Question 1

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.Which is the nurse's best response?&#10;A)&#34;You will need to watch the child more closely.&#34;&#10;B)&#34;Tell me more about your feelings.&#34;&#10;C)&#34;The child will be fine,so don't worry.&#34;&#10;D)&#34;Why did you let the child almost drown?&#34;&#10;

Accepted Answer

The most therapeutic response is to allow the parents to express their feelings without judgment or blame. This can help them come to terms with their guilt and begin the healing process. Option A is unhelpful and blaming. Option C may be dismissive of the parents' concerns and feelings. Option D is accusatory and judgmental.

Question 2

The nurse is planning care for a school-age child with bacterial meningitis.Which of the following should be included?&#10;A)Keep environmental stimuli at a minimum.&#10;B)Avoid giving pain medications that could dull sensorium.&#10;C)Measure head circumference to assess developing complications.&#10;D)Have the child move her head from side to side at least once every 2 hours.&#10;

Accepted Answer

Have the child move her head from side to side at least once every 2 hours.

Question 3

A nurse is caring for a child who has recently been diagnosed with cerebral palsy.What are the major goals of therapy for this child?&#10;A)Reversal of degenerative processes that have occurred&#10;B)Curing the underlying defect causing the disorder&#10;C)Preventing the spread to individuals in close contact with the child&#10;D)Promoting optimum development&#10;

Accepted Answer

The major goals of therapy for a child with cerebral palsy are focused on promoting optimum development, improving function, and preventing complications as much as possible. There is no cure for cerebral palsy and therapy cannot reverse the degenerative processes that have occurred. Additionally, cerebral palsy is not contagious and does not spread to others in close contact with the child.

Question 4

A 2-year-old has a tonic-clonic seizure while in the hospital crib.The child's jaws are clamped.Which is the most important nursing action at this time?&#10;A)Place a padded tongue blade between the child's jaws.&#10;B)Stay with the child and observe his respiratory status.&#10;C)Prepare the suction equipment.&#10;D)Restrain the child to prevent injury.&#10;

Accepted Answer

The most important nursing action during a tonic-clonic seizure is to stay with the child and observe their respiratory status. It is important to ensure that the child is not choking or aspirating any secretions, and to protect them from injury by keeping the crib rails up and the bed in the lowest position. Placing a padded tongue blade between the child's jaws may be necessary if their airway becomes obstructed, but should only be done by a trained healthcare provider. Suction equipment should be available if needed, but not necessarily prepared prior to the seizure. Restraint should never be used during a seizure as it may increase the risk of injury.

Question 5

A nurse is caring for a 15-year-old boy who is recovering from a grade 3 concussion.Which educational statement would be important for the nurse to present to the teen's family?&#10;A)The client should not play sports for 1 year after the concussion.&#10;B)If the client has another concussion in the near future,recovery time should remain the same.&#10;C)The client can experience dizziness for more than 6 weeks after the concussion.&#10;D)Concussions usually are associated with skull fractures.&#10;

Accepted Answer

It is important for the nurse to inform the family that the client can experience dizziness for more than 6 weeks after the concussion as this is a common symptom of post-concussion syndrome and can affect the client's daily activities and school performance. Option A is not necessarily true for every case and would require further evaluation by the healthcare provider. Option B is not accurate as repeated concussions can have cumulative effects and may result in prolonged recovery time. Option D is incorrect as most concussions occur without skull fractures.

Question 6

The nurse should suspect a child has cerebral palsy if the parent makes which statement?&#10;A)&#34;My 6-month-old baby is rolling from back to front now.&#34;&#10;B)&#34;My 3-month-old hasn't smiled at me.&#34;&#10;C)&#34;My 8-month-old can sit without support.&#34;&#10;D)&#34;My 10-month-old is not walking.&#34;&#10;

Accepted Answer

Cerebral palsy is a group of permanent movement disorders that appear in early childhood. Signs and symptoms vary among people and over time but often include poor coordination, stiff muscles, weak muscles, and tremors. A 3-month-old not smiling could indicate a delay in social or motor milestones, which could be a sign of cerebral palsy. The other options describe normal developmental milestones for those ages.

Question 7

A child with a mild traumatic brain injury is being sedated with a mild sedative so that pain and anxiety are minimized.Which action should the nurse do first?&#10;A)Place a continuous pulse oximetry monitor on the child.&#10;B)Place the child in a room away from the nurse's station.&#10;C)Allow for several visitors to remain at the child's bedside.&#10;D)Use soft restraints if the child becomes confused.&#10;

Accepted Answer

The first priority should be to ensure the safety and respiratory status of the child. Therefore, placing a continuous pulse oximetry monitor on the child will allow the nurse to monitor the child's oxygenation level and ensure that there are no complications related to sedation.

Question 8

A lumbar puncture is done on an infant suspected to have meningitis.If the infant has bacterial meningitis,the nurse would expect the cerebral spinal fluid to show what result?&#10;A)An elevated white blood cell count&#10;B)An elevated red blood cell count&#10;C)Normal glucose&#10;D)A decreased white blood cell count&#10;

Accepted Answer

Bacterial meningitis would cause an increase in white blood cells in the cerebral spinal fluid. An elevated red blood cell count would not be expected in this situation. Normal glucose levels may or may not be present, and a decreased white blood cell count would not be expected.

Question 9

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.Which assessments will be included? Select all that apply.

A)Eye opening
B)Verbal response
C)Motor response
D)Head circumference
E)Pulse oximetry

Accepted Answer

The Glasgow Coma Scale assesses three areas: eye opening, verbal response, and motor response. Head circumference and pulse oximetry would not be included in this assessment.

Question 10

A child has been diagnosed with epilepsy,and is on daily phenytoin (Dilantin).Which client education should the nurse include?&#10;A)Fluid intake&#10;B)Good dental hygiene&#10;C)A decrease in vitamin D intake&#10;D)Taking the medication with milk&#10;

Accepted Answer

Phenytoin can cause gingival hyperplasia, making good dental hygiene essential to prevent gum disease and other dental issues.

Question 11

A child has sustained a basilar skull fracture.For which complication should the nurse assess?&#10;A)Cerebral spinal fluid leakage from the nose or ears&#10;B)Headache&#10;C)Transient confusion&#10;D)Periorbital ecchymosis&#10;

Accepted Answer

The answer of A child has sustained a basilar skull...

Question 12

An infant has just been born with a myelomeningocele.The infant has been admitted to the neonatal intensive care unit.Upon noticing the nursing tech preparing an open crib for this infant,the nurse should:

A)Not say anything;the tech is doing an appropriate action.
B)Stop the tech and ask her to prepare a warmer for this infant.
C)Remind the tech to include adequate warm blankets in the crib.
D)Ask the tech to place a hat and warm gown for the infant in the crib.

Accepted Answer

The answer of An infant has just been born with...

Question 13

Which is an important nursing intervention when caring for an infant with a myelomeningocele in the preop stage?&#10;A)Place infant supine to decrease pressure on the sac.&#10;B)Apply a heat lamp to facilitate drying and toughening of the sac.&#10;C)Measure head circumference daily to identify developing hydrocephalus.&#10;D)Apply a diaper to prevent contamination of the sac.&#10;

Accepted Answer

The answer of Which is an important nursing intervention when...

Question 14

A child with a 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?&#10;A)Risk for infection&#10;B)Risk for impaired tissue perfusion-cranial&#10;C)Risk for altered urinary elimination&#10;D)Risk for altered comfort&#10;

Accepted Answer

The answer of A child with a myelomeningocele corrected at...

Deck 56: The Child With Alterations in Neurologic Function