Chapter 30 NCLEX Style Review Questions

A 15-year-old is admitted to the intensive care unit (ICU) with a spinal cord injury. The most appropriate nursing interventions for this adolescent are (Select all that apply.) A. monitoring neurologic status. B. administering corticosteroids. C. monitoring for respiratory complications. D. discussing long-term care issues with the family. E. monitoring and maintaining hemodynamic status.

A, B, C, E

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.

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.

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.

In working with parents who have a child diagnosed with cerebral palsy, which therapeutic management goals should be included in the plan of care? (Select all that apply.) A. Limit socialization to similar type affected children. B. Provide educational opportunities that are individualized to children's needs and abilities. C. To help support and maintain location, communication and self-help skills. D. To correct body image perception. E. To integrate motor function.

B, C, E

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.

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.

An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome). When explaining this disease process to the parents, what should the nurse consider? A. Paralysis is progressive, with little hope for recovery. B. Muscle function will gradually return, and recovery is possible in most children. C. Guillain-Barré syndrome results from an apparently toxic reaction to certain medications. D. Guillain-Barré syndrome is inherited as an autosomal recessive, sex-linked gene.

B.

What is associated with infant botulism? A. Contaminated soil B. Honey and corn syrup C. Commercial infant cereals D. Improperly sterilized bottles

B.

Which statement is true regarding the genetic transmission of Duchenne muscular dystrophy (DMD)? A. Multiple gene expression B. X-linked recessive C. Autosomal dominant D. No carrier states exist

B.

A newborn has been diagnosed with spinal bifida. Which allergy documentation should the nurse include in a plan of care for this child? A. Penicillin B. Cloth tape C. Latex D. Augmentin

C.

What most accurately describes bowel function in children born with a myelomeningocele? A. Incontinence cannot be prevented. B. Enemas and laxatives are contraindicated. C. Some degree of fecal continence can usually be achieved. D. A colostomy is usually required by the time the child reaches adolescence.

C.

Which presentation is found in a pediatric patient who has Brown-Sequard syndrome? A. Complete transection of the spinal cord B. Bilateral cord dysfunction with complete loss of sensation C. Unilateral cord lesion with alternate side deficits D. Transient loss of function

C.

A neural tube defect that is not visible externally in the lumbosacral area would be called A. meningocele. B. myelomeningocele. C. spina bifida cystica. D. spina bifida occulta.

D.

A nurse is taking care of a pediatric patient whose health record indicates E on the American Spinal Injury Association Impairment Scale. What does this designation mean? A. Sensory function present but no motor function B. No motor or sensory function C. Motor function is preserved below the neurologic level D. Intact motor and sensory function

D.

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.

An 8-year-old has been diagnosed with moderate cerebral palsy (CP). The child recently began participation in a regular classroom for part of the day. The child's mother asks the school nurse about joining the after-school Scout troop. The nurse's response should be based on knowledge that A. most activities such as Scouts cannot be adapted for children with CP. B. after-school activities usually result in extreme fatigue for children with CP. C. trying to participate in activities such as Scouts leads to lowered self-esteem in children with CP. D. after-school activities often provide children with CP with opportunities for socialization and recreation.

D.

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.

The major goal of therapy for children with cerebral palsy (CP) is A. reversing degenerative processes that have occurred. B. curing the underlying defect causing the disorder. C. preventing spread to individuals in close contact with the children. D. recognizing the disorder early and promoting optimal development.

D.

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.