Peds Exam 4

8. A nurse is caring for a child with suspected epilepsy. Which diagnostic test does the nurse facilitate as the priority for this child? A. Cerebral angiogram B. Electrocardiogram (ECG) C. Electroencephalogram (EEG) D. Lumbar puncture (LP)

ANS: C The EEG is the gold standard diagnostic test for a seizure disorder.

38. A child in the intensive care unit with tetanus will be receiving a neuromuscular blocking agent. Which intervention takes priority for this child? A. Monitor urinary catheter output hourly. B. Provide stimulation from TV or radio. C. Turn patient every 2 hours. D. Provide ventilator care to prevent pneumonia.

ANS: D The child receiving a neuromuscular blocking agent is completely paralyzed and needs ventilator support. Proper care is important to prevent pneumonia. Monitoring urinary output and turning the patient are important, but do not take priority over breathing. The child needs a quiet environment free of excess stimulation.

3. The pediatric nurse carefully monitors a patient's status by assessing the child's level of consciousness. The nurse understands that the Glasgow Coma Scale provides clues to which of the following? A. Encephalitis B. Irreversible coma C. Neurological impairment D. Neurological status

ANS: D The child's level of consciousness and the use of the Pediatric Glasgow Coma Scale, pupil response, and overall activity provide clues to the child's neurological status

25. A 4-year-old child is recovering from a modified Nuss procedure. Which is the priority intervention by the nurse? A. Ambulating the child as soon as allowed B. Encouraging food and fluids postoperatively C. Monitoring vital signs and wound drainage D. Playing with the child using pinwheels or bubbles

ANS: D The modified Nuss procedure is an open chest reconstruction for severe cases of pectus excavatum. Preventing pneumonia is a critical nursing action. Because this child is too young to use an incentive spirometer, "playing" with him or her using bubbles, pinwheels, or paper triangles the child can blow across the table accomplishes pulmonary hygiene. The other activities are important postoperative nursing interventions, but are not specific to this operation.

29. During assessment of a 6-year-old child with meningitis, the nurse places the child supine and attempts to put the child's chin on her chest. The child cries out in pain and flexes her knees. How does the nurse document this assessment finding in the medical record? A. Absent Moro reflex B. Exaggerated Grey-Turner sign C. Negative Kernig sign D. Positive Brudzinski sign

ANS: D Two assessment tests are used in evaluating a patient with meningitis: the Kernig sign and the Brudzinski sign. The nurse has demonstrated a positive Brudzinski sign. The Kernig sign is elicited by placing the patient supine with hips flexed and raising and straightening the leg. Pain behind the knee and resistance are abnormal findings possibly indicative of meningitis. The Moro reflex is done on infants. The Grey-Turner sign is bruising of the flanks, often accompanying pancreatitis.

7. A pediatrician asks a patient with a knee injury to squat. Which disorder is this patient suspected of having? A. Juvenile arthritis B. Muscular dystrophy C. Osgood-Schlatter disease D. Osteomyelitis

ANS: C The major symptom of Osgood-Schlatter disease is pain below the kneecap that is aggravated by activity and relieved by rest. Symptoms resolve around the time skeletal growth ceases (about puberty). The child experiences pain when asked to squat or extend the knee against resistance. This is a good indicator of Osgood-Schlatter disease.

47. A camp nurse reads on a medical history form that a camper has "drop attacks." What does the nurse understand about this condition? A. Atonic seizure activity B. Fainting spells C. Loss of consciousness D. Sudden muscle weakness

ANS: A "Drop attack" is an old term for atonic seizure activity.

1. A nurse is caring for a patient with juvenile arthritis during an exacerbation. The child weighs 95 lb (43 kg). The physician orders sulfasalazine (Azulfidine) to be given in two divided doses per day. The safe dose range for a single dose of this drug for this child is ____________________ mg per dose.

ANS: 645-1,075 The safe dose range for this drug is 30-50 mg/kg/day in two divided doses. If this drug is just being initiated, the dose begins at to the expected maintenance dose.

2. A nurse is completing a Pediatric Fall Risk Assessment on a child. The child has had no falls in the last 3 months, had surgery to repair a femur fracture on admission, is learning to use crutches, has a saline lock, is oriented to own ability, and is on narcotics. This child's fall risk score is ____________________.

ANS: 12 The child gets 3 points each for surgery, crutches, saline lock, and narcotics.

30. A 5-year-old child is hospitalized with osteomyelitis and will be going home in the next few days on intravenous (IV) antibiotics. Which action by the nurse is the most appropriate? A. Ensure that a valid permit for a PICC line is on the chart. B. Locate a pharmacy that will supply the IV medications. C. Research the patient's insurance for home infusion coverage. D. Teach the child about a PICC line using a doll.

ANS: A A child going home on IV antibiotics will need a PICC line inserted for home infusion therapy. The nurse should ensure that a consent for this procedure is on the chart. Researching pharmacies and infusion companies can be done by the social worker. Teaching the child with a doll is appropriate, but does not take priority over legal responsibilities.

37. A teen has a scoliosis curve of 35°. What treatment option does the nurse prepare the child and family for? A. Bracing B. Continued screening C. Exercise therapy D. Surgical intervention

ANS: A A curve of 35°is considered mild scoliosis. Bracing is the treatment of choice at this point. Continued screening is inappropriate, as the child has scoliosis. Research has shown that exercise alone does not improve outcomes. Surgical intervention is reserved for more serious cases.

23. A nurse is caring for an 8-year-old child hospitalized 2 days after open reduction and internal fixation (ORIF) of a femur fracture sustained in a motor vehicle crash. The child is now in a long-leg cast. Which assessment finding prompts the nurse to notify the health-care provider? A. A foul odor coming from the cast B. Child eating only 20% of meals C. Old dried drainage marked on the cast D. Request for pain medicine every 4 hours

ANS: A A foul odor coming from the cast may indicate an infection at the surgical site or at the fracture site. The nurse should notify the health-care provider. Loss of appetite may be from several causes: fatigue, stress, side effect of medications, dislike of hospital food, loss of industry (child is in Erikson's stage of industry vs. inferiority), trying to regain some control, pain, or fear of pain. The nurse needs to assess this situation further to determine the cause of this issue. Old drainage would not be worrisome; if the drainage continues to increase, the nurse should notify the health-care provider. At 2 days since surgery, wanting pain medication every 4 hours is not unreasonable.

13. A child is prescribed baclofen (Lioresal) via intrathecal pump to treat severe muscle spasms related to cerebral palsy. What teaching does the nurse provide the child and parents? A. Do not let this prescription run out. B. The medication may cause gingival hyperplasia. C. Periodic serum drug levels are needed. D. Watch for excessive facial hair growth.

ANS: A Abrupt discontinuation of intrathecal baclofen can cause drastic effects, such as high fever, altered mental status, and exaggerated rebound spasticity and muscle rigidity. The parents should ensure there is a supply of this drug on hand at all times to avoid these effects. Gingival hyperplasia and hirsutism are side effects of phenytoin (Dilantin). Serum drug levels are not obtained with an intrathecal medication.

22. A child is 3 hours postoperative, having had an open reduction and internal fixation (ORIF) of a type IV tibial fracture, which is now also casted. Which action by the nurse takes priority? A. Assess neurovascular status every hour. B. Change IV pain medication to oral pills. C. Provide an ice bag for 30 minutes every hour. D. Teach parents about activity restrictions.

ANS: A After surgery and/or casting, it is vital to assess neurovascular status, which is usually done with postoperative vital signs. Excessive swelling can disrupt circulation to the extremity, so the nurse assesses the child's neurovascular status frequently. Applying ice is also a good intervention, but not for more than 15 minutes at a time. When the child is tolerating oral foods and fluids, the nurse can switch to pain pills from IV narcotics. Teaching is important, but not as important as preventing injury from complications.

10. A nurse is conducting a sports fitness class for volunteer coaches. Which information provided by the nurse is the most appropriate? A. "Fractures heal more quickly in children because the bones are still growing." B. "Children are prone to fractures because their bones are weaker than adults' bones." C. "Ligaments are bands of fibrous tissue that hold muscles to the bones." D. "Once a child reaches adult height, bone development eventually stops."

ANS: A Although children are more prone to fractures than adults due to continued bone growth, because their bones are still growing, fractures heal quickly. Ligaments hold two or more bones or cartilages together. Bone is a dynamic tissue and continues to be developed and reabsorbed throughout life.

18. What would the nurse assess for in a child with a disturbance in the basal ganglia? A. Ataxia B. Hyperthermia C. Hypotension D. Incontinence

ANS: A Ataxia, or uncoordinated movements, may been seen in a child with a problem of the basal ganglia, which controls movement. Changes in temperature and blood pressure are more likely related to problems with the hypothalamus, and incontinence could signify a spinal cord problem.

30. A nurse is preparing to discharge a 10-year-old child who was diagnosed with bacterial meningitis. Which action by the nurse takes priority? A. Arrange home health-care visits for antibiotic infusions. B. Consult with physical therapy about a home exercise plan. C. Ensure the parents can plan high-protein meals. D. Make a social work referral for long-term care placement.

ANS: A Children with bacterial meningitis are often discharged with a PICC line in place for home IV antibiotic infusions. Depending on the needs of the child, the other options may or may not be appropriate.

43. A nurse is caring for a patient in Crutchfield tongs. Which assessment finding requires immediate notification to the health-care provider? A. Altered mental status B. Crusted drainage at pin sites C. Irritability and pain D. WBCs of 98,000/mm3

ANS: A Crutchfield tongs are inserted into the skull. Any alteration in mental status could signify a serious complication, such as infection or intracranial bleeding (both are rare but possible). The nurse would not need to report crusted drainage, irritability and pain, or a normal white blood cell count.

21. A student nurse is confused about the Monroe-Kelly doctrine. How does the registered nurse explain it to the student? A. Compensation for an increase in one of the skull's components B. Hypothesis about the length of a coma determining the outcome C. Immunomodulatory theory of an inborn resistance to rabies D. Theory that seizures change the neurons and provoke more seizures

ANS: A The brain consists of three components: brain matter, cerebral spinal fluid (CSF), and blood. Because the skull is a hard vault (after fontanels have closed), an increase in one of the components is not tolerated. The Monroe-Kelly doctrine states that in order to compensate for an increase in one of the components, there must be an equitable decrease in the other two components in order to prevent brain injury.

33. The parents of a child recently diagnosed with Duchenne's muscular dystrophy want to know if their infant twin daughters should be tested for the disease too. Which response by the nurse is the most appropriate? A. "No, Duchenne's muscular dystrophy is a sex-linked genetic disorder rarely affecting females." B. "No, infants the age of your daughters are too young to undergo testing for Duchenne's muscular dystrophy." C. "Yes, the earlier the diagnosis of any type of muscular dystrophy is made, the better the child's quality of life." D. "Yes, females are equally likely to have Duchenne's muscular dystrophy as are boys."

ANS: A Duchenne's muscular dystrophy is a sex-linked recessive disease that usually only affects males. Females with Turner's syndrome, in which the child only inherits one X chromosome from the mother, can be affected, but females are usually carriers. The infant twin daughters do not need to be tested.

36. A woman is considering a second pregnancy, but tells the nurse she is not sure she wants to get pregnant again because her first child was born with spina bifida. She is taking folic acid on the advice of her health-care provider. Which information can the nurse provide this woman? A. Alpha-fetoprotein testing can be done in pregnancy. B. Genetic testing is available for this condition. C. It is rare for two children in one family to be affected. D. Usually spina bifida affects only female children.

ANS: A During pregnancy, testing of maternal blood for elevated alpha-fetoprotein is available for an early indication of spina bifida. The other options are incorrect.

29. A child has been hospitalized with suspected osteomyelitis. The child's white blood cell count (WBC) is 22,000/mm3 and his C-reactive protein is 15 mg/dL. Which conclusion by the nurse is appropriate based on these laboratory values? A. The child has an infection somewhere. B. The child has osteomyelitis. C. The child is immunocompromised. D. These tests are not related to the condition.

ANS: A Elevations in WBCs and C-reactive protein indicate an infection is present, but are not specific for any one kind of infection.

22. A nurse is caring for four patients in the pediatric intensive care unit with head injuries or brain infections. Which child should the nurse see first? A. Blood pressure change from 110/58 to 134/40 mm Hg in a child with brain injury B. Child with brain injury who has vomited twice in 12 hours, now sleeping C. Child with meningitis who is irritable, complaining of a "bad" headache D. Oral temperature of 100.4°F (38°C) in a child with meningitis

ANS: A Hypertension (with widening pulse pressure), bradycardia, and changes in respiratory pattern are components of Cushing's triad, a late sign of increased intracranial pressure, indicative of impending herniation. The change in the child's blood pressure, including the widened pulse pressure (difference between systolic and diastolic pressures), is worrisome. A child with a head injury and minimal vomiting is not alarming. A child with a brain infection who is irritable with a headache needs attention, but not over the child with possible herniation. An oral temperature of 100°F would be expected in a child with a brain infection.

7. An ophthalmologist examining the eyes of a patient explains to the nurse that the patient has an irregular curvature or uneven contour of the eye, resulting in impaired light refraction that causes blurred vision at all distances. Which condition does the nurse inform the parents about? A. Astigmatism B. Hyperopia C. Myopia D. Strabismus

ANS: A In myopia, light rays do not reach the retina, causing blurred vision at a far range and clear vision at a close range. In hyperopia, vision is unclear at a close range and is clearer at a far range. Strabismus, or crossed-eye appearance, results in misalignment of the eyes. Astigmatism may be present at birth or acquired. Light rays are unevenly distributed in the eyes, causing blurred vision at all distances. This condition is associated with birth hyperopia and myopia.

17. A child who has been limping for several weeks is brought to the clinic and undergoes radiological studies. The results show osteonecrosis. Which information does the nurse plan to teach the parents about their child's condition? A. Non-weight-bearing status and mobility limitations B. Overcorrection with serial casting for 2-3 years C. Surgical correction with the Z-plasty technique D. Wearing and caring for a Browne splint

ANS: A Osteonecrosis is a cardinal sign of Legg-Calvé-Perthes disease. This disorder is frequently treated with non-weight-bearing status and bracing or casting. The other treatment modalities are used to treat clubfoot.

14. A parent calls the clinic to report that his child's cast seems to be looser than it was yesterday. Which instruction is most appropriate for the nurse to provide to the parent? A. "Bring your child in so we can evaluate the cast." B. "If the cast is loose, circulation won't be compromised." C. "Pad the top of the cast with a small towel so it fits." D. "This is not unusual; just keep your next appointment."

ANS: A Parents should be instructed to take their child to a health-care provider if a cast appears loose, damaged, or soft. The other answers are not appropriate.

37. An infant born with spina bifida with a repaired myelomeningocele is brought the emergency department, where the parents report that the infant is very fussy and is feeding poorly. Which nursing action takes priority? A. Assess the baby's fontanels for bulging. B. Attach a cardiac and respiratory monitor. C. Obtain and document the baby's vital signs. D. Try feeding the baby with sucrose water.

ANS: A Poor feeding and irritability are signs of increased intracranial pressure (ICP) in infants. A child with spina bifida is at risk for hydrocephalus, which can lead to increased ICP. A corroborating sign would be bulging fontanels. The nurse should quickly palpate the infant's fontanels. Monitoring the child and obtaining vital signs are important actions too, but palpating the fontanels can be done quickly as the nurse handles the child and performs other procedures. The nurse should not attempt to feed this baby now.

15. A faculty member is discussing systemic lupus erythematosus (SLE) with a group of nursing students. Which pathophysiological process does the nurse describe as the major problem in this disorder? A. Autoimmune process creates antigen-antibody complexes that damage tissues B. Genetic defect linked strictly to male offspring leading to organ damage C. Limited autoimmune process destroys tissues in specific target organs D. Rapidly progressive disease triggered by hormonal changes such as pregnancy

ANS: A SLE is an autoimmune disorder in which antigen-antibody complexes are formed and deposited widely throughout the body, damaging many organs and tissues. It is tied to a genetic disposition but is not solely genetic in origin; it affects females more than males. The destruction is widespread, not limited to a few target organs. The disease is characterized by exacerbations and remissions.

16. A parent of a child suspected of having systemic lupus erythematosus (SLE) asks why so many blood tests are being done. Which response by the nurse is the most appropriate? A. "Many of these blood tests look for possible organ damage from SLE." B. "SLE is a complicated disorder and is very hard to diagnose." C. "This is a very typical pattern of diagnostic blood tests we usually do." D. "We are also checking for other possible autoimmune diseases."

ANS: A The diagnostic workup for SLE is indeed complex, but many of the tests are done to determine if organ damage has already occurred and to obtain a baseline to which future tests can be compared. The other options are vague and do not really answer the parent's questions.

26. A child is going home with a distractor in place after surgery to repair syndactyly. Which discharge teaching is most important? A. Clean around the pin sites twice a day with soap and water. B. Don't pull the pins; they will gradually fall out on their own. C. Perform range-of-motion exercises to the affected fingers daily. D. Turn the screw with the Allen wrench twice a day for a week.

ANS: A The distractor uses pins placed in the bone fragments that extend through the skin. The parents need to care for the pins using soap and water to clean around the exit sites. The pins need to be removed surgically; they will not fall out on their own. Because the bones are pinned, range of motion is not possible. The Allen wrench is used to turn the screw on the distractor twice a week.

15. The pediatric nurse caring for hearing-impaired children teaches parents the recommended guidelines for communicating with their children. Which instruction is inconsistent with current guidelines? A. Ignoring any related stigmas B. Obtaining the child's attention before speaking C. Positioning yourself at the child's eye level D. Talking slowly and loudly to the child

ANS: A The following guidelines are used when communicating with the hearing-impaired child: obtain the child's attention prior to speaking, face the child when talking, position yourself at the child's eye level, talk slowly and loudly, modify the environment to reduce noise, and offer emotional support because the child may face stigmas related to his or her hearing loss.

46. A nurse is working with a teen who has epilepsy treated with carbamazepine (Tegretol). Laboratory results indicate a serum drug level of 2 µg/mL. Which action by the nurse is the most appropriate? A. Assess the teen for noncompliance. B. Document the results in the chart. C. Have the teen continue the regimen. D. Tell the teen to cut the dose in half.

ANS: A The therapeutic level of carbamazepine is 5-12 µg/mL. The nurse should assess the teen for noncompliance because this level is too low. It is also possible that the teen has grown since the last drug level was obtained and that he or she simply now needs a higher dose. The results should be documented, but the nurse should take other action. Because the level was too low, it is not appropriate to continue the drug regimen or to cut the dose in half.

43. An adolescent has frequent headaches accompanied by nausea and vomiting. What item is most appropriate for the nurse to include in the teaching plan for this adolescent patient? A. How to give him- or herself an injection of medication B. The maximum daily dose of acetaminophen (Tylenol) C. Ways to manage temporary ptosis or rhinorrhea D. What to do in case of a seizure during the headache

ANS: A These symptoms are characteristic of a migraine. Migraines can be treated with a variety of medications, including injectable sumatriptan (Imitrex). The nurse would determine if this medication was included in the treatment plan and offer related education. The child might also take Tylenol, in which case he or she needs to know the maximal daily dose, but that is not as specific for migraines as sumatriptan is. Ptosis and rhinorrhea are characteristic of cluster headache. Headaches are not generally accompanied by seizures.

21. A nurse is caring for a child who had an open reduction and internal fixation (ORIF) of a femur fracture 12 hours ago. The nurse finds the child pale and short of breath. What action by the nurse takes priority? A. Assess oxygen saturation while a coworker calls the physician. B. Assess and treat the child for pain or anxiety as needed. C. Raise the head of the bed to a 45°angle and reassess. D. Review the child's postoperative hemoglobin and hematocrit.

ANS: A This child appears to be experiencing a complication of fracture, which may include shock, fat embolism, deep vein thrombosis, pulmonary embolism, and infection. Shortness of breath should alert the nurse to a respiratory complication as a first priority. The nurse should have a coworker call the physician while obtaining other assessment data, including oxygen saturation, vital signs, and a respiratory assessment. Although it is possible that a postoperative hemoglobin and hematocrit are low enough that the child is experiencing shock, the priority steps in assessing and intervening are airway, breathing, and circulation (ABCs), so breathing comes before circulation. The child may have pain or anxiety, but these are not the priority. Raising the head of the bed may or may not be helpful, but the nurse first needs to assess oxygen saturation.

31. A nurse is caring for a child who had a sudden onset of muscle weakness beginning in the legs and progressing in an ascending fashion, but who otherwise appears healthy. Which laboratory result would confirm the nurse's suspicion about the origin of this problem? A. Elevated CSF protein B. Increased liver enzymes C. Leukocytosis D. Low hemoglobin

ANS: A This child has manifestations of Guillain-Barré syndrome. Elevated CSF protein in the absence of infection supports this diagnosis.

17. A student nurse is tutoring another student on anatomy and physiology. What does the tutor explain is the function of myelin sheaths on certain nerves? A. Allow rapid transmission of nerve impulses B. Assist in long-term storage of memories C. Prevent "cross-communication" between nerves D. Protect the nerves from temperature changes

ANS: A White matter in the brain consists of nerves coated with myelin sheaths, which allow nerve impulses to travel rapidly.

9. A pediatric nurse caring for patients in an emergency room performs an assessment of a child who survived a drowning incident. Which does the nurse assess when using the Orlowski scale on this child? (Select all that apply.) A. Arterial pH < 7.10 B. Comatose on admission to the emergency room C. No resuscitation efforts for more than 10 minutes after rescue D. Submersion time > 20 minutes E. Used for children who are 10 years of age or older

ANS: A, B, C According to the Orlowski scale, each item is assigned one point: 3 years of age or older, submersion time greater than 5 minutes, no resuscitation efforts for > 10 minutes after rescue, comatose on admission to the emergency room, and arterial pH < 7.10. If a child has a score of 2 or less, there is a 90% likelihood of a complete recovery. If a child has a score of 3 or more, there is a 5% rate of survival.

8. The pediatric nurse caring for a 3-year-old child with cerebral palsy (CP) prepares a home care teaching plan for the caregivers on discharge. Which items will the nurse include in the teaching plan? (Select all that apply.) A. Apply splints and braces to facilitate muscle control. B. Buy toys that are appropriate for the child's abilities. C. Encourage the child to perform self-care tasks. D. Ensure the clothing has buttons to stimulate dexterity. E. Use skeletal muscle relaxants for short-term control.

ANS: A, B, C, D The child with CP has some degree of muscular dysfunction. The nurse encourages the child to perform self-care tasks. The child may exhibit muscular hypotonia (low tension) or hypertonia (high tension). Splints and braces may be necessary to facilitate muscle control and to improve body functioning. Clothing should be easy to manipulate. Skeletal muscle relaxants may be used for short-term control with older children and adolescents.

6. A 10-year-old child has had a sunken chest since birth, but has recently been noted to have activity intolerance when playing. Which diagnostic testing does the nurse teach the child and parents about? (Select all that apply.) A. Chest x-ray B. Chromosome analysis C. ECG and echocardiogram D. Pulmonary function studies E. Ultrasound of the chest

ANS: A, B, C, D This child has signs and symptoms of pectus excavatum, which manifests with a sunken chest. If the cardiac or respiratory systems are involved, the child will show exercise intolerance (changes in vital signs, changes on ECG, complaints of chest pain or shortness of breath with activity). Common diagnostic measures for this disorder include chest x-ray, chromosomal analysis or enzyme studies, ECG and/or echocardiogram, pulmonary function studies, and a stress test. Ultrasound is not used.

5. The pediatric nurse prepares a care plan for a patient admitted to the intensive care unit for meningitis. Which nursing interventions does the nurse include in the care plan for this patient? (Select all answers that apply.) A. Assess and treat pain as needed. B. Implement transmission-based precautions. C. Initiate and maintain IV access. D. Monitor vital signs every 4 hours. E. Monitor neurological status and symptoms.

ANS: A, B, C, E The nurse should initiate transmission-based precautions to help prevent transmission of infection. The nurse should initiate and maintain intravenous access (specify fluids and rate) as ordered. The nurse should monitor vital signs every 1 to 4 hours (depending on severity of symptoms) and place the patient on a cardiac monitor as indicated. The nurse should monitor neurological status and symptoms closely, comparing with baseline values for the child. Patients with meningitis often have pain, especially headaches, and the nurse should be prepared to assess and treat.

1. A parent asks about the process of bone growth. When explaining bone development to the parent, which substances does the nurse include in the teaching session as being necessary? (Select all that apply.) A. Calcitonin B. Calcium C. Estrogen D. Thyroid hormones E. Vitamin D

ANS: A, B, E Bone growth depends on several substances, including calcium, calcitonin, parathyroid hormone, vitamin D, and other minerals and enzymes. Estrogen and thyroid hormones are not required.

4. A nurse is teaching part of a babysitting class to teenagers. Which information about fractures does the nurse include in the lesson? (Select all that apply.) A. Approximately 10% to 15% of childhood injuries are fractures. B. Bicycle crashes account for many fractures . C. Girls rarely have stress fractures from sports. D. New bone growth is complete in 6 weeks. E. Some fractures can interrupt normal growth.

ANS: A, B, E Fractures are common, accounting for about 10% to 15% of childhood injuries, and often occur due to motor vehicle crashes, bicycle crashes, falls, and sporting injuries. Depending on where the fracture is, it has the potential to disrupt or halt growth in the bone. Girls are being seen with stress fractures more frequently. New bone growth takes up to 12 weeks to occur.

3. A nurse is caring for a 1-year-old child who was admitted for seizures. The parents ask what could have caused the child's seizure. The nurse explains that seizures can be caused by which problems? (Select all that apply.) A. Brain injury B. Central nervous system infection C. Hypertension D. Renal failure E. Unknown cause

ANS: A, B, E Seizures can be caused by many things, including traumatic brain injury, infection in the central nervous system, ingestion of toxins, endocrine dysfunction, atrial-venous malformation, or anoxia. The etiology may also be unknown.

14. A young teen has been diagnosed with Osgood-Schlatter disease. Which information does the nurse teach the patient and family regarding this diagnosis? (Select all that apply.) A. Activity level is determined by pain. B. Apply ice to the knee after activity. C. Modified bedrest for 1 week is needed. D. Surgical correction is usually required. E. Use ibuprofen (Motrin) for pain.

ANS: A, B, E The nurse should teach that activity can be resumed when symptoms (pain) are gone. Icing the knee after activity is beneficial, as is wearing an elastic wrap or neoprene sleeve over the knee. Nonsteroidal anti-inflammatory medications such as ibuprofen are best for pain management. Bedrest and surgery are usually not required.

12. The pediatric nurse explains to the parents of a child with kyphosis that it is caused by a congenital or acquired condition. Which conditions are considered congenital causes of kyphosis? (Select all that apply.) A. Ankylosing spondylitis B. Chronic poor posture C. Osteogenesis imperfecta D. Osteomyelitis E. Rheumatoid arthritis

ANS: A, C In children, kyphosis is caused by a congenital or acquired condition. Some congenital causes of kyphosis are ankylosing spondylitis, metabolic disorders, osteogenesis imperfecta, spina bifida, Paget disease, and Scheuermann disease, which causes juvenile or adolescent kyphosis, in which the vertebrae in the thoracic region are wedge-shaped.

6. The nurse is admitting an adolescent with known myasthenia gravis to the intensive care unit with respiratory failure. Which questions would be most important for the nurse to ask to attempt to find the cause of the problem? (Select all that apply.) A. "Could your child have skipped doses of his medication?" B. "Do you know if your child uses drugs or drinks alcohol?" C. "Has your child been sick or overly fatigued recently?" D. "How long has your child been diagnosed with myasthenia gravis?" E. "Is it possible that your child took too much medication?"

ANS: A, C This child appears to be in a myasthenic crisis, which is usually caused by underdosing or skipping medication and illness, infection, or fatigue. The other questions will not help identify the cause of the crisis.

1. A nurse assesses an infant for signs of increased intracranial pressure. Which signs would lead the nurse to notify the rapid response team? (Select all that apply.) A. Bulging fontanels B. Change in LOC C. Irregular respirations D. Posturing E. Seizures

ANS: A, C, D Bulging fontanels, irregular respirations, and posturing are among the late signs of increased intracranial pressure and would lead the nurse to intervene quickly by notifying the health-care provider or by activating the rapid response team. The other signs are early indicators of increased intracranial pressure.

9. Following hip surgery, a patient is placed in a spica cast. What nursing interventions are appropriate for this patient? (Select all that apply.) A. Cutting a window in the cast B. Icing the area over the incision C. Increasing fiber in the diet D. Increasing fluid intake E. Maintaining the same position

ANS: A, C, D Cast syndrome can be prevented by three nursing interventions: frequent repositioning, increasing fluids and fiber in the child's diet, and cutting a "belly hole" or a window in the cast to allow for abdominal expansion. The other two interventions do not help prevent cast syndrome.

3. A nurse is teaching parents how to care for their child who is undergoing serial casting for clubfoot. Which information does the nurse provide? (Select all that apply.) A. Cast care B. Cast drying techniques C. Neurovascular assessment D. Pain management E. Wound care

ANS: A, C, D Parents need to be taught how to properly care for their child's cast. The cast is left open to air for drying, so there are no special techniques needed. Specifically, the parents should not use a hair dryer, as this may cause burns. The parents should also be taught about managing the child's pain, as stretching the muscles and ligaments will be painful. They also need instruction on performing neurovascular checks and when to call the physician. Serial casting is not a surgical procedure, so wound care instructions are not needed.

13. The pediatric nurse discusses home care with the parents of a patient who is returning home following a spinal fusion. Which teaching points will the nurse include in the discharge teaching for this patient? (Select all that apply.) A. Allow the child to return to school about 4 to 6 weeks following surgery. B. Encourage ambulation when permitted, usually 2 to 3 weeks postoperatively. C. Explain activity restrictions such as no twisting, bending, or lifting. D. Maintain a regular diet with added calcium, fiber, fluids, and vitamin C. E. Participation in contact sports such as football needs to be delayed for 1 year.

ANS: A, C, D The child may return to school about 4 to 6 weeks after surgery. Explain activity restrictions to the child and caregivers (no twisting or bending, no lifting of heavy objects, no contact or high-impact sports for 2 years). A regular diet with added calcium, fiber, vitamin C, and fluids is maintained. Ambulation is encouraged when it is permitted, usually about 5 days postoperatively. Participation in contact sports is not allowed for 2 years.

2. The pediatric nurse is caring for a child with increased intracranial pressure (ICP). The nurse places priority on completing which interventions? (Select all that apply.) A. Administering mannitol (Osmitrol) B. Lowering the head of the bed C. Maintaining a patent airway D. Performing vigorous suctioning E. Preventing hyperthermia

ANS: A, C, E Hyperthermia is to be avoided because brain metabolic needs will be greatly increased. The nurse may use a hypothermic blanket if the child's temperature is over 102°F (39°C). The head of the bed can be elevated 15 to 30° to promote venous blood return, but a side effect of elevating the head is that the pressure of blood being delivered to the brain decreases, resulting in inadequate blood supply and perfusion. A priority nursing intervention is maintenance of a patent airway. Inadequate oxygenation or excess carbon dioxide causes cerebral blood vessels to dilate, resulting in increased intracranial pressure (ICP). The nurse may administer medications to decrease cerebral edema. A drug frequently prescribed is mannitol (Osmitrol). The patient should be suctioned if needed, but suctioning can increased ICP and should be done gently and only when necessary.

10. The nurse is providing care to a pediatric patient who suffered an ankle sprain. Which interventions are appropriate to include in the patient's plan of care? (Select all that apply.) A. Apply an Ace wrap to apply pressure and reduce swelling of the joint. B. Apply heat to the extremity for the first 48 hours at 15-minute intervals. C. Elevate and move the affected joint to reduce swelling and stiffness. D. Immediately perform range-of-motion exercises on the extremity. E. Place ice on the injury for 15 minutes at a time for the first 1 to 2 days.

ANS: A, C, E The nurse should teach the RICE acronym: Rest the injured extremity to prevent further injury and allow the ligament to heal; ice for the first 48 hours, keeping ice packs in place for 15-minute intervals to decrease swelling; compression with an Ace wrap or some other method to apply pressure to the affected joint to help reduce swelling of the joint; and elevation and early motion of the affected joint (elevation reduces swelling; early motion of the affected joint helps maintain full range of motion).

10. The clinic nurse is providing community education to a parent group. The topic is over-the-counter medications containing aspirin or aspirin compounds. Which products does the nurse advise the parents to avoid? (Select all that apply.) A. Kaopectate (bismuth subsalicylate) B. Lamictal (limotragine) C. Pedia-profen (ibuprofen) D. Pepto-Bismol (bismuth subsalicylate) E. Ventolin (albuterol)

ANS: A, D Common over-the-counter products containing aspirin include Kaopectate and Pepto-Bismol. Lamictal is not an over-the-counter drug. The other three medications do not contain aspirin compounds.

2. The nurse is caring for a child diagnosed with clubfoot. Which assessment findings does the nurse anticipate in the affected extremity? (Select all that apply.) A. Adducted forefoot B. Dorsiflexion C. Everted heel D. Plantar flexion E. Rigidity

ANS: A, D, E Signs of clubfoot include plantar flexion, inverted heel, adducted forefoot, and rigidity to the point that the foot cannot be manipulated into a neutral position.

35. A nurse is preparing to discharge an infant who has developmental dysplasia of the hip (DDH). What discharge instruction would be most important? A. How to correctly perform Ortolani's maneuver B. How to properly use the Pavlik harness C. When to return for corrective surgery D. Where to take the baby to be fit for corrective shoes

ANS: B A baby with DDH will be placed in a special splint, most often the Pavlik harness, to keep the legs in a position of abduction. The harness is worn continuously for 3-6 months, during which time bone growth helps create a normal hip joint. Ortolani's maneuver is an assessment for DDH. Surgery may be required, but not until it has been determined that bone growth is not creating a normally shaped hip joint. Corrective shoes are not needed.

20. A nurse is caring for a child who has intracranial pressure (ICP) monitoring. The nurse assesses the child and notes that the ICP is 9 mm Hg. Which action by the nurse is most appropriate? A. Activate the rapid response team. B. Document the finding in the chart. C. Hyperventilate the patient. D. Prepare to administer mannitol (Osmotrol).

ANS: B A normal ICP is 0-10 mm Hg. This finding is normal and the nurse needs only to document it and continue monitoring. No other actions are needed.

20. A 10-year-old child is in the emergency department with a type IV femur fracture. Which intervention takes priority? A. Assessing the child for signs of maltreatment B. Ensuring that signed consent for surgery is on the chart C. Explaining the process of closed reduction with sedation D. Preparing the child for prolonged immobility in traction

ANS: B A type IV fracture must be reduced surgically. The nurse ensures that signed consent is on the chart. Fractures in a 10-year-old are not as commonly caused by child abuse as by bicycle crashes or sporting injuries, so unless other signs of maltreatment are noticed, this would not be a priority. Because the child is not having a closed reduction, explanation of this process is not needed. The child will also not be immobilized in traction for a prolonged period.

8. A new nurse is caring for a child after spinal fusion to correct scoliosis. Which action by the new nurse causes the experienced nurse to intervene? A. Assesses neurological status and vital signs every hour B. Instructs patient to turn by pulling on side rails C. Monitors chest tube for air leakage and drainage D. Promotes use of the incentive spirometer each hour

ANS: B After spinal fusion, the patient must be logrolled to turn. Logrolling involves two nurses turning the patient as one single unit so that the spine is maintained in a straight line. The other actions are appropriate.

1. The pediatric nurse explains to the student nurse that alterations in musculoskeletal functioning may be related to a congenital defect or an acquired defect. Which disorder is an example of a congenital defect? A. Juvenile arthritis B. Muscular dystrophy C. Osgood-Schlatter disease D. Osteomyelitis

ANS: B Alterations in musculoskeletal functioning may be related to a congenital defect such as muscular dystrophy, clubfoot, or osteogenesis imperfecta. Other musculoskeletal alterations may be related to an acquired defect such as Legg-Calvé-Perthes disease, slipped femoral capital epiphysis, Osgood-Schlatter disease, scoliosis, sprains, strains, fractures, osteomyelitis, juvenile arthritis, or tetanus.

24. A child in traction is having muscle spasms. Which medication does the nurse prepare to administer? A. Acetaminophen (Tylenol) B. Diazepam (Valium) C. Morphine sulfate (Astromorph) D. Oxycodone (Percocet)

ANS: B Diazepam is a muscle relaxant and is used to treat muscle spasms. The other medications are for pain.

35. A nurse is caring for a child with Duchenne's muscular dystrophy (MD). The child's creatinine kinase level has dropped by over half since it was last measured. What assessment finding correlates with these results? A. Better respiratory functioning B. Decreased muscle strength C. Improved posture and walking D. Stabilizing muscle strength

ANS: B Early in MD creatinine kinase levels are elevated. As muscle wasting occurs and muscle bulk diminishes, creatinine kinase levels will drop. A finding of decreased muscle strength correlates with the laboratory results.

2. The student nurse studying the anatomy of the musculoskeletal system understands that bones are classified by their size and shape. How does the student classify the pelvis? A. Flat bone B. Irregular bone C. Long bone D. Short bone

ANS: B Flat bones are located in the skull, scapulae, ribs, sternum, and clavicle. Long bones are found in the extremities, and include the fingers and toes. Short bones are located in the ankles and wrists. Irregular bones are the vertebrae, pelvis, and facial bones.

12. A nurse working in an inpatient pediatric unit cares for many children with musculoskeletal impairments. Which outcome takes priority for these children? A. Adapting to changing activity restrictions B. Continuing their growth and development C. Resuming ambulation as soon as possible D. Staying current with schoolwork with tutors

ANS: B Growth and development are dependent upon being able to interact with the environment. Any child with a musculoskeletal disorder is at risk for impaired growth and development. A priority outcome for any of these children is to maintain normal growth and development. Some children may need to adapt to changing activity restrictions. For some children, ambulation will be delayed or not possible. Staying current with education is important, but does not take priority over maintaining normal growth and development.

32. A nurse is caring for an 8-year-old with Guillain-Barré Syndrome (GBS). On hourly rounds, the nurse assesses that the child's lung sounds are diminished, respiratory rate is 8 breaths/min and shallow, and pulse oximeter is 88%. What action by the nurse takes priority? A. Administer high-flow oxygen by mask. B. Call the rapid response team; prepare for intubation. C. Encourage the patient to take slow, deep breaths. D. Have the patient use the incentive spirometer.

ANS: B In GBS, respiratory muscles can be affected, leading to respiratory failure. The nurse needs to prepare for intubation. The child's muscles are too weak for oxygen or the spirometer to help her, and she may be too weak to use the spirometer or to take deep breaths.

10. A nurse admits a 5-year-old child with bacterial meningitis to the pediatric intensive care unit. Which information obtained by the nurse during the intake history is most helpful for the nurse to document? A. Fell off swing hitting head 2 months ago B. History of recent sinus infection C. Mother with history of herpes simplex D. Sibling with upper respiratory infection

ANS: B In a child this age, common causes of bacterial meningitis include septicemia, surgical procedures involving the CNS, penetrating wounds, otitis media, sinusitis, cellulitis of the scalp or face, dental cavities, pharyngitis, and orthopedic diseases. Blunt trauma from falling off a swing and a sibling with a URI are noncontributory. Herpes simplex is an important cause of neonatal viral meningitis.

19. A child has been hospitalized with an acute-grade IV slipped femoral capital epiphysis (SFCE) and is on bedrest awaiting surgical correction. A new nurse places the following interventions on the child's care plan. Which intervention leads the experienced nurse to intervene? A. Consult child-life therapist for diversionary activities. B. Perform range-of-motion exercises to both lower extremities. C. Reinforce teaching on crutch-walking postoperatively. D. Teach child and family about non-weight-bearing status.

ANS: B In acute SFCE, range-of-motion exercises are not done to the affected extremity because they may cause further damage. The other interventions are appropriate for a child with this diagnosis.

38. A 6-week-old baby is brought to the clinic for a follow-up visit after having surgical repair of a myelomeningocele. His head circumference was 33 cm (12 inches) at birth. Now the nurse assesses his head circumference at 36 cm (14.1 inches). What action by the nurse is most appropriate? A. Assess the child for signs of hydrocephalus. B. Document the measurement in the child's chart. C. Educate the parents on possible shunt placement. D. Inquire about signs of increased intracranial pressure.

ANS: B Increasing head circumference is a sign of possible hydrocephalus. The average head circumference of an infant at birth is 33-38 cm (12-14 inches) and increases by 2 cm/month (0.75 inches/month). This child's head circumference is normal and the nurse should document the information; no other actions are needed.

31. A child has just been diagnosed with juvenile arthritis (JA). The parents want to know what caused this to happen. Which statement by the nurse is the most appropriate? A. "Genetic abnormalities are triggered by infection." B. "It seems to be an autoimmune disease." C. "Latent infections can recur and cause JA." D. "No one really understands how JA occurs."

ANS: B JA is an autoimmune, inflammatory process often thought to be triggered by an infection. The etiology is not genetic, caused by latent infections, or completely unknown.

24. A student nurse is preparing to give a 48.5-lb(22-kg) child IV mannitol (Osmitrol). What action by the student causes the nursing instructor to intervene? A. Assesses child's pain including report of headache B. Confirms the dose of 66 g in a 20% solution C. Double-checks child's urine output for the shift D. Explains to the child that nausea may occur

ANS: B Mannitol is an osmotic diuretic often used to decrease intraocular pressure. The correct dose is 1-2 g/kg, so the safe dose range is 22-44 g. The nurse would intervene if the student prepared to administer 66 g. The other actions are appropriate.

40. A new nurse is caring for a child who had a ventriculoperitoneal shunt placed 2 days ago for hydrocephalus. Which action by the new nurse causes the experienced nurse to intervene? A. Administers IV antibiotics B. Asks for medication to treat nausea C. Palpates the shunt tract with assessments D. Raises the head of the bed to 30°

ANS: B Peritonitis is a complication of this procedure and manifestations of this include rebound tenderness, abdominal muscle rigidity, nausea, and vomiting. The new nurse should conduct a more thorough abdominal assessment instead of asking for anti-nausea medication. The other actions are appropriate and do not require the experienced nurse to intervene.

4. The pediatric nurse caring for patients in a trauma center examines a patient who has increased intracranial pressure as a result of a motor vehicle crash. The nurse is aware that secondary brain injuries can result from which factor? A. Acidosis B. Ischemia C. Infections D. Reduced oxygen

ANS: B Primary brain injury is irreversible, immediate, and can result from traumatic injuries (e.g., a blow to the head) or nontraumatic injuries (e.g., a tumor or infection). Secondary brain injuries include ischemia from hypoxia, hypercapnia, hypotension, acidosis, and reduced oxygen delivery.

17. A teenage girl is diagnosed with systemic lupus erythematosus (SLE). Which health promotion guidance is important for the nurse to provide? A. "Acetaminophen (Tylenol) is best for daily pain." B. "Consider adding vitamin D to your daily routine." C. "Plan to choose a career that is sedentary." D. "You should consider elective sterilization."

ANS: B Sun exposure is a frequent cause of SLE exacerbations, so patients with SLE must use sunscreen and avoid prolonged time in the sun. This decreases vitamin D synthesis, which is required to metabolize and utilize calcium, leading to increased risk of osteoporosis. A side effect of steroid use is also osteoporosis, so patients with SLE (women especially) need to guard against this occurrence by adding supplemental vitamin D. NSAIDs are best for the pain and inflammation that accompany SLE. The patient does not have to be sedentary; a balance of rest and activity is needed. Pregnancy is not absolutely contraindicated in the patient with SLE; however, it must be considered cautiously in consultation with the health-care provider.

3. An adolescent patient is prescribed a brace to treat scoliosis. Which assessment finding by the nurse indicates that outcomes for a priority nursing diagnosis have been met by the patient? A. Is able to explain the rationale for the bracing B. No redness or breakdown seen under the brace C. Participates in social activities with friends D. Wears brace continuously for 20 hours each day

ANS: B The skin under the brace worn to treat scoliosis needs to be assessed for breakdown, especially when the brace is new. An important diagnosis would be risk for impaired skin integrity. Seeing no skin breakdown under the brace indicates the outcomes have been met for this goal. Being able to explain the rationale for the bracing and participating in social activities also indicate that outcomes for appropriate diagnoses have been met, but these do not take priority over a possible injury to the child. The brace needs to be worn continuously for 23 hours each day.

11. A nurse admits a child experiencing drowsiness and vomiting who has had a seizure at home. The parents state the child was healthy until 2 weeks ago when she had a viral illness. Which diagnostic testing does the nurse facilitate as a priority? A. Complete blood count B. Liver biopsy C. Lumbar puncture D. Serum glucose

ANS: B This child has manifestations of Reye syndrome. The definitive diagnosis of this disease is made via a liver biopsy.

48. A child is brought to the pediatric clinic by her mother, who reports redness, swelling, and pain around the child's right eye. Which information does the nurse give the mother? A. A steroid injection may be needed to reduce swelling. B. Intravenous antibiotic treatment for 7 days is usually curative. C. See an ophthalmologist to assess for any corneal damage. D. Use warm wet compresses to remove any crusting.

ANS: B This child has the manifestations of periorbital cellulitis, which is treated with a week of IV antibiotics. Steroid injections may be used for a chalazion. An ophthalmologist needs to assess the child with keratitis to assess for corneal damage. Warm moist soaks are used in conjunctivitis.

32. The pediatric nurse is caring for a child recently diagnosed with transient synovitis of the hip. Which medication order is most appropriate for this child? A. Acetaminophen (Tylenol) 10-15 mg/kg every 4 hours B. Ibuprofen (Motrin) 30-50 mg/kg/day in 3-4 divided doses C. Naproxen (Aleve) 20-30 mg/kg/dose every 4 hours D. Prednisone (Deltasone) 0.1-2 mg/kg/day in 1-4 divided doses

ANS: B This disorder is treated with NSAIDs. Acetaminophen is not an NSAID, although the dose listed is a safe dose. Prednisone is also not an NSAID, although the dose listed is a safe dose. Ibuprofen and Naproxen are both NSAIDs. The dose of ibuprofen is correct; the safe dose for naproxen is 10-15 mg/kg/dose every 12 hours.

17. A child just had a long-leg cast placed after an open reduction and fixation of a femur fracture. What interventions are appropriate for the nurse to include in the child's plan of care? (Select all that apply.) A. Assess the 4 Ps every hour, with vital signs. B. Elevate the leg and apply ice for short periods. C. Ensure that the proximal edge of the cast stays clean. D. Handle the cast carefully when wet to prevent dents. E. Use a hand-held dryer to help the cast dry faster.

ANS: B, C, D Appropriate interventions for the child with a cast include assessing the 5 Ps along with vital signs, elevating and icing the leg, keeping the proximal edges clean as part of hygiene, handling the cast carefully when wet to prevent denting, and allowing the cast to air dry.

15. A child's family history includes muscular dystrophy (MD). What diagnostic testing does the nurse prepare the child and family for? (Select all that apply.) A. Blood urea nitrogen B. Creatinine kinase C. Electromyelogram D. Muscle biopsy E. Ultrasound

ANS: B, C, D Common diagnostic tests for MD include creatinine kinase, electromyelogram, and muscle biopsy. Blood urea nitrogen and ultrasound are not used.

7. The nurse is preparing discharge teaching for the parents of a 7-year-old boy with hydrocephalus and a ventriculoperitoneal shunt. Which information does the nurse include in the discharge teaching? (Select all that apply.) A. After the shunt site has healed, contact sports are permitted B. How to accurately take the child's temperature when needed C. Monitoring for shunt infection is always a priority action. D. Report any nausea, vomiting, or change in behavior. E. Shunt removal can occur after hydrocephalus has been controlled.

ANS: B, C, D Parents are taught how to care for their child after shunt placement. They need to know common signs of infection (fever, nausea, vomiting, change in behavior), how to take a temperature, and that contact sports are not permitted. Because hydrocephalus is a lifelong condition, monitoring for infection is ongoing and the shunt stays in place permanently.

5. A nurse is teaching parents about caring for their child in a cast. Which information does the nurse provide? (Select all that apply.) A. Be sure the child does not move joints above and below the cast. B. Elevate the extremity above the heart as much as possible. C. Keep the child from playing with toys that have very small parts. D. Provide snacks high in calcium and vitamin D or provide supplements. E. Reinforce active or passive range of motion to unaffected joints.

ANS: B, C, D, E The nurse teaches parents how to care for a child in a cast, including moving the joints above and below the cast regularly, elevating the extremity above the heart as much as possible, keeping the child from putting objects down the cast (including toy parts), providing nutrition that encourages bone healing, and providing range of motion.

8. A pediatrician orders Russell traction for a 12-year-old patient with Legg-Calvé-Perthes disease. Which interventions are appropriate for the nurse to include in the care plan for this patient? (Select all that apply.) A. Bony areas are massaged frequently. B. Child is lying in a supine position. C. Hip is flexed and abducted. D. Skin is inspected every 12 hours. E. The child uses a trapeze to move.

ANS: B, C, E Russell traction is a type of skin traction used to stabilize femur fractures until a callus forms or to correct bone deformities or contractures, as in Legg-Calvé-Perthes disease. With this type of traction, the child lies supine with hip flexed, abducted, and immobile. The child can help with repositioning using a trapeze above the bed. The nurse should assess the skin more often than every 12 hours and should not massage bony prominences.

7. An 8-year-old girl has a third-degree sprain of the ankle. Based on this diagnosis, which teaching points will the nurse include in the teaching plan for this patient and family? (Select all that apply.) A. The ligament is only stretched and the affected joint is stable. B. The patient cannot bear weight or use the extremity. C. There is severe pain over the joint, making an exam difficult. D. There is full range of motion and weight bearing. E. Sprains and strains are unusual in a child this age.

ANS: B, C, E Sprains are less common in younger children than are fractures. In a third-degree sprain the injury is severe, the ligament is completely torn, and the joint is unstable. There is significant swelling and severe ecchymoses occurring within the first 30 minutes. There is also severe pain over the joint, making examination difficult. The person cannot bear weight or otherwise use the extremity.

4. A nurse is preparing discharge teaching for an adolescent with a new diagnosis of epilepsy. What information should the nurse provide? (Select all that apply.) A. "Driving is not allowed while taking anti-seizure drugs." B. "Participating in sports again in the future is possible." C. "Several drugs will be tried at once, then reduced over time." D. "Wearing a Medic-Alert bracelet is not needed for seizures." E. "You should check the school's seizure action plan."

ANS: B, E Once drug levels are therapeutic and the child has been seizure-free for several months (usually at least 6 months), he or she can return to participating in sports. School nurses should be aware of a child's diagnosis of a seizure disorder and treatment plan; the parents should check on the school's seizure action plan so they are aware of actions that will be taken if their child has a seizure on campus. Driving is allowed (depending on state law) with therapeutic drug levels and a certain period of seizure-free time. Monotherapy is the optimal treatment plan, but if a single drug does not work to control seizures, other drugs may be added to the regimen. Anyone with epilepsy or a seizure disorder should wear a Medic-Alert bracelet or necklace.

23. A nurse is caring for a 10-year-old child with a brain injury. On assessing the child, the nurse finds the following data: opens eyes only to pain, mutters inappropriate words, has abnormal extension to stimulation. Which action by the nurse takes priority? A. Alert the operating room for emergent surgery. B. Document the findings; reassess in 15 minutes. C. Notify the provider; prepare for intubation. D. Raise the head of the child's bed to 45°.

ANS: C A child with a Glasgow Coma Score of less than 8 needs to be intubated and mechanically ventilated. This child's score is 7 (eye opening = 2, verbal response = 3, motor response = 2). The child may need an invasive procedure due to the increased intracranial pressure, but this would not take priority over managing the airway and providing adequate oxygenation. The findings need to be documented, but further action is needed. Raising the head of the bed may or may not be beneficial, but does not take priority over intubation.

27. A child has had an episode of lip smacking while staring into space, but did not seem to lose consciousness. She was confused afterward but said her hands felt tingly before the other symptoms started. How should the nurse document this event? A. Alteration in consciousness B. Convulsion C. Focal seizure D. Generalized seizure

ANS: C A focal seizure involves only one part of the brain and manifests with involuntary movements, sensory symptoms, possible staring into space, no loss of consciousness, and confusion afterward. "Alteration in consciousness" is too vague in this case to be a useful description. "Convulsion" is an outdated term. A generalized seizure involves both hemispheres of the brain and manifestations usually include loss of consciousness and tonic-clonic movements.

44. A nurse completes the Pediatric Fall Risk Assessment on a patient who scores a 9. Which intervention by the nurse is most important to include on the care plan? A. Allow independent ambulation around the unit. B. Maintain forced bedrest with restraints if necessary. C. Provide assistance with transfers and ambulation. D. Use two individuals at all times for mobility.

ANS: C A pediatric fall risk score of 0 to 7 demonstrates low risk for falls, whereas a score of 8 to 17 indicates a high risk for falls. Because this child demonstrates a high risk for falls he or she should have assistance with transfers and walking.

6. A 15-year-old boy is brought to the emergency room by his parents following an injury to his arm that occurred during football practice. The x-ray shows a diagonal line that coils around the bone. Based on this x-ray, which type of fracture does the nurse prepare to teach the family about? A. Greenstick B. Oblique C. Spiral D. Transverse

ANS: C A spiral break is caused by a twisting force and shows a diagonal line that coils around the bone. An oblique break shows a diagonal line across the bone. A transverse break shows a line that crosses the shaft at a 90-degree angle. In a greenstick-type break, the bone is bent but not broken.

28. A child has been admitted with bacterial meningitis. Which action by the nurse takes priority? A. Administering broad-spectrum antibiotics B. Assessing and treating pain aggressively C. Facilitating blood cultures and lumbar puncture D. Maintaining a quiet, nonstimulating environment

ANS: C All actions are appropriate for the child with acute bacterial meningitis. However, the priority is obtaining cultures so that appropriate therapy can be identified. After cultures are obtained, the nurse will administer broad-spectrum antibiotics until the culture and sensitivity results are known.

18. A child is being cared for at home with modified bed rest for Legg-Calvé-Perthes disease. Which assessment finding indicates to the home health-care nurse that outcomes for a priority diagnosis have been met? A. The child maintains grades in school via tutoring. B. The family identifies effective coping strategies. C. Full range of motion is present in all joints. D. The family identifies appropriate diversionary activities.

ANS: C All assessment findings signify positive adaptation to this disorder. However, because the child is on bedrest, the priority is to prevent complications of immobility including contractures or decreased ROM in joints.

26. A child has an invasive intracranial pressure monitoring device in place. Which assessment finding indicates that goals for a priority nursing diagnosis have been met? A. Daily weight equals admission weight. B. Joints move freely during range of motion. C. No signs of infection are present at the insertion site. D. Skin is intact without redness or breakdown.

ANS: C All indications show that goals for various nursing diagnoses have been met; however, the priority here would be preventing infection at the intracranial pressure monitoring site, which would have a direct route to the brain.

1. The student nurse studying the neurological system learns that areas of gray matter are found deep in the brain. To determine damage to the basal ganglia, what will the nurse assess? A. Blood pressure B. Homeostasis C. Movement D. Sensory impulses

ANS: C Areas of gray matter are found deep in the brain. These areas include the basal ganglia (affect movement), the hypothalamus (maintains homeostasis and regulates blood pressure, heart rate, and temperature), and the thalamus (processes sensory impulses and sends them to the cerebral cortex).

39. An infant hospitalized with multiple fractures has just been diagnosed with osteogenesis imperfecta. The nurse finds the parents crying. Which response by the nurse is the most appropriate? A. "I know how you feel. I would be upset to find this out too." B. "There is medicine that can allow her to live a normal life." C. "Would you like me to help you with holding your baby?" D. "You are actually lucky; many of these babies die at birth."

ANS: C Causing more injury to their child is a common concern among parents of children with osteogenesis imperfecta. The nurse needs to show them how to hold, change, feed, and play with their babies. In this situation, the caring nurse offers to help the parents learn to hold their baby and offers support. The nurse should never assume to know how someone else is feeling. Medications will not help this child lead a normal life. Stating that the parents are lucky is belittling their feelings.

34. An 8-month-old child with congenital myotonic dystrophy has been hospitalized with a severe respiratory infection. Which action by the nurse is the most appropriate? A. Determine if the family wants aggressive ventilatory support. B. Discuss the option of lung transplantation with the family. C. Hold a family meeting to discuss palliative care measures and code status. D. Inform the family the child will be ventilator dependent as she gets older.

ANS: C Congenital myotonic dystrophy usually causes death before the age of 1 year due to the inability to maintain respirations. In this situation, the nurse should have a meeting with the family to explore a broad range of therapeutic options, including palliative care measures and code status. Just inquiring about ventilatory support is too narrow a focus. Lung transplantation is not a treatment for this disorder. Children with this disease die at a young age, and so they do not grow up dependent on ventilators.

39. A nurse in a well-child clinic notes that a 5-month-old is not able to hold her head up. Which action by the nurse is the most appropriate? A. Ask about other developmental milestones . B. Document the finding in the child's chart. C. Measure the child's head circumference. D. Obtain the child's length and weight.

ANS: C Difficulty holding the head up by an appropriate age is a manifestation of hydrocephalus. Another sign of this disorder is an enlarging head, so the nurse measures the child's head and compares it to age-related norms. The other actions are appropriate, but not as specifically associated with hydrocephalus as measuring head circumference.

45. A child's chart indicates he has leukocoria and a hyphema in the right eye. Which teaching does the nurse implement for the child and parents? A. Application of antibiotic ointment and eye patch B. Possibility of other children having this genetic disorder C. Surgery, possible enucleation, possible chemotherapy D. Wearing appropriate eye protection during sports

ANS: C Leukocoria (cat's eye reflex) and hyphema (blood in the anterior chamber of the eye) are manifestations of retinoblastoma, a rare and aggressive tumor of the retina. Treatment is vigorous and may include surgery (including enucleation), radiation, chemotherapy, laser, or cryotherapy.

35. The high school nurse is teaching a healthy living class to high school seniors. One student asks why she should take folic acid now when she is not planning to become pregnant. Which response by the nurse is the most appropriate? A. "It is a good habit to get into while you are young and can develop good habits." B. "Most people in this country have a serious deficiency of vitamins and folic acid." C. "Neural tube defects occur so early that you might not know you are even pregnant." D. "There are no foods that contain folic acid so you have to take a supplement."

ANS: C Neural tube defects (NTDs) generally occur between the 18th and 28th days of pregnancy, often before the woman knows she is pregnant. All women of childbearing age should get 400 µg/day of folic acid to help prevent NTDs. It is a good habit to get into prior to contemplating pregnancy, but this answer does not give specific information. Most people do not have a serious deficiency of folic acid; however, pregnant women (and those who could be pregnant) need to have a minimal amount of folic acid. Several foods are good sources of folic acid, including green leafy vegetables, liver, legumes, orange juice, and fortified breakfast cereals; it is also contained in multivitamins.

4. The nurse is providing care to a pediatric patient admitted for a workup of bone deformity. The latest laboratory values indicate calcium at 6.6 mg/dL and phosphorus at 2.1 mg/dL. Which condition does the nurse correlate with these values? A. Muscular dystrophy B. Osgood-Schlatter disease C. Rickets D. Scoliosis

ANS: C Normal calcium is 8.5-11 mg/dL, and normal phosphorus is 3-4.5 mg/dL. Low values for both are seen in rickets.

25. A child who is intubated and mechanically ventilated has an intracranial pressure monitoring device in place. The child is agitated. Which medication order would the nurse question based on the assessment data? A. Fentanyl (Sublimaze) B. Lorazepam (Ativan) C. Methylprednisolone (Solu-Medrol) D. Morphine (Astramorph)

ANS: C Pain and agitation are treated aggressively because they both can increase intracranial pressure. Appropriate drug choices include fentanyl, lorazepam, and morphine. Corticosteroids do not treat either pain or agitation and their use in cerebral edema is controversial.

15. A parent calls the nursing call center stating that his child, who has a cast after surgical treatment of a clubfoot, is very fussy even after acetaminophen (Tylenol) administration and that the child's toes seem cool. What advice does the nurse give the parent? A. "Elevate the affected extremity and apply ice for 20 minutes." B. "Make four cuts to the top of the cast, each about 1 inch long." C. "Take your child to the nearest emergency department now." D. "Try giving your child a dose of ibuprofen (Pediaprofen) instead."

ANS: C Parents always need to observe for complications of casting, including neurovascular compromise. A child who is excessively fussy and whose toes are cool should be seen by a health-care provider to assess circulation and possibly modify or change the cast. The parent should be told to take the child to the nearest emergency department (ED). The other answers are inappropriate. If circulation is compromised, elevation and ice will make the problem worse. The parent should not be instructed to modify the cast. Although ibuprofen may manage the child's pain better than acetaminophen, the priority instruction is to send the parent to the ED.

9. An adolescent expresses frustration over how long his football injury to a tendon is taking to heal. Which response by the nurse is the most appropriate? A. "I'll ask the doctor to check for a tendon infection." B. "Often these injuries never fully heal and return to normal." C. "Tendons have a poor blood supply, so healing is slow." D. "You have to be more compliant with immobilization."

ANS: C Tendons are fibrous connective tissues that have very little blood supply. Therefore healing from a tendon injury takes time. This is the best response; there is no indication that the teen has an infection interfering with recovery, it is inaccurate and disheartening to tell a young person that tendons may never heal, and the nurse should not assume the patient is noncompliant with immobilization.

41. A student nurse is caring for a patient in skin traction. What action by the student causes the registered nurse to intervene? A. Assesses neurovascular status every 2-4 hours B. Ensures correct weights are hanging freely C. Positions child perpendicular to the traction D. Removes traction to assess the skin every 4 hours

ANS: C The child should be positioned directly in line with the traction. The other interventions are correct.

28. A student athlete has a serious anterior cruciate ligament (ACL) tear, and her knee is swollen with excess synovial fluid. Which procedure does the nurse prepare this athlete for? A. Application of heat B. Immediate surgery C. Joint aspiration D. Knee reduction

ANS: C The health-care provider will remove excess synovial fluid via aspiration. Heat is not used for the first 24 hours. Immediate surgery may or may not be warranted. A knee reduction is performed for a dislocated knee.

14. A school-aged child wishes to learn embroidery from her grandmother, but the grandmother reports that the child can only concentrate on the projects for a short time and seems frustrated. What action by the nurse is the most appropriate? A. Advise that the child needs more physical activity. B. Explain that the child is too young for this project. C. Suggest that the child have a routine vision exam. D. Teach behavior modification to the grandmother.

ANS: C The most common refractive disorder in children is hyperopia (farsightedness). Symptoms include reports of objects being unclear at close range and clearer at a distance. Younger children may have trouble focusing on a project that requires close vision work. The nurse should suggest that the child have a routine eye examination. The other options may or may not be beneficial, but do not address the potential visual problem.

16. A mother brings her daughter to the clinic after noticing the child's new swimsuit fits baggily on one side of her bottom and the child's right thigh looks quite odd compared to the other one. Which assessment question would provide the nurse the most important information? A. "Do her joints dislocate easily?" B. "Does she fatigue easily?" C. "Has your child been limping?" D. "When did you see her in a swimsuit last?"

ANS: C The mother seems to have noticed thigh and buttock muscle wasting, which are signs of Legg-Calvé-Perthes disease. Other signs and symptoms include hip or knee soreness or stiffness, pain that increases with activity and decreases with rest, a painful limp, joint dysfunction, and limited ROM. Asking about a limp would be the most important question, as it is specific to this disease process.

11. The student nurse studying anatomy knows that red blood cells are produced where? A. Growth plates B. Periosteum C. Red marrow D. Yellow marrow

ANS: C The red marrow produces red and white blood cells and platelets. Yellow marrow produces fat cells. The growth plates and periosteum are not involved in producing different cells.

44. A child has been examined by a pediatric ophthalmologist, and findings indicate a dulled red reflex and cloudy lens. Which treatment plan does the nurse educate the parents on based on these findings? A. Occlusion therapy to the affected eye for 6 months B. Periodic administration of IV mannitol (Osmotrol) C. Surgery to remove the cataract and placement of a lens D. Use of eyedrops for the rest of the child's life

ANS: C These manifestations are characteristic of cataracts, which can be congenital or acquired. Typical treatment includes surgical removal of the cataract and lens implant. The other options are not part of the treatment for cataracts.

16. An 8-year-old child is being treated for suspected tetanus. Which medications are appropriate for this child? (Select all that apply.) A. Ceftriaxone (Rocephin) B. Clindamycin (Cleocin) C. Erythromycin (Erythrocin) D. Penicillin G (Pfizerpen) E. Tetracycline (Sumycin)

ANS: C, D Penicillin G and erythromycin are appropriate choices for this child. Older children can take tetracycline once they have all their adult teeth. Ceftriaxone and clindamycin are not used.

11. The pediatric nurse is caring for a patient with juvenile arthritis. The health-care provider tells the nurse the patient will be started on disease-modifying antirheumatic drugs (DMARDs). Which drugs does the nurse anticipate administering? (Select all that apply.) A. Acetaminophen (Tylenol) B. Indomethacin (Indocin) C. Infliximab (Remicade) D. Leflunomide (Arava) E. Methotrexate (Rheumatrex)

ANS: C, E DMARDs include methotrexate (Rheumatrex), cyclophosphamide (Cytoxan), sulfasalazine (Azulfidine), and infliximab (Remicade). Acetaminophen (Tylenol) has no anti-inflammatory effect and is not used to treat juvenile arthritis. Leflunomide is an immunosuppressant.

19. A nurse is caring for a child who only awakens to painful stimuli and produces no verbal responses. Which term is the most appropriate when documenting this child's status? A. Lethargy B. Obtundation C. Persistent vegetative state D. Stupor

ANS: D A child who is stuporous only responds to painful stimuli and has verbal responses that are either absent or slow. A lethargic patient opens his or her eyes to loud voices and appears confused and falls asleep without continued stimulation. Obtundation is demonstrated when a person is aroused by tactile stimulation, such as gentle shaking, but does not show great interest in surroundings. A persistent vegetative state is a coma-like condition that has lasted for over 4 weeks.

6. A pediatric nurse performs a physical examination on a neonate and notes a spinal lesion with the meninges protruding through the defect that contains spinal cord elements. The nurse documents which condition as being present? A. Hydrocephalus B. Meningitis C. Meningocele D. Myelomeningocele E. Spina bifida occulta

ANS: D A myelomeningocele is the most severe form of spina bifida and is evident on delivery. The meninges protrude through the defect, and they contain spinal cord elements. It appears as a very pronounced skin defect, usually covered by a transparent membrane, and neural tissue may be attached to the inner surface.

33. A health-care provider administers edrophonium (Tensilon) to a school-age child with new onset of muscle weakness. The child is able to hold her eyes open for the duration of the drug's half-life. Which information does the nurse plan to teach the child and parents? A. Muscle weakness will progress in an ascending fashion. B. Pain control will be an important aspect of the child's care. C. This disease is a result of a previous viral infection. D. Weakness and fatigue will probably be worse during the day.

ANS: D A positive result to a Tensilon test is diagnostic for myasthenia gravis, an autoimmune disease uncommon in children. Muscle weakness is the main symptom, and the weakness is particularly pronounced in muscles used for eye movement, chewing, swallowing, and breathing. Weakness is usually worse during the day or during times of stress. It is not painful, muscle weakness does not progress in ascending fashion as in Guillain-Barré syndrome, and the cause is unknown.

9. A hospitalized child is having a seizure. Which action by the nurse takes priority? A. Apply oxygen and oximeter. B. Give anti-seizure medications. C. Pad the side rails of the bed. D. Turn the child on his or her side.

ANS: D All actions are appropriate when a patient has a seizure. The priority, however, is on maintaining the child's airway. Placing the child in a side-lying position decreases the risk of aspiration and airway obstruction.

36. A home health-care nurse is visiting a child with Duchenne's muscular dystrophy (MD). The child has a new cough, poor appetite, fatigue, and a reddened area on his coccyx from sitting in his wheelchair all day. What intervention by the nurse takes priority? A. Assess the child for his favorite high-protein foods. B. Develop a protocol for changing positions more often. C. Encourage the family to allow the child plenty of rest. D. Notify the health-care provider and request antibiotics.

ANS: D All actions are appropriate; however, children with MD usually die of respiratory infections, so aggressive treatment at the first sign of a respiratory infection is warranted. The nurse should notify the health-care provider and request antibiotics.

16. The student nurse studying anatomy and physiology understands which of the following to be the function of axons? A. Bringing information to the brain B. Maintaining myelin sheaths on nerves C. Protecting sensory and motor pathways D. Taking information away from the brain

ANS: D Axons take information away from the brain.

41. A nurse is caring for a child and notes Battle's sign during the assessment. Which action by the nurse is the most appropriate? A. Assist with obtaining laboratory studies. B. Document the findings in the child's chart. C. Measure the child's abdominal girth. D. Notify the provider and facilitate a CT or an MRI.

ANS: D Battle's sign is indicative of a basilar skull fracture. The child will need a head CT or an MRI. The other actions are not needed as a result of this finding.

42. The nurse is providing care to a pediatric patient who has orders for Crutchfield tongs. Which diagnosis does the nurse anticipate prior to reviewing the patient's medical record? A. Dislocated hip B. Femur fracture C. Osteopenia D. Spinal fracture

ANS: D Crutchfield tongs are used to treat cervical or thoracic fractures.

5. The pediatric nurse caring for a patient with encephalitis explains to the parents that the most common origin of encephalitis is which of the following? A. Bacterial B. Fungal C. Parasitic D. Viral

ANS: D Encephalitis is usually viral in origin and occurs with an acute febrile illness that is characterized by cerebral edema and infection of surrounding meninges. Less common etiologies are fungal, bacterial, and parasitic infections; exposure to toxins or drugs; and cancer.

12. A neonate receives a diagnosis of hydrocephalus. The pediatric nurse assesses for congenital anomalies related to this condition. Which condition is inconsistent with the nurse's knowledge of hydrocephalus? A. Aqueductal stenosis B. Chiari I and II malformations C. Dandy-Walker malformation D. Folic acid deficiency

ANS: D Hydrocephalus develops when an impedance to cerebrospinal fluid (CSF) flow or absorption is present. It rarely occurs as a result of the overproduction of CSF. Congenital anomalies, including Chiari I and II malformations, Dandy-Walker malformation, and aqueductal stenosis, are the most common causes of hydrocephalus during the neonatal and early infancy periods. Acquired hydrocephalus occurs after birth and in infancy, usually resulting from intraventricular hemorrhage due to prematurity. Folic acid deficiency is related to neural tube deficits.

34. A nurse is teaching a parent group about caring for their infants and toddlers. What does the nurse teach to prevent a serious neurological problem in infants? A. Always treat any temperature elevation to prevent seizures. B. Avoid vaccinations with live, attenuated viruses. C. Do not use artificial sweeteners in your baby's food. D. Never give honey to a child less than 1 year of age.

ANS: D Infant botulism can be caused by feeding honey to a child less than 12 months of age, so the nurse teaches parents to avoid this. The other statements are inaccurate.

2. The pediatric nurse explains to the parents of a comatose child that which structure controls the child's level of consciousness? A. Basal ganglia B. Brainstem C. Central nervous system D. Reticular activating system

ANS: D Level of consciousness is controlled by the reticular activating system and the cerebral hemispheres of the brain. Cognitive cerebral function cannot occur without an active reticular activating system.

5. A pediatric nurse is caring for a 1-year-old child who is in a spica cast. The nurse teaches the parents that modifications need to be made for this child. Which modification does the nurse teach? A. Using a baby bath with shallow water to clean the child B. Using a car seat with sturdy sides to transport the child C. Using a sitting position on the floor to feed the child D. Using a wagon instead of a stroller to move the child

ANS: D Placing the child in the prone position on the floor makes it easier for feeding the child. Mobilizing a child in a wagon is a good modification for a stroller while the child is in the spica cast. Toddler car seats that do not have sides are also a good modification for a child in a spica cast. The parents will need to modify the bath by giving the child a sponge bath.

13. A woman who wishes to become pregnant again consults with the nurse about preventing her child from being born with clubfoot. She has two other children, both treated for this disorder. Which information does the nurse provide about preventing clubfoot? A. Avoid secondhand cigarette smoke while pregnant B. Fetal positioning in utero cannot be controlled C. Getting enough folic acid early in pregnancy is advisable. D. The disorder is genetic so no prevention is available.

ANS: D Recent research shows that clubfoot is genetic, so no prevention is possible. In utero positioning can possibly influence the disorder as well. Second-hand smoke exposure is not related. Folic acid is important for preventing neural tube disorders.

42. A pediatric nurse reads the diagnosis "SCIWORA" on a child's chart. Which assessment finding does the nurse anticipate to correlate with this condition? A. Altered level of consciousness B. Diplopia and visual disturbances C. Inability to hold his head up D. Weakness/paralysis of muscles

ANS: D SCIWORA stands for "spinal cord injury without radiographic abnormality." Common manifestations of spinal cord injury include increased muscle tone, loss of normal bowel and bladder function, numbness, sensory changes, pain, and weakness or paralysis of muscles.

40. The parents of a 3-year old cannot understand how their child has developed osteoporosis, stating "We didn't think children could get this disease." Which assessment by the nurse is most important? A. Attainment of developmental milestones B. Dietary intake of calcium C. Height and weight D. Labor and birth history

ANS: D Very-low-birth-weight and premature infants are at risk for developing osteoporosis because bone mass is acquired during the last weeks of pregnancy. If this child were born prematurely, that could explain the osteoporosis. Attaining milestones and height and weight are not the priority (height loss is possible with multiple fractures in older children). Although teens can develop osteoporosis from dietary deficiency of calcium and vitamin D, it is highly unlikely that a 3-year-old would have osteoporosis from this situation.

27. A new nurse is placing an elastic wrap on a patient with an ankle sprain. Which action by this nurse causes an experienced nurse to intervene? A. Exerts moderate pull on the wrap B. Instructs the patient on wrapping the injury C. Starts wrapping distal to the injury D. Wraps in a proximal-to-distal fashion

ANS: D When using an elastic wrap, start wrapping distal to the injury, work up over the injury, and end the wrapping proximal to the injury. The other actions are correct.