Saunders Comprehensive Review for the NCLEX-RN® -Pt 1

The nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure: 1. Safety with activities 2. Activities providing verbal stimulation 3. Social interactions with other children in the same age group 4. Familiarity with all activities and providing orientation throughout the activities

1 Rationale: Safety with all activities is a priority in planning activities with the child. The child with autism is unable to anticipate danger, has a tendency for self-mutilation, and has sensoriperceptual deficits.

The nurse is assisting in developing a plan of care for a child who will be returning from the operating room following a tonsillectomy. The nurse plans to place the child in which of the following positions on return from the operating room? 1. Supine 2. Side-lying 3. High-Fowler's and on the left side 4. Trendelenburg's and on the right side

2 Rationale: The child should be placed in a prone or side-lying position following tonsillectomy to facilitate drainage.

The nurse is providing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse includes which of the following instructions? 1. Call the physician if the infant is fussy. 2. Expect an increased urine output from the shunt. 3. Call the physician if the infant has a high-pitched cry. 4. Position the infant on the side of the shunt when the infant is put to bed. *ventriculoperitoneal shunt:is a surgical procedure that primarily treats a condition called hydrocephalus. This condition occurs when excess cerebrospinal fluid (CSF) collects in the brain's ventricles. CSF cushions your brain and protects it from injury inside your skull.

3 Rationale: If the shunt is malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is increased intracranial pressure, which then causes a high-pitched cry in the infant.

The nurse is collecting data on a 7-year-old child who is suspected of having episodes of absence seizures. Which of the following questions to the mother will assist in providing information that will identify the symptoms associated with these types of seizures? 1. "Does twitching occur in the face and neck?" 2. "Does the muscle twitching occur on one side of the body?" 3. "Does the muscle twitching occur on both sides of the body?" 4. "Does the child have a blank expression during these episodes?" * absence seizures: A type of seizure that involves brief, sudden lapses in attention.

4 Rationale: Absence seizures are very brief episodes of altered awareness. There is no muscle activity except eyelid fluttering or twitching. The child has a blank facial expression. These seizures last only 5 to 10 seconds but may occur one after another several times a day. Myoclonic seizures are brief, random contractions of a muscle group that can occur on one or both sides of the body.

The nurse is caring for a child who has sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse monitors for the earliest sign of increased ICP by assessing for: 1. Apnea 2. Posturing 3. Tachycardia 4. Changes in level of consciousness (LOC)

4 Rationale: An altered level of consciousness is an early sign of increased ICP. Late signs of increased ICP include tachycardia, leading to bradycardia, apnea, systolic hypertension, widening pulse pressure, and posturing.

The nurse is providing instructions to an adolescent who is taking phenytoin (Dilantin) for the control of seizures. Which of the following statements, if made by the adolescent, indicates a need for further teaching regarding the medication? 1. "The medication may cause oily skin." 2. "Drinking alcohol may affect the medication." 3. "If my gums become sore I need to stop the medication." 4. "Birth control pills may not be effective when I take this medication."

3 Rationale: The adolescent should not stop taking antiseizure medications suddenly or without discussing it with a physician or nurse.

The nurse is caring for an infant with a diagnosis of hydrocephalus and is monitoring the infant for signs of increased intracranial pressure (ICP). The nurse suspects increased ICP if which of the following is noted? 1. Proteinuria 2. Bradycardia 3. A drop in blood pressure 4. A bulging anterior fontanel *hydrocephalus :A build-up of fluid in the cavities deep within the brain.This causes increased intracranial pressure.

4 Rationale: An elevated or bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle.

The nurse is providing home care instructions to the mother of a child who is recovering from Reye's syndrome. Which of the following home instructions should the nurse provide to the mother? 1. Increase the stimuli in the environment. 2. Give the child frequent small meals, if vomiting occurs. 3. Avoid daytime naps so that the child will sleep at night. 4. Check the child's skin and eyes every day for a yellow discoloration.

4 Rationale: Checking for jaundice will assist in identifying the presence of liver complications, which are characteristic of Reye's syndrome. If vomiting occurs in Reye's syndrome, it is caused by cerebral edema and is a sign of intracranial pressure. Decreasing stimuli and providing rest decrease stress on the brain tissue.

4. The nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for: 1. Signs of hyperglycemia 2. Signs of a bacterial infection 3. The presence of protein in the urine 4. Signs of increased intracranial pressure *Reye's syndrome: exact cause of Reye's syndrome is unknown, although several factors may play a role in its development. Reye's syndrome seems to be triggered by using aspirin to treat a viral illness or infection — particularly flu (influenza) and chickenpox — in children and teenagers who have an underlying fatty acid oxidation disorder

4 Rationale: Intracranial pressure and encephalopathy are major symptoms of Reye's syndrome.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing were present? 1. Rigid extension and tremors of all extremities 2. Flaccid paralysis of all extremities 3. Flexion of the upper extremities and extension of the lower extremities 4. Abnormal extension of the upper and lower extremities with some internal rotation

4 Rationale: Decerebrate (extension) posturing is an abnormal extension of the upper extremities, with internal rotation of the upper arm and wrist and extension of the lower extremities with some internal rotation. "Flexion of the upper extremities and extension of the lower extremities" describes decorticate posturing. "Rigid extension and tremors of all extremities" and "flaccid paralysis of all extremities" are incorrect and not characteristics of decerebrate posturing.