Trigeminal Neuralgia, Bell's Palsy, Guillain-Barre, Pediatric NCLEX

A pregnant patient is scheduled for an ultrasound to attempt to diagnose the possibility of cerebral palsy (CP). Which statement should the nurse use to explain to the patient how this test is used to identify the possibility of CP? "An ultrasound can detect abnormalities of the brain that can increase the likelihood of the presence of CP." "An ultrasound can detect specific deformities and developmental disorders that are associated with CP." "An ultrasound can determine the position of the fetus in the uterus, which can identify any possible abnormality leading to CP." "An ultrasound can positively detect CP by measuring the size of the brain."

"An ultrasound can detect abnormalities of the brain that can increase the likelihood of the presence of CP." Neonatal brain abnormalities, such as intraventricular hemorrhage, can contribute to the development of CP. An ultrasound can help detect these abnormalities prior to birth. An ultrasound can detect birth defects and abnormalities, but these are not necessarily associated with CP. Fetal position is not associated with CP, although malpositioned infants, such as breech presentation, can increase risk of difficult delivery and brain injury. CP is not identified by the size of the brain."

The parent of a child with cerebral palsy (CP) ask the nurse, "What is the purpose of these braces?" Which response by the nurse is correct? "Braces help with mobility and provide stabilization." "Braces will protect your child from broken bones." "Braces will help promote flexibility." "Braces will help strengthen muscles."

"Braces help with mobility and provide stabilization." Braces for a patient with CP serve the purpose of providing stability and, in turn, promoting mobility. Braces do not provide protection; it is still possible for a patient to break a bone while wearing braces. Therapeutic massage, not braces, helps strengthen muscles and promote flexibility.

The nurse is reviewing multiple cases of patients diagnosed with cerebral palsy (CP). Which patient would benefit most from enhanced mobility? ANSWER Correct answer A 15-year-old patient who uses a manual wheelchair at school. Unselected A 17-year-old patient who works at a grocery store as a bagger. Unselected A 55-year-old patient who lives in a group home and uses a walker. Unselected A 13-year-old patient who uses a wheelchair and has a private nurse at home.

"Not all patients with CP have an intellectual disability." A high school student who uses a manual wheelchair would most likely benefit most from adaptive and assistive technology, such as a motorized wheelchair, to promote mobility. The patient working as a bagger is quite independent, as is the patient who can ambulate and use a walker. The patient who uses a wheelchair may benefit from increased mobility, but having a private nurse increases the likelihood that the patient is assisted with mobility.

The parents of a 7-year-old patient with cerebral palsy (CP) ask for strategies to help with mealtime for their child. Which statement should the nurse provide? "Provide a liquid diet only." "Provide foods that require chewing to prevent aspiration." "Provide soft foods with the use of large, padded utensils." "Continue feeding your child for nutrition purposes."

"Provide soft foods with the use of large, padded utensils." Problems with swallowing, sucking, chewing, and movements in the mouth and jaw also cause nutritional challenges. Give the child soft foods in small amounts. Utensils with large, padded handles may be easier for the child to use. Liquids only can be an aspiration risk, as well as possibly not provide adequate nutrition. The child should always be encouraged to function independently.

The parents of a 3-year-old child with cerebral palsy (CP) do not wish to begin any physical therapy or use braces or positioning devices until the child is older. Which response should the nurse make to the parents? "You may want to wait until walking occurs." "You shouldn't wait because that could make the condition much worse." "It's up to you. It really doesn't matter when therapy is started." "The earlier the intervention is started, the better the long-term result to optimize independence."

"The earlier the intervention is started, the better the long-term result to optimize independence." The earlier therapies and interventions are started in those with CP, the more effective they are and the more they will enhance independence. Parents should be encouraged to begin interventions as soon as possible and not wait for milestones such as walking. Waiting will not result in a worsened condition but will not provide the benefit of early therapy.

The nurse is obtaining a health history from the parents of a child with cerebral palsy (CP). Which question should the nurse use to determine whether the child's brain insult happened after birth? "Was the mother older than 40 years when the child was born?" "Was the child born prematurely?" "Were there any accidents before age 3?" "Was the child born subsequent to the fourth child?"

"Were there any accidents before age 3?" Asking about maternal age at birth, prematurity, and birth order all assess possible prenatal causes of CP. Asking about accidents before age 3 can help determine whether the child's brain insult happened after birth.

13. A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. the presence of hyperactive reflex activity below the level of the injury. d. flaccid paralysis and lack of sensation below the level of the injury. Correct Answer: D Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury. Cognitive Level: Comprehension Text Reference: p. 1590 Nursing Process: Assessment NCLEX: Physiological Integrity

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3. A patient with trigeminal neuralgia has a glycerol rhizotomy. During a follow-up visit after the rhizotomy, the nurse will evaluate that the patient has had a successful outcome for the surgery if the patient a. uses an eye shield at night to protect the cornea from injury. b. develops and implements a daily routine of facial exercises. c. is careful to chew foods on the unaffected side of the mouth. d. talks about enjoying social activities with family and friends. Correct Answer: D Rationale: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, enjoyment of social activities indicates successful reduction of symptoms. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing. Cognitive Level: Application Text Reference: pp. 1583-1584 Nursing Process: Evaluation NCLEX: Physiological Integrity

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5. When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include? a. "You should call the doctor if pain or herpes lesions occur near the ear." b. "Treatment of herpes with antiviral agents will prevent development of Bell's palsy." c. "Medications to treat Bell's palsy work only if started before paralysis onset." d. "You may be able to prevent Bell's palsy by doing facial exercises regularly." Correct Answer: A Rationale: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy. Cognitive Level: Application Text Reference: p. 1585 Nursing Process: Implementation NCLEX: Physiological Integrity

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The nurse explains that Bryant's traction is reserved for children who weigh less than _____ pounds.

30. Correct. Bryant's traction is a skin traction used in the treatment of orthopedic disorders of young children who weigh less than 30 pounds. Greater weight would cause excessive counterbalance and injury to soft tissues.

A child is newly diagnosed with cerebral palsy​ (CP). For which type of cerebral palsy should the nurse most likely plan​ care? A. Spastic cerebral palsy B. Mixed cerebral palsy C. Ataxic cerebral palsy D. Dyskinetic cerebral palsy

A Rationale: About​ 80% of all cases of CP are classified as spastic. The other types of cerebral palsy are less common

A yellow bruise is apporoximately: 1.) 2 days old 2.) 5 to 7 days old 3.) 7 to 10 days old 4.) 10 to 14 days old

7 to 10 days old

Which intervention should improve​ self-feeding ability in a child with spasticity caused by cerebral palsy​ (CP)? A. Providing utensils with adaptive handles B. Providing a​ low-fiber diet C. Presenting large portions of food all at one time D. Restricting hydration

A Rationale: Utensils with adaptive handles may improve​ self-feeding ability in children with spasticity associated with CP. Other possible interventions include feeding small amounts of food at a time. Restricting fluids and a​ low-fiber diet will not improve​ self-feeding ability in this client.

A 15-year-old is admitted to the intensive care unit (ICU) with a spinal cord injury. The most appropriate nursing interventions for this adolescent are (Select all that apply.) A. monitoring neurologic status. B. administering corticosteroids. C. monitoring for respiratory complications. D. discussing long-term care issues with the family. E. monitoring and maintaining hemodynamic status.

A, B, C, E

The nurse demonstrates which similarities among all traction devices? (Select all that apply.) a. Pull the limb into extension b. Decrease muscle spasm c. Reduce pain d. Align two bone fragments e. Immobilize the limb

A, B, D, E. Correct. Tractions are designed to immobilize and pull limbs into extension. Traction can also align broken bones and decrease muscle spasm. Although some traction devices may relieve pain, many may actually cause pain.

What factor(s) may trigger abuse in a parent? (Select all that apply.) a. Being abused as a child b. High self-esteem c. Substance abuse d. Overwhelming responsibility e. Knowledge deficit relative to child care

A, C, D, E. Correct. All options except high self-esteem are possible triggers for a parent to become abusive.

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? ( select all that apply) A. Time the seizure B. Restrain the child C. Stay with the child D. Place the child in a prone position E. Move furniture away from the child F. Insert a padded tongue blade in the child's mouth

A, C, E are correct

How does the pediatric skeletal system differ from that of the adult? (Select all that apply.) a. Lower mineral content b. More ossification c. Open epiphyses d. Less porosity e. Greater strength

A, C, E. Correct. The child's skeletal system has less mineral content, greater porosity, open epiphyses, greater bone strength, and a thicker periosteum.

The nurse is preparing teaching material for the parents of a child with cerebral palsy​ (CP). Which treatment should the nurse include in this​ teaching? (Select all that​ apply.) A. Positioning devices B. Surgery C. Serial casting D. A​ low-calorie diet E. Muscle relaxants

A,B,C,E ​Rationale: Muscle relaxants may help the child with spasticity often associated with CP. Surgery may be helpful for children who experience contractures as a result of CP. Serial casting may be helpful for children with CP. Positioning devices are used to prevent contractures. A​ low-calorie diet is not recommended for children with CP.

The nurse is caring for a client with cerebral palsy​ (CP) who wears bilateral leg braces and requires full assistance to mobilize. For which condition is the client at​ risk? (Select all that​ apply.) A. Muscle contractures B. Pressure injuries C. Atherosclerosis D. Fatigue E. Increased dental caries

A,B,D Rationale: The nurse should protect bony prominences and assess regularly for redness and skin breakdown under the braces. The​ client's inability to change positions independently also places her at risk for pressure wounds and muscle contractures. Fatigue results from the extended energy needed to work against the muscle contractures. Atherosclerosis is a severe problem with CP that is associated with aging but is not caused by the leg braces or immobility. Dental caries are also unrelated to the braces or physical dependence.

The family of a 4-month-old infant notices that the child does not act like other infants of the same age. The clinic nurse assesses the child for which finding to help confirm a diagnosis of cerebral palsy? A. Persistent asymmetric tonic neck reflex when infant's head is turned B. Infant removes small blanket placed over face with both hands C. Absence of persistent back arching in any position D. Absence of athetosis distally in all extremities of the infant

A-One of the first things that parents will notice in a child with cerebral palsy is that the child is not keeping up with developmental milestones. To confirm a diagnosis of cerebral palsy, the nurse would expect to see persistent asymmetric tonic neck reflex when the infant's head is turned. The nurse would expect the infant to remove a small blanket placed over the face with one hand, or not at all, due to unilateral developmental issues.

The nurse is caring for a client being evaluated for attention-deficit/hyperactivity disorder. Which assessment finding (persisting more than 6 months) is consistent with the DSM-5 diagnostic criteria for hyperactivity and impulsivity? A. Often has difficulty waiting for turn in line or activity B. Often has difficulty organizing tasks and activities C. Often loses things necessary for tasks or activities D. Often fails to finish schoolwork, chores, or duties

A-One of the symptoms associated with the DSM-5 diagnostic criteria for hyperactivity and impulsivity in clients with ADHD is "Often has difficulty waiting for his or her turn," for example, in line or activity. The other choices are criteria for inattention.

Which statement is most accurate in describing tetanus? A. Acute infectious disease caused by an exotoxin produced by an anaerobic, gram-positive bacillus B. Inflammatory disease that causes extreme, localized muscle spasm C. Acute infection that causes meningeal inflammation, resulting in symptoms of generalized muscle spasm D. Disease affecting the salivary gland with resultant stiffness of the jaw

A.

The nurse is caring for a child who has recently been diagnosed with cerebral palsy. The parents ask the nurse about the disorder. What is the nurse's best response with regard to the definition of the disorder? A. A chronic disorder in which there is difficulty controlling muscles B. An infectious disease C. A viral illness that causes inflammation of the brain D. A congenital condition causing mental retardation

A. Cerebral palsy is a chronic disability characterized by difficulty controlling muscles as a result of an abnormality in the motor system. Cerebral palsy is not an infectious disease or the result of inflammation due to a viral illness. Down syndrome is an example of a congenital condition causing mental retardation. Some children with cerebral palsy, though not all, experience mental retardation.

A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain when she raises herself onto the bedpan. Which nursing diagnosis takes highest priority for this child? a. Pain resulting from tissue trauma b. High risk for impaired skin integrity resulting from immobility c. Altered growth and development related to separation from family d. Altered urinary elimination related to immobility and traction

A. Correct. Although all of these nursing diagnoses are relevant to the child in traction, pain resulting from muscle spasm and tissue trauma is the highest priority.

Which observation may cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs? a. Red, green, and yellow bruises on his body b. Bruises are dispersed on his head, arms, and legs c. A broken arm last year, and the child being described as accident-prone d. The mother is very anxious for her son to get medical attention

A. Correct. As bruises heal, they change color in stages. Different colors of bruises indicate that injuries have not all occurred at the same time. The nurse must consider whether the bruises match the caretaker's explanation of what happened.

A nurse is caring for a child who has cerebral palsy. Which of the following medications should the nurse expect to administer to treat painful muscle spasms. (Select all that apply) A. Baclofen B. Diazepam C. Oxybutynin D. Methotrexate E. Prednisone

A. Correct. Baclofen is a centrally acting skeletal muscle relaxant that decreases muscle spasm and severe spasticity B. Correct. Diazepam is a skeletal muscle relaxant that decreases muscle spasm and severe spasticity

On entering the room of a child in Buck's traction, the nurse makes all of the following observations. Which observation requires a nursing intervention? a. Child's heels are placed firmly against the foot of the bed. b. Head of bed is elevated 20 degrees. c. Weights are hanging freely. d. Ropes are on pulleys.

A. Correct. Buck's traction is dependent on the child as a counterweight. The heels should be elevated above the level of the foot of the bed.

The nurse is checking for capillary refill on a child in Bryant's traction. How long does it take for the toe to regain color if adequate perfusion is assessed? a. 3 seconds b. 4 seconds c. 5 seconds d. 6 seconds

A. Correct. Capillary refill in 3 seconds or less is determined to be indicative of adequate perfusion.

Which nursing diagnosis would be a priority when preparing a plan of care for a child in a leg cast? a. Risk for altered peripheral tissue perfusion b. Risk for altered urine elimination c. Knowledge deficit d. Risk for infection

A. Correct. Casting can lead to compromised tissue perfusion caused by increased pressure from edema or swelling pressing on the tissues. Neurovascular checks are an assessment priority.

The nurse is providing instructions about how to treat a sprained ankle. What statement by the mother does the nurse recognize as indicative of a need for additional teaching? a. "Apply warm compresses to the ankle for the first 24 hours." b. "Put an ice pack on the ankle, alternating 30 minutes on with 30 minutes off." c. "Wrap the ankle in an Ace bandage for support." d. "Keep the leg elevated when sitting."

A. Correct. Heat is not a treatment for soft tissue injuries. The principles of managing soft tissue injuries are rest, ice, compression, and elevation.

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? A. Meningitis B. Spinal cord injury C. Intracranial bleeding D. Decreased cerebral blood flow

A. Correct. Meningitis is an infectious process of the CNS caused by bacteria and viruses

A nurse is caring for a school aged child who has juvenile idiopathic arthritis. Which of the following home care instructions should the nurse include in the teaching. (Select all that apply). A. Provide extra time for ADL's B. Use cold compress for joints C. Take ibuprofen on an empty stomach D. Remain home during periods of exacerbation E. Perform ROM exercises.

A. Correct. Providing extra time for ADL's promotes independence in the child and provides a means to maintain mobility E. Correct. ROM will assist in maintaining function of the joints

What nursing action will significantly decrease the risk of serious complications for a child in Bryant's traction? a. Neurovascular checks are done frequently. b. Bandages are wrapped tightly. c. The child is restrained from rolling over. d. The child's buttocks are resting on the bed.

A. Correct. The nurse caring for a child in traction must be alert for Volkmann's ischemia, which occurs when circulation is obstructed.

What intervention is appropriate for a nurse assessing a preadolescent child for scoliosis? a. Ask the child to bend forward at the waist and observe the child's back for asymmetry. b. Observe the gait while the child is walking forward heel to toe. c. Have the child flex the knees and look for uneven knee height. d. Look at the child's shoulders and hips while fully clothed.

A. Correct. The nurse looks at the back as the child bends forward for general body alignment and asymmetry.

The mother of a​ 4-month-old client is concerned that the client may be developmentally delayed. Which finding should lead the nurse to suspect cerebral palsy​ (CP) in the​ infant? A. Hypotonia B. Head lag C. Tonic neck reflex D. Follows objects 180 degrees

A. Hypotonia

A 13-year-old girl is diagnosed with functional scoliosis. What does the nurse explain as the cause of this spinal curvature defect? a. Juvenile rheumatoid arthritis b. Poor posture c. Heredity d. Myelomeningocele

B. Correct. Functional scoliosis usually is caused by poor posture, and it is not a spinal disease.

AN infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the PRIORITY nursing intervention in the pre operative period? A. Test the urine for protein B. Reposition the infant frequently C. Provide a stimulating environment D. Asses BP every 15 mins

B. Correct. If an infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head

A 9-year-old patient with cerebral palsy (CP) is being evaluated for a procedure that will assist with improving ambulation. For which procedure should the nurse prepare teaching? Achilles tendon lengthening Selective dorsal rhizotomy Hamstring release Joint stabilization

Achilles tendon lengthening Achilles tendon lengthening is most frequently done to improve ambulation that is impaired due to contractures of the tendon. This can assist with the ability to walk flat-footed, which can allow or improve ambulation. Selective dorsal rhizotomy is done to reduce spasticity. Hamstring lengthening will improve contractures and joint deformity. Joint stabilization can help provide support to joints that are damaged due to contractures or arthritis.

Which surgical intervention is not used to treat cerebral palsy​ (CP)? Surgically implanted intrathecal pump Achilles tendon shortening Releasing the hamstrings Dorsal rhizotomy

Achilles tendon​ lengthening, not​ shortening, is a surgical intervention used to treat CP. Other surgical treatments include surgical implantation of an intrathecal​ pump, releasing the​ hamstrings, and dorsal rhizotomy.

The nurse is visiting Gerry​ James, a​ 17-year-old adolescent with cerebral palsy​ (CP). Which would the nurse recommend to assist this client with physical mobility in his planning to begin college in a few​ months? Learn American sign language Receive therapeutic massages every week Use adaptive utensils Obtain a customized wheelchair

Adaptive and assistive technology to promote mobility includes the use of a customized wheelchair. American sign language would help with communication. Adaptive utensils ensure adequate nutritional intake. Receiving therapeutic massages would reduce spasticity and encourage muscle relaxation.

Which would be assessed in all children during healthcare provider​ visits? ​ (Select all that​ apply.) Persistent newborn sleep patterns Altered speech and difficulty swallowing Developmental abnormalities Abnormal muscle tone and abnormal posture Height and weight

Altered speech and difficulty swallowing Developmental abnormalities Abnormal muscle tone and abnormal posture Height and weight

The nurse is obtaining a health history from the parents of a child with cerebral palsy​ (CP). Which question would be most helpful in determining whether the​ child's brain insult happened after​ birth? ​"Was the child born​ prematurely?" ​"Were there any accidents before age​ 3?" ​"Was the mother older than 40 years when the child was​ born?" ​"Was the child born subsequent to the fourth​ child?"

Asking about maternal age at​ birth, prematurity, and birth order all assess possible prenatal causes of CP. Asking about accidents before age 3 can help determine whether the​ child's brain insult happened after birth.

A​ 6-year-old child with cerebral palsy​ (CP) new to a school district is experiencing severe rigidity and spasticity. What should the school nurse say to the​ parents? A. ​"Offer only​ low-carbohydrate, low-calorie foods to the​ child." B. ​"What exercises can we do during school to help with the​ rigidity?" C. ​"Look into special schools for the​ handicapped." D. ​"Discourage the use of a​ computer."

B Rationale: The child with CP most likely has been evaluated and treated by a physical therapist who developed a plan for tendon stretching and​ range-of-motion exercises to decrease the rigidity and spasticity. This plan should be shared with the school nurse. Most school districts do not require that children with physical disabilities such as those associated with CP attend alternative schools. Children with CP require​ high-calorie foods because of feeding difficulties associated with spasticity and hypotonia. Computers are encouraged to promote communication.

In working with parents who have a child diagnosed with cerebral palsy, which therapeutic management goals should be included in the plan of care? (Select all that apply.) A. Limit socialization to similar type affected children. B. Provide educational opportunities that are individualized to children's needs and abilities. C. To help support and maintain location, communication and self-help skills. D. To correct body image perception. E. To integrate motor function.

B, C, E

A​ small-for-gestational age neonate is showing signs of poor development. Which factor should the nurse identify that increases this​ client's risk of cerebral palsy​ (CP) before or during​ birth? (Select all that​ apply.) A. Hyperbilirubinemia B. Injury to the cerebral cortex C. Fetal viral infection D. Neonatal sepsis E. Premature birth

B,C,E ​Rationale: Most cases of CP are caused before or during birth by a brain​ insult; this includes premature​ birth, fetal viral​ infection, and injury to the cerebral cortex. CP can also develop after birth to age 2​ years, when it can be caused by neonatal sepsis and hyperbilirubinemia

The family of a child who is experiencing attention-deficit/hyperactivity disorder tells the nurse that they are having difficulty dealing with the child's behavior at home. The nurse teaches the family which technique to help manage the child at home? A. Put the child in the yard to exercise and run to tire the child. B. Have routines for eating, sleeping, and recreation. C. Invite the neighborhood children over to play. D. Punish unwanted behaviors.

B- Having family routines helps the child to know what to expect and to build a trusting relationship. The child should not be outside without supervision and running around is likely to increase the child's level of excitation. Inviting other children over to play may provide too much stimulation and cause the child to be more hyperactive. Punishment for unwanted behavior may decrease the child's self-esteem. The family should concentrate on positive reinforcement when the child shows desired behaviors.

The nurse is teaching a group of pregnant women about cerebral palsy. The nurse emphasizes the need for good prenatal care and nutrition, because the greatest risk for cerebral palsy is found in which situation? A. Birth asphyxia B. Prematurity C. Maternal infection with the common cold D. Poor nutrition in the mother

B- Injury to the immature periventricular white matter in premature infants is thought to be the most common risk factor and cause of cerebral palsy. The rate of cerebral palsy increases with decreasing gestational age. Birth asphyxia causes a small percentage of cerebral palsy. A maternal cold and poor nutrition in the mother do not pose as significant a risk as prematurity does. Although poor nutrition may be a cause of prematurity, it is not the only cause.

The nurse is planning care for a child with autism spectrum disorder (ASD) and selects Impaired Social Interaction as a nursing diagnosis based on which assessment finding? A. Child frequently bangs head on wall. B. Child will not cuddle with parent. C. Child babbled as an infant. D. Child bites self.

B-A sign of impaired social interaction is the inability to tolerate touch and a refusal to cuddle. Banging the head and biting self are examples of compulsive behavior. Babbling as an infant is the normal precursor of speech.

The nurse is working with a child with ASD and the child's family. The parents ask the nurse what medications will be used to help cure the child. What is the nurse's best response? A. "The doctor will order methylphenidate (Ritalin)." B. "Treatment for autism focuses on behavior change, not medications." C. "The child will be admitted to a psychiatric facility for medications." D. "The child will be given medication at an outpatient clinic."

B-Medications, if used, are not for treatment of autism but for associated conditions. Treatment focuses on changing behavior and optimizing the child's strengths. The child with autism is not usually admitted to a psychiatric facility or given medication at an outpatient clinic.

The nurse is evaluating a child with ASD and determines that a goal of treatment has been met when the parent makes which statement? A. "The child sat still for 1 minute yesterday." B. "The child learned to eat with a fork." C. "The child repeats our sentences." D. "The child repeats questions back to us."

B-One goal for the child with ASD is that the child will progress developmentally. Learning something new, such as eating with a fork, demonstrates progression. The autistic child is not hyperactive. Repeating sentences is echolalia, a symptom of ASD. Repeating questions back is another symptom of ASD.

The nurse is evaluating the child with failure to thrive to determine whether goals have been met. The nurse evaluates which finding in this child? A. Presence of reflexes B. Improved developmental progress C. Child's ability to smile D. Child's lack of anxiety

B-The nurse evaluates growth (weight) and developmental milestones to determine whether goals have been met. The other options do not meet either of these criteria as milestones for the child who experiences failure to thrive.

A child with spina bifida has developed a latex allergy from numerous bladder catheterizations and surgeries. A priority nursing intervention is to A. recommend allergy testing. B. provide a latex-free environment. C. use only powder-free latex gloves. D. limit the use of latex products as much as possible.

B.

An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome). When explaining this disease process to the parents, what should the nurse consider? A. Paralysis is progressive, with little hope for recovery. B. Muscle function will gradually return, and recovery is possible in most children. C. Guillain-Barré syndrome results from an apparently toxic reaction to certain medications. D. Guillain-Barré syndrome is inherited as an autosomal recessive, sex-linked gene.

B.

What is associated with infant botulism? A. Contaminated soil B. Honey and corn syrup C. Commercial infant cereals D. Improperly sterilized bottles

B.

Which statement is true regarding the genetic transmission of Duchenne muscular dystrophy (DMD)? A. Multiple gene expression B. X-linked recessive C. Autosomal dominant D. No carrier states exist

B.

The nurse is reviewing the characteristics of Ewing's sarcoma. Which statement if made by the nurse indicates correct understanding of this disease? a. "Amputation is the accepted treatment." b. "The disease is sensitive to radiation and chemotherapy." c. "Metastasis is rare." d. "The disease is more prevalent among toddlers and preschoolers."

B. Correct. Ewing's sarcoma is sensitive to radiation therapy and chemotherapy. Amputation of the affected extremity is not recommended. This cancer occurs in school-age children and does metastasize.

Which intervention would be helpful in relieving morning discomfort associated with juvenile rheumatoid arthritis? a. Wearing splints at night to prevent extension contractures b. Applying moist heat packs upon awakening c. Taking a warm tub bath the evening before d. Sleeping with two pillows under the head

B. Correct. Application of moist heat, with a compress or by tub bath upon awakening, will help to lessen stiffness

A child hospitalized for treatment of osteomyelitis complains that he is tired of being sick and wants to know when the antibiotic protocol will end. How long will the nurse indicate that antibiotic therapy will probably last? a. 2 weeks b. 6 weeks c. 2 months d. 3 months

B. Correct. Because osteomyelitis is an infection in the bone, antibiotics are given intravenously for 4 to 6 weeks.

What intervention will the nurse caring for a child in Buck's skin traction implement? a. Position in high Fowler's position. b. Assist the child to be pulled up in bed. c. Keep child's heel on the bed surface. d. Maintain child's feet against the foot of the bed.

B. Correct. Buck's traction is a type of skin traction that relies on the child's weight as counterbalance. The child must be kept with head elevated no more than 20 degrees and pulled up in bed, and the feet should not touch the bed surface or the foot of the bed.

The parent of a child with osteomyelitis asks why his child is in so much pain. What will the nurse respond causes the pain experienced with osteomyelitis? a. "Pressure of inelastic bone" b. "Purulent drainage in the bone marrow" c. "The cast applied on the extremity" d. "Circulatory congestion of the skin"

B. Correct. Osteomyelitis is an infection of the bone. Inflammation produces an exudate that collects under the marrow and cortex of the bone. The vessels are compressed and thrombosis occurs, producing ischemia and pain.

A nurse is developing a plan of care for a toddler who has cerebral palsy. Which of the following actions should the nurse include? A. Structure interventions according to the toddler's chronological age B. Evaluate the toddler's need for an evaluation of hearing ability C. Monitor the toddler's pain level routinely using a numeric rating scale D. Provide total care for daily hygiene activities

B. Correct. Recognize that the toddler who has CP has an increased risk for hearing impairment. Therefore, evaluate the toddlers need for an evaluation of hearing ability

What would the nurse consider an abnormal finding on a musculoskeletal assessment of a 4-year-old child? a. Has inward-turned knees while standing b. Walks on the toes c. Appears to have flat feet d. Swings his arms when walking

B. Correct. Toe walking after 3 years of age may indicate a muscle problem.

The home health nurse is planning care for a child with attention-deficit/hyperactivity disorder (ADHD). Which behavior by the child would indicate progress toward the goal of increased self-esteem? A. The child has high energy. B. The child sleeps off and on at night. C. The child is able to control impulse behavior. D. The child speaks very quickly.

C-The child with ADHD has difficulty controlling impulses. A goal of treatment would be that the child's behavior is less impulsive. High energy is not necessarily a sign of ADHD or improving behavior. Sleeping on and off at night and fast speech are symptomatic of ADHD.

The nurse is teaching the parents of a child with cerebral palsy about appropriate therapies that can be helpful for the child​'s mobility status. Which statement made by a parent indicates that this teaching has been​ effective? ​"Serial casting is not recommended for treatment​ anymore." ​"Braces will help maintain our ​child's skeletal​ alignment." ​"We should not use splints on our ​child's ​limbs." ​"Nothing will help with involuntary​ movements."

Braces and​ splints, serial​ casting, and positioning devices such as prone​ wedges, standers, and​ side-lyers are used to prevent contractures and promote range of​ motion, skeletal​ alignment, stability, and control of involuntary movements.

The caregiver of a​ 30-year-old client with cerebral palsy​ (CP) asks if there are any changes in health that might develop. Which response should the nurse​ make? A. ​"He will likely develop signs of premature aging as a result of constant stress on the​ body." B. ​"He will gradually become more and more independent as the spasticity in the muscles​ diminishes." C. ​"It is impossible to predict which health changes he will​ experience." D. ​"People with CP​ don't often live past​ 30."

C Rationale: In clients with​ CP, constant stress on the body can cause premature aging. Conditions such as​ hypertension, osteoarthritis, and atherosclerosis often develop before age 40. Numerous clients with CP do live past age​ 30, and this is increasing as symptom management becomes more effective. Independence usually does not increase as a result of​ aging, but the manifestations may become more severe or result in further complications.

What would the nurse include in planning teaching to parents of a child with Legg-Calvé-Perthes disease about the long-term effects of this disease? A. There are no long-term effects. B. The disease is self-limited and requires no long-term treatment. C. Degenerative arthritis may develop later in life. D. There is risk of osteogenic sarcoma in adulthood.

C. Correct. Marked distortion of the head of the femur may lead to an imperfect joint or to degenerative arthritis of the hip later in life.

The nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation? (Select all that apply.) a. Pulse is equal to uncasted limb. b. Patient is aware of touch and warm and cold application. c. Limb is cool to the touch. d. Capillary refill is 5 seconds. e. Distal limb can flex and extend.

C, D. Correct. The limb should be warm, and capillary refill should be less than 3 seconds.

The nurse is evaluating a 3-year-old child with a developmental delay. Which assessment finding would indicate this child might have a type of autistic spectrum disorder? A. The child does not enjoy playing frequently with the same toy. B. The child goes to bed without a nighttime routine. C. The child is using echolalia. D. The child enjoys imaginative play.

C-Abnormal communication patterns, including echolalia (repeating words spoken to the child), are symptoms of autism. The autistic child exhibits obsessive behavior such as playing repeatedly with the same toy and having a rigid bedtime routine. The autistic child does not typically engage in imaginative play.

The nurse is planning interventions for a child with failure to thrive. What would the nurse assess first before planning care? A. Draw blood for lab studies on the child. B. Have a physical therapist examine the child. C. Observe the parents when feeding the child. D. Observe the child's sleeping habits.

C-It is important to observe the parents' techniques of feeding before planning interventions. The nurse might then plan to teach holding the child or other feeding techniques to enhance the child's feeding time. Lab work, physical therapy, or observing the child's sleeping habits will not give the nurse information needed to teach the family.

The parent of a 3-year-old child who seems to be overactive asks the nurse how a diagnosis of attention-deficit/hyperactivity disorder would be made for the child. The nurse tells the parent that a diagnosis is made by which method? A. Laboratory studies B. An MRI C. History and physical assessment D. An IQ test

C-The child being evaluated for attention- deficit/hyperactivity disorder (ADHD) will have a history taken from pregnancy to current age, including behavior history and social and environmental conditions. A physical assessment is also performed. A mental health specialist administers tests to the child. Laboratory studies, MRI imaging, and IQ testing are not necessarily associated with the diagnostic process for ADHD.

The parents of a young child with cerebral palsy are in the clinic to talk with the nurse about the child's care at home. Which information will the nurse include in the instructions? A. The parents should order a wheelchair as soon as possible. B. The parents should find a school with a program for children with mental retardation. C. The parents need a good understanding of the child's medications. D. The parent should consider placing the child in a group home.

C-The nurse teaches the parents how to administer medications, the desired effects of the medications, and the potential signs of adverse effects. Not all children with cerebral palsy will be wheelchair-bound or have mental retardation. At some point, the parents may consider a group home for the child, but it is inappropriate for the nurse to suggest such a move.

A newborn has been diagnosed with spinal bifida. Which allergy documentation should the nurse include in a plan of care for this child? A. Penicillin B. Cloth tape C. Latex D. Augmentin

C.

Which presentation is found in a pediatric patient who has Brown-Sequard syndrome? A. Complete transection of the spinal cord B. Bilateral cord dysfunction with complete loss of sensation C. Unilateral cord lesion with alternate side deficits D. Transient loss of function

C.

Which statement best describes pseudohypertrophic (Duchenne) muscular dystrophy (DMD)? A. DMD is inherited as an autosomal dominant disorder. B. DMD is characterized by weakness of the proximal muscles of both the pelvic and shoulder girdles. C. DMD is characterized by muscle weakness, usually beginning at about age 3 years. D. The onset of DMD occurs in later childhood and adolescence.

C.

What instruction would the nurse provide to an adolescent who has been fitted with a Milwaukee brace? a. Wear the brace directly against the skin. b. Wear the brace over regular clothing. c. Wear the brace over a T-shirt 23 hours a day. d. Remove the brace before sleeping.

C. Correct. A Milwaukee brace is worn approximately 23 hours a day over a T-shirt, which protects the skin.

The nurse is assigned to care for an 8 year old child with a diagnosis of basilar skull fracture. The nurse reviews the pediatricians prescriptions and should contact the pediatrician to question which prescription? A. Obtain daily weight B. Provide clear liquid intake C. Nasotracheal suctioning as needed D. Maintain a patent IV line

C. Correct. A basilar skull fracture is a type of head injury. Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture because of the nature of the injury, there is a possibility that the catheter will enter the brain through the fracture, creating a high risk of secondary infection.

A nurse is caring for a child who has muscular dystrophy. For which of the following findings should the nurse assess? (Select all that apply) A. Purposeless, involuntary, abnormal movements B. Spinal defect and saclike protrusions C. Musculair weakness in lower extremities D. Unsteady, wide- based or waddling gait E. Upward slant to the eyes

C. Correct. A child who has MD will exhibit muscular weakness in the lower extremities as one of the first manifestations D. A child who has MD will exhibit an unsteady gait, wide-based, or waddling gait due to the progressive muscle weakness.

A pediatric nurse is assisting with the care of a child diagnosed with a fractured femur. What type of fracture would be the most likely to alert the nurse to the possibility of physical abuse? a. Stress fracture b. Compound fracture c. Spiral fracture d. Greenstick fracture

C. Correct. A spiral fracture of the femur is caused by a forceful twisting motion. When the history of an injury does not correlate with x-ray findings, child abuse should be suspected because spiral fractures can be the result of manual twisting of the extremity.

Approximately how old does the nurse assess a large green bruise on the thigh of a 4-year-old to be? a. 2 days b. 4 days c. 6 days d. 8 days

C. Correct. Bruises heal in various stages that are indicated according to color; after 5 to 7 days bruise are green.

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process? A. An infectious disease of the CNS B. An inflammation of the brain as a result of a viral illness C. A chronic disability characterized by impaired muscle movement and posture D. A congenital condition that results in moderate to severe intellectual disabilities

C. Correct. Cerebral palsy is a chronic disability characterized by impaired muscle movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system

The nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? A. Flaccid paralysis of all extremities B. Adduction of the arms at the shoulder C. Rigid extension and pronation of the arms and legs D. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

C. Correct. Decerebrate (extension) posturing is characterized by the rigid extension and pronation of arms and legs.

What characteristic manifestation does the nurse caring for a child with Duchenne's muscular dystrophy document? a. Ambulates by holding onto furniture b. Exhibits atrophy of the calf muscles c. Falls frequently and is clumsy d. Has delayed fine-motor development

C. Correct. Frequent falling and clumsiness are clinical manifestations of Duchenne's muscular dystrophy.

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? A. Clear CSF, decreased pressure, and elevated protein level B. Clear CSF, elevated protein, and decreased glucose levels C. Cloudy CSF, elevated protein and decrease glucose levels D. Cloudy CSF, decreased protein, and decrease glucose levels

C. Correct. Meningitis is an infectious process of the CNS caused by bacteria and viruses, it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Cloudy CSF, elevated protein and decrease glucose levels

A child is sent to the school nurse for assessment because she comes to school every day disheveled, unbathed, and hungry. The assessment does not indicate any bruises or marks on the body. What do these finding indicate? a. Sexual abuse b. Physical abuse c. Physical neglect d. Emotional abuse

C. Correct. Physical neglect is the failure to provide for the basic physical needs of the child, including food, clothing, shelter, and basic cleanliness.

What will the nurse include when caring for a child in Buck's extension? a. Positioning the child with hips flexed 90 degrees at all times b. Keeping the weights in contact with the floor c. Checking for skin irritation from traction equipment d. Releasing the weights on a schedule

C. Correct. The skin exposed to frequent friction may break down.

The nurse assessing a child with juvenile rheumatoid arthritis notes the child's right knee and ankle are swollen, warm, and tender. The child has a temperature of 38.8 ° C (102° F) and abdominal pain. What type of juvenile rheumatoid arthritis do these findings suggest? a. Psoriatic b. Enthesitis c. Systemic d. Acute febrile

C. Correct. The systemic form of juvenile rheumatoid arthritis is associated with an elevated temperature, erythrocyte sedimentation rate (ESR), and C-reactive protein; abdominal pain; and a macular rash.

The nurse is giving an overview of cerebral palsy (CP) to a group of new nurses. Which statement should the nurse include in the teaching? "CP is a progressive disease that is inherited." "Not all patients with CP have an intellectual disability." "CP is identified during the prenatal period." "The pathogenesis of CP is the same in most cases."

CP may or may not include an intellectual disability. CP is not progressive and not inherited; however, genetic mutations have been found recently in some patients with CP. Some cases of CP occur after birth and not during the prenatal period, and the pathogenesis varies from patient to patient. Pathogens, toxins, trauma, hypoxia, and genetic mutations can all lead to CP.

A teenager who had a cast applied after a tibia fracture complains that his pain medication is not working and his pain is still a 9 or 10. The nurse notices some edema of the toes and a capillary refill of 6 seconds. The priority action of the nurse would be: 1.) call the health care provider immediately 2.) check if there is an order for a stronger pain medication 3.) try nonpharmacological techniques of pain relief 4.) explain to the teen that a new fracture is expected to be painful the first day

Call the health care provider immediately

A term newborn who contracted an infection in utero may have spastic cerebral palsy (CP) caused by a brain insult from the infection. Which area of the brain should the nurse explain was affected when talking to the patient's parents? Cerebellum Multiple areas Cerebral cortex Basal ganglia

Cerebral cortex Spastic CP is generally attributable to a brain insult in the cerebral cortex. Ataxic CP is generally attributable to a brain insult in the cerebellum. Mixed CP is generally attributable to multiple injury sites. Dyskinetic CP is generally attributable to a brain insult in the basal ganglia.

The Elbows

Check here, as this area of the body will remain flexed. When pulling the arm down, it will SPRING back up. This relates to poor control of the muscle group. This is a clinical MOTOR sign of Spastic Cerebral Palsy.

Cerebral palsy (CP) may result from a variety of causes. It is now known that the most common cause of CP is

prenatal brain abnormalities.

Which nonpharmacologic therapies are used in the care of a client with cerebral palsy​ (CP)? ​(Select all that​ apply.) Speech therapy Massage therapy Special education Physical therapy Occupational therapy

Clinical therapy is used for clients who have CP to help them develop their maximum level of independence. In order to improve motor function and​ ability, referrals are made for​ physical, occupational, and speech therapy and also special education. Complementary therapies such as massage therapy and hippotherapy are recommended but do not require a medical referral.

A nurse assessing welts on the body of a 2-year-old Vietnamese child should consider the skin lesions might be the result of the cultural practice of __________.

Coining. Correct. Some Vietnamese place heated coins on the body to cure disease. This practice leaves welts that are sometimes mistaken for child abuse.

The nurse is conducting an in-service about cerebral palsy (CP). Which lifespan considerations should the nurse include? Comorbidities often shorten the lifespan of those with CP. Premature aging is uncommon in CP. Most patients with CP are severely disabled and dependent. Bowel and bladder incontinence is uncommon in CP.

Comorbidities often shorten the lifespan of those with CP. Seizures and respiratory disorders are examples of comorbidities that shorten the lifespan of patients with CP. Premature aging is often seen in patients with CP due to the continual state of stress on the body. Many children with CP grow up to lead full, independent lives and have families. Those with CP are prone to bowel and bladder incontinence, which can hinder their quality of life.

The nurse recognizes the signs of ____________________ syndrome in a child in "90-90" traction when the toes are pale and edematous and have a very slow capillary refill.

Compartment. Correct. When a limb is in traction or has been cast, the caregiver must check for adequate perfusion of the limb. Compartment syndrome occurs when the attendant edema from the injury or the traction compromises the circulation. This is an emergency and must be corrected before permanent damage can occur.

A clinic nurse is talking to the mother of a​ 4-year-old child who has cerebral palsy. The family is new to the community and needs help finding necessary services for their child. Which​ community-based intervention would the nurse​ provide? ​(Select all that​ apply.) Importance of​ high-calorie snacks Contact information for the United Cerebral Palsy Association and Shriners Hospitals Names of speech therapists Support services for financial assistance Information about recreational activities in the community

Contact information for the United Cerebral Palsy Association and Shriners Hospitals This is the correct answer. Names of speech therapists Your answer is correct. Support services for financial assistance Your answer is correct. Information about recreational activities in the community

The parents of Tyler​ Thomas, a​ 5-year-old client with mixed cerebral​ palsy, ask why a baclofen pump is scheduled to be surgically implanted in the child. Which explanation would the nurse give about the purpose of this medication​ pump? Increases ankle range of motion Prevents infections Controls muscle spasms Allows​ flat-footed walking

Controls muscle spasms

A parent asks the nurse to tell her what cerebral palsy is. The best response of the nurse would be that it is a: 1.) motor disability caused by a nonprogressive disturbance in brain development 2.) disorder of the brain that results in mental retardation 3.) complication of the birth process that causes brain damage 4.) brain disorder that involves seizures

Motor disability caused by a nonprogressive disturbance in brain development

18. A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? a. Teaching the patient how to self-catheterize b. Assisting the patient to the toilet q2-3hr c. Use of the Credé method to empty the bladder d. Catheterization for residual urine after voiding

Correct Answer: A Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence. Cognitive Level: Application Text Reference: p. 1605 Nursing Process: Planning NCLEX: Physiological Integrity

2. During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should a. examine the mouth and teeth thoroughly. b. have the patient clench and relax the jaw and eyes. c. identify trigger zones by lightly touching the affected side. d. gently palpate the face to compare skin temperature bilaterally.

Correct Answer: A Rationale: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided. Cognitive Level: Application Text Reference: p. 1583 Nursing Process: Assessment NCLEX: Physiological Integrity

24. The nurse is caring for a patient who is being evaluated for a possible metastatic spinal cord tumor. Which of these data obtained when assessing the patient requires most immediate action by the nurse? a. The patient has new onset weakness of both legs. b. The patient complains of chronic level 6 pain on a 10-point scale. c. The patient starts to cry and says, "I feel hopeless." d. The patient expresses anxiety about having surgery.

Correct Answer: A Rationale: The new onset of symptoms indicates cord compression, an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness. Cognitive Level: Application Text Reference: p. 1610 Nursing Process: Assessment NCLEX: Physiological Integrity

21. A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where "they know what they are doing." The best response by the nurse to the patient's behavior is to a. ask for the patient's input into the plan for care. b. clarify that abusive behavior will not be tolerated. c. reassure the patient that the anger will pass and rehabilitation will then progress. d. ignore the patient's anger and continue to perform needed assessments and care.

Correct Answer: A Rationale: The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Refusal to acknowledge the patient's anger by telling the patient that the anger is just a phase is inappropriate. Continuing to perform needed assessments and care is appropriate, but the nurse should seek the patient's input into what care is needed. Cognitive Level: Application Text Reference: p. 1608 Nursing Process: Implementation NCLEX: Psychosocial Integrity

6. A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to a. respect the patient's desire and arrange for privacy at mealtimes. b. offer the patient liquid nutritional supplements at frequent intervals. c. discuss the patient's concerns with visitors who arrive at mealtimes. d. teach the patient to chew food on the unaffected side of the mouth.

Correct Answer: A Rationale: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling. Cognitive Level: Application Text Reference: p. 1585 Nursing Process: Implementation NCLEX: Psychosocial Integrity

1. When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about a. triggers that lead to facial pain. b. visual problems caused by ptosis. c. poor appetite caused by a loss of taste. d. decreased sensation on the affected side.

Correct Answer: A. Rationale: The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and numbness are not characteristics of trigeminal neuralgia, although ptosis and numbness may occur after therapy, and poor appetite may be associated with pain stimulated by eating. Cognitive Level: Application Text Reference: p. 1581 Nursing Process: Assessment NCLEX: Physiological Integrity

The major goal of therapy for children with cerebral palsy (CP) is

recognizing the disorder early and promoting optimal development.

9. When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action? a. The patient complains of severe tingling pain in the feet. b. The patient has continuous drooling of saliva. c. The patient's blood pressure (BP) is 106/50 mm Hg. d. The patient's quadriceps and triceps reflexes are absent.

Correct Answer: B Rationale: Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome. Cognitive Level: Application Text Reference: pp. 1586-1587 Nursing Process: Assessment NCLEX: Physiological Integrity

7. A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barré syndrome a. results from an acute infection and inflammation of the peripheral nerves. b. is due to an immune reaction that attacks the covering of the peripheral nerves. c. is caused by destruction of the peripheral nerves after exposure to a viral infection. d. results from degeneration of the peripheral nerve caused by viral attacks.

Correct Answer: B Rationale: Guillain-Barré syndrome is believed to result from an immunologic reaction that damages the myelin sheath of the peripheral nerves. Acute infection or inflammation of the nerves is not a cause. The peripheral nerves are not destroyed and do not degenerate. Cognitive Level: Comprehension Text Reference: pp. 1585-1586 Nursing Process: Implementation NCLEX: Physiological Integrity

19. A patient with a history of a T2 spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? a. Notify the patient's health care provider. b. Check the blood pressure (BP). c. Give the ordered antiemetic. d. Assess for a fecal impaction.

Correct Answer: B Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is causing the symptoms, including hypertension. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP. Cognitive Level: Application Text Reference: p. 1603 Nursing Process: Assessment NCLEX: Physiological Integrity

14. When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to a. administer oxygen at 7 to 9 L/min with a face mask. b. place the hands on the epigastric area and push upward when the patient coughs. c. encourage the patient to use an incentive spirometer every 2 hours during the day. d. suction the patient's oral and pharyngeal airway.

Correct Answer: B Rationale: The nurse has identified that the cough effort is poor, so the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia, and oxygen will not help expel respiratory secretions. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action. Cognitive Level: Application Text Reference: p. 1602 Nursing Process: Implementation NCLEX: Physiological Integrity

16. A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.

Correct Answer: B Rationale: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level. Cognitive Level: Application Text Reference: p. 1594 Nursing Process: Implementation NCLEX: Physiological Integrity

27. When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Continuous cardiac monitoring for bradycardia b. Administration of methylprednisolone (Solu-Medrol) infusion c. Assessment of respiratory rate and depth d. Application of pneumatic compression devices to both legs

Correct Answer: C Rationale: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions are also appropriate but are not as important as assessment of respiratory effort. Cognitive Level: Application Text Reference: p. 1602 Nursing Process: Assessment NCLEX: Physiological Integrity

4. When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of trigeminal neuralgia, an appropriate action to include is a. teach facial and jaw relaxation techniques. b. assess intake and output and dietary intake. c. apply ice packs for no more than 20 minutes. d. spend time at the bedside talking with the patient.

Correct Answer: B Rationale: The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks. Cognitive Level: Application Text Reference: p. 1583 Nursing Process: Planning NCLEX: Physiological Integrity

11. A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum antitoxin is received. Before administering the antitoxin, it is most important for the nurse to a. obtain baseline vital signs. b. administer an intradermal test dose. c. ask the patient about a history of allergies. d. document the presence of neurologic symptoms.

Correct Answer: B Rationale: To prevent allergic reactions, an intradermal test dose of the antitoxin should be administered. Although baseline vital signs, allergy history, and symptom assessment and documentation are appropriate, these assessments will not impact on the decision to administer the antitoxin. Cognitive Level: Application Text Reference: pp. 1587-1588 Nursing Process: Implementation NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care? (Select all that apply.) a. Endotracheal suctioning b. Continuous cardiac monitoring c. Avoidance of cool room temperature d. Nasogastric tube feeding e. Retention catheter care f. Administration of H2 receptor blockers

Correct Answer: B, C, E, F Rationale: The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distension, a retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine. Cognitive Level: Application Text Reference: pp. 1594-1595, 1597, 1603 Nursing Process: Planning NCLEX: Physiological Integrity

26. A patient with possible botulism poisoning is admitted for observation and administration of botulinum antitoxin. Which of the following health care provider orders should the nurse question? a. Maintain NPO status. b. Obtain lumbar puncture tray. c. Give magnesium citrate 8 oz now. d. Administer 1500-ml tapwater enema.

Correct Answer: C Rationale: Magnesium is contraindicated because it may worsen the neuromuscular blockade. The other orders are appropriate for the patient. Cognitive Level: Application Text Reference: p. 1588 Nursing Process: Implementation NCLEX: Physiological Integrity

15. As a result of a gunshot wound, a patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for left leg pain b. Assessment of the patient for left arm weakness c. Positioning the patient's right leg when turning the patient d. Teaching the patient to look at the left leg to verify its position

Correct Answer: C Rationale: The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg. Cognitive Level: Application Text Reference: pp. 1591-1592 Nursing Process: Implementation NCLEX: Physiological Integrity

17. The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness of the medication the nurse will assess a. blood pressure and heart rate. b. respiratory effort and O2 saturation. c. motor and sensory function of the legs. d. bowel sounds and abdominal distension.

Correct Answer: C Rationale: The purpose of methylprednisolone administration is to help preserve neurologic function; therefore, the nurse will assess this patient for lower-extremity function. Sympathetic nervous system dysfunction occurs with injuries at or above T6, so monitoring of BP and heart rate will not be useful in determining the effectiveness of the medication. Respiratory and GI function will not be impaired by a T10 injury, so assessments of these systems will not provide information about whether the medication is effective. Cognitive Level: Application Text Reference: p. 1596 Nursing Process: Evaluation NCLEX: Physiological Integrity

OTHER 1. In which order will the nurse perform the following actions when caring for a patient with possible cervical spinal cord trauma who is admitted to the emergency department? a. Administer O2 using a non-rebreathing mask. b. Monitor cardiac rhythm and blood pressure. c. Immobilize the patient's head, neck, and spine. d. Transfer the patient to radiology for spinal CT.

Correct Answer: C, A, B, D Rationale: The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, continuous monitoring of heart rhythm and BP is indicated. CT scan to determine the extent and level of injury is needed once initial assessment and stabilization is accomplished. Cognitive Level: Application Text Reference: p. 1596 Nursing Process: Implementation NCLEX: Physiological Integrity

25. Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant? a. Nasogastric tube feeding q4hr b. Artificial tear administration q2hr c. Assessment for bladder distension q2hr d. Passive range of motion to extremities q8hr

Correct Answer: D Rationale: Assisting a patient with movement is included in nursing assistant education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills. Cognitive Level: Application Text Reference: pp. 1586-1587 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment

10. A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include a. intubation and mechanical ventilation. b. insertion of a nasogastric (NG) feeding tube. c. administration of methylprednisolone (Solu-Medrol). d. IV infusion of immunoglobulin (Sandoglobulin).

Correct Answer: D Rationale: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome. Cognitive Level: Application Text Reference: p. 1586 Nursing Process: Implementation NCLEX: Physiological Integrity

12. A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was embedded in some old lumber in a field. The patient reports having had a tetanus booster 7 years ago. The nurse will anticipate a. IV infusion of tetanus immune globulin (TIG). b. initiation of the tetanus-diphtheria immunization series. c. intradermal injection of an immune globulin test dose. d. administration of the tetanus-diphtheria (Td) toxoid booster.

Correct Answer: D Rationale: If the patient has not been immunized within 5 years, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. A test dose is not needed for immune globulin, and TIG is not indicated for the patient. Cognitive Level: Application Text Reference: p. 1589 Nursing Process: Implementation NCLEX: Physiological Integrity

22. A 26-year-old patient with a C8 spinal cord injury tells the nurse, "My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually." The most appropriate response by the nurse to the patient's comment is to a. advise the patient to talk to his wife to determine how she feels about his sexual function. b. tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal cord injury. c. inform the patient that most patients with upper motor neuron injuries have reflex erections. d. suggest that the patient and his wife work with a nurse specially trained in sexual counseling.

Correct Answer: D Rationale: Maintenance of sexuality is an important aspect of rehabilitation after spinal cord injury and should be handled by someone with expertise in sexual counseling. Although the patient should discuss these issues with his wife, open communication about this issue may be difficult without the assistance of a counselor. Sildenafil does assist with erectile dysfunction after spinal cord injury, but the patient's sexuality is not determined solely by the ability to have an erection. Reflex erections are common after upper motor neuron injury, but these erections are uncontrolled and cannot be maintained during coitus. Cognitive Level: Application Text Reference: p. 1608 Nursing Process: Implementation NCLEX: Psychosocial Integrity

23. A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient's spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the family members that the patient can perform ADLs independently. b. remind the patient about the importance of independence in daily activities. c. recognize that it is important for the patient's family to be involved in the patient's care and support their activities. d. develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and parents.

Correct Answer: D Rationale: The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the family that the patient can perform ADLs independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the family members. Supporting the activities of the spouse and parents will lead to ongoing dependency by the patient. Cognitive Level: Application Text Reference: p. 1609 Nursing Process: Implementation NCLEX: Psychosocial Integrity

8. A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is a. monitoring the cardiac rhythm continuously. b. determining the level of consciousness q2hr. c. evaluating sensation and strength of the extremities. d. performing constant evaluation of respiratory function.

Correct Answer: D Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment. Cognitive Level: Comprehension Text Reference: p. 1586 Nursing Process: Assessment NCLEX: Physiological Integrity

20. The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is a. transfers independently to a wheelchair. b. drives a car with powered hand controls. c. turns and repositions self independently when in bed. d. pushes a manual wheelchair on flat, smooth surfaces.

Correct Answer: D Rationale: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed. Cognitive Level: Application Text Reference: p. 1594 Nursing Process: Planning NCLEX: Physiological Integrity

An abdominal S-Shaped curvature of the spine seen in school-aged children is: 1.) sclerosis 2.) sciatica 3.) scabies 4.) scoliosis

scoliosis

Buck's extension is an example of: 1.) skin traction 2.) skeletal traction 3.) balanced traction 4.) Bryant's Traction

skin traction

A​ 1-year-old child is being evaluated for cerebral palsy. When assessing the​ child, which finding is the nurse least likely to​ observe? Strabismus Normal muscle tone in all extremities Arching of the back Developmental delay

Normal muscle tone in all extremities

A​ 1-year-old child is being evaluated for cerebral palsy​ (CP). Which finding should the nurse least expect to assess in this​ client? A. Strabismus B. Developmental delay C. Arching of the back D. Normal muscle tone in all extremities

D ​Rationale: Infants and children with CP do not exhibit normal muscle tone. Infants with cerebral palsy often exhibit arching of the back. Children with CP often experience delay in reaching developmental milestones. Strabismus is seen in children with CP.

The nurse is aware that adults with cerebral palsy are prone to premature aging due to the continual stress state of the individual. The nurse knows what disorder is related to this premature aging process? A. Cancer B. Dementia C. Pulmonary edema D. Atherosclerosis

D-Atherosclerosis is one of the common signs of premature aging of the adult cerebral palsy client. There is no connection with cancer, dementia, or pulmonary edema to premature aging of the cerebral palsy client.

A child who is severely malnourished is admitted to the hospital. What would be the primary focus of the plan of care for this child? A. Providing IV fluids B. Administering medications C. Conducting diagnostic studies D. Fostering adequate nutritional intake

D-Fostering adequate nutritional intake to promote growth and development is the healthcare team's focus. Providing fluids and conducting diagnostic studies may be aspects of that focus but are not the primary focus. Medications are usually not given to this client unless there is evidence of infection or some other disease process.

The nurse is teaching the family about reducing stimulation for the child who has been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which activity will the nurse teach the family to limit? A. Eating with the family B. Playing with a sibling C. Reading books D. Watching television

D-Television has been shown to be overstimulating for the child with ADHD and should be limited and monitored. The other activities are typically helpful for a child with ADHD.

A neural tube defect that is not visible externally in the lumbosacral area would be called A. meningocele. B. myelomeningocele. C. spina bifida cystica. D. spina bifida occulta.

D.

A nurse is taking care of a pediatric patient whose health record indicates E on the American Spinal Injury Association Impairment Scale. What does this designation mean? A. Sensory function present but no motor function B. No motor or sensory function C. Motor function is preserved below the neurologic level D. Intact motor and sensory function

D.

What is important when caring for a child with myelomeningocele in the preoperative stage? A. Place the child on one side to decrease pressure on the spinal cord. B. Apply a heat lamp to facilitate drying and toughening of the sac. C. Keep the skin clean and dry to prevent irritation from diarrheal stools. D. Measure the head circumference and examine the fontanels for signs that might indicate developing hydrocephalus.

D.

The nurse creates a plan of care for a child at risk for tonic clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item need to be placed at the child's bedside? A. Emergency cart B. Tracheostomy set C. Padded tongue blade D. Suctioning equipment and oxygen

D. A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? A. Maintain enteric precautions B. Maintain neutropenic precautions C. No precautions are required as long as antibiotics have been started. D. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

D. Correct. A major priority of nursing care for a child suspected to have meningitis is to administer the prescribed antibiotic as soon as culture is obtained. the child is also placed on respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

A nurse is caring for an infant who has myelomeningococele. Which of the following actions should the nurse include in the pre operative plan of care? A. Assist the caregiver with cuddling the infant B. Assess the infants temperature rectally C. Place the infant in a supine position D. Apply a sterile moist dressing on the sac

D. Correct. A sterile, moist, nonadhering dressing is placed on the sac to keep it moist until surgery. This should be in the preoperative plan of care

Why does a child's fracture heal more rapidly than the adult's? a. A child's bones are less porous than adult bone. b. A child's bones are covered by a thicker periosteum. c. A child's bones are not affected by bone overgrowth. d. A child's bones have faster callus formation.

D. Correct. Callus forms more rapidly in the child than the adult.

What finding would the nurse assessing the neurovascular status of a child in Russell traction report immediately? a. Skin that's warm to the touch b. Capillary refill less than 3 seconds c. Ability to wiggle toes d. Bluish coloration of skin

D. Correct. Cyanosis or pallor noted in an extremity is an indication of circulatory impairment.

A mother arrives at the emergency department with her 5 year old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of ICP. Which is a late sign if ICP? A. Nausea B. Irritability C. Headache D. Bradycardia

D. Correct. Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. Bradycardia, decrease LOC, decrease motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-stokes respirations, and coma are late signs.

Which assessment performed by a nursing student performing a neurovascular check alerts the instructor that further education is necessary? a. Pulses b. Capillary refill c. Movement d. Pupils

D. Correct. Neurovascular checks include assessment of pain, pulse, sensation, color, capillary refill, and movement. Pupils are assessed with a neurological check

A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan? A. Assess hearing loss B. Monitoring urine output C. Changing body positions every 2 hours D. Providing a quiet atmosphere with dimmed lighting

D. Correct. Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized by pathologically by cerebral edema and fatty changes in the liver

How does Russell traction provide adequate skin traction? a. Subluxates the tibia b. Does not interfere with range of motion c. Prevents the knee from flexing d. Supplies continuous pull in two directions

D. Correct. Russell traction is skin traction, similar to Buck's, with a sling positioned under the knee, which prevents subluxation of the tibia. Although the traction interferes with full ROM, the patient can change position without disrupting the continuous pull in two directions.

The nurse is caring for a client who has cerebral palsy​ (CP). Which intervention should the nurse use to promote flexibility and prevent​ contractures? A. Schedule speech therapy B. Administer mood stabilizers C. Provide muscle relaxants D. Perform​ range-of-motion (ROM) exercises

D Rationale: ROM exercises promote flexibility and prevent contracture formation. Muscle​ relaxants, mood​ stabilizers, and speech therapy do not promote flexibility or prevent contractures.

A​ 7-year-old client with cerebral palsy​ (CP) is learning to​ self-feed. Which action should the nurse encourage to promote independence and success with​ self-feeding? A. Reassuring the child that having to be fed is nothing to be ashamed of B. Restricting attempts at​ self-feeding to 5 minutes C. Assisting the parents with total feeding D. Providing​ large, padded eating utensils

D Rationale: Providing​ large, padded utensils makes​ self-feeding easier and facilitates success with this endeavor. Children with CP should be encouraged to do as much as they can for themselves. Insisting on total feeding or not allowing prolonged periods of time to practice​ self-feeding does not help encourage independence.

12. Which intervention will the nurse teach a parent to initiate in the home for a child with cerebral palsy? A. Lay the child in the parent's arms for feeding. B. Allow the child to eat the same foods as the family. C. Teach the child to use non-adaptive eating utensils. D. Allow extra time for chewing and swallowing.

D- Children with cerebral palsy often have feeding difficulties, so the nurse teaches the parent to allow extra time for this child, sit the child upright for feeds, use blended and soft foods, and use adaptive, not non-adaptive, utensils for feeding.

The nurse is planning care for a client with failure to thrive whose parents are giving the child skim milk instead of formula. What is the priority nursing diagnosis for this child? A. Fatigue, related to malnutrition B. Delayed Growth and Development C. Anxiety D. Risk for Impaired Parenting

D-All of the diagnoses are appropriate, but Risk for Impaired Parenting takes priority because the parents do not have a basic knowledge about the nutritional needs of the infant. Until the nurse can address that issue, the other diagnoses cannot be addressed with any chance of success.

The child with Duchenne's muscular dystrophy must push on his legs and "walk up the leg" in order to rise to a standing position. The nurse recognizes this characteristic behavior as _______________ maneuver.

Gower's. Correct. Gowers' maneuver is a unique way of rising from the floor by walking up the leg in order to get the upper body erect.

Which term describes a seizure in which the child cries out, falls to the floor, becomes rigid, and then has a convulsion? 1.) Petit mal 2.) Myoclonic 3.) Grand mal 4.) Atonic

Grand mal

During an​ assessment, the nurse suspects that an​ 11-month-old infant is demonstrating manifestations of cerebral palsy. Which assessment finding would bring the nurse to this​ conclusion? ​(Select all that​ apply.) Thumb sucking Head lag Asymmetric crawling Poor trunk control Arched back

Head lag, asymmetrical crawling, poort trunk control, arched back.

Which screening assessment is used for children showing developmental delays indicative of cerebral​ palsy? ​(Select all that​ apply.) Head turn Babinski reflex Phalen test Heeldashshin test Diaper pull

Head turn Diaper pull All infants who show symptoms of developmental delay should be evaluated by using two simple screening assessments. The first is a diaper​ pull, which is conducted by placing a clean diaper on the child​'s ​face; the infant with CP will use one hand or will not remove the cloth at all. The other test is the head​ turn, which is conducted by turning the infant​'s head to one​ side; if the child has a persistent asymmetric tonic neck reflex beyond 6 months of​ age, this indicates a pathological condition. The Babinski reflex does not indicate the presence or absence of cerebral palsy. The Phalen test is used to assess for carpal tunnel syndrome. The heeldashshin test is used with adults to determine nervous system integrity of the lower extremities.

The nurse is assessing a​ 4-month-old client because the mother is concerned that the client may be developmentally delayed. Which finding would lead the nurse to suspect cerebral palsy​ (CP) in the​ infant? Hypotonia Head lag Follows objects 180 degrees Tonic neck reflex

Head​ lag, tonic neck​ reflex, and following objects 180 degrees are all normal for a​ 4-month-old infant. If head lag and tonic neck reflex persist beyond 6​ months, then they would be a concern and suggest CP. Hypotonia is not normal and could be a sign of CP.

Spastic Manifestations

Here, there is a HYPO-tonia, like a *rag-doll appearance*, LOW muscle group.

A 9-month-old child is diagnosed with spastic cerebral palsy (CP). Which clinical manifestation should the nurse expect to assess in this patient? Hypertonia and rigidity Hemiplegia and hypotonia Bizarre twitching movements Tremors and exaggerated posturing

Hypertonia and rigidity Hypertonia in infancy and muscle rigidity are seen in spastic cerebral palsy. Hypotonia is seen in dyskinetic CP caused by an extrapyramidal injury. Tremors and exaggerated posturing are seen in dyskinetic CP. Bizarre twitching movements are seen in dyskinetic CP caused by an extrapyramidal, basal ganglia injury.

A​ 9-month-old child has been diagnosed with ataxic cerebral palsy​ (CP). Which clinical manifestation would the nurse expect to assess in this​ client? Hypertonia and persistence primitive reflexes Hemiplegia and hypertonia Hypotonia and muscle instability Tremors and exaggerated posturing

Hypotonia and muscle instability

The nurse is caring for newborns in the neonatal intensive care unit. Which infant should the nurse expect to be referred for further testing for cerebral palsy (CP)? Infant born at 30 weeks of gestation, with a difficult, prolonged delivery and infection present in the amniotic fluid at birth Infant born to a mother with gestational diabetes, weighing 10 lb, and having low Apgar scores at birth Infant born at full term, with decreased reflexes and requiring supplemental oxygen Infant born at full term to a mother who had no prenatal care, with a difficult delivery and Apgar scores of 9 and 10

Infant born at 30 weeks of gestation, with a difficult, prolonged delivery and infection present in the amniotic fluid at birth Preterm delivery is the greatest risk factor for developing CP. Birth complications and exposure to infection also increases risk. Gestational diabetes and increased birth weight are not risk factors for cerebral palsy. Any infant who requires supplemental oxygen should be monitored for complications, but this is not specific to CP. Lack of prenatal care and a difficult delivery are risk factors, but the Apgar scores and full-term delivery are not.

The parents of a 5-year-old patient with mixed cerebral palsy (CP) ask why a baclofen pump is scheduled to be surgically implanted in the child. Which explanation should the nurse give about the purpose of this medication pump? It increases ankle range of motion. It controls muscle spasms. It allows flat-footed walking. It prevents infections.

It controls muscle spasms.Implantation of a baclofen pump allows continuous delivery of the drug baclofen, which improves muscle spasms. The surgical treatment of Achilles tendon lengthening is used to increase ankle range of motion and to allow the child to walk flat-footed. Intrathecal pump implantation actually increases the risk of infection and must be carefully monitored. Baclofen is not being provided to the patient to prevent infections.

A disorder in which the blood supply to the epiphyses of the bone is disrupted is callled: 1.) muscular dystrophy 2.) cerebral palsy 3.) congenital hip dysplasia 4.) Legg-Calve-Perthes Disease

Legg-Calve-Perthes Disease

Which action provides emotional support to families of children with cerebral palsy​ (CP)? Explaining that all children with CP are eventually placed in​ long-term care facilities Referring all medical questions to the healthcare provider Making a referral for marriage counseling Listening to parental concerns and encouraging the expression of feelings

Listening to parental concerns and encouraging the expression of feelings

A​ 6-year-old child with cerebral palsy who is new to the school district is experiencing severe rigidity and spasticity. Which recommendation would the school nurse make to the child​'s ​parents? ​"Look into special schools for the​ handicapped." ​"Offer only​ low-carbohydrate, low-calorie foods to the​ child." ​"Discourage the use of a​ computer." ​"Make an appointment with a physical​ therapist."

Make an appointment with a physical​ therapist."

The parents of a child with cerebral palsy ask if there are any medications available to help control the child​'s symptoms. Which type of medication would the nurse explain is used for symptom management for cerebral​ palsy? ​ (Select all that​ apply.) Benzodiazepines Baclofen Antidepressants Botulinum toxin Muscle relaxants

Medications used to control seizures and spasms include skeletal muscle​ relaxants, baclofen,​ benzodiazepines, and botulinum toxin. Antidepressants are not used to manage the symptoms of cerebral palsy.

Which factor cause cerebral palsy before or during​ birth? ​(Select all that​ apply.) Premature birth Neonatal sepsis Fetal viral infection Hyperbilirubinemia Injury to periventricular white matter

Most cases of CP are caused before or during birth by a brain​ insult; this includes premature​ birth, fetal viral​ infection, and injury to periventricular white matter. CP can also develop after birth to age 2​ years, when it can be caused by neonatal sepsis and hyperbilirubinemia.

A 22-year-old patient with cerebral palsy (CP) is experiencing chronic pain. Which reason should the nurse identify that explains the most common cause of chronic pain in adults with this health problem? Skin breakdown Skeletal deformities Muscle contractions Brain lesions

Muscle contractions Muscle contractions place the body in a continuous state of stress. The pain that results from this increases with age. Skin breakdown may occur in those who have urinary or bowel incontinence, but this is not the most common cause of pain. Skeletal deformities can result in positional discomfort but are not the leading cause of pain. Brain lesions are not a common cause of pain in those with CP.

The mother of an 18-month-old child is concerned about the child not meeting developmental milestones and wants the child tested for cerebral palsy. Which diagnostic approach should the nurse explain to this mother? CT scan Laboratory test for certain proteins Urinalysis Observation of symptoms and ruling out other disorders

Observation of symptoms and ruling out other disorders There is no specific diagnostic test for CP. Diagnosis is usually made by observation of symptoms and ruling out other causes of manifestations. CT scan may be used to identify other organic brain diseases that may be causing certain symptoms but is not used to specifically diagnose CP. Laboratory testing for proteins and results of urinalysis are not helpful in diagnosing CP.

The nurse reminds the adolescent boy with Ewing's sarcoma that he is prohibited from vigorous weight-bearing activities during treatment with radiation to reduce the risk of a(n) _______________ fracture.

Pathological. Correct. The bone has lost its integrity because of the cancer and radiation. Excessive or vigorous weight bearing can cause a pathological fracture of the compromised bone.

The nurse prepares a teaching tool about cerebral palsy (CP) for a community clinic. Which complication should the nurse include that can lead to life-threatening health problems as a person with CP ages? Premature aging Weak blood vessels Muscle atrophy Vision and hearing loss

Premature aging The most life-threatening complication of CP is the overall stress that is placed on the body, which can lead to premature aging. Blood vessels may weaken as a result of hypertension, but not as a result of impaired circulation. Immobility does lead to muscle atrophy, which is accompanied by other complications, but this is not the most life-threatening complication. Hearing and vision loss may occur as a result of premature aging, but this is not directly life-threatening.

The mother of a​ 4-year-old child with cerebral palsy asks how this health problem occurred. Which​ pre-birth insults would the nurse explain to the mother are possible​ causes? ​ (Select all that​ apply.) Brain injury Genetic factors Hyperbilirubinemia Fetal viral infection Prematurity

Prematurity is an etiology of CP that occurs before birth. Fetal viral infection is an etiology of CP that occurs before birth. Genetic factors are an etiology of CP that occurs before birth. Hyperbilirubinemia is an etiology of CP that occurs after birth. Brain injury is an etiology of CP that occurs after birth.

A 4-year-old child with cerebral palsy (CP) becomes frustrated because of difficulty using utensils when eating. Which action should the nurse take? Feed the child Schedule an appointment with a nutritionist Discuss tube feedings with the healthcare provider Provide large, padded utensils

Provide large, padded utensils A 4-year-old child with CP should be able to self-feed if provided with the appropriate tools, such as large, padded utensils. Feeding the child will not promote independence and is likely to increase frustration. A nutritionist will not help with the patient's frustration. There is no need to recommend tube feeding in a child with CP.

The nurse is caring for a child with cerebral palsy. Which intervention should the nurse use to support this patient's nutritional status? Provide small amounts of food at a time. Use utensils with small, padded, adaptive handles. Restrict fluid intake. Provide adequate protein.

Provide small amounts of food at a time. Small amounts of food should be given to a child with CP because of problems with chewing and swallowing. Utensils with large, not small, padded, adaptive handles should be provided. There is no need to restrict this child's fluid. All nutrients are important for this patient.

The nurse is caring for a child with cerebral palsy. Which intervention would the nurse use to promote nutrition for this​ child? Providing adequate protein to prevent constipation Restricting the child​'s fluid intake Providing the child with small amounts of food at a time Using utensils with​ small, padded, adaptive handles

Providing the child with small amounts of food at a time Small amounts of food should be given to a child with cerebral palsy because of problems with chewing and swallowing. Utensils with​ large, not​ small, padded, adaptive handles should be utilized for this child. There is no need to restrict this child​'s ​fluid; the nurse would need to perform frequent assessments to determine hydration​ status, as the child may not be able to communicate thirst.​ Fiber, not​ protein, would be given to prevent constipation.

The nurse is reviewing the care of a patient with cerebral palsy (CP) with a new nurse. Which medication should the nurse emphasize would be effective in minimizing gastrointestinal side effects of CP? Baclofen Ranitidine Dantrolene Botulinum toxin

Ranitidine Ranitidine or cimetidine are used to minimize gastrointestinal side effects. Medications used to control spasms include skeletal muscle relaxants, baclofen, and benzodiazepines. Botulinum toxin has been used to decrease spasticity.

Which medication is not used to control seizures and muscle spasms in​ CP? Botulinum toxin Ranitidine Dantrolene Baclofen

Rantidine

A 3-year-old has cerebral palsy (CP) and is hospitalized for orthopedic surgery. The child's mother states the child has difficulty swallowing and cannot hold a utensil to self-feed. The child is slightly underweight for height. What is the most appropriate nursing action related to feeding?

Stabilize the child's jaw with one hand (either from a front or side position) to facilitate swallowing.

Which conditions most frequently shorten the life of adults with cerebral palsy (CP)? Incontinence and skin breakdown Respiratory disorders and seizures Muscle atrophy and brain tumors Arthritis and contractures

Respiratory disorders and seizures Respiratory disorders and seizures can shorten the life of adults with CP. Incontinence and skin breakdown can lead to infection and complications, but these are not as life-limiting as respiratory and seizure disorders. Muscle atrophy can lead to complications, and brain tumors are not necessarily prone to occur in those with CP. Arthritis and contractures can lead to further mobility but are not directly life limiting.

Tina​ White, a​ 7-year-old African American girl with dyskinetic cerebral​ palsy, has used a stroller or wheelchair for mobility since birth. During every healthcare provider​ appointment, on which finding should the nurse focus when assessing this​ client? Persistent newborn reflexes and swallowing Nutrition status and constipation Skin integrity and body alignment Height and weight

Skin integrity and body alignment

A 7-year-old girl with dyskinetic cerebral palsy (CP) uses either a stroller or wheelchair for mobility since birth. Which assessment should the nurse consider the priority? Height and weight Skin integrity and body alignment Nutrition status and bowel function Swallowing difficulty

Skin integrity and body alignment Skin integrity and good body alignment are essential for a child with CP who is in a wheelchair. Pillows, towels, and bolsters may be needed for positioning or to take pressure off reddened areas of skin. Height and weight must be assessed for every child, as should nutrition status and bowel habits. Assessment for swallowing difficulty is used to detect clinical manifestations that may indicate that a child has CP.

What most accurately describes bowel function in children born with a myelomeningocele? A. Incontinence cannot be prevented. B. Enemas and laxatives are contraindicated. C. Some degree of fecal continence can usually be achieved. D. A colostomy is usually required by the time the child reaches adolescence.

Some degree of fecal continence can usually be achieved.

The nurse is preparing to care for a child with cerebral palsy. Knowing the different​ classifications, for which type of cerebral palsy would the nurse most likely plan​ care? Spastic cerebral palsy Mixed cerebral palsy Dyskinetic cerebral palsy Ataxic cerebral palsy

Spastic cerebral palsy

Stacy Capers is a term female newborn diagnosed with an infection contracted in utero. The healthcare provider advises the parents that the newborn may have spastic cerebral palsy​ (CP) because of a brain insult related to the infection. When talking with the​ parents, which area of the brain will the nurse indicate is affected by the​ insult? Cerebral cortex Multiple areas Basal ganglia Cerebellum

Spastic cerebral palsy​ (CP) is generally attributable to a brain insult in the cerebral cortex. Ataxic CP is generally attributable to a brain insult in the cerebellum. Mixed CP is generally attributable to multiple injury sites. Dyskinetic CP is generally attributable to a brain insult in the basal ganglia.

Different types of cerebral palsy

Spastic motor dysfunction is caused by a cerebral cortex or pyramidal tract injury. Spastic motor dysfunction is seen in​ 75% of CP cases. Dyskinetic motor dysfunction is caused by​ extrapyramidal, basal ganglia injury. Dyskinetic motor dysfunction is seen in​ 10% to​ 15% of CP cases. Ataxic motor dysfunction is caused by cerebellar​ (extrapyramidal) injury. Ataxic motor dysfunction is seen in​ 5% to​ 10% of CP cases. Mixed motor dysfunction is caused by injury to multiple areas of the brain.

A 6-year-old child born with a myelomeningocele has a neurogenic bladder. The parents have been performing clean intermittent catheterization. What should the nurse recommend? A. Teach the child to do self-catheterization. B. Teach the child appropriate bladder control. C. Continue having the parents do the catheterization. D. Encourage the family to consider urinary diversion.

Teach the child to do self-catheterization.

A woman who is 6 weeks pregnant tells the nurse that she is worried her baby might have spina bifida because of a family history. What should the nurse's response be based on? A. There is no genetic basis for the defect. B. Prenatal detection is not possible yet. C. Chromosomal studies done on amniotic fluid can diagnose the defect prenatally. D. The concentration of α-fetoprotein in amniotic fluid can potentially indicate the presence of the defect prenatally.

The concentration of α-fetoprotein in amniotic fluid can potentially indicate the presence of the defect prenatally.

The nurse is preparing discharge instructions for the parents of a child with cerebral palsy. Which instruction would the nurse include to promote safety for this​ child? ​(Select all that​ apply.) The use of a helmet to protect against head injuries The use of​ range-of-motion exercises The use of adaptive seating for automobile transportation The use of splints and braces The use of seat belts in strollers and wheelchairs

The nurse should teach the use of a helmet to protect against head injuries for children with CP who experience seizures. The nurse should teach the use of seat belts for children in strollers and wheelchairs to decrease the likelihood of falling out of the seat. The use of adaptive seating in automobiles is an important area of teaching related to safety.​ Range-of-motion exercises are important to enhance physical​ mobility, not for child safety. The use of splints and braces is important to prevent contractures and promote mobility but not for child safety.

The nurse is evaluating care provided to a 9-year-old patient with cerebral palsy (CP). Which patient outcome should indicate to the nurse that the patient has achieved a developmental milestone? The patient has joined the Girl Scouts. The patient is able to feed themselves. The patient's parents administer medications appropriately. The patient returns for follow-up doctor's appointments as scheduled.

The patient has joined the Girl Scouts. Joining age-appropriate group activities indicates that the patient is achieving an age-related developmental milestone. The patient should be able to self-feed by this age. Following a prescribed medication regimen and having routine medical evaluations does not measure the success of nursing care.

During a routine exam, the nurse notices that a 2-year-old child shows signs of inadequate coordination and muscle stiffness. Which developmental disorder should the nurse suspect in this patient? Cerebral palsy Failure to thrive Autism spectrum disorder Attention-deficit/hyperactivity disorder

The patient may have the developmental disorder of cerebral palsy, which is characterized by inadequate balance and coordination (ataxia), uncontrolled movements (dyskinesia), and muscle stiffness (spasticity). The patient's symptoms are not associated with failure to thrive, autism spectrum disorder, and attention-deficit/hyperactivity disorder

The nurse is preparing an educational seminar about early intervention programs to promote growth and development of the child with cerebral palsy​ (CP). Which information would the nurse include to assist the parents of these​ children? Explain that vocational training is not appropriate but that assisting with a general job is appropriate The use of adaptive devices to help the child communicate more independently The need to use terminology 1 year below the​ child's development level The value of home schooling so that the child will not have to be exposed to children in the school setting

The use of adaptive devices to help the child communicate more independently

Primitive Reflexes (Moro, Blinking, ect.)

These are all PROLONGED in patients with Spastic Cerebral Palsy. They are supposed to be cut off at 4 months.

Excessive Irritability & No smiling.

These are clinical behavioral signs of Spastic Cerebral Palsy that can be seen at around 3 months of age.

Baclofen, Dantrolene Sodium & Valium

These are drugs used to relax muscle groups in CP patients. They are given to decrease OVERALL spasicity. - Be care, as these drugs are HEPATOTOXIC. Children will need periodic liver function tests.

Drooling, Wiggly (Worm-Like), & Imperfect Articulation

These are specific manifestations of Atheosis Cerebral Palsy.

Intrauterine Hypoxia and Asphyxia

These are the etiological causes of Cerebral Palsy. - The placenta may not be functioning adequately which is the lifeline of the fetus. This cuts off O2 to the fetus. - The fetus can be stuck in the birth canal - Or become Septic in Utero

Spastic, Athetoid, Ataxia & Mixed

These are the four primary types of Cerebral Palsy (discussed in class)

Abnormal Muscle Tone and Coordination

These are the primary disturbances that can be found in children with Cerebral Palsy.

Theraputic Management of CP

These patients may have motorized devices, wheel chairs, scooters, and specialized walkers. They may also have orthopedic surgery to help with the spastic deformities and help with the balance and control. For seizures, use Anti-Anxiety drugs.

Cord Around the Neck

This accounts for 23% of Cerebral Palsy cases. It is important to make sure the baby is well OXYGENATED on the way out.

Unable to Sit Without Support

This is a clinical MOTOR sign of Spastic Cerebral Palsy that can be identified at age 8 months.

Poor Head Control

This is a clinical MOTOR sign of Spastic Cerebral Palsy that occurs AFTER 3 years old.

Clenched Fists

This is a clinical MOTOR sign of Spastic Cerebral Palsy that occurs at age 3 months. We will have to place rolls in the child's hands because their nails can INDENT into the palm of their hands.

Stiff, Rigid Limbs

This is a clinical MOTOR sign of Spastic Cerebral Palsy that occurs, muscle tone is poor, and children have difficulty with sitting. - There is also ARCHING of the BACK, and pushing away of the body.

Scissoring of The Legs

This is a clinical MOTOR sign of Spastic Cerebral Palsy, in terms of posture, this can occur.

Cerebral Palsy

This is a common *PERMANENT* physical disability in children involving posture and movement. It denotes a *NON PROGRESSIVE* disorder, and affects: - Speech - Articulation - Body Posture - Intellectual Ability (Some Cases) The child may need glasses because of visual or sensory deficits.

Serum Electrolytes

This is a diagnostic assessment that appears because of bone deformities and the muscular flaccidity found in CP patients. We are looking for the Electrolytes that break down muscle.

Botox

This is a newer drug that is used at the muscle group to decrease the contractures at the LOWER EXTREMITIES.

Atheosis Cerebral Palsy

This is another type of Cerebral Palsy, which result in * jerky, irregular twisting motions.* In general, a child with this will have abnormal involuntary movement.

ANOXIA

This is the MOST common cause of brain damage when it occurs. Any form of this can cause Cerebral Palsy.

Spastic Cerebral Palsy

This is the most common type of Cerebral Palsy. It involves HYPER-tonicity. The child will have poor control of posture and poor coordination, as well as impairment of FINE and GROSS motor skills.

Mixed Cerebral Palsy

This type of Cerebral Palsy is a mixture of the other types. It manifests with feeding difficulties and *persistent tongue thrusting*. There is a risk for aspiration and choking. - With feeding, position and stabilization is crucial.

Ataxia Cerebral Palsy

This type of Cerebral Palsy will show HIGH STEPPING and repetitive movements. These people will have problems with their gait, they will appear as though they are *STUMBLING while walking*

_______________________is a condition in which neck motion is limited and the cervical spine is rotated because of shortening of the sternocleidomastoid muscle.

Torticollis. Correct. Torticollis (tortus, "twisted," and collium, "neck") is a condition in which neck motion is limited and the cervical spine is rotated because of shortening of the sternocleidomastoid muscle. It can be either congenital or acquired and can also be either acute or chronic.

Symptoms of an earache in and infant include: 1.) external drainage, pain, and decrease in temp 2.) tugging at the ear and rolling head from side to side 3.) crying and pointing to affected ear 4.) redness of the cheeks and cyanosis of the ear

Tugging at the ear and rolling head from side to side

Which intervention would improve​ self-feeding ability in a child with spasticity caused by cerebral​ palsy? Providing utensils with adaptive handles Restricting hydration Presenting large portions of food all at one time Providing a​ low-fiber diet

Utensils with adaptive handles may improve​ self-feeding ability in children with spasticity associated with CP. Other possible interventions include feeding small amounts of food at a​ time, providing hydration to noncommunicative clients who may not be able to indicate that they are​ thirsty, and providing adequate fiber in the diet.

A 3-year-old patient with cerebral palsy (CP) has begun having seizures. Which recommendation should the nurse make to enhance this patient's safety? Ensure adequate lighting in walkways. Use specialized safety belts when seated. Wear a helmet. Apply leg braces.

Wear a helmet. A child with CP who has seizures is at risk for a head injury from falling or trauma to the head during a seizure. A helmet would protect the child's head. Keeping hallways adequately lit is more appropriate as a precaution for older children. Seat belts are not needed every time the patient sits. Braces may be effective in preventing contractures but are not beneficial in preventing injury in children who have seizures.

ADL's

With CP patients, we must encourage these as much as possible to promote locomotion and independence.

Diagnostic Evaluation

With this: - Maternal history - Neurological Exams - Any clinical manifestations - ECG

A practice that has been helpful in preventing mental retardation is: 1.) administering the Stanford-Binet test 2.) a blood test at birth 3.) careful preschool development screening 4.) a urine test at age 6 months

a blood test at birth

An 8-year-old has been diagnosed with moderate cerebral palsy (CP). The child recently began participation in a regular classroom for part of the day. The child's mother asks the school nurse about joining the after-school Scout troop. The nurse's response should be based on knowledge that

after-school activities often provide children with CP with opportunities for socialization and recreation.

An infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection . The type of transmission-based isolation precaution the nurse would set up would be: 1.) standard precautions 2.) droplet precautions 3.) contact precautions 4.) airborne infection isolation precautions

contact precautions

Reye's syndome affects the: 1.) stomach and the intestine 2.) islet of Langerhans 3.) Liver and the brain 4.) heart and the blood vessels

liver and the brain

which sign or symptom observed in a sleeping 2-year-old child immediately after a tonsillectomy necessitates reporting and follow-up care? 1.) pulse of 110 beats/min 2.) a blood pressure of 96/64 mm Hg 3.) nausea 4.) frequent swallowing

frequent swallowing

A health care provider is preparing to examine the throat of a child diagnosed with acute epiglottis. A priority nursing responsibility would be to? 1.) have a tracheotomy set at the bedside 2.) immobilize the child's head 3.) restrain the child's arms 4.) have oxygen available

have a tracheotomy set at the bedside

Which is a priority nursing diagnosis in a child admitted with acute asthma? 1.) risk for infection 2.) imbalanced nutrition 3.) ineffective breathing pattern 4.) disturbed body image

ineffective breathing pattern

The nurse is reinforcing teaching concerning the use of a cromolyn sodium inhaler for a 10-year-old with asthma. Which would be an accurate concept to emphasize? 1.) you should use the inhaled whenever you feel some difficulty in breathing 2.) you should use the inhaler between meals 3.) you should use the inhaler regularly every day even if you are symptom free 4.) you can discontinue using the inhaler when you are feeling stronger

you should use the inhaler regularly every day even if you are symptom free

The mother of a​ 4-year-old child with cerebral palsy​ (CP) asks how this health problem occurred. Which prenatal insult should the nurse explain as a possible​ cause? (Select all that​ apply.) A. Fetal viral infection B. Hyperbilirubinemia C. Genetic factors D. Brain injury E. Prematurity

​A, C, E Rationale: Prematurity is an etiology of CP that occurs before birth. Fetal viral infection is an etiology of CP that occurs before birth. Genetic factors are an etiology of CP that occurs before birth. Hyperbilirubinemia is an etiology of CP that occurs after birth. Brain injury is an etiology of CP that occurs after birth.

The parents of a child with cerebral palsy​ (CP) are concerned about possible future health problems. The nurse knows the client is at risk for which​ complication? (Select all that​ apply.) A. Premature aging B. Urinary incontinence C. Depression D. Decreased cognitive ability E. Hypotension

​A,B,C,D Rationale: The client with CP is at risk for multiple comorbidities to include​ depression, decreased cognitive​ ability, urinary and bowel​ incontinence, and premature aging. The client with CP is at risk for developing​ hypertension, not hypotension.

The nurse is preparing teaching material about cerebral palsy​ (CP). Which nonpharmacologic therapy should the nurse include in this​ teaching? (Select all that​ apply.) A. Speech therapy B. Physical therapy C. Occupational therapy D. Oxygen therapy E. Special education

​A,B,C,E Rationale: Clinical therapy is used for clients who have CP to help them develop their maximum level of independence. To improve motor function and​ ability, referrals are made for​ physical, occupational, and speech​ therapy, as well as special education. Oxygen therapy is not necessary for all individuals with​ CP, only those with breathing disorders who require it.

An​ 18-month-old client is suspected of having cerebral palsy​ (CP). Which test should the nurse expect to be prescribed to help diagnose this​ client? (Select all that​ apply.) A. PET scan B. MRI C. Electrocardiographic studies D. CT scan E. Laboratory studies of protein levels in the bloodstream

​A,B,D Rationale: There is no specific diagnostic test for​ CP, but​ MRI, CT​ scan, and PET scan can be helpful in eliminating other organic brain​ disease, such as tumors or developmental issues. Electrocardiographic studies and laboratory studies are not used to diagnose CP.

The parents of a child with cerebral palsy​ (CP) ask if there are any medications available to help control the​ child's symptoms. Which type of medication should the nurse discuss with the​ parents? (Select all that​ apply.) A. Baclofen B. Antidepressants C. Muscle relaxants D. Botulinum toxin E. Benzodiazepines

​A,C,D,E Rationale: Medications that are used to control seizures and spasms include skeletal muscle​ relaxants, baclofen,​ benzodiazepines, and botulinum toxin. Antidepressants are not used to manage the symptoms of CP.

The nurse is preparing discharge instructions for the parents of a child with cerebral palsy​ (CP). Which instruction should the nurse include to promote safety for this​ child? (Select all that​ apply.) A. Adaptive seating for automobile transportation B. Splints and braces C. ​Range-of-motion exercises D. Seat belts in strollers and wheelchairs E. Helmet to protect against head injuries

​A,D,E Rationale: A client who has frequent falls​ and/or seizures may require a helmet to protect against head injury. Adaptive seating in an automobile may be required to ensure​ proper, safe restraint. Use of seat belts in wheelchairs or strollers will prevent spastic movements from resulting in falls. Use of splints and braces and​ range-of-motion exercises will promote mobility and muscle​ strength; they are not used to promote safety.

During an​ assessment, the nurse suspects that an​ 18-month-old client is demonstrating manifestations of cerebral palsy​ (CP). Which assessment finding should the nurse use to validate this​ conclusion? (Select all that​ apply.) A. Thumb sucking B. Head lag C. Arched back D. Poor trunk control E. Asymmetric crawling

​B,C,D,E Rationale: Abnormalities that can be assessed that indicate cerebral palsy include asymmetric​ crawling, head​ lag, arched​ back, and poor trunk control. Thumb sucking is not a manifestation of CP.

The nurse notes a high level of stress between the parents of a child with cerebral palsy​ (CP). Which action should the nurse take to support the​ parents? A. Explain that all children with CP are eventually placed in​ long-term care facilities B. Refer all medical questions to the healthcare provider C. Make a referral for marriage counseling D. Listen to concerns and encourage expression of feelings

​D Rationale: Parents require emotional support to help them cope with the diagnosis. Listen to the​ parents' concerns and encourage them to express their feelings and ask questions. The nurse should encourage the family to ask questions and should obtain answers to questions that the nurse is unable to answer. All children with CP are not eventually transferred to a​ long-term care​ facility; many are successfully cared for at home. Referrals for individual and family counseling are​ appropriate, but the nurse is not qualified to suggest a referral for marriage counseling.

Which screening assessment should the nurse use for a child demonstrating developmental delays associated with cerebral palsy​ (CP)? (Select all that​ apply.) A. Phalen test B. Heeldashshin test C. Diaper pull D. Head turn E. Babinski reflex

​Rationale: All infants who show symptoms of developmental delay should be evaluated by using two simple screening assessments. The first is a diaper​ pull, which is conducted by placing a clean diaper on the​ child's face; the infant with CP will use one hand or will not remove the cloth at all. The other test is the head​ turn, which is conducted by turning the​ infant's head to one​ side; if the child has a persistent asymmetric tonic neck reflex beyond 6 months of​ age, this indicates a pathologic condition. The Babinski reflex does not indicate the presence or absence of CP. The Phalen test is used to assess for carpal tunnel syndrome. The heeldashshin test is used with adults to determine nervous system integrity of the lower extremities.