Chapter 29 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 5th Edition Test Bank
Chapter 29

Question 1

Type: MCSA

The nurse has completed parent education related to treatment for a child with congenital clubfoot. The nurse knows that parents need further teaching when they state,

1. Were happy this is the only cast our baby will need.

2. Well watch for any swelling of the feet while the casts are on.

3. Well keep the casts dry.

4. Were getting a special car seat to accommodate the casts.

Correct Answer: 1

Rationale 1: Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every one to two weeks. Parents should be watching for swelling while the casts are on, keeping the casts dry, and using a car seat to accommodate the casts.

Rationale 2: Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every one to two weeks. Parents should be watching for swelling while the casts are on, keeping the casts dry, and using a car seat to accommodate the casts.

Rationale 3: Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every one to two weeks. Parents should be watching for swelling while the casts are on, keeping the casts dry, and using a car seat to accommodate the casts.

Rationale 4: Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every one to two weeks. Parents should be watching for swelling while the casts are on, keeping the casts dry, and using a car seat to accommodate the casts.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 02. Plan nursing care for children with structural deformities of the foot, hip, and spine.

Question 2

Type: MCSA

An infant has just returned from surgery for correction of bilateral congenital clubfeet. The infant has bilateral long-leg casts. The toes on both feet are edematous, but there is color, sensitivity, and movement to them. The nurse should

1. Call the physician to report the edema.

2. Elevate the legs on pillows.

3. Apply a warm, moist pack to the feet.

4. Encourage movement of toes.

Correct Answer: 2

Rationale 1: The legs should be elevated on a pillow for 24 hours to promote healing and help with venous return. Some amount of swelling can be expected, so it would not be appropriate to notify the physician, especially if the color, sensitivity, and movement remain normal to the toes. Ice should be applied, not heat. An infant would not be able to follow directions to move toes, and in this case it would not be as effective as elevating the legs on pillows.

Rationale 2: The legs should be elevated on a pillow for 24 hours to promote healing and help with venous return. Some amount of swelling can be expected, so it would not be appropriate to notify the physician, especially if the color, sensitivity, and movement remain normal to the toes. Ice should be applied, not heat. An infant would not be able to follow directions to move toes, and in this case it would not be as effective as elevating the legs on pillows.

Rationale 3: The legs should be elevated on a pillow for 24 hours to promote healing and help with venous return. Some amount of swelling can be expected, so it would not be appropriate to notify the physician, especially if the color, sensitivity, and movement remain normal to the toes. Ice should be applied, not heat. An infant would not be able to follow directions to move toes, and in this case it would not be as effective as elevating the legs on pillows.

Rationale 4: The legs should be elevated on a pillow for 24 hours to promote healing and help with venous return. Some amount of swelling can be expected, so it would not be appropriate to notify the physician, especially if the color, sensitivity, and movement remain normal to the toes. Ice should be applied, not heat. An infant would not be able to follow directions to move toes, and in this case it would not be as effective as elevating the legs on pillows.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Plan nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery.

Question 3

Type: MCSA

The nurse in the newborn nursery is doing the admission assessment on a neonate. Congenital hip dysplasia will be suspected when the nurse observes

1. Asymmetry of the gluteal and thigh fat folds.

2. Trendelenburg sign.

3. Telescoping of the affected limb.

4. Lordosis.

Correct Answer: 1

Rationale 1: A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat folds. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia. Lordosis does not occur with hip dysplasia.

Rationale 2: A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat folds. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia. Lordosis does not occur with hip dysplasia.

Rationale 3: A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat folds. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia. Lordosis does not occur with hip dysplasia.

Rationale 4: A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat folds. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia. Lordosis does not occur with hip dysplasia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 01. Describe pediatric variations in the musculoskeletal system.

Question 4

Type: MCSA

The nurse is teaching family members how to care for their infant in a Pavlik harness to treat congenital developmental dysplasia of the hip. The nurse will include in the parental education to

1. Apply lotion or powder to minimize skin irritation.

2. Put clothing over the harness for maximum effectiveness of the device.

3. Check at least two or three times a day for red areas under the straps.

4. Place a diaper over the harness, preferably using a thin superabsorbent disposable diaper.

Correct Answer: 3

Rationale 1: The brace should be checked two or three times for red areas under the straps. Lotion or powder can contribute to skin breakdown. A light layer of clothing should be under the brace, not over. The diaper should also be under the brace.

Rationale 2: The brace should be checked two or three times for red areas under the straps. Lotion or powder can contribute to skin breakdown. A light layer of clothing should be under the brace, not over. The diaper should also be under the brace.

Rationale 3: The brace should be checked two or three times for red areas under the straps. Lotion or powder can contribute to skin breakdown. A light layer of clothing should be under the brace, not over. The diaper should also be under the brace.

Rationale 4: The brace should be checked two or three times for red areas under the straps. Lotion or powder can contribute to skin breakdown. A light layer of clothing should be under the brace, not over. The diaper should also be under the brace.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Plan nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery.

Question 5

Type: MCSA

The nurse is caring for a child in Bryant skin traction. An appropriate nursing intervention for this child would be to

1. Remove the adhesive traction straps daily to prevent skin breakdown.

2. Check the traction frequently to ensure that proper alignment is maintained.

3. Place the child in a prone position to maintain good alignment.

4. Move the child as infrequently as possible to maintain traction.

Correct Answer: 2

Rationale 1: The traction apparatus should be checked frequently to ensure that proper alignment is maintained. The adhesive straps should not be removed. The child should be placed in a supine position, and frequent repositioning is necessary to prevent complications of immobility.

Rationale 2: The traction apparatus should be checked frequently to ensure that proper alignment is maintained. The adhesive straps should not be removed. The child should be placed in a supine position, and frequent repositioning is necessary to prevent complications of immobility.

Rationale 3: The traction apparatus should be checked frequently to ensure that proper alignment is maintained. The adhesive straps should not be removed. The child should be placed in a supine position, and frequent repositioning is necessary to prevent complications of immobility.

Rationale 4: The traction apparatus should be checked frequently to ensure that proper alignment is maintained. The adhesive straps should not be removed. The child should be placed in a supine position, and frequent repositioning is necessary to prevent complications of immobility.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Plan nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery.

Question 6

Type: MCSA

The nurse has completed discharge teaching for the family of a child diagnosed with Legg-Calve-Perthes disease. The nurse knows further teaching is needed about the condition if the family states,

1. Were glad this will only take about six weeks to correct.

2. We understand swimming is a good sport for Legg-Calve-Perthes.

3. We know to watch for areas on the skin the brace may rub.

4. We understand that abduction of the affected leg is important.

Correct Answer: 1

Rationale 1: The treatment generally takes approximately two years. Swimming is a good activity to increase mobility. A brace may be worn, so skin irritation should be monitored. The leg should be kept in the abducted position.

Rationale 2: The treatment generally takes approximately two years. Swimming is a good activity to increase mobility. A brace may be worn, so skin irritation should be monitored. The leg should be kept in the abducted position.

Rationale 3: The treatment generally takes approximately two years. Swimming is a good activity to increase mobility. A brace may be worn, so skin irritation should be monitored. The leg should be kept in the abducted position.

Rationale 4: The treatment generally takes approximately two years. Swimming is a good activity to increase mobility. A brace may be worn, so skin irritation should be monitored. The leg should be kept in the abducted position.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 04. Collaborate with families and other health-care providers to plan care for children with musculoskeletal disorders that are chronic or require long-term care.

Question 7

Type: MCMA

A school health nurse is screening for scoliosis. What assessment findings would the nurse look for?

Standard Text: Select all that apply.

1. Uneven shoulders and hips.

2. A one-sided rib hump.

3. Prominent scapula.

4. Lordosis.

5. Pain.

Correct Answer: 1,2,3

Rationale 1: The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. Lordosis and pain are not present with scoliosis.

Rationale 2: The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. Lordosis and pain are not present with scoliosis.

Rationale 3: The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. Lordosis and pain are not present with scoliosis.

Rationale 4: The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. Lordosis and pain are not present with scoliosis.

Rationale 5: The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. Lordosis and pain are not present with scoliosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 01. Describe pediatric variations in the musculoskeletal system.

Question 8

Type: MCSA

A child must wear a brace for correction of scoliosis. The nursing diagnosis that should be included in this childs plan of care is

1. Risk for Impaired Skin Integrity.

2. Risk for Altered Growth and Development.

3. Risk for Impaired Mobility.

4. Risk for Impaired Gas Exchange.

Correct Answer: 1

Rationale 1: The skin should be monitored for breakdown in any area the brace may rub. The other diagnoses would not be priority and should be corrected by the wearing of the brace.

Rationale 2: The skin should be monitored for breakdown in any area the brace may rub. The other diagnoses would not be priority and should be corrected by the wearing of the brace.

Rationale 3: The skin should be monitored for breakdown in any area the brace may rub. The other diagnoses would not be priority and should be corrected by the wearing of the brace.

Rationale 4: The skin should be monitored for breakdown in any area the brace may rub. The other diagnoses would not be priority and should be corrected by the wearing of the brace.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 05. Plan nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery.

Question 9

Type: MCSA

A child has just returned from surgery after spinal-fusion surgery. The nurse should check for signs of

1. Increased intracranial pressure.

2. Seizure activity.

3. Impaired pupillary response during neurological checks.

4. Impaired color, sensitivity, and movement to lower extremities.

Correct Answer: 4

Rationale 1: When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities. The other signs are neurological impairment and are not high risk with spinal surgery.

Rationale 2: When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities. The other signs are neurological impairment and are not high risk with spinal surgery.

Rationale 3: When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities. The other signs are neurological impairment and are not high risk with spinal surgery.

Rationale 4: When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities. The other signs are neurological impairment and are not high risk with spinal surgery.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 05. Plan nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery.

Question 10

Type: MCSA

A nurse notes blue sclerae during a newborn assessment. The infant should be checked for

1. Marfan syndrome.

2. Achondroplasia.

3. Osteogenesis imperfecta.

4. Muscular dystrophy.

Correct Answer: 3

Rationale 1: Clinical manifestations of osteogenesis imperfecta include blue sclerae. This is not present in Marfan syndrome, achondroplasia, or muscular dystrophy.

Rationale 2: Clinical manifestations of osteogenesis imperfecta include blue sclerae. This is not present in Marfan syndrome, achondroplasia, or muscular dystrophy.

Rationale 3: Clinical manifestations of osteogenesis imperfecta include blue sclerae. This is not present in Marfan syndrome, achondroplasia, or muscular dystrophy.

Rationale 4: Clinical manifestations of osteogenesis imperfecta include blue sclerae. This is not present in Marfan syndrome, achondroplasia, or muscular dystrophy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 02. Plan nursing care for children with structural deformities of the foot, hip, and spine.

Question 11

Type: MCSA

Care for an infant with osteogenesis imperfecta should include

1. Support of the trunk and extremities when moving.

2. Traction care.

3. Cast care.

4. Postop spinal-surgery care.

Correct Answer: 1

Rationale 1: With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones are fragile, the entire body must be supported when the child is moved. Traction, casts, and spinal surgery are not routinely done for osteogenesis.

Rationale 2: With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones are fragile, the entire body must be supported when the child is moved. Traction, casts, and spinal surgery are not routinely done for osteogenesis.

Rationale 3: With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones are fragile, the entire body must be supported when the child is moved. Traction, casts, and spinal surgery are not routinely done for osteogenesis.

Rationale 4: With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones are fragile, the entire body must be supported when the child is moved. Traction, casts, and spinal surgery are not routinely done for osteogenesis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 02. Plan nursing care for children with structural deformities of the foot, hip, and spine.

Question 12

Type: MCSA

A 12-year-old boy with Duchennes muscular dystrophy is being seen in the clinic for a routine health visit. An appropriate nursing diagnosis for this patient would be

1. Risk for Impaired Mobility Related to Hypertrophy of Muscles.

2. Risk for Infection Related to Altered Immune System.

3. Risk for Impaired Skin Integrity Related to Paresthesia.

4. Risk for Altered Comfort Related to Effects of the Illness.

Correct Answer: 1

Rationale 1: Nursing care for muscular dystrophy (MD) focuses on promoting independence and mobility for this progressive, incapacitating disease. Risk for Infection, Risk for Impaired Skin Integrity, and Risk for Altered Comfort are not as high a priority as Risk for Impaired Mobility.

Rationale 2: Nursing care for muscular dystrophy (MD) focuses on promoting independence and mobility for this progressive, incapacitating disease. Risk for Infection, Risk for Impaired Skin Integrity, and Risk for Altered Comfort are not as high a priority as Risk for Impaired Mobility.

Rationale 3: Nursing care for muscular dystrophy (MD) focuses on promoting independence and mobility for this progressive, incapacitating disease. Risk for Infection, Risk for Impaired Skin Integrity, and Risk for Altered Comfort are not as high a priority as Risk for Impaired Mobility.

Rationale 4: Nursing care for muscular dystrophy (MD) focuses on promoting independence and mobility for this progressive, incapacitating disease. Risk for Infection, Risk for Impaired Skin Integrity, and Risk for Altered Comfort are not as high a priority as Risk for Impaired Mobility.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 04. Collaborate with families and other health-care providers to plan care for children with musculoskeletal disorders that are chronic or require long-term care.

Question 13

Type: MCSA

A child has experienced a sprain of the right ankle. The school nurse should

1. Apply ice to the extremity.

2. Apply a warm, moist pack to the extremity.

3. Perform passive range of motion to the extremity.

4. Lower the extremity to below the level of the heart.

Correct Answer: 1

Rationale 1: For the first 24 hours for a sprain, rest, ice, compression, and elevation should be used. Therefore, the nurse should apply ice to the extremity.

Rationale 2: For the first 24 hours for a sprain, rest, ice, compression, and elevation should be used. Therefore, the nurse should apply ice to the extremity.

Rationale 3: For the first 24 hours for a sprain, rest, ice, compression, and elevation should be used. Therefore, the nurse should apply ice to the extremity.

Rationale 4: For the first 24 hours for a sprain, rest, ice, compression, and elevation should be used. Therefore, the nurse should apply ice to the extremity.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 06. Provide nursing care for fractures and other sports injuries, including teaching for injury prevention and evidence-based nursing implementations for the child who has sustained a fracture or other sports injury.

Question 14

Type: MCMA

A nurse is assessing a child after an open reduction of a fractured femur. Signs that compartment syndrome could be occurring would be

Standard Text: Select all that apply.

1. Pink, warm extremity.

2. Pain not relieved by pain medication.

3. Dorsalis pedis pulse present.

4. Prolonged capillary-refill time with paresthesia.

Correct Answer: 2,4

Rationale 1: The major serious complication post-fracture reduction is compartment syndrome. A prolonged capillary-refill time with loss of paresthesia and pain not relieved by medication are signs of compartment syndrome. Pink, warm extremity; pain relieved by medication; and a present dorsalis pedis pulse would all be normal findings post-fracture reduction.

Rationale 2: The major serious complication post-fracture reduction is compartment syndrome. A prolonged capillary-refill time with loss of paresthesia and pain not relieved by medication are signs of compartment syndrome. Pink, warm extremity; pain relieved by medication; and a present dorsalis pedis pulse would all be normal findings post-fracture reduction.

Rationale 3: The major serious complication post-fracture reduction is compartment syndrome. A prolonged capillary-refill time with loss of paresthesia and pain not relieved by medication are signs of compartment syndrome. Pink, warm extremity; pain relieved by medication; and a present dorsalis pedis pulse would all be normal findings post-fracture reduction.

Rationale 4: The major serious complication post-fracture reduction is compartment syndrome. A prolonged capillary-refill time with loss of paresthesia and pain not relieved by medication are signs of compartment syndrome. Pink, warm extremity; pain relieved by medication; and a present dorsalis pedis pulse would all be normal findings post-fracture reduction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 06. Provide nursing care for fractures and other sports injuries, including teaching for injury prevention and evidence-based nursing implementations for the child who has sustained a fracture or other sports injury.

Question 15

Type: MCSA

A child has been admitted to the hospital with osteomyelitis. Which statement does the nurse understand is true for this diagnosis?

1. Cultures should be done immediately after the first dose of antibiotic infuses.

2. Antibiotics are ineffective against this virus.

3. Methicillin is the antibiotic of choice.

4. Antibiotic therapy should continue for 36 weeks.

Correct Answer: 4

Rationale 1: Medical management of osteomyelitis begins with intravenous administration of a broad-spectrum antibiotic. Antibiotic therapy should continue for 36 weeks. Cultures are always done before an antibiotic is started. Methicillin is not the drug of choice.

Rationale 2: Medical management of osteomyelitis begins with intravenous administration of a broad-spectrum antibiotic. Antibiotic therapy should continue for 36 weeks. Cultures are always done before an antibiotic is started. Methicillin is not the drug of choice.

Rationale 3: Medical management of osteomyelitis begins with intravenous administration of a broad-spectrum antibiotic. Antibiotic therapy should continue for 36 weeks. Cultures are always done before an antibiotic is started. Methicillin is not the drug of choice.

Rationale 4: Medical management of osteomyelitis begins with intravenous administration of a broad-spectrum antibiotic. Antibiotic therapy should continue for 36 weeks. Cultures are always done before an antibiotic is started. Methicillin is not the drug of choice.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 03. Recognize signs and symptoms of infectious musculoskeletal disorders and refer for appropriate care.

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

Copyright 2012 by Pearson Education, Inc.

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