Exam 4 pediatrics Silvestri question
The nurse is evaluating the parent's understanding of discharge care regarding the functioning of the infant's ventricular peritoneal shunt. Which statement by a parent indicates an understanding of the shunt complications? a. "I should call my doctor if my baby refuses purees." b. "My baby will pass urine more often now that the shunt is in place." c. "I should position my baby on the side with the shunt when sleeping." d. "If my baby has a high-pitched cry, I should call the primary health care provider."
d. "If my baby has a high-pitched cry, I should call the primary health care provider."
An adolescent is seen in the emergency department following an athletic injury, and it is suspected that the child sprained an ankle. X-rays are taken, and a fracture has been ruled out. The nurse reinforces instructions to the adolescent regarding home care for treatment of the sprain and provides the adolescent with which information? a. Elevate the extremity and maintain strict bed rest for a period of 7 days. b. Immobilize the extremity and maintain the extremity in a dependent position. c. Apply heat to the injured area every 4 hours for the first 48 hours, and then begin to apply ice. d. Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 hours.
d. Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 hours.
The nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP? A. Nausea b. Papilledema c. Decerebrate posturing d. Alterations in pupil size
A. Nausea
The nurse is caring for a 3-year-old child with suspected bacterial meningitis. Which signs and symptoms would the nurse expect to find during the initial data collection? Select all that apply. a.Fever b.Cough c. Irritability d. Hypothermia e. Nuchal rigidity f. Closed anterior fontanel
a, c, e
The nurse is reviewing a chart of a child with a head injury. The nurse notices that the level of consciousness has been documented as obtunded. Which observation would the nurse expect to make during data collection of the child? a. The child is awake, alert, and interacting with the environment. b. The ability to think clearly and rapidly is majorly impaired. c. The ability to recognize place or person is severely affected. d. The child sleeps unless aroused and, once aroused, interacts poorly with the environment.
d. The child sleeps unless aroused and, once aroused, interacts poorly with the environment.
The nurse is assisting a primary health care provider (PHCP) during an examination of an infant with hip dysplasia. The PHCP performs the Ortolani maneuver. Which data would the nurse expect to note during the examination? a. Full range of motion of the legs b. Marked asymmetry on the affected side c. The unstable femoral head pops out of the acetabulum d. The dislocated femoral head pops back into the acetabulum
d. The dislocated femoral head pops back into the acetabulumv
A child with a fractured femur is placed in Buck's skin traction, and the nurse is planning care for the client. Which information about this type of traction is correct? a. Requires frequent pin care b. Places the child at risk for infection c. Uses skeletal traction and weights to provide a counterforce d. Is a type of skin traction that pulls the hip and leg into extension
d. Is a type of skin traction that pulls the hip and leg into extension
The nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). Which is the priority nursing action in the preoperative period? a. Check the blood pressure. b. Check specific gravity of the urine. c, Check the anterior fontanel for depression. d. Maintain moisture of the normal saline dressing on the gibbus area.
d. Maintain moisture of the normal saline dressing on the gibbus area.
The nurse assists in creating a nursing care plan for the child with an arm cast and would include which interventions in the plan? Select all that apply. a. Instruct parents to keep the cast clean and dry. b. Monitor the extremity for circulatory impairment.3 c. nstruct the child not to stick objects down the cast. d. Ensure that rough cast materials are cut off to keep smooth. e, Notify the registered nurse (RN) immediately if circulatory impairment occurs.
a, b, c, e
The nurse teaches the family of an infant with spina bifida that the infant should not be given which baby foods that may trigger a latex-type food allergy? Select all that apply. a.Kiwi b. Prunes c. Apples d. Bananas e. Avocados
a, d, e
The nurse should anticipate that which medication is the most likely to be prescribed prophylactically for a child with spina bifida (myelomeningocele) who has a neurogenic bladder? a. Prednisone b. Sulfasalazine c. Furosemide d. Intravenous immune globulin (IVIG)
b. Sulfasalazine
A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse would take which action? a. Administer an antiemetic. b. Increase the intravenous fluids. c. Place the child in a Sims' position. d. Notify the registered nurse.
d. Notify the registered nurse.
Which finding would indicate that a child had a tonic-clonic seizure during the night? a. High-pitched cry b. Blanched toenails c. Blood on the pillow d. Migraine headaches
c. Blood on the pillow
The mother of a 5-year-old child brings the child to the emergency department and tells the nurse that the child fell. A fracture is suspected, and an x-ray is taken. The results indicate that the child has a comminuted fracture of the right humerus. The mother asks the nurse to describe this type of fracture, and the nurse draws a picture for the mother. Which picture identifies this type of fracture? Refer to figure. A B C D
B
The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement, if made by one of the parents, indicates an understanding of the use of the harness? a. "I can remove the harness to bathe my infant." b. "I need to remove the harness to feed my infant." c. "I need to remove the harness to change the diaper." d. "My infant needs to remain in the harness at all times."
a. "I can remove the harness to bathe my infant."
The nurse is reinforcing instructions to the parents of an infant with clubfoot about the care of a plaster cast. Which statement would the nurse include in the instructions? Select all that apply. a. "The cast can be cleansed with a wet cloth on the outside." b. "The foot should be kept elevated for the first 24 to 48 hours." c. "The cast will dry in 30 minutes, so it can be handled after that time." d. "Reposition the infant every 2 to 4 hours until cast is thoroughly dried." e. "The edges of the cast can be 'petaled' with small pieces of moleskin or adhesive tape."
b, d, e
The nurse is collecting data from a child suspected of having juvenile idiopathic arthritis (JIA). Which findings would the nurse expect to note if JIA were present? Select all that apply. a. Malaise, fatigue, and lethargy b. Painful, stiff, and swollen joints c. Limited range of motion of the joints d. Stiffness that develops later in the day e. Cool temperature of the skin over the affected joints f. History of late afternoon temperature, with temperature spiking up to 105°F
a, b, c, f
The mother of a child with Marfan syndrome asks the nurse what can be done at home to help her child. Which are the best responses by the nurse? Select all that apply. a. "You may need to consider surgery in the future." b. "You will need to make regular pediatric appointments for your child." c."You will need to keep your child indoors and avoid sports." d. "You will need to make regular eye examination appointments for your child." e. "You will need to have your child take cardiac medication(s) to decrease stress on the aorta." f. "You will need to let the dentist know that antibiotics should be given before any procedure."
a, b, d, e, f
The nurse is monitoring an infant for signs of increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant is sleeping. Based on this finding, which is the priority nursing action? a. Increase oral fluids. b. Document the finding. c. Notify the registered nurse. d. Place the infant in a side-lying position.
c. Notify the registered nurse.
The nurse is assisting in preparing a plan of care for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which components would be included in the plan of care? Select all that apply. a. Maintain the bed in a low position. b. Restrain the child if a seizure occurs. c. Pad the side rails of the bed with blankets. d. Place the child in a side-lying lateral position if a seizure occurs. e. Protect the child's head, body, and extremities if a seizure occurs. f. Place a padded tongue blade in the child's mouth if a seizure occurs.
a, c. d, e
The nurse provides homecare instructions to the parent of a child with attention deficit hyperactivity disorder regarding behavioral therapy interventions. Which statement by the parent indicates a need for further teaching? a. "I hear that the side effects of the medication that my child will be on can cause overeating." b. "I know that consistent medication and regular follow-up visits are a part of the plan for my child." c. "I know I need to maintain a consistent home environment because my child is easily distracted." d. "I understand that I will need to learn some behavioral modification techniques to help my child's impulsivity."
a. "I hear that the side effects of the medication that my child will be on can cause overeating."
The nurse is caring for a newborn with a diagnosis of spina bifida (myelomeningocele). Which would the nurse perform to monitor for a major symptom of this condition? a. Test the urine for blood. b. Palpate the abdomen for masses. c. Check for responses to painful stimuli from the torso downward. d. Check the capillary refill on the nail beds of the upper extremities.
c. Check for responses to painful stimuli from the torso downward.
The nurse reinforces instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which instruction provided by the nurse is accurate? a. The harness must be worn 8 hours a day. b. The infant should never be moved when out of the harness. c. The harness must be removed for diaper changes and for feeding. d. The harness needs to be removed to check the skin and for bathing.
d. The harness needs to be removed to check the skin and for bathing.
The nurse would implement which actions in the care of a child who is having a seizure? Select all that apply. a. Time the seizure. b. Restrain the child. c. Stay with the child. d. Insert an oral airway. e. Place the child in a supine position. f. Loosen clothing around the child's neck.
a,c,f
The nurse is caring for a child who sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse plans to monitor for an early sign of increased ICP by checking for which sign? a.Apnea b. Posturing c. Tachycardia d. Changes in level of consciousness
d. Changes in level of consciousness
The nurse is monitoring a child with a cast on the forearm for signs of compartment syndrome. The nurse understands that which data collection technique is unlikely to provide information about this complication? a. Checking the quality of the radial pulse b. Checking the child's ability to extend the fingers c. Checking for effectiveness of analgesics administered for pain d. Checking the child's ability to perform range of motion to the shoulder area of the affected extremity
d. Checking the child's ability to perform range of motion to the shoulder area of the affected extremity
Which is the primary goal that would be included in the plan of care for a child who has cerebral palsy? a. Eliminate the cause of the disease. b. Improve muscle control and coordination. c. Prevent the occurrence of emotional disturbances. d. Maximize the child's assets and minimize the limitations.
d. Maximize the child's assets and minimize the limitations.
A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse would perform which actions in order to protect the child from injury? Select all that apply. a. Restrict the client's fluid intake. b. Turn the client to the side during a seizure. c. Keep side rails and other hard objects padded. d. Keep hospital room lights on all of the time. e. Keep a padded tongue blade at the bedside for use during a seizure.
b,c
The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further teaching? a. "I need to have my child wear a soft fabric under the brace." b. "I will apply lotion under the brace to prevent skin breakdown." c. "I need to encourage my child to perform the prescribed exercises." d. "I need to avoid applying powder under the brace, because it will cake."
b. "I will apply lotion under the brace to prevent skin breakdown."
The nurse is caring for a newborn diagnosed with Down syndrome. The parents are asking questions about the disorder. The nurse would provide which information when discussing Down syndrome? a. The condition is characterized by above-average intellectual functioning with deficits in adaptive behavior. b. The condition is characterized by average intellectual functioning and the absence of deficits in adaptive behavior c. The condition is characterized by subaverage intellectual functioning with the absence of deficits in adaptive behavior. d. The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G).
d. The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G).
The nurse is providing information to the family of a child about a synthetic cast that has been applied to the child for the treatment of a clubfoot. Which information would the nurse provide to the mother? a. The synthetic cast takes 24 hours to dry. b. The synthetic cast is heavier than a plaster cast. c. The synthetic cast is stronger than a plaster cast. d. The synthetic cast allows for greater mobility than a plaster cast.
d. The synthetic cast allows for greater mobility than a plaster cast.
The nurse is preparing to care for a child with a head injury. On review of the records, the nurse notes that the primary health care provider has documented decorticate posturing. The nurse plans care, knowing that this type of posturing indicates which finding? a. Damage to the midbrain b. Dysfunction of the pons d. Damage to the diencephalon e. Dysfunction in the cerebral hemisphere
e. Dysfunction in the cerebral hemisphere
The nurse is assisting with collecting data on a child with seizures. The nurse is interviewing the child's parents to establish their adjustment to caring for their child with a chronic illness. Which statement by the parents indicates a need for further teaching? a. "Our child sleeps in our bedroom at night." b. "We worry about injuries when our child has a seizure." c. "Our child is involved in a swim program with neighbors and friends." d. "Our babysitter just completed first-aid and child resuscitation training."
a. "Our child sleeps in our bedroom at night."
The nurse is developing a plan of care for a child with autism. The nurse would identify which priority problem for this child? a. Risk for injury b. Inability to interact socially c. Troubling thought processes d. Inability to verbally communicate
a. Risk for injury
Which statement would the nurse include when providing safety instructions to the parents of an infant with a diagnosis of hydrocephalus? a. "Feed your infant in a side-lying position." b. "Place a helmet on your infant when in bed." c. "Hyperextend your infant's head with a rolled blanket under the neck area." d. "When picking up your infant, support the infant's neck and head with the open palm of your hand."
d. "When picking up your infant, support the infant's neck and head with the open palm of your hand."
The nurse in a newborn nursery is told that a newborn with spina bifida (myelomeningocele type) will be transported from the delivery room. The nurse is asked to prepare for the arrival of the newborn. The nurse places which priority item at the newborn's bedside? a. A rectal thermometer b. A blood pressure cuff c. A specific gravity urinometer d. A bottle of sterile normal saline
d. A bottle of sterile normal saline
When checking a child's trochlear nerve function, the nurse would perform which data collection technique? a. Have the child look down and in. b. Have the child look toward the temporal side. c. Have the child bite down hard and open the jaw. d. Have the child show the teeth to note symmetry of expression.
a. Have the child look down and in.
The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which finding would the nurse expect to note documented in the infant's record regarding this condition? a. Hip joint laxity b. Symmetric thigh and gluteal folds c. Full range of motion in the affected hip d. An apparent short femur on the unaffected side
a. Hip joint laxity
To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse would include which in the plan of care? a. Initiating seizure precautions b. Using a wheelchair for out-of-bed activities c. Assisting the child with ambulation at all times d. Avoiding contact with other children on the nursing unit
a. Initiating seizure precautions
The nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is best described by which statement? a. Cerebral palsy is an infectious disease of the central nervous system. b. Cerebral palsy is an inflammation of the brain as a result of a viral illness. c. Cerebral palsy is a congenital condition that results in moderate to severe retardation. d. Cerebral palsy is a chronic disability characterized by a difficulty in controlling the muscles.
d. Cerebral palsy is a chronic disability characterized by a difficulty in controlling the muscles.
The nurse reviews the plan of care for a child with Reye's syndrome. Which priority complication would the nurse plan to monitor? a. Signs of hyperglycemia b. Signs of a bacterial infection c. The presence of protein in the urine d. Signs of increased intracranial pressure
d. Signs of increased intracranial pressure
A child has a basilar skull fracture. Which primary health care provider's prescription would the nurse question? a. Restrict fluid intake. b. Insert an indwelling urinary catheter. c. Keep an intravenous (IV) line patent. d. Suction via the nasotracheal route as needed.
d. Suction via the nasotracheal route as needed.
An infant is seen in a clinic and is diagnosed with unilateral hip dysplasia. Which finding is associated with this condition? a. Limited range of motion in the unaffected hip b. An apparent short femur on the unaffected side c. Adduction of the affected hip when placed supine with the knees and hips flexed d. Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table
d. Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table
A child is to be admitted to the orthopedic unit following a Harrington rod insertion for the treatment of scoliosis. The nurse is assisting in preparing a plan of care for the child. The nurse plans to monitor which priority item in the immediate postoperative period? a. Pain level b. Ability to turn using the logroll technique c. Ability to flex and extend the lower extremities d. Capillary refill, sensation, and motion in all extremities
d. Capillary refill, sensation, and motion in all extremities
A child is diagnosed with Reye's syndrome. The nurse assists with developing a nursing care plan for the child and would include which intervention in the plan? a. Assess hearing loss. b. Monitor urine output. c. Change body position every 2 hours. d. Provide a quiet atmosphere with dimmed lighting.
d. Provide a quiet atmosphere with dimmed lighting.
The nurse assists with preparing a nursing care plan for a child who has Reye's syndrome. Which is the priority nursing intervention? a. Monitoring the output b. Checking pupillary responses c. Changing the body position every 2 hours d. Providing a quiet atmosphere with dimmed lights
d. Providing a quiet atmosphere with dimmed lights
The nurse is reinforcing information to parents regarding the signs of meningitis. The nurse informs the parents that which are the primary signs/symptoms of meningitis? a. Nausea and delirium b. Anorexia and back pain c. Night blindness and confusion d. Severe headache and neck stiffness
d. Severe headache and neck stiffness
The nurse has reinforced prior teaching of a school-age child who was given a brace to wear for the treatment of scoliosis. The child needs further teaching if which statement is made? a. "This brace will correct my curve." b. "I will wear my brace under my clothes." c. :I will do back exercises at least five times a week." d. "I will wear my brace whenever I am not sleeping."
a. "This brace will correct my curve."
The nurse is assigned to care for a child with a spica cast. Which action would be avoided when caring for the child? a. Observing for nonverbal signs of pain b. Using pillows to elevate the head and shoulders c. Checking neurovascular status of the extremities d. Placing the child on a stretcher and bringing the child to the playroom
b. Using pillows to elevate the head and shoulders
The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child? A. Keeping the weights hanging freely b. Ensuring that the ropes are in the pulleys c. Placing the bed linens on the traction ropes d. Ensuring that the weights are out of the child's reach
c. Placing the bed linens on the traction ropes
The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this finding, which action would the nurse take? a. Document the findings. b. Lower the head of the bed. c, Place the infant on nothing-by-mouth (NPO) status. d. Ask the registered nurse to notify the primary health care provider immediately.
a. Document the findings.
The nurse is checking the capillary refill of a child with a cast applied to the left arm. The nurse compresses the nail bed of a finger, and it returns to its original color in 2 seconds. Which action would be taken by the nurse? a. Document the findings. b. Notify the registered nurse (RN). c. Prepare the child for bivalving the cast. d. Elevate the extremity and recheck the capillary refill immediately.
a. Document the findings.
A 4-year-old child sustains a fall at home and is brought to the emergency department by the mother. Following x-ray examination, it has been determined that the child has a fractured arm, and a plaster cast is applied. The nurse reinforces instructions to the mother regarding cast care for the child. Which statement by the mother indicates a need for further teaching? a. "The cast will feel warm when it is dried." b. "I can apply ice to the casted area to prevent swelling." c. "If the cast becomes wet, a fan may be used to dry the cast." d. "I need to call the primary health care provider if any blood or drainage appears on the cast."
a. "The cast will feel warm when it is dried."
The nurse notes that a 6-year-old child does not recognize that objects exist when the objects are outside of the visual field. Based on this observation, which action would the nurse take? A. Move the objects in the child's direct field of vision. b. Teach the child how to visually scan the environment. c. Report the observation to the primary health care provider. d. Provide additional lighting for the child during play activities.
c. Report the observation to the primary health care provider.
A school nurse is preparing a physical education plan for a child with Down syndrome. Before preparing the plan, the nurse obtains which copy of an x-ray report? a. The child's hands b. The child's heart c. The child's cervical spine d. The child's chest and lungs
c. The child's cervical spine
The nurse is monitoring a child with a head injury. On data collection, the nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. The nurse documents that the child is experiencing which? a. Decorticate posturing b. Decerebrate posturing c. Flexion of the arms and legs d. An expected position post-head injury
a. Decorticate posturing
The nurse is initiating seizure precautions for a child being admitted to the nursing unit. Which items are essential for the nurse to place at the bedside? a. Oxygen and a tongue depressor b. A suction apparatus and oxygen c. An airway and a tracheotomy set d. An emergency cart and an oxygen mask
b. A suction apparatus and oxygen
The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition? a. An infectious disease of the central nervous system b. An inflammation of the brain as a result of a viral illness c. A congenital condition that results in moderate to severe retardation d. A chronic disability characterized by impaired muscle movement and posture
d. A chronic disability characterized by impaired muscle movement and posture
The nurse is assisting in preparing a plan of care for a child who will be returning from surgery following the application of a hip spica cast. Which would be the priority action in the plan of care for this child on return from the procedure? a. Elevate the head of the bed. b. Check circulation in the feet. c. Abduct the hips using pillows. d. Turn the child onto the right side.
b. Check circulation in the feet.
A 13-year-old child is diagnosed with osteogenic sarcoma of the femur. Following a course of chemotherapy, it is decided that leg amputation is necessary. Following the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which statement made by the nurse will best assist in alleviating the child's fear? a. "The pain medication that I give you will take these feelings away." b. "This aching and cramping are normal and temporary and will subside." c. "This pain is not real pain and relaxation exercises will help it go away." d. "This always occurs after the surgery, and we will teach you ways to deal with it."
b. "This aching and cramping are normal and temporary and will subside."
The nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care knowing that this type of fracture involves which specific characteristic? a. The entire bone fractured straight across b. A greater risk of infection than a simple fracture c. The bone being fractured but not producing a break in the skin d. One side of the bone being broken and the other side being bent
b. A greater risk of infection than a simple fracture
The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for which? a. A lack of appetite b. An elevated temperature c. A decrease in the urinary output d. An increase in the blood pressure
b. An elevated temperature
The nurse employed in the emergency department is collecting data on a 7-year-old child with a fractured arm. The child is hesitant to answer questions that the nurse is asking and consistently looks at the parents in a fearful manner. The nurse suspects physical abuse and continues with the data collection procedures. Which finding would most likely assist in verifying the suspicion? a. Poor hygiene b. Bald spots on the scalp c. Swelling of the genitals d. Lacerations in the anal area
b. Bald spots on the scalp
A licensed practical nurse (LPN) is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. The LPN would take which best action? a. Notify the registered nurse of the finding. b. Check for other associated anomalies and document carefully. c. Tell the mother and father that this may indicate spina bifida. d. Recognize that this is normal in the neonate and continue the bath.
a. Notify the registered nurse of the finding
A child with cerebral palsy (CP) is working to achieve maximum potential for locomotion, self-care, and socialization in school. To meet these goals, which action would the nurse take when working with the child? a. Place the child on a wheeled scooter board. b. Remove ankle-foot orthoses and braces once the child arrives at school. c. Keep the child in a special education classroom with other children with similar disabilities. d. Lay the child in the supine position with a 30-degree elevation of the head to facilitate feeding.
a. Place the child on a wheeled scooter board.
The nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure which need is met? a. Safety with activities. b. Activities providing verbal stimulation c. Social interactions with other children in the same age group d. Familiarity with all activities and providing orientation throughout the activities
a. Safety with activities.
A licensed practical nurse is providing care for a child with hydrocephalus who has had a ventriculoperitoneal shunt revision. Which data collection finding would be reported to the registered nurse immediately? a. Temperature 100.9°F b. Pulse 78 beats per minute c. Blood pressure 110/70 mm Hg d. Respirations 22 breaths per minute Submit
a. Temperature 100.9°F
A nursing student is caring for a child with increased intracranial pressure. On review of the chart, the student nurse notes that a transtentorial herniation has occurred. A nursing instructor asks the student about this type of herniation. Which statement by the student indicates a need for further research about this condition? a. "It can cause death if large amounts of tissue are involved." b. "It involves only the anterior portions of the client's brain." c. "The herniation can be either unilateral or bilateral in nature." d. "The brain herniates downward and around the tentorium cerebelli."
b. "It involves only the anterior portions of the client's brain."
A child with a brain tumor returns from the recovery room following "debulking" of the tumor. The nurse assigned to care for the child monitors the child for brainstem involvement. Which sign would indicate that brainstem involvement occurred during the surgical procedure? a. Inability to swallow b. Altered hearing ability c. Elevated temperature d. Orthostatic hypotension
c. Elevated temperature
The nurse assists with developing a plan of care for the child with meningitis. Which would be the priority client problem for a child with a meningitis diagnosis? a. Pain b. inadequate knowledge c. Neurological dysfunction\ d, Difficult family coping
c. Neurological dysfunction\
The nurse is performing a neurovascular check on a hospitalized child who had a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action would the nurse take? a. Elevate the extremity. b. Document the findings. c. Notify the registered nurse (RN). d. Ambulate the child with crutches. Submit
c. Notify the registered nurse (RN).
The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. During data collection about the child, the nurse expects to note which characteristic of this type of posturing? a. Flaccid paralysis of all extremities b. Adduction of the arms at the shoulders c. Rigid extension and pronation of the arms and legs d. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities
c. Rigid extension and pronation of the arms and legs
The nurse is caring for a pediatric client in skin traction. To prevent skin breakdown, which nursing intervention for this child is best? a. Vigorously massage bony prominences every 4 hours. b. Replace the elastic bandage on skin traction every 8 hours. c. Stimulate circulation with gentle massage over pressure areas. d. Change the child's position at least every 4 hours to relieve pressure.
c. Stimulate circulation with gentle massage over pressure areas.
A child is admitted to the hospital, and a diagnosis of bacterial meningitis is suspected. A lumbar puncture is performed, and the results reveal cloudy cerebrospinal fluid (CSF) with high protein and low glucose levels. The nurse determines that these results are indicative of which finding? a. A negative test b. The need to repeat the test c. confirmation of the diagnosis d. Possible contamination of the specimen
c. confirmation of the diagnosis
The nurse is reinforcing instructions to the mother of a child with juvenile idiopathic arthritis regarding measures to take if a painful exacerbation of the disease occurs. Which statement by the mother indicates the need for further teaching? a. "Hot or cold packs will assist in reducing discomfort." b. "The painful joint should be splinted and positioned in a neutral position." c. "I should have my child perform simple isometric exercises during exacerbations." d. "The full range-of-motion (ROM) exercises must be performed every day, even during the exacerbations."
d. "The full range-of-motion (ROM) exercises must be performed every day, even during the exacerbations."
The nurse is reinforcing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse plans to include which instruction? a. Expect an increased urine output from the shunt." b. "Call the primary health care provider if the infant is fussy." c. "Call the primary health care provider if the infant has a high-pitched cry." d. "Position the infant on the side of the shunt when the infant is put to bed."
c. "Call the primary health care provider if the infant has a high-pitched cry."
The nurse assists in monitoring for early signs of meningitis in a child and assists with attempting to elicit Kernig's sign. Which is the appropriate procedure to elicit a Kernig's sign? a. Tap the facial nerve and check for spasm. b. Extend the leg and knee and check for pain. c. Compress the upper arm and check for tetany. d. Bend the head toward the knees and hips and check for pain.
b. Extend the leg and knee and check for pain.
A nursing student is asked to discuss juvenile idiopathic arthritis (JIA) at a clinical conference scheduled for the end of the clinical day. Which statement by the nursing student indicates the need for further research of this disorder? a. "The cause of this disease is unknown." b. "JIA most often occurs by age of 10 years." c. "This disease is twice as likely to occur in boys as in girls." d. "Clinical manifestations include morning stiffness and painful, stiff, swollen joints."
c. "This disease is twice as likely to occur in boys as in girls."
The client asks the nurse about which product should be taken for a headache. The client is taking lansoprazole for long-term management of the diagnosis of Zollinger-Ellison syndrome. The nurse would determine that which medication is the most appropriate choice for this client? a.Naproxen b.Ibuprofen c. Acetaminophen d. Acetylsalicylic acid
c. Acetaminophen
The nurse reinforces home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further teaching? a. I need to check for jaundiced skin and eyes every day." b. "I need to have my child nap during the day to provide rest." c. "I need to decrease the stimuli at home to prevent intracranial pressure." d. "I need to give frequent, small, nutritious meals if my child starts to vomit."
d. "I need to give frequent, small, nutritious meals if my child starts to vomit."
When reinforcing instructions to the caregiver of a child about cast care, the nurse anticipates the need for further teaching when the caregiver makes which statement? a. "I will encourage my child to avoid standing for too long." b. "I will instruct my child to not put anything inside the cast." c. "I will allow my child to put cotton balls inside the cast to relieve pressure." d. "I will encourage my child to keep the injured extremity elevated while resting."
c. "I will allow my child to put cotton balls inside the cast to relieve pressure."
The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse would make which response to the mother? a. "Avoid all exercise during painful periods." b. "The ROM exercises must be performed every day." c. "Have the child perform simple isometric exercises during this time." d. "Administer additional pain medication before performing the ROM exercises."
c. "Have the child perform simple isometric exercises during this time."
The nurse provides information to the parent of a 2-week-old infant who was diagnosed with clubfoot at the time of birth. Which statement by the parent indicates the need for further teaching regarding this disorder? a. "I understand treatment needs to be started as soon as possible." b. "I realize my child will require follow-up care until full grown." c. "I need to bring my child back to the clinic in 1 month for a new cast." d. "I need to come to the clinic every week with my child for the casting." Submit
c. "I need to bring my child back to the clinic in 1 month for a new cast."
A client has been prescribed valproic acid for the treatment of generalized seizures, and the nurse reinforces instructions to the child about the potential side effects of the medication. Which statement by the client would indicate a need for further teaching? a. "I need to take the pills whole and not crush them." b. "I need to take the medication with food so that I won't get an upset stomach." c. "I am so glad that I won't lose any of my hair. I was worried what my friends would think." d. "I know that I might gain weight with the medication, so I need to be careful to not eat a lot of sweets and to eat more fruits and vegetables."
c. "I am so glad that I won't lose any of my hair. I was worried what my friends would think."
The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching? a. "I will inspect the skin under the brace for redness or breakdown." b. "I will encourage my child to do their exercises to maintain strength." c. "I understand that my child needs to wear this brace for 12 hours a day." d. "I understand that this brace is not a cure for scoliosis, it only slows the progression of the curvature."
c. "I understand that my child needs to wear this brace for 12 hours a day."
The nurse instructs a mother of a child who has seizures regarding seizure precautions. Which statement by the mother indicates a need for further teaching? a. "I will make my child wear a medical identification alert bracelet." b. "I know that my child will need to have a companion when swimming." c. "I will need to give antiseizure medications when my child has a seizure." d. "I will have my child wear a bike helmet when riding a bike or skateboarding."
c. "I will need to give antiseizure medications when my child has a seizure."c. "I will need to give antiseizure medications when my child has a seizure."
A child is brought to the emergency department, and a fracture of the left lower arm is suspected. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. The child receives diagnostic x-rays, from which it has been determined that a fracture is present. A plaster of Paris cast is applied to the arm, and the nurse reinforces instructions to the mother regarding cast care at home. Which instructions would the nurse provide to the mother? a. "The cast should be dry in about 6 hours." b. "The cast is water resistant, so the child is able to take a bath or a shower." c. "The cast needs to be kept dry because when wet it will begin to disintegrate." d. "The cast will not mold to the body and should heal the fracture in no time at all."
c. "The cast needs to be kept dry because when wet it will begin to disintegrate."
The nurse is reviewing the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a ventriculoperitoneal shunt. Which of the primary health care provider's prescriptions does the nurse question? a. Position the infant on the inoperative side. b. Keep the head of the bed elevated 45 degrees. c. Monitor for signs of infection and check dressings for drainage. d. Observe for irritability, a high shrill cry, lethargy, and poor feeding.
b. Keep the head of the bed elevated 45 degrees.
The nurse is caring for a child following surgical removal of a brain tumor. The nurse is monitoring the child and notes that the pulse rate has increased and the blood pressure has dropped significantly. Bloody drainage also is noted on the posterior dressing. Which is the best nursing action? a. Document the findings. b. Notify the registered nurse (RN). c. Recheck the vital signs in 1 hour. d. Place the child in Trendelenburg's position.
b. Notify the registered nurse (RN).
