Peds Exam 4

a. febrile episodes b. hypoglycemia c. sodium imbalances Rationale: a. Febrile episodes can cause general tonic-clonic seizures in infants and young children. b. Seizure activity is a late manifestation of hypoglycemia. c. Seizure activity is a manifestation of hyponatremia and hypernatremia. d. High serum lead levels are a risk factor for seizure activity. e. Diphtheria is a respiratory illness causing difficulty breathing and is not a risk factor for seizures. (ATI Ch 13: Seizures)

A nurse is teaching a group of parents about the risk factors for seizures. Which of the following should be included in the teaching? (select all that apply) a. febrile episodes b. hypoglycemia c. sodium imbalances d. low serum lead levels e presence of diphtheria

d. "Hot spots" felt on the cast surface Rationale: If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so that a window can be made in the cast to observe the site. Cold toes may indicate too tight a cast and need further evaluation. Increased respirations may indicate a respiratory infection or pulmonary emboli. This should be reported, and the child should be evaluated. The five Ps of ischemia from a vascular injury include pain, pallor, pulselessness, paresthesia, and paralysis. Paresthesia is an indication of vascular injury, not infection. (Evolve Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

Which of the following would cause a nurse to suspect that an infection has developed under a cast? a. Cold toes b. Increased respirations c. Complaint of paresthesia d. "Hot spots" felt on the cast surface

c. Respiratory isolation will remain in place for 24 hours after antibiotics are started (Wong Ch 32: The Child with Cerebral Dysfunction)

As the nurse assigned to a child diagnosed with bacterial meningitis, you know that: a. The child will not need to be placed in isolation because antibiotics have been started b. Enteric precautions will remain in place for up to 48 hours c. Respiratory isolation will remain in place for 24 hours after antibiotics are started d. Due to headache, the child will want the head of the bed elevated with two pillows

a. Use of diet pills and laxatives b. Fasting d. Restriction of certain foods e. Inadequate caloric intake (Wong Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

Disordered eating patterns, which may be observed in the female athlete triad, may include which of the following? Select all that apply. a. Use of diet pills and laxatives b. Fasting c. Binge eating d. Restriction of certain foods e. Inadequate caloric intake f. Excessive vitamin consumption

d. Musculoskeletal support of the head is insufficient. Rationale: The relatively large head size coupled with insufficient musculoskeletal support increases the risk to infants. The anterior fontanel, nervous tissue, and scalp of the head do not have an effect on this type of injury. (Evolve Ch 32: The Child with Cerebral Dysfunction)

Why are infants particularly vulnerable to acceleration-deceleration head injuries? a. The anterior fontanel is not yet closed. b. The nervous tissue is not well developed. c. The scalp of the head has extensive vascularity. d. Musculoskeletal support of the head is insufficient.

d. Decrease in heart rate over the last hour (Wong Ch 32: The Child with Cerebral Dysfunction)

You are caring for a child with hydrocephalus who is post- operative from a shunt revision. Which assessment finding is your priority for increased intercranial pressure? a. Nausea and refusal to eat postoperatively b. Complaint of a headache c. Irritability and wanting to sleep d. Decrease in heart rate over the last hour

b. "I should place a cool mist humidifier in his room." Rationale: a. The nurse should teach the parent that Down syndrome increases the risk for constipation, resulting in the need for additional fluid and fiver in the diet. b. The nurse should teach the parent that Down syndrome increases the risk for respiratory infections. Using a cool mist humidifier in the infant's room helps prevent respiratory infections. c. The nurse should teach the parent that Down syndrome causes the infant to have dry skin that cracks easily. The parent should practice good skin care, including the application of lotion. d. The nurse should teach the parent that Down syndrome results in reduced growth in length for infants and height for children. (ATI Ch 15: Cognitive and Sensory Impairments)

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

b. Contact a practitioner or orthotist if skin redness does not disappear. Rationale: Redness is a sign of skin irritation from the brace. The brace needs to be adjusted to be functional. The skin should not be softened. The brace is specially designed for the child. Padding may alter the alignment of the brace. Rubbing alcohol would be painful. If the brace causes blisters, it needs to be adjusted. (Evolve Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

A young child has recently been fitted with a knee, ankle, and foot orthosis (brace). Care of the skin should include which of the following? a. Apply lotion or cream to soften the skin. b. Contact a practitioner or orthotist if skin redness does not disappear. c. Place padding between the skin and brace if the child experiences a burning sensation under the brace. d. If a small blister develops, apply rubbing alcohol and place padding between the skin and the

3. Cloudy CSF, elevated protein, and decreased glucose levels Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy CSF; and elevated leukocyte, elevated protein, and decreased glucose levels. Test-Taking Strategy: Use knowledge regarding the diagnostic findings in meningitis. Eliminate options 1 and 2 first because they are comparable or alike; recall that clear CSF is not likely to be found in an infectious process such as meningitis. From this point, recall that an elevated protein level indicates a possible diagnosis of meningitis to direct you to the correct option. (NCLEX Ch 42: Neurologic and Cognitive Disorders)

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? 1. Clear CSF, decreased pressure, and elevated protein level 2. Clear CSF, elevated protein, and decreased glucose levels 3. Cloudy CSF, elevated protein, and decreased glucose levels 4. Cloudy CSF, decreased protein, and decreased glucose levels

1. Meningitis Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses. The inability to extend the leg when the thigh is flexed anteriorly at the hip is a positive Kernig's sign, noted in meningitis. Kernig's sign is not seen specifically with spinal cord injury, intracranial bleeding, or decreased cerebral blood flow. Test-Taking Strategy: Focus on the subject, the characteristics of Kernig's sign. Knowledge regarding this sign is needed to answer correctly. Think about the neurological exam and physical assessment findings to answer correctly. (NCLEX Ch 42: Neurologic and Cognitive Disorders)

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? 1. Meningitis 2. Spinal cord injury 3. Intracranial bleeding 4. Decreased cerebral blood flow

d. Adolescents may not possess the insight and judgment to recognize when an activity is beyond their capabilities. Rationale: Children and adolescents may not possess the insight and judgment to recognize when an activity is beyond their capabilities. Rapidly growing bones, muscles, joints, and tendons are especially vulnerable to unusual strain. The increase in strength and vigor in adolescence may tempt adolescents to overextend themselves. More injuries occur during recreational sports participation than in organized athletic competition. (Evolve Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

Which of the following statements is correct regarding sports injuries during adolescence? a. Rapidly growing bones, muscles, joints, and tendons offer some protection from unusual strain. b. The increase in strength and vigor during adolescence helps prevent injuries related to fatigue. c. More injuries occur during organized athletic competition than during recreational sports participation. d. Adolescents may not possess the insight and judgment to recognize when an activity is beyond their capabilities.

1. Limited range of motion in the affected hip Rationale: In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Asymmetrical and restricted abduction of the affected hip, when the child is placed supine with the knees and hips flexed, would be an assessment finding in developmental dysplasia of the hip in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity. Test-Taking Strategy: Note the subject, assessment findings in developmental dysplasia of the hip. Also, note the age of the infant and focus on the infant's diagnosis. Visualizing each of the assessment findings described in the options will direct you to the correct option. (NCLEX Ch 43: Musculoskeletal Disorders)

A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition? 1. Limited range of motion in the affected hip 2. An apparent lengthened femur on the affected side 3. Asymmetrical adduction of the affected hip when the infant is placed supine with the knees and hips flexed 4. Symmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table

d. Notify the surgeon of the findings immediately (Wong Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

A 12-year-old who was in an ATV accident has a long-leg fiberglass cast on his left leg for a tibia-fibula fracture. He requests pain medication at 2:00 am for pain he rates at a 10/10 on the Numeric Scale. The nurse brings the pain medi- cation and notes that he has removed the pillows that kept his leg elevated. He complains of pain in the left foot, and she notes that there is 3+ edema in the exposed leg and foot and she is unable to slip a finger under the cast. The nurse's priority interventions in this situation should include: a. Administer the pain medication and elevate the child's leg on the pillows b. Elevate the leg on the pillows and follow up within 2 to 3 hours to see if the edema has decreased c. Let the child know he cannot have any additional pain medication until 6:00 am d. Notify the surgeon of the findings immediately

c. Remove the Pavlik harness once a day for no more than 2 hours and inspect skin (Wong Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

A 2-day-old infant in the newborn nursery is diagnosed with developmental dysplasia of the hip, and treatment is started by the orthopedist. The nurse assists the parents by provid- ing home care instructions that include: a. Return to the orthopedist's office in 2 weeks to remove the hip spica cast b. The infant's bilateral foot casts should be elevated on pillows as much as possible c. Remove the Pavlik harness once a day for no more than 2 hours and inspect skin d. Remove the Pavlik harness while the infant is awake to allow "tummy time"

d. "The reason for hospitalization is that complications could still occur." Rationale: Complications such as respiratory compromise and cerebral edema can occur 24 hours after the incident. If the child needed oxygen, the mother would not state the child is perfectly fine. Telling the mother that the doctor wants to make sure the child is fine minimizes the role of the nurse and the need for observation for potential life-threatening complications. Physiologic causes may need to be identified in the case of a submersion injury, but it is not the reason for hospitalization. (Evolve Ch 32: The Child with Cerebral Dysfunction)

A 3-year-old child is hospitalized after submersion injury. The child's mother complains to the nurse, "This seems unnecessary when he is perfectly fine." The nurse's best reply would be which of the following? a. "He still needs a little extra oxygen." b. "I'm sure he is fine, but the doctor wants to make sure." c. "It is important to observe for possible physical reasons for the accident." d. "The reason for hospitalization is that complications could still occur."

d. Teach the family the care and management of the corrective appliance. Rationale: The family needs to learn the purpose, function, application, and care of the corrective device and the importance of compliance to achieve the desired outcome. The initial therapy is rest and non-weight-bearing activity, which help reduce inflammation and restore motion. Legg-Calvé-Perthes is a disease of unknown etiology. A disturbance of circulation to the femoral capital epiphysis produces an ischemic aseptic necrosis of the femoral head. The disease is self-limiting, but the ultimate outcome depends on early and efficient therapy and the age of the child at onset. (Evolve Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

A 4-year-old child is newly diagnosed with Legg-Calvé-Perthes disease. Nursing considerations include which of the following? a. Encourage normal activity for as long as possible. b. Explain the cause of the disease to the child and family. c. Prepare the child and family for long-term, permanent disabilities. d. Teach the family the care and management of the corrective appliance.

2. "I can use lotion or powder around the cast edges to relieve itching." Rationale: Teaching about cast care is essential to prevent complications from the cast. The parents need to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation. Options 1, 3, and 4 are appropriate statements. Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Remember that lotions or powders can become sticky or caked and cause skin irritation. (NCLEX Ch 43: Musculoskeletal Disorders)

A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction? 1. "The cast may feel warm as the cast dries." 2. "I can use lotion or powder around the cast edges to relieve itching." 3. "A small amount of white shoe polish can touch up a soiled white cast." 4. "If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast."

4. Notify the health care provider (HCP). Rationale: An absent pulse to an extremity of the affected limb after a bone fracture could mean that the child is developing or experiencing compartment syndrome. This is an emergency situation, and the HCP should be notified immediately. Administering analgesics would not improve circulation. The skin traction should not be released without an HCP's prescription. Applying ice to an extremity with absent perfusion is incorrect. Ice may be prescribed when perfusion is adequate to decrease swelling. Test-Taking Strategy: Use the ABCs—airway-breathing-circulation. Focusing on the data in the question indicates that circulation is impaired. This should direct you to the correct option. (NCLEX Ch 43: Musculoskeletal Disorders)

A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take? 1. Administer an analgesic. 2. Release the skin traction. 3. Apply ice to the extremity. 4. Notify the health care provider (HCP).

c. "The seizure may or may not mean that your child has epilepsy." Rationale: A single seizure event is not classified as epilepsy and is generally not treated with long-term antiepileptic drugs. It can be the result of an acute medical or neurologic disease. True epilepsy is not easily treated, so saying that it is easily treated minimizes the father's concern. The statistics on epilepsy do not address the father's issues about his child. The seizure may or may not mean that a child has epilepsy, so it may not happen again. The nurse needs to provide the information to the parent that the diagnosis is not based on one seizure episode. (Evolve Ch 32: The Child with Cerebral Dysfunction)

A child is brought to the emergency department after experiencing a seizure at school. He has no history of seizures. The father tells the nurse that he cannot believe the child has epilepsy. The nurse's best response is which of the following? a. "Epilepsy is easily treated." b. "Very few children have actual epilepsy." c. "The seizure may or may not mean that your child has epilepsy." d. "Your child has had only one convulsion; it probably won't happen again."

4. Providing a quiet atmosphere with dimmed lighting Rationale: Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. In Reye's syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be positioned with the head elevated to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid. Test-Taking Strategy: Focus on the subject, nursing care for the child with Reye's syndrome. Think about the pathophysiology associated with Reye's syndrome. Recalling that cerebral edema is a concern for a child with Reye's syndrome will direct you to the correct option. (NCLEX Ch 42: Neurologic and Cognitive Disorders)

A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan? 1. Assessing hearing loss 2. Monitoring urine output 3. Changing body position every 2 hours 4. Providing a quiet atmosphere with dimmed lighting

4. Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied. Rationale: When a child is in traction, the nurse would check the HCP's prescription to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as prescribed, ensure that the weights hang freely, check the ropes for fraying and ensure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms of immobilization. The nurse would provide therapeutic and diversional play activities for the child. Test-Taking Strategy: Focus on the subject, care of the child in traction. Eliminate option 3 first because of the word restrict. Next recall the general principles related to traction, recalling that weights should hang freely and ropes should remain in the pulleys. (NCLEX Ch 43: Musculoskeletal Disorders)

A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention? 1. Ensure that all ropes are outside the pulleys. 2. Ensure that the weights are resting lightly on the floor. 3. Restrict diversional and play activities until the child is out of traction. 4. Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied.

4. Notify the health care provider (HCP). Rationale: Scoliosis is a three-dimensional spinal deformity that usually involves lateral curvature, spinal rotation resulting in rib asymmetry, and hypokyphosis of the thorax. A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child's abdominal contents, resulting from lengthening of the child's body. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or children who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Focus on the subject, complications following surgical treatment for scoliosis. Eliminate option 2 first because it should not be implemented unless prescribed by the HCP. Eliminate option 3 next because this child requires logrolling, and Sims' position may cause injury after surgery. From the remaining options, note the assessment signs and symptoms in the question. These should alert you that notification of the HCP is necessary. (NCLEX Ch 43: Musculoskeletal Disorders)

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of "vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action? 1. Administer an antiemetic. 2. Increase the intravenous fluids. 3. Place the child in a Sims' position. 4. Notify the health care provider (HCP).

b. Trendelenburg sign Rationale: a. Use a Barlow test to assess development dysplasia of the hip for infants. b. The Trendelenburg sign assesses for developmental dysplasia of the hip. The preschooler bears weight on the affected leg while holding on to something for balance. The examiner observes from behind for abnormal downward tilting of the pelvis on the unaffected side. c. Manipulation of foot and ankle is a test that assesses for clubfoot. d. The Ortolani test assesses development dysplasia of the hip for infants. (ATI Ch 28: Musculoskeletal Congenital Disorders)

A nurse is assessing a preschool age child for developmental dysplasia of the hip. Which of the following assessments should the nurse include? a. Barlow test b. Trendelenburg sign c. Manipulation of foot and ankle d. Ortolani test

b. Bone growth can be affected by this type of fracture. Rationale: Detection of epiphyseal injuries is sometimes difficult, but fractures involving the epiphysis or epiphyseal plate present special problems in determining whether bone growth will be affected. The epiphysis is the weakest point of the long bones. This is a frequent site of damage during trauma. Healing of epiphyseal injuries is usually prompt. (Evolve Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

A child, age 10 years, sustained a fracture in the epiphyseal plate of her right fibula when she fell out of a tree. When discussing this injury with her parents, the nurse should consider which of the following? a. This type of fracture is inconsistent with a fall. b. Bone growth can be affected by this type of fracture. c. This is an unusual fracture site in young children. d. Healing is usually delayed in this type of fracture.

4. Bradycardia Rationale: Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased ICP. In a child, early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), and seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma. Test-Taking Strategy: Note the age of the child and the strategic word, late. Think about the pathophysiology that occurs when pressure increases in the cranial vault to assist in answering correctly. (NCLEX Ch 42: Neurologic and Cognitive Disorders)

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? 1. Nausea 2. Irritability 3. Headache 4. Bradycardia

a. Stabilize the child's neck. Rationale: a. The greatest risk to child following a motor vehicle crash is cervical injury. Therefore, keeping the neck stabilized until cervical injury can be ruled out is the priority action. b. Cleaning the laceration with soap and water is important. However, this is not the priority action. c. Implementing seizure precautions is important. However, this is not the priority action. d. Establishing IV access is important. However, this is not the priority action. (ATI Ch 14: Head Injury)

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

b. Hip stiffness d. Limited ROM e. Limp with walking Rationale: a. A child who has Legg-Calve-Perthes exhibits shortening of the affected leg. b. A child who has Legg Calve Perthes exhibits hip stiffness due to the necrosis of the femoral head. c. A child who has Legg-Calve-Perthes exhibits a painless intermittent limp. d. A child who has Legg Calve Perthes exhibits limited ROM due to the necrosis of the femoral head. e. A child who has Legg Calve Perthes exhibits a limp with walking due to the necrosis of the femoral head. (ATI Ch 28: Musculoskeletal Congenital Disorders)

A nurse is assessing a child who has Legg Calve Perthes disease. Which of the following findings should the nurse expect? (Select all that apply.) a. Longer affected leg b. Hip stiffness c. Intense pain d. Limited ROM e. Limp with walking

a. Amnesia c. Bradycardia d. Respiratory depression e. Confusion Rationale: a. Amnesia is a manifestation of a concussion. b. Systemic hypertension is a manifestation of Cushing's triad in a child who has an epidural hematoma. c. Bradycardia is a manifestation of Cushing's triad in a child who has an epidural hematoma. d. Respiratory depression is a manifestation of Cushing's triad in a child who has an epidural hematoma. e. Confusion is a manifestation of a concussion. (ATI Ch 14: Head Injury)

A nurse is assessing a child who has a concussion. Which of the following findings should the nurse expect? (Select all that apply). a. Amnesia b. Systemic hypertension c. Bradycardia d. Respiratory depression e. Confusion

a. Headaches c. Difficulty reading e. Poor school performance Rationale: a. Headache are a manifestation of myopia. b. Photophobia is a manifestation of strabismus. c. Difficult reading is a manifestation of myopia. d. Difficulty focusing on close objects is a manifestation of hyperopia. e. Poor school performance is a manifestation of myopia. (ATI Ch 15: Cognitive and Sensory Impairments)

A nurse is assessing a child who has myopia. Which of the following findings should the nurse expect? (Select all that apply.) a. Headaches b. Photophobia c. Difficulty reading d. Difficulty focusing on close objects e. Poor school performance

a. Uses monotone speech b. Speaks loudly d. Appears shy Rationale: a. Monotone speech is a manifestation of a hearing impairment. b. Speaking loudly is a manifestation of a hearing impairment. c. Repeating sentences is an expected developmental task for a toddler. d. Shyness and withdrawn behavior are manifestations of a hearing impairment. e. Inattentiveness to surroundings is a manifestation of a hearing impairment. (ATI Ch 15: Cognitive and Sensory Impairments)

A nurse is assessing a toddler for possible hearing loss. Which of the following findings are indications of a hearing impairment? (Select all that apply) a. Uses monotone speech b. Speaks loudly c. Repeats sentences d. Appears shy e. Is overly attentive to the surroundings

d. High-pitched cry Rationale: a. A bulging anterior fontanel is a finding associated with meningitis in a 4-month-old infant. b. Vomiting is a finding associated with meningitis in a 4-month-old infant. c. The rooting reflex is expected in infants until the age of 3 to 4 months, and can remain until the age of 12 months. d. A high-pitched cry is a finding associated with meningitis in a 4-month-old infant (ATI Ch 12: Acute Neurological Disorders)

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

b. Maintain a quiet environment d. Administer a stool softener e. Maintain body alignment Rationale: a. Routine suctioning of the endotracheal tube is contraindicated because there is a risk of the catheter entering the brain through a skull fracture. b. Stimulation can cause increased intracranial pressure; therefore, the nurse should maintain a quiet environment. c. Pillows under the head cause flexion of the neck and increase intracranial pressure. d. Increased pressure in the abdomen with the Valsalva maneuver can increase intracranial pressure; therefore, the nurse should administer a stool softener. e. Flexion and extension of the neck increase intracranial pressure; therefore, the nurse should maintain body alignment. (ATI Ch 14: Head Injury)

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

a. Crepitus b. Edema c. Pain e. Ecchymosis Rationale: a. A fracture can leave bone fragments that will exhibit a grating sound. Crepitus is a manifestation of a fracture. b. Swelling at the site occur related to the trauma. Edema is a manifestation of a fracture. c. A child who has a fracture will experience pain from the trauma. d. A child who has a fracture will not exhibit a fever related to the fracture. e. Bleeding under the skin can occur related to the trauma. Ecchymosis is a manifestation of a fracture. (ATI Ch 27: Fractures)

A nurse is caring for a child who has a fracture. Which of the following are manifestations of a fracture? (Select all that apply.) a. Crepitus b. Edema c. Pain d. Fever e. Ecchymosis

a. loss of consciousness b. appearance of day dreaming c. dropping held objects Rationale: a. Loss of consciousness for 5 to 10 seconds is a manifestation of an absence seizure. b. Behavior that resembles daydreaming is a manifestation of an absence seizure. c. A child who is having absence seizures might drop a help object. d. Falling to the floor is a manifestation of a tonic-clonic seizure. e. piercing cry is a manifestation of a tonic-clonic seizure. (ATI Ch 13: Seizures)

A nurse is caring for a child who has absence seizures. Which of the following findings can the nurse expect? (select all that apply) a. loss of consciousness b. appearance of day dreaming c. dropping held objects d. falling to the floor e. having a piercing cry

a. Baclofen (Lioresal) b. Diazepam (Valium) Rationale: a. Baclofen is a centrally acting skeletal muscle relaxant that decreases muscle spasm and severe spasticity. b. Diazepam is a skeletal muscle relaxant that decreases muscle spasms and severe spasticity. c. Oxybutynin is an antispasmodic, anticholinergic medication that decreases bladder spasms. d. Methotrexate is a cytotoxic disease-modifying antirheumatic drug that slows joint degeneration and progression of rheumatoid arthritis. It is used used for children who have juvenile idiopathic arthritis (JIA). e. Prednisone is a corticosteroid that increases muscle strength for children who have muscular dystrophy. It decreases inflammation in children who have JIA. (ATI Ch 29: Chronic Neuromuscular Disorders)

A nurse is caring for a child who has cerebral palsy. Which of the following medications should the nurse expect to administer to treat painful muscle spasms. (Select all that apply.) a. Baclofen (Lioresal) b. Diazepam (Valium) c. Oxybutynin chloride (Ditropan) d. Methotrexate (Rheumatrex) e. Prednisone (Deltasone)

c. Muscular weakness in lower extremities d. Unsteady, wide-based or waddling gait Rationale: a. A child who has cerebral palsy exhibits purposeless, involuntary, abnormal movements. b. An infant who has the spinal defect myelomeningocele will exhibit a saclike protrusion. c. A child who has MD will exhibit muscular weakness in the lower extremities as one of the first manifestations. d. A child who has MD will exhibit an unsteady, wide-based, or waddling gait due to the progressive muscle weakness. e. A child who has Down syndrome can exhibit an upward slant to the eyes. (ATI Ch 29: Chronic Neuromuscular Disorders)

A nurse is caring for a child who has muscular dystrophy. For which of the following findings should the nurse assess? (Select all that apply.) a. Purposeless, involuntary, abnormal movements b. Spinal defect and saclike protrusion c. Muscular weakness in lower extremities d. Unsteady, wide-based or waddling gait e. Upward slant to the eyes

d. Apply moleskin to the edges of the cast. Rationale: a. A cool fan can be used to facilitate drying of a plaster cast. b. The child should be turned every 2 hours to expose all areas of the cast to facilitate drying. c. A client who has a spica cast is non-weight-bearing until the cast is removed d. The nurse should apply moleskin to the edges of the cast to prevent the cast from rubbing on the client's skin. (ATI Ch 27: Fractures)

A nurse is caring for a child who is in a plaster spica cast. Which of the following actions should the nurse take? a. Use a heat lamp to facilitate drying. b. Avoid turing the child until the cast is dry. c. Assist the client with crutch walking after the cast is dry. d. Apply moleskin to the edges of the cast.

b. Assess the child's position frequently. c. Assess pin sites every 4 hours. d. Ensure the weights are hanging freely. Rationale: a. The weights should only be removed by the provider or in an emergency situation. b. The nurse should assess the child's position frequently to ensure proper alignment is present. This avoids putting stress on the pinned areas and other areas of the body causing pain. c. Pin sites should be assessed frequently to monitor for the development of infection or loosening of the pins. Pin site care should be administered per facility policy. d. The nurse should ensure that the weights are hanging freely to allow for prescribed traction. e. The knot in the rope should not touch the pulley as this will alter the weight of the traction. (ATI Ch 27: Fractures)

A nurse is caring for a child who is in skeletal traction. Which of the following actions should the nurse take? (Select all that apply.) a. Remove the weights to reposition the client. b. Assess the child's position frequently. c. Assess pin sites every 4 hours. d. Ensure the weights are hanging freely. e. Ensure the rope's knot is in contact with the pulley.

c. Confusion Rationale: a. Tachycardia is an adverse effect of mannitol. b. Weight gain due to urinary retention is an adverse effect of mannitol. c. The nurse should monitor the child for increased confusion and report this adverse effect to the provider. This could be an indication of electrolyte imbalance. d. Diarrhea is an adverse effect of mannitol. (ATI Ch 14: Head Injury)

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

a. maintain a side lying position Rationale: a. Following a seizure, children often experience vomiting. Using the airway, breathing, circulation, priority-setting framework, the first action the nurse should take is to place the child in a side-lying position to maintain a patent airway and prevent aspiration of secretions. b. Loosening the child's restrictive clothing is an appropriate action. However, it is not the priority action. c. Reorienting the child to the environment following a generalized seizure is an appropriate action. However, it is not the priority action. d. Noting the time and characteristics of the child's seizure is an appropriate action. However, it is not the priority action. (ATI Ch 13: Seizures)

A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take? a. maintain a side lying position b. monitor vital signs c. reorient the child to the environment d. assess for injuries

b. Elevate the affected limb. c. Assess neurovascular status frequently. e. Stabilize the injury. Rationale: a. The nurse should place a cold pack on the site of injury to decrease swelling. b. Elevating the limb can decrease swelling at the injury site. c. Assessing neurovascular status assists the nurse in determining if the affected limb has adequate blood supply. d. The nurse should encourage ROM of the nonaffected limb. e. Stabilizing the injury will prevent further injury and damage. (ATI Ch 27: Fractures)

A nurse is caring for a child who sustained a fracture. Which of the following are appropriate actions for the nurse to take? (Select all that apply.) a. Place a heat pack on the site of injury. b. Elevate the affected limb. c. Assess neurovascular status frequently. d. Encourage ROM of the affected limb. e. Stabilize the injury.

a. Place the client on NPO status. Rationale: a. Due to the client's decreased level of consciousness, placing the client on NPO status is an appropriate action by the nurse. b. This is not an appropriate action by the nurse. Liver biopsies are used to diagnose Reye syndrome. c. This is not an appropriate action by the nurse. Position the client without a pillow and slightly elevate the head of the bed. d. This is not an appropriate action by the nurse. Clients who have undergone allogeneic hematopoietic stem cell transplants are put in protective environments. This client should be placed on droplet precautions. (ATI Ch 12: Acute Neurological Disorders)

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

a. Provide extra time for completion of ADLs. e. Perform range-of-motion exercises. Rationale: a. Providing extra time for the completion of ADLs promotes independence in the client and provides a means to maintain mobility. b. Using a warm compress or moist packs can provide comfort and relieve stiffness. c. Ibuprofen should be taken with food to prevent GI distress. d. The client should be encouraged to attend school, even during periods of exacerbation when pain is increased. e. Range of motion will assist in maintaining function of the joints. (ATI Ch 29: Chronic Neuromuscular Disorders)

A nurse is caring for a school-age child who has juvenile idiopathic arthritis. Which of the following home care instructions should the nurse include in the teaching? (Select all that apply.) a. Provide extra time for completion of ADLs. b. Use cold compresses for joint pain. c. Take ibuprofen on an empty stomach. d. Remain home during periods of exacerbation. e. Perform range-of-motion exercises.

c. Recent episode of gastroenteritis Rationale: a. A recent history of infectious cystitis caused by Candida, a fungal infection, is not a risk factor for Reye syndrome. b. A recent history of bacterial otitis media is not a risk factor for Reye syndrome. c. A recent episode of gastroenteritis, a viral illness, is a risk factor for Reye syndrome. Reye syndrome typically follows a viral illness, such as influenza, gastroenteritis, or varicella. d. A recent episode of Haemophilus influenzae meningitis, a bacterial infection, is not a risk factor for Reye syndrome. (ATI Ch 12: Acute Neurological Disorders)

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

a. decaffeinated beverages should be offered in the morning of the procedure Rationale: a. Caffeine can alter the results of an EEG and should be avoided prior to the test. b. The child's hair should be washed to remove oils that permit adherence of the EEG electrodes. c. Foods are not withheld prior to an EEG. d. Analgesics can alter the results of an EEG and should be avoided prior to the test. (ATI Ch 13: Seizures)

A nurse is providing teaching to the parent of a child who is to have an electroencephalogram (EEG). Which of the following should be included in the teaching? a. decaffeinated beverages should be offered in the morning of the procedure b. do not wash your child's hair the night before the procedure c. withhold all foods the morning of the procedure d. give your child an analgesic the night before the procedure

d. "The Pavlik harness is used for infants less than 6 months of age." Rationale: a. The Pavlik harness is for infants who have hip dysplasia. This is not a correct response for the nurse to make. b. The Pavlik harness is for infants who have hip dysplasia. This is not a correct answer for the nurse to make. c. The Pavlik harness is for infants who have hip dysplasia. This is not a correct answer for the nurse to make. d. The Pavlik harness is a soft brace designed for infants less than 6 months of age. A toddler is too large to fit into the brace. (ATI Ch 28: Musculoskeletal Congenital Disorders)

A nurse is caring for a toddler who is diagnosed with hip dysplasia and has been placed in a hip spica cast. The child's mother asks the nurse why a Pavlik harness is not being used. Which of the following responses should the nurse make? a. "The Pavlik harness is used for children with scoliosis, not hip dysplasia." b. "The Pavlik harness is used for school-age children." c. "The Pavlik harness cannot be used for your child because her condition is too severe." d. "The Pavlik harness is used for infants less than 6 months of age."

a. Report of headache b. Alteration in pupillary response d. Increased sleeping Rationale: a. A headache is an indication of ICP. b. Alteration in pupillary response is an indication of ICP. c. Decreased motor response is not an indication of ICP. d. Increased sleep is an indication of ICP. e. Decreased sensory response is an indication of ICP. (ATI Ch 14: Head Injury)

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

d. Apply a sterile, moist dressing on the sac. Rationale: a. Cuddling the infant could cause pressure on the sac, which could cause rupture. This should not be in the preoperative plan of care. b. Rectal temperature could cause irritation or rectal prolapse. This should not be in the preoperative plan of care. c. Placing the infant in supine position could cause pressure on the sac, which could cause rupture. This should not be in the preoperative plan of care. d. A sterile, moist, nonadhering dressing is placed on the sac to keep it moist until surgery. This should be in the preoperative plan of care. (ATI Ch 29: Chronic Neuromuscular Disorders)

A nurse is caring for an infant who has myelomeningocele. Which of the following actions should the nurse include in the preoperative plan of care? a. Assist the mother with cuddling the infant. b. Assess the infant's temperature rectally. c. Place the infant in a supine position. d. Apply a sterile, moist dressing on the sac.

c. "You will need to receive blood." Rationale: a. Clients who have spinal instrumentation for scoliosis are hospitalized for approximately one week. b. Clients who have spinal instrumentation for scoliosis experience intense pain that requires a PCA pump. c. Clients who have spinal instrumentation for scoliosis have a lengthy surgery with blood loss and require blood replacements. d. Clients who have spinal instrumentation for scoliosis are allowed to advance the diet as tolerated. (ATI Ch 28: Musculoskeletal Congenital Disorders)

A nurse is completing preoperative teaching with an adolescent client who is scheduled to receive spinal instrumentation for scoliosis. Which of the following information should the nurse include in the teaching? a. "You will go home the same day of surgery." b. "You will have minimal pain." c. "You will need to receive blood." d. "You will not be able to eat until the day after surgery."

b. Evaluate the toddler's need for an evaluation of hearing ability. Rationale: a. The nurse should structure interventions according to the toddler's developmental level, rather than to chronological age. b. The nurse should recognize that the toddler who has CP has an increased risk for hearing impairment; therefore, the nurse should evaluate the toddler's need for an evaluation of hearing ability. c. The nurse should routinely monitor the toddler's pain level using a developmentally appropriate pain tool, such as a FACES pain rating scale. The numeric rating scale is appropriate for children as young as 5 years of age who have a concept of numbers. d. Though a preschooler requires assistance and supervision with hygiene activities, the nurse should promote as much independence as possible. (ATI Ch 29: Chronic Neuromuscular Disorders)

A nurse is developing a plan of care for a toddler who has cerebral palsy. Which of the following actions should the nurse include? a. Structure interventions according to the toddler's chronological age. b. Evaluate the toddler's need for an evaluation of hearing ability. c. Monitor the toddler's pain level routinely using a numeric rating scale. d. Provide total care for daily hygiene activities.

b. Pneumococcal conjugate vaccine (PCV) Rationale: a. The introduction of the IPV did not decrease the incidence of bacterial meningitis. b. The introduction of the PCV decreased the incidence of bacterial meningitis in children, as it provides immunity against bacteria that causes the illness. c. The introduction of the DTaP vaccine did not decrease the incidence of bacterial meningitis. d. The introduction of the Hib vaccine decreased the incidence of bacterial meningitis in children, as it provides immunity against bacterium that cause the illness. e. The introduction of the TIV did not decrease the incidence of bacterial meningitis. (ATI Ch 12: Acute Neurological Disorders)

A nurse is developing an in-service about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (Select all that apply.) a. Inactivated polio vaccine (IPV) b. Pneumococcal conjugate vaccine (PCV) c. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) d. Haemophilus influenzae type B (Hib) vaccine e. Trivalent inactivated influenza vaccine (TIV)

a. place the child 10 feet away from the chart Rationale: a. The nurse should place the child 10 feet away from a Snellen chart when performing a visual acuity test. b. The nurse should show a set of cards to the child one at a time when performing a color test. c. The nurse should cover the child's eye while performing the test on the other eye when performing a cover test. d. When performing a peripheral vision test, the nurse asks the child to focus on an object while bringing a pencil into the child's peripheral vision. (ATI Ch 15: Cognitive and Sensory Impairments)

A nurse is planning to perform a peripheral vision test on a child. Which of the following actions should the nurse take away? a. place the child 10 feet away from the chart b. show a set of cards to to the child one at a time c. cover the child's eye while performing the test on the other eye d. have the child focus on an object while performing the test

a. Negative gram stain b. Normal glucose content e. Normal protein content Rationale: a. A negative gram stain indicates viral meningitis. b. Normal glucose content indicates viral meningitis. c. A clear color indicates viral meningitis. d. A slightly elevated WBC count indicates viral meningitis. e. Normal protein content indicates viral meningitis. (ATI Ch 12: Acute Neurological Disorders)

A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following results indicate viral meningitis? (Select all that apply.) a. Negative gram stain b. Normal glucose content c. Cloudy color d. Decreased WBC count e. Normal protein content

a. vagal nerve stimulator b. additional antiepileptic medications c. corpus callosotomy d. focal resection Rationale: a. The implementation of a vagal nerve stimulation is an option to provide seizure control. b. Additional antiepileptic medication can be added to the current medication regime to control seizures. c. A corpus callosotomy can be performed for uncontrolled seizures. d. focal resection can be performed for uncontrolled seizures. e. Radiation therapy is used in cancer treatment and is not used to control seizures. (ATI Ch 13: Seizures)

A nurse is reviewing treatment options with the parent of a child who has worsening seizures. Which of the following should be included in the discussion? (select all that apply a. vagal nerve stimulator b. additional antiepileptic medications c. corpus callosotomy d. focal resection e. radiation therapy

b. "Epiphyseal plate injuries may result in altered bone growth." Rationale: a. Children heal from fracture quicker than adults due to a thicker periosteum and good blood supply. b. Detection and early treatment is crucial for an epiphyseal plate injury to prevent altered bone growth. c. A greenstick fracture is a partial break in the bone. d. Children's bones are soft and pliable, and can bend up to 45 percent before breaking. (ATI Ch 27: Fractures)

A nurse is teaching a group of parent about fractures. Which of the following should be included in the teaching? a. "Children need a longer time to heal from a fracture than an adult." b. "Epiphyseal plate injuries may result in altered bone growth." c. "A greenstick fracture is a complete break in the bone." d. "Bones are unable to bend, so they break."

c. Protruding abdomen d. Broad, short feet and hands e. Hypotonia Rationale: a. A child who has hydrocephalus will exhibit a large head with bulging fontanels due to increased CSF in the head. b. A child who has Down syndrome will exhibit small features, such as small ears with a short pinna. c. A child who has Down syndrome will exhibit a protruding abdomen. d. A child who has Down syndrome will exhibit small features, such as broad, short feet and hands. e. A child who has Down syndrome will exhibit hyperflexibilty and hypotonia. (ATI Ch 15: Cognitive and Sensory Impairments)

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

c. Teach the child and family the correct administration of medications. Rationale: The management of juvenile idiopathic arthritis is primarily pharmacologic. The family should be instructed regarding administration of medications and the value of a regular schedule of administration to maintain a satisfactory blood level in the body. They need to know that nonsteroidal antiinflammatory drugs should not be given on an empty stomach and to be alert for signs of toxicity. Warm, moist heat is best for relieving stiffness and pain. Acetaminophen does not have antiinflammatory effects. Range of motion exercises should not be done during periods of inflammation. (Evolve Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

An important nursing consideration when caring for a child with juvenile idiopathic arthritis is which of the following? a. Apply ice packs to relieve stiffness and pain. b. Administer acetaminophen to reduce inflammation. c. Teach the child and family the correct administration of medications. d. Encourage range of motion exercises during periods of inflammation.

2. Reposition the infant frequently. Rationale: Hydrocephalus occurs as a result of an imbalance of cerebrospinal fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma. It results in head enlargement and increased intracranial pressure (ICP). In infants with hydrocephalus, the head grows at an abnormal rate, and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help to prevent skin breakdown. Proteinuria is not specific to hydrocephalus. Stimulus should be kept at a minimum because of the increase in ICP. It is not necessary to check the blood pressure every 15 minutes. Test-Taking Strategy: Note the strategic word, priority. Focus on the child's diagnosis. Eliminate option 4 because of the words 15 minutes. From the remaining options, recall that because of the severe head enlargement, the nursing intervention that has priority is to reposition the infant frequently to prevent the development of pressure areas (NCLEX Ch 42: Neurologic and Cognitive Disorders)

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? 1. Test the urine for protein. 2. Reposition the infant frequently. 3. Provide a stimulating environment. 4. Assess blood pressure every 15 minutes.

c. An AED can be effective in the resuscitation of a child or adolescent with a shockable rhythm. (Wong Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

Following the sudden death of a 14-year-old seemingly healthy basketball player, his parents ask the school administration to install an automatic external defibrillator (AED) in a central area of the athletic center. The school nurse is asked to participate in a meeting with the parents in which the administrators insist such a device is not necessary. The school nurse advocates by providing which information about AEDs and children? a. An AED should be used only by health care persons trained in its use. b. An AED provides too much of an energy shock dose for children under 12 years of age. c. An AED can be effective in the resuscitation of a child or adolescent with a shockable rhythm. d. An AED is more commonly used in adults who have heart attacks than in children with undiagnosed heart conditions.

a. Venous stasis Rationale: The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. A decreased vasopressor mechanism results in orthostatic hypotension, syncope, decreased cerebral blood flow, and tachycardia. An altered distribution of blood volume is found with decreased cardiac workload and exercise tolerance. Immobilization causes a decreased efficiency of orthostatic neurovascular reflexes with an inability to adapt readily to the upright position and with pooling of blood in the extremities in the upright position. (Evolve Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

Immobilization causes which of the following effects on the cardiovascular system? a. Venous stasis b. Increased vasopressor mechanism c. Normal distribution of blood volume d. Increased efficiency of orthostatic neurovascular reflexes

3. "I need to bring my infant back to the clinic in 1 month for a new cast." Rationale: Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. This will assist you in eliminating options 1 and 2. Recalling that serial manipulations and casting are required weekly will assist in directing you to the correct option. (NCLEX Ch 43: Musculoskeletal Disorders)

Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder? 1. "Treatment needs to be started as soon as possible." 2. "I realize my infant will require follow-up care until fully grown." 3. "I need to bring my infant back to the clinic in 1 month for a new cast." 4. "I need to come to the clinic every week with my infant for the casting."

c. eye opening and verbal and motor response. Rationale: The scale is a three-part assessment that includes eye opening, verbal response, and motor response. It is an observational tool to detect a life-threatening complication such as cerebral edema. Pupil reactivity, level of consciousness, and intracranial pressure are not included in the scale. (Evolve Ch 32: The Child with Cerebral Dysfunction)

The Glasgow Coma Scale consists of an assessment of a. pupil reactivity and motor response. b. level of consciousness and verbal response. c. eye opening and verbal and motor response. d. intracranial pressure and level of consciousness.

4. Suctioning equipment and oxygen Rationale: A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. A type of generalized seizure is a tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by intense jerking movements. Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. No object, including a padded tongue blade, is placed into the child's mouth during a seizure. An emergency cart would not be left at the bedside, but would be available in the treatment room or nearby on the nursing unit. Test-Taking Strategy: Focus on the subject, seizure precautions. Note the words need to be placed at the child's bedside. Eliminate option 2, knowing that a tracheotomy is not performed. Next, recalling that no object is placed into the mouth of a child experiencing a seizure assists in eliminating option 3. From the remaining options, focus on the primary concern during seizure activity. This will direct you to the correct option. (NCLEX Ch 42: Neurologic and Cognitive Disorders)

The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen

c. Administer antibiotic therapy as soon as it is available. Rationale: Administering antibiotic therapy is the priority action. Antibiotics are begun as soon as possible to avoid resultant disabilities and to prevent death. Isolation should be instituted as soon as diagnosis is anticipated. It is important to decrease the external stimuli. The nurse should keep the room as quiet as possible. Antibiotics are the priority function; pain should be managed if it occurs. (Evolve Ch 32: The Child with Cerebral Dysfunction)

The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. Which of the following is a priority of nursing care? a. Initiate isolation precautions as soon as diagnosis is confirmed. b. Provide environmental stimulation to keep the child awake. c. Administer antibiotic therapy as soon as it is available. d. Administer sedatives and analgesics on a preventive schedule to manage pain.

3. Nasotracheal suction as needed. Rationale: A basilar skull fracture is a type of head injury. Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture: Because of the nature of the injury, there is a possibility that the catheter will enter the brain through the fracture, creating a high risk of secondary infection. Fluid balance is monitored closely by daily weight determination, intake and output measurement, and serum osmolality determination to detect early signs of water retention, excessive dehydration, and states of hypertonicity or hypotonicity. The child is maintained on NPO (nothing by mouth) status or restricted to clear liquids until it is determined that vomiting will not occur. An intravenous line is maintained to administer fluids or medications, if necessary. Test-Taking Strategy: Note the words question which prescription. Eliminate options 1, 2, and 4 because they are comparable or alike in that they address the subject of fluids. Remember that nasotracheal suctioning is contraindicated in a child with a skull fracture because of the risk of infection. (NCLEX Ch 42: Neurologic and Cognitive Disorders)

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the health care provider's (HCP's) prescriptions and should contact the HCP to question which prescription? 1. Obtain daily weight. 2. Provide clear liquid intake. 3. Nasotracheal suction as needed. 4. Maintain a patent intravenous line.

3. Ortolani's maneuver Rationale: In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Ortolani's maneuver is a test to assess for hip instability and can be done only before 4 weeks of age. The examiner abducts the thigh and applies gentle pressure forward over the greater trochanter. A "clicking" sensation indicates a dislocated femoral head moving into the acetabulum. Babinski's sign is abnormal in anyone older than 2 years of age and indicates central nervous system abnormality. The Moro reflex is normally present at birth but is absent by 6 months; if still present at 6 months, there is an indication of neurological abnormality. The palmar-plantar grasp is present at birth and lessens within 8 months. Test-Taking Strategy: Options 1 and 2 can be eliminated first because they are comparable or alike and are both tests of neurological function. To select from the remaining options, remember that Ortolani's maneuver is an assessment technique for hip dysplasia that must be done before 4 weeks of age. This will direct you to the correct option. (NCLEX Ch 43: Musculoskeletal Disorders)

The nurse is assisting a health care provider (HCP) examining a 3-week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the HCP to assess? 1. Babinski's sign 2. The Moro reflex 3. Ortolani's maneuver 4. The palmar-plantar grasp

b. Encourage the parents to hold, talk, and sing to her as they usually would. Rationale: The parents should be encouraged to interact with their daughter. Senses of hearing and tactile perception may be intact, and stimulation of these senses is important. The daughter may be able to hear that they are present. Oral care is essential in an unconscious child. Mouth care should be done at least twice daily. The head of the bed should be elevated, not lowered. (Evolve Ch 32: The Child with Cerebral Dysfunction)

The nurse is caring for a 2-year-old girl who is unconscious but stable after a car accident. Her parents are staying at the bedside most of the time. Which of the following is an appropriate nursing intervention? a. Suggest that the parents go home until she is alert enough to know they are present. b. Encourage the parents to hold, talk, and sing to her as they usually would. c. Use ointment on her lips but do not attempt to cleanse her teeth until swallowing returns. d. Position her with proper body alignment and the head of the bed lowered 15 degrees.

c. requires astute nursing assessment and management. Rationale: Because the child cannot communicate pain through one of the standard pain rating scales, the nurse must focus on physiologic and behavioral manifestations. The child can be in pain while comatose. The family can provide insight into different responses, but the nurse should monitor physiologic and behavioral manifestations. (Evolve Ch 32: The Child with Cerebral Dysfunction)

The nurse is caring for a child with multiple injuries who is comatose. The nurse should recognize that pain a. cannot occur if the child is comatose. b. may occur if the child regains consciousness. c. requires astute nursing assessment and management. d. is best assessed by family members who are familiar with the child. Rationale: Because the child cannot communicate pain through one of the standard pain rating scales, the nurse must focus on physiologic and behavioral manifestations. The child can be in pain while comatose. The family can provide insight into different responses, but the nurse should monitor physiologic and behavioral manifestations.

1. Time the seizure. 3. Stay with the child. 5. Move furniture away from the child. Rationale: A seizure is a disorder that occurs as a result of excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side prevents aspiration because saliva drains out the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure. Test-Taking Strategy: Focus on the subject and visualize this clinical situation. Recalling that airway patency and safety is the priority will assist in determining the appropriate interventions. (NCLEX Ch 42: Neurologic and Cognitive Disorders)

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child. 6. Insert a padded tongue blade in the child's mouth.

a. Reactivity of pupils Rationale: Pupil reactivity is an important indication of neurologic health. The pupils should be assessed for no reaction, unilateral reaction, and rate of reactivity. The doll's head maneuver should not be performed if there is a cervical spine injury. The oculovestibular response is a painful test that should not be done on a child who is having variable levels of consciousness. Papilledema does not develop until 24 to 48 hours into the course of unconsciousness. (Evolve Ch 32: The Child with Cerebral Dysfunction)

The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. Which of the following is the most essential in this assessment? a. Reactivity of pupils b. Doll's head maneuver c. Oculovestibular response d. Funduscopic examination to identify papilledema

4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics. Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. A major priority of nursing care for a child suspected to have meningitis is to administer the antibiotic as soon as it is prescribed. The child also is placed on respiratory isolation precautions for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Enteric precautions and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when a child has a low neutrophil count. Test-Taking Strategy: Focus on the subject, the mode of transmission of meningitis. Eliminate options 1 and 2 first because they are comparable or alike, and are unrelated to the mode of transmission. Recalling that it takes about 24 hours for antibiotics to reach a therapeutic blood level will assist in directing you to the correct option. (NCLEX Ch 42: Neurologic and Cognitive Disorders)

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? 1. Maintain enteric precautions. 2. Maintain neutropenic precautions. 3. No precautions are required as long as antibiotics have been started. 4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

a. Blood administration may be an option. Rationale: Spinal surgery usually involves considerable blood loss. Several options are considered for blood replacement. Ambulation is allowed as soon as possible. Depending on the instrumentation used, most patients are walking by the second or third postoperative day. Casting and bracing are required postoperatively. The child usually has considerable pain for the first few days after surgery. Intravenous opioids should be administered on a regular basis. (Evolve Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

The nurse is preparing an adolescent girl for surgery to treat scoliosis. Which of the following should the nurse include? a. Blood administration may be an option. b. Ambulation will not be allowed for up to 3 months. c. Surgery eliminates the need for casting and bracing. d. Discomfort can be controlled with nonpharmacologic methods.

a. Irritability Rationale: Irritability is one of the changes that may indicate increased ICP. Photophobia is not indicative of increased ICP in infants. A pulsing anterior fontanel is normal. Vomiting is one of the signs of increased ICP in children, but when present with diarrhea, it is indicative of a gastrointestinal disturbance. (Evolve Ch 32: The Child with Cerebral Dysfunction)

Which of the following is a clinical manifestation of increased intracranial pressure (ICP) in infants? a. Irritability b. Photophobia c. Vomiting and diarrhea d. Pulsating anterior fontanel

3. "I should apply lotion under the brace to prevent skin breakdown." Rationale: A brace may be prescribed to treat scoliosis. Braces are not curative, but may slow the progression of the curvature to allow skeletal growth and maturity. The use of lotions or powders under a brace should be avoided because they can become sticky and cake under the brace, causing irritation. Options 1, 2, and 4 are appropriate interventions in the care of a child with a brace. Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Careful reading of the options will assist in directing you to the correct option. Also, applying the principles associated with cast care will direct you to the correct option. (NCLEX Ch 43: Musculoskeletal Disorders)

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? 1. "I will encourage my child to perform prescribed exercises." 2. "I will have my child wear soft fabric clothing under the brace." 3. "I should apply lotion under the brace to prevent skin breakdown." 4. "I should avoid the use of powder because it will cake under the brace."

3. Rigid extension and pronation of the arms and legs Rationale: Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing. Test-Taking Strategy: Focus on the subject, characteristics of decerebrate (extension) posturing. Recalling the clinical manifestations associated with decerebrate posturing will direct you to the correct option. Remember that decerebrate posturing is characterized by the rigid extension and pronation of the arms and legs. (NCLEX Ch 42: Neurologic and Cognitive Disorders)

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

2. Keep small toys and sharp objects away from the cast. 5. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. 6. Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity. Rationale: While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified. Test-Taking Strategy: Use of the ABCs—airway, breathing, and circulation—and safety principles related to care of a child with a cast will assist in answering this question. (NCLEX Ch 43: Musculoskeletal Disorders)

The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply. 1. Use the fingertips to lift the cast while it is drying. 2. Keep small toys and sharp objects away from the cast. 3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. 4. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. 5. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. 6. Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity.

d. Confusion or abnormal behavior Rationale: Altered mental status is a clinical manifestation that the damage from the head injury is progressing. Medical evaluation is necessary. Vomiting may occur after a minor head injury. Observation is required for changes in behavior or vital signs that indicate progression. Sleepiness may occur after a minor head injury. Observation is required to ensure that the child is arousable. Headache is common after a head injury and does not require medical evaluation unless accompanied by other signs of progression. (Evolve Ch 32: The Child with Cerebral Dysfunction)

The nurse should recommend medical attention if a child with a slight head injury experiences which of the following? a. Vomiting b. Sleepiness c. Headache, even if slight d. Confusion or abnormal behavior Rationale: Altered mental status is a clinical manifestation that the damage from the head injury is progressing. Medical evaluation is necessary. Vomiting may occur after a minor head injury. Observation is required for changes in behavior or vital signs that indicate progression. Sleepiness may occur after a minor head injury. Observation is required to ensure that the child is arousable. Headache is common after a head injury and does not require medical evaluation unless accompanied by other signs of progression.

a. Rapid assessment should begin with ABC status: airway, breathing, and circulation. Rationale: The first priority is always airway, breathing, and circulation. Assessment of the injured area occurs after the child's cardiopulmonary status has been addressed. Transport can occur by immobilizing the cervical spine. The head is maintained in a neutral position, and movement of the head or body is not allowed in any direction. Infants have the greatest discrepancy in body surface areas. Children old enough to ride bikes have similar body proportions to adults. (Evolve Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

The nurse stops to assist a child who has been hit by a car while riding a bicycle. Someone has activated the emergency medical system. Until paramedics arrive, the nurse should consider which of the following in caring for this child who has experienced severe trauma? a. Rapid assessment should begin with ABC status: airway, breathing, and circulation. b. Assessment should begin with the area injured; assessment of other areas can wait. c. The possibility of spinal cord injury should be ruled out before transporting the child to the hospital. d. Temperature maintenance is more difficult than in adults because young children have a larger surface area related to body mass.

3. A chronic disability characterized by impaired muscle movement and posture Rationale: Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe intellectual disabilities. Test-Taking Strategy: Eliminate options 1 and 2 first, noting that they are comparable or alike. Next, note the relationship between the words palsy in the question and impaired muscle movement in the correct option. (NCLEX Ch 42: Neurologic and Cognitive Disorders)

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process? 1. An infectious disease of the central nervous system 2. An inflammation of the brain as a result of a viral illness 3. A chronic disability characterized by impaired muscle movement and posture 4. A congenital condition that results in moderate to severe intellectual disabilities

3. "Have the child perform simple isometric exercises during this time." Rationale: Juvenile idiopathic arthritis is an autoimmune inflammatory disease affecting the joints and other tissues, such as articular cartilage. During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain. Although resting the extremity is appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important. These exercises do not involve joint movement. Test-Taking Strategy: Focus on the subject, exercise during an acute exacerbation of the disease. Eliminate options 1 and 2, because of the closed-ended words all and must, and option 4 because of the word additional. (NCLEX Ch 43: Musculoskeletal Disorders)

The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse should make which response? 1. "Avoid all exercise during painful periods." 2. "Range-of-motion exercises must be performed every day." 3. "Have the child perform simple isometric exercises during this time." 4. "Administer additional pain medication before performing range-of-motion exercises."

a. Orthostatic intolerance b. Deep vein thrombosis c. Pressure ulcer formation d. Pneumonia f. Kidney stones h. Constipation (Wong Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

The potential physiologic and psychologic effects of pro- longed immobilization on a 9-year-old child who has experienced significant trauma in a motor vehicle crash include which of the following? Select all that apply. a. Orthostatic intolerance b. Deep vein thrombosis c. Pressure ulcer formation d. Pneumonia e. Diarrhea f. Kidney stones g. Sense of euphoria and elation h. Constipation

c. Produces deep tissue vasodilation Rationale: Nine to 15 minutes of ice exposure produces deep tissue vasodilation without increased metabolism. Ice has a rapid cooling effect on tissues that reduces pain. The decreased temperature slows metabolism, thus reducing tissue oxygen requirements. Fewer histamine-like substances are released. (Evolve Ch 34: The Child with Musculoskeletal or Articular Dysfunction)

Which of the following results when ice is applied immediately after a soft tissue injury, such as a sprained ankle? a. Increases the pain threshold b. Increases metabolism in the tissues c. Produces deep tissue vasodilation d. Leads to release of more histamine-like substances

d. Recreational drug users should not share needles or other equipment. Rationale: Human immunodeficiency virus is spread through blood and body fluids. Intravenous needles that have been used should not be shared. They may be contaminated with the virus. The virus is not easily transmitted. It requires direct contact with blood or body fluids on a nonintact skin surface. Body fluids may also transmit the virus. Condoms should be used for both heterosexual and homosexual sex. (Evolve Ch 30: The Child with Hematologic or Immunologic Dysfunction )

The school nurse is discussing prevention of acquired immunodeficiency syndrome with some adolescents. Which of the following is appropriate to include? a. The virus is easily transmitted. b. It is only transmitted through blood. c. Condoms should be used if adolescents are homosexual. d. Recreational drug users should not share needles or other equipment.

d. Changes in posturing, such as any signs of extension or flexion posturing, unusual response to stimuli, and random versus purposeful movement (Wong Ch 32: The Child with Cerebral Dysfunction)

You are the nurse assigned to care for a child with a basilar skull fracture. Your most important nursing observation is change in level of consciousness. You will be highly alert for: a. Alterations in vital signs that often appear before alterations in consciousness or focal neurologic signs b. Bleeding from the ear, which is indicative of an anterior basal skull fracture c. Seizures that are relatively uncommon in children at the time of head injury d. Changes in posturing, such as any signs of extension or flexion posturing, unusual response to stimuli, and random versus purposeful movement

a. The presence or absence of an aura b. If the child appeared disoriented after the seizure d. The duration of the seizure (Wong Ch 32: The Child with Cerebral Dysfunction)

You are working with a family that brought their child into the pediatric clinic. The mother describes what may be a type of seizure. What subjective data will help you determine the type? Select all that apply. a. The presence or absence of an aura b. If the child appeared disoriented after the seizure c. Presence of vomiting after the seizure d. The duration of the seizure e. If the seizure was related to certain foods or occurred after a certain activity

b. "If there is a language barrier, written instructions can be given, followed by discharge." (Wong Ch 32: The Child with Cerebral Dysfunction)

You are working with a pediatric nurse who has just transferred to the pediatric clinic. You are role-playing phone triage related to a child with a head injury. You ascertain that the nurse needs more teaching based on what response? a. "After initial physical exam, if there was no loss of consciousness with the head injury, the child can be observed at home." b. "If there is a language barrier, written instructions can be given, followed by discharge." c. "Another physical exam should take place in 1 or 2 days." d. "Parents should call the doctor if their child has any of these signs: blurred vision, walking unsteadily, or is hard to awaken."

A nurse is caring for a child who is suspected of having Legg Calve Perthes disease. The nurse should prepare the child for which of the following diagnostic procedures? a. Bone biopsy b. Genetic testing c. MRI d. Radiographs Rationale: a. A bone biopsy is used to diagnose cancer, infection, and other bone disorders. It is not indicated to diagnose Legg-Calve-Perthes. b. Legg-Calve-Perthes is necrosis of the femoral head and is not genetic. Genetic testing is not indicated to diagnose Legg-Calve-Perthes. c. An MRI is used to visualize structure inside the body. Legg-Calve-Perthes is nexrosis of the femoral head. An MRI is not indicated to diagnose Legg-Calve-Perthes. d. A child who has Legg Calve Perthes exhibits necrosis of the femoral head and can be diagnosed by radiographs of the hip and pelvis. (ATI Ch 28: Musculoskeletal Congenital Disorders)

d. Radiographs