Nclex question review 1
The nurse is teaching the parents of a 3-year-old child who has been diagnosed with tonic-clonic seizures. What statement by the parent should indicate a correct understanding of the teaching? • "I should attempt to restrain my child during a seizure." • "My child will need to avoid contact sports until adulthood." • "I should place a pillow under my child's head during a seizure." • "My child will need to be taken to the emergency department [ED] after each seizure."
"I should place a pillow under my child's head during a seizure."
The nurse is preparing a school-age child for computed tomography (CT) scan to assess cerebral function. The nurse should include what statement in preparing the child? • "The scan will not hurt." • "Pain medication will be given." • "You will be able to move once the equipment is in place." • "Unfortunately no one can remain in the room with you during the test."
"The scan will not hurt."
The nurse is preparing to admit an adolescent with bacterial meningitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.) • Fever • Chills • Headache • Poor tone • Drowsiness
Fever, Chills, Headache, Drowsiness
The nurse is caring for a child with a subdural hematoma. The nurse should assess for what signs that can indicate brainstem compression? (Select all that apply.) • Coma • Lethargy • Hemiplegia • Hemiparesis • Unequal pupils
Hemiplegia, Hemiparesis, Unequal pupils
The nurse is preparing to admit a 6-month-old infant with increased intracranial pressure (ICP). What clinical manifestations should the nurse expect to observe in this infant? (Select all that apply.) • High-pitched cry • Poor feeding • Setting-sun sign • Sunken fontanel • Distended scalp veins • Decreased head circumference
High-pitched cry, Poor feeding, Setting-sun sign, Distended scalp veins
When taking the history of a child hospitalized with Reye syndrome, the nurse should not be surprised if a week ago the child had recovered from what? • Measles • Influenza • Meningitis • Hepatitis
Influenza
A pregnant woman asks about prenatal diagnosis of hydrocephalus. The nurse's response should be based on which knowledge? • It can be diagnosed only after birth. • It can be diagnosed by chromosome studies. • It can be diagnosed with fetal ultrasonography. • It can be diagnosed by measuring the lecithin-to-sphingomyelin ratio.
It can be diagnosed with fetal ultrasonography.
The nurse is preparing to admit a neonate with bacterial meningitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.) • Jaundice • Cyanosis • Poor tone • Nuchal rigidity • Poor sucking ability
Jaundice, Cyanosis, Poor tone, Poor sucking ability
After a tonic-clonic seizure, what symptoms should the nurse expect the child to experience? • Diarrhea and abdominal discomfort • Irritability and hunger • Lethargy and confusion • Nervousness and excitability
Lethargy and confusion
A child has been admitted with status epilepticus. An emergency medication has been ordered. What medication should the nurse expect to be prescribed? • Lorazepam (Ativan) • Phenytoin (Dilantin) • Topiramate (Topamax) • Ethosuximide (Zarontin)
Lorazepam (Ativan)
A 2-year-old child starts to have a tonic-clonic seizure. The child's jaws are clamped. What is the most important nursing action at this time? • Place a padded tongue blade between the child's jaws. • Stay with the child and observe his respiratory status. • Prepare the suction equipment. • Restrain the child to prevent injury.
Stay with the child and observe his respiratory status.
The nurse is preparing to admit an adolescent with encephalitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.) • Malaise • Apathy • Lethargy • Hypoactivity • Hypothermia
Malaise, Apathy, Hypoactivity
Coma
No motor or verbal response to noxious stimuli
What cerebrospinal fluid (CSF) analysis should the nurse expect with viral meningitis? (Select all that apply.) • Color is turbid. • Protein count is normal. • Glucose is decreased. • Gram stain findings are negative. • White blood cell (WBC) count is slightly elevated.
Protein count is normal, Gram stain findings are negative. White blood cell (WBC) count is slightly elevated.
The nurse is caring for a child with meningitis. What acute complications of meningitis should the nurse continuously assess the child for? (Select all that apply.) • Seizures • Cerebral palsy • Cerebral edema • Hydrocephalus • Cognitive impairments
Seizures, Cerebral edema, Cognitive impairments
What effects of an altered pituitary secretion in a child with meningitis indicates syndrome of inappropriate antidiuretic hormone (SIADH)? (Select all that apply.) • Hypotension • Serum sodium is decreased • Urinary output is decreased • Evidence of overhydration • Urine specific gravity is increased
Serum sodium is decreased, Urinary output is decreased, Evidence of overhydration, Urine specific gravity is increased
The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt. What issues should be addressed? • Most childhood activities must be restricted. • Cognitive impairment is to be expected with hydrocephalus. • Wearing head protection is essential until the child reaches adulthood. • Shunt malfunction or infection requires immediate treatment.
Shunt malfunction or infection requires immediate treatment.
A 3-year-old child is hospitalized after submersion injury. The child's mother complains to the nurse, "This seems unnecessary when he is perfectly fine." The nurse's best reply would be which of the following? • "He still needs a little extra oxygen." • "I'm sure he is fine, but the doctor wants to make sure." • "It is important to observe for possible physical reasons for the accident." • "The reason for hospitalization is that complications could still occur."
"The reason for hospitalization is that complications could still occur."
What is a nursing intervention to reduce the risk of increasing intracranial pressure (ICP) in an unconscious child? • Suction the child frequently. • Turn the child's head side to side every hour. • Provide environmental stimulation. • Avoid activities that cause pain or crying.
Avoid activities that cause pain or crying.
What intervention should be beneficial in reducing the risk of Reye syndrome? • Immunization against the disease • Medical attention for all head injuries • Prompt treatment of bacterial meningitis • Avoidance of aspirin for children with varicella or those suspected of having influenza
Avoidance of aspirin for children with varicella or those suspected of having influenza
Which of the following is an important nursing intervention when performing a bladder catheterization on a young boy? • Insert 2% lidocaine lubricant into the urethra. • Clean technique, not Standard Precautions, is needed. • Lubricate the catheter with water-soluble lubricant such as K-Y Jelly. • Delay catheterization for 20 minutes while anesthetic lubricant is absorbed
Insert 2% lidocaine lubricant into the urethra.
Which of the following is a clinical manifestation of increased intracranial pressure (ICP) in infants? • Irritability • Photophobia • Vomiting and diarrhea • Pulsating anterior fontanel
Irritability
What type of dehydration is defined as "dehydration that occurs in conditions in which electrolyte and water deficits are present in approximately balanced proportion?" • Isotonic dehydration • Hypotonic dehydration • Hypertonic dehydration • All types of dehydration in infants and small children
Isotonic dehydration
The nurse needs to do a heel stick on an ill neonate to obtain a blood sample. Which of the following is recommended to facilitate this? • Elevate the foot for 5 minutes. • Apply a tourniquet to the ankle. • Apply cool, moist compresses. • Wrap the foot in a warm washcloth.
Wrap the foot in a warm washcloth.
Which of the following would be helpful word(s) to substitute for the word "shot" when working with a 4-year-old? • Stick • Bee sting • Injection • Medication under the skin
Medication under the skin
Depression of the central nervous system (CNS), manifested by lethargy, delirium, stupor, and coma, is observed in which of the following? • Metabolic acidosis • Respiratory alkalosis • Metabolic and respiratory acidosis • Metabolic and respiratory alkalosis
Metabolic and respiratory acidosis
What nursing intervention is appropriate when caring for an unconscious child? • Avoid using narcotics or sedatives to provide comfort and pain relief. • Change the child's position infrequently to minimize the chance of increased intracranial pressure (ICP). • Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema. • Give tepid sponge baths to reduce fevers above 38.3° C (101° F) because antipyretics are contraindicated.
Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.
Which of the following statements best describes hypopituitarism? • Skeletal proportions are normal for age. • Weight is usually more retarded than height. • Growth is normal during the first 3 years of life. • Most of these children have subnormal intelligence.
Skeletal proportions are normal for age.
A school-age child recently diagnosed with type 1 diabetes mellitus asks the nurse if he can still play soccer, play baseball, and swim. The nurse's response should be based on knowledge that • exercise is contraindicated. • the level of activity depends on the type of insulin required. • exercise is not restricted unless indicated by other health conditions. • soccer and baseball are too strenuous, but swimming is acceptable.
exercise is not restricted unless indicated by other health conditions.
The Glasgow Coma Scale consists of an assessment of • pupil reactivity and motor response. • level of consciousness and verbal response. • eye opening and verbal and motor response. • intracranial pressure and level of consciousness.
eye opening and verbal and motor response.
The nurse is preparing a 12-year-old girl for a bone marrow aspiration. She tells the nurse she wants her mother with her "like before." The most appropriate nursing action is to • grant her request. • explain why this is not possible. • identify an appropriate substitute for her mother. • offer to provide support to her during the procedure.
grant her request.
Which of the following would cause a nurse to suspect that an infection has developed under a cast? • Cold toes • Increased respirations • Complaint of paresthesia • "Hot spots" felt on the cast surface
"Hot spots" felt on the cast surface
A 6-year-old child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. What sign or symptom does the child have that indicates a revision is necessary? • Tachycardia • Gastrointestinal upset • Hypotension • Alteration in level of consciousness
Alteration in level of consciousness
A young child's parents call the nurse after their child is bitten by a raccoon in the woods. The nurse's recommendation should be based on what knowledge? • Antirabies prophylaxis must be initiated immediately. • The child should be hospitalized for close observation. • No treatment is necessary if thorough wound cleaning is done. • Antirabies prophylaxis must be initiated as soon as clinical manifestations appear.
Antirabies prophylaxis must be initiated immediately.
Obtundation
Arousable with stimulation
A 23-month-old child is admitted to the hospital with a diagnosis of meningitis. She is lethargic and very irritable with a temperature of 102° F. What should the nurse's care plan include? • Observing the child's voluntary movement • Checking the Babinski reflex every 4 hours • Checking the Brudzinski reflex every 1 hour • Assessing the level of consciousness (LOC) and vital signs every 2 hours
Assessing the level of consciousness (LOC) and vital signs every 2 hours
The nurse is caring for a child with increased intracranial pressure (ICP). What interventions should the nurse plan for this child? (Select all that apply.) • Avoid jarring the bed. • Keep the room brightly lit. • Keep the bed in a flat position. • Administer prescribed stool softeners. • Administer a prescribed antiemetic for nausea.
Avoid jarring the bed, Administer prescribed stool softeners, Administer a prescribed antiemetic for nausea.
If an intramuscular (IM) injection is administered to a child who has Reye syndrome, the nurse should monitor for what? • Bleeding • Infection • Poor absorption • Itching at the injection site
Bleeding
The nurse is caring for a child with an epidural hematoma. The nurse should assess for what signs that can indicate Cushing triad? (Select all that apply.) • Fever • Flushing • Bradycardia • Systemic hypertension • Respiratory depression
Bradycardia, Systemic hypertension, Respiratory depression
An injury to which part of the brain will cause a coma? • Brainstem • Cerebrum • Cerebellum • Occipital lobe
Brainstem
What clinical manifestations suggest hydrocephalus in an infant? • Closed fontanel and high-pitched cry • Bulging fontanel and dilated scalp veins • Constant low-pitched cry and restlessness • Depressed fontanel and decreased blood pressure
Bulging fontanel and dilated scalp veins
Disorientation
Confusion regarding time and place
A child has a seizure disorder. What test should be done to gather the most specific information about the type of seizure the child is having? • Sleep study • Skull radiography • Serum electrolytes • Electroencephalogram (EEG)
Electroencephalogram (EEG)
The nurse is caring for a 10-year-old child who has an acute head injury, has a pediatric Glasgow Coma Scale score of 9, and is unconscious. What intervention should the nurse include in the child's care plan? • Elevate the head of the bed 15 to 30 degrees with the head maintained in midline. • Maintain an active, stimulating environment. • Perform chest percussion and suctioning every 1 to 2 hours. • Perform active range of motion and nontherapeutic touch every 8 hours.
Elevate the head of the bed 15 to 30 degrees with the head maintained in midline.
The nurse is teaching the parents of a child with a seizure disorder about the triggers that can cause a seizure. What should the nurse include in the teaching session? (Select all that apply.) • Cold • Sugared drinks • Emotional stress • Flickering lights • Hyperventilation
Emotional stress, Flickering lights, Hyperventilation
A child develops syndrome of inappropriate antidiuretic hormone secretion (SIADH) as a complication to meningitis. What action should be verified before implementing? • Forcing fluids • Daily weights with strict input and output (I and O) • Strict monitoring of urine volume and specific gravity • Close observation for signs of increasing cerebral edema
Forcing fluids
What is a priority of care when a child has an external ventricular drain (EVD)? • Irrigation of drain to maintain flow • As-needed dressing changes if dressing becomes wet • Frequent assessment of amount and color of drainage • Maintaining the EVD below the level of the child's head
Frequent assessment of amount and color of drainage
A child is on phenytoin (Dilantin). What should the nurse encourage? • Fluid restriction • Good dental hygiene • A decrease in vitamin D intake • Taking the medication with milk
Good dental hygiene
A child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. What is a common reason for elective revision of this shunt? • Meningitis • Gastrointestinal upset • Hydrocephalus resolution • Growth of the child since the initial shunting
Growth of the child since the initial shunting
The nurse is preparing to admit a 5-year-old with an epidural hemorrhage. What clinical manifestations should the nurse expect to observe? (Select all that apply.) • Headache • Vomiting • Irritability • Cephalhematoma • Pallor with anemia
Headache, Vomiting, Irritability
Confusion
Impaired decision making
The nurse is preparing to admit a 7-year-old child with complex partial seizures. What clinical features of complex partial seizures should the nurse recognize? (Select all that apply.) • They last less than 10 seconds. • There is usually no aura. • Mental disorientation is common. • There is frequently a postictal state. • There is usually an impaired consciousness.
Mental disorientation is common. There is frequently a postictal state. There is usually an impaired consciousness.
What is the antiepileptic medication that requires monitoring of vitamin D and folic acid? • Topiramate (Topamax) • Valproic acid (Depakene) • Gabapentin (Neurontin) • Phenobarbital (Luminal)
Phenobarbital (Luminal)
Stupor
Remaining in a deep sleep, responsive only to repeated stimulation
What is an early sign of heart failure that the nurse should recognize
Tachypnea
The nurse is preparing to admit a 10-year-old child with absence seizures. What clinical features of absence seizures should the nurse recognize? (Select all that apply.) • There is no aura. • There is a postictal state. • They usually last longer than 30 seconds. • There is a brief loss of consciousness. • There is an occasional clonic movement.
There is no aura. There is a brief loss of consciousness. There is an occasional clonic movement.
The nurse wears gloves during a dressing change. When the gloves are removed, the nurse should do which of the following? • Wash hands thoroughly. • Check the gloves for leaks. • Rinse gloves in disinfectant solution. • Apply new gloves before touching the next patient.
Wash hands thoroughly.
A toddler is admitted to the pediatric unit with presumptive bacterial meningitis. The initial orders include isolation, intravenous access, cultures, and antimicrobial agents. The nurse knows that antibiotic therapy will begin when? • After the diagnosis is confirmed • When the medication is received from the pharmacy • After the child's fluid and electrolyte balance is stabilized • As soon as the practitioner is notified of the culture results
When the medication is received from the pharmacy
A lumbar puncture (LP) is being done on an infant with suspected meningitis. The nurse expects which results for the cerebrospinal fluid that can confirm the diagnosis of meningitis? • ¬↑WBCs; ↓glucose • ¬↑RBCs; normal WBCs • ¬↑glucose; normal RBCs • Normal RBCs; normal glucose
¬↑WBCs; ↓glucose
Which of the following occurs in septic shock? • Massive vasodilation • Increased respiratory rate • Decreased capillary permeability • Increased systemic vascular resistance
Massive vasodilation
What finding is a clinical manifestation of increased intracranial pressure (ICP) in children? • Low-pitched cry • Sunken fontanel • Diplopia, blurred vision • Increased blood pressure
Diplopia, blurred vision
A child is brought to the emergency department after experiencing a seizure at school. He has no history of seizures. The father tells the nurse that he cannot believe the child has epilepsy. The nurse's best response is which of the following? • "Epilepsy is easily treated." • "Very few children have actual epilepsy." • "The seizure may or may not mean that your child has epilepsy." • "Your child has had only one convulsion; it probably won't happen again."
"The seizure may or may not mean that your child has epilepsy."
To prevent burns from hot water in the home, the nurse should recommend that families set their water heater thermostat to • 38º C (100º F). • 49º C (120º F). • 60º C (140º F). • 71º C (160º F).
49º C (120º F).
The nurse should recognize that when a child develops diabetic ketoacidosis, this is which of the following? • Expected outcome • Best treated at home Incorrect • A life-threatening situation • Best treated at practitioner's office or clinic
A life-threatening situation
A child has been seizure free for 2 years. A father asks the nurse how much longer the child will need to take the antiseizure medications. How should the nurse respond? • Medications can be discontinued at this time. • The child will need to take the drugs for 5 years after the last seizure. • A step-wise approach will be used to reduce the dosage gradually. • Seizure disorders are a lifelong problem. Medications cannot be discontinued.
A step-wise approach will be used to reduce the dosage gradually.
Which of the following should the nurse recognize as an early clinical sign of compensated shock in a child? • Confusion • Sleepiness • Hypotension • Apprehension
Apprehension
What type of seizure may be difficult to detect? • Absence • Generalized • Simple partial • Complex partial
Absence
Which of the following is a priority of nursing care? • Initiate isolation precautions as soon as diagnosis is confirmed. • Provide environmental stimulation to keep the child awake. • Administer antibiotic therapy as soon as it is available. • Administer sedatives and analgesics on a preventive schedule to manage pain.
Administer antibiotic therapy as soon as it is available.
When giving liquid medication to a crying 10-month-old infant, which approach minimizes the possibility of aspiration? • Keep the child upright with the nasal passages blocked for 1 minute after administration. • Mix the medication with the infant's regular formula or juice and administer by bottle. • Administer the medication with a cup as rapidly as possible with the infant securely restrained. • Administer the medication with a syringe (without needle) placed along the side of the infant's tongue.
Administer the medication with a syringe (without needle) placed along the side of the infant's tongue.
Which of the following statements is correct regarding sports injuries during adolescence? • Rapidly growing bones, muscles, joints, and tendons offer some protection from unusual strain. • The increase in strength and vigor during adolescence helps prevent injuries related to fatigue. • More injuries occur during organized athletic competition than during recreational sports participation. • Adolescents may not possess the insight and judgment to recognize when an activity is beyond their capabilities.
Adolescents may not possess the insight and judgment to recognize when an activity is beyond their capabilities.
A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. What sign or symptom is considered a manifestation of postconcussion syndrome and does not necessitate medical attention? • Vomiting • Blurred vision • Behavioral changes • Temporary loss of consciousness
Behavioral changes
What statement best describes a subdural hematoma? • Bleeding occurs between the dura and the skull. • Bleeding occurs between the dura and the cerebrum. • Bleeding is generally arterial, and brain compression occurs rapidly. • The hematoma commonly occurs in the parietotemporal region.
Bleeding occurs between the dura and the cerebrum.
The nurse is preparing an adolescent girl for surgery to treat scoliosis. Which of the following should the nurse include? • Blood administration may be an option. • Ambulation will not be allowed for up to 3 months. • Surgery eliminates the need for casting and bracing. • Discomfort can be controlled with nonpharmacologic methods.
Blood administration may be an option.
A child, age 10 years, sustained a fracture in the epiphyseal plate of her right fibula when she fell out of a tree. When discussing this injury with her parents, the nurse should consider which of the following? • This type of fracture is inconsistent with a fall. • Bone growth can be affected by this type of fracture. • This is an unusual fracture site in young children. • Healing is usually delayed in this type of fracture.
Bone growth can be affected by this type of fracture.
What is the forces that favor filtration from the capillary
Capillary hydrostatic pressure and interstitial oncotic pressure
The parent of a 10-year-old child with diabetes asks the nurse why home blood glucose monitoring is being recommended. The nurse should base the explanation on which of the following? • It is an easier method of testing. • Parents are better able to manage the diabetes. • Children have a greater sense of control over the diabetes. • Fewer visits to the primary care provider will be necessary.
Children have a greater sense of control over the diabetes.
What are quick, jerky, grossly uncoordinated, irregular movements that may disappear on relaxation called? • Twitching • Spasticity • Choreiform movements • Associated movements
Choreiform movements
The nurse should recommend medical attention if a child with a slight head injury experiences which of the following? • Vomiting • Sleepiness • Headache, even if slight • Confusion or abnormal behavior
Confusion or abnormal behavior
A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The child's level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. What is the most appropriate nursing action? • Explain that analgesia is contraindicated with a head injury. • Have the parents describe the child's previous experiences with pain. • Consult with a practitioner about what analgesia can be safely administered. • Teach the parents that analgesia is unnecessary when the child is not fully awake and alert.
Consult with a practitioner about what analgesia can be safely administered.
A young child has recently been fitted with a knee, ankle, and foot orthosis (brace). Care of the skin should include which of the following? • Apply lotion or cream to soften the skin. • Contact a practitioner or orthotist if skin redness does not disappear. • Place padding between the skin and brace if the child experiences a burning sensation under the brace. • If a small blister develops, apply rubbing alcohol and place padding between the skin and the brace.
Contact a practitioner or orthotist if skin redness does not disappear.
An adolescent girl is cooking on a gas stove when her bathrobe catches fire. Her father smothers the flames with a rug and calls an ambulance. She has sustained major burns over much of her body. Which of the following is also important in her immediate care? • Cool with a single application of tepid water. • Encourage her to drink clear liquids. • Remove her burned clothing and jewelry. • Leave the rug in place until the ambulance arrives.
Cool with a single application of tepid water.
What is an important nursing responsibility when a dysrhythmia is suspected
Count the apical rate for 1 full minute and compare with radial rate.
The nurse is assessing a child with a cardiac problem. The child's extremities are cool with thready pulses, and urinary output is diminished. This is most suggestive of what?
Decreased contractility
What is important to incorporate in the plan of care for a child who is experiencing a seizure? • Describe and record the seizure activity observed. • Suction the child during a seizure to prevent aspiration. • Place a tongue blade between the teeth if they become clenched. • Restrain the child when seizures occur to prevent bodily harm.
Describe and record the seizure activity observed.
Which of the following should the nurse include when discussing a child's precocious puberty with the parents? • The child is not yet fertile. • Heterosexual interest is usually advanced. • Dress and activities should be appropriate to chronologic age. • Appearance of secondary sexual characteristics does not proceed in the usual order.
Dress and activities should be appropriate to chronologic age.
Several types of long-term central venous access devices are used. Which of the following is a benefit of using an implanted port (e.g., Port-a-Cath)? • Accessed without piercing skin • Easy to use for self-administered infusions • Easy access for blood work • Catheter unable to dislodge from port even if the child "plays" with the port site
Easy access for blood work
What procedure uses high-frequency sound waves obtained by a transducer to produce an image of cardiac structures
Echocardiography
The nurse is caring for a 2-year-old girl who is unconscious but stable after a car accident. Her parents are staying at the bedside most of the time. Which of the following is an appropriate nursing intervention? • Suggest that the parents go home until she is alert enough to know they are present. • Encourage the parents to hold, talk, and sing to her as they usually would. • Use ointment on her lips but do not attempt to cleanse her teeth until swallowing returns. • Position her with proper body alignment and the head of the bed lowered 15 degrees.
Encourage the parents to hold, talk, and sing to her as they usually would.
A 3-year-old child has a fever. Her mother calls the nurse reporting a fever of 38.8º C (102º F) even though the child had acetaminophen 2 hours ago. The nurse's action should be based on which of the following? • Fevers such as this are common with viral illnesses. • Temperatures this high indicate greater severity of illness. • Fevers over 102º F indicate a probable bacterial infection. • Seizures are common in children when antipyretics are ineffective
Fevers such as this are common with viral illnesses.
What term refers to seizures that involve both hemispheres of the brain? • Absence • Acquired • Generalized • Complex partial
Generalized
An appropriate intervention to encourage food and fluid intake in a hospitalized child is which of the following? • Force the child to eat to combat caloric losses. • Administer large quantities of flavored fluids at frequent intervals. • Give high-quality foods and snacks whenever the child expresses hunger. • Discourage participation in noneating activities until caloric intake is sufficient.
Give high-quality foods and snacks whenever the child expresses hunger.
A 13-year-old girl is brought to the clinic with the complaint of insomnia and hyperactivity. Other symptoms include gradual weight loss despite a good appetite; warm, flushed, and moist skin; and unusually fine hair. These manifestations are most suggestive of which of the following? • Hypothyroidism • Hyperthyroidism • Hypoparathyroidism • Hyperparathyroidism
Hyperthyroidism
Rapid replacement of fluid is essential in the treatment of which of the following types of dehydration? • Isotonic, osmotic • Hypotonic, isotonic • Osmotic, hypertonic • Hypertonic, hypotonic
Hypotonic, isotonic
An 18-month-old child is brought to the emergency department after being found unconscious in the family pool. What does the nurse identify as the primary problem in drowning incidents? • Hypoxia • Aspiration • Hypothermia • Electrolyte imbalance
Hypoxia
In which of the following conditions is the fluid requirement for children decreased? • Burns • Fever • Vomiting • Increased intracranial pressure
Increased intracranial pressure
What statement is descriptive of a concussion? • Petechial hemorrhages cause amnesia. • Visible bruising and tearing of cerebral tissue occur. • It is a transient and reversible neuronal dysfunction. • It is a slight lesion that develops remote from the site of trauma.
It is a transient and reversible neuronal dysfunction.
Which of the following statements best describes Cushing syndrome? • It is caused by excessive production of cortisol. • Treatment involves replacement of cortisol. • The major clinical features are exophthalmia and pigmentary changes. • The diagnosis is suspected with findings of hypotension, hyperkalemia, and polyuria.
It is caused by excessive production of cortisol.
The nurse is planning care for a school-age child with bacterial meningitis. What intervention should be included? • Keep environmental stimuli to a minimum. • Have the child move her head from side to side at least every 2 hours. • Avoid giving pain medications that could dull sensorium. • Measure head circumference to assess developing complications.
Keep environmental stimuli to a minimum.
The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What clinical manifestation is the most essential part of the nursing assessment to detect early signs of a worsening condition? • Posturing • Vital signs • Focal neurologic signs • Level of consciousness
Level of consciousness
Which of the following is a major complication of total parenteral nutrition in children? • Anemia • Asthma • Liver disease • Renal impairment
Liver disease
What is the initial clinical manifestation of generalized seizures? • Confusion • Feeling frightened • Loss of consciousness • Seeing flashing lights
Loss of consciousness
Why are infants particularly vulnerable to acceleration-deceleration head injuries? • The anterior fontanel is not yet closed. • The nervous tissue is not well developed. • The scalp of the head has extensive vascularity. • Musculoskeletal support of the head is insufficient.
Musculoskeletal support of the head is insufficient.
The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. How should the nurse interpret these findings? • Neurologic health • Severe brain damage • Decorticate posturing • Decerebrate posturing
Neurologic health
The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. How should the nurse interpret this? • Eye trauma • Brain death • Severe brainstem damage • Neurosurgical emergency
Neurosurgical emergency
When caring for a child with an intravenous infusion, the nurse should do which of the following? • Change the insertion site every 24 hours. • Use a macrodropper to facilitate the prescribed flow rate. • Observe the insertion site frequently for signs of infiltration. • Avoid restraining the child to prevent undue emotional stress.
Observe the insertion site frequently for signs of infiltration.
What term is used to describe a child's level of consciousness when the child is arousable with stimulation? • Stupor • Confusion • Obtundation • Disorientation
Obtundation
What test is never performed on a child who is awake? • Doll's head maneuver • Oculovestibular response • Assessment of pyramidal tract lesions • Funduscopic examination for papilledema
Oculovestibular response
Nursing care of the infant and child with heart failure would include
Organize activities to allow for uninterrupted sleep
Therapeutic management of the child with rheumatic fever includes what medication
Penicillin
The nurse is caring for a child with severe head trauma after a car accident. What is an ominous sign that often precedes death? • Delirium • Papilledema • Flexion posturing • Periodic or irregular breathing
Periodic or irregular breathing
A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, the nurse should do which of the following? • Place the child in a side-lying position. • Set up a tray with equipment the same size as for adults. • Apply EMLA to the puncture site 15 minutes before the procedure. • Reassure the parents that the test is simple, painless, and risk free.
Place the child in a side-lying position.
Which of the following is the primary clinical manifestation of diabetes insipidus? • Oliguria • Glycosuria • Nausea, vomiting • Polyuria, polydipsia
Polyuria, polydipsia
When administering a gavage feeding to a school-age child, the nurse should do which of the following? • Administer feedings over 5 to 10 minutes. • Position the child on the right side after administering the feeding. • Check the placement of the tube by inserting 20 ml of sterile water. • Lubricate the tip of the feeding tube with Vaseline to facilitate passage
Position the child on the right side after administering the feeding.
The nurse is caring for a child hospitalized with acute adrenocortical insufficiency. Because of the sudden, severe nature of the disease, the family needs a great deal of emotional support. The most appropriate nursing action is which of the following? • Prepare the family for the child's impending death. • Prepare the family for each procedure. • Prepare the family for the long-term consequences of paralysis. • Reassure the family that flaccid paralysis is not problematic.
Prepare the family for each procedure.
Which of the following results when ice is applied immediately after a soft tissue injury, such as a sprained ankle? • Increases the pain threshold • Increases metabolism in the tissues • Produces deep tissue vasodilation • Leads to release of more histamine-like substances
Produces deep tissue vasodilation
Nurses counseling parents regarding the home care of the child with a cardiac defect before corrective surgery should stress
Promoting normality within the limits of the child's condition
· The nurse stops to assist a child who has been hit by a car while riding a bicycle. Someone has activated the emergency medical system. Until paramedics arrive, the nurse should consider which of the following in caring for this child who has experienced severe trauma? • Rapid assessment should begin with ABC status: airway, breathing, and circulation. • Assessment should begin with the area injured; assessment of other areas can wait. • The possibility of spinal cord injury should be ruled out before transporting the child to the hospital. • Temperature maintenance is more difficult than in adults because young children have a larger surface area related to body mass.
Rapid assessment should begin with ABC status: airway, breathing, and circulation.
The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. Which of the following is the most essential in this assessment? • Reactivity of pupils • Doll's head maneuver • Oculovestibular response • Funduscopic examination to identify papilledema
Reactivity of pupils
The nurse is caring for a 12-year-old boy who sustained major burns when he put charcoal lighter on a campfire. The nurse observes that he is "very brave" and appears to accept pain with little or no response. The most appropriate nursing action related to this is which of the following? • Request a psychologic consultation. • Ask the child why he doesn't have pain. • Praise the child for ability to withstand pain. • Encourage continued bravery as a coping strategy.
Request a psychologic consultation.
A 10-year-old boy on a bicycle has been hit by a car in front of a school. The school nurse immediately assesses airway, breathing, and circulation. What should be the next nursing action? • Place the child on his side. • Take the child's blood pressure. • Stabilize the child's neck and spine. • Check the child's scalp and back for bleeding.
Stabilize the child's neck and spine.
A 10-year-old child, without a history of previous seizures, experiences a tonic-clonic seizure at school that lasts more than 5 minutes. Breathing is not impaired. Some postictal confusion occurs. What is the most appropriate initial action by the school nurse? • Stay with child and have someone else call emergency medical services (EMS). • Notify the parent and regular practitioner. • Notify the parent that the child should go home. • Stay with the child, offering calm reassurance.
Stay with child and have someone else call emergency medical services (EMS).
What term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? • Coma • Stupor • Obtundation • Persistent vegetative state
Stupor
A young adolescent experiences infrequent migraine episodes. What pharmacologic intervention is most likely to be prescribed? • Opioid • Lorazepam • Ergotamine • Sumatriptan
Sumatriptan
The nurse is assessing an infant brought to the clinic with diarrhea. He is lethargic and has dry mucous membranes. Which of the following should the nurse recognize as an early sign of dehydration? • Tachycardia • Bulging, tense fontanel • Decreased blood pressure • Capillary refill of less than 3 seconds
Tachycardia
An important nursing consideration when caring for a child with juvenile idiopathic arthritis is which of the following? • Apply ice packs to relieve stiffness and pain. • Administer acetaminophen to reduce inflammation. • Teach the child and family the correct administration of medications. • Encourage range of motion exercises during periods of inflammation.
Teach the child and family the correct administration of medications.
A 4-year-old child is newly diagnosed with Legg-Calvé-Perthes disease. Nursing considerations include which of the following? • Encourage normal activity for as long as possible. • Explain the cause of the disease to the child and family. • Prepare the child and family for long-term, permanent disabilities. • Teach the family the care and management of the corrective appliance.
Teach the family the care and management of the corrective appliance.
The nurse is planning how to prepare a 4-year-old child for some diagnostic procedures. Guidelines for preparing this preschooler should include which of the following? • Keep equipment out of the child's view. • Plan for a short teaching session of about 30 minutes. • Tell the child procedures are never a form of punishment. • Use correct scientific and medical terminology in explanations.
Tell the child procedures are never a form of punishment.
What heart defect causes hypoxemia and cyanosis because desaturated venous blood is entering the systemic circulation
Tetralogy of Fallot
Which of the following statements regarding burn injuries in children is correct? • Burns are the most frequent cause of accidental death during childhood. • The prognosis for a burned child is directly related to the amount of tissue destroyed. • The standard "rule of nines" chart is typically used for assessing the size of a burn in small children. • Children younger than age 2 years have significantly lower mortality rates than older children with similar burns.
The prognosis for a burned child is directly related to the amount of tissue destroyed.
Which of the following should the nurse consider when having informed consent forms signed for surgery and procedures on children? • Only a parent or legal guardian can give consent. • The person giving consent must be at least 18 years old. • The risks and benefits of a procedure are part of the consent process. • A mental age of 7 years or older is required for a consent to be considered "informed."
The risks and benefits of a procedure are part of the consent process.
What is an important nursing consideration when chest tubes will be removed from a child
To administer analgesics before procedure
When should clear liquids be stopped before scheduled surgery? • Two hours before surgery • Six hours before surgery • The night before surgery at 8 PM • The night before surgery at midnight
Two hours before surgery
The nurse is caring for an unconscious 10-year-old child. Skin care should include which of the following? • Avoid use of a pressure-reduction device on the bed. • Massage reddened bony prominences to prevent deep tissue damage. • Use a draw sheet to move the child in bed to reduce friction and shearing injuries. • Avoid rinsing the skin after cleansing with mild antibacterial soap to provide a protective barrier.
Use a draw sheet to move the child in bed to reduce friction and shearing injuries.
The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like the child's younger brother had when he was an infant. The nurse should base a response on which information? • Meningitis rarely occurs during infancy. • Often a genetic predisposition to meningitis is found. • Vaccination to prevent all types of meningitis is now available. • Vaccinations to prevent pneumococcal and Haemophilus influenzae type B meningitis are available.
Vaccinations to prevent pneumococcal and Haemophilus influenzae type B meningitis are available.
Which of the following is a potential cause of a postoperative decrease in blood pressure? • Shock (early sign) • Carbon dioxide retention • Vasodilating anesthetic agents • Increased intracranial pressure
Vasodilating anesthetic agents
Immobilization causes which of the following effects on the cardiovascular system? • Venous stasis • Increased vasopressor mechanism • Normal distribution of blood volume • Increased efficiency of orthostatic neurovascular reflexes
Venous stasis
The nurse is caring for a child with multiple injuries who is comatose. The nurse should recognize that pain • cannot occur if the child is comatose. • may occur if the child regains consciousness. • requires astute nursing assessment and management. • is best assessed by family members who are familiar with the child.
requires astute nursing assessment and management.
The primary therapy for secondary hypertension in children is
treatment of underlying cause