exam 2 - peds

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? 1.Administer an oral antibiotic. 2.Maintain strict intake and output. 3.Draw blood for a culture and sensitivity. 4.Place the child on droplet precautions in a private room.

1.Administer an oral antibiotic.

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? 1.Meningitis 2.Spinal cord injury 3.Intracranial bleeding 4.Decreased cerebral blood flow

1.Meningitis

The nurse creates a plan of care for a child with Reye's syndrome. Which priority intervention should the nurse include in the plan of care? 1.Monitor for signs of increased intracranial pressure. 2.Immediately check the presence of protein in the urine. 3.Reassure the parents hyperglycemia is a common symptom. 4.Teach the parents signs and symptoms of a bacterial infection.

1.Monitor for signs of increased intracranial pressure.

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 should assess the child frequently for which early sign of increased ICP? 1.Nausea 2.Papilledema 3.Decerebrate posturing 4.Alterations in pupil size

1.Nausea

Which nursing actions apply to the care of a child who is having a seizure? Select all that apply. 1.Time the seizure. 2.Restrain the child. 3.Stay with the child. 4.Insert an oral airway. 5.Loosen clothing around the child's neck. 6.Place the child in a lateral side-lying position.

1.Time the seizure. 3.Stay with the child. 5.Loosen clothing around the child's neck. 6.Place the child in a lateral side-lying position.

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1.Time the seizure. 2.Restrain the child. 3.Stay with the child. 4.Place the child in a prone position. 5.Move furniture away from the child. 6.Insert a padded tongue blade in the child's mouth.

1.Time the seizure. 3.Stay with the child. 5.Move furniture away from the child.

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? 1.Choking 2.Infection 3.Inability to tolerate stimulation 4.Delayed growth and development

2.Infection

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? 1.Test the urine for protein. 2.Reposition the infant frequently. 3.Provide a stimulating environment. 4.Assess blood pressure every 15 minutes.

2.Reposition the infant frequently.

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 should contact the pediatrician to question which prescription? 1. Obtain daily weight. 2. Provide clear liquid intake. 3. Nasotracheal suction as needed. 4. Maintain a patent intravenous line.

3. Nasotracheal suction as needed.

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process? 1.An infectious disease of the central nervous system 2.An inflammation of the brain as a result of a viral illness 3.A chronic disability characterized by impaired muscle movement and posture 4.A congenital condition that results in moderate to severe intellectual disabilities

3.A chronic disability characterized by impaired muscle movement and posture

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 should be performed that will best detect the presence of an increase in intracranial pressure? 1.Check urine for specific gravity. 2.Monitor for signs of dehydration. 3.Assess anterior fontanel for bulging. 4.Assess blood pressure for signs of hypotension.

3.Assess anterior fontanel for bulging.

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? 1.Clear CSF, decreased pressure, and elevated protein level 2.Clear CSF, elevated protein, and decreased glucose levels 3.Cloudy CSF, elevated protein, and decreased glucose levels 4.Cloudy CSF, decreased protein, and decreased glucose levels

3.Cloudy CSF, elevated protein, and decreased glucose levels

The nurse is monitoring an infant for signs of increased intracranial pressure. On assessment of the fontanelles, the nurse notes that the anterior fontanelle bulges when the infant is sleeping. Based on this finding, which is the priority nursing action? 1.Increase oral fluids. 2.Document the finding. 3.Notify the primary health care provider. 4.Place the infant supine in a side-lying position.

3.Notify the primary health care provider.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1.Flaccid paralysis of all extremities 2.Adduction of the arms at the shoulders 3.Rigid extension and pronation of the arms and legs 4.Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3.Rigid extension and pronation of the arms and legs

The nurse enters a child's room and discovers that the child is having a seizure. Which actions should the nurse take? Select all that apply. 1.Call a code. 2.Run to get the crash cart. 3.Turn the child on her side. 4.Loosen any restrictive clothing. 5.Check the child's respiratory status. 6.Place an airway into the child's mouth.

3.Turn the child on her side. 4.Loosen any restrictive clothing. 5.Check the child's respiratory status.

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? 1.Nausea 2.Irritability 3.Headache 4.Bradycardia

4.Bradycardia

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 should include which action to maintain the infant's safety? 1.Covering the back dressing with a binder 2.Placing the infant in a head-down position 3.Strapping the infant in a baby seat sitting up 4.Elevating the head with the infant in the prone position

4.Elevating the head with the infant in the prone position

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? 1.Maintain enteric precautions. 2.Maintain neutropenic precautions. 3.No precautions are required as long as antibiotics have been started. 4.Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

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

A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan? 1.Assessing hearing loss 2.Monitoring urine output 3.Changing body position every 2 hours 4.Providing a quiet atmosphere with dimmed lighting

4.Providing a quiet atmosphere with dimmed lighting

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? 1.Nausea, delirium, and fever 2.Severe headache and back pain 3.Photophobia, fever, and confusion 4.Severe headache, fever, and a change in the level of consciousness

4.Severe headache, fever, 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) need to be placed at the child's bedside? 1.Emergency cart 2.Tracheotomy set 3.Padded tongue blade 4.Suctioning equipment and oxygen

4.Suctioning equipment and oxygen