Peds Exam #3
A nurse is assessing a toddler for possible hearing loss. Which of the following findings are indications of a hearing impairment? (Select all that apply) A. Uses monotone speech B. Speaks loudly C. Repeats sentences D. Appears shy E. Is overly attentive to the surroundings
A. Uses monotone speech B. Speaks loudly D. Appears shy
The nurse is suspecting increased intracranial pressure in a 4-month-old. Which assessment data would cause the nurse to suspect this problem? A. Irritability B. Photophobia C. A pulsating anterior fontanel D. Vomiting and diarrhea
A. Irritability
A nurse is caring for a child who is taking mannitol for cerebral edema. Which of the findings should the nurse monitor for as an adverse effect of mannitol? A. Bradycardia B. Weight loss C. Confusion D. Constipation
C. Confusion
A nurse is assessing a 4-month-old infant who has meningitis. Which of the following manifestations should the nurse expect? A. Depressed anterior fontanel B. Constipation C. Presence of the rooting reflex D. High-pitched cry
D. High-pitched cry
A nurse is teaching a group of parents about possible manifestations of Down syndrome. Which of the following findings should the nurse include in the teaching? (Select all that apply.) A. A large head with bulging fontanels B. Larger ears that are set back C. Protruding abdomen D. Broad, short feet and hands E. Hypotonia
C. Protruding abdomen D. Broad, short feet and hands E. Hypotonia
A nurse is providing teaching to the guardians of a child who is to have an electroencephalogram (EEG). Which of the following statements, by a guardian indicates teaching was effective? A. "My child should remain quiet and still during this procedure." B. "I cannot wash my child's hair prior to the procedure." C. "I should not give my child anything to eat prior to the procedure." D. "This procedure will be very painful for my child."
A. "My child should remain quiet and still during this procedure."
A child with recurrent infections, facial edema, hypertension, and delayed growth in height is seen in the pediatrician's office. Which question would be most important for the nurse to ask the mother? A. "What medications are being taken by your child?" B. "When did this current infection begin?" C. "Are your other children shorter than usual?" D. "Is your child having headaches?"
A. "What medications are being taken by your child?"
A nurse is teaching the guardian of an infant who has seborrheic dermatitis of the scalp. Which of the following instructions should the nurse include in the teaching? A. "You can use petrolatum to help soften and remove patches from your infant's scalp." B. "When patches are present, you should keep your infant away from others." C. "You should avoid washing your infant's hair while patches are present on the scalp." D. "When patches are present, it indicates that your infant has a systemic infection."
A. "You can use petrolatum to help soften and remove patches from your infant's scalp."
A nurse is caring for a client who has a major burn and is experiencing severe pain. Which of the following actions should the nurse implement to manage this client's pain? A. Administer morphine sulfate IV via continuous infusion. B. Administer meperidine IM as needed. C. Administer acetaminophen PO every 4 hr. D. Administer hydrocodone PO every 6 hr.
A. Administer morphine sulfate IV via continuous infusion.
A nurse is caring for a child who has cellulitis on the hand. Which of the following actions should the nurse take? A. Administer oral antibiotics. B. Cleanse area using Burrow solution. C. Prepare for cryotherapy. D. Apply a topical antifungal medication.
A. Administer oral antibiotics.
A nurse is caring for a child who has cellulitis on the hand. Which of the following actions should the nurse take? A. Administer oral antibiotics. B. Cleanse area using Burrow solution, C. Prepare for cryotherapy. D. Apply a topical antifungal medication.
A. Administer oral antibiotics.
Parents rush their 7-year-old child to a free-standing emergency clinic because of the child's having been stung by bees and is having rapid, labored breathing. What is the priority action by the nurse when the child gets into the examining room? A. Administer oxygen using a nasal cannula. B. Obtain a complete health history from the parents. C. Place a tourniquet distal to the area where the bee stings are. D. Get the code cart located down the hall in the locked treatment room.
A. Administer oxygen using a nasal cannula.
A nurse is assessing a child who has a concussion. Which of the following findings should the nurse expect? (Select all that apply.) A. Amnesia B. Systemic hypertension C. Bradycardia D. Respiratory depression E. Confusion
A. Amnesia E. Confusion
When assessing a child with atopic dermatitis, the nurse should ask the parents about a history of which of the following? A. Asthma B. Nephrosis C. Lower respiratory tract infections D. Neurotoxicity
A. Asthma
A nurse is caring for a child who has cerebral palsy. Which of the following medications should the nurse expect to administer to treat painful muscle spasms? (Select all that apply.) A. Baclofen B. Diazepam C. Oxybutynin D. Methotrexate E. Prednisone
A. Baclofen B. Diazepam
A group of teenage boys have just gotten on the basketball team and will be showering in the school's locker room after practice. What suggestions should the school nurse provide to these adolescents to decrease the chance of contracting athlete's foot (tinea pedis)? A. Bring your own soap and towel, and don't share them with others. B. Dry your feet completely. C. Wear your practice shoes home. D. Change your socks every other day when not practicing. E. Use talcum powder or antifungal powder to keep your feet dry. F. Make sure your shoes are thoroughly dry before wearing them.
A. Bring your own soap and towel, and don't share them with others. B. Dry your feet completely. E. Use talcum powder or antifungal powder to keep your feet dry. F. Make sure your shoes are thoroughly dry before wearing them.
A nurse is caring for an adolescent who has acne and a prescription for isotretinoin from the dermatologist. Which of the following laboratory findings should the nurse plan to monitor? A. Cholesterol and triglycerides B. BUN and creatinine C. Blood potassium D. Blood sodium
A. Cholesterol and triglycerides
A nurse is teaching a group of caregivers about the risk factors for seizures. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Febrile episodes B. Hypoglycemia C. Sodium imbalances D. Low blood lead levels E. Presence of diphtheria
A. Febrile episodes B. Hypoglycemia C. Sodium imbalances
A nurse is assessing an infant who has eczema. Which of the following findings should the nurse expect? (Select all that apply.) A. Generalized distribution of lesions B. Papules C. Ecchymosis in flexural areas D. Crusting lesions E. Keratosis pilaris
A. Generalized distribution of lesions B. Papules D. Crusting lesions
A nurse is assessing a child who has myopia. Which of the following findings should the nurse expect? (Select all that apply.) A. Headaches B. Photophobia C. Difficulty reading D. Difficulty focusing on close objects E. Poor school performance
A. Headaches C. Difficulty reading E. Poor school performance
A nurse is caring for a client who has major burns and suspected septic shock. Which of the following findings are consistent with septic shock? (Select all that apply) A. Increased body temperature B. Altered sensorium C. Decreased capillary refill time D. Decreased urine output E. Increased bowel sounds
A. Increased body temperature B. Altered sensorium D. Decreased urine output
The nurse is planning care for a school-age child with bacterial meningitis. Which nursing action should be included? A. Keep environmental stimuli at a minimum. B. Avoid giving pain medications that could dull sensorium. C. Measure head circumference to assess developing complications. D. Have the child move his head side to side at least every 2 hours.
A. Keep environmental stimuli at a minimum.
What procedure is contraindicated in the care of a child with a minor partial thickness burn injury wound? A. Leaving all loose tissue or skin intact B. Cleaning the affected area with mild soap and water C. Applying antimicrobial ointment to the burn wound D. Change dressings daily
A. Leaving all loose tissue or skin intact
A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse expect? (Select all that apply) A. Loss of consciousness B. Appearance of daydreaming C. Dropping held objects D. Falling to the floor E. Having a piercing cry
A. Loss of consciousness B. Appearance of daydreaming C. Dropping held objects
A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following findings should the nurse identify as indicating viral meningitis? (Select all that apply.) A. Negative Gram stain B. Normal glucose content C. Cloudy color D. Decreased WBC count E. Normal protein content
A. Negative Gram stain B. Normal glucose content E. Normal protein content
A nurse is caring for a toddler after surgery for a brain tumor. During an assessment the nurse notes that the toddler is becoming irritable and that the pupils are unequal and sluggish. What is the most appropriate nursing action? A. Notify the physician immediately. B. Assess for level of consciousness. C. Administer a low dose of pain medication. D. Continue monitoring for signs of increased intracranial pressure (ICP).
A. Notify the physician immediately.
A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions should the nurse take? A. Place the client on NPO status. B. Prepare the client for a liver biopsy. C. Position the client dorsal recumbent. D. Put the client in a protective environment.
A. Place the client on NPO status.
A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take? A. Position the child in a side-lying position. B. Try to determine the seizure trigger. C. Reorient the child to the environment. D. Note the time of the postictal period.
A. Position the child in a side-lying position.
A nurse is caring for a school-age child who has juvenile idiopathic arthritis. Which of the following home care instructions should the nurse include in the teaching? (Select all that apply.) A. Provide extra time for completion of ADLs. B. Use cold compresses for joint pain. C. Take ibuprofen on an empty stomach. D. Remain home during periods of exacerbation E. Perform range-of-motion exercises.
A. Provide extra time for completion of ADLs. E. Perform range-of-motion exercises.
A nurse is caring for a child who has contact dermatitis due to poison ivy. Which of the following actions should the nurse take? (Select all that apply.) A. Remove the clothing over the rash. B. Initiate contact isolation precautions while the rash is present. C. Expose the rash to a heat lamp for 15 min. D. Cleanse the affected skin with hydrogen peroxide solution. E. Apply calamine lotion to the skin.
A. Remove the clothing over the rash. E. Apply calamine lotion to the skin.
A nurse is caring for an adolescent who has a closed head injury. Which of the following findings are indications of increased intracranial pressure (ICP)? (Select all that apply.) A. Report of headache B. Alteration in pupillary response C. Increased motor response D. Increased sleeping E. Increased sensory response
A. Report of headache B. Alteration in pupillary response D. Increased sleeping
A nurse is in the emergency department is assessing a child following a motor-vehicle crash. The child is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following actions should the nurse take first? A. Stabilize the child's neck. B. Clean the child's laceration with soap and water. C. Implement seizure precautions for the child. D. Initiate IV access for the child.
A. Stabilize the child's neck.
The nurse is caring for a 12-year-old boy who sustained major burns when putting charcoal lighter on a campfire. The nurse observes that boy is "very brave" and appears to accept pain with little or no response. Based on the nurse's knowledge of burns, pain, and age-specific development, what is the most appropriate nursing action? A. Talk with the health care provider about the possibility of requesting a psychological consultation. B. Spend time with the child to better understand why he doesn't seem to respond to pain. C. Praise the child frequently for his ability to deal with the pain. D. Encourage continued bravery as a coping strategy.
A. Talk with the health care provider about the possibility of requesting a psychological consultation.
A nurse is planning care for a child who has tinea capitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Treat infected house pets. B. Use selenium sulfide shampoo. C. Cleanse area with Burrow solution. D. Administer antiviral medication. E. Use moist, warm compresses.
A. Treat infected house pets. B. Use selenium sulfide shampoo.
A nurse is planning care for a child who has tinea capitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Treat infected house pets. B. Use selenium sulfide shampoo. C. Cleanse area with Burrow solution. D. Administer antiviral medication. E. Use moist, warm compresses.
A. Treat infected house pets. B. Use selenium sulfide shampoo.
The nurse is caring for a child with the beginning ascending paralysis of Guillain-Barré syndrome. What nursing actions should be implemented in the care of this child? Select all that apply. A. Use play as a means of assessing the child's neurologic abilities. B. Assess pulse oximetry measurements daily. C. Listen to lung sounds several times daily. D. Reposition the child every 4 hours. E. Allow the child to eat as long as the cranial nerves are intact. F. Measure each urine, watching for decreasing amounts.
A. Use play as a means of assessing the child's neurologic abilities. C. Listen to lung sounds several times daily. E. Allow the child to eat as long as the cranial nerves are intact. F. Measure each urine, watching for decreasing amounts.
An adolescent female with systemic lupus erythematosus (SLE) is trying to learn how to live with her illness. What teaching by the nurse is priority? A. Use protection against the sun whenever she is outside, regardless of the season. B. Maintain a high-protein diet to maintain healthy skin integrity and muscle fibers. C. Plan her schedule so she gets at least 10 hours of solid, deep sleep each night. D. Keep a diary so she can document her thoughts and feelings as she adjusts.
A. Use protection against the sun whenever she is outside, regardless of the season.
A nurse is reviewing treatment options with the guardian of a child who has worsening seizures. Which of the following treatment options should the nurse include in the discussion? (Select all that apply.) A. Vagal nerve stimulator B. Additional antiepileptic medications C. Corpus callosotomy D. Focal resection E. Radiation therapy
A. Vagal nerve stimulator B. Additional antiepileptic medications C. Corpus callosotomy D. Focal resection
A nurse is reviewing the medical record of a client who has Reye syndrome. Which of the following findings should the nurse identify as a risk factor for Reye syndrome? A. Recent history of infectious cystitis caused by Candida B. Recent history of bacterial otitis media C. Recent episode of gastroenteritis D. Recent episode of Haemophilus influenzae meningitis
C. Recent episode of gastroenteritis
A nurse is teaching the parent of an infant who has Down syndrome. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should expect him to have frequent diarrhea." B. "I should place a cool mist humidifier in his room." C. "I should avoid the use of lotion on his skin." D. "I should expect him to grow faster in length than other infants."
B. "I should place a cool mist humidifier in his room."
The parents of a 5-month-old with infant botulism ask how their infant got sick. What is the best response by the nurse? A. "Infants who have crawled around a dirty kitchen floor can pick up the toxin from food scraps." B. "The use of honey to sweetened the infant's formula can cause botulism." C. "Feeding commercial infant cereals too early can cause the problem." D. "Improperly sterilized bottles can contain the toxin causing infant botulism."
B. "The use of honey to sweetened the infant's formula can cause botulism."
The parents of a young boy with burns covering 40% of the total body surface area (TBSA) ask why he is receiving enteral feedings at night while he is sleeping and is eating during the day. Which response by the nurse is best? A. "His appetite is really poor right now and he needs more fluid." B. "Your son needs more protein and calories than he can eat while awake." C. "Your child needs a large quantity of high carbohydrate and low protein." D. "His intestinal activity is slow right now, and this is easier on his system."
B. "Your son needs more protein and calories than he can eat while awake."
The nurse is admitting a young child to the hospital with possible bacterial meningitis. What is the priority nursing care? A. Initiate isolation precautions as soon as the diagnosis is confirmed. B. Administer antibiotic therapy as soon as it is ordered. C. Initiate isolation precautions as soon as the causative agent is identified. D. Administer sedatives or analgesics on a preventive schedule to manage pain.
B. Administer antibiotic therapy as soon as it is ordered.
The nurse is reviewing the orders for a child with cellulitis. What would the nurse expect to see ordered for this patient? A. Damp to dry compresses using Burow's solution B. Administration of oral or parenteral antibiotics for several days C. Topical application of an antibiotic cream to the involved area D. Incision and drainage of cellulitis lesions covering a wide area
B. Administration of oral or parenteral antibiotics for several days
A nurse is planning care for an infant who has diaper dermatitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Apply talcum powder with every diaper change. B. Allow the buttocks to air dry. C. Use commercial baby wipes to cleanse the area. D. Use cloth diapers until the rash is gone, E. Apply zinc oxide ointment to the affected area.
B. Allow the buttocks to air dry. E. Apply zinc oxide ointment to the affected area.
The mother of a 2-year-old with recurrent and resistant respiratory tract infections and chronic diarrhea and who is below the 50th percentile on the growth chart calls the pediatrician's office because her child is now pulling at her ears. In addition to the possibility of an ear infection, what might the nurse suspect the child is also experiencing? A. An oncology problem B. An immunology problem C. Some type of nut-related allergy D. An inner emotional conflict
B. An immunology problem
The temperature of an adolescent who is unconscious is 105º F (ax). What is the priority nursing action? A. Initiate a pain assessment. B. Apply a hypothermia blanket. C. Continue to monitor temperature. D. Administer acetaminophen or ibuprofen.
B. Apply a hypothermia blanket.
A nurse is caring for a client who has a superficial partial-thickness burn. Which of the following actions should the nurse take? A. Administer IV infusion of 0.9% sodium chloride. B. Apply cool, wet compresses to the affected area. C. Clean the affected area using a soft-bristle brush. D. Administer morphine sulfate.
B. Apply cool, wet compresses to the affected area.
What should the nurse teach an adolescent who is taking isotretinoin (Retin-A) to treat acne? A. The medication should be taken with meals B. Apply sunscreen before going outdoors C. Wash with Benzoyl peroxide before application D. The effect of the medication should be evident within one week
B. Apply sunscreen before going outdoors
A nurse is teaching a group of parents about preventing insect bites. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Wear perfumes when outside. B. Avoid areas of tall grass. C. Wear bright-colored clothing. D. Wear insect repellent. E. Check house pets frequently.
B. Avoid areas of tall grass. D. Wear insect repellent. E. Check house pets frequently.
A nurse is teaching a group of parents about preventing insect bites. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Wear perfumes when outside. B. Avoid areas of tall grass. C. Wear bright-colored clothing. D. Wear insect repellent. E. Check house pets frequently.
B. Avoid areas of tall grass. D. Wear insect repellent. E. Check house pets frequently.
The pediatric office nurse is giving instructions to a parent whose child has scabies. What information should the school nurse include? A. Treat all of the family members if symptoms develop. B. Be prepared for symptoms to last 2 to 3 weeks. C. Notify your health care practitioner so an antibiotic can be prescribed. D. Carefully treat only those areas where there is a rash.
B. Be prepared for symptoms to last 2 to 3 weeks.
Which is an important nursing consideration when caring for a child with impetigo? A. Apply topical corticosteroids to decrease inflammation B. Carefully wash hands and maintain cleanliness when caring for an infected child C. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris D. Examine a child under a Wood lamp for possible spread of lesions
B. Carefully wash hands and maintain cleanliness when caring for an infected child
The nurse is caring for a child with tetanus. Nursing care is correct if which actions are taken? A. Maintain a well-lit room so localized muscle spasms can be detected. B. Decrease the environmental stimulation, including no bumping of the child's bed. C. Provide oral rinsing to stimulate the salivary glands and relax any jaw stiffness. D. Put cool packs on the back to reduce meningeal inflammation and muscle spasms.
B. Decrease the environmental stimulation, including no bumping of the child's bed.
A nurse is developing a plan of care for a toddler who has cerebral palsy. Which of the following actions should the nurse include? A. Structure interventions according to the toddler's chronological age. B. Evaluate the toddler's need for an evaluation of hearing ability. C. Monitor the toddler's pain level routinely using a numeric rating scale. D. Provide total care for daily hygiene activities.
B. Evaluate the toddler's need for an evaluation of hearing ability.
The nurse is teaching a mother about the use of oral corticosteroids to her 8-year-old child. Instruction by the nurse is correct if which information is given? Select all that apply. A. Administer the medication on an empty stomach to promote absorption. B. Give the medication with milk or food to prevent stomach upset. C. Postpone the administration of live virus vaccines until the oral corticosteroids are no longer being taken. D. Give live virus vaccines when the dose of oral corticosteroids is being reduced. E. Keep the child away from anyone with colds and coughs.
B. Give the medication with milk or food to prevent stomach upset. C. Postpone the administration of live virus vaccines until the oral corticosteroids are no longer being taken. E. Keep the child away from anyone with colds and coughs.
A nurse is caring for a child who has ICP. Which of the following actions should the nurse take? (Select all that apply.) A. Suction the endotracheal tube every 2 hr. B. Maintain a quiet environment. C. Use two pillows to elevate the head. D. Administer a stool softener. E. Maintain body alignment.
B. Maintain a quiet environment. D. Administer a stool softener. E. Maintain body alignment.
The nurse is working with a teenager with systemic lupus erythematosus (SLE). What therapeutic management would the nurse expect to include during patient and family education? A. Foods that are high protein and low sodium B. Oral corticosteroids to control inflammation C. Gold salts to suppress the inflammatory process D. An exercise regimen to build up muscle strength and endurance
B. Oral corticosteroids to control inflammation
A nurse is assessing an infant who has scabies. Which of the following findings should the nurse expect? (Select all that apply.) A. Presence of nits on the hair shaft B. Pencil-like marks on hands C. Blisters on the soles of the feet D. Small, red bumps on the scalp E. Pimples on the trunk
B. Pencil-like marks on hands C. Blisters on the soles of the feet E. Pimples on the trunk
A nurse is assessing an infant who has scabies. Which of the following findings should the nurse expect? (Select all that apply.) A. Presence of nits on the hair shaft B. Pencil-like marks on hands C. Blisters on the soles of the feet D. Small, red bumps on the scalp E. Pimples on the trunk
B. Pencil-like marks on hands C. Blisters on the soles of the feet E. Pimples on the trunk
A nurse is developing an educational program about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (Select all that apply) A. Inactivated polio vaccine (IPV) B. Pneumococcal conjugate vaccine (PCV) C. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTP) D. Haemophilus influenzae type B (Hib) vaccine E. Trivalent inactivated influenza vaccine (TIV)
B. Pneumococcal conjugate vaccine (PCV) D. Haemophilus influenzae type B (Hib) vaccine
A child with spina bifida has a latex allergy from exposure to numerous bladder catheterizations and surgeries. What is a priority nursing intervention in this child's care? A. Recommend allergy testing. B. Provide a latex-free environment. C. Use only powder-free latex gloves. D. Limit use of latex products as much as possible.
B. Provide a latex-free environment.
The nurse is discussing long-term care with the parents of a child with a ventriculoperitoneal shunt to correct hydrocephalus. What should the teaching plan include? A. Parental protection is essential until the child reaches adulthood. B. Shunt malfunction or infection requires immediate treatment. C. Intellectual impairment is to be expected with hydrocephalus. D. Most usual childhood activities must be restricted.
B. Shunt malfunction or infection requires immediate treatment.
A young child is having a seizure that has lasted 35 minutes with loss of consciousness. What type of seizure would the nurse document? A. An absence seizure B. Status epilepticus C. A generalized seizure D. A simple partial seizure
B. Status epilepticus
A child is experiencing intestinal cramping, diarrhea, and mucosal lesions. Which allergens would the nurse suspect are triggering these responses? Select all that apply. A. Pears B. Strawberries C. Apples D. Pollen E. Wheat F. Grass
B. Strawberries E. Wheat
During the rehabilitative phase of care, the nurse applies pressure dressings to the patient's severely burned areas. This activity is used to accomplish which goal? A. To relieve as much pain as possible B. To decrease the development of scar tissue C. To promote motion during the healing process D. To protect underlying tissue by encouraging scar formation
B. To decrease the development of scar tissue
A school-age child begins to have a tonic-clonic seizure in bed as the nurse walks into her room. What actions should the nurse take? Select all that apply. A. Gently place an oral airway in the child's mouth. B. Turn the child on her side once the seizure subsides. C. Hold the child's head so it doesn't hit the headboard. D. Get additional pillows to pad the siderails. E. Note how long the seizure lasts. F. Note whether any incontinence occurs during or after the seizure.
B. Turn the child on her side once the seizure subsides. E. Note how long the seizure lasts. F. Note whether any incontinence occurs during or after the seizure.
A nurse is caring for a client who has a skin graft. Which of the following manifestations indicate infection? (Select all that apply.) A. Pink color to subcutaneous fat B. Unstable body temperature C. Generation of granulation tissue D. Subeschar hemorrhage E. Change in skin color around the affected area
B. Unstable body temperature D. Subeschar hemorrhage E. Change in skin color around the affected area
The nurse is further explaining the disease process to the parents of an 8-year-old child who is hospitalized with infectious polyneuritis (Guillain-Barré syndrome). Information is correct if which statement is made by the nurse? A. "The paralysis is progressive, with little hope for recovery." B. "The disease is inherited as an autosomal, sex-linked, recessive gene." C. "Muscle function will gradually return, and recovery is possible in most children." D. "The disease results from an apparently toxic reaction to certain medications."
C. "Muscle function will gradually return, and recovery is possible in most children."
The mother of a 3-year-old with a myelomeningocele at the L2 level asks the nurse about the amount of bowel control her child might have. What is the best response by the nurse regarding bowel control once toilet training is complete? A. "Your child will have periodic incontinence." B. "Moderate control should be present using enemas and laxatives." C. "Your child should experience total fecal continence." D. "Your child will most likely have no bowel control."
C. "Your child should experience total fecal continence."
What best describes a full thickness (third degree) burn? A. Erythema and pain B. Skin showing erythema followed by blister formation C. Destruction of all layers of skin evident with extension into subcutaneous tissue D. Destruction injury involving underlying structures such as muscle, fascia, and bone
C. Destruction of all layers of skin evident with extension into subcutaneous tissue
A nurse is caring for a client who has a moderate burn. Which of the following actions should the nurse take? A. Maintain immobilization of the affected area. B. Expose affected area to the air. C. Initiate a high-protein, high-calorie diet. D. Implement contact isolation.
C. Initiate a high-protein, high-calorie diet.
The school nurse is discussing prevention of human immunodeficiency virus (HIV) transmission with adolescents in a health class. What information is appropriate to include? A. The virus is easily transmitted. B. The virus is only transmitted through blood. C. Intravenous drug users should not share needles. D. Condoms should be used for homosexual sex.
C. Intravenous drug users should not share needles.
A nurse is caring for a comatose child with multiple recent orthopedic injuries. What assumption can the nurse make about the pain being experienced by the child? A. Pain cannot occur if the child is comatose. B. Pain may occur if child regains consciousness. C. It requires frequent and comprehensive assessment by the nurse. D. It is best assessed by family members who are familiar with the child.
C. It requires frequent and comprehensive assessment by the nurse.
A nurse is caring for a child who has muscular dystrophy. For which of the following findings should the nurse assess? (Select all that apply) A. Purposeless, involuntary, abnormal movements B. Spinal defect and saclike protrusion C. Muscular weakness in lower extremities D. Unsteady, wide-based or waddling gait E. Upward slant to the eyes
C. Muscular weakness in lower extremities D. Unsteady, wide-based or waddling gait
A child has painful, fluid filled vesicles on the upper lip. What medication does the nurse anticipate teaching parents about? A. Corticosteroids B. Oral griseofulvin C. Oral antiviral agent D. Topical antibiotic
C. Oral antiviral agent
After being told that her premature, 8-month-old most likely has cerebral palsy, the distraught mother asks the nurse after the physician left the room about what could have caused this. Which explanation regarding common causes of cerebral palsy should be shared by the nurse? A. A sex-linked recessive inheritance pattern and neonatal disease B. Birth-related brain anoxia and post-maturity status C. Prematurity and faulty brain development D. Faulty mother-infant bonding and neonatal meningitis
C. Prematurity and faulty brain development
The school nurse is seeing a child who brought poison ivy to school in his leaf collection. The child says, "It only touched my hands." What is the initial nursing action? A. Apply compresses using Burow's solution. B. Soak the child's hands in warm water. C. Rinse the child's hands in cold, running water. D. Scrub the child's hands thoroughly with antibacterial soap.
C. Rinse the child's hands in cold, running water.
The nurse is caring for an infant with recurrent atopic dermatitis (eczema). What information would the nurse expect to see in the infant's history? A. It last happened in the summer. B. The infant recently traveled to a humid climate. C. The infant has several allergies similar to her mother. D. The infant had an upper respiratory infection a week ago.
C. The infant has several allergies similar to her mother.
A nurse is teaching a parent of a child who has pediculosis capitis. Which of the following instructions should the nurse include in the teaching? A. Apply mayonnaise to the affected area at night. B. Treat all household pets. C. Use an over-the-counter medication containing 1% permethrin. D. Discard the child's stuffed animals.
C. Use an over-the-counter medication containing 1% permethrin.
A nurse is teaching a parent of a child who has pediculosis capitis. Which of the following instructions should the nurse include in the teaching? A. Apply mayonnaise to the affected area at night. B. Treat all household pets. C. Use an over-the-counter medication containing 1% permethrin. D. Discard the child's stuffed animals.
C. Use an over-the-counter medication containing 1% permethrin.
A 9-year-old child with a known peanut allergy has an allergic reaction right after eating potato chips with his classmates served from a large bowl during a party. After the child has been cared for, what action is most important for the nurse to initiate? A. A further investigation of the potato chips B. Asking if the child is allergic to potatoes C. Washing the serving bowl with soap and hot water D. Asking the child if this reaction happens often
C. Washing the serving bowl with soap and hot water
A woman 6 weeks pregnant tells the nurse that she is worried the baby might have spina bifida because of a family history. What response would be most helpful to the patient? A. "There is no definite genetic basis for the defect." B. "Low levels of folic acid at the time of conception have been strongly linked to neural tube defects." C. "Chromosomal studies done on amniotic fluid can diagnose the defect prenatally." D. "The concentration of alpha-fetoprotein in amniotic fluid can indicate the presence of the defect prenatally."
D. "The concentration of alpha-fetoprotein in amniotic fluid can indicate the presence of the defect prenatally."
The parents of an infant with suspected cerebral palsy ask what can be done for their child. Which response by the nurse is best? A. "The physician will talk with you about reversing the degenerative processes that have occurred." B. "The focus for the child will be to cure the underlying defect causing the disorder." C. "Your child will most likely need speech therapy and lower extremity bracing." D. "The therapies will be focused on promoting optimal development by identifying the condition early."
D. "The therapies will be focused on promoting optimal development by identifying the condition early."
A nurse is caring for an infant who has a myelomeningocele. Which of the following actions should the nurse include in the preoperative plan of care? A. Assist the caregiver with cuddling the infant. B. Assess the infant's temperature rectally, C. Place the infant in a supine position. D. Apply a sterile, moist dressing on the sac.
D. Apply a sterile, moist dressing on the sac.
The nurse is caring for a child after multiple trauma resulting from an automobile accident. Which nursing intervention should prevent increased intracranial pressure (ICP) in this unconscious child? A. Suctioning any secretions frequently B. Providing environmental stimulation C. Turning the head side to side every hour D. Avoiding activities that cause pain
D. Avoiding activities that cause pain
A nurse is planning to perform a peripheral vision test on a child. Which of the following actions should the nurse take? A. Place the child 10 feet away from a Snellen chart. B. Show a set of cards to the child one at a time. C. Cover the child's eye while performing the test on the other eye. D. Have the child focus on an object while performing the test.
D. Have the child focus on an object while performing the test.
A child is being discharged home on a regimen of oral corticosteroids. What information is most important for the nurse to explain to the parents? A. Reduce the dosage as quickly as possible so dependence on the medication is avoided. B. Any new cuts should be washed with soap and water and then covered with a bandage. C. Increased appetite and energy are interpreted as a positive response to the medication. D. If the child becomes ill, notify the physician who ordered the medication immediately.
D. If the child becomes ill, notify the physician who ordered the medication immediately.
The school nurse is educating a group of elementary school teachers about ringworm (tinea capitis). Which explanation of the condition by the nurse is best? A. It is self-limiting and not contagious. B. It is a sign of uncleanliness. C. The patient should recover spontaneously without interventions. D. It is spread by direct and indirect contact.
D. It is spread by direct and indirect contact.
A newborn with a myelomeningocele is scheduled for surgery within the next 48 hours. What is the correct nursing care during the preoperative stage? A. Place the child in the side-lying position to decrease pressure on the spinal cord. B. Apply a heat lamp to facilitate drying and toughening of the sac. C. Keep skin clean and dry to prevent irritation from diarrheal stools. D. Measure head circumference and examine fontanels for signs that might indicate developing hydrocephalus.
D. Measure head circumference and examine fontanels for signs that might indicate developing hydrocephalus.
Parents of a child with lice infestation should be instructed carefully in the use of anti lice products because of which potential side effect? A. Nephrotoxicity B. Ototoxicity C. Bone marrow depression D. Neurotoxicity
D. Neurotoxicity
When taking a history on a child with possible diagnosis of cellulitis, what should be the priority nursing assessment to help establish a diagnosis? A. Any pain the child is experiencing B. Enlarged, mobile and tender lymph nodes C. Child's urinalysis results D. Recent infections or signs of infection
D. Recent infections or signs of infection
When assessing a newborn, the nurse notes a small dimpling with some hair at the base of the spine. What documentation would be expected by the nurse to explain this finding? A. A meningocele B. A myelomeningocele C. Spina bifida cystica D. Spina bifida occulta
D. Spina bifida occulta
