Chapter 27 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 5th Edition Test Bank
Chapter 27

Question 1

Type: MCSA

A child has been diagnosed with epilepsy and is on daily phenytoin (Dilantin). Client education should include

1. Fluid intake.

2. Good dental hygiene.

3. A decrease in vitamin D intake.

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:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 03. Differentiate between the signs of a seizure and status epilepticus in infants and children, and plan appropriate nursing care for each condition.

Question 2

Type: MCSA

A 2-year-old starts to have a tonic-clonic seizure while in a crib in the hospital. The childs jaws are clamped. The most important nursing action at this time is to

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:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 03. Differentiate between the signs of a seizure and status epilepticus in infants and children, and plan appropriate nursing care for each condition.

Question 3

Type: MCSA

A lumbar puncture is being done on an infant suspected of having meningitis. If the infant has bacterial meningitis, the nurse would expect the cerebral spinal fluid to show

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:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 04. 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 with bacterial meningitis. Which of the following should be included?

1. Keep environmental stimuli at a minimum.

2. Avoid giving pain medications that could dull sensorium.

3. Measure head circumference to assess developing complications.

4. Have child move head 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:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 04. 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 doing a postoperative assessment on an infant who has just had a ventriculoperitoneal shunt placed for hydrocephalus. Which assessment would indicate a malfunction in the shunt?

1. Incisional pain.

2. Movement of all extremities.

3. Negative Brudzinskis 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 Brudzinskis 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 Brudzinskis 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 Brudzinskis 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 Brudzinskis sign are all normal findings after a ventriculoperitoneal shunt has been placed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 05. Plan the nursing care for the child with myelodysplasia and hydrocephalus and family.

Question 6

Type: MCSA

An important nursing intervention when caring for an infant with a myelomeningocele in the preoperative stage would be to

1. Place infant supine to decrease pressure on the sac.

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

3. Measure head circumference every shift to identify developing hydrocephalus.

4. Apply 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:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Plan the nursing care for the child with myelodysplasia and hydrocephalus and family.

Question 7

Type: MCSA

A child with myelomeningocele, corrected at birth, is now 5 years old. What is a 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:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 05. Plan the nursing care for the child with myelodysplasia and hydrocephalus and family.

Question 8

Type: MCSA

The nurse should suspect a child has cerebral palsy if the parent says,

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:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 06. Plan the nursing care for the child with cerebral palsy and family in a community setting.

Question 9

Type: MCSA

A nurse is caring for a child who has recently been diagnosed with cerebral palsy. The major goals of therapy for this child will include

1. Reversal of 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:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 06. Plan the nursing care for the child with cerebral palsy and family in a community setting.

Question 10

Type: MCMA

A child has sustained a traumatic brain injury and is being monitored in the pediatric intensive-care unit. The nurse is using the Glasgow Coma Scale to assess the child. What will the nurse be assessing for this scale?

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:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 07. Contrast the initial nursing management for mild and severe traumatic brain injury.

Question 11

Type: MCMA

A child with a mild traumatic brain injury is being sedated with a mild sedative so that pain and anxiety are minimized. The nurse should

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:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 07. Contrast the initial nursing management for mild and severe traumatic brain injury.

Question 12

Type: MCSA

A child has sustained a basilar skull fracture. The priority symptom the nurse should watch for is

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:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 07. Contrast the initial nursing management for mild and severe traumatic brain injury.

Question 13

Type: MCSA

A child has experienced a near-drowning episode and is admitted to the pediatric intensive-care unit. The parents express guilt over the near drowning of their child. The nurses best response is

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:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 08. Discuss initiatives to prevent drowning in children.

Question 14

Type: MCSA

With a group of new parents, the nurse is reviewing treatment for viral illness such as influenza. The nurse knows teaching was understood when a parent states:

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:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 04. Differentiate between signs of bacterial meningitis, viral meningitis, encephalitis, Reye syndrome, and Guillain-Barr syndrome in infants and children.

Question 15

Type: MCSA

A 10-year-old child is transported to the emergency room by ambulance from the scene of a car accident. He is alert and oriented 3; his pulse, respirations, and blood pressure are stable; and his neck and back are immobilized on a backboard. The nurse sees no obvious bleeding. The child states, I cant feel or move my legs. What injury is most likely?

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:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 07. Contrast the initial nursing management for mild and severe traumatic brain injury.

Question 16

Type: MCSA

A child is being discharged 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:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Plan the nursing care for the child with myelodysplasia and hydrocephalus and family.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 5th Ed. Test Bank

Copyright 2012 by Pearson Education, Inc.

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