Exam 2 Practice Questions

The nurse is assessing a client that has myopia. Which of the following should the nurse expect? A. poor school performance B. headaches C. difficulty reading D. photophobia

A. poor school performance B. headaches C. difficulty reading

What lifelong concerns should be included in discharge teaching for a child that had a valve replaced?

- Aspirin (6 months) - Anticoagulants (6 months) - Antibiotics

After being diagnosed with graves disease, a teenager begins taking propylthiouracil (PTU) for treatment of the disease. What symptom would indicate to the nurse that the dose may be too high? A. Weight loss B. Polyphagia C. Lethargy D. Difficulty with school work

C. Lethargy

An 8-year-old client with a VP(ventriculoperitoneal) shunt was admitted for shunt malfunction. He presents with symptoms of ICP. The mechanism of the development of his symptoms is most probably related to: A. Increased flow of cerebrospinal fluid B. Increased reabsorption of cerebrospinal fluid C. Obstructed flow of cerebrospinal spinal fluid D. Decreased production of cerebrospinal fluid

C. Obstructed flow of cerebrospinal spinal fluid

Upon performing a physical assessment of a 7-month-old child the nurse notes the following findings. The nurse concludes that which finding is abnormal and could suggest CP A .No head lag when pulled to a sitting position B. No moro or startle reflex C. Positive tonic neck reflex D. Absence of tongue extrusion

C. Positive tonic neck reflex

A mother of a toddler with congenital heart disease asks the nurse what activities the child can participate in, what do you tell her?

No strenuous exercises (i.e. child may swim but no running)

A child with a myelomeningocele is started on a bowel management plan. The child's mother questions why this is being done. The nurse's response will be based on the understanding that lack of : a. Innervation to the colon predisposes the child to diarrhea b. Innervation to the anal sphincter predisposes the child to be incontinent. c. Mobility increases the gastric colic reflex d. Mobility decreases the need for regular bowel movements

b. Innervation to the anal sphincter predisposes the child to be incontinent.

Mandy just gave birth vaginally to her first child. Mandy and James had attended prenatal classes and had a natural childbirth. They were totally unprepared to see that baby "Rose" has a severe left-sided unilateral cleft lip and cleft palate. James is having a hard time with this and just keeps staring at the baby. Mandy begins to cry and states "I thought I was going to breast-feed my baby and now it's impossible." a) Discuss the implications for bottle-feeding and breast-feeding a baby with a unilateral cleft lip. Is it possible for Mandy to breast-feed Rose? b) What is involved in the surgical correction of the defect? When can she eventually have a "normal" mouth and facial features? c) What other problems may develop for Rose since she has this type of defect? d) How can you assist the family with bonding with Rose?

a. Many infants born with cleft lip and palate are unable to be breast-fed. Those with cleft palate cannot produce the negative pressure necessary for suction. Mothers of infants with a unilateral cleft lip may succeed with breast-feeding when the infant is positioned so that the cleft in the lip is obstructed by the mother's breast. Because Rose has both, Mandy will not be able to breast-feed but can pump her milk to be given to her daughter. b. Repairing the facial anomaly as soon as possible is important to facilitate bonding between the newborn and the parents and to improve nutritional status. Treatment of cleft lip is surgical repair between the ages of 6 and 12 weeks. Surgical correction for cleft palate is done around 6 to 18 months of age to allow for developmental growth to occur. A plastic palate guard to form a synthetic palate may need to be used to allow for introduction of solid foods and to prevent aspiration in the interim. c. Infants with cleft lip and palate may have problems with dentition, language acquisition, and hearing. d. On first glance, parents may be upset with the appearance of their newborn. Encourage the parents to express their feelings about this highly visible anomaly. Emphasize the newborn's positive features and role-model nurturing behaviors when interacting with the infant. Encourage parents to interact with the newborn. Provide support to the parents, especially related to feeding difficulties. Allow them to vent their frustrations. Offer practical suggestions and continued encouragement for their efforts.

Which of the following represents an effective nursing intervention to reduce cardiac demands and decrease cardiac workload? A. Clustering nursing care to provide for periods of uninterrupted rest B. Developing and implanting a consistent plan of care C. Feeding the infant over longer period of time D. Allowing the infant to have his or her own way to avoid conflict

A. Clustering nursing care to provide for periods of uninterrupted rest

A 2-week-old white female is admitted to the hospital for high fever and irritability. She was a full term, vaginal birth to a G2P2 mother. The infant is diagnosed with meningitis. Her parents both work full time and have health insurance. She has a 3-year-old brother. The family does not have any relatives living closer than a 3-hour drive. A. What specific physical parameters should the nurse monitor? B. Which nursing interventions would have priority during the first 48 hours of her care? C. What would be the usual medical treatment for this health problem? D. What developmental implications are there for providing family centered care for the infant? E. In Planning for discharge, identify specific areas of support for or teaching with the family. F. Why are there specific details about her history in the case study and why does that matter?

A. Fever, irritability, restlessness, changing in feeding, vomiting, lethargic, bulging/sunken in fontanels\ B. Cultures, potential lumbar puncture, isolation, antibiotics, cool/dark/quiet room, low stimuli C. Antibiotics, steroids, anticonvulsants, pain meds, continuous pulse oximeter D. Education, vaccines, childcare for brother, potential of home health, financial/health insurance burden E. Education, home health F. Look at whole picture

The nurse is teaching a client about bacterial meningitis. What should be included in the information about vaccinations? A. Hib decreases the incidence of bacterial meningitis B. Influenza decreases the incidence of bacterial meningitis C. PCV decreases the incidence of bacterial meningitis D. DTaP decreases the incidence of bacterial meningitis

A. Hib decreases the incidence of bacterial meningitis C. PCV decreases the incidence of bacterial meningitis

A mother brings her 2 week old infant to a clinic for treatment following a diagnosis of clubfoot made at the time of birth. Which of the following statement if made by the mother indicates a need for further education regarding this disorder? A. I need to bring my infant back to the clinic in 1 month for a new cast B. Treatment needs to be started as soon as possible C. I need to come to the clinic every week with my infant for casting D. I realize my infant will require follow up care until full grown.

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

The home health nurse is monitoring the status of a child with a known cyanotic heart defect. In addition to monitoring cardiac function, the nurse monitors other body systems for problems secondary to the heart defect. Which of the following nursing diagnoses should the nurse write on the client care plan? A. Imbalanced nutrition, less than body requirements B. Risk for injury, seizures C. Chronic pain D. Diversional activity deficit

A. Imbalanced nutrition, less than body requirements

A nurse is assessing a new admission. The 6-month-old infant displays irritability, bulging fontanels, and setting-sun eyes. The nurse would suspect: A. Increased intracranial pressure B. Hypertension C. Skull fracture D. Myelomeningocele

A. Increased intracranial pressure

Which of the following should be included in routine immunizations for a child entering kindergarten? A. MMR B. Hib C. DTaP D. IPV

A. MMR C. DTaP D. IPV

Which of the following assessments are associated with shaken baby syndrome (non accidental head trauma)? A. discrepancies between injuries and description of how injury occured B. previous injuries or old injuries C. conflicting reports from caregivers D. fever and runny nose

A. discrepancies between injuries and description of how injury occured B. previous injuries or old injuries C. conflicting reports from caregivers

Select all the correct nursing assessments for a infant with clubfoot A. educate parents on stretching exercises B. keep infant prone to promote leg stretching C. monitor for skin assessment and neurovascular checks when casted

A. educate parents on stretching exercises C. monitor for skin assessment and neurovascular checks when casted

Which answer is correct in caring for an infant with cleft lip/palate? A. educate parents on the need for speech and dental issues in the future B. infants will need to be fed through a peg tube to avoid aspiration C. educate parents on the use of an apnea monitor

A. educate parents on the need for speech and dental issues in the future

Which of the following actions should the nurse include for developing a plan of care for a toddler with cerebral palsy? A. evaluate hearing ability B. structure interventions according to their age C. monitor pain level with numeric scale D. provide total care for ADLs

A. evaluate hearing ability

Risk factors for seizures include which of the following? A. high serum lead levels B. hypoglycemia C. fever D. sodium imbalance

A. high serum lead levels B. hypoglycemia C. fever D. sodium imbalance

The nurse is caring for an adolescent with a closed head injury. Which would indicate increased ICP? A. increased sleeping B. increased sensory response C. alteration in pupillary response D. report of a headache

A. increased sleeping C. alteration in pupillary response D. report of a headache

Which of the following are interventions a nurse can utilize with an infant who has bacterial meningitis? (select all that apply) A. institute seizure precautions B. administer antipyretics C. decrease temperature rapidly to induce shivering D. keep room brightly lit to monitor oxygenation level E. keep child flat or have head elevated 10-15 degrees

A. institute seizure precautions B. administer antipyretics E. keep child flat or have head elevated 10-15 degrees

What interventions/assessments should the nurse include preoperatively for an infant born with gastroschisis? A. monitor for hypothermia B. leave bowel open to air C. NG tube to low intermittent suction D. monitor tissue perfusion to bowel

A. monitor for hypothermia C. NG tube to low intermittent suction D. monitor tissue perfusion to bowel

A mother of a 4-month-old tells the nurse that her child has been diagnosed with hypothyroidism. The mother asks the nurse what symptoms led to the diagnosis? (select all that apply) A. High pitched shrill cry B. Prolonged jaundice at birth C. Described as a "good baby" D. Constipation E. Tall for gestation age at birth

B. Prolonged jaundice at birth C. Described as a "good baby" D. Constipation

A young child has just been diagnosed with spastic cerebral palsy. The nurse is teaching the parents how to meet the dietary needs of their child. The nurse would explain that children with CP frequently have special dietary needs or feeding challenges because: A. The paralysis of their muscles decreases their caloric need B. The spasticity of their muscles increases their caloric need C. The hypotonic muscles make eating difficult D. The child's inactivity increases the risk of obesity

B. The spasticity of their muscles increases their caloric need

The nurse is caring for an infant with myelomeningocele. Which should be include in preoperative care? A. assess rectal temperature B. apply sterile, moist dressing to sac C. assist with cuddling the infant D. place in supine position

B. apply sterile, moist dressing to sac

Which of the following are characteristic symptoms of a child with Tetrolagy of Fallot? (select all that apply) A. frequent bleeding into the joints B. cyanosis of extremities C. squatting position or tripod position D. metabolic alkalosis E. failure to thrive

B. cyanosis of extremities C. squatting position or tripod position E. failure to thrive

Which of the following clinical findings are associated with cystic fibrosis? (select all that apply) A. excessive weight gain B. history of meconium ileus at birth C. thick mucus production D. frequent respiratory infections

B. history of meconium ileus at birth C. thick mucus production D. frequent respiratory infections

When planning long term goals in care for a child with osteogensis imperfecta, the nurse should include which of the following? (select all that apply) A. bone infections B. osteoporosis C. misalignment of lower joints D. contractures and deformities E. muscle weakness

B. osteoporosis C. misalignment of lower joints D. contractures and deformities E. muscle weakness

Which over the counter product should parents not give their child as it might contain salicylates (aspirin) and put them at risk for Reye Syndrome? A. mylanta B. pepto-bismol C. triaminic D. benedryl

B. pepto-bismol

Which of the following should the nurse include in teaching for an infant newly diagnosed with pyloric stenosis? A. breast feeding mothers should exclude all dairy from their diet B. surgery is necessary to correct the abnormality C. infants should be maintained upright after feeding D. symptoms can be managed with proton pump inhibitors

B. surgery is necessary to correct the abnormality

A 4 month old infant has been diagnoses with PKU. The child has eczema and sensitivity to sunlight. The mother asks the nurse why her child's skin is so sensitive. An appropriate explanation by the nurse would be: A. "Some children just have sensitive skin. There is no reason to be excessively concerned." B. "Your child will outgrow his sensitivity when he is 5 years old. Just use sunscreen for now." C. "Your child has a deficiency in melanin because of decreased tyrosine. You will always have to take special care of his skin." D. "The phenylketones in your baby's blood concentrate the sun's rays, making burning more likely. Children with PKU can never be in the sun."

C. "Your child has a deficiency in melanin because of decreased tyrosine. You will always have to take special care of his skin."

An 18 month old is being discharged following surgical repair of hypospadias. Which postop nursing care measure should the nurse stress to the parents as they prepare to take this child home? A. Encourage toilet training to ensure that flow of urine is normal B. Restrict fluid intake to reduce urinary output for the first few days C. Avoid tub baths until the stent has been removed D. Leave the diapers off to allow the site to heal

C. Avoid tub baths until the stent has been removed

A clinic nurse reviews the record of an infant seen in the clinic. The nurse notes a diagnosis of TEF is suspected. The nurse expects to note which most likely sign of this condition documented in the record? A. Severe projectile vomiting B. Coughing at nighttime C. Choking with feedings D. Incessant crying

C. Choking with feedings

A clinic nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which of the following does the nurse include in the instructions? A. The harness should be worn 12 hours a day B. The harness needs to be removed for diaper changes and for feeding C. The harness should be removed only to check the skin and bathing D. The infant should not be moved when out of the harness

C. The harness should be removed only to check the skin and bathing

A child with a cyanotic heart defect is being discharged home to await surgical repair. In the discharge teaching, the nurse instructs the parents: A. To prevent the child from crying at all. B. To observe for signs of increased intracranial pressure. C. To perform cardiopulmonary resuscitation D. To identify growth and development milestones.

C. To perform cardiopulmonary resuscitation

Which of the following interventions are associated for caring for a child with congestive heart disease? (select all that apply) A. with hold immunizations to protect from retractions B. provide fewer, larger meals to promote nutrition C. monitor for symptoms of digoxin toxicity D. organize cares to promote adequate rest periods E. monitor intake, output, and weight

C. monitor for symptoms of digoxin toxicity D. organize cares to promote adequate rest periods E. monitor intake, output, and weight

After a pediatric client has a cardiac catheterization which intervention would the nurse consider to be of highest priority during the immediate post‐procedure period? A. Encourage intake of small amounts of fluid B. Teach parents signs of congestive heart failure C. Monitor the site for signs of infection D. Apply direct pressure to entry site for 15 minutes

D. Apply direct pressure to entry site for 15 minutes

A nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement indicates a need for further instruction? A. "I will use a nipple with a small hole to prevent choking." B. I will stimulate sucking by rubbing the nipple on the lower lip. C. I will allow the infant time to swallow D. I will allow the infant to rest frequently to provide time for swallowing what has been placed in the mouth

D. I will allow the infant to rest frequently to provide time for swallowing what has been placed in the mouth

An 18-month-old child is observed having a seizure. The nurse notes that the child's jaw is clamped. The priority nursing responsibility at this time would be: A. Start O2 via mask B. Insert padded tongue blade C. Restrain child to prevent injury to soft tissue D. Protect the child from harm from the environment

D. Protect the child from harm from the environment

Which of the following are characteristics of seizures in newborns? A. headache and urea B. sudden cessation of motor activity C. numbness and tingling to exremities D. apnea and chewing motions

D. apnea and chewing motions

When caring for an infant with hydrocephalus, which nursing assessments are to be included? A. sunken fontanels B. fixed and dilated pupils C. assess for smaller than normal head size D. rapid increase of head circumference

D. rapid increase of head circumference

A child with a history of a seizure was admitted 2 hours ago. The history indicates fever, chills, and vomiting for the past 24 hours. In report, the nurse is told that the child has a positive Brudzinski's sign. The nurse infers this is most likely caused by: a. Increased intracranial pressure b. Meningeal irritation c. Encephalitis d. Intraventricular hemorrhage

b. Meningeal irritation

A child has just been diagnosed with bacterial meningitis. The parent asks the nurse how long the child will be in isolation. The nurse's reply will be based on a protocol that isolation continues until. a. The organism is located b. The antibiotics are initiated c. The antibiotics have been administered for 24 hours d. Ten days of antibiotic therapy have been completed

c. The antibiotics have been administered for 24 hours