DPS Neuromuscular Disorders
Which should the nurse expect in a 2-week-old with a brachial plexus injury? Select all that apply. 1. History of a normal vaginal delivery. 2. Small infant. 3. Absent Moro refl ex on one side. 4. No sensory loss. 5. Associated clavicle fracture.
3, 4, 5 3. The infant will have an absent Moro refl ex on one side and no sensory loss. 4. The infant will have an absent Moro refl ex on one side and no sensory loss. 5. The injury may be associated with a fractured clavicle.
A 15-year-old with spina bifi da is seen in the clinic for a well-child checkup. The teen uses leg braces and crutches to ambulate. Which nursing diagnosis takes priority? 1. Potential for infection. 2. Alteration in mobility. 3. Alteration in elimination. 4. Potential body image disturbance.
2 This is a nursing diagnosis that affects many aspects of the teen ' s life. Mobility is important in all aspects of their lives. Braces and crutches enable him to more fully participate in activities and maintain some degree of independence.
Which should the nurse tell the parent of an infant with spina bifi da? 1. "Bone growth will be more than that of babies who are not sick because your baby will be less active." 2. "Physical and occupational therapy will be helpful to stimulate the senses and improve cognitive skills." 3. "Nutritional needs for your infant will be calculated based on activity level." 4. "Fine motor skills will be delayed because of the disability."
2 Children with decreased activity due to illness or trauma are helped by physical and occupational therapy. The varied activities stimulate the senses.
The nurse is developing a plan of care for a child recently diagnosed with cerebral palsy (CP). Which should be the nurse ' s priority goal? 1. Ensure the ingestion of suffi cient calories for growth. 2. Decrease intracranial pressure. 3. Teach appropriate parenting strategies for a special-needs child. 4. Ensure that the child reaches full potential.
3 Teaching appropriate parenting strategies for a special-needs child is important and is done so that the child can maximize her personal skills and minimize her limitation.
The parent of a young child with CP brings the child to the clinic for a checkup. Which parent ' s statement indicates an understanding of the child ' s long-term needs? 1. "My child will need all my attention for the next 10 years." 2. "Once in school, my child will catch up and be like the other children." 3. "My child will grow up and need to learn to do things independently." 4. "I ' m the one who knows the most about my child and can do the most for my child."
3 The parent of a child with a disability should have the goal of assisting the child in achieving as much self-care as he is capable of, given his particular limitations.
A child has a provisional diagnosis of myasthenia gravis. Which should the nurse expect in this child? Select all that apply. 1. Double vision, ptosis. 2. Tremors and seizures. 3. Coughing and choking. 4. Ascending paralysis. 5. Sensory disturbance.
1, 3 1. Symptoms in a child with myasthenia gravis include fatigue, double vision, ptosis, and difficulty swallowing and chewing. This is an autoimmune disease triggered by a viral or bacterial infection. Antibodies attack acetylcholine receptors and block their functioning 3. Symptoms in a child with myasthenia gravis include fatigue and diffi culty swallowing and chewing
Which priority item should be placed at the bedside of a newborn with myelomeningocele? Select all that apply. 1. A bottle of normal saline. 2. A rectal thermometer. 3. Extra blankets. 4. A blood pressure cuff. 5. Latex-free gloves.
1, 5. 1. Before the surgical closure of the sac, the infant is at risk for infection. A sterile dressing is placed over the sac to keep it moist and help prevent it from tearing. Because the dressings dry out at least every hour, it is important to assess them frequently and apply saline as needed. Good hand washing is also important 5. Latex-free clean gloves would be used for all care of this infant. A box should be kept at the infant ' s bedside. Children with spina bifi da are at risk for latex allergy and should not be exposed to latex.
Over the past week, an infant with a repaired myelomeningocele has had a highpitched cry and been irritable. Length, weight, and head circumference have been at the 50th percentile. Today, length is at the 50th percentile, weight is at the 70th percentile, and head circumference is at the 90th percentile. The nurse should do which of the following? 1. Tell the parent this is normal for an infant with a repaired myelomeningocele. 2. Tell the parent this might mean the baby has increased intracranial pressure. 3. Suspect the baby ' s intracranial pressure is low because of a leak. 4. Refer the baby to the neurologist for follow-up care.
2 The increase in head size is one of the fi rst signs of increased intracranial pressure; other signs include highpitched cry and irritability.
Causes of autonomic dysrefl exia include which of the following? Select all that apply. 1. Decrease in blood pressure. 2. Abdominal distention. 3. Bladder distention. 4. Diarrhea. 5. Tight clothing. 6. Hyperthermia.
2, 3, 5 2. Autonomic dysrefl exia may be caused by abdominal pressure from a fecal impaction. 3. An distended bladder is usually the precipitating factor causing an increase in abdominal pressure. 5. Tight clothing can increase pressure to the central core of the body.
The nurse should tell the parents of a child with Duchenne (pseudohypertrophic) muscular dystrophy that some of the progressive complications include: Select all that apply. 1. Dry skin and hair, hirsutism, protruding tongue, and mental retardation. 2. Anorexia, gingival hyperplasia, dry skin and hair. 3. Contractures, obesity, and pulmonary infections. 4. Trembling, frequent loss of consciousness, and slurred speech. 5. Increasing diffi culty swallowing and shallow breathing.
3, 5 3. The major complications of muscular dystrophy include contractures, disuse atrophy, infections, obesity, respiratory complications, and cardiopulmonary problems. 5. The muscles of a child with MD tend to show increasing weakness and atrophy over time. The children are at risk for swallowing, aspiration, and pneumonia.
The nurse knows that teaching has been successful when the parent of a child with muscle weakness states that the diagnostic test for muscular dystrophy is which of the following? 1. Electromyelogram. 2. Nerve conduction velocity. 3. Muscle biopsy. 4. Creatine kinase level.
3. Muscle biopsy confi rms the type of myopathy that the patient has.
A child with GBS has had lots of oral fl uids but has not urinated for 8 hours. Which is the nurse ' s fi rst action? 1. Check the child ' s serum blood urea nitrogen level. 2. Check the child ' s complete blood count. 3. Catheterize the child in and out. 4. Run water in the bathroom to stimulate urination.
3. The child must be in-and-out catheterized to avoid the possibility of developing a urinary tract infection from urine left in the bladder for too long.
Which foods would be best for a child with Duchenne muscular dystrophy? Select all that apply. 1. High-carbohydrate, high-protein foods. 2. No special food combinations. 3. Extra protein to help strengthen muscles. 4. Low-calorie foods to prevent weight gain. 5. Thickened liquids and smaller portions that are cut up.
4, 5 4. As the child becomes less ambulatory, moving the child will become more of a problem. It is not good for the child to become overweight for several health reasons in addition to decreased ambulation. 5. As the child loses muscle control, the need for thickened liquids and small, well-cut-up solids becomes essential.
An adolescent presents with sudden-onset unilateral facial weakness with drooping of one side of the mouth. The teen is unable to close the eye on the affected side, but has no other symptoms and otherwise feels well. The nurse could summarize the condition by which of the following? 1. The prognosis is poor. 2. This may be a CVA. 3. It is a fi fth CN palsy. 4. This is paralysis of the facial nerve.
4. This client has Bell ' s palsy, which is an idiopathic mononeuritis of CN VII (the facial nerve) that innervates the face and muscles of expression.
Which gross motor skills should the nurse assess in a 3-month-old with spina bifi da? 1. Head control. 2. Pincer grasp. 3. Sitting alone. 4. Rolling over.
1 A 3-month-old should have good head control.
A school-age child is admitted to the unit preoperatively for bladder reconstruction. The child is latex-sensitive. Which intervention should the nurse implement? 1. Post a sign on the door and note in the chart that the child is latex-allergic. 2. Use powder-free latex gloves when giving care. 3. Keep personal items such as stuffed animals in a plastic bag to avoid latex contamination. 4. Use a disposable plastic-covered blood pressure cuff that will stay in the child ' s room.
1 Posting a sign on the door and charting that the child has a latex allergy is important so that others will be aware of the allergy.
The nurse is planning care for a child with a T12 spinal cord injury. Which lifelong complication should the child and family know about? Select all that apply. 1. Skin integrity. 2. Incontinence. 3. Loss of large and small motor activity. 4. Loss of voice. 5. Spasticity.
1, 2, 3, 5 1. Spinal cord-injury clients experience many issues because of the loss of innervation below the level of the injury. Skin integrity and incontinence are issues because of immobility and loss of pain receptors below the level of the injury. 2. Skin integrity and incontinence are issues because of immobility and loss of pain receptors below the level of the injury. 3. Loss of motor activity is also a result of loss of innervation below the level of the injury 5. With incomplete severing of the spinal cord, fl accid spasticity occurs initially as a result of the injury and shock, but oftentimes converts to muscle spasticity during the rehabilitation stage.
Which would the nurse expect a child with spastic CP to demonstrate? Select all that apply. 1. Increased deep tendon refl exes. 2. Decreased muscle tone. 3. Scoliosis. 4. Contractures. 5. Scissoring. 6. Good control of posture. 7. Good fi ne motor skills.
1, 3, 4, 5 1. Children with spastic CP have increased deep tendon refl exes. 3. Children with spastic CP have scoliosis. 4. When children with spastic CP have quadriplegia, they can also develop contractures of the Achilles tendons, knees, and adductor muscles. 5. Children with spastic CP have scissoring when walking
Which should the nurse include when teaching sexuality education to an adolescent with a spinal cord injury? Select all that apply. 1. "You can enjoy a healthy sex life and most likely conceive children." 2. "You will never be able to conceive if you have no genital sensation." 3. "Development of secondary sex characteristics is delayed." 4. "A few females have regular menstrual periods after injury." 5. "You can get the same sexually transmitted infections that those without spinal cord injuries get."
1, 4, 5 1. The reproductive system continues to function properly after a spinal cord injury. Much sexual activity and response occurs in the brain as well. 4. Females may have irregular periods after the injury, but most return to their normal cycles. 5. Those with spinal cord injuries can acquire sexually transmitted infections and need to use safe sex practices.
Which symptoms will a child suffering from complete spinal cord injury experience? Select all that apply. 1. Loss of motor and sensory function below the level of the injury. 2. Loss of interest in normal activities. 3. Extreme pain below the level of the injury. 4. Loss of some function, with sparing of function below the level of the injury. 5. Loss of bowel and bladder control.
1, 5 1. Children with complete spinal cord injury lose motor and sensory function below the level of the injury as a result of interruption of nerve pathways. 5. The nerves to the perineal are affected when injuries occur to the lumbar region. The child develops a neurogenic bladder and bowel
The parents of a preschooler diagnosed with muscular dystrophy are asking questions about the course of their child ' s disease. Which should the nurse tell them? Select all that apply. 1. "Muscular dystrophies usually result in progressive weakness." 2. "The weakness that your child is having will probably not increase." 3. "Your child will be able to function normally and not need any special accommodations." 4. "The extent of weakness depends on doing daily physical therapy." 5. "Your child may have pain in his legs with muscle weakness."
1, 5 1. Muscular dystrophies are progressive degenerative disorders. The most common is Duchenne muscular dystrophy, which is an X-linked recessive disorder. 5. The child may have pain due to loss of strength and muscle wasting.
Which should the nurse do for a 7-year-old living in a rural area who is missing school shots and who has sustained a puncture wound? 1. Administer TdaP vaccine. 2. Start the child on an antibiotic. 3. Clean the wound with hydrogen peroxide. 4. Send the child to the emergency department.
1. A 7-year-old child who is not fully immunized and has a tetanus-prone wound should receive TdaP vaccine to prevent tetanus. Tetanus-prone wounds include puncture wounds and those contaminated with dirt, feces, or soil.
The mother of a newborn relates that this is her fi rst child; the baby seems to sleep a lot and does not cry much. Which question would the nurse ask the mother? 1. "How many ounces of formula does your baby take at each feeding?" 2. "How many bowel movements does your baby have in a day?" 3. "How much sleep do you get every night?" 4. "How long does the baby stay awake at each feeding?"
1. Babies can lose up to 10% of birth weight but should regain it by 2 weeks of age. Knowing how much the baby eats can help the nurse determine whether the infant is receiving adequate nutrition.
When assessing the neurological status of an 8-month-old, the nurse should check for which of the following? Select all that apply. 1. Clarity of speech. 2. Interaction with staff. 3. Vision test. 4. Romberg test. 5. Ability to roll over and sit independently.
2, 5 2. Assessment for alteration in developmentally expected behaviors, such as stranger anxiety, is helpful. Interaction with staff is not to be expected due to stranger anxiety. 5. Sitting and rolling over are two skills that an 8-month-old infant should be able to accomplish.
Which should be the priority nursing diagnosis for a 12-hour-old newborn with a myelomeningocele at L2? 1. Altered bowel elimination related to neurological defi cits. 2. Potential for infection related to the physical defect. 3. Altered nutrition related to neurological defi cit. 4. Disturbance in self-concept related to physical disability.
2. Because this infant has not had a repair, the sac is exposed. It could rupture, allowing organisms to enter the CSF, so this is the priority.
An adolescent with a T4 spinal cord injury suddenly becomes dangerously hypertensive and bradycardic. Which intervention is appropriate? 1. Call the neurosurgeon immediately, as this sounds like sudden intracranial hypertension. 2. Check to be certain that the client ' s bladder is not distended. 3. Administer diazoxide (Hyperstat) to treat the blood pressure. 4. Administer atropine for bradycardia.
2. The fi rst assessment is of the bladder and bowel to check for fullness. The presence of either could trigger autonomic dysrefl exia.
The parent of a child diagnosed with Werdnig-Hoffmann disease notes times of not being able to hear the child breathing. Which should the nurse do fi rst? 1. Check pulse oximetry on the child. 2. Count the child ' s respirations. 3. Listen to the child ' s lung sounds. 4. Ask the parent if the child coughs at night.
2. The fi rst intervention is to check the respiratory rate of the child to see if it is abnormal, then listen to the lung sounds, and then check pulse oximetry.
After spinal cord surgery, an adolescent suddenly complains of a severe headache. Which should be the nurse ' s fi rst action? 1. Check the blood pressure. 2. Check for a full bladder. 3. Ask if pain is present somewhere else. 4. Ask if other symptoms are present.
2. The sympathetic nervous system responds to a full bladder or bowel resulting from an uncontrolled, paroxysmal, continuous lower motor neuron refl ex arc. This response is usually from stimulation of sensory receptors (e.g., distended bladder or bowel). Because the efferent pulse cannot pass through the spinal cord, the vagus nerve is not "turned off," and profound symptomatic bradycardia may occur.
The nurse evaluates the teaching as successful when a parent states that which of the following can cause autonomic dysrefl exia? 1. Exposure to cold temperatures. 2. Distended bowel or bladder. 3. Bradycardia. 4. Headache.
2. Autonomic dysrefl exia results from an uncontrolled, paroxysmal, continuous lower motor neuron refl ex arc due to stimulation of the sympathetic nervous system. It is a response that typically results from stimulation of sensory receptors such as a full bladder or bowel
Which should the nurse expect as an intervention in a child in the recovery phase of GBS? Select all that apply. 1. Assist with self-feeding skills. 2. Assist with grooming and dressing. 3. Arrange for in-home schooling. 4. Begin an active physical therapy program. 5. Begin active PT.
3, 5 3. Working with the child ' s teacher and the school staff to keep the child at the same pace as his classmates is crucial for the healthy recovery of the child. 5. Beginning active physical therapy is important for helping muscle recovery and preventing contractures.
A newborn with a repaired myelomeningocele is assessed for hydrocephalus. Which would the nurse expect in an infant with hydrocephalus? 1. Low-pitched cry and depressed fontanel. 2. Low-pitched cry and bulging fontanel. 3. Bulging fontanel and downwardly rotated eyes. 4. Depressed fontanel and upwardly rotated eyes.
3. An alteration in the circulation of the cerebrospinal fl uid causes hydrocephalus. The anterior fontanel bulges because of an increase in cerebrospinal fl uid, and an increase in intracranial pressure causes a high-pitched cry in infants and downward deviation of the eyes, also called sunset eyes. With sunset eyes, the sclera can be seen above the iris.
A child with spastic CP had an intrathecal dose of baclofen (Lioresal) in the early afternoon. What is the expected result 3. hours post-dose that suggests the child would benefi t from a baclofen pump? 1. The ability to self-feed. 2. The ability to walk with little assistance. 3. Decreased spasticity. 4. Increased spasticity.
3. If baclofen (Lioresal) were to work for this child, one could tell because spasticity would be decreased
The parent of an infant with CP asks the nurse if the infant will be mentally retarded. Which is the nurse ' s best response? 1. "Children with CP have some amount of mental retardation." 2. "Approximately 20% of children with CP have normal intelligence." 3. "Many children with CP have normal intelligence." 4. "Mental retardation is expected if motor and sensory defi cits are severe."
3. Many children with CP have normal intelligence.
Which can elicit the Gower sign? Have the child: 1. Close the eyes and touch the nose with alternating index fi ngers. 2. Hop on one foot and then the other. 3. Bend from the waist to touch the toes. 4. Walk like a duck and rise from a squatting position.
4. Children with muscular dystrophy display the Gower sign, which is great diffi culty rising and standing from a squatting position because of the lack of muscle strength.
The nurse is caring for a school-age child with Duchenne muscular dystrophy in the elementary school. Which would be an appropriate nursing diagnosis? 1. Anticipatory grieving. 2. Anxiety reduction. 3. Increased pain. 4. Activity intolerance.
4. The child would not be able to keep up with peers because of weakness, progressive loss of muscle fi bers, and loss of muscle strength
Which developmental milestone should the nurse be concerned about if a 10-month-old cannot do it? 1. Crawl. 2. Cruise. 3. Walk. 4. Have a pincer grasp.
1 Most infants are able to crawl unassisted by 8 months.
The mother of a child with Duchenne muscular dystrophy asks the nurse who in the family should have genetic screening. Who should the nurse say must be tested? Select all that apply. 1. Mother. 2. Sister. 3. Brother. 4. Aunts and all female cousins. 5. Uncles and all male cousins.
1, 2, 4 1. Genetic counseling is important in all inherited diseases. Duchenne muscular dystrophy is inherited as an X-linked recessive trait, meaning the defect is on the X chromosome. Women carry the disease, and males are affected. All female relatives should be tested. 2. The X chromosome carries the disease, and males are affected. The sister should have genetic testing to determine whether she carries the gene and identify her risks for having male offspring with the disease. 4. The X chromosome carries the disease and males are affected. All female relatives should be tested
Which will help a school-age child with muscular dystrophy stay active longer? Select all that apply. 1. Normal activities, such as swimming. 2. Using a treadmill every day. 3. Several periods of rest every day. 4. Using a wheelchair upon getting tired. 5. Sleeping as late as needed.
1, 3, 4 1. Swimming is an excellent exercise that uses many muscles and helps build strength. Children who are active are usually able to postpone use of a wheelchair. It is important to keep using muscles for as long as possible, and aerobic activity is good for a child. 3. Any child with a chronic disease should be kept as active as possible for as long as possible; short rest periods built into the day are helpful in maintaining stamina. 4. Children with neuromuscular diseases oftentimes will use a wheelchair to conserve energy and increase mobility. The wheelchair acts as the child ' s means of getting to where they want to go as independently as possible.
A 5-year-old has been diagnosed with pseudohypertrophic muscular dystrophy. Which nursing intervention(s) would be appropriate? Select all that apply. 1. Discuss with the parents the potential need for respiratory support. 2. Explain that this disease is easily treated with medication. 3. Suggest exercises that will limit the use of muscles and prevent fatigue. 4. Assist the parents in fi nding a nursing facility for future care. 5. Encourage the parents to contact the school to develop an IEP.
1, 3, 5 1. Muscles become weaker, including those needed for respiration, and a decision will need to be made about whether respiratory support will be provided. 3. Physical therapy will be part of the treatment plan, but respiratory support is a priority. 5. Parents should be encouraged to allow the child to go to school and participate in activities as tolerated.
Which is the best advice to offer the parent of a 6-month-old with Werdnig- Hoffman disease on how to treat the infant ' s constipation? 1. Offer extra water every day. 2. Add corn syrup to two bottles a day. 3. Give the infant a glycerine suppository today. 4. Let the infant go 3 days without a stool before intervening.
1. Constipation means hard stools and infrequent passage. Adding extra water to the diet helps make the stool softer in a child of this age.
Which intervention should be included in the plan of care for a newborn with a newly repaired myelomeningocele? 1. Offer formula/breast milk every 3 hours. 2. Turn the infant back to front every 2 hours. 3. Place a wet dressing on the sac. 4. Provide pain medication every 4 hours.
1. Following surgery, a newborn may want formula/breast milk every 2 to 4 hours. Be sure to monitor intake and output.
Why does spinal cord injury without radiographic abnormality sometimes occur in children? 1. Children can suffer momentary severe subluxation and trauma to the spinal cord. 2. The immature spinal column in children does not allow for quality fi lms. 3. The hemorrhaging that occurs with injury obscures radiographic abnormalities. 4. Radiographic abnormalities are not evident because of incomplete ossifi cation of the vertebrae.
1. Spinal cord injury without radiographic abnormality results from the spinal cord sliding between the vertebrae and then sliding back into place without injury to the bony spine. It is thought to be the result of an immature spinal column that allows for reduction after momentary subluxation.
A child with a repaired myelomeningocele is in the clinic for a regular examination. The child has frequent constipation and has been crying at night because of pain in the legs. After an MRI, the diagnosis of a tethered cord is made. Which should the nurse tell the parent? 1. Tethered cord is a postsurgical complication. 2. Tethered cord occurs during times of slow growth. 3. Release of the tethered cord will be necessary only once. 4. Offering laxatives and acetaminophen (Tylenol) daily will help control these problems.
1. Tethered cord is caused by scar tissue formation from the surgical repair of the myelomeningocele and may affect bowel, bladder, or lower extremity functioning. As the child grows, this will affect continence and mobility.
Parents bring their 2-month-old into the clinic with concerns that the baby seems "fl oppy." The parents say the baby seems to be working hard to breathe, eats very slowly, and seems to fatigue quickly. The nurse assesses intercostal retractions, although the baby is otherwise in no distress. The parents add there was a cousin whose baby had similar symptoms. The nurse would be most concerned with which possible complication? 1. Respiratory compromise. 2. Dehydration. 3. Need for emotional support for the family. 4. Feeding intolerance.
1. This baby may have Werdnig-Hoffman disease, which is characterized by progressive generalized muscle weakness that eventually leads to respiratory failure. Respiratory compromise is the most important complication.
The nurse is doing a follow-up assessment of a 9-month-old. The infant rolls both ways, sits with some support, pushes food out of the mouth, and pushes away when held. The parent asks about the infant ' s development. The nurse responds by saying which of the following? 1. "Your child is developing normally." 2. "Your child needs to see the primary care provider." 3. "You need to help your child learn to sit unassisted." 4. "Push the food back when your child pushes food out."
2 A 9-month-old should be able to sit alone, crawl, pull up, not push food out of the mouth (tongue thrust), and push away when held when wanting to get down. The developmental screening the child received should be followed by a complete history, physical exam, and more specifi c developmental testing.
The parent of a toddler newly diagnosed with CP asks the nurse what caused it. The nurse should answer with which of the following? 1. Most cases are caused by unknown prenatal factors. 2. It is commonly caused by perinatal factors. 3. The exact cause is not known. 4. The exact cause is known in every instance.
2 It is generally thought that the majority of infants with CP had an insult in utero. Some of the causes of perinatal insult include hypoxia, trauma, infections, or genetic abnormalities.
A 3-year-old child with CP is admitted for dehydration following an episode of diarrhea. The nurse ' s assessment follows: awake; pale, thin child lying in bed; multiple contractures; drooling; coughing spells noted when parent feeds. T 97.8ÅãF (36.5ÅãC), P 75, R 25, weight 7.2 kg, no diarrheal stool for 48 hours. Which nursing diagnosis is most important? 1. Potential for skin breakdown: lying in one position. 2. Alteration in nutrition: less than body requirements. 3. Potential for impaired social support: parent sole caretaker. 4. Alteration in elimination: diarrhea.
2 This child is severely underweight and malnourished for a 3-year-old. The coughing episodes while feeding put the child at risk for aspiration and pneumonia. A thorough history, physical examination, and a feeding study should be performed to determine whether it is even safe to feed the child orally. This is the priority nursing diagnosis for this severely underweight child. Weight is average for a 4-month-old. The coughing episodes while feeding may indicate aspiration. The parent needs help to learn how to feed so that less coughing occurs.
The nurse is performing an admission assessment on a 9-year-old who has just been diagnosed with systemic lupus erythematosus. Which assessment fi ndings should the nurse expect? Select all that apply. 1. Headaches and nausea. 2. Fever, malaise, and weight loss. 3. A papular rash covering the trunk and face. 4. Abdominal pain and dysuria. 5. Joint pain, proteinuria, and lymphadenopathy.
2, 5 2. Fever, malaise, and weight loss are common presenting signs. 5. Joint pain, proteinuria, and lymphadenopathy are common presenting symptoms in children.
The parents of a toddler diagnosed with Werdnig-Hoffmann disease ask the nurse what they can feed their child that would be quality food. Which would be good choices for the nurse to recommend? 1. A hot dog and chips. 2. Chicken and broccoli. 3. A banana and almonds. 4. A milkshake and a hamburger.
2. Chicken is a good source of protein, and broccoli is a good choice for naturally occurring vitamins. The parent may have to chop the food up for the infant to safely eat.
The nurse knows that teaching was successful when a parent states which of the following are early signs of muscular dystrophy? 1. Increased muscle strength. 2. Difficulty climbing stairs. 3. High fevers and tiredness. 4. Respiratory infections and obesity.
2. Difficulty climbing stairs, running, and riding a bicycle are frequently the fi rst symptoms of Duchenne muscular dystrophy.
Which should the nurse do fi rst when caring for an infant who just had a repair of a myelomeningocele? 1. Weigh diapers for 24-hour urine output. 2. Measure head circumference. 3. Offer clear fl uids. 4. Assess for infection.
2. Hydrocephalus occurs in about 90% of infants with myelomeningocele, so measuring the head circumference daily and watching for an increase are important. Accumulation of cerebrospinal fl uid can occur after closure of the sac.
The nurse judges teaching as successful when the parent of a child with myasthenia gravis states which of the following? Select all that apply. 1. "My child should play on the school ' s basketball team." 2. "My child should meditate every day." 3. "My child should be allowed to do what other kids do." 4. "My child should be watched carefully for signs of illness." 5. "My child should sleep in my room so that I can watch him better."
3, 4 3. Children with myasthenia gravis can do many things other children do. They should be advised not to play strenuous sports, and they should learn how to control stress. 4. Children are watched for signs of illness because of the exacerbation of signs of myasthenia gravis.
Which should a nurse in the ED be prepared for in a child with a possible spinal cord injury? Select all that apply. 1. Severe pain. 2. Elevated temperature. 3. Respiratory depression. 4. Increased intracranial pressure. 5. Multiple sites of injury.
3, 5 3. A spinal cord injury can occur at any level. The higher the level of the injury, the more likely the child is to have respiratory insuffi ciency or failure. The nurse should be prepared to support the child ' s respiratory system 5. The nurse should expect that the child may have multiple injury sites as many spinal cord injuries are the result of trauma from falls from heights, violence, or sporting injuries. A complete headto- toe assessment of the child should be performed.
The nurse is planning care for a child who was recently admitted with GBS. Which is a priority nursing diagnosis? 1. Risk for constipation related to immobility. 2. Chronic sorrow related to presence of chronic disability. 3. Impaired skin integrity related to infectious disease process. 4. Activity intolerance related to ineffective cardiac muscle function.
3. The goal is to prevent complications related to immobility. Efforts include maintaining skin integrity, maintaining respiratory function, and preventing contractures.
The nurse is caring for an infant with myelomeningocele who is going to surgery later today for closure of the sac. Which would be a priority nursing diagnosis before surgery? 1. Alteration in parent-infant bonding. 2. Altered growth and development. 3. Risk of infection. 4. Risk for weight loss.
3. The unrepaired myelomeningocele is oftentimes a thin membrane that covers the neural contents of the spine. A normal saline dressing is placed over the sac to prevent tearing. The tearing would allow the CSF to escape and microorganisms to enter. The infant is at high risk for spinal cord infections. The priority nursing diagnosis is risk of infection.
A child presents with a history of having had an upper respiratory tract infection 2 weeks ago; complains of symmetrical lower extremity weakness, back pain, muscle tenderness; and has absent deep tendon refl exes in the lower extremities. Which is important regarding this condition? 1. The disease process is probably bacterial. 2. The recent upper respiratory infection is not important information. 3. This may be an acute infl ammatory demyelinating neuropathy. 4. CN involvement is rare.
3. This child probably has GBS, which is an acute infl ammatory demyelinating neuropathy.
The mother of an infant diagnosed with Werdnig-Hoffmann disease asks the nurse what she could have done during her pregnancy to prevent this. The nurse explains that the cause of Werdnig-Hoffmann is which of the following? 1. Unknown. 2. Restricted movement in utero. 3. Inherited as an autosomal-recessive trait. 4. Inherited as an autosomal-dominant trait.
3. Werdnig-Hoffmann disease is inherited as an autosomal-recessive trait. There is an affected gene from both mother and father passed to the baby.
Which should the nurse prepare the parents of an infant for following surgical repair and closure of a myelomeningocele shortly after birth? The infant will: 1. Not need any long-term management and should be considered cured. 2. Not be at risk for urinary tract infections or movement problems. 3. Have continual drainage of cerebrospinal fl uid, needing frequent dressing changes. 4. Need lifelong management of urinary, orthopedic, and neurological problems.
4 Although immediate surgical repair decreases infection, morbidity, and mortality rates, these children will require lifelong management of neurological, orthopedic, and elimination problems.
The parent of an infant asks the nurse what to watch for to determine whether the infant has CP. Which is the nurse ' s best response? 1. "If the infant cannot sit up without support before 8 months." 2. "If the infant demonstrates tongue thrust before 4 months." 3. "If the infant has poor head control after 2 months." 4. "If the infant has clenched fi sts after 3 months."
4 Clenched fi sts after 3 months of age may be a sign of upper motor injury and CP.
The nurse evaluates teaching of parents of a child newly diagnosed with CP as successful when the parents state that CP is which of the following? 1. Inability to speak and uncontrolled drooling. 2. Involuntary movements of lower extremities only. 3. Involuntary movements of upper extremities only. 4. An increase in muscle tone and deep tendon refl exes.
4 The primary disorder is of muscle tone, but there may be other neurological disorders such as seizures, vision disturbances, and impaired intelligence. Spastic CP is the most common type and is characterized by a generalized increase in muscle tone, increased deep tendon refl exes, and rigidity of the limbs on both fl exion and extension.
