Child_2
The nurse is initiating seizure precautions for a child being admitted to the nursing unit. Which items are essential for the nurse to place at the bedside? 1.Oxygen and a tongue depressor 2.A suction apparatus and oxygen 3.An airway and a tracheotomy set 4.An emergency cart and an oxygen mask
2. Rationale: Seizures cause a tightening of all body muscles that is followed by tremors. An obstructed airway and increased oral secretions are the major complications during and after the seizure. Suctioning and oxygen are helpful to prevent choking and cyanosis. A tongue depressor is not needed because nothing should be placed into the client's mouth during a seizure because of the risk for injury. Inserting a tracheostomy is not done because this is a surgical procedure. An emergency cart should not be left at the bedside; however, it should be available in the treatment room or on the nursing unit.
A child with a fractured femur is placed in Buck's skin traction, and the nurse is planning care for the client. Which information about this type of traction is correct? 1.Requires frequent pin care 2.Places the child at risk for infection 3.Uses skeletal traction and weights to provide a counterforce 4.Is a type of skin traction that pulls the hip and leg into extension
4. Rationale: Buck's skin traction is a type of skin traction used in fractures of the femur and in hip and knee contractures. It pulls the hip and leg into extension. Countertraction is applied by the child's body.
An adolescent is seen in the emergency department following an athletic injury, and it is suspected that the child sprained an ankle. X-rays are taken, and a fracture has been ruled out. The nurse reinforces instructions to the adolescent regarding home care for treatment of the sprain and provides the adolescent with which information? 1.Elevate the extremity and maintain strict bed rest for a period of 7 days. 2.Immobilize the extremity and maintain the extremity in a dependent position. 3.Apply heat to the injured area every 4 hours for the first 48 hours, and then begin to apply ice. 4.Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 hours.
4. Rationale: To treat a sprain, the injured area should be wrapped immediately to support the joint and control the swelling. Ice is applied to reduce the swelling and should be applied for no longer than 30 minutes every 4 to 6 hours for the first 24 to 48 hours. The joint should be immobilized and elevated, but strict bed rest for a period of 7 days is not required. A dependent position will cause swelling in the affected area.
The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this finding, which action should the nurse take? 1.Document the findings. 2.Lower the head of the bed. 3.Place the infant on nothing-by-mouth (NPO) status. 4.Ask the registered nurse to notify the health care provider immediately.
1. Rationale: The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 18 to 24 months of age. The posterior fontanel closes by 2 to 3 months of age. A bulging or tense fontanel may result from crying or increased intracranial pressure. If the nurse notes a bulging fontanel when the infant cries, this is a normal finding that should be documented and monitored. It is not necessary to notify the health care provider for this finding.
A health care provider has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. Which time frame for the surgery should the nurse explain to the mother? 1.Immediately 2.Before the child is 3 years old 3.Shortly before the child starts school 4.Just before the child begins to learn to read
2. Rationale: In a child diagnosed with strabismus, surgery may be indicated to realign the weakened muscles. It is most often indicated when amblyopia (decreased vision in the deviated eye) is present. The surgery should be performed before the child is 3 years old.
A 4-year-old child is diagnosed with otitis media, and the mother asks the nurse about the causes of this illness. The nurse responds, knowing that which is an unassociated risk factor related to otitis media? 1.Bottle-feeding 2.Household smoking 3.A history of urinary tract infections 4.Exposure to illness in other children
3. Rationale: Factors that increase the risk of otitis media include exposure to illness, household smoking, bottle-feeding, and congenital conditions such as Down syndrome and cleft palate. The use of a pacifier beyond age 6 months has also been identified as a risk factor. Allergies are also thought to precipitate otitis media. Urinary tract infections are not a risk factor for otitis media.
A mother of a child who underwent a myringotomy with insertion of tympanostomy tubes calls the nurse and reports that the child is complaining of discomfort. Which should the nurse instruct the mother to do? 1.Give the child children's aspirin for the discomfort. 2.Be sure that the child is resuming normal activities. 3.Give the child acetaminophen (Tylenol) for the discomfort as per discharge instructions. 4.Speak to the health care provider because the child should not be having any discomfort.
3. Rationale: Following myringotomy with insertion of tympanostomy tubes, the child may experience some discomfort. Acetaminophen or ibuprofen can be given to relieve the discomfort. Aspirin should not be administered to the child. The child should rest if discomfort is present. Parents need to be instructed that the child should not blow the nose for 7 to 10 days. Bath and lake water are potential sources of bacterial contamination. Diving and swimming deeply under water are prohibited. The child's ears need to be kept dry.
The nurse is caring for a child who sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse plans to monitor for an early sign of increased ICP by checking for which sign? 1.Apnea 2.Posturing 3.Tachycardia 4.Changes in level of consciousness
4. Rationale: An altered level of consciousness is an early sign of increased ICP. Late signs of increased ICP include tachycardia leading to bradycardia, apnea, systolic hypertension, widening pulse pressure, and posturing.
The nurse assists in developing a plan of care for the child with meningitis. Which should be the priority client problem for a child with a meningitis diagnosis? 1.Pain 2.Inadequate knowledge 3.Neurological dysfunction 4.Difficult family coping processes
3. Rationale: Neurological dysfunction is the priority client care concern for the child with meningitis. Pain related to meningeal irritation may also be a concern, but it is not the priority. There are no data in the question to indicate that there are psychosocial issues.
Which finding would indicate that a child had a tonic-clonic seizure during the night? 1.High-pitched cry 2.Blanched toenails 3.Blood on the pillow 4.Migraine headaches
3. Rationale: The complications associated with seizures include airway compromise, extremity and teeth injuries, and tongue lacerations. Night seizures can cause the child to bite down on the tongue. Seizures do not cause a high-pitched cry unless a tumor or intracranial pressure is the cause of the seizure diagnosis. Cyanosis can occur during the tonic-clonic part of the seizure activity, but blanching does not occur. Migraine headaches are not common in children with seizures.
The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation may be indicative of this condition? 1.The child has difficulty hearing. 2.The child does not respond when spoken to. 3.The child consistently tilts his or her head to see. 4.The child consistently turns his or her head to see.
3. The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see
The nurse reinforces home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further teaching? 1."I need to check for jaundiced skin and eyes every day." 2."I need to have my child nap during the day to provide rest." 3."I need to decrease the stimuli at home to prevent intracranial pressure." 4."I need to give frequent, small, nutritious meals if my child starts to vomit."
4. Rationale: The vomiting that occurs in Reye's syndrome is caused by cerebral edema and is a symptom of increased intracranial pressure. Small, frequent meals will not affect the amount of vomiting, and the health care provider is notified if vomiting occurs. Decreasing stimuli and providing rest decrease stress on the brain tissue. Checking for jaundice will assist in identifying the presence of liver complications, which are characteristic of Reye's syndrome.
The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child. Which should be included in the plan? 1.Wear gloves when administering the eardrops. 2.Pull the ear up and back before instilling the eardrops. 3.Pull the earlobe down and back before instilling the eardrops. 4.Hold the child in a sitting position when administering the eardrops.
3. Rationale: When administering eardrops to a child who is younger than 3 years old, the ear should be pulled down and back. For children who are older than 3 years old, the ear is pulled up and back. Gloves do not need to be worn by the parents, but hand washing needs to be performed before and after the procedure. The child should be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal by gravity.
The nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP? 1.Nausea 2.Papilledema 3.Decerebrate posturing 4.Alterations in pupil size
1. Rationale: Nausea is an early sign of increased ICP. Late signs of increased ICP include a significant decrease in level of consciousness, Cushing's triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils. Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema.
The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for which? 1.A lack of appetite 2.An elevated temperature 3.A decrease in the urinary output 4.An increase in the blood pressure
2. Rationale: The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used with the traction. Osteomyelitis may occur with any open fracture. Signs and symptoms include complaints of localized pain, swelling, warmth, tenderness, an unusual odor from the fracture site, and an elevated temperature.
Which is the primary goal that should be included in the plan of care for a child who has cerebral palsy? 1.Eliminate the cause of the disease. 2.Improve muscle control and coordination. 3.Prevent the occurrence of emotional disturbances. 4.Maximize the child's assets and minimize the limitations.
4. Rationale: The goal of managing the child with cerebral palsy is early recognition and intervention to maximize the child's abilities. The cause of the disease cannot be eliminated. It is best to minimize emotional disturbances, if possible, but not to prevent them because it is healthy for the child to express emotions. Improvement of muscle control and coordination is a component of the plan, but the primary goal is to maximize the child's assets and minimize the limitations caused by the disease.
The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding, which action should the nurse take? 1.Document the findings. 2.Notify the registered nurse immediately. 3.Change the ear tubes so that they do not become blocked. 4.Check the ear drainage for the presence of cerebrospinal fluid.
1. Rationale: After a myringotomy with the insertion of tympanostomy tubes, the child is monitored for ear drainage. A small amount of reddish drainage is normal during the first few days after surgery. However, any heavy bleeding or bleeding that occurs after 3 days should be reported. The nurse would document the findings. Options 2, 3, and 4 are not necessary.
