Nur 353 in class quiz
A 7-year-old child survives a near-drowning episode in a cold pond. What factor does the nurse identify that will have the greatest effect on the child's prognosis? 1 Hypoxia 2 Hyperthermia 3 Emotional trauma 4 Aspiration pneumonia
1
An infant with congenital hypothyroidism receives levothyroxine for three months. During the return appointment, which statement by the mother indicates to the nurse that the drug is effective? 1 The infant is alert and interactive. 2 The skin is cool to the touch. 3 The baby's fine tremor has ceased. 4 The baby's thyroid stimulating hormone level has increased
1
The mother of an infant who just underwent cleft lip repair tells the nurse, "He seems restless. May I hold him?" What information influences the nurse's response? 1 Holding may meet needs and reduce tension on the suture line. 2 Sedation limits activity and decreases tension on the suture line. 3 Handling may increase irritability, causing tension on the suture line. 4 Arm movements cannot be controlled, placing tension on the suture line
1
The nurse assesses a 5-year-old child after a shunt procedure is performed to correct increased intracranial pressure. Which finding is of most concern? 1 Marked irritability 2 Complaints of pain 3 Pulse of 100 beats/min 4 Temperature of 99.4° F (37.4° C)
1
The nurse assesses a newborn and observes central cyanosis. What type of congenital heart defect usually results in central cyanosis? 1 Shunting of blood from right to left 2 Shunting of blood from left to right 3 Obstruction of blood flow from the left side of the heart 4 Obstruction of blood flow between the left and right sides of the heart
1
A 3-year-old child with mild iron deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit? 1 Cold, clammy skin 2 Increased pulse rate 3 Increased blood pressure 4 Cyanosis of the nail beds
2
A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? nausea lethargy vomitng cold skin
2
During discharge planning the parents of an infant with spina bifida express concern about skin care and ask the nurse what can be done to avoid problems. What is the best response by the nurse? 1 Diapers should be changed at least every 4 hours. 2 Frequent diaper changes with cleansing are needed. 3 Medicated ointment should be applied six times a day. 4 Powder may be used in the perineal area when it becomes wet.
2
What is the priority of preoperative nursing care for an infant with a cleft lip? 1 Preventing crying 2 Modifying feeding 3 Preventing infection 4 Minimizing handling
2 key word = "prep"
Before discharging a 9-year-old child who is being treated for acute poststreptococcal glomerulonephritis (APSGN), what information should the nurse plan to give the parents? How to obtain the vital signs daily 2 Date on which to return to prepare for renal dialysis 3 Instructions about which high-sodium foods to avoid 4 List of activities that will encourage the child to remain active
3
A 16-year-old adolescent with recently diagnosed type 1 diabetes will receive NPH insulin subcutaneously. The nurse teaches the adolescent about peak action of the drug and the risk for hypoglycemia. How many hours after NPH insulin administration does the insulin peak? 1 1 to 2 hours 2 2 to 4 hours 3 5 to 10 hours 4 4 to 12 hours
4
An infant with hydrocephalus has a ventriculoperitoneal shunt surgically inserted. What nursing care is essential during the first 24 hours after this procedure? 1 Medicating the infant for pain 2 Placing the infant in a high Fowler position 3 Positioning the infant on the side that has the shunt 4 Monitoring the infant for increasing intracranial pressure
4
An infant with a cardiac defect is fed in the semi-Fowler position. After the nurse feeds and burps the infant and changes the infant's position, the infant has a bowel movement and almost immediately becomes cyanotic, diaphoretic, and limp. Which activity most likely caused the infant's response? 1 Burping 2 Feeding 3 Position change 4 Bowel movement
4 / do to the vagus nerve response
The day after undergoing abdominal appendectomy a school-aged child is prepared for ambulation. Which nursing action would be most effective before the start of ambulation? 1 Providing a rest period 2 Offering a reward for walking 3 Encouraging use of the spirometer 4 Administering the prescribed pain medication
Correct4 Administering the prescribed pain medication
The nurse is performing the nursery intake assessment of a 1-hour-old newborn. The assessment reveals that the newborn's hands and feet are cyanotic, and there is circumoral pallor when the infant cries or feeds. What action should the nurse perform based on these findings? 1 Notify the practitioner, because circumoral pallor may indicate cardiac problems 2 Notify the practitioner, because both signs are indicative of increased intracranial pressure 3 Take no specific action, because both signs are expected in a newborn until 2 weeks of age 4 Take no specific action, because circumoral pallor is an expected finding during feedings and periods of crying
1
A child is admitted to the pediatric intensive care unit with acute bacterial meningitis. What is the nurse's priority intervention? 1 Offering clear fluids whenever the child is awake 2 Checking the child's level of consciousness hourly 3 Assessing the child's blood pressure every four hours 4 Administering the prescribed oral antibiotic medication
2 Checking the level of consciousness is part of a total neurological check. It can reveal increasing intracranial pressure, which may occur as a result of cerebral inflammation. The child is too ill to ingest anything by mouth; also, vomiting is likely. Hydration is maintained intravenously. Taking the blood pressure and other vital signs every four hours is insufficient monitoring; many changes can occur in this time span. Intravenous antibiotics have a rapid systemic effect and are preferable to those administered by way of the oral route.
Which nursing action should be included in the plan of care for a child with acute poststreptococcal glomerulonephritis? 1 Encouraging fluids 2 Monitoring for seizures 3 Measuring abdominal girth 4 Checking for pupillary reactions
2 Cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures. Increasing fluid intake may lead to an increase in blood pressure and edema. Measuring abdominal girth is appropriate for children with nephrotic syndrome, in which the child has hypoalbuminemia that causes fluid to shift from plasma to the abdominal cavity. Glomerulonephritis will not alter pupillary reactions.
A young child from a developing country is admitted to the pediatric unit for surgery to correct a congenital heart defect. The mother asks the nurse why her child squats after exertion. The nurse responds, in language that the mother understands, that this position does what? 1 Decreases the number of muscle aches 2 Improves walking capacity and hip mobility 3 Reduces how hard the heart must work 4 Helps more blood return to the heart
3
What findings should a nurse expect when examining the laboratory report of a preschooler with rheumatic fever? 1 Negative C-reactive protein 2 Increased reticulocyte count 3 Positive antistreptolysin titer 4 Decreased sedimentation rate
3
Which explanation should the nurse consider when formulating a response to a client's inquiry about intussusception of the bowel? 1 Kinking of the bowel onto itself 2 A band of connective tissue compressing the bowel 3 Telescoping of a proximal loop of bowel into a distal loop 4 A protrusion of an organ or part of an organ through the wall that contains it
3
A child with hip dysplasia has undergone a closed reduction surgery. The nurse assesses the child 2 days after the surgery and feels that the treatment and care provided for the child were not effective. The nurse made this conclusion based on what findings? 1 The child has a staggering gait. 2 The child is unable to walk independently. 3 The child has impaired muscle tone and flexibility. 4 The child's femoral head did not return to the hip socket
4
After a discussion with the primary healthcare provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond? 1 The diameter of the aorta is enlarged. 2 The wall between the right and left ventricles is open. 3 It is a narrowing of the entrance to the pulmonary artery. 4 It is a connection between the pulmonary artery and the aorta.
4
An 8-year-old child is being discharged after recovery from a sickle cell vaso-occlusive (painful crisis) episode. The nurse teaches the parents the do's and don'ts of the child's care. What statement by the parents satisfies the nurse that they understand the principles of care? 1 Have the child schooled by a private tutor 2 Restrict the child's fluid intake during the night 3 Permit the child to play with just one peer at a time 4 Encourage the child to engage in low-intensity activities
4
An infant who has a congenital heart defect with left-to-right shunting of blood is admitted to the pediatric unit. What early sign of heart failure should the nurse identify? 1 Cyanosis 2 Restlessness 3 Decreased heart rate 4 Increased respiratory rate
4 - cyanosis = late sign of HF - not restless - will be tired d/t fatigue quickly - HR in early HF increases, not decreases
A 1-month-old infant is admitted to the pediatric unit with a tentative diagnosis of Hirschsprung disease (congenital aganglionic megacolon). What procedure does the nurse expect to be used to confirm the diagnosis? 1 Colonoscopy 2 Rectal biopsy 3 Multiple saline enemas 4 Fiberoptic nasoenteric tube
2
What should the plan of care for a newborn with hypospadias include? 1 Preparing the infant for insertion of a cystostomy tube 2 Explaining to the parents the genetic basis for the defect 3 Keeping the infant's penis wrapped with petrolatum gauze 4 Giving the parents reasons why circumcision should not be performed
Correct4 Giving the parents reasons why circumcision should not be performed