Unit 5 Exam

Which statement is accurate concerning a child's musculoskeletal system and how it may be different from an adult's? a. Growth occurs in children as a result of an increase in the number of muscle fibers. b. Infants are at greater risk for fractures because their epiphyseal plates are not fused. c. Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. d. Their bones have less blood flow.

A A child's growth occurs because of an increase in size rather than an increase in the number of the muscle fibers. B This is not a true statement. Fractures in children younger than 1 year are unusual because a large amount of force is necessary to fracture their bones. Answer C Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. This is an accurate statement. D A child's bones have greater blood flow than an adult's bones.

Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis? a. Nuclear brain scan b. Echoencephalography c. CT scan d. MRI

A A nuclear brain scan uses a radioisotope that accumulates where the blood-brain barrier is defective. B Echoencephalography identifies shifts in midline structures of the brain as a result of intracranial lesions. C A CT scan provides a visualization of the horizontal and vertical cross sections of the brain at any axis. D MRI permits visualization of morphologic features of target structures and permits tissue discrimination that is unavailable with any other techniques.

Parents of a child with lice infestation should be instructed carefully in the use of antilice products because of which potential side effect? a. Nephrotoxicity b. Neurotoxicity c. Ototoxicity d. Bone marrow depression

A Antilice products are not known to be nephrotoxic. Answer B Because of the danger of absorption through the skin and potential for neurotoxicity, antilice treatment must be used with caution. A child with many open lesions can absorb enough to cause seizures. C Antilice products are not ototoxic. D Products that treat lice are not known to cause bone marrow depression.

During a well-child visit, the nurse identifies that an 18-month-old infant is bowlegged. She is aware that this assessment is a. Common in children with nutritional deficiencies b. Common in infants and toddlers c. A serious condition needing further evaluation d. An indication of neurologic impairment

A Bowlegs are not usually associated with nutritional deficiencies. Answer B Bowlegs are common in infants and toddlers. C Bowlegs may need intervention but do not generally indicate serious abnormalities. D Bowlegs do not generally indicate a neurologic impairment.

Tissue ischemia and nerve damage are serious complications that may result from immobilization in a cast or from traction. The five Ps of vascular impairment can be used as a guide when assessing for neurovascular problems. List the five Ps.

ANS: pain, pallor, pulselessness, paresthesia, paralysis Prompt referral to a physician and intervention is crucial if neurovascular impairment is to be prevented.

Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? a. Coma b. Stupor c. Obtundation d. Persistent vegetative state

A Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Answer B Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. C Obtundation describes a level of consciousness in which the child is arousable with stimulation. D Persistent vegetative state describes the permanent loss of function of the cerebral cortex.

An important nursing consideration when caring for a child with impetigo contagiosa is to a. Apply topical corticosteroids to decrease inflammation. b. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris. c. Carefully wash hands and maintain cleanliness when caring for an infected child. d. Examine child under a Wood lamp for possible spread of lesions.

A Corticosteroids are not indicated in bacterial infections. B Dressings are usually not indicated. The undermined skin, crusts, and debris are carefully removed after softening with moist compresses. Answer C A major nursing consideration related to bacterial skin infections, such as impetigo contagiosa, is to prevent the spread of the infection and complications. This is done by thorough handwashing before and after contact with the affected child. D A Wood lamp is used to detect fluorescent materials in the skin and hair. It is used in certain disease states, such as tinea capitis.

The primary clinical manifestation of scabies is a. Edema b. Redness c. Pruritus d. Maceration

A Edema is not observed in scabies. B Redness is not observed in scabies. Answer C Scabies is caused by the scabies mite. The inflammatory response and intense itching occur after the host has become sensitized to the mite. This occurs approximately 30 to 60 days after initial contact. In the previously sensitized person, the response occurs within 48 hours. D Maceration is not observed in scabies.

When infants are seen for fractures, which nursing intervention is a priority? a. No intervention is necessary. It is not uncommon for infants to fracture bones. b. Assess the family's safety practices. Fractures in infants usually result from falls. c. Assess for child abuse. Fractures in infants are often nonaccidental. d. Assess for genetic factors.

A Fractures in infancy are not common. B Infants should be cared for in a safe environment and should not be falling. Answer C Fractures in infants warrant further investigation to rule out child abuse. Fractures in children younger than 1 year are unusual because of the cartilaginous quality of the skeleton; a large amount of force is necessary to fracture their bones. D Fractures in infancy are usually nonaccidental rather than related to a genetic factor.

With what beverage should the parents of a child with ringworm be taught to give griseofulvin? a. Water b. A carbonated drink c. Milk d. Fruit juice

A Griseofulvin is insoluble in water. B Carbonated drinks do not contain fat, which aids in the absorption of griseofulvin. Answer C Griseofulvin is insoluble in water. Giving the medication with a high-fat meal or milk increases absorption. D Fruit juice does not contain any fat; fat aids absorption of the medication.

The pediatric nurse understands that cellulitis is most often caused by a. Herpes zoster b. Candida albicans c. Human papillomavirus d. Streptococcus or Staphylococcus organisms

A Herpes zoster is the virus associated with varicella and shingles. B Candida albicans is associated with candidiasis or thrush. C Human papillomavirus is associated with various types of human warts. Answer D Streptococcus, Staphylococcus, and Haemophilus influenzae are the organisms usually responsible for cellulitis.

A maculopapular rash with a red base and a small white papule in the center is a. Milia b. Mongolian spots c. Erythema toxicum d. Cafe-au-lait spots

A Milia are minute epidermal cysts on the face of the newborn. B Mongolian spots are bluish-black discolorations found on dark-skinned newborns, usually on the sacrum. Answer C This is a description of erythema toxicum, a normal rash in the newborn. D These spots are pale tan (the color of coffee with milk) macules. Occasional spots occur normally in newborns.

The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. The most essential part of nursing assessment to detect early signs of a worsening condition is a. Posturing b. Vital signs c. Focal neurologic signs d. Level of consciousness

A Neurologic posturing is indicative of neurologic damage. B Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes. C Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes. Answer D The most important nursing observation is assessment of the child's level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurologic signs.

A nurse is conducting a health education class for a group of school-age children. Which statement made by the nurse is correct about the body's first line of defense against infection in the innate immune system? a. Nutritional status b. Skin integrity c. Immunization status d. Proper hygiene practices

A Nutritional status is an indicator of overall health, but it is not the first line of defense in the innate immune system. Answer B The first lines of defense in the innate immune system are the skin and intact mucous membranes. C Immunizations provide artificial immunity or resistance to harmful diseases. D Practicing good hygiene may reduce susceptibility to disease, but it is not a component of the innate immune system.

When taking a history on a child with a possible diagnosis of cellulitis, what should be the priority nursing assessment to help establish a diagnosis? a. Any pain the child is experiencing b. Enlarged, mobile, and nontender lymph nodes c. Child's urinalysis results d. Recent infections or signs of infection

A Pain is important, but the history of recent infections is more relevant to the diagnosis. B Lymph nodes may be enlarged (lymphadenitis), but they are not mobile and are nontender. Lymphangitis may be seen with red "streaking" of the surrounding area. C An abnormal urinalysis result is not usually associated with cellulitis. Answer D Cellulitis may follow an upper respiratory infection, sinusitis, otitis media, or a tooth abscess. The affected area is red, hot, tender, and indurated.

Impetigo ordinarily results in a. No scarring b. Pigmented spots c. Slightly depressed scars d. Atrophic white scars

Answer A Impetigo tends to heal without scarring unless a secondary infection occurs. B Hyperpigmentation may occur; however, only in dark skinned children. C No scarring usually occurs. D No scarring usually occurs.

The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum? a. Negative Ortolani's sign b. Thigh and gluteal creases are asymmetric c. Negative Barlow test d. Knee heights are equal

A Positive Ortolani's sign yields a "clunking" sensation and indicates a dislocated femoral head moving into the acetabulum. Answer B Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip. C During a positive Barlow test, the examiner can feel the femoral head move out of acetabulum. D If the hip is dislocated, the knee on the affected side will be lower.

Which term is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine? a. Scoliosis b. Ankylosis c. Lordosis d. Kyphosis

A Scoliosis is a complex spinal deformity usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis. B Ankylosis is the immobility of a joint. C Lordosis is an accentuation of the cervical or lumbar curvature beyond physiologic limits. Answer D Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine.

A 4-year-old child with a long leg cast complains of "fire" in his cast. The nurse should a. Notify the physician on his next rounds. b. Note the complaint in the nurse's notes. c. Notify the physician immediately. d. Report the complaint to the next nurse on duty.

A The child's symptom requires immediate attention. Notifying the physician on the next rounds is inappropriate. B Charting the complaint in the nurse's notes is an inappropriate action. Careful notation of symptoms is important, but the priority action is to contact the physician. Answer C A burning sensation under the cast is an indication of tissue ischemia. It may be an early indication of serious neurovascular compromise, such as compartmental syndrome, that requires immediate attention. D Communication across shifts is important to the continuing assessment of the child; however, this symptom requires immediate evaluation, and the physician should be contacted.

Which nursing intervention is appropriate to assess for neurovascular competency in a child who fell off the monkey bars at school and hurt his arm? a. The degree of motion and ability to position the extremity b. The length, diameter, and shape of the extremity c. The amount of swelling noted in the extremity and pain intensity d. The skin color, temperature, movement, sensation, and capillary refill of the extremity

A The degree of motion in the affected extremity and ability to position the extremity are incomplete assessments of neurovascular competency. B The length, diameter, and shape of the extremity are not assessment criteria in a neurovascular evaluation. C Although the amount of swelling is an important factor in assessing an extremity, it is not a criterion for a neurovascular assessment. Answer D A neurovascular evaluation includes assessing skin color and temperature, ability to move the affected extremity, degree of sensation experienced, and speed of capillary refill in the extremity.

Which factor should the nurse include when teaching a parent about the care of a newborn in a Pavlik harness for hip dysplasia? a. The harness may be removed with every diaper change. b. The harness is used to maintain the infant's hips in flexion and abduction and external rotation. c. The harness is only the first step of treatment. d. The harness is worn for 2 weeks.

A The harness must be worn for 23 hours per day and should be removed only according to the physician's recommendation. Hips that remain unstable become progressively more deformed as maturity takes place. Answer B The harness is used to maintain the infant's hips in flexion and external rotation to allow the hips (femoral head and acetabulum) to mold and grow normally. C With early diagnosis and treatment, the Pavlik harness is often the only treatment necessary. D The length of treatment is determined by radiographic documentation of the maturity of the hips.

Which assessment finding is considered a neurologic soft sign in a 7-year-old child? a. Plantar reflex b. Poor muscle coordination c. Stereognostic function d. Graphesthesia

A The plantar reflex is a normal response. When the lateral aspect of the sole of the foot is stroked in a movement curving medially from the heel to the ball, the response will be plantar flexion of the toes. Answer B Poor muscle coordination is a neurologic soft sign. C Stereognostic function refers to the ability to identify familiar objects placed in each hand. D Graphesthesia is the ability to identify letters or numbers traced on the palm or back of the hand with a blunt point.

Ringworm, frequently found in schoolchildren, is caused by a(n) a. Virus b. Fungus c. Allergic reaction d. Bacterial infection

A These are not the causative organisms for ringworm. Answer B Ringworm is caused by a group of closely related filamentous fungi, which invade primarily the stratum corneum, hair, and nails. They are superficial infections that live on, not in, the skin. C Ringworm is not an allergic response. D These are not the causative organisms for ringworm.

A Vitamin A does not have a relation to the prevention of spina bifida. B Folic acid supplementation is recommended for the preconceptual period, as well as during the pregnancy. C The widespread use of folic acid among women of childbearing age is expected to decrease the incidence of spina bifida significantly. D Folic acid supplementation is recommended for the preconceptual period, as well as during the pregnancy.

A 1.0 mg is too low a dose. Answer B It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age has contributed to a reduction in the number of children with neural tube defects. C 1.5 mg is not the recommended dosage of folic acid. D 2.0 mg is not the recommended dosage of folic acid.

Which type of fractures describes traumatic separation of cranial sutures? a. Basilar b. Linear c. Commuted d. Depressed

A A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. B A linear fracture includes a straight-line fracture without dura involvement. Answer C Commuted skull fractures include fragmentation of the bone or a multiple fracture line. D A depressed fracture has the bone pushed inward, causing pressure on the brain.

Nursing care of the infant who has had a myelomeningocele repair should include a. Securely fastening the diaper b. Measurement of pupil size c. Measurement of head circumference d. Administration of seizure medications

A A diaper should be placed under the infant but not fastened. Keeping the diaper open facilitates frequent cleaning and decreases the risk for skin breakdown. B Pupil size measurement is usually not necessary. Answer C Head circumference measurement is essential because hydrocephalus can develop in these infants. D Seizure medications are not routinely given to infants who do not have seizures.

Which statement best describes a subdural hematoma? a. Bleeding occurs between the dura and the skull. b. Bleeding occurs between the dura and the cerebrum. c. Bleeding is generally arterial, and brain compression occurs rapidly. d. The hematoma commonly occurs in the parietotemporal region.

A An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region. Answer B A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of cortical veins that bridge the subdural space. C An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region. D An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.

A nurse is explaining to parents how the central nervous system of a child differs from that of an adult. Which statement accurately describes these differences? a. The infant has 150 mL of CSF compared with 50 mL in the adult. b. Papilledema is a common manifestation of ICP in the very young child. c. The brain of a term infant weighs less than half of the weight of the adult brain. d. Coordination and fine motor skills develop as myelinization of peripheral nerves progresses.

A An infant has about 50 mL of CSF compared with 150 mL in an adult. B Papilledema rarely occurs in infancy because open fontanels and sutures can expand in the presence of ICP. C The brain of the term infant is two thirds the weight of an adult's brain. Answer D Peripheral nerves are not completely myelinated at birth. As myelinization progresses, so does the child's coordination and fine muscle movements.

A child is brought to the emergency department in generalized tonic-clonic status epilepticus. Which medication should the nurse expect to be given initially in this situation? a. Clorazepate dipotassium (Tranxene) b. Fosphenytoin (Cerebyx) c. Phenobarbital d. Lorazepam (Ativan)

A Clorazepate dipotassium (Tranxene) is indicated for cluster seizures. It can be given orally. B Fosphenytoin can be given intravenously as a second round of medication if seizures continue. C Phenobarbital can be given intravenously as a second round of medication if seizures continue. Answer D Lorazepam (Ativan) or diazepam (Valium) is given intravenously to control generalized tonic-clonic status epilepticus and may also be used for seizures lasting more than 5 minutes.

A child with a head injury sleeps unless aroused, and when aroused responds briefly before falling back to sleep. What should the nurse chart for this child's level of consciousness? a. Disoriented b. Obtunded c. Lethargic d. Stuporous

A Disoriented refers to lack of ability to recognize place or person. B Obtunded describes an individual who sleeps unless aroused and once aroused has limited interaction with the environment. C An individual is lethargic when he or she awakens easily but exhibits limited responsiveness. Answer D Stupor refers to requiring considerable stimulation to arouse the individual.

Which type of seizures involves both hemispheres of the brain? a. Focal b. Partial c. Generalized d. Acquired

A Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. B Partial seizures are caused by abnormal electric discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. Answer C Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. D A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure.

A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. Which statement made by the mother indicates a correct understanding of the teaching? a. "I should expect my child to have a few episodes of vomiting." b. "If I notice sleep disturbances, I should contact the physician immediately." c. "I should expect my child to have some behavioral changes after the accident." d. "If I notice diplopia, I will have my child rest for 1 hour."

A If the child has these clinical signs, they should be immediately reported for evaluation. B If the child has these clinical signs, they should be immediately reported for evaluation. Answer C The parents are advised of probable posttraumatic symptoms. These include behavioral changes and sleep disturbances. D If the child has these clinical signs, they should be immediately reported for evaluation.

After a tonic-clonic seizure, it would not be unusual for a child to display a. Irritability and hunger b. Lethargy and confusion c. Nausea and vomiting d. Nervousness and excitability

A Neither irritability nor hunger is typical of the period after a tonic-clonic seizure. Answer B In the period after a tonic-clonic seizure, the child may be confused and lethargic. Some children may sleep for a period of time. C Nausea and vomiting are not expected reactions in the postictal period. D The child will more likely be confused and lethargic after a tonic-clonic seizure.

The nurse is preparing a school-age child for computed tomography (CT scan) to assess cerebral function. Which statement should the nurse include when preparing the child? a. "Pain medication will be given." b. "The scan will not hurt." c. "You will be able to move once the equipment is in place." d. "Unfortunately no one can remain in the room with you during the test."

A Pain medication is not required; however, sedation is sometimes necessary. Answer B For CT scans, the child must be immobilized. It is important to emphasize to the child that at no time is the procedure painful. C The child will not be allowed to move and will be immobilized. D Someone is able to remain with the child during the procedure.

The Glasgow Coma Scale consists of an assessment of a. Pupil reactivity and motor response b. Eye opening and verbal and motor responses c. Level of consciousness and verbal response d. ICP and level of consciousness

A Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. Answer B The Glasgow Coma Scale assesses eye opening, and verbal and motor responses. C Level of consciousness is not a part of the Glasgow Coma Scale. D Intracranial pressure and level of consciousness are not part of the Glasgow Coma Scale.

Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury? a. Rapid, shallow breathing b. Irregular, rapid heart rate c. Increased diastolic pressure with narrowing pulse pressure d. Confusion and altered mental status

A Respiratory changes occur with ICP. One pattern that may be evident is Cheyne-Stokes respiration. This pattern of breathing is characterized by increasing rate and depth, then decreasing rate and depth, with a pause of variable length. B Temperature elevation may occur in children with ICP. C Changes in blood pressure occur, but the diastolic pressure does not increase, nor is there a narrowing of pulse pressure. Answer D The child with a head injury may have confusion and altered mental status, a change in vital signs, retinal hemorrhaging, hemiparesis, and papilledema.

What should be the nurse's first action when a child with a head injury complains of double vision and a headache, and then vomits? a. Immobilize the child's neck. b. Report this information to the physician. c. Darken the room and put a cool cloth on the child's forehead. d. Restrict the child's oral fluid intake.

A Stabilizing the child's neck does not address the child's symptoms. Answer B Any indication of ICP should be promptly reported to the physician. C This intervention may facilitate the child's comfort. It would not be the nurse's first action. D The child's episode of vomiting does not necessitate a fluid restriction.

What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic-clonic seizure? a. Guide the child to the floor if standing and go for help. b. Turn the child's body on the side. c. Place a padded tongue blade between the teeth. d. Quickly slip soft restraints on the child's wrists.

A The child should be placed on a soft surface if he is not in bed; however, it is inappropriate to leave the child during the seizure. Answer B Positioning the child on his side will prevent aspiration. C Nothing should be inserted into the child's mouth during a seizure to prevent injury to the mouth, gums, or teeth. D Restraints could cause injury. Sharp objects and furniture should be moved out of the way to prevent injury.

What is the most appropriate nursing response to the father of a newborn infant with myelomeningocele who asks about the cause of this condition? a. "One of the parents carries a defective gene that causes myelomeningocele." b. "A deficiency in folic acid in the father is the most likely cause." c. "Offspring of parents who have a spinal abnormality are at greater risk for myelomeningocele." d. "There may be no definitive cause identified."

A The exact cause of most cases of neural tube defects is unknown. There may be a genetic predisposition, but no pattern has been identified. B Folic acid deficiency in the mother has been linked to neural tube defect. C There is no evidence that children who have parents with spinal problems are at greater risk for neural tube defects. Answer D The etiology of most neural tube defects is unknown in most cases. There may be a genetic predisposition or a viral origin, and the disorder has been linked to maternal folic acid deficiency; however, the actual cause has not been determined.

How should the nurse explain positioning for a lumbar puncture to a 5-year-old child? a. "You will be on your knees with your head down on the table." b. "You will be able to sit up with your chin against your chest." c. "You will be on your side with the head of your bed slightly raised." d. "You will lie on your side and bend your knees so that they touch your chin."

A The knee-chest position is not appropriate for a lumbar puncture. B An infant can be placed in a sitting position with the infant facing the nurse and the head steadied against the nurse's body. C A side-lying position with the head of the bed elevated is not appropriate for a lumbar puncture. Answer D The child should lie on her side with knees bent and chin tucked in to the knees. This position exposes the area of the back for the lumbar puncture.

What is the best response to a father who tells the nurse that his son "daydreams" at home and his teacher has observed this behavior at school? a. "Your son must have an active imagination." b. "Can you tell me exactly how many times this occurs in one day?" c. "Tell me about your son's activity when you notice the daydreams." d. "He is probably overtired and needs more rest."

A This response does not address the child's symptoms or the father's concern. B This behavior is consistent with absence seizures, which can occur one after the other several times a day. Determining an exact number of absence seizures is not as useful as learning about behavior before the seizure that might have precipitated seizure activity. Answer C The daydream episodes are suggestive of absence seizures, and data about activity associated with the daydreams should be obtained. D This response ignores both the child's symptoms and the father's concern about the daydreaming behavior.

What finding should cause the nurse to suspect a diagnosis of spastic cerebral palsy? a. Tremulous movements at rest and with activity b. Sudden jerking movement caused by stimuli c. Writhing, uncontrolled, involuntary movements d. Clumsy, uncoordinated movements

A Tremulous movements are characteristic of rigid/tremor/atonic cerebral palsy. Answer B Spastic cerebral palsy, the most common type of cerebral palsy, will manifest with hypertonicity and increased deep tendon reflexes. The child's muscles are very tight and any stimuli may cause a sudden jerking movement. C Slow, writhing, uncontrolled, involuntary movements occur with athetoid or dyskinetic cerebral palsy. D Clumsy movements, loss of coordination, equilibrium, and kinesthetic sense occur in ataxic cerebral palsy.

A recommendation to prevent neural tube defects is the supplementation of a. Vitamin A throughout pregnancy b. Multivitamin preparations as soon as pregnancy is suspected c. Folic acid for all women of childbearing age d. Folic acid during the first and second trimesters of pregnancy

A Vitamin A does not have a relation to the prevention of spina bifida. B Folic acid supplementation is recommended for the preconceptual period, as well as during the pregnancy. Answer C The widespread use of folic acid among women of childbearing age is expected to decrease the incidence of spina bifida significantly. D Folic acid supplementation is recommended for the preconceptual period, as well as during the pregnancy.

The nurse teaches parents to alert their health care provider about which adverse effect when a child receives valproic acid (Depakene) to control generalized seizures? a. Weight loss b. Bruising c. Anorexia d. Drowsiness

A Weight gain, not loss, is a side effect of valproic acid. Answer B Thrombocytopenia is an adverse effect of valproic acid. Parents should be alert for any unusual bruising or bleeding. C Drowsiness is not a side effect of valproic acid, although it is associated with other anticonvulsant medications. D Anorexia is not a side effect of valproic acid.

Match the activities listed with the appropriate functional level of ability: Use A for instrumental activities of daily living (IADLs) and use B for basic activities of daily living (BADLs). (Your answer should appear as letters separated by commas and spaces [e.g., A, A, A, A, A, A].)

A. Uses a cane B. Bathes daily C. Takes medications as prescribed D. Dresses self E. Balances the checkbook F. Cleans the house ANS: B, B, A, B, A, A Functional impairment, disability, or handicap refers to varying degrees of an individual's inability to perform the tasks required to complete normal life activities without assistance. IADLs are more complex skills that are essential to living in the community.

The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would bea. change in level of consciousness. b. inability to focus visually. c. loss of primitive reflexes. d. unequal pupil size.

ANS: A A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refers to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS.

When caring for the patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes,a. hypertension, and bradycardia. b. hypertension, and tachycardia. c. hypotension, and bradycardia. d. hypotension, and tachycardia.

ANS: A Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushing's triad). It is bradycardia, not tachycardia, which is the component of this ominous triad. It is hypertension, not hypotension, which is the component of this ominous triad.

A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease

ANS: A, B, C Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.

A nurse is teaching parents about prevention of diaper dermatitis. Which should the nurse include in the teaching plan? Select all that apply. a. Clean the diaper area gently after every diaper change with a mild soap. b. Use a protective ointment to clean dry intact skin. c. Use a steroid cream after each diaper change. d. Use rubber or plastic pants over the diaper. e. Wash cloth diapers in hot water with a mild soap and double rinse.

ANS: A, B, ECorrect Prompt, gentle cleaning with water and mild soap (e.g., Dove, Neutrogena Baby Soap) after each voiding or defecation rids the skin of ammonia and other irritants and decreases the chance of skin breakdown and infection. A bland, protective ointment (e.g., A&D, Balmex, Desitin, zinc oxide) can be applied to clean, dry, intact skin to help prevent diaper rash. If cloth diapers are laundered at home, the parents should wash them in hot water, using a mild soap and double rinsing. Incorrect Occlusion increases the risk of systemic absorption of a steroid; thus steroid creams are rarely used for diaper dermatitis because the diaper functions as an occlusive dressing. Rubber or plastic pants increase skin breakdown by holding in moisture and should be used infrequently. A steroid cream is not recommended.

A nurse should expect which cerebral spinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis? Select all that apply. a. Elevated white blood count (WBC) b. Decreased protein c. Decreased glucose d. Cloudy in color e. Increase in red blood cells (RBC)

ANS: A, C, D Correct The CSF laboratory results for bacterial meningitis include elevated WBC counts, cloudy or milky in color, and decreased glucose. Incorrect The protein is elevated and there should be no RBCs present. RBCs are present when the tap was traumatic.

Where do the lesions of atopic dermatitis most commonly occur in the infant? Select all that apply. a. Cheeks b. Buttocks c. Extensor surfaces of arms and legs d. Back e. Trunk

ANS: A, C, E Correct The lesions of atopic dermatitis are generalized in the infant. They are most commonly on the cheeks, scalp, trunk, and extensor surfaces of the extremities. Incorrect These lesions are not typically on the back or the buttocks.

Which interventions should the nurse implement to prevent complications of immobility for a child in skeletal traction? Select all that apply. a. Reposition the child every 2 hours. b. Avoid use of an egg-crate or sheepskin mattress. c. Limit fluid intake. d. Administer stool softeners as prescribed. e. Encourage coughing and deep breathing.

ANS: A, D, ECorrect Complications of immobility can affect the skin, the gastrointestinal system, and the respiratory system. The child should be repositioned every 2 hours to prevent skin breakdown. Stool softeners should be administered to avoid constipation and the child should cough and deep breathe to maintain respiratory function. Incorrect Egg-crate or sheep skin mattresses can be useful in preventing skin breakdown, and fluids should be increased to prevent constipation, not decreased.

1. The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe?a. Aligning the neck with the body b. Clustering many nursing activities c. Elevating the head of the bed 30 degrees d. Providing stool softeners or laxatives as ordered

ANS: B It is important to minimize stress and activities that could increase intracranial pressure. Combining many nursing activities could increase oxygen demand and intracranial pressure. This would not be safe. Interventions which can promote venous outflow can help decrease intracranial pressure. The stress of constipation or bowel movements can increase intracranial pressure; stool softeners or laxatives can minimize this.

A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure c. Myoclonic seizure d. Absence seizure

ANS: B Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.

A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis? Select all that apply. a. Pain with deep palpation of the spinal column b. Unequal shoulder heights c. The trouser pant leg length appears shorter on one side d. Inability to bend at the waist e. Unequal waist angles

ANS: B, C, ECorrect The assessment findings associated with scoliosis include unequal shoulder heights, trouser pant leg length appearing shorter on one side meaning unequal leg length, and unequal waist angles. Incorrect Scoliosis is a nonpainful curvature of the spine so pain is not expected and the child is able to bend at the waist adequately.

What nursing actions are indicated when the nurse is administering phenytoin (Dilantin) by the intravenous route to control seizures? Select all that apply. a. It must be given with D51/2NS. b. The child will require monitoring of therapeutic serum levels while taking this medication. c. Dilantin should be given with food because it causes gastrointestinal distress. d. It must be given in normal saline. e. It must be filtered.

ANS: B, D, E The child should have serum levels drawn to monitor for optimal therapeutic levels. In addition, liver function studies should be monitored because this anticonvulsant may cause hepatic dysfunction. The IV dose must be given in normal saline, not D51/2NS. The IV dose must be filtered.

A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Intermittent rigidity b. Lip smacking c. Sudden loss of muscle tone d. Brief jerking of the extremities e. Picking at clothing f. Patting of the hand on the leg

ANS: B, E, F Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, picking at clothing, and patting. Rigidity of muscles is associated with the tonic phase of a seizure, and jerking of the extremities is associated with the clonic phase of a seizure. Loss of muscle tone occurs with atonic seizures.

A nurse is instructing parents on treatment of pediculosis (head lice). Which should the nurse include in the teaching plan? Select all that apply. a. Bedding should be washed in warm water and dried on a low setting. b. After treating the hair and scalp with a pediculicide, shampoo the hair with regular shampoo. c. Retreat the hair and scalp with a pediculicide in 7 to 10 days. d. Items that cannot be washed should be dry cleaned or sealed in plastic bags for 2 to 3 weeks. e. Combs and brushes should be boiled in water for at least 10 minutes.

ANS: C, D, ECorrect An over-the-counter pediculicide, permethrin 1% (Nix, Elimite, Acticin), kills head lice and eggs with one application and has residual activity (i.e., it stays in the hair after treatment) for 10 days. Nix crème rinse is applied to the hair after it is washed with a conditioner-free shampoo. The product should be rinsed out after 10 minutes. Incorrect The hair should not be shampooed for 24 hours after the treatment. Even though the kill rate is high and there is residual action, retreatment should occur after 7 to 10 days. Combs and brushes should be boiled or soaked in antilice shampoo or hot water (greater than 60° C [140° F]) for at least 10 minutes. Advise parents to wash clothing (especially hats and jackets), bedding, and linens in hot water and dry at a hot dryer setting.

Components of the GCS the nurse would use to assess a patient after a head injury includea. blood pressure. b. cranial nerve function. c. head circumference. d. verbal responsiveness.

ANS: D Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness. The nurse would want to assess the blood pressure, but this is not a component of the coma scale. Assessment of cranial nerve function is appropriate as alterations such as cranial nerve VI palsies may occur, but this is not part of the coma scale. Increases in head circumference are associated with alterations in intracranial pressure in infants, but this is not part of the coma scale.

What should the nurse teach parents when the child is taking phenytoin (Dilantin) to control seizures? a. The child should use a soft toothbrush and floss the teeth after every meal. b. The child will require monitoring of renal function while taking this medication. c. Dilantin should be taken with food because it causes gastrointestinal distress. d. The medication can be stopped when the child has been seizure free for 1 month.

Answer A A side effect of Dilantin is gingival hyperplasia. Good oral hygiene will minimize this adverse effect. B The child should have liver function studies because this anticonvulsant may cause hepatic dysfunction, not renal dysfunction. C Dilantin has not been found to cause gastrointestinal upset. The medication can be taken without food. D Anticonvulsants should never be stopped suddenly or without consulting the physician. Such action could result in seizure activity.

A mother reports that her child has episodes where he appears to be staring into space. This behavior is characteristic of which type of seizure? a. Absence b. Atonic c. Tonic-clonic d. Simple partial

Answer A Absence seizures are very brief episodes of altered awareness. The child has a blank expression. B Atonic seizures cause an abrupt loss of postural tone, loss of consciousness, confusion, lethargy, and sleep. C Tonic-clonic seizures involve sustained generalized muscle contractions followed by alternating contraction and relaxation of major muscle groups. D There is no change in level of consciousness with simple partial seizures. Simple partial seizures consist of motor, autonomic, or sensory symptoms.

In caring for a child with a compound fracture, the nurse should carefully assess for a. Infection b. Osteoarthritis c. Epiphyseal disruption d. Periosteum thickening

Answer A Because the skin has been broken, the child is at risk for organisms to enter the wound. B The incidence of osteoarthritis does not increase with a compound fracture. C The chance of epiphyseal disruption is not increased with compound fracture. D Periosteum thickening is part of the healing process and not a complication.

Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include a. Avoiding using any latex product b. Using only nonallergenic latex products c. Administering medication for long-term desensitization d. Teaching family about long-term management of asthma

Answer A Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment. Latex allergy is estimated to occur in 75% of this patient population. B There are no nonallergic latex products. C At this time, desensitization is not an option. D The child does not have asthma. The parents must be taught about allergy and the risk of anaphylaxis.

Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with a diagnosis of bacterial meningitis? a. CSF appears cloudy. b. CSF pressure is decreased. c. Few leukocytes are present. d. Glucose level is increased compared with blood.

Answer A In acute bacterial meningitis, the CSF is cloudy to milky or yellowish in color. B The CSF pressure is usually increased in acute bacterial meningitis. C Many polymorphonuclear cells are present in CSF with acute bacterial meningitis. D The CSF glucose level is usually decreased compared with the serum glucose level.

When assessing the child with atopic dermatitis, the nurse should ask the parents about a history of a. Asthma b. Nephrosis c. Lower respiratory tract infections d. Neurotoxicity

Answer A Most children with atopic dermatitis have a family history of asthma, hay fever, or atopic dermatitis, and up to 80% of children with atopic dermatitis have asthma or allergic rhinitis. B Complications of atopic dermatitis relate to the skin. The renal system is not affected by atopic dermatitis. C There is no link between lower respiratory tract infections and atopic dermatitis. D Atopic dermatitis does not have a relationship to neurotoxicity.

The most common problem of children born with a myelomeningocele is a. Neurogenic bladder b. Intellectual impairment c. Respiratory compromise d. Cranioschisis

Answer A Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder dysfunction among children. B Risk of intellectual impairment is minimized through early intervention and management of hydrocephalus. C Respiratory compromise is not a common problem in myelomeningocele. D Cranioschisis is a skull defect through which various tissues protrude. It is not associated with myelomeningocele.

A nurse is teaching parents the difference between pediatric fractures and adult fractures. Which observation is true about pediatric fractures? a. They seldom are complete breaks. b. They are often compound fractures. c. They are often at the epiphyseal plate. d. They are often the result of decreased mobility of the bones.

Answer A Pediatric fractures seldom are complete breaks. Rather, children's bones tend to bend or buckle. B Compound fractures are no more common than simple fractures in children. C Epiphyseal plate fractures are no more common than any other type of fracture. D Increased mobility of the bones prevents children from having complete fractures.

When changing an infant's diaper, the nurse notices small bright red papules with satellite lesions on the perineum, anterior thigh, and lower abdomen. This rash is characteristic of a. Primary candidiasis b. Irritant contact dermatitis c. Intertrigo d. Seborrheic dermatitis

Answer A Small red papules with peripheral scaling in a sharply demarcated area involving the anterior thighs, lower abdomen, and perineum are characteristic of primary candidiasis. B A shiny, parchment-like erythematous rash on the buttocks, medial thighs, mons pubis, and scrotum, but not in the folds, is suggestive of irritant contact dermatitis. C Intertrigo is identified by a red macerated area of sharp demarcation in the groin folds. It can also develop in the gluteal and neck folds. D Seborrheic dermatitis is recognized by salmon-colored, greasy lesions with a yellowish scale found primarily in skin-fold areas or on the scalp.

Which statement by the mother of an adolescent being discharged after spinal fusion for severe scoliosis indicates the need for further teaching? a. "I am glad we chose surgery. Now it is all over and done." b. "I'll see you in a month; we'll be back fairly regularly." c. "I have to pick up some more T-shirts on the way home." d. "Those exercises the physical therapist showed us were not too hard."

Answer A Spinal fusion requires long-term follow-up to assess the stability of the spinal correction. B This statement indicates the mother's understanding of the need for long-term follow-up. C T-shirts are needed to protect the skin under the orthoplasty jacket, which is worn after fusion. D This statement indicates the mother received instructions and understands that continued interventions are needed.

A priority nursing intervention when caring for a child in a Pavlik harness is a. Skin care b. Bowel function c. Feeding patterns d. Respiratory function

Answer A The child in a Pavlik harness needs special attention to skin care because the infant's skin is sensitive and the harness may cause irritation. B The harness should not affect normal bowel function in the infant. C Families are typically instructed on techniques for holding and feeding. The harness should not affect feeding patterns in the infant. D The harness should not affect normal respiratory function in the infant.

What is the most appropriate intervention for an adolescent with a mild scoliosis? a. Long-term monitoring b. Surgical intervention c. Bracing d. No follow-up

Answer A The child with mild scoliosis requires long-term follow-up to determine whether the curve will progress or remain stable. B Surgical intervention is not needed for mild scoliosis. C Mild scoliosis is not braced if it is stable. D Follow-up to monitor the curve is important until skeletal maturity has occurred.

What should be included in teaching a parent about the management of small red macules and vesicles that become pustules around the child's mouth and cheek? a. Keep the child home from school for 24 hours after initiation of antibiotic treatment. b. Clean the rash vigorously with Betadine three times a day. c. Notify the physician for any itching. d. Keep the child home from school until the lesions are healed.

Answer A To prevent the spread of impetigo to others, the child should be kept home from school for 24 hours after treatment is initiated. Good handwashing is imperative in preventing the spread of impetigo. B The lesions should be washed gently with a warm soapy washcloth three times a day. The washcloth should not be shared with other members of the family. C Itching is common and does not necessitate medical treatment. Rather, parents should be taught to clip the child's nails to prevent maceration of the lesions. D The child may return to school 24 hours after initiation of antibiotic treatment.

A mother whose 7-year-old child has been placed in a cast for a fractured right arm reports that he will not stop crying even after taking acetaminophen with codeine. He also will not straighten the fingers on his right arm. The nurse tells the mother to a. Take him to the emergency department. b. Put ice on the injury. c. Avoid letting him get so tired. d. Wait another hour; if he is still crying, call back.

Answer A Unrelieved pain and the child's inability to extend his fingers are signs of compartmental syndrome, which requires immediate attention. B Placing ice on the extremity is an inappropriate action for the symptoms. C This is an inappropriate response to give to a mother who is concerned about her child. D A child who has signs and symptoms of compartmental syndrome should be seen immediately. Waiting an hour could compromise the recovery of the child.

When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with observable distended scalp veins, the nurse recognizes these signs as indicative of a. Hydrocephalus b. Syndrome of inappropriate antidiuretic hormone (SIADH) c. Cerebral palsy d. Reye's syndrome

Answer A The combination of signs is strongly suggestive of hydrocephalus. B SIADH would not manifest in this way. The child would have decreased urination, hypertension, weight gain, fluid retention, hyponatremia, and increased urine specific gravity. C The manifestations of cerebral palsy vary but may include persistence of primitive reflexes, delayed gross motor development, and lack of progression through developmental milestones. D Reye's syndrome is associated with an antecedent viral infection with symptoms of malaise, nausea, and vomiting. Progressive neurologic deterioration occurs.

What is a sign of increased intracranial pressure (ICP) in a 10-year-old child? a. Headache b. Bulging fontanel c. Tachypnea d. Increase in head circumference

Answer: A Headaches are a clinical manifestation of increased ICP in children. A change in the child's normal behavior pattern may be an important early sign of increased ICP. B This is a manifestation of increased ICP in infants. A 10-year-old child would have a closed fontanel. C A change in respiratory pattern is a late sign of increased ICP. Cheyne-Stokes respiration may be evident. This refers to a pattern of increasing rate and depth of respirations followed by a decreasing rate and depth with a pause of variable length. D By 10 years of age, cranial sutures have fused so that head circumference will not increase in the presence of increased ICP.

Which information should the nurse give to a child who is to have magnetic resonance imaging (MRI) of the brain? a. "Your head will be restrained during the procedure." b. "You will have to drink a special fluid before the test." c. "You will have to lie flat after the test is finished." d. "You will have electrodes placed on your head with glue."

Answer: A To reduce fear and enhance cooperation during the MRI, the child should be made aware that the head will be restricted to obtain accurate information. B Drinking fluids is usually done for gastrointestinal procedures. C A child should lie flat after a lumbar puncture, not during an MRI. D Electrodes are attached to the head for an electroencephalogram.

The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient's functional ability. What question would be the most appropriate?

a. "Are you able to shop for yourself?" b. "Do you use a cane, walker, or wheelchair to ambulate?" c. "Do you know what today's date is?" d. "Were you sad or depressed more than once in the last 3 days?" ANS: B "Do you use a cane, walker, or wheelchair to ambulate?" will assist the nurse in determining the patient's ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Assessing sadness is a question to ask in the depression screening.

A older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to check himself or herself?

a. "Limit the time you spend in the sun." b. "Monitor for signs of infection." c. "Monitor spots for color change." d. "Use skin creams to prevent drying." ANS: C The ABCD method (check for asymmetry, border irregularity, color variation, and diameter) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer.

A patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. The nurse's best response is which of the following?

a. "Walk at least 5 miles every day for exercise." b. "Wear proper fitting shoes to prevent tripping." c. "Talk with your physician about a calcium supplement." d. "Stand up slowly so you don't feel faint." ANS: C Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones but a calcium supplement is a good addition. Wearing proper shoes and standing slowly to prevent dizziness is important but they will not prevent fractures.

A patient asks the nurse what the purpose of the Wood's light is. Which response by the nurse is accurate?

a. "We will put an anesthetic on your skin to prevent pain." b. "The lamp can help detect skin cancers." c. "Some patients feel a pressure-like sensation." d. "It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions." ANS: D The Wood's light examination is the use of a black light and darkened room to assist with physical examination of the skin. The examination does not cause discomfort.

What percentage of hip fractures are the result of falls?

a. 50% b. 80% c. 90% d. 100% ANS: C About 90% of falls end with a hip fracture.

A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient?

a. Apply the cream generously to affected areas. b. Apply a thin coat to affected areas. c. Apply a thin coat to affected areas; avoid the face and groin. d. Apply an antihistamine along with applying a thin coat of steroid to affected areas. ANS: C The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient's risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patient's history and physical. (Select all that apply.)

a. Being a woman b. Taking more than six medications c. Having hypertension d. Having cataracts e. Muscle strength 3/5 bilaterally f. Incontinence ANS: B, D, E, F Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not contribute to falls. Dizziness does contribute to falls.

A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate

a. Candida albicans. b. group A beta-hemolytic streptococci. c. Staphylococcus aureus. d. Streptococcus pyogenes. ANS: D Streptococcus pyogenes is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.

The nurse is assessing a patient's functional performance. What assessment parameters will be most important in this assessment?

a. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment b. Height, weight, body mass index (BMI), vital signs assessment c. Sleep assessment, energy assessment, memory assessment, concentration assessment d. Healthy individual, volunteers at church, works part time, takes care of family and house ANS: A Functional impairment, disability, or handicap refers to varying degrees of an individual's inability to perform the tasks required to complete normal life activities without assistance. Height, weight, BMI, and vital signs are physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance.

A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on?

a. Decreasing pain b. Decreasing pruritus c. Preventing infection d. Promoting drying of lesions ANS: B Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

After shunt procedure, the nurse would monitor the patient's neurologic status by using the

a. electroencephalogram. b. GCS. c. National Institutes of Health Stroke Scale. d. Monro-Kellie doctrine. ANS: B The GCS gives a standardized numeric score of the neurologic patient assessment. An electroencephalogram is used in diagnosing and localizing the area of seizure origin. This scale is an example of one type of specific tool for nurses to use when assessing a patient following stroke. The Monroe-Kellie doctrine is not an assessment or monitoring strategy; it describes the interrelationship of volume and compliance of the three cranial components, brain tissue, cerebral spinal fluid, and blood.

The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient?

a. Eating and drinking, personal cleansing and dressing, working and playing b. Toileting, transferring, dressing, and bathing activities c. Sleeping, expressing sexuality, socializing with peers d. Maintaining a safe environment, breathing, maintaining temperature ANS: D The most critical aspects of care for an unconscious patient are safe environment, breathing, and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting, transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, and socializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however, these are not the most critical for developing the plan of care in an unconscious patient.

The nurse is assessing a patient's functional abilities and asks the patient, "How would you rate your ability to prepare a balanced meal?" "How would you rate your ability to balance a checkbook?" "How would you rate your ability to keep track of your appointments?" Which tool would be indicated for the best results of this patient's perception of their abilities?

a. Functional Activities Questionnaire (FAQ)™ b. Mini Mental Status Exam (MMSE) c. 24hFAQ d. Performance-based functional measurement ANS: A The FAQ is an example of a self-report tool which provides information about the patient's perception of functional ability. The MMSE assesses cognitive impairment. The 24hFAQ is used to assess functional ability in postoperative patients. Performance-based tools involve actual observation of a standardized task, completion of which is judged by objective criteria.

The nurse is assessing a patient's functional ability. Which activities most closely match the definition of functional ability?

a. Healthy individual, works outside the home, uses a cane, well groomed b. Healthy individual, college educated, travels frequently, can balance a checkbook c. Healthy individual, works out, reads well, cooks and cleans house d. Healthy individual, volunteers at church, works part time, takes care of family and house ANS: D Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option.

The home care nurse is trying to determine the necessary services for a 65-year-old patient who was admitted to the home care service status after left knee replacement. Which tool(s) will assist with this determination?

a. Minimum Data Set (MDS) b. Functional Status Scale (FSS) c. 24-Hour Functional Ability Questionnaire (24hFAQ) d. The Edmonton Functional Assessment Tool ANS: C The 24hFAQ assesses the postoperative patient in the home setting. The MDS is for nursing home patients. The FSS is for children. The Edmonton is for cancer patients.

A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient?

a. Obtaining a complete blood count (CBC) b. Protection from excessive heat c. Protection from excessive UV exposure d. Instructing the patient to take their multivitamin prior to treatment ANS: C Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis.

Mobility for the patient changes throughout the life span; this is known as the process of

a. aging and illness. b. illness and disease. c. health and wellness. d. growth and development. ANS: D Growth and development happens from infancy to death. Muscular changes are always happening, and these changes affect the individual and his or her performance in life. Aging, illness, health, and wellness do have an effect on a person, but they don't always affect mobility.

The nurse preparing to care for a patient after a suspected stroke would question an order for a(n)

a. antihypertensive. b. antipyretic. c. osmotic diuretic. d. sedative. ANS: A Anti-hypertensive medications may be detrimental because the mean arterial pressure must be adequate to maintain cerebral blood flow and limit secondary injury. Fever can worsen the outcome after a stroke, and antipyretics can promote normothermia. Osmotic diuretics such as mannitol can decrease interstitial volume and decrease intracranial pressure. Short-acting sedatives can decrease intracranial pressure by reducing metabolic demand. Long-acting sedatives would be avoided to provide times for periodic neurologic assessments.

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient; the nursing assistant understands the instruction when she agrees to

a. bathe and dry the skin vigorously to stimulate circulation. b. keep the head of the bed elevated 30 degrees. c. limit intake of fluid and offer frequent snacks. d. turn the patient at least every 2 hours. ANS: D The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

Primary prevention strategies to reduce the occurrence of head injuries would include

a. blood pressure control. b. smoking cessation. c. maintaining a healthy weight. d. violence prevention. ANS: D Injury prevention measures such as wearing a seat belt, helmet use, firearm safety, and violence prevention programs reduce the risk of traumatic brain injuries. Blood pressure control and exercising can decrease the risk of vascular disease, impacting the cerebral arteries, rather than head injuries. Smoking cessation is one primary prevention strategy which can decrease the risk of vascular disease. Maintaining a healthy weight can decrease the risk of vascular disease.

The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when he or she states, "Patients must

a. have a trapeze over the bed to move properly." b. move themselves in bed to prevent immobility." c. always have a two-person assist to move in bed." d. be moved correctly in bed to prevent shearing." ANS: D Patients must be moved properly in bed to prevent shearing of the skin. Having a trapeze over the bed is only functional is the patient can assist in the moving process. A two-person assist is good, but the patient still needs to be moved properly. A patient may move himself or herself if he or she is able, but shearing may still occur.

The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when she states, "Patients with impaired bed mobility

a. have an increased risk for pressure ulcers." b. like to have extra visitors." c. need to have a mechanical soft diet." d. are prone to constipation." ANS: A Patients who cannot move themselves in bed are more susceptible to pressure ulcers because they cannot relieve the pressure they feel. Extra visitors or diet consistency do not have any bearing on mobility. Constipation should not be a by-product of immobility if a bowel regimen is instituted.

A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. The nurse's best response is "You are weak because

a. your iron level is low. This is known as anemia." b. of your immobility in the hospital. This is known as deconditioning." c. of your poor appetite. This is known as malnutrition." d. of your medications. This is known as drug induced weakness." ANS: B When a person is ill and immobile the body becomes weak. This is known as deconditioning. Anemia, malnutrition, and medications may have an adverse effect on the body, but this is not known as deconditioning.

The lack of weight bearing leads to bone _________ and __________ from the skeletal system.

demineralization, calcium loss calcium loss, demineralization Weight bearing helps to strengthen the bone. Lack of weight bearing means that the bone is losing minerals and calcium that strengthen it.