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74 Cards in this Set

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  • Back
Emergency care for the child who has ingested a cleaning product with bleach includes which of the following interventions?
Have child drink 3 to 4 ounces of water to dilute the poisonous agent.
Which of the folowing statements best describes Hirschsprung's disease:
1. The colon has an aganglionic segment.
2. There is passage of excessive amounts of meconium in the neonate.
3. It results in excessive peristalic movmeents within the gastrointestinal tract.
4 It results in frequent evacuation of solids, liquids, gas.
The colon has an aganglionic segment
The nurse assesses the neonate immediately after birth. A tracheoesophageal fistula should be suspected if which of the following is present?
1. Jaundice
2. Bile-stained vomitus
3. Absence of sucking
4. Excessive amount of frothy saliva in the mouth
Excessive amount of frothy saliva in the mouth. Drooling.
The nurse is caring for a boy with probably intussusception. He had diarrhea before admission, but while waiting for administration of air pressure to reduce the intussusception, he passed a normal brown stool What should nurse do?
Call the physician. Indicative of resolved intussusception.
Which of the following is a seondary effect when a child experiences decreased muscle, strenght, tone and endurance.
- Increased Metabolism - Increased Venous Return
- Increased Cardiac output
- Decreased exercise tolerance
Muscle disuse leads to tissue breakdown and loss of mucscle mass or muscle atrophy. IT may take weeks or months to recover.
Which of the following measures is important in managing hypercalcemia in a child who is immobilized?
- Promote adequate hydration
- Change position frequently
- Encourage diet high in calcium
- Provide diet high in protein and calories
Promote adequate hydration for flusihing out calcium.
The nurse Is caring for a an immobilized preschool child. Which of the following is helpful during this period of immobilization?
1. Encourage wearing pajamas
2. Let child have few behaviorla limitations.
3. Keep child away from other immobilized children if possible.
4. Take a walk by wagon outside the room.
Take child for a "walk" by wagon outside of room - important for activities outside of room if possible. Gives them opporutnities to meet their normal g and d needs.
Which of the following is the rationale for elevating an extremity after a soft-tissue injury such as a sprined ankle?
. Elevation increases the pain threshold
.Elevation increases metabolism in the tissues
.Elevation produces deep tissue vasodilation.
.Elevation reduces edema formation
Elevation reduces edema formation. Uses gravity to facilitate venous return to reduce edema.
Which of the following is characteristic of fractures in children?
.Fractures rearely occur at grwoth plate site , since it absorbs shock well.
.Rapidity f healing is inversely related to the child's ages.
Pliable bones of growing children are less porous than those of adults
.Periosteum of a child's bone is thinner, is weaker and has less osteogenic potential compared with that of the adult.
Rapidity of healing is inversely related to the child's age.
The callus that develops at the fracture site is important because it provides which of the following?
Functional use of the injured part
sufficient support for weight bearing
means for adeuate blood supply
Means for holding bone fragments together.
Means for holding bone fragments together - New bone cells are formed in large numbers and stimulated to maximum activity. They are found at the site of the injury. In time, calcium salts are absorbed to form the callus.
An younster has just retunred from surgery in a hip spica cast. The priority nursing intervention would be which of the following?
Elevate HOB
Check circulation, sensation and motion of toes
Turn child to right side, then left side every 4 hours
offer sips of water
Check circulation, sensation, and motion of toes. Chief concern is that the extremity may continue to swell. This must be assessed to ensure that the cast does not become a tourniquet and cause complications.
An adolescent who had a lower leg amputated after a motorcycle accident complains of pain in the missing extremity. The nurse should recognize that this is:
Normal and called phantom limb sensation
Which of the following statements is true concerning osteogenesis imperfecta (OI)
OI is easily treated
OI is an inherited disorder
Later onset of the disease usually runs a more difficult course.
Braces and exercises are of no therapeutic value
OI is an autosomal dominant inherited disorder. OI is a lifelong problem caused by defective bone mineralization, abnormal bone architecture, and increased susceptibility to fracture. OI has a predicatble course of disease that is determined by the pathophysiologic processes, not the time of onset. Lightweight braces and splints can help support limbs and fractures.
Which of the following is characteristic of most neonatal seizures?
Well organized
Subtle and barely discernible
Subtle and barely discernible. Signs of seizures in newborns are subtle. They include symptoms such as lip smacking, tongue thrusting, eye rolling, and arching of the back.
Which of the following is a clnical manifestation of Increased ICP in infants?
Shrill, high pitched cry
pulsating anterior fontanel
Vomiting and diarrhea
Shrill, high pitched cry. A shrill, high-pitched cry is common clin manifestation of IICP in infants. The characteristic cry occurs secondary to the pressure being placed on the miningeal nerves, causing pain. Photophobia is not indicative of IICP in infants. A pulsating anterior fonanel is normal in infants. Would see a bulging anterior fontanel in IICP. Vomiting is in children.
The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. Which of the following is the priority assessment for this child?
Reactivity of pupils
Doll's head maneuver
Oculovestibular response
Funduscopic exam to identify papilledema
Reactivity of pupils - indication of neurologic health. Pupils shuld be assessed for no reaction, unilateral reaction, and rate of reactivity.
Dolls head maneuver should not be performed if there is a cervical spine injury.
Assessing for oculosvestibular response is a painful test that should not be done on a child ho is having variable levels of consciousness.
Papilledema does not develop for 24 - 48 hours in the course of unconsciousness.
The nurse is performing a neurologic assessment on a 2-month old infant after a car accident. Moro, tonic neck, wand withdrawal reflexes are present. The nurse should recognize that these reflexes suggest which of the following?
Neurologic health
Severe brain damage
Decorticate posturing
Decerebrate posturing
Neurologic Health
The temperature of an adolescent who is unconscious is 105 degrees F. The priority nursing action is to:
Continue to monitor temperature
Initiate a pain asessment NON Apply a hypothermia blanket
Adminster aspirin stat
Apply a hypothermia blanket - Brain damage can occur at temperatures as high as 105. It is extremely important to institute temperateure-lowering interventions such as hypothermia blankets and tepid baths immediately.
The nurse is caring for a child with multiple injuries who is comatose. The nurse should recognize that pain:
cannot occur if child is comatose
may occur if child regains consciousness
requires astute nursing assessmetn and managemetn
Is best assessed by family members who are familiar with child.
Requires astute nursing assessment and management - Since the child cannot communicate pain through one of the standard pain rating scales, the nurse must focus on physiologic and behavioral manifestations to accurately assess pain.
Which of the following is a nurinsg intervention used to prevent increased intracranial pressure (ICP) in an unconsious child?
Suction child frequently
Provide enviornmental stimulation
Turn head side to side every hour
Avoid activities that cause pain or crying
Avoid activities that cause pain or crying.
The nurse is instructing a group of parents about head injuries in children. The nurse should explain that infants are particularly vulnerale to acceleration-decelearation head injuries because:
Musculskeletal support of head is insufficient - The relatively large head size coupled with insufficient musculoskeltal support increases the risk to infants of accel-decel head injuries.
The nusre is admitting a young child to the hospital b/c bacterial meningitis is suspected. Which of the following is the major priority of nursing care?
Initiate isolation precautions as soon as diagnosis confirmed.
Initiate isolation precautions as soon as the causative agent is identified.
Administered antibiotic therapy as soon as it is orderd
Admin sedatives and analgesics on a preventive scheduled to manage pain.
Admin Antibiotic therapy as soon as the causative agent is identified - Are begun as soon as possible to prevent death and to avoid resultant disabilities.
The nurse is planning care for a school aged child with bacterial meningitis. Which of the following nursing interventions should be included?
Keep enviornment stimuli to a minimum.
Avoid giving pain medications that could dull sensorium.
Measure head circumference to assess developing complications
Have child move head side to side at least every 2 hours.
Children with meningitis are sensitive to noise, bright lights, and other extenral stimuli because of the irritation on the meningeal nerves. The nurse should keep the room as quite as possible with a minimum of external stimuli, including lighting. A school aged child will have closed sutures; thus head circum cannot change. Child should be placed on side-lying position with HOB slightly elevated. Should avoid measures such as lifting head that increases discomfort and puts tension on the neck.
A young child is having a seizure that has lasted 35 minutes. There is a loss of consciousness. The nurse should recognize that this is:
Status epilepticus
The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt to correct hydrocephalus. Which of the following should the nurse include:
Parenteral protection is essential until child reaches adulthood.
Mental retardation is to be expected with hydrocephalus
Shunt malfunction or infection requires immediate treatment.
Most usual childhood activities must be restricted
Shunt malfunction or infection requires immediate treatment
Cerebral Palsy (CP) may result from a variety of causes. It is now known that the most common cause of CP is which of the following?
Birth asphyxia
Neonatal diseases
Cerebral trauma
Prenatal brain abnormalities
Prenatal brain abnormalities: Most common currently identifiable cause of CP is exhisting brain abnormalities during the prenatal period.
The major goals of therapy for children with CP include:
Reversing degenerative process that have occurred
Curing the underlying defect causing the disorder
Preventing spread to individuals in close contract with the chidlren NON Recognizing the disorder early and promoting optimal development
Recognizing the disorder early and promoting optimal development.
A 3 year old has CP, and is hospitalized for orthopedic surgery. His mother says he has difficulty swallowing and cannot hold a utensil to feed himself. He is slightly underweight for his height. Which of the following is the most appropriate nursing action related to feeding the boy?
Bottle- or tube-feed him a sepcialized formula until he gains sufficient weight.
Stabilize his jaw with one hand (either from a front or side position) to facilitate swallowing
Place him in well-supported , semireclining position to make use of gravity flow.
Plae him in a sitting position with his neck hyperextended to make use of gravity flow.
Stailize his jaw with one hand
An 8 year old has been diagnosed with moderate cerebral palsy (CP). She recently began participation in a regular classroom for part of the day. Her mother asks the school nurse about joing the after-school Girl Scout troop. The nurse's response should be based on knowledge that:
Most activities such as girl scouts cannot be adapted for children with CP
After school activities usually result in extreme fatigue for children with CP
trying to participate in activities such as Girl socuts leads to lowering self esteem in children with CP
after-school activities often provide children with CP with opportunities for socialization and recreation
Opportunities for scoializtion and recreation.
A neural tube defect that is not visible externally in the lumbosacral area would be called:
Spina bifida Cystica
Spina Bifida occulta
Spina Bifida Occulta: often will not be noticed. A clue to the presence of this internal disorder will be a dimple or tuft of hair on the lumbosacral area.
A woman who is 6 weeks pregnant tells the nurse that she is worried her baby might have spina bifida because of a family history. The nurses repsonse should be based on which of the following?
There is no genetic basis for the defect
Prenatla detection is not possible yet
Chromosomal studies done on amniotic fluid can diagnose the defect prenatally.
The concentration of a fetoprotein in amniotic fluid can potentially indicate the presence of defect prenatally.
Fetal ultrasound and elevated concentrations of a - fetoprotein in amniotic fluid many indicate the presence of anecephaly, myelominogecele or other neural tube defects. No chromosoma lstudies that currently diagnose SB
A 6 year old girl born with a myelomeningocele has a neurogenic bladder. Her parents have been performing clean intermittent catheterization. The nurse should recommend which of the following?
Teach the child to do self cath
Teach the child appropriate bladder control
Continue having the parents do the cath
Encourage the family to consider urinary diversion
Teach the child to do self- cath _ At 6 years of age this child should have deterity to perform the intermittent cath herself. This will give her more control and master over her disability.
Which of the following most accurately describes bowel function in children born with myelomeningocele?
Incontinence cannot be prevented
Enemas and laxatives are contraindicated
Some degree of fecal incontinence can usually be achieved
A colostomy is usually required by the time the child reaches adolescence.
Some degree of fecal continence can usually be achieved - With diet modification and regular toliet habits to prevent constipation and impaction, some degree of fecal continence can be achieved.
Which of the following is an important nursing intervention when caring for a child with myelomeningocele in preop stage?
Place child on side to decrease pressure on the spinal cord
Apply aheat lamp to facilitate drying and toughening of the sac
Keep skin clean and dry to prevent irritation from diarrheal stools
Measure head circum and examine fontanels for signs that might indicating developing hydrocephalus
Measure head circum…Obstructive hydrocephalus is freqently associated with myelomeninogcele.
A child with spina bifida has developed a latex allergy from numerous bladder cathertizations and surgeirs. A priority nursing intervention is to:
Recommend allergy testing.
Provide a latex-free enviornement
Use only powder-free latex gloves
Limit the use of latex products as much as possible
Provide a latex-free environment. From birht on, limitation of exposure to latex is essnetial in an attempt to minmize sensitization.
Which of the following factors predispose an infant to fluid imbalances?
Decreased surface area
Lower metabolic rate
Immature kidney functioning
Decreased daily exchange of extracellular fluid
Imature kidney Functioning - Infant's kidneys are unable to concentrate or dilute urine, to conserve or excrete sodium, and to acidify urine.
When evaluating the extent of an infan'ts dehydration, the nurse should recognize that the symptoms of severe dehydration (15%) include:
Tachycardia, decreased tears, 5% weight loss
Normal pulse and blood pressure, intesne thirst
Irritability, moderate thirst, normal eyes and fontanels,
Tachycardia, parched mucous membranes, sunken eyes and fontanels
Symptoms of severe dehydration include tachycardia, parched mucous membranes and sunken eyes and fontanels. Severe = 15% weight loss,
A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solution (ORS). The child's mother calls the clinic nurse because he is also occasionally vomiting. The nurse should recommend which of the following?
Bring the child to the hospital for IV fluids
Alternate giving ORS and carbonated drinks
Continue to give ORS frequently in small amounts
Institute NPO status for the child for 8 hours and resume ORS if vomiting has subsided.
Continue to give ORS frequently in small amounts- Vomiting is not a contraindication to the use of ORS unless it is severe. The mother should continue to give ORS in small amounts at freq intervals.
A 2 month old breast fed infant is susccessfully rehydrated with oral rehydration solutions for aute diarrhea. Instructions to the mother about breastfeeding should include which of the following?
Continue breastfeeding
Stop breastfeeding until breast milk is cultured
Stop breastfeeding until diarrhea is absent for 24 hours
Express breast milk and dilute with sterile water before feeidng
Continue breastfeeding - should continue even if the infant has acute diarrhea.
Which of the following urine tests would be considered abnormal?
pH: 4
SG: 1.020
Protein Level: absent
Glucose level: absent
pH 4 - expected pH of urine is 4.8-7.8
SG Range: 1.015 - 1.030
Protein - should not be present would indidcate abnormality in glomerular filtration
Glucose - indicate DM, glomerulonephritis, or a response to infusion or fluids with high glucose concentrations
A young child is diagnosed wit hVesicoureteral reflux. The nurse should know that this is usually associated with:
Reccurent Kidney Infections: Refulx allows urine to flow back to the kidneys. When the urine is infected, this contributes to kidney infections.
A 5 year old child has been sent to the school nurse for urinary incontinence three times in the past 2 days. The nurse should recommend to her parent that the first action is to have the child evaluated for which of the following?
School phobia
Emotioanl causes
Possible urinary tract infection
Possible structural defects of urinary tract
Incontinence in a previously toliet trained child can be an indication of a urinary tract infection.
External defects of GI Tract such as hypospadias, are usually repaired as early as possible to ensure which of the following?
Prevention of urinary tract complications
Prevention of seperation anxiety
Acceptance of hospitalization
Development of Normal body image
Development of Normal body image: Promoion is extremely important. Surgery involving sexual organs can b eupsetting to children, esspecialy prescholers whofear mutilation and castration. Surgical intervention for external defects of the genitourinary system should be done as soon as possible.
Which of the following lab findings, in conjunction with the presenting symptoms indicates nephrosis?
Low specific gravity
Decreased Hemoglobin
Decreased Hematocrit
Hypoalbuminemia: Result of large amounts of protein that leak through the glomerular membrane into the urine in a child with nephrosis
In a non-potty trained child with nephrotic syndrome, the best way to detect fluid retention is which of the following?
Weigh child daily
Test urine for hematuria
Measure abdominal girth weekly
Count the number of wet diapers
Weight child daily: At same time in same clothing is most accurate way to determine fluid gains and losses.
What is an appropriate nursing intervention while the child with nephrotic syndrome is confidned to bed?
Restrain child as necessary
Discourage parents from holding child
Do passive-range of motion exercises once a day
Adjust activities to child's tolerance level
Adjust activitiees to child's tolerance level: The child will have variable level of tolerance for activity. The activity tolerane will also be affected by labile moods associated with steroid admin. The nurs should assist the family in adjusting activities for the child that are age appropriate.
The parent of a child hospitalized with acute glomerulonephritis (AGN) asks the nurse why blood pressure readings are being taken so often. The nurse's reply should be based on knowledge of which of the following?
BP flucturations are a common side effect of antibiotic therapy
BP fluctuations are a sign that the condition has become chronic
Acute hypertension must be anticipated and identified
Hypotension leading to sudden shock can develop at any time
Acute HTN must be anticipated and identified: Vital signs ,in particular BP, provide information about the severity of AGN and early signs of complications. Acute HTN is anticipated and requires frequent monitoring for ealry intervention.
A 3 year old child is scheduled for surgery to remove Wilms Tumor from one kidney. The parents ask the nurse about what treamtents, if any will be necessary after recovery from surgery. The nurse's explanation should be based on knowledge that:
No additonal treatments are usually necessary.
Chemo is usually not necessary
Chemotherapy with or without radioatherapy is indicated
Kidney transplant will be indicated within the year.
Chemotherapy with or without radioterapy is indicated: Detemrination of chemo and / or radio therapy as tx modatlities will be made based on histologic pattern of the tumor.
The nurse is caring for a child with Wilms tumor. Which of the following is the most important nursing intervetnion preoperatively?
Avoid abdominal palpation
Closely monitor arterial blood gases
Prepare child and family for long-term dialysis
Prepare child and family for renal transplantation
Avoid abdominal palpation: Wilms tumors are encapsulated. It is extremely important to avoid any palpation of the mass to minimize the risk of disemination of cancer cells to adjacent and other sites. A sign should be placed over the bed indicating that no abdominal palpation should be conducted.
A toddler is hospitalized with acute renal failure secondary to severe dehydration. The nurse should assess the child for which of the following possible complications?
Water Intoxication
Water Intoxication: child with ARF has tendency to develop water intoxication with hyponatremia. Control water balance requires careful monitoring of intake, output, body weight, and electrolytes.
Monitored for HTN not hypo, Hyponatremia not Hyper and HyperKalemia not Hypo
6 year old child with acute renal failure is being transferred out of the ICU. Which of the following children, considereing their diagnosis would be most appropriate roomate for this child?
6 year old child with pneumonia
4 year old child with gastroenteritis
5 year old child who has a fractured femur
7 year old child who had surgery for a ruptured appendix
The 5 year old with fractured femur would be best, this child does not have an illness of viral or bacterial orgin.
The newborn diagnosed with phenylketonuria (PKU) will require long-term follow-up to assess for the development of:
Diabetes Insipidus
Resp distress
Mental retardation
Mental Retardation: PKU an inborn error of meatabolism, may lead to mental retardation if early intervetnion is not performed.
Which of the following is described as the time interval between early manifestations of a disease and the overt clinical syndrome?
Incubation period
Prodomal period
Desquamation Period
Period of communicability
Prodromal Period: Defined as the symptoms that occur between early manifestaitons of the disease and the overt clnical symptoms
Intubation time from exposure to apperance of first symptom
Desquamation refers to shedding of skin when applicable for a syndrome of disorder
Communicability: Child is infectious
The nusre is concerned with the prevention of commnicable disease. Primary prevention results from which of the following?
Early diagnosis
Strict Isolation
Treatment of disease
Immunizations : Communicable disease are prevented through immuniztions, which constitute primary prevention.
Which of the following is the best ay for the nurse to maintain adeuate fluid intake for a toddler with nausea, vomiting, and diarrhea?
Keep the patient NPO and give hypotnic solutions IV
Force fluids and give hypertonic solutions IV
Provide Jell-O and Popsicles to increase fluid intake
Offere oral rehydration solutions (ORS) to rehydrate the patient
Offer oral rehdyration solutions to rehydrate patient: Contain sodium potassium, choloride, citrate, and glucose; amount given determined by degree of dehydration and child's weight; if child vomiting give small amount of oral rehydration solution at frequent intervals.
Parenteral fluids are necessary only if toddler is severely dehydrated or in shock
No longer recommended to give clear fluids such as fruit juices, carbonated soft drinks, geatin b/c therse are high in carbs, low in electrolytes and have high osmolarity.
The home care nurse visits a 3 year old child diagnosed at birth with phenylketonuria. The nurse assesses the child's intake for the previous eek. The nurse is MOST concerned if the child's parent makes which of the following statements?
My child snacks on oranges
eats low-porein pasta for dinner
Likes potatoe chips
My child's fav lunch is a peanut butter and jelly sandwich.
My child's fav lunch is pb and j sand. Peaut butter is not allowed on diet; can have a low-protein bread jelly sandwich. Phenylketonurai is absence of the enzyme needed to metabolize the essential amino acid phenylalanine; treatment is dietary; food with low phenylaline levels allowed, such as vegetables, fruit, juices and some low protein breads andcereals; oranges are allowed on diet. Essential to prevent mental retardation.
The nurse cares for a newborn diagnosed with DDH. The nurse expects which of the following methods of treatment to be used for the newborn?
Pavlik harness
Double diapering
Placing a small pillow between the legs
Bracing the affected leg
Pavlik harness: during the early newborn period a harness is appllied to hold the hips in wide abduction; if tx does not achieve the correction in a few months then surgery is indicated and a postop spica hip bandage or body cast is applied.
Double diaper can cause hip extension
Parents should asses for skin breakdown when infant is in pavlik harness; put undershirt on infant under the chest straps nd knee socks on under the foot and leg pieces; check for skin breakdown 2-3 times per day; avoid lotions and powders; place diaper understraps.
Gently massage skin under straps once per day to stimulate circulation.
Which med should the nurse have available for the treatment of acetaminophen overdose?
When planning care for an infant diagnosed with a myelominocele, it is MOST important the nurse identifieds which of the following principles of nursince care is MOSt important to paply when caring for an infant with myelomingocele?
Asepsis : infection may cause meningitis and damage the brain; the CNS is very delicate; asepsis is extremly important.
Infant placed in prone position; head turned to one side for feeding; gentle ROB may be restricted to foot, ankle, and knee joints,
Diapering may be contraindicated until after surgical repair of defect; change paddening benath infant as needed
Frequent stroking and caressing wil meet need for tactile stimulation
A brace is ordered for an adolescent to correct a scoliosis deformity. Which of the following statements, if made by the parent to the nurse, indicates teaching is succssful?
A bed board may replace the brace at night
My child's diet should be low in calories
Daily tub baths are preferred to showers
The brace should be worn 23 hours a day.
The brace should be worn 23 hours a day. Remove for bathing; asses skin for signs of iritation; wear cotton T-shirt under brace to prevent irritation. Teach child how to prevent falls by using handrais and avoiding slippary surfaces.
Home care monitors pediatric client diagnosed with chrnoic seizure disorder. The nurse should intervene if which of the following is observed?
The parent takes the child's temp using an oral electronic thermometer
Parent encourages child to play with boats during bath time
Child wears a helmet when riding a bicycle
The child eats p nut buta and jelly sand.
The parent takes the child's temp with oral electronic thermometer: Seizures can occur without warning ; its dangerous to have a thermometer in the mouth b/c the child may start seizing.
A four-week-old infant is brought to a health care provider by the parent b/c of vomiting and abdomianl distention. The infant is diagnosed as having pyloric stenosis and is admitted to the hospital. The nurse should expect the infan'ts emesis to have which of these qualities?
Black in apperance
Diminished after feeindgs
Be projectile
Be accompanied by diarrhea
Be projectile: other symptoms include weight loss, constipaiotion, dehydration, visible peristalic waves.
Coffe ground enemsis indicates bleeding; pyloric stenosis is obstruction of the passage way from the stomach to the duodenum due to enlargement of the sphincter muscle
vomiting ocurs after feeindg; give small freq meals and psotion infant upright. May cause constipation not diarrhea.
The nurse performs a home care visit for a child diagnosed with cystic fibrosis. The nurse should intervene if which of the following is observed?
The child eats a high-protein, high cal diet
The child has two to three stools per day
The child swallows the pancreatic enzyme capsules whole.
The child takes the pancreatic enzymes on hour after eating
The child takes enzyme capusles one hour after eating: Should be taken at beginning of meal or with snacks or withing 30 min of eating; chewing or crushing beads destroys enteric coating.
The nurse performs assessments in the well-baby clinic. The nurse identifies which of the following is a warning sign of CP?
The infant has poor head control after 3 months
The infant sits with support by 8 months
The infant uses arms and legs to crawl across the room
The infant smiles at the mother by 3 months
The infant has poor head control after 3 months
Adolescent is evaluated for scoliosis. The client asks the nurse, "what is scoliosis?" Which of the following statements by the nurse BEST describes scoliosis?
It is inward curvature of the lower spine
It is an exaggerated convexitity In the rhoracic region of the spine
it is the herniation of an intervertebral disc
it is a lateral curvature of a portion of the spine
It is a lateral curvature of a portion of the spine: brace worn 23 hours a day.
A 3 day old infant is born with a myelomeningocele. The nurse caring for the neonate should place the infant in which of the following positions?
Prone: Neural tube fails to close and fuse during development: prone position helps prevent pressure on the fatlike protrusion on the back; pressure on the area may rsult in IICP and may also cause a rupture of the sac leading to infection
An 18 mont old toddler diagnosed with cystic fibrosis is admitted to the hospital with a resp infection. The nurse should expect to see which of the following charateristic features of CF?
Absence of gastric enzymes
An altered viscosity of mucous
An absence of liver enzymes
Poor ventilatory functioning
An altered viscosity of Mucus:
The nurse is asked to explain the major difference between a clubfoot and a postional deformity to a student nurse. Which of the following statements, if made by the nurse is appropriate?
A clubfoot can be passively corrected, but a postitional deformity must be corrected with surgery and casting
A clubfoot is corrected with surgery and casting, but a postional defomrity can be passively corrected.
A clubfoot is not correctable, but a positional deformity is correctable
A clubfoot is correctable but a positional deformity is not correctable.
A clubfoot is corrected with surgery and casting but a positional deformity can be passively corrected.
The nurse supervises a family caring for a child diagnosed with CP. The nurse should intervene if which of the folowing is observed?
The parent allows the child to rest prior to a physical therapy session
The child wears a helmet when ambulationg in the house
The older sister places a toy in the child's hands
The parents offere high-calorie snacks to the child
Apply a moist, sterile dressing
Prior to surgery for myelomeningocele, which of the following actions should the nurse perform to care for the area of the defect?
Cleans the defect and leave the defect open to air
Apply a dry steril dressing
Apply a moist sterile dresing
Apply antibiotic ointment and leave the area open to air
Moist sterile dressing
The nurse instructs the parents of a 7 year old child diagnosed with CF about required dietary modifications. Which of the following adjustments is likely to be made in a normal diet?
Increased protien
Increased Fat
Increased Carb
Increased Potassium
The older sister places a toy in child's hand: Important to offere child with CP incentives to move; place toy out of immediate reach
The nurse cares for an infant immediately after insertion of a shunt due to hydrocephalus. Which of the folowing observations by the nurse should be reported to the physician immediately?
The infant is lying flat in bed
The infan'ts pupils are dilated
The suture is pink
Bowel sounds are heard in all quadrants
Pupils dilated = IICP
An infant is found to have excessive amount of oral secretions after birth. During the first feeidng infant has a choking episode accompanied by cyanosis. The nurse knows that these symptoms are indicative of which of the following problems?
Pyloric Stenosis
Tracheosophagela defect
Cleft Palat
A 3 year old child is brought to the ER with a Hx of vomiting and diarrhea for the past 3 days. Which of the following signs and symptoms is the nurse MOST likely to see?
Shorntess of breath
Slow heart rate
Sunken eyes
Sunken Eyes