Chapter 37

2. Which assessment findings help confirm a diagnosis of Down syndrome? (Select all that apply.) a. High-arched, narrow palate b. Protruding tongue c. Long, slender fingers d. Transverse palmar crease e. Hypertonic muscle tone

ANS: A, B, D The assessment findings of Down syndrome include high-arched, narrow palate; protruding tongue; and transverse palmar creases. The fingers are stubby and the muscle tone is hypotonic, not hypertonic.

33. The nurse is talking to the parent of a 13-month-old child. The mother states, "My child does not make noises like 'da' or 'na' like my sister's baby, who is only 9 months old." Which statement by the nurse would be most appropriate to make? a. "I am going to request a referral to a hearing specialist." b. "You should not compare your child to your sister's child." c. "I think your child is fine, but we will check again in 3 months." d. "You should ask other parents what noises their children made at this age."

ANS: A By 11 months of age, a child should be making well-formed syllables such as "da" or "na" and should be referred to a specialist if not. "You should not compare your child to your sister's child," "I think your child is fine, but we will check again in 3 months," and "You should ask other parents what noises their children made at this age" are not appropriate statements to make to the parent.

17. Which term refers to opacity of the crystalline lens that prevents light rays from entering the eye and refracting on the retina? a. Myopia b. Amblyopia c. Cataract d. Glaucoma

ANS: C A cataract refers to opacity of the crystalline lens that prevents light rays from entering the eye and refracting on the retina.Myopia, or nearsightedness, refers to the ability to see objects clearly at close range but not at a distance. Amblyopia, or lazy eye, is reduced visual acuity in one eye. Glaucoma is a group of eye diseases characterized by increased intraocular pressure.

30. The nurse assesses a toddler for excessive tearing and corneal haziness to confirm which medical diagnosis? a. Viral conjunctivitis b. Paralytic strabismus c. Congenital cataract d. Infantile glaucoma

ANS: D Excessive tearing and corneal haziness are indicative of glaucoma. Because the child is younger than 3 years of age, it would be classified as "infantile." Discharge is noted with conjunctivitis. Corneal haziness is not a symptom of conjunctivitis. Paralytic strabismus is caused by weakness or paralysis of one or more of the extraocular muscles. Neither tearing nor corneal haziness is a symptom of paralytic strabismus. Congenital cataract will present as an opacity, but not excessive tearing.

26. An adolescent male visits his primary care provider complaining of difficulty with his vision. When the nurse asks the adolescent to explain what visual deficits he/she is experiencing, the adolescent states, "I am having difficulty seeing distant objects; they are less clear than things that are close." What disorder does the nurse suspect the adolescent has? a. Hyphema b. Astigmatism c. Amblyopia d. Myopia

ANS: D Myopic patients have the ability to see near objects more clearly than those at a distance; it is caused by the image focusing beyond the retina. Hyphema includes hemorrhage in the anterior chamber and is not a refractive disorder. Astigmatism is caused by an abnormal curvature of the cornea or lens. Amblyopia is a problem of reduced visual acuity not correctable by refraction.

21. What intervention should the nurse implement when noting gross bleeding in a child's eye after being hit in the eye? a. Apply a Fox shield. b. Instruct the adolescent to apply ice for 24 hours. c. Have adolescent rest with eye closed and heat applied. d. Notify parents that adolescent needs to see an ophthalmologist.

ANS: D The parents should be notified that the adolescent must see an ophthalmologist as soon as possible. Applying a Fox shield, instructing the adolescent to apply ice for 24 hours, and having the adolescent rest with the eye closed and heat applied may cause further damage.

29. The teaching plan for the parents of a 3-year-old child with amblyopia should include which instruction? a. Apply a patch to the child's eyeglass lenses. b. Apply a patch only during waking hours. c. Apply a patch over the "bad" eye to strengthen it. d. Cover the "good" eye completely with a patch.

ANS: D Treatment for amblyopia (lazy eye) requires that the "good" eye is patched to force the child to use the "bad" eye, thus strengthening the muscles. The patch should always be applied directly to the child's face, not to eyeglasses. The patch should be left in place even when the child is sleeping. Covering the "bad" eye will not contribute to strengthening it. The "good" eye should be patched.

15. Which action best facilitates lipreading by the hearing-impaired child? Speaking at an even rate a. Exaggerating pronunciation of words b. Avoiding using facial expressions c. Repeating in exactly the same way if d. child does not understand

ANS: A The child should be helped to learn and understand how to read lips by speaking at an even rate. Exaggerating word pronunciation, avoiding facial expressions, and repeating words are characteristics of communication that would interfere with the child's comprehension of the spoken word.

16. Prevention of hearing impairment in children is a major goal for the nurse. How can this be best achieved? a. Being involved in immunization clinics for children. b. Assessing a newborn for hearing loss. c. Answering parents' questions about hearing aids. d. Participating in hearing screening in the community.

ANS: A Childhood immunizations can eliminate the possibility of acquired sensorineural hearing loss from rubella, mumps, or measles encephalitis. Assessing a newborn for hearing loss, answering parents' questions about hearing aids, and participating in community hearing screenings are screening interventions to identify the presence of hearing loss, not prevention.

11. What term is used to identify the most common type of hearing loss, which results from interference of transmission of sound to the middle ear? a. Conductive b. Sensorineural c. Mixed conductive-sensorineural d. Central auditory imperceptive

ANS: A Conductive or middle ear hearing loss is the most common type. It results from interference of transmission of sound to the middle ear, most often from recurrent otitis media. Sensorineural, mixed conductive-sensorineural, and central auditory imperceptive are less common types of hearing loss. P

35. A child with autism spectrum disorder (ASD) is admitted to the hospital with pneumonia. The nurse should plan which priority intervention when caring for the child? a. Maintain a structured routine and keep stimulation to a minimum. b. Place the child in a room with a roommate of the same age. c. Maintain frequent touch and eye contact with the child. d. Take the child frequently to the playroom to play with other children.

ANS: A Providing a structured routine for the child to follow is key in the management of ASD. Decreasing stimulation by using a private room, avoiding extraneous auditory and visual distractions, and encouraging the parents to bring in possessions the child is attached to may lessen the disruptiveness of hospitalization. Because physical contact often upsets these children, minimum holding and eye contact may be necessary to avoid behavioral outbursts. Children with ASD need to be introduced slowly to new situations, with visits with staff caregivers kept short whenever possible. The playroom would be too overwhelming with new people and situations and should not be a priority of care. P

2. What is the major consideration when selecting toys for a child who is cognitively impaired? a. Safety b. Age appropriateness c. Ability to provide exercise d. Ability to teach useful skills

ANS: A Safety is the primary concern in selecting recreational and exercise activities for all children. This is especially true for children who are cognitively impaired. Age appropriateness, the ability to provide exercise, and the ability to teach useful skills are all factors to consider in the selection of toys, but safety is of paramount importance.

1. When should a child diagnosed with cognitive impairment be referred for stimulation and educational programs? a. As young as possible. b. As soon as they have the ability to communicate in some way. c. At age 3 years, when schools are required to provide services. d. At age 5 or 6 years, when schools are required to provide services.

ANS: A The child's education should begin as soon as possible. Considerable evidence exists that early-intervention programs for children with disabilities are valuable for cognitively impaired children. The early intervention may facilitate the child's development of communication skills. States are encouraged to provide early-intervention programs from birth under Public Law 101-476, the Individuals with Disabilities Act.

3. A nurse is instructing a nursing assistant on techniques to facilitate lipreading with a hearing-impaired child who lip-reads. Which techniques should the nurse include? (Select all that apply.) a. Speak at eye level. b. Stand at a distance from the child. c. Speak words in a loud tone. d. Use facial expressions while speaking. e. Keep sentences short.

ANS: A, D, E To facilitate lipreading for a hearing-impaired child who can lip-read, the speaker should be at eye level, facing the child directly or at a 45-degree angle. Facial expressions should be used to assist in conveying messages, and the sentences should be kept short. The speaker should stand close to the child, not at a distance. Using a loud tone while speaking will not facilitate lipreading.

18. A nurse would suspect possible visual impairment in a child who displays: a. excessive rubbing of the eyes. b. rapid lateral movement of the eyes. c. delay in speech development. d. lack of interest in casual conversation with peers.

ANS: AExcessive rubbing of the eyes is a clinical manifestation of visual impairment. Rapid lateral movement of the eyes, delay in speech development, and lack of interest in casual conversation with peers are not associated with visual impairment.

5. A 9 year old diagnosed with Down syndrome is mainstreamed into a regular third-grade class for part of the school day. His mother asks the school nurse about programs such as Cub Scouts that he might join. The nurse's recommendation should be based on what knowledge? a. Programs such as Cub Scouts are inappropriate for children who are cognitively impaired. b. Children with Down syndrome have the same need for socialization as other children. c. Children with Down syndrome socialize better with children who have similar disabilities. d. Parents of children with Down syndrome encourage programs such as scouting because they deny that their children have disabilities.

ANS: B Children of all ages need peer relationships. Children with Down syndrome should have peer experiences similar to those of other children, such as group outings, Cub Scouts, and Special Olympics, which can all help children with cognitive impairment to develop socialization skills. Although all children should have an opportunity to form a close relationship with someone of the same developmental level, it is appropriate for children with disabilities to develop relationships with children who do not have disabilities. The parents are acting as advocates for their child.

25. A child with autism is hospitalized with asthma. The nurse should plan care so that the: a. parents' expectations are met. b. child's routine habits and preferences are maintained. c. child is supported through the autistic crisis. d. parents need not be at the hospital.

ANS: B Children with autism are often unable to tolerate even slight changes in routine. The child's routine habits and preferences are important to maintain. Focus of care is on the child's needs rather than on the parent's desires. Autism is a lifelong condition. The presence of the parents is almost always required when an autistic child is hospitalized.

14. An implanted ear prosthesis for children with sensorineural hearing loss is a(n): a. hearing aid. b. cochlear implant. c. auditory implant. d. amplification device.

ANS: B Cochlear implants are surgically implanted, and they provide a sensation of hearing for individuals who have severe or profound hearing loss of sensorineural origin. Hearing aids are external devices for enhancing hearing. An auditory implant does not exist. An amplification device is an external device for enhancing hearing.

12. A parent asks the nurse why a developmental assessment is being conducted for a child during a routine well-child visit. The nurse answers based on what knowledge about such routine developmental assessments? a. Not necessary unless the parents request them. b. The best method for early detection of cognitive disorders. c. Frightening to parents and children and should be avoided. d. Valuable in measuring intelligence in children.

ANS: B Early detection of cognitive disorders can be facilitated through assessment of development at each well-child examination. Developmental assessment is a component of all well-child examinations; however, they are not intended to measure intelligence. Developmental assessments are not frightening when the parent and child are educated about the purpose of the assessment.

10. Distortion of sound and problems in discrimination are characteristic of which type of hearing loss? a. Conductive b. Sensorineural c. Mixed conductive-sensorineural d. Central auditory imperceptive

ANS: B Sensorineural hearing loss, also known as perceptive or nerve deafness, involves damage to the inner ear structures or the auditory nerve. It results in distortion of sounds and problems in discrimination. Conductive hearing loss involves mainly interference with loudness of sound. Mixed conductive-sensorineural hearing loss manifests as a combination of both sensorineural and conductive loss. The central auditory imperceptive category includes all hearing losses that do not demonstrate defects in the conduction or sensory structures.

3. Which intervention is focused on facilitating socialization of the cognitively impaired child? a. Provide age-appropriate toys and play activities. b. Provide peer experiences such as Special Olympics when older. c. Avoid exposure to strangers who may not understand cognitive development. d. Emphasize mastery of physical skills because they are delayed more often than verbal skills.

ANS: B The acquisition of social skills is a complex task. Children of all ages need peer relationships. Parents should enroll the child in preschool. When older, the child should have peer experiences similar to other children, such as group outings, Boy or Girl Scouts, and Special Olympics. Providing age-appropriate toys and play activities is important, but peer interactions will facilitate social development. Parents should expose the child to strangers so the child can practice social skills. Verbal skills are delayed more than physical skills.

19. The school nurse is caring. What emergency treatment is appropriate for a child with a penetrating eye injury? a. Applying a regular eye patch. b. Applying a Fox shield to the affected eye and any type of patch to the other eye. c. Applying ice until the physician is seen. d. Irrigating the eye copiously with a sterile saline solution.

ANS: B The nurse's role in a penetrating eye injury is to prevent further injury to the eye. A Fox shield (if available) should be applied to the injured eye, and a regular eye patch to the other eye to prevent bilateral movement. Applying a regular eye patch or ice until the physician is seen, or irrigating the eye with a copious amount of sterile saline, may cause more damage to the eye.

23. A nurse is providing a parent information regarding autism spectrum disorder (ASD). Which statement made by the parent indicates understanding of the teaching? a. "Autism is characterized by periods of remission and exacerbation." b. "The onset of autism usually occurs before toddler stage." c. "Children with autism have imitation and gesturing skills." d. "Autism can be treated effectively with medication."

ANS: B The onset of ASD is now frequently diagnosed in toddlers because of their atypical development is being recognized early. Autism does not have periods of remission and exacerbation. Autistic children lack imitative skills. Medications are of limited use in children with autism.

22. A parent whose child has been diagnosed with a cognitive deficit should be counseled about what fact related to intellectual impairment? a. Is usually due to a genetic defect. b. Is likely caused by a variety of factors. c. Is rarely due to first-trimester events. d. Is usually caused by parental intellectual impairment.

ANS: B There are a multitude of causes for intellectual impairment. In most cases, a specific cause has not been identified. Only a small percentage of children with intellectual impairment are affected by a genetic defect. One third of children with intellectual impairment are affected by first-trimester events. Intellectual impairment can be transmitted to a child only if the parent has a genetic disorder.

6. A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed nasal bridge, protruding tongue, and transverse palmar creases. These findings are most suggestive of: a. microcephaly. b. Down syndrome. c. cerebral palsy. d. fragile X syndrome.

ANS: B These are characteristics associated with Down syndrome. The infant with microcephaly has a small head. Cerebral palsy is a diagnosis not usually made at birth. No characteristic physical signs are present. The infant with fragile X syndrome has increased head circumference; long, wide, and/or protruding ears; long, narrow face with prominent jaw; hypotonia; and high, arched palate.

1. Which interventions should the nurse plan when caring for a child with a visual impairment? (Select all that apply.) a. Touch the child upon entering the room before speaking. b. Keep items in the room in the same location. c. Describe the placement of the eating utensils on the meal tray. d. Use color examples to describe something to a child who has been blind since birth. e. Identify noises for the child.

ANS: B, C, E Keep all items in the room in the same location and order. Describing how many steps away something is or the placement of eating utensils on a tray are both useful tactics. Identify noises for the child because children who are visually impaired or blind often have difficulty establishing the source of a noise. Never touch the child without identifying yourself and explaining what you plan to do. When describing objects or the environment to a child who is blind or visually impaired use familiar terms. If the child has been blind since birth, color has no meaning.

31. The nurse is discussing sexuality with the parents of an adolescent with moderate cognitive impairment. Which should the nurse consider when dealing with this issue? a. Sterilization is recommended for any adolescent with cognitive impairment. b. Sexual drive and interest are limited in individuals with cognitive impairment. c. Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct. d. Sexual intercourse rarely occurs unless the individual with cognitive impairment is sexually abused.

ANS: C Adolescents with moderate cognitive impairment may be easily persuaded and lack judgment. A well-defined, concrete code of conduct with specific instructions for handling certain situations should be laid out for the adolescent. Permanent contraception by sterilization presents moral and ethical issues and may have psychologic effects on the adolescent. It may be prohibited in some states. The adolescent needs to have practical sexual information regarding physical development and contraception. Cognitively impaired individuals may desire to marry and have families. The adolescent needs to be protected from individuals who may make intimate advances.

34. A nurse is preparing to perform a dressing change on a 6-year-old child with mild cognitive impairment (CI) who sustained a minor burn. Which strategy should the nurse use to prepare the child for this procedure? a. Verbally explain what will be done. b. Have the child watch a video on dressing changes. c. Demonstrate a dressing change on a doll. d. Explain the importance of keeping the burn area clean.

ANS: C Children with CI have a marked deficit in their ability to discriminate between two or more stimuli because of difficulty in recognizing the relevance of specific cues. However, these children can learn to discriminate if the cues are presented in an exaggerated, concrete form and if all extraneous stimuli are eliminated. Therefore, demonstration is preferable to verbal explanation, and learning should be directed toward mastering a skill rather than understanding the scientific principles underlying a procedure. Watching a video would require the use of both visual and auditory stimulation and might produce overload in the child with mild CI. Explaining the importance of keeping the burn area clean would be too abstract for the child.

7. The child diagnosed with Down syndrome should be evaluated for which characteristic before participating in some sports? a. Hyperflexibility b. Cutis marmorata c. Atlantoaxial instability d. Speckling of iris (Brushfield's spots)

ANS: C Children with Down syndrome are at risk for atlantoaxial instability. Atlantoaxial instability (AAI) is characterized by excessive movement at the junction between the atlas (C1) and axis (C2) as a result of either a bony or ligamentous abnormality. Before participating in sports that put stress on the head and neck, a radiologic examination should be done. Although hyperflexibility, cutis marmorata, and Brushfield's spots are characteristics of Down syndrome, they do not affect the child's ability to participate in sports.

24. What should the nurse keep in mind when planning to communicate with a child who is diagnosed with an autism spectrum disorder (ASD)? a. The child has normal verbal communication. b. The child is expected to use sign language. c. The child may exhibit monotone speech and echolalia. d. The child is not listening if he/she is not looking at the nurse.

ANS: C Children with autism have abnormalities in the production of speech, such as a monotone voice or echolalia, or inappropriate volume, pitch, rate, rhythm, or intonation. The child has impaired verbal communication and abnormalities in the production of speech. Some autistic children may use sign language, but it is not assumed. Children with autism often are reluctant to initiate direct eye contact.

4. Which is the most common congenital anomaly associated with Down syndrome? a. Hypospadias b. Pyloric stenosis c. Septal defects d. Congenital hip dysplasia

ANS: C Congenital heart malformations, primarily septal defects, are very common congenital anomalies in Down syndrome. Hypospadias, pyloric stenosis, and congenital hip dysplasia are not frequent congenital anomalies associated with Down syndrome.

9. Which statement accurately describes fragile X syndrome? a. It is a chromosome defect affecting only females. b. It is a chromosome defect that follows the pattern of X-linked recessive disorders. c. It is the second most common genetic cause of cognitive impairment. d. It is the most common cause of noninherited cognitive impairment.

ANS: C Fragile X syndrome is the most common inherited cause of cognitive impairment and the second most common genetic cause of cognitive impairment after Down syndrome. Fragile X primarily affects males and follows the pattern of X-linked dominant disorders with reduced penetrance.

28. Which teaching guideline helps prevent eye injuries during sports and play activities? a. Restrict helmet use to those who wear eyeglasses or contact lenses. b. Discourage the use of goggles with helmets. c. Wear eye protection when participating in high risk sports such as paintball. d. Wear a face mask when playing any sport or playing roughly.

ANS: C High risk sports such as paintball can cause penetrating eye injuries. Eye protection should be worn. All children who participate in sports should be protected by the appropriate headgear. Goggles and helmets can and should be used concurrently. A face mask does not prevent damage to the child's head.

8. Which action is contraindicated when a child diagnosed with Down syndrome is hospitalized? a. Determine the child's vocabulary for specific body functions. b. Assess the child's hearing and visual capabilities. c. Encourage parents to leave the child alone at night. d. Have meals served at the child's usual mealtimes.

ANS: C The child with Down syndrome needs routine schedules and consistency. Having familiar people present, especially parents, helps to decrease the child's anxiety. To communicate effectively with the child, it is important to know the child's particular vocabulary for specific body functions. Children with Down syndrome have a high incidence of hearing loss and vision problems and should have hearing and vision assessed whenever they are in a health care facility. Meals should be served at the usual mealtimes because routine schedules and consistency are important to children with Down syndrome.

20. A father calls the emergency department nurse saying that his child's eyes burn after getting some dishwasher detergent in them. What should the nurse recommend before the child is transported to the emergency department? a. Keep the eyes closed. b. Apply cold compresses. c. Irrigate eyes copiously with tap water for 20 minutes. d. Prepare a normal saline solution (salt and water) and irrigate eyes for 20 minutes.

ANS: C The first action is to flush the eyes with clean tap water. This will rinse the detergent from the eyes. Keeping the eyes closed and applying cold compresses may allow the detergent to do further harm to the eyes during transport. Normal saline is not necessary. The delay during preparation can allow the detergent to cause continued injury to the eyes.

13. The nurse is talking with a 10 year old who wears bilateral hearing aids. The left hearing aid is making an annoying whistling sound that the child cannot hear. What is the most appropriate nursing action to address this issue? a. Ignore the sound. b. Ask the child to reverse the hearing aids. c. Suggest that the child reinsert the hearing aid. d. Suggest that the child raise the volume of the hearing aid.

ANS: C The whistling sound is acoustic feedback. The nurse should have the child remove the hearing aid and reinsert it, making sure that no hair is caught between the ear mold and the ear canal. Ignoring the sound and suggesting that he raise the volume of the hearing aid would be annoying to others. The hearing aids are molded specifically for each ear.

27. Which statement by a parent about a child's conjunctivitis indicates that further teaching is needed? a. "I'll have separate towels and washcloths for each family member." b. "I'll notify my doctor if the eye gets redder or the drainage increases." c. "When the eye drainage improves, we'll stop giving the antibiotic ointment." d. "After taking the antibiotic for 24 hours, my child can return to school."

ANS: CThe antibiotic should be continued for the full prescription. Maintaining separate towels and washcloths will prevent the other family members from acquiring the infection. If the infection proliferates, the physician should be contacted. The child should be kept home from school or day care until the child receives the antibiotic for 24 hours.

32. A nurse is preparing a teaching session for parents on the prevention of childhood hearing loss. The nurse identify what as being the most common cause of hearing impairment in children? a. Auditory nerve damage b. Congenital ear defects c. Congenital rubella d. Chronic otitis media

ANS: D Chronic otitis media is the most common cause of hearing impairment in children. It is essential that appropriate measures be instituted to treat existing infections and prevent recurrences. Auditory nerve damage, congenital ear defects, and congenital rubella are rarer causes of hearing impairment.