Practice Questions Exam 5

The nurse is performing an assessment on a child with a head injury. The nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. What would the nurse document that the child is experiencing?

Decorticate posturing

The nurse is caring for an infant with spina bifida (myelomeningocele type) who had the sac on the back containing cerebrospinal fluid, the meninges, and the nerves (gibbus) surgically removed. The nursing plan of care for the postoperative period would include which action to maintain the infant's safety?

Elevating the head with the infant in the prone position

A 9-year-old child fractures the left tibia along an epiphyseal line while using a skateboard. What is the nurse's priority concern during future growth?

uneven leg growth

A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm, and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction?

"I can use lotion or powder around the cast edges to relieve itching."

Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder?

"I need to bring my infant back to the clinic in 1 month for a new cast."

The nurse is providing education to the parents of a child diagnosed with Osgood-Schlatter disease. Which statement from the parents would indicate understanding of the instructions?

"I need to call the office for an appointment if my child's joint becomes red, warm or swollen."

The nurse is implementing a teaching plan for a 4-month-old child who has been diagnosed with developmental dysplasia of the hip. The child will be placed in the Pavlik harness. Which statement by the family indicates that they understand the care of their child while placed in the Pavlik harness?

"I will watch for any redness or skin irritation where the straps are applied and call the primary health care provider for red areas."

The nurse is assisting a primary health care provider (PHCP) during the examination of an infant with developmental hip dysplasia. The PHCP performs the Ortolani maneuver. The nurse determines that the infant exhibits a positive response to this maneuver if which finding is noted?

A palpable click during abduction of the affected hip

The nurse notes that an infant with the diagnosis of hydrocephalus has a head that is heavier than that of the average infant. The nurse would determine that special safety precautions are needed when moving the infant with hydrocephalus. Which statement would the nurse plan to include in the discharge teaching with the parents to reflect this safety need?

"When picking up your infant, support the infant's neck and head with the open palm of your hand."

What assessment findings would the nurse expect to note in a child who has been diagnosed with JRA?

- Morning stiffness - Painful, stiff, and swollen joints - Limited range of motion of the joints - History of late-afternoon temperature

The nurse in the pediatric unit is preparing for the admission of a child with a dislocated hip. The child will be placed in Buck's extension traction preoperatively for short-term immobilization. The nurse prepares to place the child in which type of traction setup?

1

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?

Cloudy CSF, elevated protein, and decreased glucose levels

_____________ is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral.

Clubfoot

The nurse is reviewing the pathophysiology of Osgood-Schlatter disease. Which client would the nurse identify as being at highest risk of developing this disorder?

14-year-old who plays on the high school basketball and football teams

Carbamazepine's therapeutic serum range is _______________.

6 to 12 mcg/mL (34 to 51 mmol/L)

An infant is brought to the child care clinic for a follow-up visit. The nurse notes that the infant is wearing this apparatus. The nurse documents that the infant is wearing which device? Refer to figure.

A Pavlik harness for the treatment of congenital hip dislocation

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse plans to respond by explaining that the limitations occur as a result of which pathophysiological process?

A chronic disability characterized by impaired muscle movement and posture

What is osteomyelitis most commonly caused by?

staph aureus

A child is admitted to the hospital with a diagnosis of acute bacterial meningitis. In reviewing the primary health care provider's prescriptions, which would the nurse question as appropriate for a child with this diagnosis?

Administer an oral antibiotic.

The nurse is caring for a client diagnosed with a hydrocephalus. Which would the nurse anticipate as being the cause of this disorder?

Closure of cranial sutures

An adolescent is seen in the emergency department for a suspected sprain of the ankle. X-rays have been obtained, and a fracture has been ruled out. Which instruction would the nurse provide to the adolescent regarding home care for treatment of the sprain?

Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 to 48 hours.

The nurse is creating a plan of care for a newborn infant with spina bifida (myelomeningocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure. Which assessment technique would be performed that will best detect the presence of an increase in intracranial pressure?

Assess anterior fontanel for bulging.

The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which assessment finding would the nurse expect to note documented in the infant's record regarding this condition?

Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table

Which is a late sign of increased ICP?

Bradycardia

A child who sustained a fractured ankle has a short leg cast applied, and the nurse provides home care instructions to the parent. The parent returns to the emergency department 16 hours later because the child is complaining of severe pain. The nurse notes that the child's toes are cool, pale, and puffy, and that the child is agitated and crying loudly. The parent states, "I gave her the pain medication you sent with us just like you told us, and I have kept her foot up on two pillows since we left, except when she gets up to go to the bathroom. I don't understand why she hurts so much. Do something!" What is the most likely clinical situation that occurred?

Compartment syndrome

The nurse is reviewing the results of a test on a blood sample drawn from a child who is receiving carbamazepine for the control of seizures. The results indicate a serum carbamazepine level of 10 mcg/mL (42.33 mmol/L). The nurse analyzes the results and anticipates that the primary health care provider (PHCP) will note which prescription?

Continuation of the presently prescribed dosage

The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child?

Crayons and a coloring book

The pediatric nurse educator provides a teaching session to the nursing staff regarding juvenile idiopathic arthritis (JIA). Which action by a nursing staff member in the care of a child with JIA indicates a need for further education?

Emphasizes the importance of rising quickly in the mornings

A neighborhood nurse is attending a soccer game at a local middle school. One of the students falls off the bleachers and sustains an injury to the left arm. The nurse quickly attends to the child and suspects that the child's arm may be broken. Which nursing action would be the priority before transferring the child to the hospital emergency department?

Immobilize the arm

A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding would be noted in this condition?

Limited range of motion in the affected hip2

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention would be included in the plan of care?

Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the pediatrician's prescriptions and would contact the pediatrician to question which prescription?

Nasotracheal suction as needed.

An alert child who is crying loudly is brought to the hospital emergency department for a simple fracture to the lower right arm that occurred after a fall off a bicycle. What is the nurse's priority assessment?

Neurovascular

The nurse is reviewing a chart for a child with a head injury. The nurse notes that the level of consciousness has been documented as obtunded. Which finding would the nurse expect to note on assessment of the child?

Not easily arousable and limited interaction

A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action would the nurse take?

Notify the primary health care provider (PHCP).

The community health nurse is providing information to parents of children in a local school regarding the signs of meningitis. The nurse informs the parents that the classic signs/symptoms of meningitis include which findings?

Severe headache, fever, stiff neck, and a change in the level of consciousness

The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) needs to be placed at the child's bedside?

Suctioning equipment and oxygen

The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) needs to be placed at the child's bedside?

Suctioning equipment and oxygen

The nurse is collecting data on a child diagnosed with Osgood-Schlatter disease. Which clinical manifestations would the nurse expect on inspection of the child?

Tender bony bump on the tibia below the knee joint

True or False: Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

True

True or False: Bracing can halt the progression of most curvatures, but it is not curative for scoliosis.

True

The nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside?

a bottle of sterile normal saline

A child with developmental dysplasia of the hip is placed in a Pavlik harness. The nurse would demonstrate to the parents how to place the child in this harness by placing the child's legs in which position?

abduction

The newborn with spina bifida is at risk for infection before the closure of the sac, which is done soon after birth. A _____________________ is placed over the sac to maintain moisture of the sac and its contents. This prevents tearing or breakdown of the skin integrity at the site.

sterile normal saline dressing

The nurse is monitoring a 3-month-old infant with hydrocephalus for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate?

document the finding

The nurse is caring for a child who sustained a head injury after falling from a tree. On assessment of the child, the nurse notes the presence of a watery discharge from the child's nose. The nurse would immediately test the discharge for the presence of which substance?

glucose

The nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, which is the priority problem?

infection

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?

meningitis

The nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse would assess the child frequently for which early sign of increased ICP?

nausea

The nurse is assisting a primary health care provider (PHCP) in the examination of a 3-week-old infant with developmental dysplasia of the hip. What test or sign would the nurse expect the PHCP to assess?

ortolani's maneuver

The nurse is providing education on Osgood-Schlatter disease to a child diagnosed with the disorder and the child's parents. The nurse states that Osgood-Schlatter disease is due to the inflammation of which anatomical structure?

patellar tendon

A child with an autism spectrum disorder (ASD) is being admitted to the hospital for diagnostic tests. Which room assignment is the most appropriate for the child?

private room

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

reposition the infant frequently

The nurse is caring for a pediatric client who just arrived at the emergency department with an extremity fracture. The nurse uses the five "Ps" to assess the extent of the client's injury. What are some of the five "Ps"? Select all that apply. - Pallor - Pain and point of tenderness - Paralysis distal to the fracture site - Pulses proximal to the fracture site - Sensation distal to the fracture site

- Pallor - Pain and point of tenderness - Paralysis distal to the fracture site - Sensation distal to the fracture site

Cerebral palsy (CP) is suspected in an infant, and the parents ask the nurse about the potential warning signs of CP. The nurse would provide which information? Select all that apply. - The infant's arms or legs are stiff or rigid. - A high risk factor for CP is very low birth weight. - By 8 months of age, the infant can sit without support. - The infant has strong head control but a limp body posture. - The infant has feeding difficulties, such as poor sucking and swallowing. - If the infant is able to crawl, only one side is used to propel themsleves.

- The infant's arms or legs are stiff or rigid. - A high risk factor for CP is very low birth weight. - The infant has feeding difficulties, such as poor sucking and swallowing.

The nurse is caring for a child who fractured the ulna bone and had a cast applied 24 hours ago. The child tells the nurse that the arm feels like it is falling asleep. Which nursing action is appropriate?

Call HCP

A child with cerebral palsy is in a management program to achieve maximum potential for locomotion, self-care, and socialization in school. The nurse works with the child to meet these goals by performing which action?

Placing the child on a wheeled scooter board

The nurse is assessing for Kernig's sign in a child with a suspected diagnosis of meningitis. Which action would the nurse perform for this test?

Raise the child's leg with the knee flexed and then extend the leg at the knee and assess for pain.

True or False: The Pavlik harness would be worn 23 hours a day and can be removed only to check the skin and for bathing, if allowed by the surgeon or primary health care provider.

True

The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions would be included on the list? Select all that apply. - Use a padded ruler or another padded object to scratch the skin under the cast if it itches. - Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. - Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. - Contact the primary health care provider (PHCP) if the child complains of numbness or tingling in the extremity. - Keep small toys and sharp objects away from the cast.

- Keep small toys and sharp objects away from the cast. - Contact the primary health care provider (PHCP) if the child complains of numbness or tingling in the extremity. - Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.