Chapter 27 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 27

Question 1

Type: MCSA

A child is diagnosed with epilepsy and is prescribed daily phenytoin (Dilantin). Which topic is most appropriate for the nurse to include in the discharge teaching?

1. Increasing fluid intake

2. Performing good dental hygiene

3. Decreasing intake of vitamin D

4. Taking the medication with milk

Correct Answer: 2

Rationale 1: Because phenytoin (Dilantin) can cause gingival hyperplasia, good dental hygiene should be encouraged. Fluid intake does not affect the drugs effectiveness, an adequate intake of vitamin D should be encouraged, and phenytoin (Dilantin) should not be taken with dairy products.

Rationale 2: Because phenytoin (Dilantin) can cause gingival hyperplasia, good dental hygiene should be encouraged. Fluid intake does not affect the drugs effectiveness, an adequate intake of vitamin D should be encouraged, and phenytoin (Dilantin) should not be taken with dairy products.

Rationale 3: Because phenytoin (Dilantin) can cause gingival hyperplasia, good dental hygiene should be encouraged. Fluid intake does not affect the drugs effectiveness, an adequate intake of vitamin D should be encouraged, and phenytoin (Dilantin) should not be taken with dairy products.

Rationale 4: Because phenytoin (Dilantin) can cause gingival hyperplasia, good dental hygiene should be encouraged. Fluid intake does not affect the drugs effectiveness, an adequate intake of vitamin D should be encouraged, and phenytoin (Dilantin) should not be taken with dairy products.

Global Rationale: Because phenytoin (Dilantin) can cause gingival hyperplasia, good dental hygiene should be encouraged. Fluid intake does not affect the drugs effectiveness, an adequate intake of vitamin D should be encouraged, and phenytoin (Dilantin) should not be taken with dairy products.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 27.3 Differentiate between the signs of a seizure and status epilepticus in infants and children, and describe appropriate nursing management for each condition.

Question 2

Type: MCSA

A toddler-age client has a tonic-clonic seizure while in a crib in the hospital. The clients jaw is clamped. Which nursing action is the priority?

1. Place a padded tongue blade between the childs jaws.

2. Stay with the child and observe the respiratory status.

3. Prepare the suction equipment.

4. Restrain the child to prevent injury.

Correct Answer: 2

Rationale 1: During a seizure, the nurse remains with the child, watching for complications. The childs respiratory rate should be monitored. Be sure nothing is placed in the childs mouth during a seizure. Suction equipment should already be set up at the bedside before a seizure begins. The child should not be restrained during a seizure.

Rationale 2: During a seizure, the nurse remains with the child, watching for complications. The childs respiratory rate should be monitored. Be sure nothing is placed in the childs mouth during a seizure. Suction equipment should already be set up at the bedside before a seizure begins. The child should not be restrained during a seizure.

Rationale 3: During a seizure, the nurse remains with the child, watching for complications. The childs respiratory rate should be monitored. Be sure nothing is placed in the childs mouth during a seizure. Suction equipment should already be set up at the bedside before a seizure begins. The child should not be restrained during a seizure.

Rationale 4: During a seizure, the nurse remains with the child, watching for complications. The childs respiratory rate should be monitored. Be sure nothing is placed in the childs mouth during a seizure. Suction equipment should already be set up at the bedside before a seizure begins. The child should not be restrained during a seizure.

Global Rationale: During a seizure, the nurse remains with the child, watching for complications. The childs respiratory rate should be monitored. Be sure nothing is placed in the childs mouth during a seizure. Suction equipment should already be set up at the bedside before a seizure begins. The child should not be restrained during a seizure.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 27.3 Differentiate between the signs of a seizure and status epilepticus in infants and children, and describe appropriate nursing management for each condition.

Question 3

Type: MCSA

A lumbar puncture is performed on an infant suspected of having meningitis. Which finding does the nurse expect in the cerebral spinal fluid if the infant has meningitis?

1. Elevated white blood cell count

2. Elevated red blood cell count

3. Normal glucose

4. Decreased white blood cell count

Correct Answer: 1

Rationale 1: The lumbar puncture is done to obtain cerebral spinal fluid (CSF). Elevated white blood cell count is seen with bacterial meningitis. The red blood cell count is not elevated, and the glucose is decreased in meningitis.

Rationale 2: The lumbar puncture is done to obtain cerebral spinal fluid (CSF). Elevated white blood cell count is seen with bacterial meningitis. The red blood cell count is not elevated, and the glucose is decreased in meningitis.

Rationale 3: The lumbar puncture is done to obtain cerebral spinal fluid (CSF). Elevated white blood cell count is seen with bacterial meningitis. The red blood cell count is not elevated, and the glucose is decreased in meningitis.

Rationale 4: The lumbar puncture is done to obtain cerebral spinal fluid (CSF). Elevated white blood cell count is seen with bacterial meningitis. The red blood cell count is not elevated, and the glucose is decreased in meningitis.

Global Rationale: The lumbar puncture is done to obtain cerebral spinal fluid (CSF). Elevated white blood cell count is seen with bacterial meningitis. The red blood cell count is not elevated, and the glucose is decreased in meningitis.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 27.4 Differentiate between signs of bacterial meningitis, viral meningitis, encephalitis, Reye syndrome, and Guillain-Barr syndrome in infants and children.

Question 4

Type: MCSA

The nurse is planning care for a school-age child diagnosed with bacterial meningitis. Which intervention is most appropriate?

1. Keeping environmental stimuli at a minimum

2. Avoiding giving pain medications that could dull sensorium

3. Measuring head circumference to assess developing complications

4. Having the child move the head from side to side at least every two hours

Correct Answer: 1

Rationale 1: A quiet environment should be maintained because noise can disturb a child with meningitis. Pain medications are appropriate to give and should be used when needed. Measuring head circumference would only be appropriate for a child less than 2 years. Excessive head movement should be avoided because it can increase irritation of the meninges.

Rationale 2: A quiet environment should be maintained because noise can disturb a child with meningitis. Pain medications are appropriate to give and should be used when needed. Measuring head circumference would only be appropriate for a child less than 2 years. Excessive head movement should be avoided because it can increase irritation of the meninges.

Rationale 3: A quiet environment should be maintained because noise can disturb a child with meningitis. Pain medications are appropriate to give and should be used when needed. Measuring head circumference would only be appropriate for a child less than 2 years. Excessive head movement should be avoided because it can increase irritation of the meninges.

Rationale 4: A quiet environment should be maintained because noise can disturb a child with meningitis. Pain medications are appropriate to give and should be used when needed. Measuring head circumference would only be appropriate for a child less than 2 years. Excessive head movement should be avoided because it can increase irritation of the meninges.

Global Rationale: A quiet environment should be maintained because noise can disturb a child with meningitis. Pain medications are appropriate to give and should be used when needed. Measuring head circumference would only be appropriate for a child less than 2 years. Excessive head movement should be avoided because it can increase irritation of the meninges.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 27.4 Differentiate between signs of bacterial meningitis, viral meningitis, encephalitis, Reye syndrome, and Guillain-Barr syndrome in infants and children.

Question 5

Type: MCSA

A nurse is conducting a postoperative assessment on an infant who has just had a ventriculoperitoneal shunt placed for hydrocephalus. Which assessment finding would indicate a malfunction in the shunt?

1. Incisional pain

2. Movement of all extremities

3. Negative Brudzinski sign

4. Bulging fontanel

Correct Answer: 4

Rationale 1: A bulging fontanel would be an abnormal finding and could indicate that the shunt is malfunctioning. Incisional pain, movement of all extremities, and negative Brudzinski sign are all normal findings after a ventriculoperitoneal shunt has been placed.

Rationale 2: A bulging fontanel would be an abnormal finding and could indicate that the shunt is malfunctioning. Incisional pain, movement of all extremities, and negative Brudzinski sign are all normal findings after a ventriculoperitoneal shunt has been placed.

Rationale 3: A bulging fontanel would be an abnormal finding and could indicate that the shunt is malfunctioning. Incisional pain, movement of all extremities, and negative Brudzinski sign are all normal findings after a ventriculoperitoneal shunt has been placed.

Rationale 4: A bulging fontanel would be an abnormal finding and could indicate that the shunt is malfunctioning. Incisional pain, movement of all extremities, and negative Brudzinski sign are all normal findings after a ventriculoperitoneal shunt has been placed.

Global Rationale: A bulging fontanel would be an abnormal finding and could indicate that the shunt is malfunctioning. Incisional pain, movement of all extremities, and negative Brudzinski sign are all normal findings after a ventriculoperitoneal shunt has been placed.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 27.5 Develop a nursing care plan for the infant with hydrocephalus and spina bifida.

Question 6

Type: MCSA

Which nursing intervention is most appropriate when caring for an infant with a myelomeningocele in the preoperative stage?

1. Placing infant supine to decrease pressure on the sac

2. Appling a heat lamp to facilitate drying and toughening of the sac

3. Measuring head circumference every shift to identify developing hydrocephalus

4. Appling a diaper to prevent contamination of the sac

Correct Answer: 3

Rationale 1: The infant should be monitored for developing hydrocephalus, so the head circumference should be monitored daily. The infant will be placed prone, not supine, and the defect will be protected from trauma or infection. Therefore, applying heat and a diaper around the defect would not be recommended. A sterile saline dressing may be used to cover the sac to maintain integrity.

Rationale 2: The infant should be monitored for developing hydrocephalus, so the head circumference should be monitored daily. The infant will be placed prone, not supine, and the defect will be protected from trauma or infection. Therefore, applying heat and a diaper around the defect would not be recommended. A sterile saline dressing may be used to cover the sac to maintain integrity.

Rationale 3: The infant should be monitored for developing hydrocephalus, so the head circumference should be monitored daily. The infant will be placed prone, not supine, and the defect will be protected from trauma or infection. Therefore, applying heat and a diaper around the defect would not be recommended. A sterile saline dressing may be used to cover the sac to maintain integrity.

Rationale 4: The infant should be monitored for developing hydrocephalus, so the head circumference should be monitored daily. The infant will be placed prone, not supine, and the defect will be protected from trauma or infection. Therefore, applying heat and a diaper around the defect would not be recommended. A sterile saline dressing may be used to cover the sac to maintain integrity.

Global Rationale: The infant should be monitored for developing hydrocephalus, so the head circumference should be monitored daily. The infant will be placed prone, not supine, and the defect will be protected from trauma or infection. Therefore, applying heat and a diaper around the defect would not be recommended. A sterile saline dressing may be used to cover the sac to maintain integrity.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 27.5 Develop a nursing care plan for the infant with hydrocephalus and spina bifida.

Question 7

Type: MCSA

A child with myelomeningocele, corrected at birth, is now 5 years old. Which is the priority nursing diagnosis for a child with corrected spina bifida at this age?

1. Risk for Altered Nutrition

2. Risk for Impaired Tissue PerfusionCranial

3. Risk for Altered Urinary Elimination

4. Risk for Altered Comfort

Correct Answer: 3

Rationale 1: A child with spina bifida will continue to have a risk for altered urinary elimination because the bowel and bladder sphincter controls are affected. Urinary retention is a problem, so bladder interventions are initiated early to prevent kidney damage. Risk for Altered Nutrition, Impaired Tissue Perfusion, and Altered Comfort are not problems once surgery has been performed to close the defect.

Rationale 2: A child with spina bifida will continue to have a risk for altered urinary elimination because the bowel and bladder sphincter controls are affected. Urinary retention is a problem, so bladder interventions are initiated early to prevent kidney damage. Risk for Altered Nutrition, Impaired Tissue Perfusion, and Altered Comfort are not problems once surgery has been performed to close the defect.

Rationale 3: A child with spina bifida will continue to have a risk for altered urinary elimination because the bowel and bladder sphincter controls are affected. Urinary retention is a problem, so bladder interventions are initiated early to prevent kidney damage. Risk for Altered Nutrition, Impaired Tissue Perfusion, and Altered Comfort are not problems once surgery has been performed to close the defect.

Rationale 4: A child with spina bifida will continue to have a risk for altered urinary elimination because the bowel and bladder sphincter controls are affected. Urinary retention is a problem, so bladder interventions are initiated early to prevent kidney damage. Risk for Altered Nutrition, Impaired Tissue Perfusion, and Altered Comfort are not problems once surgery has been performed to close the defect.

Global Rationale: A child with spina bifida will continue to have a risk for altered urinary elimination because the bowel and bladder sphincter controls are affected. Urinary retention is a problem, so bladder interventions are initiated early to prevent kidney damage. Risk for Altered Nutrition, Impaired Tissue Perfusion, and Altered Comfort are not problems once surgery has been performed to close the defect.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 27.5 Develop a nursing care plan for the infant with hydrocephalus and spina bifida.

Question 8

Type: MCSA

Which statement made by a parent during a well-child visit would cause the nurse to suspect the child has cerebral palsy?

1. My 6-month-old baby is rolling from back to prone now.

2. My 3-month-old seems to have floppy muscle tone.

3. My 8-month-old can sit without support.

4. My 10-month-old is not walking.

Correct Answer: 2

Rationale 1: Children with cerebral palsy are delayed in meeting developmental milestones. The infant with hypotonia is showing a clinical manifestation of cerebral palsy. A baby rolls over from back to prone at 6 months, sits without support at 8 months, and walks at 12 months.

Rationale 2: Children with cerebral palsy are delayed in meeting developmental milestones. The infant with hypotonia is showing a clinical manifestation of cerebral palsy. A baby rolls over from back to prone at 6 months, sits without support at 8 months, and walks at 12 months.

Rationale 3: Children with cerebral palsy are delayed in meeting developmental milestones. The infant with hypotonia is showing a clinical manifestation of cerebral palsy. A baby rolls over from back to prone at 6 months, sits without support at 8 months, and walks at 12 months.

Rationale 4: Children with cerebral palsy are delayed in meeting developmental milestones. The infant with hypotonia is showing a clinical manifestation of cerebral palsy. A baby rolls over from back to prone at 6 months, sits without support at 8 months, and walks at 12 months.

Global Rationale: Children with cerebral palsy are delayed in meeting developmental milestones. The infant with hypotonia is showing a clinical manifestation of cerebral palsy. A baby rolls over from back to prone at 6 months, sits without support at 8 months, and walks at 12 months.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 27.6 Plan family-centered nursing care for the child with cerebral palsy in a community setting.

Question 9

Type: MCSA

A nurse is caring for a child who is diagnosed with cerebral palsy. Which goal of therapy is most appropriate for the nurse to include in the plan of care?

1. Reversing the degenerative processes that have occurred

2. Curing the underlying defect causing the disorder

3. Preventing the spread to individuals in close contact with the child

4. Promoting optimum development

Correct Answer: 4

Rationale 1: Recognition of the disorder is important so that optimal development can be maintained. Cerebral palsy cannot be reversed or cured. It is not caused by a contagious process, so there is no risk of spread.

Rationale 2: Recognition of the disorder is important so that optimal development can be maintained. Cerebral palsy cannot be reversed or cured. It is not caused by a contagious process, so there is no risk of spread.

Rationale 3: Recognition of the disorder is important so that optimal development can be maintained. Cerebral palsy cannot be reversed or cured. It is not caused by a contagious process, so there is no risk of spread.

Rationale 4: Recognition of the disorder is important so that optimal development can be maintained. Cerebral palsy cannot be reversed or cured. It is not caused by a contagious process, so there is no risk of spread.

Global Rationale: Recognition of the disorder is important so that optimal development can be maintained. Cerebral palsy cannot be reversed or cured. It is not caused by a contagious process, so there is no risk of spread.

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 27.6 Plan family-centered nursing care for the child with cerebral palsy in a community setting.

Question 10

Type: MCMA

A child sustains a traumatic brain injury and is monitored in the pediatric intensive-care unit (PICU). The nurse is using the Glasgow Coma Scale to assess the child. Which items will the nurse assess when using this tool?

Standard Text: Select all that apply.

1. Eye opening

2. Verbal response

3. Motor response

4. Head circumference

5. Pulse oximetry

Correct Answer: 1,2,3

Rationale 1: The Glasgow Coma Scale for infants and children scores parameters related to eye opening, verbal response, and motor response. The maximum score is 15, indicating the highest level of neurological functioning. Head circumference and pulse oximetry are not included on the scale.

Rationale 2: The Glasgow Coma Scale for infants and children scores parameters related to eye opening, verbal response, and motor response. The maximum score is 15, indicating the highest level of neurological functioning. Head circumference and pulse oximetry are not included on the scale.

Rationale 3: The Glasgow Coma Scale for infants and children scores parameters related to eye opening, verbal response, and motor response. The maximum score is 15, indicating the highest level of neurological functioning. Head circumference and pulse oximetry are not included on the scale.

Rationale 4: The Glasgow Coma Scale for infants and children scores parameters related to eye opening, verbal response, and motor response. The maximum score is 15, indicating the highest level of neurological functioning. Head circumference and pulse oximetry are not included on the scale.

Rationale 5: The Glasgow Coma Scale for infants and children scores parameters related to eye opening, verbal response, and motor response. The maximum score is 15, indicating the highest level of neurological functioning. Head circumference and pulse oximetry are not included on the scale.

Global Rationale: The Glasgow Coma Scale for infants and children scores parameters related to eye opening, verbal response, and motor response. The maximum score is 15, indicating the highest level of neurological functioning. Head circumference and pulse oximetry are not included on the scale.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.2: Choose the appropriate assessment guidelines and tools to examine infants and children with altered levels of consciousness and other neurologic conditions.

Question 11

Type: MCMA

A child diagnosed with a mild traumatic brain injury is being sedated with a mild sedative so that pain and anxiety are minimized. Which nursing interventions are appropriate for this child?

Standard Text: Select all that apply.

1. Place a continuous-pulse oximetry monitor on the child.

2. Place the child in a room near the nurses station.

3. Allow for several visitors to remain at the childs bedside.

4. Use soft restraints if the child becomes confused.

5. Use sedation around the clock to decrease agitation.

Correct Answer: 1,2

Rationale 1: When a child is sedated, respiratory status should be monitored with a pulse-oximetry machine. The child should be close to the nurses station so that frequent monitoring can be done. Several visitors at the bedside would increase the childs anxiety. Soft restraints may increase agitation. Sedation around the clock is not recommended due to the need to evaluate the neurologic system.

Rationale 2: When a child is sedated, respiratory status should be monitored with a pulse-oximetry machine. The child should be close to the nurses station so that frequent monitoring can be done. Several visitors at the bedside would increase the childs anxiety. Soft restraints may increase agitation. Sedation around the clock is not recommended due to the need to evaluate the neurologic system.

Rationale 3: When a child is sedated, respiratory status should be monitored with a pulse-oximetry machine. The child should be close to the nurses station so that frequent monitoring can be done. Several visitors at the bedside would increase the childs anxiety. Soft restraints may increase agitation. Sedation around the clock is not recommended due to the need to evaluate the neurologic system.

Rationale 4: When a child is sedated, respiratory status should be monitored with a pulse-oximetry machine. The child should be close to the nurses station so that frequent monitoring can be done. Several visitors at the bedside would increase the childs anxiety. Soft restraints may increase agitation. Sedation around the clock is not recommended due to the need to evaluate the neurologic system.

Rationale 5: When a child is sedated, respiratory status should be monitored with a pulse-oximetry machine. The child should be close to the nurses station so that frequent monitoring can be done. Several visitors at the bedside would increase the childs anxiety. Soft restraints may increase agitation. Sedation around the clock is not recommended due to the need to evaluate the neurologic system.

Global Rationale: When a child is sedated, respiratory status should be monitored with a pulse-oximetry machine. The child should be close to the nurses station so that frequent monitoring can be done. Several visitors at the bedside would increase the childs anxiety. Soft restraints may increase agitation. Sedation around the clock is not recommended due to the need to evaluate the neurologic system.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 27.7 Contrast the appropriate initial nursing management for mild versus severe traumatic brain injury.

Question 12

Type: MCSA

A school-age client sustains a basilar skull fracture. Which symptom is a priority for this nurse to assess for when providing care to this client?

1. Cerebral spinal fluid leakage from the nose or ears

2. Headache

3. Transient confusion

4. Periorbital ecchymosis

Correct Answer: 1

Rationale 1: Cerebral spinal fluid leakage could be present from the nose or ears and, if it persists, may indicate that surgical repair will be needed. Headache, transient confusion, and periorbital ecchymosis are findings that commonly present with a basilar skull fracture but do not indicate that surgical repair will be needed.

Rationale 2: Cerebral spinal fluid leakage could be present from the nose or ears and, if it persists, may indicate that surgical repair will be needed. Headache, transient confusion, and periorbital ecchymosis are findings that commonly present with a basilar skull fracture but do not indicate that surgical repair will be needed.

Rationale 3: Cerebral spinal fluid leakage could be present from the nose or ears and, if it persists, may indicate that surgical repair will be needed. Headache, transient confusion, and periorbital ecchymosis are findings that commonly present with a basilar skull fracture but do not indicate that surgical repair will be needed.

Rationale 4: Cerebral spinal fluid leakage could be present from the nose or ears and, if it persists, may indicate that surgical repair will be needed. Headache, transient confusion, and periorbital ecchymosis are findings that commonly present with a basilar skull fracture but do not indicate that surgical repair will be needed.

Global Rationale: Cerebral spinal fluid leakage could be present from the nose or ears and, if it persists, may indicate that surgical repair will be needed. Headache, transient confusion, and periorbital ecchymosis are findings that commonly present with a basilar skull fracture but do not indicate that surgical repair will be needed.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO27.7 Contrast the appropriate initial nursing management for mild versus severe traumatic brain injury.

Question 13

Type: MCSA

A school-age client experiences a near-drowning episode and is admitted to the pediatric intensive-care unit (PICU). The parents express guilt over the near drowning of their child. Which response by the nurse is most appropriate?

1. You will need to watch the child more closely.

2. Tell me more about your feelings related to the accident.

3. The child will be fine, so dont worry.

4. Why did you let the child almost drown?

Correct Answer: 2

Rationale 1: In near-drowning cases, the nurse should be nonjudgmental and provide a forum for parents to express guilt. Telling the parents to watch the child more closely or asking them why they let the child almost drown is judgmental. Saying the child will be fine may not be true. The nurse should reassure the parents that the child is receiving all possible medical treatment.

Rationale 2: In near-drowning cases, the nurse should be nonjudgmental and provide a forum for parents to express guilt. Telling the parents to watch the child more closely or asking them why they let the child almost drown is judgmental. Saying the child will be fine may not be true. The nurse should reassure the parents that the child is receiving all possible medical treatment.

Rationale 3: In near-drowning cases, the nurse should be nonjudgmental and provide a forum for parents to express guilt. Telling the parents to watch the child more closely or asking them why they let the child almost drown is judgmental. Saying the child will be fine may not be true. The nurse should reassure the parents that the child is receiving all possible medical treatment.

Rationale 4: In near-drowning cases, the nurse should be nonjudgmental and provide a forum for parents to express guilt. Telling the parents to watch the child more closely or asking them why they let the child almost drown is judgmental. Saying the child will be fine may not be true. The nurse should reassure the parents that the child is receiving all possible medical treatment.

Global Rationale: In near-drowning cases, the nurse should be nonjudgmental and provide a forum for parents to express guilt. Telling the parents to watch the child more closely or asking them why they let the child almost drown is judgmental. Saying the child will be fine may not be true. The nurse should reassure the parents that the child is receiving all possible medical treatment.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 27.8 Discuss initiatives to prevent drowning in children.

Question 14

Type: MCSA

With a group of new parents, the nurse is reviewing treatment for viral illnesses such as influenza. Which statement by the parents indicates appropriate understanding of the teaching session?

1. Some over-the-counter medications contain aspirin.

2. Acetaminophen is good for treatment of fevers in young children.

3. I can use ibuprofen as needed when my child has aches and pains.

4. Aspirin is acceptable if my child does not have a virus.

Correct Answer: 1

Rationale 1: Reye syndrome is a serious consequence of aspirin use in children with viral illnesses. Over-the-counter medications should be checked to see whether they contain aspirin before being used. Aspirin is avoided in children. Ibuprofen and acetaminophen are acceptable to use in children.

Rationale 2: Reye syndrome is a serious consequence of aspirin use in children with viral illnesses. Over-the-counter medications should be checked to see whether they contain aspirin before being used. Aspirin is avoided in children. Ibuprofen and acetaminophen are acceptable to use in children.

Rationale 3: Reye syndrome is a serious consequence of aspirin use in children with viral illnesses. Over-the-counter medications should be checked to see whether they contain aspirin before being used. Aspirin is avoided in children. Ibuprofen and acetaminophen are acceptable to use in children.

Rationale 4: Reye syndrome is a serious consequence of aspirin use in children with viral illnesses. Over-the-counter medications should be checked to see whether they contain aspirin before being used. Aspirin is avoided in children. Ibuprofen and acetaminophen are acceptable to use in children.

Global Rationale: Reye syndrome is a serious consequence of aspirin use in children with viral illnesses. Over-the-counter medications should be checked to see whether they contain aspirin before being used. Aspirin is avoided in children. Ibuprofen and acetaminophen are acceptable to use in children.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 27.4 Differentiate between signs of bacterial meningitis, viral meningitis, encephalitis, Reye syndrome, and Guillain-Barr syndrome in infants and children.

Question 15

Type: MCSA

A school-age client is transported to the emergency department by ambulance from the scene of a car accident.  The client is alert and oriented 3; pulse, respirations, and blood pressure are stable; and the neck and back are immobilized on a backboard. The nurse sees no obvious bleeding. The client states, I cant feel or move my legs. Which injury does the nurse suspect?

1. Traumatic brain injury

2. Ruptured spleen

3. Traumatic shock

4. Spinal cord injury

Correct Answer: 4

Rationale 1: Spinal cord injury results in paralysis and anesthesia of the affected body parts below the level of the lesion. Altered levels of consciousness may indicate traumatic brain injury. The child may have a ruptured spleen, but it is not evident from the data given. Traumatic shock results in initially increasing then decreasing pulse and respirations, and falling blood pressure.

Rationale 2: Spinal cord injury results in paralysis and anesthesia of the affected body parts below the level of the lesion. Altered levels of consciousness may indicate traumatic brain injury. The child may have a ruptured spleen, but it is not evident from the data given. Traumatic shock results in initially increasing then decreasing pulse and respirations, and falling blood pressure.

Rationale 3: Spinal cord injury results in paralysis and anesthesia of the affected body parts below the level of the lesion. Altered levels of consciousness may indicate traumatic brain injury. The child may have a ruptured spleen, but it is not evident from the data given. Traumatic shock results in initially increasing then decreasing pulse and respirations, and falling blood pressure.

Rationale 4: Spinal cord injury results in paralysis and anesthesia of the affected body parts below the level of the lesion. Altered levels of consciousness may indicate traumatic brain injury. The child may have a ruptured spleen, but it is not evident from the data given. Traumatic shock results in initially increasing then decreasing pulse and respirations, and falling blood pressure.

Global Rationale: Spinal cord injury results in paralysis and anesthesia of the affected body parts below the level of the lesion. Altered levels of consciousness may indicate traumatic brain injury. The child may have a ruptured spleen, but it is not evident from the data given. Traumatic shock results in initially increasing then decreasing pulse and respirations, and falling blood pressure.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 27.7 Contrast the appropriate initial nursing management for mild versus severe traumatic brain injury.

Question 16

Type: MCSA

A child is ready for discharge after surgery for a myelomeningocele repair. Before discharge, the nurse works with the parents to establish a catheterization schedule to prevent urinary tract infection. With what frequency should the nurse instruct the parents to catheterize the child?

1. Every 12 hours

2. Every 34 hours

3. Every 68 hours

4. Every 1012 hours

Correct Answer: 2

Rationale 1: To decrease the incidence of bladder or urinary tract infections, catheterization should occur every 34 hours.

Rationale 2: To decrease the incidence of bladder or urinary tract infections, catheterization should occur every 34 hours.

Rationale 3: To decrease the incidence of bladder or urinary tract infections, catheterization should occur every 34 hours.

Rationale 4: To decrease the incidence of bladder or urinary tract infections, catheterization should occur every 34 hours.

Global Rationale: To decrease the incidence of bladder or urinary tract infections, catheterization should occur every 34 hours.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 27.5 Develop a nursing care plan for the infant with hydrocephalus and spina bifida.

Question 17

Type: MCMA

The nurse educator is describing the pediatric differences associated with the anatomy and physiology of the neurologic system to a group of nursing students. Which statements made by the class indicate appropriate understanding of this topic after the teaching session?

Standard Text: Select all that apply.

1. The bones of the cranium are connected by connective tissue to allow for brain growth.

2. The spine of infants is excessively mobile due to immature neck muscles and incompletely developed vertebral bodies.

3. Maturation of the nerves continues until age 10.

4. Myelination is complete at birth,

5. Myelination proceeds in a cephalocaudal direction.

Correct Answer: 1,2,5

Rationale 1: There are several pediatric differences associated with the anatomy and physiology of the neurological system and include: the bones of the cranium are connected by connective tissue to allow for brain growth; the spine of infants is excessively mobile due to immature neck muscles and incompletely developed vertebral bodies; and myelination proceeds in a cephalocaudal direction. Maturation of the nerves continues until the age of 4, not 10.  Myelination is incomplete at birth.

Rationale 2: There are several pediatric differences associated with the anatomy and physiology of the neurological system and include: the bones of the cranium are connected by connective tissue to allow for brain growth; the spine of infants is excessively mobile due to immature neck muscles and incompletely developed vertebral bodies; and myelination proceeds in a cephalocaudal direction. Maturation of the nerves continues until the age of 4, not 10.  Myelination is incomplete at birth.

Rationale 3: There are several pediatric differences associated with the anatomy and physiology of the neurological system and include: the bones of the cranium are connected by connective tissue to allow for brain growth; the spine of infants is excessively mobile due to immature neck muscles and incompletely developed vertebral bodies; and myelination proceeds in a cephalocaudal direction. Maturation of the nerves continues until the age of 4, not 10.  Myelination is incomplete at birth.

Rationale 4: There are several pediatric differences associated with the anatomy and physiology of the neurological system and include: the bones of the cranium are connected by connective tissue to allow for brain growth; the spine of infants is excessively mobile due to immature neck muscles and incompletely developed vertebral bodies; and myelination proceeds in a cephalocaudal direction. Maturation of the nerves continues until the age of 4, not 10.  Myelination is incomplete at birth.

Rationale 5: There are several pediatric differences associated with the anatomy and physiology of the neurological system and include: the bones of the cranium are connected by connective tissue to allow for brain growth; the spine of infants is excessively mobile due to immature neck muscles and incompletely developed vertebral bodies; and myelination proceeds in a cephalocaudal direction. Maturation of the nerves continues until the age of 4, not 10.  Myelination is incomplete at birth.

Global Rationale: There are several pediatric differences associated with the anatomy and physiology of the neurological system and include: the bones of the cranium are connected by connective tissue to allow for brain growth; the spine of infants is excessively mobile due to immature neck muscles and incompletely developed vertebral bodies; and myelination proceeds in a cephalocaudal direction. Maturation of the nerves continues until the age of 4, not 10.  Myelination is incomplete at birth.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 27.1 Describe the pediatric differences associated with the anatomy and physiology of the neurologic system.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 6th Ed. Test Bank

Copyright 2015 by Pearson Education, Inc.

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