagon outside the room.

d) Take the child for a "walk" by wagon outside the room. It is important for children to have activities outside of the room if possible. This can give them opportunities to meet their normal growth and developmental needs.The child should be encouraged to wear street clothes during the day.Limit setting is necessary with all children.There is no reason to segregate children who are immobilized unless there are other medical issues that need to be addressed.

A woman who is 6 weeks pregnant tells the nurse that she is worried her baby might have spina bifida because of a family history. What should the nurse's response be based on? a) There is no genetic basis for the defect. b) Prenatal detection is not possible yet. c) Chromosomal studies done on amniotic fluid can diagnose the defect prenatally. d) The concentration of α-fetoprotein in amniotic fluid can potentially indicate the presence of the defect prenatally

d) The concentration of α-fetoprotein in amniotic fluid can potentially indicate the presence of the defect prenatally Fetal ultrasound and elevated concentrations of α-fetoprotein in amniotic fluid many indicate the presence of anencephaly, myelomeningocele, or other neural tube defects.The origin of neural tube defects is unknown but appears to have a multifactorial inheritance pattern. Prenatal detection is possible through amniotic fluid or chorionic villi sampling.There are no chromosomal studies currently that can diagnose spina bifida prenatally.

What should nurses stress when counseling parents regarding the home care of the child with a cardiac defect before corrective surgery? a) The importance of reducing caloric intake to decrease cardiac demands b) The importance of relaxing discipline and limit setting to prevent crying c) The need to be extremely concerned about cyanotic spells d) The desirability of promoting normalcy within the limits of the child's condition

d) The desirability of promoting normalcy within the limits of the child's condition The child needs to have social interactions, discipline, and appropriate limit setting. Parents need to be encouraged to promote as normal a life as possible for their child.The child needs increased caloric intake after cardiac surgery.The child needs discipline and appropriate limit setting, as would be done with any other child his or her age.Because cyanotic spells will occur in children with some defects, the parents need to be taught how to assess for and manage them appropriately, thereby decreasing their anxiety and concern.

What is considered a mixed cardiac defect? a) Pulmonic stenosis b) Atrial septal defect c) Patent ductus arteriosus d) Transposition of the great arteries

d) Transposition of the great arteries Transposition of the great arteries allows the mixing of both oxygenated and unoxygenated blood in the heart.Pulmonic stenosis is classified as an obstructive defect.Atrial septal defect is classified as a defect with increased pulmonary blood flow.Patent ductus arteriosus is classified as a defect with increased pulmonary blood flow.

The most appropriate nursing intervention when caring for a child experiencing a seizure is to a) restrain the child when a seizure occurs to prevent bodily harm. b) place a padded tongue between the teeth if they become clenched. c) suction the child during the seizure to prevent aspiration. d) described and document the seizure activity observed.

d) described and document the seizure activity observed. The priority nursing intervention is to observe the child and seizure and document the activity observed.The child should not be restrained, because this may cause an injury.Nothing should be placed in the child's mouth, because this may cause an injury not only to the child but to the nurse.To prevent aspiration, the child should be placed on the side if possible to facilitate drainage.

Surgical repair for patent ductus arteriosus (PDA) is done to prevent the complication of a) pulmonary infection. b) right-to-left shunt of blood. c) decreased workload on left side of heart. d) increased pulmonary vascular congestion.

d) increased pulmonary vascular congestion. A PDA allows blood to flow from the aorta (high pressure) to the pulmonary artery (low pressure). If the PDA stays open, increased pulmonary vascular congestion can occur.The increased pulmonary vascular congestion is the primary complication; pulmonary infection may occur, but it is not the priority complication.A PDA involves a left-to-right shunt of blood. The decreased workload on the left side of the heart is not a priority complication of a PDA.

The callus that develops at a fracture site is important because it provides a) use of the injured part. b) sufficient support for weight bearing. c) means for adequate blood supply. d) means for holding bone fragments together

d) means for holding bone fragments together New bone cells are formed in large numbers and stimulated to maximum activity. They are found at the site of the injury. In time, calcium salts are absorbed to form the callus.Functional use cannot occur until the fracture site is stable.Sufficient support for weight bearing cannot occur until the fracture site is stable.The callus does not provide an adequate blood supply.

The nurse is instructing a group of parents about head injuries in children. The nurse should explain that infants are particularly vulnerable to acceleration-deceleration head injuries because the a) anterior fontanel is not yet closed. b) nervous tissue is not well developed. c) scalp of head has extensive vascularity. d) musculoskeletal support of head is insufficient.

d) musculoskeletal support of head is insufficient. The relatively large head size coupled with insufficient musculoskeletal support increases the risk to infants of acceleration-deceleration head injuries.The lack of closure of the anterior fontanel is not relevant to the development of acceleration-deceleration head injuries in infants.The lack of well-developed nervous tissue is not relevant to the development of acceleration-deceleration head injuries in infants.The vascularity of the scalp is not relevant to the development of acceleration-deceleration injuries in infants.

Cerebral palsy (CP) may result from a variety of causes. It is now known that the most common cause of CP is a) birth asphyxia b) neonatal diseases c) cerebral trauma d) prenatal brain abnormalities

d) prenatal brain abnormalities The most common currently identifiable cause of CP is existing brain abnormalities during the prenatal period.Birth asphyxia had previously been thought of as a factor in the development of CP.Neonatal diseases have previously been thought of as factors in the development of CP.Cerebral trauma has previously been thought of as a factor in the development of CP.

A young child with tetralogy of Fallot may assume a posturing position as a compensatory mechanism. The position automatically assumed by the child is a) the low Fowler position. b) the prone position. c) the supine position. d) the squatting position.

d) the squatting position. The squatting or knee-chest position increases the return of blood flow to the heart for oxygenation in a child with a defect that consists of decreased pulmonary blood flow.The low Fowler position does not offer any physiologic advantage to the child related to cardiac compensation.The prone position does not offer any physiologic advantage to the child related to cardiac compensation.The supine position does not offer any physiologic advantage to the child related to cardiac compensation.

The primary therapy for secondary hypertension in children is a) weight reduction. b) low-salt diet. c) increased exercise and fitness. d) treatment of underlying cause.

d) treatment of underlying cause. Secondary hypertension is a result of an underlying disease process or structural abnormality. It is usually necessary to treat the problem before the hypertension will be resolved.Weight reduction is usually effective in managing essential hypertension.A low-salt diet is usually effective in managing essential hypertension.Increased exercise and fitness are usually effective in managing essential hypertension.