quizZeSs
Which respiratory change would a nurse see most often in a client with increased intracranial pressure?
Slow, irregular respirations - Because increased ICP presses on the structures of the brain, it causes irregularities such as Cheyne-Stokes respirations.
The school nurse is observing an 18 month old child during lunchtime in the nursery school cafeteria. Which of the following behaviors would the nurse expect to see
The child uses a spoon but drops quite a bit. Picks up a sippy cup with 2 hands and drinks
The nurse is giving a child a vaccine injection the child cries loudly during the procedure. Which of the following interventions would be appropriate for the nurse to perform after the injection
comfort the child and give the child a sticker as a present
A kindergarten child who has developed a fever since arriving at school, is resting in the school nurses office. It is 1130 am the child asks when is my mommy going to get me The nurse knows the mother will arrive in approximately 30 minutes , Which is the best response for the nurse to give to the child " your mommy should get here...." d
when lunch time begins for everyone
The nurse reports to the primary health care provider signs of increased ICP in an infant with myelomeningocele who has which of the following?
A high pitched cry - A chiari malformation obstructs the flow of cerebral spinal fluid resulting in hydrocephalus. This is a common problem in infants with myelomeningocele and will require surgical intervention with a shunt. A high pitched cry is on sign of increase ICP that may indicate the presence of a Chiari malformaiton and requires further evaluation. Minimal movement of the lower extremities is an expected finding associated with spinal cord damage. Overflow voiding comes from a neurogenic bladder, not increased ICP. It is normal for the fontanel to bulge with crying.
A child hospitalized with hydrocephalus is being treated with an externalized ventricular drain (EVD). A nurse begins the afternoon assessment and discovers that the drain is positioned several inches below the childs ear level. What should be the nurse's priority action?
Clamp the drain and complete a neurological assessment - The external Ventricular drain (EVD) should be at ***
Assessment of a school age child with Guillain-Barre syndrome reveals absent gag and cough reflexes. Which of the following problems should receive the highest priority during the acute phase?
Ineffective breathing pattern related to neuromuscular impairment - An ineffective breathing pattern caused by the ascending paralysis of the disorder interferes with the childs ability to maintain an adequate oxygen supply. Therefore, this nursing diagnosis takes precedence. Additionally, as the neurologic impairment progresses, it will probably have an effect on the childs ability to maintain respirations. An increased risk for infection related to an altered immune system is not associated with Guillan Barre. Although impaired swallowing and incontinence may occur with the ascending paralysis of this disorder, oxygenation is the priority.
A nurse in a daycare center is observing a 2 year old child during recess. Which of the following actions would the nurse expect the child to perform
Kick a ball
A school nurse is preparing to teach a group of teenagers how to prevent meningitis. What aspect of meningitis prevention should the nurse be certain to include in the presentation?
Refraining from sharing food and drinks is a good way to prevent meningitis infection - Meningitis is primarily spread through contact with droplets that arise from the nasopharynx of a person who is infected. Teenagers should be taught to not share food, drinks or any other item that touches the nose or mouth of another person.
What is an expected assessment finding in a child with coarctation of the aorta? a. disparity in blood pressure between the upper and lower extremities b.blood pressure higher on the left side of the body c.orthostatic hypotension d.systolic hypertension in the lower extremities
a. disparity in blood pressure between the upper and lower extremities rationale: the classic finding in children with coarctation is a disparity in pulses and blood pressures between the upper and lower extemities. orthostatic hypotension is not present with coarctation of the aorta. systolic hypertension may be detected in the upper extremities. the left arm may not accurately reflect systolic hypertension because the left subclavian artery can be involved in the coarctation.
A newborn is diagnosed with a congenital heart defect. the test results reveal that the lumen of the duct between the aorta and the pulmonary artery remain open. The nurse knows which of the following defects this occurs in? a. patent ductus arteriosus b.pulmonic stenosis c.coarctation of the aorta d. aortic stenosis
a. patent ductus arteriosus rationale: this is a defect with increased pulmonary flow. it should close within the first few weeks of life.
Nursing care for the child in congestive heart failure includes which of the following activites a. organizing care to provide rest periods b.removing oxygen while the infant is crying c.counting the number of saturated diapers d. putting the infant in the trendelenburg position
a.organizing care to provide rest periods rationale: nursing care should be planned to allow for periods of undisturbed rest. diapers must be weighted for an accurate record of output. The head of the bed should be raised to decrease the work of breathing. Oxygen should be admister during stressful periods such as when the child is crying
The nurse enters the examination room of a mother and her 8 month old the baby is asleep in the mothers arms which of the following actions would be best for the nurse to perform at this time
auscultate the babys heart, lung and bowel sounds
which defect results in increased pulmonary blood flow a. transposition of the great arteries b. atrial septal defect c. pulmonic stenosis d. tricuspid artresia
b. atrial septal defect rationale: the atrial septal defect results in increased pulmonary blood flow blood flow from the left atrium (higher pressure) in to the right atrium (lower pressure) and then to the lungs via the pulmonary artery. The other three diseases do not result in increased pulmonary blood flow.
Before giving a dose of digoxin the nurse checked an infants apical heart rate and it was 114 beats/minute. What should the nurse do next ? a. notify the physician about the infants heart rate b. wait and recheck the apical heart rate in 30 minutes c. administer the dose as ordered d. hold the medication until the next dose
c. administer the dose as ordered rationale: the infants heart rate is above the lower limit for which the medication is held ( 100 in an infant) the dose can be given
a beneficial effect of administering digoxin is that is a. increases venous pressure b. increases heart size c. decreases edema d. decreases cardiac output
c. decreases edema rationale: digoxin improves cardiac output, which will lead to decreased edema although it is not a diuretic. it does not increase heart size or increase venous pressure.
The nurse is caring for an 8 year old girl whose parents indicate she has developed spastic movements of her extremities and trunk, facial grimace and speech disturbances. They state it seems worse when she is anxious and does not occur when she is sleeping. The nurse questions the parents about what recent illness a. atrial fibrillation b. malignant hypertension c kawaski disease d. rheumatic fever
d. rheumatic fever rationale: these are symptoms of chorea. chorea is a manifestation of rheumatic fever, esp in children (higher incidences in females)
The parents of a 9 month old bring the infant to the clinic for a regular check up the infant has received no immunizations which of the following would be appropriate for the nurse to administer at this visit
diphtheria, tetanus and aceelular pertussis d Tap, haemophilus influenza type b Hib and inactivated poliomyelitis vaccine IPV
An 8 year old child is in the playroom drawing a picture the childs painful dressing change is due to be performed. Which of the following actions by the nurse is appropriate
escort the child to the treatment room for the dressing change and back to the playroom once it is done
A nurse advises the parent of a 2 year old that the child will have blood drawn during that days well child checkup. The nurse should advise the parents that the childs blood levels are being checked for which of the following substances
lead
The parents of a 2 year old child state that their child begins nursery school in one week. Which of the following actions should the nurse advise the parents to perform on the childs first day of school
make sure to let the child take to school any special object the child is attached to
Which intervention should the nurse employ to reduce trauma caused by vaccine administration to an infant
simultaneously administer vaccines at separate sites
After reading the vaccine information sheets the parents of a 2 month old infant is hesitant to consent to the recommended vaccinations the nurse should first ask the parent
what personal beliefs or safety concerns do you have about vaccinations
a child had an aortic stenosis defect surgically repaired 5 months ago which antibiotic prophylaxis is indicated for an upcoming tonsillectomy a. parenteral antibiotics are admin for 5-7 days after the procedure b.oral penicillin is given for 7-10 days before the procedure c. no antibiotic prophylaxis is needed d.amoxicillin is taken orally 1 hour before the procedure
d. amoxicillin is taken orally 1 hour before the procedure rationale the standard prophylactic agent is amoxicillin give orally 1 hour before the procedure antibiotic prophylaxis is indicated for the first 6 months after surgical repair antibiotic prophylaxis is not given for 7-10 days not is it given parenterally
A toddler with kawaski disease is being evaluated by a primary care clinic nurse 1 week after discharge. The nurse understands that it is a priority to instruct the parents to contact the clinic immediately if the child: a.develops a low grade fever b.experiences night terrors c.throws frequent temper tantrums d.is exposed to someone with chicken pox
d. is exposed to someone with chickenpox rationale: children with kawaski disease are placed on aspirin therapy, so exposure to chicken pox puts the child at risk for reye syndrome. temper tantrums are normal in this age group; night terrors can occur in toddlers and are a normal part of development; low grade fever can be related to minor infections, unlike the high unremitting fever present in kawaski disease.
The parent asks why it is recommended that the second dose of the measles mumps and rubella MMR vaccine be given at 4-6 years of age. The nurse should explain to the parent that the second dose is given at this age for what reason
if the child reaches puberty and becomes pregnant when receiving the vaccine the risks to the fetus are high
The parents of a 12 year old girl ask why their nonsexually active daughter should receive the human papillomavirus HPV vaccine the nurse should tell the parents
the vaccine is most effective against cervical cancer if given before becoming sexually active
Leakage of spinal fluid is a potential neurosurgical complication. How should a nurse assess for this complication?
Test all nasal and ear drainage for glucose - Spinal fluid contains glucose. The nurse should also look for the "halo" sign of blood drainage with a yellow ring of spinal fluid. In addition, nose and ears should be kept clean to reduce the chance of infection.
A nurse is providing anticipatory guidance to a young man who is at a tanner stage 2 which of the following information should the nurse discuss with the young man
voice changes
An adolescent girl with a seizure disorder controlled with phenytoin (Dilantin) and carbamazepine (Tegretol) asks the nurse about getting married and having children. Which of the following responses by the nurse would be MOST appropriate?
When you decide to have children, talk to the doctor about changing your medication. - Phenytoin is a known teratogenic agent, causing numerous fetal problems. Therefore, the adolescent should be advised to take to the doctor about changing the medication. Additionally, anticonvulsant requirement usually increase during pregnancy. Seizures can be controlled but cannot be cured. There is a familial tendency for seizure disorders. Seizure disorders and infertility are not related.
the following are examples of acquired heart disease select all that apply a.kawaski disease b.cardiomyopathy c.transposition of the great vessels d.hypoplastic left heart syndrome e.infective endocarditis f.rheumatic fever
a. kawaski disease b.cardiomyopathy e.infective endocarditis f.rheumatic fever rationale: acquired means occuring after birth and seen in an otherwise normal and healthy heart. hypoplastic left heart sydrome and transposition of the great vessels are congenital heart defects.
The nurse caring for a child diagnosed with acute rheumatic fever should assess the child for which of the following a tender warm inflamed joints b. desquamation of the fingers and toes c. sore throat d. elevated blood pressure
a. tender warm inflamed joints rationale: arthritis characterized by tender warm erythematous joints is one of the major manifestation of acute rheumatic fever in the first 1-2 weeks of the illness. the child may have had a sore throat previously associated with a group a hemolytic strep infection a few weeks earlier. a sore throat is not a manifestation of rheumatic fever, hypertension is not associated with reheumatic fever , desquamination of the fingers and toes is a manifestation of kawaski syndrome
The nurse assesses a 6 month old for vaccination readiness. Which finding would most likely indicate the need to delay administering the diptheria, tetanus and acellular pertussis dTap vaccine ?
an acute bilateral ear infection
The nurse caring for a 7 year old child who has undergone a cardiac catheterization 2 hours ago finds the dressing and bed saturated with blood the nurse should first: a. notify the physician b. apply pressure just above the catheter insertion site c. assess the vital signs d. reinforce the dressing
b. apply pressure just above the catheter insertion site rationale: Direct pressure is the first measure that should be used to control bleeding. Taking the vital signs will not control the bleeding. This should be done while another person is being sent to notify the physician. The dressing can be reinforced after the bleeding has been contained.
A nurse is providing health promotion education to a 10 year old child during a well child clinic visit. Which of the following is an appropriate patient care goal for the teaching session the child will:
brush teeth using a fluoride toothpaste at least twice each day
what intervention should be included in the plan of care for an infant with the nursing diagnosis of excess fluid volume related to congested heart failure a. admin digoxin as ordered by the physician b. put the infant in a car seat to minimize movement c. weigh the infant every day on the same scale at the same time d. notify the physician when weight gain exceeds more than 20/g day
c weigh the infant every day on the same scale at the same time rationale: excess fluid volume may not be overtly visible , weight changes may indicate fluid retention. weighing the infant on the same scale at the same time each day ensures consistency. an excessive weight gain for an infant is an increase of more than 50 g/ day. with fluid volume excess, skin will be edematous. the infants position should be changed frequently to prevent undesirable polling of fluid in certain areas. Digoxin is used in the treatment of congestive heart failure to improve cardiac function. diuretics will help the body get rid of excess fluids.
a 12 year old with rheumatic fever has a history of long term aspirin use. which statement by the client indicates that the nurse should notify the health care provider a. these pills make me cough b. my stomach hurts after i take that medicine c. i hear ringing in my ears d. is it alright to put lotion on my itchy skin
c. i hear ringing in my ears rationale: tinnitus is an adverse effect of prolonged aspirin therapy and the child should be examined by a healthcare provider for hearing loss. Itchy skin commonly accompanies the rash associated with rheumatic fever and the nurse can encourage lotion use. The nurse teaches clients to take aspirin with food or milk to avoid abdominal discomfort. The nurse can also address the fact that coughing after ingesting aspirin can be caused by inadequate fluid intake during administration
a 10 year old child is recovering from a severe sore throat. the caregiver now states that the child complains of chest pain. the nurse observes that the child has swollen joints, nodules on the fingers and a rash on the chest. which of the following conditions would the nurse suspect a. decreased cardiac output b.congestive heart failure c.rheumatic fever d. kawaski disease
c. rheumatic fever rationale: rheumatic fever this is an inflammatory disease caused by group A beta hemolytic strep. Major criteria include carditis, subcutatneous nodules, erythema marginaturm, chorea, and arthritis. Minor criteria include fever and previous history of RF.
Which congenital heart defect results in increased pulmonary blood flow a. pulmonary stenosis b.tetralogy of fallot c.ventricular septal defect d.coarctation of the aorta
c.ventricular septal defect rationale: ventricular septal defect causes a left to right shunting of blood, thus increasing pulmonary blood flow. Coarctation of the aorta is a stenotic lesion that causes increased resistance to blood flow from the proximal to distal aorta. The defects associated with tetralogy of Fallot result in the right to left shunting of blood, thus decreasing pulmonary blood flow. Pulmonary stenosis causes obstruction of blood flow from the right ventricle to the pulmonary artery. Pulmonary blood flow is decreased.
which statement best describes patent ductus arteriosus (PDA) a. PDA causes an abnormal opening between the four chambers of the heart b.PDA is a stenotic lesion that must be surgically corrected at birth c. PDA involves a defect that results in right to left shunting of the blood in the heart d. PDA involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close
d. PDA involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close rationale: PDA is failure of the fetal shunt between the aorta and pulmonary artery to close. PDA allows blood to flow from the high pressure aorta to the low pressure pulmonary artery resultingin a left to right shunt. PDA is not a stenotic lesion and can be closed both medically and surgically. Atrioventricular defect occurs when fetal development of the endocardial cushions is disturbed, resulting in abnormalities in the atrial and ventricular septa and the atrioventricular valves
What is the appropriate priority nursing action for the infant with congenital heart defect who has an increased respiratory rate, is sweating and is not feeding well a. increase the oxygen rate b. with hold oral feeding c. recheck the infants blood pressure d. alert the provider
d. alert the provider rationale: these are signs of early congestive heart failure and the provider should be notified. rechecking the blood pressure is not necessary. withholding the infants feeding is an incomplete response to the problem. increasing oxygen may alleviate symptoms but medication such as digoxin and furosemide are necessary to improve heart function and fluid retention. notifying the provider is the priority nursing action
