Nursing Final multiple choice (chapter 72, 73, 74)

the nurse is caring for a child diagnosed with spina bifida. what would the nurse include in the plan of care? a. protect the child from lower extremity injury b. use latex medical products and equipment as much as possible c. monitor closely for development of pertussis d. provide thickened feedings orally or via G-tube insertion

A Rationale: the nurse would be careful to protect the child from injury to the legs secondary to loss of sensation. the child is not at a feeding risk, so typical age appropriate diet is acceptable. the child is not at a higher risk for pertussis than a child without spina bifida. latex allergies are common in children with spina bifida so latex items should be avoided.

which statement is true about children with school phobia? a. this condition is more common in boys than in girls b. these children are usually very good students c. this condition usually occurs before summer vacations d. these children do not get physically ill in reality

B Rationale: Children with school phobia are usually very good students. This condition is more common in girls than boys. School phobia usually occurs after summer vacations or after an illness. Often, children with school phobia may be so tense that they actually become physically ill.

The nurse is caring for a child pre-operatively with Wilms tumor. When following the plan of care for this child, what intervention is essential? a. Palpate the tumor to be sure it has not grown. b. Place a clear warning sign over the bed. c. Limit visitors d. Place the child in isolation

B Rationale: There should be a clear warning sign over the child's bed so that that palpation of the tumor is not performed since it may disseminate and cause spread of the cancerous cells. Visitors do not need to be limited and the child does not require isolation at this time.

the nurse is caring for a child newly diagnosed with muscular dystrophy. The parents ask the nurse what the goal should be for their child. What is the best response by the nurse? a. ensuring the child has adequate support systems to avoid being wheelchair bound b. maintaining physical function and preventing complications will be ongoing c. preventing the disease spreading to other siblings if very important at this time d. improving the disease and eventual cure using medications and treatment

B Rationale: there is no current cure for muscular dystrophy and treatment is aimed at maintaining physical functioning and prevention of complications.

a 10-month old baby is brought to the healthcare facility. the parents report the child's abdominal pain and passage of stool mixed with clear mucus and blood. the healthcare provider diagnoses it as a case of intestinal intussusception. What complication would the nurse monitor the client for following diagnosis? a. pain when voiding urine b. gangrene leading to bowel rupture c. distention of the abdomen d. inadequate weight gain.

B Rationale: intussusception is the telescoping of one bowel part into another. The bowel's blood supply may be blocked, causing gangrene and possible bowel rupture. intussusception does not lead to inadequate weight gain, distention of the abdomen, or pain when voiding urine.

the nurse is working with a child with attention deficit disorder. what nursing intervention would the nurse include in the child's care plan? a. focus on negative behaviors b. give just on direction at a time c. increase environmental stimuli d. use varying discipline approaches.

B Rationale: when working with a child with ADHD the nurse should give just one direction at a time so that the child is not overloaded with directions to remember and organize.

a school aged child visits the healthcare clinic with reports of watery blisters over the skin between the toes. what client teaching should the nurse provide for this client? SATA. a. avoid sandals and cotton sock b. frequently change the shoes c. avoid exposure of the feet to air d. wear flip-flops at swimming pools

B D Rationale: the client is advised to wear flip-flops at swimming pools because the fungal organism responsible for causing tinea pedis is often found in damp places and on the floor of public baths, showers, locker rooms, and pools. clients are instructed to frequently change their shoes or alternate between two pairs of shoes because the mircoorganisms live longer in the shoes and can further aggravate the condition.

an 18-yo client is admitted to the rehab center for polysubstance abuse. the client was addicted to smoking marijuana and tobacco and was regularly consuming alcohol. what damage could marijuana abuse cause to the client's central nervous system? SATA. a. disturbed equilibrium b. tactile hallucinations c. myocardial infarction d. perceptual difficulties e. personality changes

B D E Rationale: Effects of marijuana abuse on the client's central nervous system include tactile hallucinations, perceptual difficulties such as anxiety and irritability, and personality changes. Disturbed equilibrium results from the effects of marijuana abuse on the sensory system. Effects of marijuana on the cardiovascular system result in elevated blood pressure leading to acute myocar-dial infarction.

An Ashkenazi Jewish couple is suspected to be pregnant but concerned about the child having Tay-Sachs disease. For what testing option should the nurse prepare the mother? a. A complete blood count (CBC) at 16 to 18 weeks b. An MRI upon confirmation of pregnancy c. Chorionic villus sampling between 10 to 12 weeks d. An amniocentesis between 4 to 5 weeks

C Rationale: A mother can get prenatal testing via chorionic villus sampling (CVS) between the 10th and 12th week of pregnancy for testing of Tay-Sachs. An amniocentesis can be done between the 15th and 18th week of pregnancy. An MRI is not diagnostic of Tay-Sachs in the fetus. A CBC is not diagnostic of any form of hereditary disorders.

a 7-yo boy is brought to the healthcare facility with complaints of painful enlargement of the scrotum. Which term should be used to describe this condition? a. encephalocele b. meningocele c. hydrocele d. meningomyelocele

C Rationale: Hydrocele is the term used to describe the condition in which accumulation of serous fluid within the scrotal sac occurs, causing the scrotum to become large and painful. Encephalo-cele is a condition in which a portion of the brain protrudes through an opening. Meningocele is the condition in which one layer of the meninges protrudes through an opening in the vertebral column. Meningomyelocele is the condition in which the meninges and part of the spinal cord protrude through an opening.

an adolescent female client has been diagnosed with anemia due to nutritional deficiency. what dose would the nurse recommend the client to increase in the diet? a. calcium b. protein c. iron d. fat

C Rationale: iron intake is important, especially for girls beginning menses, to prevent iron deficiency anemia. the other nutrients listed are not significantly associated with anemia.

Which pregnant mother is at greatest risk for having a child with Down syndrome? a. A 25-year-old mother who smokes b. A 35-year-old mother with 4 children c. A 16-year-old mother without prenatal care d. A 45-year-old mother with a previous child with Down syndrome

D Rationale: Advancing maternal age increases the chances of giving birth to a baby with Down syndrome because the mother's eggs are older and at a greater risk of improper chromosomal division. A woman of 25 years has a 1 in 1,250 risk; by age 30 the risk is 1 in 1,000. Increasing significantly at the age of 35, the risk is about 1 in 350 and by the age of 40, the risk is about 1 in 100. At age 45, the risk is about 1 in 30. If a mother has already given birth to a Down syndrome child, she has a 1 in 100 chance of having another impaired child.

which statement about narcolepsy is true? a. it is associated with seizures and convulsions b. girls are affected more often than boys c. it is not associated with hallucinations d. it may be precipitated by an emotional disturbance

D Rationale: Narcolepsy may be precipitated by an emotional disturbance. There is no significant relationship between narcolepsy and seizure disorders. Boys are affected more often than girls. Hypnagogic hallucinations may occur in narcoleptic clients.

a newborn infant is diagnosed with Down syndrome. where would the nurse find Brushfield spots in the infant? a. irises b. hands c. tongue d. cheeks

A Rationale: Brushfield spots are characteristic white dots seen on the irises in children affected with Down syndrome. Brushfield spots are seen only on irises and not on hands, tongue, or cheeks.

a nurse is caring for a child with plumbism at the healthcare facility. which sign would the nurse observe in this client? a. blue line on the gums b. echolalia and coprolalia c. twitching of the nose d. scissors-like gait

A Rationale: blue line on gums is a sign of plumbism. nose twitching, echolalia, and coprolalia are signs of Tourette syndrome. Scissor-like gait is seen in cerebral palsy, whereas unsteady ataxic gait is seen in plumbism.

a 15-yo client is brought to the healthcare facility with complaints of loss of control during overeating, followed by purging. which sign and symptom must the nurse expect to find in the client during routine examination and care? a. feelings of guilt and depression are rare b. the client is usually underweight due to excessive vomiting. c. the client has a higher incidence of dental caries d. severe electrolyte imbalance is rarely seen.

C Rationale: Bulimic clients are at a higher risk of developing dental cavities and throat irritation because they recurrently vomit, causing the hydrochloric acid from the stomach to erode the enamel from the front teeth. Feelings of guilt and depression are common in clients with bulimia nervosa during binges. Bulimic clients are usually of normal weight or overweight. Electrolytic imbalances and even death are possible in clients with bulimia nervosa.

a nurse is caring for a 9-yo boy diagnosed with ADHD. which feature will the nurse notice in this client? a. takes good care of belongings b. continuously clears his throat c. has a poor attention span d. has difficulty talking

C Rationale: Children with ADHD have a distinc-tively poor attention span. These children do not take good care of their belongings and tend to lose them often. Children with ADHD do not tend to clear their throat continuously. This finding is seen in children with Tourette syndrome. Children with ADHD do not have any difficulty talking; instead, they often talk excessively.

an adolescent client with kyphosis is admitted to the healthcare facility to undergo a surgical procedure for correction of the skeletal defect. what will the nurse be able to observe in this client? a. intermittent limp on the affected side with hip pain, soreness, and stiffness b. lateral curvature of the spine, resulting in an S-shaped spinal appearance c. abnormal curvature of the thoracic spine resulting in a hunchback appearance d. exaggerated curvature of the lumbar spine and forward tipping of the pelvis

C Rationale: Clients with Kyphosis generally exhibit an abnormal curvature of the thoracic spine resulting in a "hunchback" appearance.

A child is diagnosed with chicken pox. What medication should the nurse inform the parents to avoid when treating the fever? a. Diphenhydramine b. Acetaminophen c. Ibuprofen d. Aspirin

D Rationale: Never give aspirin to the child with chickenpox, in order to protect against the danger of Reye syndrome. Diphenhydramine may be used in order to alleviate the itching caused by the lesions. Acetaminophen and ibuprofen may be used to control the fever caused by the virus.

a nurse is caring for a 10-yo client diagnosed with impetigo contagiosa. which symptom would the nurse expect to find in this client? a. distinct ring-shaped rash on the thighs and face b. pain, soreness, and stiffness of hip joints c. watery blisters over the skin between the toes d. honey-colored crust on the face and hands

D Rationale: client with impetigo contagiosa usually develop reddened vesicles over the face and hands, which break open and leave a sticky, honey-colored crust.

when observing a young adolescent client sleeping in a hospital room, the nurse notes the client stops breathing for short periods of time. the nurse recognizes this condition as: a. narcolepsy b. somniloquism c. somnambulism d. sleep apnea

D Rationale: the nurse recognizes this as sleep apnea, which is marked by cessation of breathing for short periods while sleeping.

a 2-yo child with significant behavioral changes, lack of response to verbal stimuli, and a dislike of being touched or cuddled is diagnosed as autistic. which is a feature of autism spectrum disorder (ASD)? a. it is not actually a disease but a syndrome of specific behaviors b. autism spectrum disorder usually has a well-identified cause c. compared to boys, more girls are affected with autism d. autistic children typically demonstrate a profound loss of hearing

A Rationale: Autism spectrum disorder is not actually a disease but a syndrome of specific behaviors that vary widely. Autism is characterized by intellectual, social, and communication deficits. The cause of ASD is unknown. Statistics show that more boys are affected with autism than girls. Autistic children typically demonstrate a profound loss of social interaction and not hearing loss.

which symptom is seen in clients with diabetes mellitus type 1? a. increased thirst b. decreased urine output c. increased weight gain d. decreased hunger

A Rationale: Clients with diabetes mellitus type 1 abruptly experience increased thirst (polydipsia) as a classic symptom. The other classic symptoms of diabetes mellitus type 1 are increased hunger and increased urinary output. Diabetes mellitus is usu-ally accompanied by weight loss or failure to gain weight.

A parent brings a school-age child to the clinic with a sore throat due to a streptococcus infection. What should the nurse be sure to inform the parent to do if drooling or difficulty breathing occurs? a. Seek immediate medical attention. b. Gargle with warm saline solution. c. Use ibuprofen to decrease the swelling. d. Increase the dose of the antibiotic.

A Rationale: Often, a sore throat is an early indicator of more serious problems. When a sore throat occurs, monitor the individual for fever, dry mouth, drooling, difficulty breathing, poor skin turgor, lethargy, decreased intake and output, headache, and few or no tears when crying. A healthcare provider needs to be contacted if breathing or swallowing difficulty develops, pus forms on the back of the throat, a body rash develops, or blood-tinged secretions occur. Excessive drooling may indicate a swollen esophagus or blocked trachea caused by inflammation.

A child is found to be asymptomatic but tests positive as a carrier for diphtheria. What action does the nurse anticipate providing? a. Informing the parents about the importance of adhering to prophylactic antibiotics b. Informing the parents that the child will need to be quarantined c. Informing the parents that the child will eventually get the disease d. Informing the parents that the child will have to take antiviral medications for at least 6 months

A Rationale: People who show no symptoms of diphtheria may be carriers and are treated prophylactically with antibiotics. With the use of antibiotics, quarantine is not required. The pathogen is a bacteria and not a virus so the use of antivirals will not be effective for diphtheria. The child that is a carrier will not get the disease and remains asymptomatic.

A school-aged child is diagnosed with the common cold. The parent is concerned that the child did not receive an antibiotic and wants to know how the child can get rid of the cold without it. What is the best response by the nurse? a. A virus causes a cold and antibiotics are used for bacterial infections. b. Your primary care provider must have forgotten to write the prescription. c. An antibiotic will worsen the cold symptoms. d. If the cold is not better in 3 days, an antibiotic will be prescribed.

A Rationale: The cold is caused by a viral infection and is not treated with an antibiotic. Antibiotics are ineffective as an agent to treat viruses but they do treat bacterial infections. The healthcare provider needs to be called if symptoms worsen or persist longer than 7 to 10 days. High-risk individuals are more likely to develop complications such as pneumonia. An antibiotic is not effective but it will not make the symptoms worse.

A child with attention deficit hyperactivity disorder is taking methylphenidate (Ritalin). What instructions should the nurse give the parents? a. Measure height, weight, and plot on growth chart. b. Give several directions at one time so the child can learn to prioritize. c. Alter routines to prevent boredom d. Point out negative behaviors.

A Rationale: The height and weight of the child on stimulants (Ritalin) should be measured at frequent intervals and plotted on a growth chart. Failure to gain in either area should be reported. Teach family caregivers to minimize environmental stimuli, use consistent discipline, set limits, and focus on positive behaviors. Encourage caregivers to give directions one step at a time, e.g. brush your teeth or wash your face and hands. Avoid generalizations such as "get ready for school." They should give the child just one direction at a time so that the child is not overloaded with details to remember and organize. Praise such as "good job" is more effective than criticism.

A nurse is required to care for a 4-yo with sickle cell anemia. which should the nurse include in the parent teaching? a. avoid cold environments and high altitudes b. practice handwashing to prevent disease transmission c. give oral rehydration supplements to prevent dehydration d. avoid gluten-containing food supplements

A Rationale: The nurse should instruct the parents to avoid cold environments and high altitudes, because cold environments may worsen the clumping of red blood cells. Sickle cell anemia is not a communicable disease, so providing instruc-tion such as practicing handwashing to prevent disease transmission is unnecessary. Oral rehydra-tion supplements are prescribed in the case of diarrhea. Gluten-containing foods are avoided in clients with celiac disease.

A newborn is observed to have tremors, hyperactive reflexes, a high-pitched cry, and irritability. What action does the nurse anticipate performing first? a. Obtain urine and meconium for drug screen. b. Report the mother to child protective service. c. Increase stimulation of the newborn. d. Withhold all feedings.

A Rationale: The symptoms described may be indicators of maternal drug use that has been transferred to the neonate. Diagnosis of drug use is based on observation of the infant's behaviors and toxicology tests. A drug test may be done by urine. Meconium (the first bowel movement) may be tested for drugs. A maternal drug history may be helpful; however, the mother may deny use of any drugs for fear of legal repercussions. Facilities may require notification of child protective services if illicit drugs are suspected or confirmed after results of drug screens. It is also important to rule out other disorders that may mimic symptoms of drug effects in the neonate. The nurse should decrease rather than increase the stimulation of the neonate. Withholding feedings is not an appropriate intervention for the neonate; rather, ensure adequate nutrition.

a 10-yo client is brought to the healthcare facility with multiple superficial cuts on both his wrists. the client is reported to be unusually quiet and has lost interest in playing following the divorce of his parents. the client is diagnosed with severe depression, which has led to the suicide ideation. which intervention should the nurse perform for this client? a. consider using a no-suicide contract with the child b. arrange for short-term psychological counseling c. provide intensive and long-term psychological counseling d. avoid hospitalization in children with severe depression

A Rationale: consider using a no-suicide contact with the client, as children tend to keep their word.

the nurse is working with a group of adolescent girls at a summer. which assessment findings would alert the nurse to further assess a camper for anorexia nervosa? a. a camper has calloused kuckles and poor dentation b. a camper seeks treatment for sun burnt skin on shoulders c. a camper eats without conversation at lunch with peers d. a camper request to have a vegan diet offered during the camp

A Rationale: the adolescent with anorexia may exhibit calloused knuckles from repeated induction of vomiting and may have loss of tooth enamel from the repeated vomiting.

a nurse is caring for a child with celiac disease. what foods, if served on the meal tray, would alert the nurse to hold the food until verification can be done? SATA a. lunch meat sandwich with oat bran bread b. honey oat cereal c. processed vanilla ice cream d. steamed green beans with apple slices e. gluten-free pasta with fresh fruit salad

A B C Rationale: the nursing care plan should include strict adherence to a gluten-free diet, including foods such as fruits, veggies and products labeled as "gluten free". celiac disease is caused by intolerance to the protein gluten. protein gluten is found in wheat, oats, barley,and rye. gluten is also found in prepared soups, processed ice cream, cakes, cookies, pastas, and some milk products.

a 10-yo child with reports of stuttering is diagnosed with speech impairment. the client's hearing is tested and found to be intact. what important consideration should the nurse make when caring for clients with speech difficulties? SATA. a. encourage the client to listen b. promote the use of pictures c. allow the client to say each word slowly d. repeat instructions often e. use a recorder to reinforce information

A B C Rationale: when providing care for clients with speech impairments, the nurse should encourage them to look at pictures to promote understanding. Children should be encouraged to listen and to say each word slowly and clearly to promote understanding at the child's developmental level.

the nurse is caring for a school aged child with reports of abdominal pain, bloody diarrhea, and a loss of 10lbs in the last 9 weeks. what interventions would the nurse include in the plan of care for this client?. SATA. a. refer the client/family to resources and support groups b. prepare the client for a colonoscopy procedure c. obtain a stool sample as ordered d. instruct on a diet that eliminates trigger foods e. encourage the client to avoid vitamin supplements

A B C D Rationale: the client is exhibiting Crohn disease. the nurse would prepare to assist in diagnostic procedures such as stool sampling and colonoscopy. the client would be taught to avoid dietary components that exacerbate symptoms. the nurse would be a good listener and provide resources and support group info to the client and family. the nurse would encourage the use of supplements as prescribed due to the decreased nutrient intake noted with bowel disorders.

a 9-yo client with chronic ulcerative colitis is being cared for at the healthcare facility. Which of the following would the nurse expect to find in such a client? SATA. a. weight loss b. growth delays c. constipation d. anorexia e. precocious puberty

A B D Rationale: Clients with chronic ulcerative colitis generally develop symptoms of weight loss, growth delays, and anorexia. The client usually experiences severe diarrhea, which may be bloody, and not constipation. If chronic ulcerative colitis occurs before puberty, it can lead to a delay in the appearance of secondary sexual characteristics and the onset of puberty. It does not cause precocious puberty.

An adolescent client is diagnosed with irritable bowel syndrome and the nurse is providing nutritional information to assist the client with control of symptoms. What food triggers should the nurse suggest the client avoid? Select all that apply. a. Fatty foods b. Dairy products c. Chicken and fish d. Alcohol e. Bread and pasta

A B D Rationale: Treatment is palliative. Initially, a food diary (record of what is eaten) is helpful. If a specific food, condition, or stressful situation is identified as a possible trigger, actions need to be taken to avoid the issue. Educate the client and other caregivers to avoid common triggers such as caffeine, fatty foods, dairy products, and alcohol. Chicken, fish, and breads, and pastas are generally well-tolerated and not usually seen as a trigger.

A client is diagnosed with hemochromatosis. What should the nurse be sure to include when reinforcing education? Select all that apply. a. Avoid vitamin C supplements. b. Avoid iron supplements .c. Avoid vegetables. d. Avoid eating raw shellfish. e. Avoid alcohol intake.

A B D E Rationale: Nursing implications for the treatment of hemochromatosis include teaching the client methods that will help prevent complications. Avoid iron supplements, multivitamins containing iron, and vitamin C. Vitamin C, especially if taken with food such as orange juice, will increase the absorption of iron. Avoid eating raw shellfish because individuals with hereditary hemochromatosis are more susceptible to infections caused by bacteria in raw shellfish. Avoid alcohol, which has the risk of increasing liver damage. Drink tannin-rich teas that may slow the storage of iron. Avoiding vegetables will not affect a client with hemochromatosis.

a 10 month old baby who had a facial deformity has undergone cheiloplasty. which of the following should be included in the postoperative care plan? SATA. a. apply a tongue-blade arm restraint b. use a straw to feed the baby c. give the child water after the formula feed d. cleanse the suture line after each feeding e. position the child on the abdomen

A C D Rationale: During the postoperative care of a baby who has undergone surgery for cleft lip, the nurse should apply a tongue-blade arm restraint to prevent the child from bending the elbows to touch the suture line. The child should be positioned on the back or side but not on the abdomen, to prevent the child from rubbing the surgical site against the bed. The suture line should be cleansed after each feeding with the prescribed solution for rapid healing and to prevent undue scarring. The child should be given water after the formula to remove mucus. A straw should not be used for feeding, unless ordered by the healthcare provider, because the use of a straw may cause pressure on the surgical site.

which of the following distinctive physical features should the nurse associate with fragile X syndrome in a client? SATA. a. long face b. small head c. large ears d. broad nose e. low palate

A C D Rationale: Long face, large ears, and broad nose are the typical physical features in clients with fragile X syndrome. Children with fragile X syn-drome typically have a large head and not a small head. They also have a high-arched palate and not a low palate.

an 8-yo child diagnosed with infectious mononucleosis. which nursing considerations should the nurse employ when caring for the client? SATA. a. instruct the client to avoid strenuous exercise and contact sports b. administer measured doses of antibiotics to the client c. administer measured doses of systemic steroids to the client d. administer analgesics and encourage the client to rest e. administer antiviral meds to the client to decrease severity of illness

A C D Rationale: clients with infectious mono are generally advised to avoid strenuous exercise and contact sports because of the risk of rupture of the client's spleen during the first 2-4 weeks of illness. analgesics provide symptomatic relief to clients with mono. systemic steroids help in reducing severe pharyngeal inflammation and edema. mono is a viral infection, therefore, administering antibiotics to the client will not be beneficial unless a bacterial infection is diagnosed with the virus. anitviral meds are no longer recommended and may lengthen recovery time.

which of the following symptoms would the nurse expect to find in the client with lyme disease? SATA. a. intellectual impairment b. watery blisters that burn and itch c. arthritis resembling rheumatoid arthiritis d. honey-colored crust over the face and hands e. psychiatric disturbances

A C E Rationale: Many clients with Lyme disease complain and exhibit symptoms of intellectual impairment, psychiatric disturbances, and arthritis resembling rheumatoid arthritis many weeks after the tick bite. A honey-colored crust over the face does not occur in clients with Lyme disease; this is usually seen in clients with impetigo contagiosa. Watery blisters that burn and itch are not seen in clients with Lyme disease, but rather in clients with tinea pedis.

a 2-yo child with distended abdomen and absence of stool is diagnosed with cystic fibrosis. the client is prescribed a pancreatic enzyme preparation and some fat-soluble vitamin supplements. which of the following nursing care measures should be followed when caring for the child? SATA a. administer water-soluble forms of fat soluble vitamins b. restrict salt in client's diet plan c. monitor the weight frequently d. provide a low-calorie, low-protein, moderate-fat diet e. give a pancreatic enzyme preparation along with cold milk

A C E Rationale: When caring for a child with cystic fibrosis, the nurse should provide food containing supplementary water-soluble forms of fat-soluble vitamins, because such clients have poor fat diges-tion. Frequent monitoring of the weight of the client is necessary. The nurse need not restrict salt in the client. High-calorie, high-protein, moderate- fat food should be included in the client's diet plan. The nurse should give the pancreatic enzyme preparation along with cold, not hot, milk, because heat can decrease the activity of the enzyme.

an 8-yo client has been diagnosed with ADHD by the healthcare provider. The client lives with her grandparents, who are very old and have a low family income. What special nursing considerations should be kept in mind when providing care for such clients? SATA. a. be aware of the client's economic condition b. encourage homebound education c. encourage participation in age-appropriate activities d. emphasize the importance of regular follow-up care e. observe and document functional level of the child

A D E Rationale: The nurse plays an important role in providing special considerations to children with special needs. These special considerations include being aware of the client's condition, emphasizing the importance of regular follow-up care with the healthcare team to provide efficient treatment, and observing and documenting the functional level of the child. All of these measures help in providing effective treatment to the child. Accord-ing to federal laws, education must be provided for children with special needs. Homebound educa-tion may be necessary only during acute episodes of illness. Children should be encouraged to par-ticipate in activities appropriate to their develop-mental level, and not necessarily their age.

a nurse is caring for a newborn with neonatal abstinence syndrome. which action should the nurse take in caring for this client? SATA. a. using pacifiers b. increased environmental stimulation c. frequent handling d. rocking e. swaddling

A D E Rationale: a nurse caring for a newborn with neonatal abstinence syndrome should use swaddling, rocking, and pacifiers to provide supportive care. the nurse should handle the infant minimally but gently and should try to decrease environmental stim.

a 14-yo client is admitted to the healthcare facility with complaints of headaches, low-grade fever, anorexia, and cervical lymphadenopathy. ON further evaluation, the client is diagnosed with acute infectious mononucleosis. which fact about mononucleosis must the nurse keep in mind when caring for the client? a. mononucleosis is caused by a bacterial infection b. upper airway obstruction can occur in clients with mono c. systemic steroids are always avoided in client with mono d. mono is often spread through food and water

B Rationale: Clients with mononucleosis can develop upper airway obstruction along with severe dysphasia and dehydration during the first week of the acute phase. Acute infectious mono-nucleosis is a viral infection caused by the Epstein-Barr virus, which is one of the herpesviruses. Systemic steroids may be used in clients with mononucleosis to reduce the severe pharyngeal inflammation and edema. Infectious mononucleo-sis typically infects the salivary glands and is trans-mitted by droplets in saliva, coughs, sneezes, and direct contact with mucous membranes.

a 5-yo client is brought to the healthcare facility with symptoms of intermittent limp on the left side and hip pain or soreness and stiffness. after further examinations, the client is diagnosed with Legg-Calve-Perthes disease. Which teaching must the nurse provide for the client's family members? a. the client should be on bed rest for an extended period b. the disorder is self-limited and often resolves spontaneously c. the client needs to move his leg frequently during bed rest d. application of heat in the form of whirlpool treatment is helpful

B Rationale: Legg-Calvé-Perthes disease is a self- limited and spontaneously resolving condition; therefore, sudden recovery can be anticipated as the child grows. Extended bed rest and immobilization of the child's hips was earlier considered to be necessary; however, keeping a child on bed rest for an extended period is often difficult. For successful treatment of clients with Legg-Calvé-Perthes disease, the client's parents must ensure that the client does not move his legs often during bed rest. Application of heat in the form of whirlpool treatment is helpful in juvenile rheumatoid arthritis and not in Legg-Calvé-Perthes disease.

An adolescent is treated for bacterial conjunctivitis. What instruction should the nurse include when discussing care? a. Save the eye drops not used in case the infection comes back. b. Avoid touching or rubbing the area around the affected eye. c. Contact lenses may continue to be worn during treatment. d. Use a little bit of saliva on the contact lenses to clean them.

B Rationale: Nursing considerations for conjunctivitis include teaching awareness of and avoiding touching or rubbing the area around the eyes. If contacts are worn, discharge instructions typically include guidelines to remove and discard any contact lenses, storage solutions, or storage containers. Regular glasses need to be worn during the entire time of the infection. There is a high probability of recurrent conjunctivitis due to cross-contamination if lenses or storage supplies are not replaced. Never use mouth saliva on a lens. Conjunctivitis in contact lens wearers can be an early symptom of more severe and permanent eye damage.

an 11-yo client with somniloquism is referred to the healthcare facility by the family healthcare provider. which symptom would the nurse expect to find in the client during initial examination and case history recording? a. cessation of breathing for short duration during sleep b. logical conversation or talking while sleeping c. difficulty in falling asleep due to an emotional problem d. walking, usually during the later stages of non-REM sleep

B Rationale: Somniloquism is a sleep disorder in which the client talks in the sleep. Cessation of breathing for short durations during sleep is generally seen in clients with sleep apnea. Difficulty in falling asleep is especially noticed in clients with insomnia. Walking in the later stages of non-REM sleep is a characteristic feature of clients with somnambulism.

A parent of a newborn asks the nurse, "When should I start introducing solid foods into my child's diet?" What is the best response by the nurse? a. "Whenever you feel like your child is still hungry after eating" b. "When your child is about 4 to 6 months old" c. "You can start in a couple of weeks with rice cereal in the bottle." d. "After the child drinks 6 oz of milk without hunger satisfaction."

B Rationale: The introduction of solid foods may begin at 4 to 6 months of age when the GI tract has matured and is less sensitive to potentially allergenic foods. Rice cereal should not be placed in the bottle. Solid foods should be given with a spoon. If the child is still hungry after drinking 32 ounces of formula, they may be ready for solid foods

a 5yo child is diagnosed with iron deficiency anemia. the physician has prescribed administration of iron-containing preparations. which should be taken into consideration when administering iron-containing preparations to the client? a. administer the preparation along with food to enhance absorption b. dilute the liquid iron preparation with water before administration c. avoid rinsing of the mouth after ingestion of the prepartation d. aboid giving orange juice along with the medicine.

B Rationale: The liquid iron preparation should be well diluted with water or fruit juice before admin-istration. Iron preparations should be given on an empty stomach to enhance absorption. Orange juice can be administered with iron preparations; it helps to enhance the body's iron absorption. The mouth can be rinsed to reduce staining after administration of the iron preparation.

a nurse is required to care fora 10-month old baby who has undergone palatoplasty for repair of a cleft palate. which nursing care measure should be employed when caring for the child? a. avoid position the child on the abdomen or the side b. discourage the child from sucking or blowing c. avoid feeding the child using a spoon d. always use a nipple or straw to feed the child

B Rationale: The nurse should discourage the child from sucking and blowing, because sucking can cause strain in the suture line, and blowing can force fluids into the eustachian tube. The nurse should position the child on the abdomen or the side to decrease choking and danger of aspiration. The child can be fed from the side of a spoon, but the nurse should not insert the spoon into the child's mouth. The nurse should not use a nipple or straw to feed the child.

a neonate born to a client who used narcotic analgesics during the last trimester of her pregnancy is diagnosed with neonatal abstinence syndrome. which feature would the nurse observe in the baby? a. blue-black line on the gums b. hyperactive Moro reflex c. positive Gowers sign d. White spots on the iris

B Rationale: The nurse should look for hyperactive Moro reflex in clients with neonatal abstinence syndrome. A blue-black line on the gums near the teeth is seen in clients with lead poisoning. Positive Gowers sign occurs as a characteristic feature in clients with Duchenne muscular dystrophy. White spots on the irises are a distinctive feature in children with Down syndrome.

a young adolescent girl is diagnosed with juvenile rheumatoid arthritis (JRA). which nursing measure must the nurse employ when caring for this client? a. avoid giving hot baths or whirlpool treatment b. exercise the client's limbs during the acute stage c. encourage the client to perform daily activities on her own d. ensure that the diet does not contain dairy products

B Rationale: during the acute stage of JRA, the nurse should assist in the exercising the client's legs to improve the circulation and prevent complications. Nurses are often asked to assist clients with JRA by applying heat in the form of hot baths, packs, or whirlpool treatments. Restriction of dairy products is not necessary for clients with JRA.

a nurse is caring for a 2 month old child who has undergone surgery for pyloric stenosis. which should the nurse do as part of the post op care? a. start glucose water feeding immediately after surgery b. bubble the baby as frequently as possible during feeding c. schedule care to provide bath only after feeding d. position the baby supine with the head remaining flat

B Rationale: during the post op care for a baby who has undergone surgery for pyloric stenosis, the nurse should bubble the baby frequently to remove fundic gas. the care should be scheduled such that bathing is done before, not after, the feeding. the baby should be positioned on the right side with his or her head slightly elevated. glucose water feeding should be started 2 to 3 hours after surgery, and not immediately after surgery.

a school aged child has a diagnosis of DM type 1. how can the nurse best assist this client in managing this condition? a. encourage the child to maintain a sedentary lifestyle as much as possible b. encourage the child to self-administer his injections as soon as possible c. explain only a healthcare professional should test the child's blood glucose level d. caution the child to avoid summer camps and overnight camps

B Rationale: the nurse should encourage the child to self-administer his injections as soon as possible. the nurse should also encourage the child to exercise, to test his own blood glucose level, and to attend summer camps for diabetic children so that he can gain the understanding that other children share his condition.

A 10yo girl complains of frequent urination and pain during micturition. On further examination, she is diagnosed with a urinary tract infection. What instruction should the nurse provide to prevent urinary tract infection in the future? SATA a. wipe the perineal area from back to front b. drink plenty of cranberry juice and water c. take a bubble bath to prevent irritaiton d. use white, unscented toilet paper e. wear loose, white cotton panties

B D E Rationale:The nurse should instruct the client to drink plenty of cranberry juice and water; to wear loose, white cotton panties; and to use unscented white toilet paper. The nurse should also instruct the client to wipe the perineal area from front to back, instead of from back to front. The nurse should also inform the client not to take bubble baths, because they can be irritating.

a 12-yo client with degenerative disorder of the basal ganglia and cerebellum is admitted to the hospital for special nursing care and attention. the client is instructed to stay in the hospital for an extended period. which is most important during the long-term care of such clients? a. allow two to three nurses to assist in caring for the client. b. allow the client to learn self-care fradually c. explain treatments just before they are done d. keep the client away from social contacts

C Rationale: During long-term care, the treatments should be explained to the client just before they are done, to avoid confusion and apprehension. A client receiving long-term care should have the same nurse for providing assistance, which helps the client develop trust in the nurse. The client should be allowed to learn self-care as soon as possible and not gradually. Clients should be allowed to maintain social contacts with others to encourage socialization.

a client diagnosed with Ewing sarcoma is admitted to the healthcare facility with excruciating pain in his left leg. Which fact should the nurse provide to the client's family members? a. the growth of tumors is often slow in children b. cancer cells rarely spread to the lungs in children c. this cancer can also involve flat bones in the body d. this cancer is more often seen in children younger than 6 years of age

C Rationale: Ewing sarcoma is a bone malignancy that arises from the bone marrow and affects the long and also the flat bones. Tumors often tend to grow faster in children than in adults. The cancer cells spread by way of the circulation system, often to the lungs first in children. Ewing sarcoma is more common in young men between 10 and 20 years of age and not in children younger than 6 years of age.

a nurse is required to care for a 5-yo child who is in a cast with traction after a fracture of the right femur. which should the nurse monitor to check the blood circulation toward the injury? a. heartbeat b. urine color c. skin color d. blood pressure

C Rationale: It is important to check the blood circulation toward the injured area after applying a cast and traction. Observing skin color, sensitivity, temperature, motion, and pulse distal to the injury can help check blood circulation. Checking the blood pressure, heartbeat, or urine color does not help to determine the blood circulation toward the injured area.

an 11-yo child with Down syndrome is hospitalized to undergo minor dental surgery. which nursing measure should the nurses perform when caring for this client? a. assist with all activities of daily life b. avoid using child's personal items c. note any verbal or nonverbal expressions d. give a detailed explanation of the surgery

C Rationale: The nurse should note any verbal or nonverbal expressions, because nursing care is based on the client's unique responses to the stress of illness. Assistance should be offered as needed, and not with all activities of daily living, in order to minimize the feelings of frustration. Use of personal items should be recommended to reduce the level of stress and promote the child's comfort. Explanation of the surgical procedure should be simple, in a manner the child can easily understand.

a nurse is caring for children with specific disabilities in a pediatric rehab center. what special consideration should the nurse keep in mind when helping in behavior modification of these children? a. teach feeding skills in group b. use baby talk with those who have speech impairments c. praise them for all work that is done well d. do not allow family members to interfere

C Rationale: The nurse should praise the children for all work that is done well and refrain from punishing them even if they are not able to do something as directed. Feeding and dressing skills are better taught in a quiet place away from distraction and not in a group. Baby talk should not be used with children who have speech impairments. Involving family members in their care helps ensure that the children feel a sense of belonging to the family. Family members should be included in the care of such children as feasible.

An adolescent arrives in the clinic reporting a rash and feeling "flu-like" after finding a tick embedded in the leg 2 weeks ago on a camping trip. What does the nurse anticipate discussing with the teen? a. The laboratory results that will give a definitive diagnosis b. The use of physical therapy to prevent contractures from arthritis c. The use of an antibiotic for 2 to 4 weeks d. Hand washing to prevent disease transmission

C Rationale: Treatment consists of 2 to 4 weeks of antibiotics (doxycycline, amoxicillin, erythromycin). Early treatment usually prevents the development of more serious illnesses and long-lasting systemic illness. Laboratory results do not give a definitive diagnosis so treatment with antibiotics is used. Arthritic symptoms may occur if the child is not treated as well as other complications of the disease. Handwashing will not prevent disease transmission

a nurse is required to care for a 9-yo child who has Wilms tumor. which nursing care measures should be employed when caring for the child? a. take tympanic temp to reduce hemorrhage b. gently touch or move the child to prevent injury c. avoid palpating the abdomen preop d. give gavage feedings or parenteral nutrition

C Rationale: When caring for a client with Wilms tumor, the nurse should not palpate the abdomen unnecessarily. Doing so could cause rupture and dissemination of the tumor. The nurse need not take tympanic temperatures to reduce hemorrhage in the case of Wilms tumor. When caring for a client with spina bifida, the nurse should gently touch or move the child to prevent injury. Hydrocephalic clients are fed through gavage feedings or parenteral nutrition.

a 7-yo child was admitted to the healthcare facility because of frequent passage of loose and watery stools. The healthcare provider diagnoses it as a case of diarrhea. which should be included in the nursing care plan for the child? a. encourage the late reintroduction of regular nutrients b. provide only clear fluids and juices to the child c. observe the child for any signs of dehydration d. cover the child's buttocks to prevent contact with air.

C Rationale: When caring for a client with diarrhea, the nurse should observe the child for any signs of dehydration. The nurse should encourage the early reintroduction of regular nutrients. Clear fluids and juices are inadequate because they are high in carbohydrates but low in electrolytes. Instead, the nurse should provide oral rehydration solution (ORS) and other low-carbohydrate food supple-ments to the client. The nurse should expose the child's buttocks to air as much as possible to prevent maceration of the skin.

The nurse is preparing to administer immunizations to an infant. The parent states, "Won't those vaccinations give my child autism?" What is the best response by the nurse? a. "There is always a possibility but it would be worse to get the diseases." b. "That only occurs with children who have weak immune systems." c. "Recent research shows no connection between vaccines and autism." d. "You can refuse them but your child won't be able to go to school."

C Rationale: Your major responsibility, as a nurse, is to stress to families with children the importance of up-to-date immunizations. Numerous clinical studies have demonstrated that immunizations are safe, even for newborns, and may be administered as recommended. The persistent myth that autism is associated with immunizations has been disproven by numerous scientific studies. The nurse does not have evidence to prove that there is a possibility. Some children that are immunocompromised may have complications related to the use of live viruses but not autism. Informing parents they can refuse, does not provide them with a rationale or address their fears.

which genetic disorder primarily affects children of Ashkenazi Jewish descent and involves the child becoming hypotonic, losing vision, and dying before 4 years of age? a. down syndrome b. neurofibromatosis c. tay-sachs disease d. fragile x syndrome

C Rationale: is an inborn error of metabolism, primarily affecting children of Ashkenazi Jewsih descent. syptoms begin at about 1yr of age. the child becomes hypotonic and loses vision. death usually occurs before 4 yrs.

a nurse is caring for a 3-yo child. the child is known to have PKU, a hereditary metabolic disorder. The nurse knows that which food item can be safely included in the child's diet plan? a. milk b. legumes c. oranges d. bread

C Rationale: oranges can be safely included in the client's diet plan. the client can have low-protein natural foods such as fruits, vegetables, and certain cereals. clients with PKU should avoid phenylalanine-containing foods such as most breads, eggs, meat, milk, cheese, legumes, nuts, and artificial sweeteners containing phenylalanine.

a 3-yo boy is diagnosed with otitis media. what further assessment question would the nurse ask the family? a. how often do you swim in a pool? b. has the child flown recently? c. do you smoke in the home? d. is the child exposed to loud noises?

C Rationale: passive smoke inhalation is one primary cause of otitis media. exposure to loud noises, pressure due to flying in an airplane, and swimming in a public pool are not primary causes of this condition.

a 5-yo cognitively challenged child is admitted to the pediatric rehab center. which measure may the nurse need to take when feeding this child? a. avoid flexing the child's head to prevent closure of the larynx against the epiglottis b. place the food in the center of the mouth, not on the side of the mouth c. encourage the child to move food around in the mouth with the tongue d. encourage the child to use the tongue to remove food from the spoon.

C Rationale: the nurse must encourage the child to move food particles around in the mouth with the help of the tongue, as this exercise prepares the muscles for speech.

a 7-yo boy at the healthcare facility with reports of multiple involuntary movements is diagnosed with Tourette syndrome. The nurse knows that which is true for Tourette syndrome. a. tics can be controlled for long periods b. tics remain constant in number c. tics worsen during stressful periods d. tic activity increases during sleep

C Rationale: the tip episodes worsen during stressful periods. Tourette syndrome is characterized by tics that manifest as multiple involuntary movements and uncontrollable vocalizations. they periodically change in number and do not remain constant. the client can control such tics for only a short period of time. During sleep, tic activity decreases rather than increases.

the nurse is educating a nursing student about the diagnosis of whooping cough (pertussis) for an 8-yo child. which statements would the nurse include in the teaching plan? SATA. a. salivary glands may become swollen and painful causing the child to have poor intake b. small read areas may appear on the client's face and continue throughout the disease c. the initial symptom include bronchitis and temp elevation and the cough worsens d. monitor the child closely for bronchopneumonia which is a serious complication e. whooping cough is transmitted through direct contact and through droplets

C D E Rationale: pertussis is transmitted mainly through direct contact and through droplets. bronchopneumonia is one of the serious complications of this disease. Bronchitis and slight temp elevation along with a worsening cough are the initial symptoms of this disease. small red areas over the face may be seen in measles , not in clients with pertussis cough. swollen and painful salivary glands are seen in mumps not in pertussis.

a 4-yo girls is admitted to the hospital with symptoms that include inadequate physical growth, retarded motor development, inadequate social response, and delayed language development. the nurse recognizes these as symptoms of what condition? a. plumbism b. sexual abuse c. torticollis d. failure to thrive

D Rationale: inadequate physical growth is termed failure to thrive. characteristic developmental symptoms include retarded motor development, inadequate social response, and delayed language development.

the nurse assesses a child and notes a pimple-like red rash. the child is observed scratching the area. the nurse would expect the healthcare provider to further assess the child for what condition? a. giardia b. pinworms c. pediculosis d. scabies

D Rationale: scabies are microscopic mites that burrow into the epidermis, where they live and lay eggs. the symptoms include a pimple-like red, itchy rash. They are transmitted easily among children and adults of all socioeconomic classes via direct, skin to skin contact.

a 10-yo girl is admitted to a same-day surgery center to have a tonsillectomy and adenoidectomy. which intervention would the nurse include in the post op care plan? a. encourage the child to drink warmed milk b. position the child supine with the head of the bed down c. encourage the child to drink OJ d. encourage the child to drink water.

D Rationale: the nurse should encourage fluids after the child is awake and fully responding. clear, bland fluids are best, milk tends to form a film in the throat. children usually accept popsicles, nonacidic fruit drinks, gelatins, and sherbet very well. the nurse should also position the child on the side or abdomen with the head of the bed elevated to prevent aspiration.

a 7-yo boy is admitted to the healthcare center. the nurse notes that he has a small, flat nose and upward, outward slanting eyes, along with sparse eyelashes, small and low set ears, and a downward curved mouth with protruding tongue. the nurse recognizes that this child has which condition? a. dyslexia b. fetal alcohol syndrome c. fragile x syndrome d. down syndrome

D Rationale: these are all characteristics of down syndrome.