quiz 4 nurse labs

1. A nurse is caring for an infant who has a hydrocele. Which of the following actions should the nurse take? A. Prepare the child for surgery. B. Explain to the parents that the issue will self-resolve. C. Retract the foreskin and cleanse several times daily. D. Refer the family for genetic counseling.

1. A. Hydroceles are surgically repaired if they have not resolved spontaneously in 1 year. B. CORRECT: Hydrocele is fluid in the scrotum and resolves spontaneously in the majority of cases. C. Retracting foreskin and cleansing several times each day is done when an infant has phimosis. D. A referral for genetic counseling is recommended for families who have an infant with ambiguous genitalia. NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures

Buck's traction

is a type of skin traction with the legs in an extended position. It is used primarily for short-term immobilization, preoperatively with dislocated hips, for correcting contractures, or for bone deformities such as Legg-Calvé-Perthes disease.

Bryant's traction

is skin traction with the legs flexed at a 90-degree angle at the hip. Modified Bryant's Traction is used mainly to help reduce congenital hip dislocation. When the child is lying on his back, the traction holds the legs upright and the weight on the traction gently stretches the child's leg. This loosens the ligaments, tendons, and muscles around the child's hip

Russell's traction

uses skin traction on the lower leg and a padded sling under the knee. The combination of longitudinal and perpendicular traction allows realignment of the lower extremity and immobilizes the hips and knees in a flexed position.

Hannah's child is scheduled for surgery due to myelomeningocele; the primary reason for surgical repair is which of the following? A. To prevent hydrocephalus B. To reduce the risk of infection C. To correct the neurologic defect D. To prevent seizure disorders

Correct Answer: B. To reduce the risk of infection Surgical closure decreases the risk of infection stemming from damage to the fragile sac, which can lead to meningitis. Prenatal surgery was proven to be more effective than postnatal surgery in lowering the occurrence of future complications.

2. A nurse is caring for a male infant who has an epispadias. Which of the following findings should the nurse expect? (Select all that apply.) A. Bladder exstrophy B. Inability to retract foreskin C. Widened pubic symphysis D. Urethral opening on the dorsal side of the penis. E. Pain

2. A. CORRECT: Bladder exstrophy is a possible expected finding of a male infant who has epispadias. B. Inability to retract foreskin is a manifestation of phimosis. C. CORRECT: Widened pubic symphysis is an expected finding for a male infant who has epispadias. D. CORRECT: Presence of the urethral opening on the dorsal side of the penis is an expected finding for a male infant who has epispadias. E. Pain is a manifestation of testicular torsion, varicocele, and hydrocele. © NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. A nurse is caring for an infant who has ambiguous genitalia. Which of the following actions should the nurse take? (Select all that apply.) A. Prepare the child for surgery. B. Test the child's infant's function. C. Cover the genitals with a sterile dressing. D. Refer the family for genetic counseling. E. Explain the need for a chromosomal analysis.

3. A. CORRECT: Infants who have ambiguous genitalia will need surgery. Preparing the family for surgery is an appropriate action for the nurse to take. B. Plan to test the infant's adrenal function to rule out adrenal insufficiency. C. Cover the bladder with a sterile dressing for bladder exstrophy. D. CORRECT: Families with an infant who has ambiguous genitalia will need ongoing support. Referring to genetic counseling is an appropriate action for the nurse to take. E. CORRECT: Chromosomal analysis is used for sex assignment, and is therefore an appropriate action for the nurse to take. © NCLEX® Connection: Health Promotion and Maintenance, Aging Process

4, Anurse is caring for an infant who has obstructive uropathy. Which of the following findings should the nurse expect? (Select all that apply.) A. Decreased urine flow B. Urinary tract infection C. Intrauterine polyhydramnios D. Concentrated urine E. Hydronephrosis

4. A. Increased urine flow is a manifestation of obstructive uropathy. B. CORRECT: Urinary tract infection is a manifestation of obstructive uropathy. C. Intrauterine oligohydramnios is an indicator of possible obstruction in the fetus. D. Inability to concentrate is a manifestation of obstructive uropathy. E. CORRECT: Hydronephrosis is a manifestation of obstructive uropathy. @ NCLEX® Connection: Physiological Adaptation, Pathophysiology

The school nurse assesses Brook, a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Which of the following symptoms are characteristic of the disorder? Select all that apply. A. Constant fidgeting and squirming B. Excessive fatigue and somatic complaints C. Difficulty paying attention to details D. Easily distracted E. Running away F. Talking constantly, even when inappropriate

Correct Answer: A, C, D, & F These behaviors are all characteristic of ADHD and indicate that the child is inattentive, hyperactive, and impulsive. Individuals suffering from this disorder show patterns of developmentally inappropriate levels of inattentiveness, hyperactivity, or impulsivity. Although there used to be two different diagnoses of Attention Deficit Disorder vs Attention Deficit Hyperactivity Disorder, the DSM IV combined this into one disorder with three subtypes: predominantly inattentive, predominantly hyperactive, or combined type.

Hydrocortisone cream 1% is given to a child with eczema. The nurse gives instruction to the mother to apply the cream by? A. Apply a thin layer of cream and spread it into the area thoroughly. B. Avoid cleansing the area before the application. C. Apply a thick layer of the cream to affected areas only. D. Apply the cream to other areas to avoid occurrence.

Correct Answer: A. Apply a thin layer of cream and spread it into the area thoroughly. Topical corticosteroids are administered sparingly and rubbed into the area thoroughly. Topical steroid creams and ointments should be applied in a thin layer and massaged into the affected area.

A 1-year-and 2-month-old child weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip dislocation. When preparing the patient's room, the nurse anticipates using which traction system? A. Bryant's traction B. Buck's extension traction C. Overhead suspension traction D. 90-90 traction

Correct Answer: A. Bryant's traction Bryant's traction is used to treat femoral fractures of congenital hip dislocation in children under age 2 who weigh less than 30 lb (13.6 kg). In Bryant's traction, the child's body and the weights are used as tension to keep the end of the femur (the large bone that goes from the knee to the hip) in the hip socket.

Nurse Cheryl is assessing Fred, a 14-year-old boy who had scoliosis; besides checking neurologic status directly after Harrington rod instrumentation and spinal fusion, she should be regarded with which of the following factors? A. Comfort level B. Dietary tolerance C. Physical therapy needs D. Understanding of the procedure

Correct Answer: A. Comfort level Instrumentation and spinal fusion cause considerable pain. Therefore, the adolescent needs vigorous pain management, which involves assessment, administration of pain medication, and evaluation of the response. In the immediate postoperative period, the child is conscious of sensation and surroundings.

An inborn error of metabolism that causes premature destruction of RBC? A. G6PD B. Homocystinuria C. Phenylketonuria D. Celiac Disease

Correct Answer: A. G6PD Glucose-6-phosphate dehydrogenase deficiency (G6PD) is an X-linked recessive hereditary disease characterized by abnormally low levels of glucose-6-phosphate dehydrogenase (abbreviated G6PD or G6PDH), a metabolic enzyme involved in the pentose phosphate pathway, especially important in red blood cell metabolism.

Nurse Chole is evaluating a female child with acute post-streptococcal glomerulonephritis for signs of improvement. Which finding typically is the earliest sign of improvement? A. Increased urine output B. Increased appetite C. Increased energy level D. Decreased diarrhea

Correct Answer: A. Increased urine output Increased urine output, a sign of improving kidney function, typically is the first sign that a child with acute post-streptococcal glomerulonephritis (APSGN) is improving. PSGN typically presents with features of the nephritic syndrome such as hematuria, oliguria, hypertension, and edema, though it can also present with significant proteinuria.

Niklaus was born with hypospadias; which of the following should be avoided when a child has such condition? A. Surgery B. Circumcision C. Intravenous pyelography (IVP) D. Catheterization

Correct Answer: B. Circumcision Hypospadias refers to a condition in which the urethral opening is located below the glans penis or anywhere along the ventral surface (underside) of the penile shaft. The ventral foreskin is lacking, and the distal portion gives an appearance of a hood. Early recognition is important so that circumcision is avoided; the foreskin is used for surgical repair.

What is most likely the underlying physiology of primary enuresis? A. Psychogenic stress B. Delayed bladder maturation C. Urinary tract infection D. Vesicoureteral reflux

Correct Answer: B. Delayed bladder maturation The most likely cause of primary enuresis is delayed or incomplete maturation of the bladder. Primary enuresis is that which occurs in a child who has not been dry for at least 6 months, whereas secondary enuresis is the one that has an onset after a period of nocturnal dryness of at least 6 months.

In diagnosing seizure disorder, which of the following is the most beneficial? A. Skull radiographs B. EEG C. Brain scan D. Lumbar puncture

Correct Answer: B. EEG The EEG recognizes abnormal electrical activity in the brain. The pattern of multiple spikes can assist in the diagnosis of particular seizure disorders. Electroencephalography (EEG) is a biomarker for epilepsy. Focal or generalized epileptiform discharges constitute the EEG hallmark of seizure activity. Frequently EEG is obtained as a risk-stratification tool for a patient with a seizure of possibility of seizures.

Mrs. Lodge's child requires the use of a Pavlik harness. Which of the following would Nurse Betty do to best assess the mother's ability to care for her child? A. Demonstrate to the mother how to remove and reapply the device. B. Have the mother remove and reapply the harness before discharge. C. Have the mother verbalize the purpose of using the device. D. Request a home health care nurse visit after discharge.

Correct Answer: B. Have the mother remove and reapply the harness before discharge. Having the mother remove and reapply the harness before discharge allows the nurse to directly observe the mother's method and comfort level. It also provides time for reinstruction if needed. A successful transition also depends on whether hospitals have adequately educated patients about key elements of care such as diagnosis and follow-up plans.

Tiffany is diagnosed with increased intracranial pressure (ICP); which of the following if stated by her parents would indicate a need for Nurse Charlie to reexplain the purpose for elevating the head of the bed at a 10 to 20-degree angle? A. Help alleviate headache B. Increase intrathoracic pressure C. Maintain neutral position D. Reduce intra-abdominal pressure.

Correct Answer: B. Increase intrathoracic pressure Head elevation decreases, not increases, intrathoracic pressure. In most patients with intracranial hypertension, head and trunk elevation up to 30 degrees is useful in helping to decrease ICP, providing that a safe CPP of at least 70 mmHg or even 80 mmHg is maintained.

Lily , age 5, with an intelligence quotient of 65 is admitted to the hospital for evaluation. When planning care, the nurse should keep in mind that this child is: A. Within the lower range of normal intelligence B. Mildly retarded but educable C. Moderately retarded but trainable D. Completely dependent on others for care

Correct Answer: B. Mildly retarded but educable. According to the American Association on Mental Deficiency, a person with an intelligence quotient (IQ) between 50 and 70 is classified as mildly mentally retarded but educable. However, it is no longer a standard to classify intellectual disability by IQ score alone. For instance, if an individual has an IQ below 70, but has a good adaptive function, the subject does not have an intellectual disability.

Which of the following would be inappropriate when administering chemotherapy to a child? A. Monitoring the child for both general and specific adverse effects B. Observing the child for 10 minutes to note for signs of anaphylaxis C. Administering medication through a free-flowing intravenous line D. Assessing for signs of infusion infiltration and irritation

Correct Answer: B. Observing the child for 10 minutes to note for signs of anaphylaxis. When administering chemotherapy, the nurse should observe for an anaphylactic reaction for 20 minutes and stop the medication if one is suspected. Anaphylaxis is a severe allergic reaction, which can cause shock, low blood pressure, and occasionally death. Food allergies, including allergy to peanuts and tree nuts, are said to account for the majority of fatal or near-fatal anaphylactic reactions in the U.S.A. Care is taken especially when chemotherapy medications are known to be common allergic reaction producers, to premedicate to prevent or lessen the reaction.

Nurse Kevin is assessing a newborn for developmental dysplasia of the hip (DDH); he would expect to assess which of the following? A. Characteristic limp B. Ortolani's sign C. Symmetrical gluteal folds D. Trendelenburg's signs

Correct Answer: B. Ortolani's sign Ortolani's sign is felt and heard when a newborn's or neonate's hip is flexed and abducted. The hip is held in the way the thumb on the inner aspect and index and ring finger on the greater trochanter. While applying anterior force on the greater trochanter, gently abduct the hip. If the hip is dislocated, one would feel a jerk or clunk. "Hip clicks" are clinically insignificant without instability.

Neurovascular assessment for a fracture patient includes: Select all that apply. A. Prosthesis B. Polyps C. Pain D. Pallor E. Pulselessness F. Paresthesia G. Paralysis H. Poikilothermia

Correct Answer: C, D, E, F, G, and H When damage occurs to a muscle or muscle group within the fascial compartment, the resulting swelling and bleeding can create an increased pressure that, if left untreated, can choke off circulation, eventually leading to localized cellular hypoxia and death. The six P's of compartment syndrome for warning signs to watch for are Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia.

Among toddlers and children up to age five, femur fractures usually result from a low energy fall. In most cases, the orthopedic surgeon realigns the fracture using fluoroscopy or x-ray imaging as a guide and immobilizes the leg in a type of cast called a spica cast. Approximately how many weeks does it take for a fractured femur to heal in a 3-year-old? A. 1-2 weeks B. 2-4 weeks C. 3-8 weeks D. 10-12 weeks

Correct Answer: C. 3-8 weeks In most cases, three to six weeks of early healing is necessary before the child can begin walking on the injured leg. When the bone is completely healed, usually around one year after the injury occurs, the child returns to the hospital to have the nails removed. Following treatment, the orthopedic surgeon continues to monitor the patient for a period of several years to ensure that there is no limb length discrepancy.

Janae has a seizure disorder; which of the following would be the lowest priority when caring for her? A. Observing and taking down data on all seizures B. Assuring safety and protection from injuring C. Assessing for signs and symptoms of increased intracranial pressure (ICP) D. Educating the family about anticonvulsant therapy

Correct Answer: C. Assessing for signs and symptoms of increased intracranial pressure (ICP) Signs and symptoms of increased intracranial pressure (ICP) are not associated with seizure activity and therefore would be the lowest priority. A sudden alteration in consciousness with associated motor movements is the common description of a convulsive seizure. For generalized seizures with associated motor movements, the convulsion typically has a stiffening or tonic phase followed by clonic movements - rhythmic phased motor movements.

Buck's traction with a 10 lb. weight is securing a patient's leg while she is waiting for surgery to repair a hip fracture. It is important to check circulation-sensation-movement: A. Every shift B. Every day C. Every 4 hours D. Every 15 minutes

Correct Answer: C. Every 4 hours The patient can lose vascular status without the nurse being aware if left for more than 4 hours, yet checks should not be so frequent that the patient becomes anxious. Vital signs are generally checked q4h, at which time the CSM checks can easily be performed.

Incomplete development of teeth, bones, and ligaments is the result of: A. Congenital hip dysplasia B. Duchenne's muscular dystrophy C. Osteogenesis imperfecta D. Osteomyelitis

Correct Answer: C. Osteogenesis imperfecta Osteogenesis imperfecta (OI), also known as brittle bone disease, is a group of genetic disorders that principally affect the bones. It results in bones that break quickly. The severity may be mild to severe. Other symptoms may include problems with the teeth, loose joints, a blue tinge to the whites of the eye, short height, hearing loss, and breathing problems.

The nurse is aware that the following laboratory values support a diagnosis of pyelonephritis? A. Myoglobinuria B. Ketonuria C. Pyuria D. Low white blood cell (WBC) count

Correct Answer: C. Pyuria Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. A urinary specimen should be obtained for a urinalysis. On urinalysis, one should look for pyuria as it is the most common finding in patients with acute pyelonephritis

Dr. Jones prescribes corticosteroids for a child with nephritic syndrome. What is the primary purpose of administering corticosteroids to this child? A. To increase blood pressure B. To reduce inflammation C. To decrease proteinuria D. To prevent infection

Correct Answer: C. To decrease proteinuria The primary purpose of administering corticosteroids to a child with nephritic syndrome is to decrease proteinuria. It helps relieve the inflammation in the kidney and promotes healing. The proteinuria usually ranges in the sub nephrotic range (less than 3.5 g/day), but it can go up to the nephrotic range. A 24-hours urinary protein assay is required if the attendant nephrotic syndrome is suspected.

A child is diagnosed with Wilms' tumor. During assessment, the nurse in charge expects to detect: A. Gross hematuria B. Dysuria C. Nausea and vomiting D. An abdominal mass

Correct Answer: D. An abdominal mass The most common sign of Wilms' tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth. Wilms tumor usually presents as an asymptomatic abdominal mass in the majority of children. The mother may have discovered the mass during bathing the infant.

Benjamin was rushed to the emergency department with possible increased intracranial pressure (ICP); which of the following is an early clinical manifestation of increased ICP in older children? A. Macewen's sign B. Setting sun sign C. Papilledema D. Diplopia

Correct Answer: D. Diplopia Diplopia is an early sign of increased ICP in an older child. Visual changes can range from blurred vision, double vision from cranial nerve defects, photophobia to optic disc edema and eventually optic atrophy. Clinical suspicion for intracranial hypertension should be raised if a patient presents with the following signs and symptoms: headaches, vomiting, and altered mental status varying from drowsiness to coma.

The adolescent patient has symptoms of meningitis: nuchal rigidity, fever, vomiting, and lethargy. The nurse knows to prepare for the following test: A. blood culture. B. throat and ear culture. C. CAT scan. D. lumbar puncture.

Correct Answer: D. Lumbar puncture. Meningitis is an infection of the meninges, the outer membrane of the brain. Since it is surrounded by cerebrospinal fluid, a lumbar puncture will help to identify the organism involved. The CSF findings expected in bacterial, viral, and fungal meningitis are listed in the chart: Expected CSF findings in bacterial versus viral versus fungal meningitis.

A spica cast was put on Baby Betty after an unfortunate incident to immobilize her hips and thighs. Which of the following is the priority nursing action immediately after application? A. Keep the cast dry and clean. B. Cover the perineal area. C. Elevate the cast. D. Perform neurovascular checks.

Correct Answer: D. Perform neurovascular checks. A neurovascular assessment is always a priority in the assessment of a freshly applied cast to ensure adequate circulation and neurologic function and prevent complications or injury. Neurovascular observations should be conducted hourly for the first 24 hours then 2-4 hourly for the next 48 hours depending on the condition. Document findings on appropriate limb observation flowsheet.

Stephen was diagnosed with minimal-change nephrotic syndrome; which of the following signs and symptoms are characteristics of the said disorder? A. Hypertension, edema, hematuria B. Hypertension, edema, proteinuria C. Gross hematuria, fever, proteinuria D. Poor appetite, edema, proteinuria

Correct Answer: D. Poor appetite, edema, proteinuria Clinical manifestations of nephrotic syndrome include loss of appetite due to edema of the intestinal mucosa, proteinuria, and edema. The classic NS presentation is edema, in the early phase is located in the face in the morning on waking with puffiness of the eyelids and the impression of the folds of sheets on the skin and ankles at the end of the day.

The twelve-year-old boy has fractured his arm because of a fall from his bike. After the injury has been casted, the nurse knows it is most important to perform all of the following assessments on the area distal to the injury except: A. capillary refill. B. radial and ulnar pulse. C. finger movement. D. skin integrity.

Correct Answer: D. Skin integrity Capillary refill, pulses, and skin temperature and color are indicative of intact circulation and absence of compartment syndrome. Skin integrity is less important. Check the edges of the cast and all skin areas where the cast edges may cause pressure. If there are signs of edema or circulatory impairment, notify the charge nurse or physician immediately.

You have learned that in babies and children with developmental dysplasia (dislocation) of the hip (DDH), the hip joint has not formed normally. Which of the following is the most common form of DDH? A. Acetabular dysplasia B. Dislocation C. Preluxation D. Subluxation

Correct Answer: D. Subluxation DDH is a group of congenital abnormalities of the hip joints, which includes subluxation, dislocation, and preluxation. Of the types of congenital hip abnormalities, subluxation is the most common. In mild cases of DDH, the head of the femur is simply loose in the socket. During a physical examination, the bone can be moved within the socket, but it will not dislocate.