chapters 23 and 24 quiz
What information would the nurse give to parents of a young child following surgical insertion of a pressure equalization tube during myringotomy after eardrum rupture?
The tube may fall out spontaneously within 6 to 12 months
The nurse completed a neurovascular check on a child in Russell's traction for a fractured femur. Which finding should be reported to the charge nurse?
Toes feel tingly
18. Which assessment finding in a child with meningitis should be reported immediately?
a. Irregular respirations Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported immediately because they could indicate increased intracranial pressure.
15. What nursing action will significantly decrease the risk of serious complications for a child in Bryants traction?
a. Neurovascular checks are done frequently. The nurse caring for a child in traction must be alert for Volkmanns ischemia, which occurs when circulation is obstructed.
15. A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would the nurse expect to assess after a generalized tonic-clonic seizure?
b. Sleepiness Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness.
36. The nurse records the finding of ---------- when the child with meningitis cries out in pain when his head is flexed toward his chest.
nuchal rigidity Stiffness of the neck resulting from inflamed meninges is a sign of meningitis called nuchal rigidity.
is a condition in which neck motion is limited and the cervical spine is rotated because of shortening of the sternocleidomastoid muscle.
Torticollis Torticollis (tortus, twisted, and collium, neck) is a condition in which neck motion is limited and the cervical spine is rotated because of shortening of the sternocleidomastoid muscle. It can be either congenital or acquired and can also be either acute or chronic.
9. The nurse is checking for capillary refill on a child in Bryants traction. How long does it take for the toe to regain color if adequate perfusion is assessed?
a. 3 seconds Capillary refill in 3 seconds or less is determined to be indicative of adequate perfusion.
12. A parent reports that her child has begun to do poorly at school and experiences episodes where he appears to be staring into space. Of which type of seizure is this behavior a characteristic?
a. Absence Absence seizures are characterized by transient loss of consciousness where the child appears to stare blankly, and may last only a few seconds.
7. The nurse is providing instructions about how to treat a sprained ankle. What statement by the mother does the nurse recognize as indicative of a need for additional teaching?
a. Apply warm compresses to the ankle for the first 24 hours Heat is not a treatment for soft tissue injuries. The principles of managing soft tissue injuries are rest, ice, compression, and elevation.
14. What intervention is appropriate for a nurse assessing a preadolescent child for scoliosis?
a. Ask the child to bend forward at the waist and observe the childs back for asymmetry. The nurse looks at the back as the child bends forward for general body alignment and asymmetry.
Which is an expected assessment finding in a child with suspected scoliosis?
Asymmetry of the shoulders
---------------occurs when there is a change in the atmospheric pressure between the internal body systems and the surrounding environment.
Barotrauma Barotrauma occurs when there is a change in the atmospheric pressure between the internal body systems and the surrounding environment.
Which type of traction would the nurse expect to be used for a 20 month old child who has a fractured femur?
Bryant's
One of the most common causes of death in a child with muscular dystrophy is:
Cardiac failure
Which disease is usually inherited as a sex linked disorder?
Duchenne's muscular dystrophy
What is an appropriate nursing intervention for feeding a child with spastic type cerebral palsy?
Feed with a ribber coated spoon
34. The child with Duchennes muscular dystrophy must push on his legs and walk up the leg in order to rise to a standing position. The nurse recognizes this characteristic behavior as ----------- maneuver.
Gowers Gowers maneuver is a unique way of rising from the floor by walking up the leg in order to get the upper body erect.
The nurse recognizes which as symptoms of meningitis?
Irritability and fever
What is the priority for the care of a child with decreased level of consciousness resulting from a head injury?
Maintain a patent airway
An infant brought to the emergency department wit a high fever, irritability, and a high pitched cry would immediately be evaluated for:
Meningitis
When taking the history of a child with encephalitis, it is important to note recent:
Respiratory infection
28. What factor(s) may trigger abuse in a parent? (Select all that apply.)
-Being abused as a child -Substance abuse -Overwhelming responsibility -Knowledge deficit relative to child care
Which factor is most likely to trigger seizures in a child with epilepsy?
Sensitivity to light
Which nursing action is appropriate when caring for a hospitalized child who is hearing impaired?
Speak at eye level with the child
23. The nurse urges the mother of a 6-month-old to get her child inoculated with Haemophilus influenzae type B. What does this immunization protect against?
a. Bacterial meningitis H. influenzae type B and conjugated pneumococcal vaccines have decreased the incidence of bacterial meningitis.
32. The nurse is educating parents on prevention of eyestrain in their 5-year-old child. What information will the nurse include? (Select all that apply.)
-Encourage books with large type -Provide adequate lightening without glare. -Be sure desks and chairs are adequate height. Children who are beginning to read need books with large type in which the letters are spaced far apart. The lighting must be adequate and without glare. Chairs and desks must be of the proper height
28. Which assessments would cause the pediatric nurse to suspect the probability of an ear infection in a 6- month-old child? (Select all that apply.)
-Irritability -Rolls head from side to side -Temperature of 39.4 C ( 103 F) Infants signal ear infections by being irritable, rolling their heads from side to side, spiking a temperature, and pulling at or rubbing their ears.
22. On entering the room of a child in Bucks traction, the nurse makes all of the following observations. Which observation requires a nursing intervention?
a. Childs heels are placed firmly against the foot of the bed. Bucks traction is dependent on the child as a counterweight. The heels should be elevated above the level of the foot of the bed
30. What intervention(s) would the nurse caring for a child with infectious meningitis include? (Select all that apply.)
-Isolation precautions -Observation for increasing intracranial pressure -Preparation for spinal tap -Seizure precautions All elements of nursing care listed in the options, except a brightly lit room, would be part of comprehensive care of a child with meningitis.
31. What will the nurse include then documenting a grand mal seizure? (Select all that apply.)
-Presence of incontinence -Activity level prior to and following seizure -Level of consciousness following seizure -Length of seizure Documentation on a seizure should include LOC following episode, activity prior to and following seizure, change in color, respiration, muscle tone, and length of seizure. Reporting of medication regimen is not necessary.
29. The nurse demonstrates which similarities among all traction devices? (Select all that apply.)
-Pull the limb into extension -Decrease muscle spasm -Align two bone fragments -Immobilize the limb Tractions are designed to immobilize and pull limbs into extension. Traction can also align broken bones and decrease muscle spasm. Although some traction devices may relieve pain, many may actually cause pain.
The nurse is reinforcing the health care provider's explanation of treatment for Legg Calve perthes disease. What information would the nurse review with parents?
Ambulation abduction casts or braces
34. An 8-year-old near-drowning victim is rushed into the ED. What priorities of care will be implemented? (Select all that apply.)
-Respiratory support -Cardiovascular support -Controlled rewarming -Adequate cerebral oxygenation Respiratory and cardiovascular support, controlled rewarming, and maintenance of adequate cerebral oxygenation are priorities of care. The parents should be offered support, explanations of the therapy, and referral to social services, religious, or community agencies for follow-up.
31. How does the pediatric skeletal system differ from that of the adult? (Select all that apply.)
-lower mineral content -Open epiphyses -Greater strength The childs skeletal system has less mineral content, greater porosity, open epiphyses, greater bone strength, and a thicker periosteum.
29. Which aspect(s) of a childs development does the nurse caution parents that hearing impairment can affect? (Select all that apply.)
-speech clarity -Language development -Personality development -Academic achievement
When a child is referred to a health care provider after scoliosis screening, the plan is to defer treatment and watch the child. The nurse determines that the child's curvature must be less than:
20 degrees
32. The nurse explains that Bryants traction is reserved for children who weigh less than ------ pounds.
30 Bryants traction is a skin traction used in the treatment of orthopedic disorders of young children who weigh less than 30 pounds. Greater weight would cause excessive counterbalance and injury to soft tissues
19. A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain when she raises herself onto the bedpan. Which nursing diagnosis takes highest priority for this child?
a. Pain resulting from tissue trauma Although all of these nursing diagnoses are relevant to the child in traction, pain resulting from muscle spasm and tissue trauma is the highest priority.
7. What might the nurse explain as a common treatment for amblyopia?
a. Patching the good eye to force the brain to use the affected eye Early detection and treatment are essential for the child with amblyopia. Treatment includes patching the good eye and using glasses to correct refractive errors
18. Which observation may cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs?
a. Red, green, and yellow bruises on his body As bruises heal, they change color in stages. Different colors of bruises indicate that injuries have not all occurred at the same time. The nurse must consider whether the bruises match the caretakers explanation of what happened.
25. Which nursing diagnosis would be a priority when preparing a plan of care for a child in a leg cast?
a. Risk for altered peripheral tissue perfusion Casting can lead to compromised tissue perfusion caused by increased pressure from edema or swelling pressing on the tissues. Neurovascular checks are an assessment priority.
13. An adolescent has just had a generalized seizure and collapsed in the school nurses office. When should the nurse should call 911?
a. The seizure lasts more than 5 minutes. If there are multiple seizures or if seizures last more than 5 minutes, call 911 because these are indicators of possible status epilepticus, a medical emergency.
26. Parents of a 10-year-old child diagnosed with an intellectual deficit are sharing multiple approaches they implement in dealing with various challenges. Which of the following a statements by the parents alerts the nurse that they need further instruction?
a. We dress our son every morning for school. The mentally handicapped child needs to develop a sense of accomplishment. Caregivers should not take over projects because of their own need to assist or speed up the process.
11. A child hospitalized for treatment of osteomyelitis complains that he is tired of being sick and wants to know when the antibiotic protocol will end. How long will the nurse indicate that antibiotic therapy will probably last?
b. 6 weeks Because osteomyelitis is an infection in the bone, antibiotics are given intravenously for 4 to 6 weeks.
16. Which intervention would be helpful in relieving morning discomfort associated with juvenile rheumatoid arthritis?
b. Applying moist heat packs upon awakening Application of moist heat, with a compress or by tub bath upon awakening, will help to lessen stiffness.
2. What intervention will the nurse caring for a child in Bucks skin traction implement?
b. Assist the child to be pulled up in bed. Bucks traction is a type of skin traction that relies on the childs weight as counterbalance. The child must be kept with head elevated no more than 20 degrees and pulled up in bed, and the feet should not touch the bed surface or the foot of the bed.
6. What assessment made by the school nurse would lead to the suspicion of strabismus?
b. Child covers one eye to read the chalkboard Indicators of strabismus include covering one eye to see, tilting the head to see, and missing objects in attempts to pick them up. Although headaches may be associated with amblyopia, this symptom is too vague to point suspicion to any disorder
25. A child is diagnosed with nonparalytic strabismus. How will this disorder most likely be corrected?
b. Corrective lenses In nonparalytic strabismus the refractory error is usually corrected with eyeglasses.
24. The nurse is caring for a 3-year-old with a head injury. Which assessment would lead the nurse to report the probability of increasing intracranial pressure (ICP)?
b. Increase in blood pressure with an attendant decrease in pulse Increasing blood pressure, accompanied by decreasing pulse, and accompanied by unequal pupils are indicators of ICP.
14. What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?
b. Move objects out of the childs immediate area. During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury.
13. A 13-year-old girl is diagnosed with functional scoliosis. What does the nurse explain as the cause of this spinal curvature defect?
b. Poor posture Functional scoliosis usually is caused by poor posture, and it is not a spinal disease.
10. The parent of a child with osteomyelitis asks why his child is in so much pain. What will the nurse respond causes the pain experienced with osteomyelitis?
b. Purulent drainage in the bone marrow Osteomyelitis is an infection of the bone. Inflammation produces an exudate that collects under the marrow and cortex of the bone. The vessels are compressed and thrombosis occurs, producing ischemia and pain.
4. The nurse is reviewing the characteristics of Ewings sarcoma. Which statement if made by the nurse indicates correct understanding of this disease?
b. The disease is sensitive to radiation and chemotherapy Ewings sarcoma is sensitive to radiation therapy and chemotherapy. Amputation of the affected extremity is not recommended. This cancer occurs in school-age children and does metastasize.
20. What would the nurse consider an abnormal finding on a musculoskeletal assessment of a 4-year-old child?
b. Walks on the toes Toe walking after 3 years of age may indicate a muscle problem.
23. Approximately how old does the nurse assess a large green bruise on the thigh of a 4-year-old to be?
c. 6 days Bruises heal in various stages that are indicated according to color; after 5 to 7 days bruise are green
8. What assessment does the school nurse recognize as the cardinal sign of a hyphema?
c. A dark-red spot in front of the iris A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury.
9. The nurse is planning to teach parents about prevention of Reyes syndrome. What information would the nurse include in this teaching?
c. Avoid giving salicylate-containing medications to a child who has viral symptoms Prevention of Reyes syndrome includes educating parents not to give aspirin-containing medication to children with viral symptoms.
5. What would the nurse include when planning postoperative teaching for a child who has had a tympanostomy with insertion of tubes?
c. Avoiding getting water in the ears After a tympanostomy, care should be taken to avoid getting water in the ears.
22. A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks she has had headaches, with vomiting, that are worse in the morning. What does the nurse suspect?
c. Brain tumor The signs and symptoms of a brain tumor are related to its size and location. Most tumors create increased intracranial pressure (ICP) with the hallmark symptoms of headache, vomiting, drowsiness, and seizures.
21. A child is brought to the emergency department after he fell and hit his head on the ground. Which nursing assessment suggests the child has a concussion?
c. Cannot remember what happened to him A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness. It is accompanied often by a loss of memory of the events that occurred immediately before, during, or after the injury.
3. What will the nurse include when caring for a child in Bucks extension?
c. Checking for skin irritation from traction equipment The skin exposed to frequent friction may break down.
20. What will the nurse teach parents when giving instructions for acute conjunctivitis?
c. Clear drainage from the inner to the outer aspect of the eye. Eye secretions are always cleared from the inner canthus downward and away from the opposite eye (inner to outer direction).
19. The nurse observes a childs position is supine with his arms and legs rigidly extended and the hands pronated. How does the nurse identify this posture?
c. Decerebrate In decerebrate posturing, arms are extended along the side of the body and hands are pronated. This posture indicates brainstem function only.
1. What would the nurse include in planning teaching to parents of a child with Legg-Calv-Perthes disease about the long-term effects of this disease?
c. Degenerative arthritis may develop later in life. Marked distortion of the head of the femur may lead to an imperfect joint or to degenerative arthritis of the hip later in life.
4. What is the best way for the nurse to communicate with a 10-year-old child who has a hearing impairment?
c. Face the child and speak clearly in short sentences. The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality.
5. What characteristic manifestation does the nurse caring for a child with Duchennes muscular dystrophy document?
c. Falls frequently and is clumsy Frequent falling and clumsiness are clinical manifestations of Duchennes muscular dystrophy.
16. What would the nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)?
c. Gums should be massaged regularly to prevent hyperplasia Dilantin can cause gum overgrowth, which can be minimized by regular massaging. Dilantin frequently causes drowsiness and should be given with meals at the same time each day.
27. What would the nurse include in teaching when preparing to teach parents about air travel instructions to prevent barotrauma in infants?
c. Letting the infant nurse during descent Encouraging an infant to swallow reduces the pressure in the ears during descent.
30. The nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation? (Select all that apply.)
c. Limb is cool to the touch. d. Capillary refill is 5 seconds The limb should be warm, and capillary refill should be less than 3 seconds.
26. A child is sent to the school nurse for assessment because she comes to school every day disheveled, unbathed, and hungry. The assessment does not indicate any bruises or marks on the body. What do these finding indicate?
c. Physical neglect Physical neglect is the failure to provide for the basic physical needs of the child, including food, clothing, shelter, and basic cleanliness.
17. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy?
c. Spastic Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles jerky and uncoordinated.
24. A pediatric nurse is assisting with the care of a child diagnosed with a fractured femur. What type of fracture would be the most likely to alert the nurse to the possibility of physical abuse?
c. Spiral fracture A spiral fracture of the femur is caused by a forceful twisting motion. When the history of an injury does not correlate with x-ray findings, child abuse should be suspected because spiral fractures can be the result of manual twisting of the extremity.
10. What symptom leads the nurse caring for a 5-month-old with viral influenza to suspect the development of Reyes syndrome?
c. Sudden vomiting without effort A child with a viral infection is at risk for Reyes syndrome, the onset of which is effortless vomiting, lethargy, and a change in level of consciousness. A 5-month-old child who sleeps after eating is normal
6. The nurse assessing a child with juvenile rheumatoid arthritis notes the childs right knee and ankle are swollen, warm, and tender. The child has a temperature of 38.8 C (102 F) and abdominal pain. What type of juvenile rheumatoid arthritis do these findings suggest?
c. Systemic The systemic form of juvenile rheumatoid arthritis is associated with an elevated temperature, erythrocyte sedimentation rate (ESR), and C-reactive protein; abdominal pain; and a macular rash.
17. What instruction would the nurse provide to an adolescent who has been fitted with a Milwaukee brace?
c. Wear the brace over a T-shirt 23 hours a day. A Milwaukee brace is worn approximately 23 hours a day over a T-shirt, which protects the skin.
36. A nurse assessing welts on the body of a 2-year-old Vietnamese child should consider the skin lesions might be the result of the cultural practice of ----------.
coining Some Vietnamese place heated coins on the body to cure disease. This practice leaves welts that are sometimes mistaken for child abuse.
35. The nurse recognizes the signs of syndrome in a child in 90-90 traction when the toes are pale and edematous and have a very slow capillary refill.
compartment When a limb is in traction or has been cast, the caregiver must check for adequate perfusion of the limb. Compartment syndrome occurs when the attendant edema from the injury or the traction compromises the circulation. This is an emergency and must be corrected before permanent damage can occur.
The nurse monitors fluid intake and output in children with a head injury to:
control cerebral edema
3. Which situation would cause the nurse to suspect a hearing impairment?
d. 24-month-old toddler who communicates by pointing The child who is not making verbal attempts by 18 months should undergo a complete physical examination.
33. The nurse is performing a neurological assessment on a 10-month-old infant using a modified Glasgow Coma Scale. What score will the nurse give if the child is babbling?
d. 4 ANS: D If babbling, the 10-month-old infant receives a score of 4 for responses.
21. Why does a childs fracture heal more rapidly than the adults?
d. A childs bones have faster callus formation. Callus forms more rapidly in the child than the adult.
12. What finding would the nurse assessing the neurovascular status of a child in Russell traction report immediately?
d. Bluish coloration of skin Cyanosis or pallor noted in an extremity is an indication of circulatory impairment.
2. What statement by a patients mother leads the nurse to determine she understands instructions about administering an oral antibiotic for otitis media?
d. I will administer prescribed doses until all the medication is used. ANS: D Antibiotic therapy for otitis media is continued until the prescribed amount has been completed, even if symptoms are alleviated.
27. Which assessment performed by a nursing student performing a neurovascular check alerts the instructor that further education is necessary?
d. Pupils Neurovascular checks include assessment of pain, pulse, sensation, color, capillary refill, and movement. Pupils are assessed with a neurological check.
8. How does Russell traction provide adequate skin traction?
d. Supplies continuous pull in two directions Russell traction is skin traction, similar to Bucks, with a sling positioned under the knee, which prevents subluxation of the tibia. Although the traction interferes with full ROM, the patient can change position without disrupting the continuous pull in two directions.
1. A parent comments that her infant has had several ear infections in the past few months. Why are infants more susceptible to otitis media?
d. The eustachian tube is short, straight, and wide. ANS: D An infants eustachian tubes are short, wide, and straight, allowing microorganisms easy access to the middle ear.
11. What does the nurse explains to parents of a child with febrile seizures?
d. They occur when the temperature rises quickly. ANS: D Febrile seizures occur in response to a rapid rise in temperature, often above 38.8 C (102 F).
35. The sign that suggests possible damage to the cortex of the brain is ----------------posturing.
decorticate Decorticate posturing is a flexor rigidity of the arms, wrists, fingers, and feet. This posture suggests injury to the brain cortex.
The nurse teaching parents about adverse effects of phenytoin (Dilantin) would explain this medication can cause:
gum overgrowth
37. The cranial nerve responsible for allowing an infant to suck and swallow formula from a bottle is the ------- nerve.
hypoglossal The hypoglossal (XII) nerve allows the infant to be able to suck and swallow. It is also responsible for tongue movement.
The nurse is aware that a fracture involving the epiphyseal plate in a long bone can result in:
impaired bone growth
The treatment of osteomyelitis includes the use of
juvenile rheumatoid arthritis
An appropriate nursing intervention for an infant with bacterial meningitis is to:
keep the room quiet and indirectly lit
33. The nurse reminds the adolescent boy with Ewings sarcoma that he is prohibited from vigorous weight- bearing activities during treatment with radiation to reduce the risk of a(n) -----------fracture.
pathological The bone has lost its integrity because of the cancer and radiation. Excessive or vigorous weight bearing can cause a pathological fracture of the compromised bone.
An appropriate nursing action when caring for a child in Bryant's traction is to
position the child's legs at right angles to the body
A 7 month old child had a febrile seizure. Which statement would the nurse give to the infant's parents?
rarely develop into epilepsy
Nursing care for a child following a generalized tonic clonic seizure would include:
turning on his or er side
Early signs of Reye's syndrome include?
vomiting and lethargy
Which question will elicit the best information to determine a plan of care during hospitalization for a 5 year old child who has intellectual impairment?
what is her bedtime routine
