A&S Quiz 3
A nurse is caring for an adolescent who has sustained a closed head injury. Which of the following are clinical manifestations 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
A. CORRECT: A headache is a clinical manifestation of ICP. B. CORRECT: Alterations in pupillary response are a clinical manifestation of ICP. C. INCORRECT: Decreased motor response is a clinical manifestation of ICP. D. CORRECT: Increased sleeping is a clinical manifestation of ICP. E. INCORRECT: Decreased sensory response is a clinical manifestation of ICP.
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. CORRECT: A negative gram stain indicates viral meningitis. B. CORRECT: Normal glucose content indicates viral meningitis. C. INCORRECT: A clear color indicates viral meningitis. D. INCORRECT: A slightly elevated WBC count indicates viral meningitis. E. CORRECT: Normal protein content indicates viral meningitis
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 offered on 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."
A. CORRECT: Caffeine can alter the results of an EEG and should be avoided prior to the test. B. INCORRECT: The child's hair should be washed to remove oils that permit adherence of the EEG electrodes. C. INCORRECT: Foods are not withheld prior to an EEG. D. INCORRECT: Analgesics may alter the results of an EEG and should be avoided prior to the test.
A nurse is teaching a parent about dexamethasone (Decadron) to treat head injury. Which of the following should be included in the teaching? A. "It decreases cerebral edema." B. "It promotes control of seizures." C. "It promotes improved pain management." D. "It is used to treat an infection."
A. CORRECT: Dexamethasone is a corticosteroid and is used to decrease cerebral edema associated with a head injury. B. INCORRECT: Antiepileptics control seizures. C. INCORRECT: Analgesics are used for pain management. D. INCORRECT: Antibiotics treat infections
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. CORRECT: Due to the client's decreased level of consciousness, placing the client on NPO status is an appropriate action by the nurse. B. INCORRECT: This is not an appropriate action by the nurse. Liver biopsies are used to diagnose Reye syndrome. C. INCORRECT: This is not an appropriate action by the nurse. Position the client without a pillow and slightly elevate the head of the bed. D. INCORRECT: 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.
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
A. CORRECT: Febrile episodes can cause general tonic-clonic seizures in infants and young children. B. CORRECT: Seizure activity is a late manifestation of hypoglycemia. C. CORRECT: Seizure activity is a manifestation of hyponatremia and hypernatremia. D. INCORRECT: High serum lead levels is a risk factor for seizure activity. E. INCORRECT: Diphtheria is a respiratory illness causing difficulty breathing and is not a risk factor for seizures.
A nurse is assessing a child. Which of the following are clinical manifestations of epiglottitis? (Select all that apply.) A. Hoarseness and difficulty speaking B. Difficulty swallowing C. Low-grade fever D. Drooling E. Dry, barking cough F. Stridor
A. CORRECT: Hoarseness and difficulty speaking is a clinical manifestation of epiglottitis. B. CORRECT: Difficulty swallowing is a clinical manifestation of epiglottitis. C. INCORRECT: A high fever is a clinical manifestation of epiglottitis. D. CORRECT: Drooling is a clinical manifestation of epiglottitis. E. INCORRECT: Dry, barking cough is a clinical manifestation of croup. F. CORRECT: Stridor is a clinical manifestation of epiglottitis.
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 daydreaming C. Dropping held objects D. Falling to the floor E. Having a piercing cry
A. CORRECT: Loss of consciousness for 5 to 10 seconds is a clinical manifestation of an absence seizure. B. CORRECT: Behavior that resembles daydreaming is a clinical manifestation of an absence seizure. C. CORRECT: A child who is having absence seizures may drop a held object. D. INCORRECT: Falling to the floor is a clinical manifestation of a tonic-clonic seizure. E. INCORRECT: The presence of a piercing cry is a clinical manifestation of a tonic-clonic seizure.
A nurse is caring for an infant. Which of the following are clinical manifestations of coarctation of the aorta? (Select all that apply.) A. Weak femoral pulses B. Cool skin of lower extremities C. Severe cyanosis D. Clubbing of the fingers E. Heart failure
A. CORRECT: Narrowing of the lumen of the aorta results in obstruction of blood flow from the ventricle, resulting in weak or absent femoral pulses. B. CORRECT: Narrowing of the lumen of the aorta results in obstruction of blood flow from the ventricle, resulting in cool skin of the lower extremities. C. INCORRECT: A client who has coarctation of the aorta exhibits adequate oxygenation of blood. Therefore, severe cyanosis is not present. D. INCORRECT: Clubbing of the fingers is a clinical manifestation of chronic hypoxemia and will not be observed in an infant who has coarctation of the aorta. E. CORRECT: Heart failure occurs when the heart is unable to meet the body's demands, and is a clinical manifestation of coarctation of the aorta.
A nurse is caring for a child who is suspected of having rheumatic fever. Which of the following manifestations support this diagnosis? (Select all that apply.) A. Erythema marginatum (rash) B. Continuous joint pain of the digits C. Tender, subcutaneous nodules D. Decreased erythrocyte sedimentation rate E. Elevated C-reactive protein
A. CORRECT: Rheumatic fever is caused by Group A β-hemolytic streptococcus. An erythema marginatum (rash) is a clinical manifestation. B. INCORRECT: A client who has rheumatic fever exhibits migratory joint pain of the large joints. C. INCORRECT: A client who has rheumatic fever exhibits nontender subcutaneous nodules of bony prominences. D. INCORRECT: Rheumatic fever is caused by Group A β-hemolytic streptococcus, which results in an elevated erythrocyte sedimentation rate. E. CORRECT: Rheumatic fever is caused by Group A β-hemolytic streptococcus. An increase in C-reactive protein is a clinical manifestation.
A nurse is caring for a child who was admitted to the emergency department after 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 is the priority nursing action at this time? A. Keep the neck stabilized. B. Insert a nasogastric tube. C. Obtain vital signs. D. Establish IV access.
A. CORRECT: The greatest risk to a 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. INCORRECT: Inserting a nasogastric tube in is important. However, this is not the priority action. C. INCORRECT: Obtaining vital signs is important. However, this is not the priority action. D. INCORRECT: Establishing IV access is important. However, this is not the priority action.
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
A. CORRECT: The implantation of a vagal nerve stimulator is an option to provide seizure control. B. CORRECT: Additional antiepileptic medication can be added to the current medication regime to control seizures. C. CORRECT: A corpus callosotomy can be performed for uncontrolled seizures. D. CORRECT: A focal resection can be performed for uncontrolled seizures. E. INCORRECT: Radiation therapy is used in cancer treatment and is not used to control 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 in a side-lying position. B. Monitor vital signs. C. Reorient the child to the environment. D. Assess for injuries.
A. CORRECT: Using the airway, breathing, circulation priority-setting framework, the first action is to place the child in a side-lying position to maintain a patent airway and prevent aspiration of secretions. B. INCORRECT: Monitoring the child's vital signs is an appropriate action. However, it is not the priority action. C. INCORRECT: Reorienting the child to the environment following a generalized seizure is an appropriate action. However, it is not the priority action. D. INCORRECT: Assessing for injuries is an appropriate action. However, it is not the priority action
A nurse is assessing a child who has a concussion. Which of the following are clinical manifestations of a minor head injury? (Select all that apply.) A. Vomiting B. Delayed pupillary response C. Drowsiness D. Pallor E. Confusion
A. CORRECT: Vomiting is a clinical manifestation of a minor head injury. B. INCORRECT: Alterations in pupillary response are a clinical manifestation of a major injury. C. CORRECT: Drowsiness is a clinical manifestation of a minor head injury. D. CORRECT: Pallor is a clinical manifestation of a minor head injury. E. CORRECT: Confusion is a clinical manifestation of a minor head injury.
A nurse is discussing care of a child who has Kawasaki disease with a newly hired nurse. What should be included in this discussion? Use the ATI Active Learning Template: Systems Disorder to complete this item to include: A. Clinical Manifestations: Identify for the acute, subacute, and convalescent phase. B. Nursing Care: List seven for this client.
A. Clinical Manifestations ●● Acute phase: onset of high fever that is unresponsive to antipyretics, with development of other manifestations ◯◯ Fever greater than 38.9° C (102° F) lasting 5 days to 2 weeks and unresponsive to antipyretics ◯◯ Irritability ◯◯ Red eyes without drainage ◯◯ Bright red, chapped lips ◯◯ Strawberry tongue with white coating or red bumps on the posterior aspect ◯◯ Red oral mucous membranes ◯◯ Swelling of hands and feet with red palms and soles ◯◯ Non-blistering rash ◯◯ Bilateral joint pain ◯◯ Enlarged lymph nodes ●● Subacute phase: resolution of the fever and gradual subsiding of other manifestations ◯◯ Irritability ◯◯ Peeling skin around the nails, on the palms and soles ●● Convalescent phase: no clinical manifestations seen except altered laboratory findings. Resolution in about 6 to 8 weeks from onset. B. Nursing Care ●● Monitor vital signs, ECG, and cardiac status. ●● Assess client for heart failure (decreased urine output, gallop heart rhythm, tachycardia, respiratory distress). ●● Monitor I&O. Obtain daily weight. ●● Administer IV fluids. Offer clear liquids and soft foods. ●● Administer IV gamma globulin according to facility policy. ●● Administer aspirin as prescribed. ●● Provide care to include oral hygiene, cool cloths to extremities, application of skin lotion; providing for a quiet environment to promote rest; cluster nursing care.
A nurse is caring for a child who is in the postoperative period following a tonsillectomy. Which of the following is a clinical finding of postoperative bleeding? A. Hgb of 11.6 and Hct of 37% B. Inflamed and reddened throat C. Frequent swallowing and clearing of the throat D. Blood-tinged mucus
A. INCORRECT: A Hgb of 11.6 and Hct of 37% are within the expected reference range. B. INCORRECT: Inflamed and reddened throat is an expected finding following a tonsillectomy. C. CORRECT: Frequent swallowing and clearing of the throat indicates that there is an increased amount of fluid in the back of the throat, which is a clinical finding in the client who is experiencing postoperative bleeding. D. INCORRECT: Blood-tinged mucus is an expected finding following a tonsillectomy.
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
A. INCORRECT: A bulging anterior fontanel is a finding associated with meningitis in a 4-month-old infant. B. INCORRECT: Vomiting is a finding associated with meningitis in a 4-month-old infant. C. INCORRECT: 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. CORRECT: A high-pitched cry is a finding associated with meningitis in a 4-month-old infant.
A nurse is assessing an infant. Which of the following should the nurse recognize as clinical manifestations of heart failure? (Select all that apply.) A. Bradycardia B. Cool extremities C. Peripheral edema D. Increased urinary output E. Nasal flaring
A. INCORRECT: A client who has heart failure will exhibit tachycardia as the heart attempts to meet the body's demands. B. CORRECT: A client who has heart failure will exhibit cool extremities as the heart is unable to adequately circulate oxygenated blood. C. CORRECT: A client who has heart failure will exhibit peripheral edema as the heart is unable to adequately circulate blood through the body and back to the heart. D. INCORRECT: With heart failure, the heart is unable to keep up with the body's demands. A decrease in urinary output is a clinical manifestation of heart failure. E. CORRECT: A client who has heart failure will exhibit nasal flaring due to inadequate oxygenation of blood.
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. INCORRECT: A recent history of infectious cystitis caused by Candida, a fungal infection, is not a risk factor for Reye syndrome. B. INCORRECT: A recent history of bacterial otitis media is not a risk factor for Reye syndrome. C. CORRECT: 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. INCORRECT: A recent episode of Haemophilus influenzae meningitis, a bacterial infection, is not a risk factor for Reye syndrome.
A nurse is teaching a group of parents about influenza. Which of the following should be included in the teaching? A. "Amantadine will prevent the illness." B. "Rimantadine is administered intramuscularly." C. "Zanamivir can be given to children 1 year and older." D. "Oseltamivir should be given within 48 hours of onset of symptoms."
A. INCORRECT: Amantadine can shorten the length of the illness. B. INCORRECT: Rimantadine is administered orally two times per day for 7 days. C. INCORRECT: Zanamivir is approved for children over the age of 5 years. D. CORRECT: Oseltamivir decrease flu manifestations in clients who have findings for less than 48 hr.
A nurse is caring for a child in the postoperative period following a tonsillectomy. Which of the following is an appropriate action for the nurse to take? A. Encourage the child to blow her nose gently. B. Administer analgesics on a schedule. C. Offer orange juice. D. Position the child supine
A. INCORRECT: Blowing the nose causes pressure and could increase the risk of bleeding. B. CORRECT: Analgesics should be administered on a scheduled basis to provide pain relief. C. INCORRECT: Citrus juices such as orange juice can cause discomfort and should be avoided postoperatively. D. INCORRECT: The client should be positioned on the abdomen or side-lying following a tonsillectomy
A nurse is caring for a child who has bronchiolitis. Which of the following are appropriate actions for the nurse to take? (Select all that apply.) A. Administer oral prednisone. B. Initiate chest percussion and postural drainage. C. Administer humidified oxygen. D. Suction the nasopharynx as needed. E. Administer oral penicillin.
A. INCORRECT: Corticosteroids are not indicated for a client who has bronchiolitis. B. INCORRECT: Chest percussion and postural drainage are not indicated for a client who has bronchiolitis. C. CORRECT: Humidified oxygen provides moisture to the airway and is an appropriate action for the nurse to take. D. CORRECT: Suctioning the nasopharynx will assist the client to clear secretions and is an appropriate action for the nurse to take. E. INCORRECT: Antibiotics are not indicated for a client who has bronchiolitis
A nurse is providing teaching to the mother of an infant who is to start taking digoxin (Lanoxin). Which of the following instructions should the nurse include? A. "Do not offer your baby fluids after giving the medication." B. "Digoxin increases your baby's heart rate." C. "Give the correct dose of medication at regularly scheduled times." D. "If your baby vomits a dose, you should repeat the dose to ensure that he gets the correct amount."
A. INCORRECT: Digoxin can be given without regard to food or fluids. B. INCORRECT: Digoxin slows the heart rate by increasing contractility of the heart. C. CORRECT: The correct amount of digoxin should be administered at regularly scheduled times to maintain therapeutic blood levels. D. INCORRECT: It is not recommended to repeat digoxin following an emesis because it is impossible to determine how much medication was lost.
A nurse is caring for a child who has increased intracranial pressure. Which of the following are appropriate actions by the nurse? (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. INCORRECT: Routine suctioning of the endotracheal tube is poorly tolerated, not recommended, and raises intracranial pressure. B. CORRECT: Stimulation can cause increased intracranial pressure, and maintaining a quiet environment is an appropriate action for the nurse to take. C. INCORRECT: Pillows under the head cause flexion of the neck and increase intracranial pressure. D. CORRECT: Increased pressure in the abdomen with the Valsalva maneuver can increase intracranial pressure. Administering a stool softener is an appropriate action by the nurse. E. CORRECT: Flexion and extension of the neck or hips increase intracranial pressure. Therefore, maintaining body alignment is an appropriate action by the nurse.
A nurse is caring for a 2-year-old child who is cyanotic and is in the hospital for a cardiac catheterization to repair cardiac defects. The child will be transferred to the pediatric ICU following the procedure. Which of the following is an appropriate nursing action when providing care to this child? A. Place on NPO status for 12 hr prior to the procedure. B. Check for iodine or shellfish allergies prior to the procedure. C. Elevate the affected extremity following the procedure. D. Limit fluid intake following the procedure
A. INCORRECT: The child should remain NPO 4 to 6 hr prior to the procedure. B. CORRECT: Iodine-based dyes may be used in this procedure, so the child is assessed for allergies to iodine or shellfish which could lead to anaphylaxis. C. INCORRECT: The affected extremity should be maintained in a straight position following the procedure. D. INCORRECT: Fluids should be encouraged after the procedure to maintain adequate urine output and promote excretion of the dye.
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. INCORRECT: The introduction of the IPV did not decrease the incidence of bacterial meningitis. B. CORRECT: The introduction of the PCV decreased the incidence of bacterial meningitis in children, as it provides immunity against bacteria that causes the illness. C. INCORRECT: The introduction of the DTaP vaccine did not decrease the incidence of bacterial meningitis. D. CORRECT: 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. INCORRECT: The introduction of the TIV did not decrease the incidence of bacterial meningitis.
A nurse is teaching a parent of a child who has an infectious respiratory illness. What should be included in the teaching? Use the ATI Active Learning Template: Basic Concept to complete this item to include Related Content: Identify at least three strategies to decrease the spread of infection.
Using the ATI Active Learning Template: Basic Concept ●● Related Content ◯◯ Perform appropriate hand hygiene. ◯◯ Cover the nose and mouth with tissues when sneezing and coughing. ◯◯ Dispose of tissues properly. ◯◯ Do not share cups, eating utensils, or towels. ◯◯ Keep infected children from contact with children who are well.
A nurse is admitting a client who has Reye Syndrome. Use the ATI Active Learning Template: Systems Disorder complete this item to include the following: A. Description of Disorder/Disease Process B. Objective and Subjective Data: Identify five. C. Laboratory Tests: List two results indicative of Reye syndrome.
Using the ATI Active Learning Template: Systems Disorder A. Description of Disorder/Disease Process ●● Reye syndrome is a life-threatening disorder involving acute encephalopathy and fatty changes of the liver. B. Objective and Subjective Data ●● Recent viral illness ●● Recent use of aspirin (Bayer Children's) ●● Lethargy ●● Irritability ●● Combativeness ●● Confusion ●● Delirium ●● Profuse vomiting ●● Convulsions ●● Loss of consciousness C. Laboratory Tests ●● Altered serum electrolytes due to cerebral edema and liver changes ●● Possibly extended coagulation times ●● Elevated liver enzymes ●● Elevated serum ammonia levels
A nurse is planning care for a child who has tonic-clonic seizures. What nursing actions should be included in the plan of care? Use the ATI Active Learning Template: Systems Disorder to complete this item to include Nursing Care: Describe nursing actions during and after a seizure.
Using the ATI Active Learning Template: Systems Disorder ●● During a seizure ◯◯ Protect the child from injury. (Move furniture away, hold head in lap if on the floor.) ◯◯ Position the child to maintain a patent airway. ◯◯ Be prepared to suction oral secretions. ◯◯ Turn the child to the side (decreases risk of aspiration). ◯◯ Loosen restrictive clothing. ◯◯ Do not attempt to restrain the child. ◯◯ Do not attempt to open the jaw or insert an airway during seizure activity. (This may damage teeth, lips, or tongue.) Do not use padded tongue blades. ◯◯ Remove glasses. ◯◯ Administer oxygen. ◯◯ Remain with the child. ◯◯ Note the onset, time, and characteristics of the seizure. ◯◯ Allow the seizure to end spontaneously. ●● Postseizure ◯◯ Maintain the child in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions. ◯◯ Check vital signs. ◯◯ Assess for injuries, including the mouth. ◯◯ Perform neurologic checks. ◯◯ Allow the child to rest if necessary. ◯◯ Reorient and calm the child (she may be agitated or confused). ◯◯ Maintain seizure precautions, including placing the bed in the lowest position and padding the side rails to prevent future injury. ◯◯ Note the time of the postictal period. ◯◯ Remain with the child. ◯◯ Do not offer food or liquids until completely awake and has a swallow reflex. ◯◯ Encourage the child to describe the period before, during, and after the seizure activity. ◯◯ Determine if the child experienced an aura, which may indicate the origin of seizure in the brain. ◯◯ Try to determine the possible trigger, such as fatigue or stress. ◯◯ Document the onset and duration of seizure and client findings/observations prior to, during, and following the seizure (level of consciousness, apnea, cyanosis, motor activity, incontinence).
A nurse is teaching a parent of a child about complications of a head injury. What should be included in the teaching? Use the ATI Active Learning Template: Systems Disorder to complete this item to include Potential Complications: Identify three and their corresponding clinical manifestation.
Using the ATI Active Learning Template: Systems Disorder ●● Potential Complications ◯◯ Epidural hemorrhage Bleeding between the dura and the skull Clinical manifestations: short period of unconsciousness followed by a normal period leading to herniation, coma, and death ◯◯ Subdural hemorrhage Bleeding between the dura and the arachnoid membrane Results from birth injury, falls, or violent shaking Clinical manifestations: irritability, vomiting, seizures ◯◯ Cerebral edema Develops 24 to 72 hr posttrauma Clinical manifestations: increased ICP ◯◯ Brain herniation Downward shift of brain tissue Clinical manifestations: loss of blinking, loss of gag reflex, decreased pupillary response, coma, and respiratory arrest
