Exam 3 Practice Questions

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. 1. Time the seizure 2. Restrain the child 3. Stay with the child 4. Place the child in a prone position 5. Move furniture away from the child 6. Insert a padded tongue blade in the child's mouth

1, 3, 5

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? 1. Meningitis 2. Spinal cord injury 3. Intracranial bleeding 4. Decreased cerebral blood flow

1

A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? 1. Encourage the client to rest and read. 2. Encourage the parents to room in with the client. 3. Allow the family to bring in the client's favorite computer games. 4. Allow the client to interact with others in his or her same age group.

4

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? 1. Assessing hearing loss 2. Monitoring urine output 3. Changing body position every 2 hours 4. Providing a quiet atmosphere with dimmed lighting

4

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 increased intracranial pressure (ICP). Which is a LATE sign of increased ICP? 1. Nausea 2. Irritability 3. Headache 4. Bradycardia

4

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(s) need to be placed at the child's bedsides? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen

4

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of the infection, which precautionary intervention should be included in the plan of care? 1. Maintain enteric precautions 2. Maintain neutropenic precautions 3. No precautions are required as long as antibiotics have been started 4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

4

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? 1. Test the urine for protein 2. Reposition the infant frequently 3. Provide a stimulating environment 4. Assess blood pressure every 15 minutes

2

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? 1. Clear CSF; decreased pressure, and elevated protein level 2. Clear CSF; elevated protein and decreased glucose levels 3. Cloudy CSF; elevated protein, and decreased glucose levels 4. Cloudy CSF; decreased protein, and decreased glucose levels

3

The nurs is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the pediatrician's prescriptions and should contact the pediatrician to question which prescription? 1. Obtain daily weight 2. Provide clear liquid intake 3. Nasotracheal suction as needed 4. Maintain a patent intravenous line

3

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? 1. An infectious disease of the central nervous system 2. An inflammation of the brain as a result of a viral illness 3. A chronic disability characterized by impaired muscle movement and posture 4. A congenital condition that results in moderate to severe intellectual disabilities

3