ATI Ped's 12-15

4. A nurse is teaching a group of parents about the risk factors for seizures. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Febrile episodes B. Hypoglycemia C. Sodium imbalances D. Low serum lead levels e. Presence of diphtheria

. A. CORRECT: Febrile episodes can cause general tonic-clonic seizures in infants and young children. B. CORRECT: Seizure activity is a late manifestation of hypoglycemia. C. CORRECT: Seizure activity is a manifestation of hyponatremia and hypernatremia. D. High serum lead levels are a risk factor for seizure activity. e. Diphtheria is a respiratory illness causing difficulty breathing and is not a risk factor for seizures.

1. A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse expect? (Select all that apply.) A. Loss of consciousness B. Appearance of daydreaming C. Dropping held objects D. Falling to the floor e. Having a piercing cry

1. A. CORRECT: Loss of consciousness for 5 to 10 seconds is a manifestation of an absence seizure. B. CORRECT: Behavior that resembles daydreaming is a manifestation of an absence seizure. C. CORRECT: A child who is having absence seizures might drop a held object. D. Falling to the floor is a manifestation of a tonic-clonic seizure. e. A piercing cry is a manifestation of a tonic-clonic seizure.

1. A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions by the nurse is appropriate? A. Place the client on NPo status. B. Prepare the client for a liver biopsy. c. Position the client dorsal recumbent. D. Put the client in a protective environment.

1. A. CORRECT: the nurse should place the client on NPo status due to the client's decreased level of consciousness to prevent aspiration. B. the nurse should expect a client who has reye syndrome to require a liver biopsy. c. the nurse should position the client without a pillow and slightly elevate the head of the bed to prevent increasing intracranial pressure. D. clients who are immunocompromised require a protective environment. the nurse should place a client who has suspected meningitis should be placed on droplet precautions for at least 24 hr after the initiation of antibiotic therapy.

1. a nurse is in the emergency department is assessing a child following a motor‐vehicle crash. The child is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following actions should the nurse take first? a. Stabilize the child's neck. B. Clean the child's laceration with soap and water. C. Implement seizure precautions for the child. d. Initiate IV access for the chi

1. a. CORRECT: The greatest risk to a child following a motor vehicle crash is cervical injury. Therefore, keeping the neck stabilized until cervical injury can be ruled out is the priority action. B. Cleaning the child's laceration with soap and water is important. However, this is not the priority action. C. Implementing seizure precautions is important. However, this is not the priority action. d. establishing IV access is important. However,

1. a nurse is planning to perform a peripheral vision test on a child. Which of the following actions should the nurse take? a. place the child 10 feet away from a Snellen chart. B. Show a set of cards to the child one at a time. C. Cover the child's eye while performing the test on the other eye. d. Have the child focus on an object while performing the test.

1. a. the nurse should place the child 10 feet away from a Snellen chart when performing a visual acuity test. B. the nurse should show a set of cards to the child one at a time when performing a color test. C. the nurse should cover the child's eye while performing the test on the other eye when performing a cover test. d. CORRECT: When performing a peripheral vision test, the nurse asks the child to focus on an object while bringing a pencil into the child's peripheral vision.

2. A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take? A. Maintain the child in a side-lying position. B. Loosen the child's restrictive clothing. C. reorient the child to the environment. D. Note the time and characteristics of the child's seizure.

2. A. CORRECT: Following a seizure, children often experience vomiting. using the airway, breathing, circulation priority-setting framework, the first action the nurse should take is to place the child in a side-lying position to maintain a patent airway and prevent aspiration of secretions. B. Loosening the child's restrictive clothing is an appropriate action. However, it is not the priority action. C. reorienting the child to the environment following a generalized seizure is an appropriate action. However, it is not the priority action. D. Noting the time and characteristics of the child's seizure is

2. A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following findings should the nurse identify as indicating viral meningitis? (select all that apply.) A. Negative gram stain B. Normal glucose content c. cloudy color D. Decreased WBc count e. Normal protein content

2. A. CORRECT: the nurse should expect a client who has viral meningitis to have a negative gram stain. B. CORRECT: the nurse should expect a client who has viral meningitis to have a normal glucose content. c. the nurse should expect a clear color for a client who has viral meningitis. D. the nurse should expect a slightly elevated WBc count for a client who has viral meningitis. E.CORRECT: the nurse should expect a client who has viral meningitis to have a normal protein content.

2. a nurse is caring for an adolescent who has a closed head injury. Which of the following findings are indications of increased intracranial pressure (ICP)? (Select all that apply.) a. report of headache B. alteration in pupillary response C. Increased motor response d. Increased sleeping e. Increased sensory response

2. a. CORRECT: a headache is an indication of ICP. B. CORRECT: alterations in pupillary response is an indication of ICP. C. decreased motor response is an indication of ICP. d. CORRECT: Increased sleeping is an indication of ICP. e. decreased sensory response is an indication of ICP.

2. a nurse is teaching a group of parents about possible manifestations of down syndrome. Which of the following findings should the nurse include in the teaching? (Select all that apply.) a. a large head with bulging fontanels B. Larger ears that are set back C. protruding abdomen d. Broad, short feet and hands e. Hypotonia

2. a. a child who has hydrocephalus will exhibit a large head with bulging fontanels due to the increased CSF in the head. B. a child who has down syndrome will exhibit small features, such as small ears with a short pinna. C. CORRECT: a child who has down syndrome will exhibit a protruding abdomen. d. CORRECT: a child who has down syndrome will exhibit small features, such as broad, short feet and hands. e. CORRECT: a child who has down syndrome will exhibit hyperflexibility and hypotonia.

3. a nurse is assessing a child who has myopia. Which of the following findings should the nurse expect? (Select all that apply.) a. Headaches B. photophobia C. difficulty reading d. difficulty focusing on close objects e. poor school performance

3. a. CORRECT: Headaches are a manifestation of myopia. B. photophobia is a manifestation of strabismus. C. CORRECT: difficulty reading is a manifestation of myopia. d. difficulty focusing on close objects is a manifestation of hyperopia. e. CORRECT: poor school performance is a manifestation of myopia.

4.A nurse is caring for a school-age client who possibly has reye syndrome. Which of the following is a risk factor for developing reye syndrome? A. recent history of infectious cystitis caused by Candida B. recent history of bacterial otitis media c. recent episode of gastroenteritis D. recent episode of Haemophilus influenzae meningitis

4. A. the nurse should recognize that Candida is a fungal infection and is therefore not a risk factor for reye syndrome. B. the nurse should recognize that a bacterial infection is not a risk factor for reye syndrome. c. CORRECT: the nurse should recognize that gastroenteritis is a viral illness, which is a risk factor for developing reye syndrome. reye syndrome typically follows a viral illness, such as influenza, gastroenteritis, or varicella. D. the nurse should recognize that Haemophilus influenzae is a bacteria and is therefore not a risk factor for reye syndrome.

4. a nurse is assessing a child who has a concussion. Which of the following findings should the nurse expect? (Select all that apply.) a. amnesia B. Systemic hypertension C. Bradycardia d. respiratory depression e. Confusion

4. a. CORRECT: amnesia is a manifestation of a concussion. B. Systemic hypertension is a manifestation of Cushing's triad in a child who has an epidural hematoma. C. CORRECT: Bradycardia is a manifestation of Cushing's triad in a child who has an epidural hematoma. d. CORRECT: respiratory depression is a manifestation of Cushing's triad in a child who has an epidural hematoma. e. CORRECT: Confusion is a manifestation of a concussion.

4. a nurse is assessing a toddler for possible hearing loss. Which of the following findings are indications of a hearing impairment? (Select all that apply.) a. Uses monotone speech B. Speaks loudly C. repeats sentences d. appears shy e. is overly attentive to the surroundings

4. a. CORRECT: monotone speech is a manifestation of a hearing impairment. B. CORRECT: Speaking loudly is a manifestation of a hearing impairment. C. repeating sentences is an expected developmental task for a toddler. d. CORRECT: Shyness and withdrawn behavior are manifestations of a hearing impairment. e. inattentiveness to surroundings is a manifestation of a hearing impairment.

5. a nurse is caring for a child who is taking mannitol for cerebral edema. Which of the following adverse effects should the nurse monitor the child for and report to the provider? a. Bradycardia B. Weight loss C. Confusion d. Constipation

5. a. Tachycardia is an adverse effect of mannitol. B. Weight gain due to urinary retention is an adverse effect of mannitol. C. CORRECT: The nurse should monitor the child for increased confusion and report this adverse effect to the provider. This could be an indication of electrolyte imbalance. d. diarrhea is an adverse effect of mannitol.

5. a nurse is teaching the parent of an infant who has down syndrome. Which of the following statements by the parent indicates an understanding of the teaching? a. "i should expect him to have frequent diarrhea." B. "i should place a cool mist humidifier in his room." C."i should avoid the use of lotion on his skin." d."i should expect him to grow faster in length than other infants."

5. a. the nurse should teach the parent that down syndrome increases the risk for constipation, resulting in the need for additional fluid and fiber in the diet. B. CORRECT: the nurse should teach the parent that down syndrome increases the risk for respiratory infections. Using a cool mist humidifier in the infant's room helps prevent respiratory infections. C. the nurse should teach the parent that down syndrome causes the infant to have dry skin that cracks easily. the parent should practice good skin care, including the application of lotion. d. the nurse should teach the parent that down syndrome results in reduced growth in length for infants and height for children.

3. A nurse is providing teaching to the parent of a child who is to have an electroencephalogram (eeG). Which of the following responses should the nurse include in the teaching? A. "Decaffeinated beverages should be offered on the morning of the procedure." B. "Do not wash your child's hair the night before the procedure." C."Withhold all foods the morning of the procedure." D."Give your child an analgesic the night before the procedure."

A. CORRECT: Caffeine can alter the results of an eeG and should be avoided prior to the test. B. The child's hair should be washed to remove oils that permit adherence of the eeG electrodes. C. Foods are not withheld prior to an eeG. D. Analgesics can alter the results of an eeG and should be avoided prior to the test.

5. A nurse is reviewing treatment options with the parent of a child who has worsening seizures. Which of the following treatment options should the nurse include in the discussion? (Select all that apply.) A. Vagal nerve stimulator B. Additional antiepileptic medications C. Corpus callosotomy D. Focal resection e. radiation therapy

A. CORRECT: The implantation of a vagal nerve stimulator is an option to provide seizure control. B. CORRECT: Additional antiepileptic medication can be added to the current medication regime to control seizures. C. CORRECT: A corpus callosotomy can be performed for uncontrolled seizures. D. CORRECT: A focal resection can be performed for uncontrolled seizures. e. radiation therapy is used in cancer treatment and is not used to control seizures.

3.A nurse is caring for a 4-month-old infant who has meningitis. Which of the following findings is associated with this diagnosis? A. Depressed anterior fontanel B. constipation c. Presence of the rooting reflex D. High-pitched cry

A. the nurse should expect a 4-month-old infant who has meningitis to have a bulging anterior fontanel. B. the nurse should identify vomiting as an expected finding of meningitis. c. the nurse should identify the rooting reflex as expected in infants until the age of 3 to 4 months, and can remain until the age of 12 months. D. CORRECT: the nurse should identify a high-pitched cry as a finding associated with meningitis between ages 3 months to 2 years.

5. A nurse is developing an in-service about viral and bacterial meningitis. the nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (select all that apply.) A. inactivated polio vaccine (iPV) B. Pneumococcal conjugate vaccine (PcV) c. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DtaP) D. Haemophilus influenzae type B (Hib) vaccine e. trivalent inactivated influenza vaccine (tiV)

A. the nurse should not include the iPV because it does not decrease the incidence of bacterial meningitis. B. CORRECT: the introduction of the PcV decreased the incidence of bacterial meningitis in children, as it provides immunity against bacteria that causes the illness. c. the nurse should not include the DtaP vaccine because it does not decrease the incidence of bacterial meningitis. D. CORRECT: the introduction of the Hib vaccine decreased the incidence of bacterial meningitis in children, as it provides immunity against bacterium that cause the illness. e. the nurse should not include the tiV because it does not decrease the incidence of bacterial meningitis.

3. a nurse is caring for a child who has ICP. Which of the following actions should the nurse take? (Select all that apply.) a. Suction the endotracheal tube every 2 hr. B. Maintain a quiet environment. C. use two pillows to elevate the head. d. administer a stool softener. e. Maintain body alignment.

a. routine suctioning of the endotracheal tube is contraindicated because there is a risk of the catheter entering the brain through a skull fracture. B. CORRECT: Stimulation can cause increased intracranial pressure; therefore, the nurse should maintain a quiet environment. C. Pillows under the head cause flexion of the neck and increase intracranial pressure. d. CORRECT: Increased pressure in the abdomen with the Valsalva maneuver can increase intracranial pressure; therefore, the nurse should administer a stool softener. e. CORRECT: Flexion and extension of the neck or hips increase intracranial pressure; therefore, the nurse should maintain body alignment.