EXAM 6 Practice questions and rationales

The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position in what way? 1. astride one of her hips 2. strapped in an infant seat 3. wrapped tightly in a blanket 4. under the arm in a football hold

1 rationale: Carrying the infant astride the parent's hip prevents scissoring by keeping the infant's legs abducted. An infant seat will not prevent scissoring. Tight wrapping maintains the infant's legs in a scissored position. When the football hold is used, the infant is carried in a supine position with the legs adducted, which promotes scissoring.

The nurse is assessing the client diagnosed with meningococcal meningitis. Whichassessment data would warrant notifying the HCP? 1. Purpuric lesions on the face. 2. Complaints of light hurting the eyes. 3. Dull, aching, frontal headache. 4. Not remembering the day of the week.

1. In clients with meningococcalmeningitis, purpuric lesions over theface and extremity are the signs of afulminating infection that can lead todeath within a few hours.

Which documentation further supports the diagnosis of CF? Select all that apply 1. A history of frequent respiratory infections. 2. An elevated white blood cell count (WBC). 3. Reports of episodic abdominal pain and crying 4. A sweat chloride level of 35 mEq/L (35 mmol/L). 5. Bulky loose stools

1. A history of frequent respiratory infections. The respiratory system is affected by abnormally thick, sticky secretions that cause airway obstruction to the lungs. Other clinical manifestations of CF include poor growth and/or weight loss, a dry and non-productive cough, and increased bleeding tendencies caused by a deficiency of the fat-soluble vitamin K. 5. Bulky loose stools The term for undigested fat in the stools of clients with CF is steatorrhea. The foul smell is a result of the presence of protein. Large, loose, and sticky are also terms that characterize the stools of a client with CF.

The nurse anticipates that the family of a child with cerebral palsy is at risk for difficult parenting issues. What does the nurse conclude is the probable basis for this difficulty? 1. lack of social support 2. unrealistic expectations 3. loss of the expected healthy child 4. having a child with cognitive impairment

3 rationale:All parents initially grieve over the loss of a healthy child, what could have been, and what may never be. Many families have support systems. Unrealistic expectations may be true of some, but not all, parents. Not all children with cerebral palsy are cognitively impaired; approximately 30% to 50% of children with cerebral palsy are mentally challenged.

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. Occupational therapy B. Special education C. Speech therapy D. Oxygen therapy E. Physical therapy

A, B, C, E

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. Benzodiazepines C. Muscle relaxants D. Baclofen E. Botulinum toxin

A, C, D, E

What information will the nurse include when teaching about the sweat test? Select all that apply A. its simple B. a score of 49 mmol indicates a positive test C. the procedure is painless D. this measures the chloride in sweat E. this test is one of the most reliable test

A, C, D, E

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

A, Hypertonia and rigidity

The nurse documents 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. The inability to extend the leg when the thigh is flexed at the hip is a positive kerning's sign

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? A. "The earlier the intervention is started, the better the long-term result to optimize independence. "B. "You may want to wait until walking occurs. "C. "You shouldn't wait because that could make the condition much worse." D. "It's up to you. It really doesn't matter when therapy is started."

A. " the earlier the intervention is started, the better long-term result to optimize independence"

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? A. "Were there any accidents before age 3? "B. "Was the mother older than 40 years when the child was born?" C. "Was the child born prematurely?" D. "Was the child born subsequent to the fourth child?"

A. Where there any accidents before age 3?

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. Arched back B. Asymmetric crawling C. Head lag D. Thumb sucking E. Poor trunk control

A. arched back B, asymmetric crawling C. head lag E. poor trunk control

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

A. muscle contractions

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. Normal muscle tone in all extremities B. Arching of the back C. Developmental delay D. Strabismus

A. normal muscle tone in all extremities

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. Dyskinetic cerebral palsy C. Ataxic cerebral palsy D. Mixed cerebral palsy

A. spastic cerebral palsy

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. Splints and braces​ B. Range-of-motion exercises C. Seat belts in strollers and wheelchairs D. Adaptive seating for automobile transportation E. Helmet to protect against head injuries

A. splints and braces C. seat belts in strollers and wheelchairs E. helmet to protect against head injuries

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? A. Wear a helmet. B. Ensure adequate lighting in walkways .C. Use specialized safety belts when seated. D. Apply leg braces.

A. wear a helmet

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? A. Cerebellum B. Cerebral cortex C. Multiple areas D. Basal ganglia

B. cerebral cortex

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? A. It increases ankle range of motion. B. It controls muscle spasms. C. It allows flat-footed walking. D. It prevents infections.

B. it controls muscle spams

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. Neonatal sepsis B. Premature birth C. Hyperbilirubinemia D. Injury to the cerebral cortex E. Fetal viral infection

B. premature brith D. injury to the cerebral cortex E. fetal viral infection

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

B. provide small amounts of food at a time

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. Brain injury B. Hyperbilirubinemia C. Genetic factors D. Prematurity E. Fetal viral infection

C. genetic factors D. prematurity E. fetal viral infection

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. Atherosclerosis B. Increased dental caries C. Muscle contractures D. Fatigue E. Pressure injuries

C. muscle contractures D. fatigue E. pressure injuries

A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is: A) Hair loss B) Brittle nails C) Weight gain D) Sore throat

D

The mother of a child with cystic fibrosis tells the nurse that her child makes "snoring" sounds when breathing. The nurse is aware that many children with cystic fibrosis have: A) Enlarged adenoids B) Choanal atresia C) Septal deviations D) Nasal polyps

D

An infant, who is not meeting developmental goals and is displaying spastic motion, will be evaluated for possible cerebral palsy (CP). Which component of the infant's medical history should the nurse identify as the greatest risk factor for the health problem? A. Family history of CP B. The mother having had numerous respiratory infections during pregnancy C. No prenatal care during pregnancy D. Born premature at 29 weeks of gestation

D. Born premature at 29 weeks of gestation

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? A. Height and weight B. Nutrition status and bowel function C. Swallowing difficulty D. Skin integrity and body alignment

D. skin integrity and body alignment

The nurse is providing education to the parents of a 2-year-old boy with hydrocephalus who has just had a ventriculoperitoneal shunt placed. Which information is most important for the parents to be taught? a. "limit the amount of t.v. he watches" b. "watch for changes in his behavior or eating patterns" c. "call the doctor if he gets a headache." d. "always keep his head raised 30 degrees"

b. "watch for changes in his behavior or eating patterns" rationale: Changes in behavior or in eating patterns can suggest a problem with his shunt, such as infection or blockage. Irritability, lack of appetite, increased crying, or inability to settle down may indicate increased intracranial pressure. Any headache needs to be monitored, but if it goes away quickly, such as after eating, it probably isn't a problem. It is not necessary to keep the child's head raised 30 degrees. The child's shunt will not be affected by the amount of television viewed.

Which assessment supports the diagnosis of CF? 1. A fever of 102 ºF (38.9 ºC), 2. inflamed larynx with exudate. 3. Eyes with redness and yellow exudate 4. Weight loss and delayed growth despite a hearty appetite. 5. A brassy cough with inspiratory stridor.

4. Weight loss and delayed growth despite a hearty appetite. Pancreatic insufficiency and malabsorption are characteristic of CF and result in weight loss and delayed growth.

An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a chest physiotherapy treatment. The therapy should be properly coordinated by the nurse with the respiratory therapy department so that treatments occur during: A) Between meals B) After meals C) After medication D) Around the child's play schedule

A

When planning long-term care for a 2-year-old child with cerebral palsy (CP), what is it important for the nurse to consider? 1. CP is not progressively degenerative. 2. The effects of CP are unpredictable. 3. The child probably has some degree of cognitive impairment (CI) .4. The child should have genetic counseling before planning a family.

1 rationale: CP is a non progressive chronic condition, and its effects are predictable. Although CI may be present in some children with CP, all children with this disorder have CI. A variety of prenatal, perinatal, and postnatal factors contribute to the development of CP. It is estimated that the cause of CP is unknown in as many as 80% of people with the disorder.

The nurse is preparing a client diagnosed with rule-out meningitis for a lumbarpuncture. Which interventions should the nurse implement? Select all that apply .1. Obtain an informed consent from the client or significant other. 2. Have the client empty the bladder prior to the procedure. 3. Place the client in a side-lying position with the back arched. 4. Instruct the client to breathe rapidly and deeply during the procedure. 5. Explain to the client what to expect during the procedure

1,2,3,5 1. A lumbar puncture is an invasiveprocedure; therefore, an informedconsent is required .2. This could be offered for clientcomfort during the procedure. 3. This position increases the spacebetween the vertebrae, which allowsthe HCP easier entry into the spinalcolumn. 5. The nurse should always explain to theclient what is happening prior to andduring a procedure.

The nurse is caring for a client diagnosed with meningitis. Which collaborativeintervention should be included in the plan of care? 1. Administer antibiotics. 2. Obtain a sputum culture. 3. Monitor the pulse oximeter. 4. Assess intake and output.

1. A nurse administering antibiotics is acollaborative intervention because theHCP must write an order for theintervention; nurses cannot prescribemedications unless they have additionaleducation and licensure and are nursepractitioners with prescriptiveauthority.

The 29-year-old client is admitted to the medical floor diagnosed with meningitis.Which assessment by the nurse has priority? 1. Assess lung sounds. 2. Assess the six cardinal fields of gaze .3. Assess apical pulse. 4. Assess level of consciousness.

4. Meningitis directly affects the client'sbrain. Therefore, assessing theneurological status would have priorityfor this client.

A nurse is teaching the parents of an infant with cerebral palsy how to provide optimal care. What should the nurse include in the teaching? 1. focusing on cognitive rather than motor skills 2. maintaining immobility of the limbs with splints 3. preserving muscle tone to prevent joint contractures 4. continuing to offer a special formula to limit gagging

3 rationale: Children with cerebral palsy are especially prone to muscle tone disorders, including spasticity, which can lead to joint contractures. The therapy program must be balanced to promote progress in all areas of growth and development. Splinting of limbs is contraindicated because immobility promotes the development of joint contractures. Although these infants tend to gag and choke during feedings, a special formula is not necessary unless the child is allergic to dairy products.

A nurse is concerned about helping the parents of an infant with cerebral palsy set long-term goals for the family. What is most important to understand when setting long-term goals? 1. cognitive impairments require special education 2. progressive deterioration requires future institutionaliztion 3. unknown extent of the disability requires continual adjustments 4. diminished immune responses require protection from infection

3 rationale:The infant is too young for specific long-term plans; different problems may manifest as the child grows older. Children with cerebral palsy may or may not have cognitive impairments. Cerebral palsy does not get progressively worse; placement outside the home depends on the child's needs and the parents' abilities and desires. There is no relationship between cerebral palsy and a lowered immune response.

While working in a neuromuscular clinic the nurse monitors infants for symptoms of cerebral palsy. Which statements by infants' mothers indicate the need for further evaluation for cerebral palsy? Select all that apply. 1. my baby doesn't make eye contact 2. my baby seems to have a voracious appetite 3. my baby was able to turn from front to back by 2 months of age 4. i've noticed that this baby clings to me more than other children of the same age 5. all of my other children were sitting alone by this age. this baby doesn't seem to be anywhere near sitting alone

3, 5 rationale:An infant that turns from front to back at an early age will often be found to have spastic cerebral palsy; it is the spasticity that causes an unintentional turn from front to back. Cerebral palsy is a neurologic problem and is commonly recognized when the child fails to meet developmental norms. Failure to make eye contact is often associated with eye issues or autism. Neither anorexia nor a voracious appetite are associated with cerebral palsy. Personality traits are not related to a diagnosis of cerebral palsy.

While discussing pancreatic enzymes, the CNS explains that the dosage of the pancreatic enzyme is adjusted according to stool formation, which indicates how well client is digesting her food. Which adjustment would the nurse anticipate will be required, if client has constipation? 1. The pancreatic enzymes would not be administered for 24 hours 2 .The amount of pancreatic enzymes would be decreased at each meal. 3. The pancreatic enzymes would be increased with each meal and snack. 4. No adjustment in the dosage would be made at this time.

3. The pancreatic enzymes would be increased with each meal and snack. Pancreatic enzymes are adjusted to decrease the bulk of the stool.

The nurse is assessing the client diagnosed with bacterial meningitis. Which clinicalmanifestations would support the diagnosis of bacterial meningitis? 1. Positive Babinski's sign and peripheral paresthesia. 2. Negative Chvostek's sign and facial tingling. 3. Positive Kernig's sign and nuchal rigidity. 4. Negative Trousseau's sign and nystagmus.

3. A positive Kernig's sign (client unableto extend leg when lying flat) andnuchal rigidity (stiff neck) are signs ofbacterial meningitis, occurring becausethe meninges surrounding the brainand spinal column are irritated.

An infant is found to have cerebral palsy (CP) several months after birth. When the infant is 10 months old the mother comes to the pediatric clinic because the child has begun to exhibit slow writhing movements. The nurse explains that these movements are characteristically associated with what type of CP? 1. ataxic 2. spastic 3. dystonic 4 athetoid

4 rationale :The athetoid type of CP consists of slow, wormlike, writhing movements. The ataxic type of CP is characterized by rapid, repetitive movements. The spastic type of CP is characterized by hypertonicity of muscles. The dystonic type of CP is a combination of the spastic and athetoid types.

nurse in the pediatric clinic should be most observant for signs of cerebral palsy in a 6-month-old infant in which instance? 1. has a 40-year-old mother 2. was born exhibiting the moro reflex 3. was delivered by elective cesarean birth 4. was born during the 32nd week of gestation

4 rationale: Studies indicate that a large percentage of children with cerebral palsy had preterm births and weighed less than 3 lb 5 oz (1500 g) at birth. Studies do not indicate a greater incidence of cerebral palsy in children born to older women. There is no greater incidence of cerebral palsy in children born in cesarean births that are not performed because of fetal distress. The Moro reflex is expected at birth.

What information will the nurse include when teaching about the sweat test? 1. Informed consent will be needed for this invasive, diagnostic test. 2. It will take 2 hours to obtain the sweat. 3. This procedure will require the child to be NPO (nothing by mouth) 4. It is a simple and reliable test that measures the chloride in sweat.

4. The sweat test is a simple, painless, and reliable diagnostic test that is performed to determine the amount of chloride in the client's sweat. The sweat chloride test involves stimulating the production of sweat with a special device and collecting the sweat on filter paper, and measuring the sweat electrolytes. It has been the gold standard for diagnosing CF for the past 40 years

Which type of precautions should the nurse implement for the client diagnosed withseptic meningitis? 1. Standard Precautions. 2. Airborne Precautions. 3. Contact Precautions. 4. Droplet Precautions.

4. Droplet Precautions are respiratoryprecautions used for organisms thathave a limited span of transmission.Precautions include staying at least four(4) feet away from the client or wearinga standard isolation mask and gloveswhen coming in close contact with theclient. Clients are in isolation for 24 to48 hours after initiation of antibiotics.

A lumbar puncture is performed on a child suspected to have bacterial meningitis and CSF is obtained for analysis. The nurse reviews the results of the CSF fluid 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 C. Cloudy CSF, elevated protein, decreased glucose D. Cloudy CSF, decreased protein, decreased glucose levels

C. Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; meningitis is diagnosed by testing the CSF obtained by lumbar puncture. in the case of bacterial meningitis, findings usually include elevated pressure, cloudy CSF, elevated leukocyte, elevated protein, decreased glucose levels.

The parents of a child recently diagnosed with cerebral palsy ask the nurse about 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 central nervous system B. An inflammation of the brain as a result of 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. Cerebral palsy is a chronic disability characterized by impairment of movement and posture resulting from and abnormality in the extrapyramidal or pyramidal motor system.

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? A. "CP is a progressive disease that is inherited. "B. "CP is identified during the prenatal period. "C. "Not all patients with CP have an intellectual disability ."D. "The pathogenesis of CP is the same in most cases."

C. "Not all patients with CP have an intellectual disability."

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. Refer all medical questions to the healthcare provider B. Make a referral for marriage counseling C. Listen to concerns and encourage expression of feelings D. Explain that all children with CP are eventually placed in​ long-term care facilities

C. listen to concerns and encourage expression of feelings

The clinic nurse is providing instructions to the parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement would the m=nurse make to the parent? A. "The immunization schedule will need to be altered" B. "The child should not receive any hepatitis vaccines" C. "The child will receive all vaccines except for the polio vaccine" D. "The child will receive the recommended basic series of immunizations along with the yearly flu vaccine."

D. cystic fibrosis is a chronic multisystem disorder (autosomal recessive trait disorder) characterized by exocrine gland dysfunction. The mucous produced by the exorince glands is abnormally thick, tenacious and copious causing obstruction of the small passageways. Adequately protecting children with cystic fibrosis from communicable diseases by immunizations is essential, in addition to a basic series of immunizations, a yearly flu vaccine is recommended for children with CF.

The nurses recognize that energy needs are increased as a result of malabsorption of nutrients and that extra effort is needed for respirations and frequent pulmonary infections. The nurse teaches the client's parents about pancreatic replacement enzymes. Which of the following statements by the parents would indicate a correct understanding of the teaching? 1.Pancreatic enzymes are needed to digest fats and proteins. 2. Pancreatic enzymes are needed until the steatorrhea stops 3. Administration of pancreatic enzymes will replace the need to take vitamin supplements 4. Pancreatic enzymes should be taken at night before bedtime.

Pancreatic enzymes are needed to digest fats and proteins. With cystic fibrosis, the body lacks the ability to excrete the pancreatic enzymes needed to digest fats and proteins, so replacement enzymes must be administered.