N6 Week 3 Sherpath

Loss of weight and male sex are additional characteristics of type __ diabetes mellitus.

1

Which are the cardinal signs of diabetes insipidus? (DI) a. Vascular anomalies b. Polyuria and polydipsia c. Hypotension and dehydration d. Dehydration and diminished urine output

b. Polyuria and polydipsia

Lumbar puncture (LP) is contraindicated in patients with...

Increased ICP

What does methylprednisone do?

It helps minimize inflammation and reduces risk of further complications in spinal cord injuries.

Which would be the most serious neural tube defect, consisting of congenital malformation in which both cerebral hemispheres are absent? a. Anencephaly b. Myelodysplasia c. Spina bifida occulta d. Spina bifida cystica

a. Anencephaly

A father brings his 5-year-old son to the clinic because he has recently lost a lot of weight. He reports to the nurse that the boy is always hungry, thirsty, and complaining that he has to use the bathroom. Which disorder is best described by these symptoms? a. Diabetes Mellitus b. Addison Disease c. Cushing Syndrome d. Pheochromocytoma

a. Diabetes Mellitus Rationale: polyuria, polydipsia, and polyphagia are three common presenting symptoms of diabetes mellitus

A nurse is caring for an adolescent who has sustained a spinal cord injury. Which complication may occur as a result of a disruption in the descending sympathetic pathways with loss of vasomotor tone and sympathetic innervation of the cardiovascular system? a. Neurogenic shock b. Autonomic dysreflexia c. Spinal shock syndrome d. Spinal cord compression

a. Neurogenic shock Rationale: Neurogenic shock may occur after a spinal cord injury as a result of disruption of the descending sympathetic pathways with loss of vasomotor tone and sympathetic innervation of the cardiovascular system. Autonomic dysreflexia or hyperreflexia replaces the paralytic nature of autonomic function when the lesion lies about the midthoracic level. Spinal shock syndrome is caused by a sudden disruption of central and autonomic pathways. Spinal cord compression is a form of cord trauma that results in a temporary neural dysfunction without visible damage to the cord.

The nurse is performing a neurologic assessment of a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse would recognize these reflexes are suggestive of which finding? a. Neurologic health b. Head trauma c. Severe brain damage d. Increased intracranial pressure (ICP)

a. Neurologic health

The nurse is performing a neurologic assessment of a child whose level of consciousness has been variable since she sustained a cervical neck injury 12 hours ago. Which would be the appropriate assessment for this child? a. Reactivity of pupils b. Doll's head maneuver c. Oculovestibular response d. Funduscopic examination to identify papilledema

a. Reactivity of pupils Rationale: The doll's head maneuver should not be performed if there is a cervical spine injury. Assessment for n oculovestibular response is a painful test that should not be done in a child who is displaying a variable level of consciousness. Papilledema does not develop for 24 to 48 hours in the course of unconsciousness.

A young child is having a seizure that has lasted for 35 minutes and includes a loss of consciousness. The nurse, drawing on knowledge of seizures, recognizes this as which disorder? a. Status epilepticus b. An absence seizure c. A generalized seizure d. A simple partial seizure

a. Status epilepticus Rationale: Status epilepticus is a generalized seizure that lasts for longer than 30 minutes. This is considered a medical emergency and requires immediate treatment.

Which acquired neuromuscular disorder is characterized by muscular rigidity primarily involving the masseter and neck muscles? a. Tetanus b. Botulism c. Gullain-Barre Syndrome d. Duchenne (muscular dystrophy)

a. Tetanus

After assessing a teenager who has had a spinal injury, the nurse identifies gray matter destruction in which the patient has tetraplegia or loss of functional use of the limbs. Which condition would the nurse deduce from this finding? a. The teenager has central cord syndrome. b. The teenager has a spinal cord concussion. c. The teenager has posterior cord syndrome. d. The teenager has Brown-Sequard syndrome.

a. The teenager has central cord syndrome

Which physiologic alteration is characterized by destruction of pancreatic beta cells that produce insulin? a. Type 1 diabetes b. Type 2 diabetes c. Gestational diabetes d. Impaired glucose tolerance

a. Type 1 diabetes

The imbalance of which hormone causes symptoms of polydipsoa, polyuria, overeating, weight loss, fatigue, and irritability? a. insulin b. thyroid hormone c. parathyroid hormone d. antidiuretic hormone

a. insulin

The nurse is teaching a group of nursing students about the precautions to be taken while caring for a latex-hypersensitized child. Which statement made by the nurse is appropriate? a. "You should wash your hands frequently before administering any type of medication." b. "Use disposable plastic gloves while caring for patients who have a latex allergy." c. "Practice skin prick testing frequently to assess the status of the patient." d. "Incorporate chestnuts into their diet to reduce the risk of latex reactions."

b. "Use disposable plastic gloves while caring for patients who have a latex allergy." Rationale: Patients with latex allergy are likely to develop hypersensitivity reactions to rubber (latex) gloves, *so use plastic*

A young child is having a seizure that is characterized by brief loss of consciousness, blank staring, and fluttering of the eyelids. The nurse, drawing on knowledge of seizures, recognizes this as which disorder? a. Status epilepticus b. An absence seizure c. A generalized seizure d. A simple partial seizure

b. An absense seizure

A child with Spina Bifida has developed a latex allergy as a result of numerous bladder catheterizations and surgeries. Which would be the priority nursing intervention? a. Recommend allergy testing b. Provide a latex-free environment c. Use only powder-free latex gloves d. Limit the use of latex products as much as possible

b. Provide a latex-free environment

The parents of a child who is on growth hormone replacement therapy are not satisfied with the outcome of the treatment because the child's height is not increasing. The child is still shorter than school peers. Which would be the most appropriate action of the nurse? a. Increase the dose of growth hormone given to the child b. Reassure the parents and set realistic expectations. c. Change the route of administration of the growth hormone d. Advise the parents to feed the child a high-protein diet

b. Reassure the parents and set realistic expectations.

A patient who has sustained a head injury exhibits rhinorrhea. Which immediate nursing intervention is appropriate for this patient? a. Reassure the patient because it is an insignificant finding b. Test the discharge for presence of glucose c. Sedate the patient and administer antihistamine d. Ask the patient to report immediately if the nose bleeds

b. Test the discharge for presence of glucose Rationale: Presence of glucose suggests that there is CSF leakage from skull fracture

After assessing a teenager who has had a spinal cord injury, the nurse identifies a loss of neural function below the acute spinal cord lesion and flaccid paralysis. Which condition would the nurse deduce from this finding? a. The teenager has central cord syndrome. b. The teenager has a spinal cord concussion. c. The teenager has posterior cord syndrome. d. The teenager has Brown-Sequard syndrome.

b. The teenager has spinal cord concussion Rationale: Loss of neural function below an acute spinal cord lesion and flaccid paralysis indicate that the patient has a spinal cord concussion.

Which would the nurse recognize about a toddler's hemoglobin A1c value of 9.0%? a. Too low b. Too high c. A high risk for hypoglycemia d. Within the recommended range

b. Too high Rationale: The goal value set bu the American Diabetes Association for hemoglobin A1c in a toddler is 8.5% or less but no lower than 7.5%

Which physiologic alteration is characterized by insulin resistance? a. Type 1 diabetes b. Type 2 diabetes c. Gestational diabetes d. Impaired glucose tolerance

b. Type 2 diabetes

Which does the nurse recognize as the primary clinical manifestations of diabetes insipidus? a. Nausea and vomiting b. Polyuria and polydipsia c. Oliguria and facial edema d. Glycosuria and ketonuria

b. polyuria and polydipsia

The imbalance of which hormone causes symptoms of warm, moist skin; protruding eyeballs; difficulty breathing; and heat intolerance? a. insulin b. thyroid hormone c. parathyroid hormone d. antidiuretic hormone

b. thyroid hormone

The parents of a child with cerebral palsy ask the nurse about advantages of ankle-foot orthoses (AFOs). Which would be the most appropriate response by the nurse? a. "AFOs have custom seats for dependent mobilization." b. "AFOs are useful for independent mobility." c. "AFO are used to increase energy efficiency of gait." d. "AFOs provide sitting balance."

c. "AFO are used to increase energy efficiency of gait." Rationale: AFOs (or braces) are used to prevent deformity, increase the energy efficiency of gait, and control alignment. AFOs do not have custom seats for dependent mobilization. They are supportive devices for the ankle or a part of the foot.

Which type of seizure is the most common form of seizures, which includes tonic-clonic (Grand mal) seizures and absence (petit mal) seizures? a. Status epilepticus b. An absence seizure c. A generalized seizure d. A simple partial seizure

c. A generalized seizure

An infant presents with hypospadias, micropenis, and no palpable gonads. How would the nurse document these findings? a. Atrophy b. Cushing syndrome c. Ambiguous genitalia d. Adrenal insufficiency

c. Ambiguous genitalia

Which specific dressing would a nurse caring for an infant with a myelomeningocele provide? a. Application of a sterile, dry, nonadherent dressing over the defect b. Application of a clean, moist, nonadherent dressing over the defect c. Application of a sterile, moist, nonadherent dressing over the defect d. Application of a sterile, moist, nonadherent dressing around the defect

c. Application of a sterile, moist, nonadherent dressing over the defect

Which endocrine disorder can result from prolonged steroid therapy? a. Goiter b. Addison disease c. Diabetes mellitus c. Cushing syndrome

c. Cushing syndrome Rationale: Cushing syndrome can occur from prolonged steroid therapy. Goiter, Addison disease, and diabetes mellitus are not associated with prolonged steroid therapy.

Which acquired neuromuscular disorder is characterized by progressive, usually ascending flaccid paralysis? a. Tetanus b. Botulism c. Gullain-Barre Syndrome d. Duchenne (muscular dystrophy)

c. Guillain-Barre Syndrome

Which would be the current treatment option for children with type 1 diabetes? a. Diet only b. Oral agents c. Insulin and diet d. Diet and oral agents

c. Insulin and diet Rationale: Insulin and dietary changes are the current treatment for children with type 1 diabetes. Dietary changes alone are not effective in treating type 1 diabetes. *Oral agents are effective against type 2 diabetes, not type 1.* Diet and oral agents are used to treat type 2 diabetes, not type 1 diabetes.

The nurse is reviewing the computed tomography (CT) scan results of a newborn and finds that the newborn has a hernial protrusion of a saclike cyst filled with spinal fluid. What condition would the nurse suspect in the infant from this finding? a. Rachischisis b. Exencephaly c. Meningocele d. Myelomeningocele

c. Meningocele

Which statement made by the child indicates the need for further education about how to manage newly diagnosed type 1 diabetes mellitus (DM)? a. "I should check my blood glucose levels before meals and at bedtime." b. "It is important to rotate the injection sites to prevent tissue damage." c. "I should check my blood glucose and ketones every 3 hours when I'm sick." d. "I can eat cake and candy as long as I give myself extra insulin to compensate."

d. "I can eat cake and candy as long as I give myself extra insulin to compensate." Rationale: The child should refrain from eating concentrated sweets. Meals can cause the glucose levels in the blood to fluctuate; therefore the patient should check the blood glucose level before meals and at bedtime.

Which type of seizures are characterized by varying sensations and motor behaviors? a. Status epilepticus b. An absence seizure c. A generalized seizure d. A simple partial seizure

d. A simple partial seizure

The imbalance of which hormone causes symptoms of polyuria and polydipsia? a. insulin b. thyroid hormone c. parathyroid hormone d. antidiuretic hormone

d. Antidiuretic hormone

A 17-year-old with type 1 diabetes mellitus tells the school nurse about recently starting to drink alcohol with friends on weekends. Which would be the most appropriate intervention by the nurse? a. Tell the adolescent not to drink alcohol b. Ask the adolescent about the reasonings for drinking alcohol c. Recommend counseling so the adolescent understands the serious consequences of alcohol comsumption d. Teach the adolescent about the effects of alcohol on type 1 diabetes mellitus and how to prevent problems associated with alcohol intake

d. Teach the adolescent about the effects of alcohol on type 1 diabetes mellitus and how to prevent problems associated with alcohol intake

The nurse is caring for a child with impaired motor activity. On further examination, the nurse finds that the child has reduced range of abduction movement in the upper limb, lack of mobility, and forward slope of the shoulders. Which illness is the nurse likely to recognize based on this observation? a. The child is having some symptoms of Duchenne muscular dystrophy. b. The child is having some symptoms of Becker muscular dystrophy. c. The child is having symptoms of Lou Gehrig's muscular dystrophy. d. The child is having symptoms of Landouzy-Dejerine muscular dystrophy.

d. The child is having symptoms of Landouzy-Dejerine muscular dystrophy.

A woman who is 6 weeks pregnant tells the nurse that she is worried that her baby might have spina bifida because of family history. On which known information would the nurse's response be based? a. Prenatal detection is not possible yet b. Ultrasound would be the most optimal way to identify any abnormality c. Chromosomal studies done on amniotic fluid can diagnose the defect prenatally. d. The concentration of a-fetoprotein may indicate the presence of the defect.

d. The concentration of a-fetoprotein may indicate the presence of the defect. Rationale: The optimal time for an ultrasound would be between 16 to 18 weeks of age.

After assessing a teenager, the nurse identifies a unilateral cord lesion in which the patient has loss of motor function on the opposite side of the body. Which condition would the nurse deduce from this finding? a. The teenager has central cord syndrome. b. The teenager has a spinal cord concussion. c. The teenager has posterior cord syndrome. d. The teenager has Brown-Sequard syndrome.

d. The teenager has Brown-Sequard syndrome.

Which condition is characterized by polydipsia, polyuria, overeating, weight loss, and fatigue? a. Goiter b. Hypothyroidism c. Hyperparathyroidism d. Type 1 diabetes mellitus

d. Type 1 diabetes mellitus

Which is the type of neural tube defect that is not visible externally in the lumbosacral area? a. Meningocele b. Myelomeningocele c. Spina bifida cystica d. Spina bifida occulta

d. Spina bifida occulta Rationale: Spina bifida occulta is completely enclosed

A mother calls the clinic to tell the nurse that her young child hit her head when she tripped and fell down three stairs. Which sign of head injury, requiring immediate medical attention, is of greatest concern to the nurse? a. The child refuses to eat b. The child becomes sleepy c. The child becomes confused d. The child has a mild headache

c. The child becomes confused Rationale: Altered mental status is a clinical manifestation that indicates that the damage from the head injury is progressing

Which statement best describes hyperthyroidism? a. The treatment involves replacement of cortisol b. It is caused by excessive production of cortisol c. The major clinical features are exopthalmia and pigment changes d. Diagnosis is suspected with findings of hypotension, hyperkalemia, and polyuria

c. The major clinical features are exopthalmia and pigment changes

After assessing a teenager who has had a spinal cord injury, the nurse identifies that the patient has a loss of sensation and pain but may have slight movements. Which condition would the nurse deduce from this finding? a. The teenager has central cord syndrome. b. The teenager has a spinal cord concussion. c. The teenager has posterior cord syndrome. d. The teenager has Brown-Sequard syndrome.

c. The teenager has posterior cord syndrome

The imbalance of which hormone causes symptoms of confusion, anorexia, muscle pain, and fatigue? a. insulin b. thyroid hormone c. parathyroid hormone d. antidiuretic hormone

c. parathyroid hormone

What would be the major goal of therapy for children with cerebral palsy (CP)? a. Curing the underlying defects causing the disorder b. Reversing degenerative processes that have occurred c. Preventing spread to individuals in close contact with children d. Recognizing the disorder early and promoting optimal development

d. Recognizing the disorder early and promoting optimal development Rationale: Because CP is currently a permanent disorder, the goal of therapy is the promotion of optimal development. CP defects can not be cured and CP is not contagious.

What would be the purpose of a lumbar puncture (LP)?

To analyze cerebrospinal fluid

The nurse is admitting a young child to the hospital with suspicion for bacterial meningitis. Which would be the priority of nursing care? a. Administer antibiotic therapy as soon as it is ordered b. Initiate isolation precautions as soon as the diagnosis is confirmed c. Initiate isolation precautions as soon as the causative agent is identified d. Administer sedatives and analgesics on a preventative schedule to manage pain

a. Administer antibiotic therapy as soon as it is ordered Rationale: Initiation of antibiotic therapy is the priority action. Antibiotics are begun as soon as possible to prevent death and avoid responsibilities. Isolation should be instituted as soon as diagnosis is anticipated, not as soon as the diagnosis is confirmed or the causative agent is identified, and should remain in effect until bacterial or viral origin is determined. Analgesics are administered on an as-needed basis.

Type 1 diabetes mellitus has just been diagnosed in a teenage boy who is actively involved in sports. Which important instruction would the nurse include in the teaching plan? a. Because exercise can lower the blood glucose level, blood glucose needs to be closely monitored b. Because exercise can increase the blood glucose level, blood glucose needs to be closely monitored c. Because exercise can increase the blood glucose level, additional insulin should be taken before physical activity d. Because exercise can lower the blood glucose level, additional insulin should be token before physical activity

a. Because exercise can lower the blood glucose level, blood glucose needs to be closely monitored

The nurse is teaching an adolescent with newly diagnosed type 1 diabetes ways to minimize discomfort with insulin injections. Which recommendation is helpful in minimizing injection discomfort? a. Do not reuse needles b. Inject insulin when it is cold c. Flex or tense the muscle during injection d. Remove all bubbles from the syringe before the injection e. Inject at a 90-degree angle

a. Do not reuse needles d. Remove all bubbles from the syringe before the injection e. Inject at a 90-degree angle

The nurse assesses a child for the doll's head maneuver. The absence of the doll's head maneuver indicates which clinical finding? a. Dysfunction of the brainstem b. Dysfunction of the parietal lobe c. Dysfunction of the frontal cortex d. Dysfunction of the temporal lobe

a. Dysfunction of the brainstem Rationale: Absence of the doll's head maneuver suggests dysfunction of the brainstem or oculomotor nerve (cranial nerve III). Its absence does not suggest dysfunction of the parietal lobe, frontal cortex, or temporal lobe.

The nurse is planning care for a child recently diagnosed with diabetes insipidus (DI). Which nursing intervention would be planned? a. Encouraging the child to wear medical identification b. Discussing with the child and family ways to limit fluid intake c. Teaching the child and family how to do required urine testing d. Reassuring the child and family that DI is usually not a chronic or life-threatening illness

a. Encouraging the child to wear medical identification

Which condition occurs because of a lack of iodine in the diet and is characterized by enlargement of the thyroid gland? a. Goiter b. Hypothyroidism c. Hyperparathyroidism d. Type 1 diabetes mellitus

a. Goiter

During the summer, many children are more physically active. What changes in the management of the child with type 1 diabetes mellitus should be expected as a result of more exercise? a. Increased food intake b. Decreased food intake c. Increased risk of hyperglycemia d. Decreased risk of insulin shock

a. Increased food intake Rationale: During races and other competitions, more food may be required to practice to maintain a balance between glucose and exogenously administered insulin.

Which levels of thyroid hormone (TH) and thyroid-stimulating hormone (TSH) characterize primary congenital hypothyroidism? a. Low level of circulating TH, raised level of TSH at birth b. Low level of circulating TH, low level of TSH at birth c. Low level circulating TH, normal level of TSH at birth d. High level of circulating TH, increased level of TSH at birth

a. Low level of circulating TH, raised level of TSH at birth

Which manifestation of type 2 diabetes helps the nurse to distinguish it from type 1 diabetes? a. Excessive thirst and hunger b. Absence of serum insulin c. Rapid, deep breathing d. Relative insulin deficiency

d. Relative insulin deficiency Rationale: Type 2 diabetes has relative insulin deficiency while Type 1 diabetes has absolute insulin deficiency. Rapid, deep breathing, or Kussmaul's is a characteristic of Type 1 Diabetes.

The nurse is caring for a child who has sustained a spinal cord injury in an accident. Which immediate step would the nurse take to prevent the complications of spinal cord injury? a. Assess for changes in the neurological status. b. Assess the child's respiratory status and pattern. c. Administer methylprednisone. d. Implement some rehabilitation techniques.

b. Assess the child's respiratory status and pattern Rationale: The initial care for patients with spinal cord injuries includes assessment of the airway, breathing, and circulation. This helps prevent the risk of cervical spine damage. It is followed by the assessment of neurologic status by techniques like magnetic resonance imaging and computed tomography (CT). Administration of methylprednisone is done after the assessment of respiratory and neurological status. Finally, rehabilitation techniques such as the use of an electrical stimulator and neuromuscular rehabilitation are performed for the development of motor activity in patients.

Which acquired neuromuscular disorder is characterized by acute flaccid paralysis caused by the performed toxin produced by clostridium botulinum? a. Tetanus b. Botulism c. Gullain-Barre Syndrome d. Duchenne (muscular dystrophy)

b. Botulism

The nurse is caring for an infant in the pediatric unit. The nurse observes that the infant has a weak cry and reduced gag reflex. On obtaining the history from the mother, the nurse finds that the mother gives honey to the child on a regular basis. Which condition is likely responsible for the symptoms observed in the infant? a. Tetanus b. Botulism c. Spinal cord injury d. Guillain-Barre Syndrome

b. Botulism The main cause of botulism in infants is the feeding of honey. It is a food-borne infection, and the bacterium (Clostridium botulinum) mostly resides in anaerobic conditions. The toxin mostly affects the neuromuscular system, causing impaired motor activity.

An infant has an endocrine disorder that involves excessive circulating free cortisol. How would the nurse document these findings? a. Atrophy b. Cushing syndrome c. Ambiguous genitalia d. Adrenal insufficiency

b. Cushing syndrome

Which are the clinical manifestations of juvenile hypothyroidism? a. Sleepiness, dry skin, diarrhea b. Dry skin, sparse hair, slowed growth c. Diarrhea, dry skin, decelerated growth d. Constipation, dry skin, enlarged thyroid

b. Dry skin, sparse hair, slowed growth Rationale: Clinical manifestations of juvenile hypothyroidism include dry skin, sparse hair, decelerated growth, constipation, puffiness around the eyes, sleepiness, and mental decline. Diarrhea and enlarged thyroid are not associated with juvenile hypothyroidism.

The nurse is providing postoperative care of a ventriculoperitoneal (VP) shunt for a child with hydrocephalus. Which assessment does the nurse recognize as a sign of infection of the cerebrospinal fluid? a. Increased intracranial pressure (ICP) b. Elevated temperature c. Dilation of the pupils d. Improved feeding

b. Elevated temperature Rationale: signs of infection include elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity.

The nurse is educating a group of pregnant women about the importance of folic acid supplementation in the diet. Which suggestion given by the nurse is appropriate? a. Foods rich in folic acid prevent the onset of cerebral palsy in infants b. Foods rich in folic acid prevent the development of neural tube defects c. Foods rich in folic acid prevent Guillain-Barre syndrome in infants d. Foods rich in folic acid prevent the Werdnig-Hoffmann disease in infants

b. Foods rich in folic acid prevent the development of neural tube defects

Which factor is associated with infant botulism? a. Contaminated soil b. Honey c. Commercial infant cereals d. Improperly sterilized bottles

b. Honey

Which condition may be suspected in a child who has dry skin, puffiness around the eyes, sparse hair, and constipation? a. Goiter b. Hypothyroidism c. Hyperparathyroidism d. Type 1 diabetes mellitus

b. Hypothyroidism

Which statement best describes Cushing syndrome? a. The treatment involves replacement of cortisol b. It is caused by excessive production of cortisol c. The major clinical features are exopthalmia and pigment changes d. Diagnosis is suspected with findings of hypotension, hyperkalemia, and polyuria

b. It is caused by excessive production of cortisol Rationale: Hypertension and hypokalemia are expected in Cushing syndrome

Which condition increases blood calcium levels? a. Goiter b. Hypothyroidism c. Hyperparathyroidism d. Type 1 diabetes mellitus

c. Hyperparathyroidism

Which condition does the nurse suspect in a patient with anxiety and mental depression who has facial muscle spasms elicited by tapping the facial nerve in the region of the parotid gland and the carpopedal spasm? a. Thyrotoxicosis b. Hyperthyroidism c. Hypoparathyroidism d. Lymphocytic thyroiditis

c. Hypoparathyroidism

The nurse would recognize that when a child develops diabetic ketoacidosis (DKA), treatment will be instituted as described in which of the following statements? a. DKA is best treated at home b. DKA is best treated at the practitioner's office or clinic c. Immediate treatment is required because DKA is a life-threatening situation d. No treatment is required because DKA is an expected outcome of type 1 diabetes mellitus

c. Immediate treatment is required because DKA is a life-threatening situation

Which statement is the most accurate description of tetanus? a. It is an inflammatory disease that causes extreme localized muscle spasm. b. It is a disease affecting the salivary gland with resultant stiffness of the jaw. c. It is an acute infectious disease caused by an exotoxin produced by an anaerobic gram-positive bacillus d. It is an acute infection that causes meningeal inflammation, resulting in symptoms of generalized muscle spasm

c. It is an acute infectious disease caused by an exotoxin produced by an anaerobic gram-positive bacillus (Clostridium tetani.) Rationale: Tetanus is caused by the effect of the exotoxin's becoming fixed on nerve cells; it is not an inflammatory disorder that causes muscle spasms.

The nurse is caring for a child with multiple injuries. The nurse would recognize which fact about pain? a. It cannot occur if the child is comatose b. It may occur if the child regains consciousness c. It requires astute nursing assessment and management d. It is best assessed by family members who are familiar with the child

c. It requires astute nursing assessment and management Rationale: Pain can occur in a comatose child. The nurse should be monitoring the physiologic and behavioral manifestations

The nurse is assessing the level of consciousness of a patient who has received a high dose of morphine. Which medication would allow the nurse to reverse the effects or morphine in this patient? a. Fentanyl b. Midazolam c. Naloxone d. Vecuronium

c. Naloxone Rationale: duh

Which manifestation helps the nurse identify hyperglycemia in a child with diabetes mellitus (DM?) *Examination of skin*: Sweating, pallor, flushed *Examination of respiration*: Kussmaul respiration, shallow normal respirations *Assessment of breath odor*: Normal, fruity, acetone a. Presence of paleness or pallor b. Shallow normal respirations c. Presence of acetone breath d. Excessive sweating

c. Presence of acetone breath Rationale: Fruity, acetone breath is easily identified in a child with hyperglycemia

The nurse is examining a child who had a head injury. Which assessment finding does the nurse recognize as a comminuted fracture? a. Presence of irregular fragments of broken bones b. Presence of a single fracture line and a soft-tissue swelling c. Presence of multiple associated linear fracture d. Presence of bleeding around the eyes (raccoon eyes)

c. Presence of multiple associated linear fracture Rationale: Comminuted fractures consist of multiple associated linear fractures as a result of intense impact from repeated blows against an object.

The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal (VP) shunt to correct hydrocephalus. Which information is an important part of the discussion with the parents? a. Most usual childhood activities must be restricted b. Cognitive impairment is to be expected with hydrocephalus c. Shunt malfunction or infection requires immediate treatment d. Parental protection is essential until the child reaches adulthood

c. Shunt malfunction or infection requires immediate treatment Rationale: Except for contact sports, the child will have few restrictions. The development of cognitive impairment depends on the extent of damage before the shunt was placed.

A patient with chronic diabetes has been on insulin injections for the past 3 months. The patient's blood reports show the hemoglobin A1c is 6%. Which statement by the nurse would be correct? a. "The patient's diabetes is cured; therefore you need not take insulin henceforth." b. "The patient has high blood glucose, so you need to visit the endocrinologist." c. "The patient has anemia because of an iron deficiency, so the patient needs iron-rich food." d. "The patient's diabetes is under control; please continue the same regimen of treatment."

d. "The patient's diabetes is under control; please continue the same regimen of treatment." Rationale: Hemoglobin 7% or less indicates that the blood glucose is well controlled by the current regimen of treatment.

Which would the nurse include in the plan of care for a patient when administering intravenous (IV) phenytoin? a. Administering phenytoin with glucose solution b. Administering phenytoin at a rate of 70 mg/min c. Administering phenytoin at a rate of 150 mg/min d. Administering phenytoin with normal saline solution

d. Administering phenytoin with normal saline solution Rationale: Normal saline solution does not react with phenytoin, so it is appropriate to administer phenytoin intravenously with normal saline solution. Phenytoin precipitates when mixed with glucose, so it is not appropriate to mix the two. The appropriate IV push rate for phenytoin is 50 mg/min. Pushing at 70 mg/min or 150 mg/min may cause complications for the patient.

An 8-year-old has been found to have moderate cerebral palsy (CP). The child recently began participating in a regular classroom for part of the day. The child's mother asks the school nurse about joining the after school scout troop. The nurse's response would be based on which knowledge? a. Most activities such as scouts cannot be adapted for children with CP b. After-school activities usually result in extreme fatigue for children with CP. c. Trying to participate in activities such as scouts leads to lowered self-esteem in children with CP. d. After-school activities often provide children with CP with opportunities for socialization and recreation.

d. After-school activities often provide children with CP with opportunities for socialization and recreation.

Which nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious child? a. Frequent suctioning b. Providing environmental stimulation c. Turning the head from side to side every hour d. Avoiding activities that result in pain or crying

d. Avoiding activities that result in pain or crying

A child with cerebral palsy is admitted to the hospital for corrective surgery. In which way would the nurse approach the subject of family participation in the child's care during hospitalization? a. By assigning the parents specific times to visit their child in the hospital b. By telling the parents to room-in and take part in all aspects of the child's care c. By scheduling nursing care when the parents are out of the child's hospital room d. By discussing the parents' desire to participate in the care of the child during hospitalization

d. By discussing the parents' desire to participate in the care of the child during hospitalization

Which acquired neuromuscular disorder is characterized pseudohypertrophy of muscles and atrophy in later stages? a. Tetanus b. Botulism c. Gullain-Barre Syndrome d. Duchenne (muscular dystrophy)

d. Duchenne (muscular dystrophy)

A school-age child recently diagnosed with type 1 diabetes mellitus asks the nurse if playing soccer, baseball, and swimming are still possible. The nurse's response would be based on which knowledge? a. exercise is contraindicated in a child with type 1 diabetes mellitus b. the level of activity depends on the type of insulin required c. soccer and baseball are too strenuous, but swimming is acceptable d. exercise is not restricted unless indicated by other health conditions

d. Exercise is not restricted unless indicated by other health conditions

Which treatment does the nurse understand can help ease spasticity in a child with cerebral palsy? a. Exercises b. Diuretic medications c. Anticonvulsant medications d. Implanted medication pump

d. Implanted medication pump Rationale: Implantation of a pump to deliver medication into the intrathecal space can help ease spasticity in a child with cerebral palsy.

Which finding is most often observed with destruction of the pancreatic beta cells? a. Increased insulin secretion in the body b. Decreased growth hormone in the body c. Increased serum thyroxin levels in the body d. Increased blood glucose levels in the body

d. Increased blood glucose levels in the body

The parents report that their child has excessive urination, thirst, hunger, irritability, fatigue, flushed skin, headache, blurred vision, and dry skin. The child is diagnosed with type 1 diabetes mellitus. Based on the diagnosis, which would the nurse include in the plan of care? a. Assess the feet for open sores b. Obtain a urine dipstick for bacteria c. Administer corticosteroids to decrease inflammation d. Monitor capillary blood glucose levels before meals and at bedtime

d. Monitor capillary blood glucose levels before meals and at bedtime Rationale: Type 1 diabetes mellitus is a carbohydrate-metabolism disorder characterized by polyuria, polydipsia, overeating weight loss, fatigue, and irritability. The patient with type 1 diabetes mellitus may have hyperglycemia because of an inability of the pancreas to secrete insulin. Therefore, the nurse should monitor the capillary blood glucose levels before meals and at bedtime. It is important to assess the feet of patients with diabetes for open sores, but this is a long-term complication of uncontrolled diabetes mellitus.

When educating a group of parents about head injuries in children, the nurse explains that infants are particularly vulnerable to acceleration-deceleration head injuries because of which developmental issue? a. The anterior fontanel is not yet closed. b. Nervous tissue is not well developed. c. The infant's scalp has extensive vascularity. d. Musculoskeletal support of the head is insufficient.

d. Musculoskeletal support of the head is insufficient Rationale: A relatively large head size couples with insufficient musculoskeletal support increases the risk to infants of acceleration-deceleration head injuries.

The nurse is examining a child who had a head injury. Which assessment finding does the nurse recognize as a basilar fracture? a. Presence of irregular fragments of broken bones b. Presence of a single fracture line and a soft-tissue swelling c. Presence of multiple associated linear fracture d. Presence of bleeding around the eyes (raccoon eyes)

d. Presence of bleeding around the eyes (raccoon eyes) Rationale: Basilar fractures involve the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bones. Clinical features may include bleeding around the eyes.

A 3-year-old has cerebral palsy and is hospitalized for an upcoming orthopedic surgery. The child's mother states that the child has difficulty swallowing and cannot hold a utensil to self-feed. The child is slightly underweight for height. Which would be the most appropriate nursing action related to feeding? a. Placing the child in a well-supported semi-reclining position to make use of gravity flow b. Bottle or tube feeding the child with a specialized formula until sufficient weight is gained c. Placing the child in a sitting position with the neck hyperextended to make use of gravity flow d. Stabilizing the child's jaw with one hand (either from a front or side position) to facilitate swallowing

d. Stabilizing the child's jaw with one hand (either from a front or side position) to facilitate swallowing Rationale: Because the jaw is compromised, more normal control can be achieved if the feeder provides stability. Manual jaw controls assist with head control, correction of neck and trunk hyperextension, and jaw stabilization. This child is too old to be bottle-fed. The neuromuscular compromise of the jaw interferes with the child's ability to eat. The child should be sitting up for meals to prevent aspiration. For swallowing, the neck should not be hyperextended.