Question 1

An infant is diagnosed with congenital CP caused by a meningitis infection.Based on this diagnosis,the nurse understands that the pathway for cellular damage is
A)genetic mutation to the brain cells prompted by infection with the causative agent.
B)accumulation of causative agents in the blood stream that gradually build up in the brain.
C)stretching and shearing of the neural pathways and brain tissue.
D)consumption of brain tissue and production of lactic acid by the causative pathogen.

Accepted Answer

A)Streptococcus pneumonia is the pathogen that causes meningitis in infants, and it causes cellular damage through consumption of the brain's tissue and production of the byproduct lactic acid. Genetic mutations are not caused by infections. Neurotoxins like bilirubin accumulate in the bloodstream and eventually damage nerve cells in the brain. Trauma stretches and shears neural pathways and brain tissue.
B)Streptococcus pneumonia is the pathogen that causes meningitis in infants, and it causes cellular damage through consumption of the brain's tissue and production of the byproduct lactic acid. Genetic mutations are not caused by infections. Neurotoxins like bilirubin accumulate in the bloodstream and eventually damage nerve cells in the brain. Trauma stretches and shears neural pathways and brain tissue.
C)Streptococcus pneumonia is the pathogen that causes meningitis in infants, and it causes cellular damage through consumption of the brain's tissue and production of the byproduct lactic acid. Genetic mutations are not caused by infections. Neurotoxins like bilirubin accumulate in the bloodstream and eventually damage nerve cells in the brain. Trauma stretches and shears neural pathways and brain tissue.
D)Streptococcus pneumonia is the pathogen that causes meningitis in infants, and it causes cellular damage through consumption of the brain's tissue and production of the byproduct lactic acid. Genetic mutations are not caused by infections. Neurotoxins like bilirubin accumulate in the bloodstream and eventually damage nerve cells in the brain. Trauma stretches and shears neural pathways and brain tissue.

Question 2

The parents of an infant report that the baby is often withdrawn and lethargic and does not eat or sleep well.The nurse notes that the child is underweight and small for its age.Which action by the nurse is most appropriate?
A)Giving the baby medicine for colic
B)Drawing blood for laboratory work
C)Feeding the baby
D)Observing interactions between the parents and the infant

Accepted Answer

A)Because the parents' concerns and nurse's observations are possibly related to failure to thrive, the nurse would assess the relationship and interactions between the infant and the parents. Assessment is the priority, not feeding the baby. The physician-not the nurse-orders labs and medications.
B)Because the parents' concerns and nurse's observations are possibly related to failure to thrive, the nurse would assess the relationship and interactions between the infant and the parents. Assessment is the priority, not feeding the baby. The physician-not the nurse-orders labs and medications.
C)Because the parents' concerns and nurse's observations are possibly related to failure to thrive, the nurse would assess the relationship and interactions between the infant and the parents. Assessment is the priority, not feeding the baby. The physician-not the nurse-orders labs and medications.
D)Because the parents' concerns and nurse's observations are possibly related to failure to thrive, the nurse would assess the relationship and interactions between the infant and the parents. Assessment is the priority, not feeding the baby. The physician-not the nurse-orders labs and medications.

Question 3

What does a nonorganic cause of failure to thrive (FTT)mean?
A)The FTT is not the result of a disease process or medical condition.
B)The FTT is the result of inborn errors in metabolism.
C)The FTT is the result of congenital disease.
D)The FTT is the result of a congenital anomaly such as cleft palate.

Accepted Answer

A nonorganic cause of FTT means that the condition is not caused by a disease or medical condition.

Question 4

The nurse is planning care for a child who is diagnosed with cerebral palsy (CP).Which of the following are appropriate nursing diagnoses for this child? Select all that apply.
A)Impaired Mobility
B)Risk for Injury
C)Anxiety
D)Caregiver Role Strain
E)Deficient Diversional Activity

Accepted Answer

A)The child with cerebral palsy will demonstrate poor social skills; therefore, Deficient Diversional Activity would be an appropriate diagnosis for the child. The child with CP is more likely to have impaired mobility. Risk for Injury may be an appropriate diagnosis for the child with CP depending on the type and severity. The parent will experience anxiety and caregiver role strain, not the child.
B)The child with cerebral palsy will demonstrate poor social skills; therefore, Deficient Diversional Activity would be an appropriate diagnosis for the child. The child with CP is more likely to have impaired mobility. Risk for Injury may be an appropriate diagnosis for the child with CP depending on the type and severity. The parent will experience anxiety and caregiver role strain, not the child.
C)The child with cerebral palsy will demonstrate poor social skills; therefore, Deficient Diversional Activity would be an appropriate diagnosis for the child. The child with CP is more likely to have impaired mobility. Risk for Injury may be an appropriate diagnosis for the child with CP depending on the type and severity. The parent will experience anxiety and caregiver role strain, not the child.
D)The child with cerebral palsy will demonstrate poor social skills; therefore, Deficient Diversional Activity would be an appropriate diagnosis for the child. The child with CP is more likely to have impaired mobility. Risk for Injury may be an appropriate diagnosis for the child with CP depending on the type and severity. The parent will experience anxiety and caregiver role strain, not the child.
E)The child with cerebral palsy will demonstrate poor social skills; therefore, Deficient Diversional Activity would be an appropriate diagnosis for the child. The child with CP is more likely to have impaired mobility. Risk for Injury may be an appropriate diagnosis for the child with CP depending on the type and severity. The parent will experience anxiety and caregiver role strain, not the child.

Question 5

A nurse is teaching a mother of an infant who has been diagnosed with failure to thrive (FTT)about the treatment for the condition.Which statement by the nurse is appropriate?
A)"Appetite stimulant medications will be prescribed to help your child gain weight."
B)"If your child is breastfeeding,you must stop and feed your child formula."
C)"A home care nurse will be visiting to see how your child eats."
D)"A home care nurse will be visiting to insert a nasogastric feeding tube in your child."

Accepted Answer

Option A is incorrect because appetite stimulants are not often prescribed for infants with FTT. Option B is incorrect because breastfeeding is encouraged in infants with FTT as breast milk is the best source of nutrition for them. Option D is incorrect because nasogastric feeding tubes are not typically used for infants with FTT. Option C is appropriate because a home care nurse can observe and assess the infant's feeding ability and provide support to the mother in optimizing feeding techniques.

Question 6

A nurse is caring for a pregnant client who has a history of depression.When including information to decrease the client's risk for having an infant diagnosed with failure to thrive (FTT),which of the following rationales is appropriate?
A)Women with mental illness have a decreased breast-milk supply,increasing the risk of FTT.
B)Women with mental illness may be socially isolated,increasing the risk of FTT.
C)Women with mental illness take medications that pass through the breast milk,increasing the risk of FTT.
D)Women with mental illness lack the knowledge required to provide adequate nutrition,increasing the risk of FTT.

Accepted Answer

Women with mental illness may experience social isolation, which can affect their ability to provide adequate support and care for their infant, potentially leading to FTT. Breast-milk supply and medication can also play a role in FTT, but they are not directly related to the client's history of depression. Lack of knowledge may be a factor in some cases, but it is not specific to women with mental illness.

Question 7

Which of the following best describes the relationship of nutrition,immunity,and geriatric failure to thrive (GFTT)?
A)Illness leads to decreased appetite,which leads to decreased nutrition.This leads to decreased ability to recover from illness.Illness increases susceptibility to GFTT.
B)Decreased nutrition leads to increased appetite.If appetite is so great that it cannot be satiated,GFTT develops.Once GFTT develops,risk of illness and infection increases.
C)Decreased appetite leads to decreased in nutrition.This leads to decreased ability to recover from infection,which increases susceptibility to illness.Illness increases susceptibility to GFTT.
D)GFTT leads to decreased appetite.This leads to imbalanced nutrition and increased susceptibility to illness.This increases the likelihood that GFTT will become chronic.

Accepted Answer

Decreased appetite leads to decreased nutrition, which in turn weakens the immune system and makes the body more susceptible to infection and illness. This increases the risk of GFTT, as an already weakened body is unable to recover from the illness and becomes further malnourished. Thus, decreasing appetite is a key factor in the development of GFTT.

Question 8

The nurse is planning care for a family with five children,one of whom has been diagnosed with cerebral palsy (CP).The child is being cared for in the home,has a tracheostomy,and is on a home ventilator.Which intervention best supports the needs of needs of the family?
A)Meals-on-Wheels
B)Food stamps
C)Psychologic counseling
D)Respite care

Accepted Answer

Respite care allows the family to have a temporary break from the constant care of the child with cerebral palsy, which can alleviate stress and prevent burnout. This intervention supports the needs of the entire family, including the caregiver(s) and siblings. Meals-on-Wheels and food stamps address the family's need for food but do not provide relief from the burdens of care. Psychologic counseling may be beneficial, but is not the best choice for this situation.

Question 9

Which of the following sets of symptoms would the nurse identify in an infant exhibiting hypotonia?
A)Tense muscles and uncoordinated,awkward,stiff movements
B)Increased range of motion of joints,diminished reflex response,floppiness
C)Constant involuntary writhing motions that are more severe distally.
D)Paralysis of one side of the body,with greater upper extremity dysfunction

Accepted Answer

Hypotonia is characterized by decreased muscle tone and an inability to maintain normal posture. Infants with hypotonia typically have increased range of motion of joints, diminished reflex response, and a "floppiness" in their movements. Tense muscles and uncoordinated, awkward, stiff movements (A) are more indicative of hypertonia. Constant involuntary writhing motions that are more severe distally (C) are indicative of dystonia. Paralysis of one side of the body, with greater upper extremity dysfunction (D), is characteristic of hemiplegia.

Question 10

Which statement made by a parent would cause the nurse to suspect that the infant may have a developmental condition like cerebral palsy (CP)?
A)"My 6-month-old baby is rolling from back to prone now."
B)"My 8-month-old cannot sit without support."
C)"My 10-month-old is not walking."
D)"My 3-month-old smiles at me all the time."

Accepted Answer

Infants typically begin to sit unsupported between 4 and 8 months of age. The fact that the 8-month-old cannot sit without support may indicate a developmental delay or condition like cerebral palsy. Rolling from back to prone at 6 months and not walking at 10 months are not necessarily concerning, as these milestones have a wide age range for achievement. Smiling at 3 months is a normal developmental milestone.

Question 11

The nurse caring for a child recently diagnosed with cerebral palsy (CP)is discussing the plan of care with the parents.Which should the nurse identify as a major goal of therapy for this child?
A)Promoting optimal global development
B)Increasing the child's IQ level
C)Reversing the degenerative processes that have occurred
D)Curing the underlying defect

Accepted Answer

The major goal of therapy for a child with CP is to promote optimal global development, which includes improving motor function, communication, and socialization skills. Increasing IQ level, reversing degenerative processes, and curing the underlying defect are not realistic goals for CP, as it is a permanent neurological condition.

Question 12

Which of the following would the nurse anticipate observing in the client with geriatric failure to thrive (GFTT)?
A)Decreased salivation and slowed gastrointestinal (GI)motility
B)Neurologic disease or condition
C)Excessive caloric expenditure
D)Congenital errors of metabolism

Accepted Answer

A)Age-related changes impact food intake and digestion and can lead to GFTT, including decreased sense of taste, decreased secretion of digestive enzymes, and decreased salivation. GI motility also slows with age, decreasing metabolism. Neurologic diseases or conditions can lead to either FTT or GFTT, as can excessive caloric expenditure. Congenital errors of metabolism often cause FTT, not GFTT.
B)Age-related changes impact food intake and digestion and can lead to GFTT, including decreased sense of taste, decreased secretion of digestive enzymes, and decreased salivation. GI motility also slows with age, decreasing metabolism. Neurologic diseases or conditions can lead to either FTT or GFTT, as can excessive caloric expenditure. Congenital errors of metabolism often cause FTT, not GFTT.
C)Age-related changes impact food intake and digestion and can lead to GFTT, including decreased sense of taste, decreased secretion of digestive enzymes, and decreased salivation. GI motility also slows with age, decreasing metabolism. Neurologic diseases or conditions can lead to either FTT or GFTT, as can excessive caloric expenditure. Congenital errors of metabolism often cause FTT, not GFTT.
D)Age-related changes impact food intake and digestion and can lead to GFTT, including decreased sense of taste, decreased secretion of digestive enzymes, and decreased salivation. GI motility also slows with age, decreasing metabolism. Neurologic diseases or conditions can lead to either FTT or GFTT, as can excessive caloric expenditure. Congenital errors of metabolism often cause FTT, not GFTT.

Question 13

Which of the following statements should the nurse include in a teaching session for an adult client with cerebral palsy (CP)?
A)"Adults with CP are at increased risk of bladder infections,which may result in incontinence."
B)"It's important to undergo regular depression screenings,because undiagnosed depression can contribute to incontinence."
C)"Clients with CP are prone to incontinence as they age."
D)"If you experience urinary incontinence,you will likely need to be assessed by a neurologist to see if the problem is related to nerve function."

Accepted Answer

A)As individuals with CP age, they are more prone to both urinary and bowel incontinence. CP does not increase the risk of bladder infection. Incontinence is often a cause of depression in CP patients, not the other way around. Urinary incontinence in adults with CP is usually not due to neurologic problems. In addition, the doctor-not the nurse-would refer the client to a neurologist.
B)As individuals with CP age, they are more prone to both urinary and bowel incontinence. CP does not increase the risk of bladder infection. Incontinence is often a cause of depression in CP patients, not the other way around. Urinary incontinence in adults with CP is usually not due to neurologic problems. In addition, the doctor-not the nurse-would refer the client to a neurologist.
C)As individuals with CP age, they are more prone to both urinary and bowel incontinence. CP does not increase the risk of bladder infection. Incontinence is often a cause of depression in CP patients, not the other way around. Urinary incontinence in adults with CP is usually not due to neurologic problems. In addition, the doctor-not the nurse-would refer the client to a neurologist.
D)As individuals with CP age, they are more prone to both urinary and bowel incontinence. CP does not increase the risk of bladder infection. Incontinence is often a cause of depression in CP patients, not the other way around. Urinary incontinence in adults with CP is usually not due to neurologic problems. In addition, the doctor-not the nurse-would refer the client to a neurologist.

Question 14

During a home visit,the nurse suspects that a newborn is at risk for failure to thrive (FTT).Which statement by the child's mother supports this assessment?
A)"I do not like to cook."
B)"I needed help at first learning to breastfeed my baby."
C)"I have a glass of wine with dinner once a week."
D)"I have been feeling depressed for the past several weeks."

Accepted Answer

A)The mother who is depressed and anxious may not be interacting appropriately with her infant and puts the child at risk for failure to thrive. A glass of wine once a week is appropriate. The mother's aversion to cooking will not affect the infant. Needing help with breastfeeding is normal for a first-time mother.
B)The mother who is depressed and anxious may not be interacting appropriately with her infant and puts the child at risk for failure to thrive. A glass of wine once a week is appropriate. The mother's aversion to cooking will not affect the infant. Needing help with breastfeeding is normal for a first-time mother.
C)The mother who is depressed and anxious may not be interacting appropriately with her infant and puts the child at risk for failure to thrive. A glass of wine once a week is appropriate. The mother's aversion to cooking will not affect the infant. Needing help with breastfeeding is normal for a first-time mother.
D)The mother who is depressed and anxious may not be interacting appropriately with her infant and puts the child at risk for failure to thrive. A glass of wine once a week is appropriate. The mother's aversion to cooking will not affect the infant. Needing help with breastfeeding is normal for a first-time mother.

Question 15

A child with cerebral palsy (CP)is scheduled for casting of the lower extremities.When instructing the parents about the purpose of the casts,which of the following will the nurse include in the teaching session? Select all that apply.
A)Promote skeletal alignment
B)Maintain stability
C)Improve muscle tone
D)Improve muscle function
E)Control involuntary movements

Accepted Answer

A)Serial casting is used to promote skeletal alignment, maintain stability, and control involuntary movements. Serial casting will not improve muscle tone or function.
B)Serial casting is used to promote skeletal alignment, maintain stability, and control involuntary movements. Serial casting will not improve muscle tone or function.
C)Serial casting is used to promote skeletal alignment, maintain stability, and control involuntary movements. Serial casting will not improve muscle tone or function.
D)Serial casting is used to promote skeletal alignment, maintain stability, and control involuntary movements. Serial casting will not improve muscle tone or function.
E)Serial casting is used to promote skeletal alignment, maintain stability, and control involuntary movements. Serial casting will not improve muscle tone or function.

Question 16

The nurse sees several adult clients between the ages of 30 and 40 for annual checkups,one of whom has CP.Which of the following client statements represents a common consequence of the stress state caused by CP?
A)"My muscles seem to always hurt all over,and my joints are sore a lot,too."
B)"I have a really hard time socializing and understanding nonverbal communication.
C)"There are times when I just cannot control my anger and I hurt other people."
D)"I just have no appetite lately,and I seem to get dehydrated a lot."

Accepted Answer

CP can cause chronic stress on the body, leading to general muscle and joint pain. Choice B is a common consequence of autism spectrum disorder, not CP. Choice C is not a common consequence of CP, and may be indicative of other underlying mental health issues. Choice D is not typically associated with stress caused by CP.

Question 17

The nurse suggests that the mother of an infant with failure to thrive (FTT)see a lactation specialist to assist with breastfeeding.Which goal is appropriate when planning care for this family?
A)Increase the number of well-child checkups for the child.
B)Convince the mother to use formula instead of continuing with breastfeeding.
C)Improve the parent-child relationship.
D)Prevent complications associated with poor nutrition.

Accepted Answer

A)The goal is to prevent complications associated with poor nutrition. There is no evidence that the mother is not relating well to the child. Increasing the amount of checkups will not improve nutrition. If the mother wishes to continue breastfeeding and help can be obtained, it may be harmful to her self-esteem to insist she bottle feed the infant, although supplementation with formula is an option.
B)The goal is to prevent complications associated with poor nutrition. There is no evidence that the mother is not relating well to the child. Increasing the amount of checkups will not improve nutrition. If the mother wishes to continue breastfeeding and help can be obtained, it may be harmful to her self-esteem to insist she bottle feed the infant, although supplementation with formula is an option.
C)The goal is to prevent complications associated with poor nutrition. There is no evidence that the mother is not relating well to the child. Increasing the amount of checkups will not improve nutrition. If the mother wishes to continue breastfeeding and help can be obtained, it may be harmful to her self-esteem to insist she bottle feed the infant, although supplementation with formula is an option.
D)The goal is to prevent complications associated with poor nutrition. There is no evidence that the mother is not relating well to the child. Increasing the amount of checkups will not improve nutrition. If the mother wishes to continue breastfeeding and help can be obtained, it may be harmful to her self-esteem to insist she bottle feed the infant, although supplementation with formula is an option.

Question 18

The nurse is caring for a child with intellectual deficits who has been diagnosed with failure to thrive (FTT).The family is expressing difficulty with managing the child's care needs.Which nursing diagnosis would be appropriate for this situation?
A)Impaired Parenting related to poor parenting skills
B)Dysfunctional Family Processes related to a child with intellectual disability
C)Hopelessness related to terminal condition of the child
D)Compromised Family Coping related to the child's developmental variations

Accepted Answer

The nursing diagnosis that is appropriate for this situation is Compromised Family Coping related to the child's developmental variations. The child has been diagnosed with failure to thrive and has intellectual deficits, which increases the complexity of caring for the child. The family is expressing difficulty with managing the child's care needs, indicating a need for support to manage the child's developmental variations. Impaired Parenting related to poor parenting skills is not appropriate because the family is not indicating a lack of parenting skills but rather difficulty managing the child's care needs. Dysfunctional Family Processes related to a child with intellectual disability is also not appropriate because there is no indication that the family is experiencing dysfunction, and the child's diagnosis is failure to thrive, not intellectual disability. Hopelessness related to terminal condition of the child is not appropriate because there is no indication that the child has a terminal condition.

Question 19

While conducting a well-child assessment,the nurse suspects that a 2-month-old has failure to thrive (FTT).Which of the following height and weight measurement parameters should the nurse use to help diagnose this health problem?
A)Height and weight below the 50th percentile
B)Height and weight below the 15th percentile
C)Height and weight below the 5th percentile
D)Height and weight below the 10th percentile

Accepted Answer

The standard definition of FTT is that the child's weight is below the 5th percentile for their age and/or their weight is decelerating more rapidly than expected. Height is not typically used as a diagnostic parameter for FTT.

Quiz 25: Development

An infant is diagnosed with congenital CP caused by a meningitis infection.Based on this diagnosis,the nurse understands that the pathway for cellular damage is

The parents of an infant report that the baby is often withdrawn and lethargic and does not eat or sleep well.The nurse notes that the child is underweight and small for its age.Which action by the nurse is most appropriate?

What does a nonorganic cause of failure to thrive (FTT) mean?

The nurse is planning care for a child who is diagnosed with cerebral palsy (CP) .Which of the following are appropriate nursing diagnoses for this child? Select all that apply.

A nurse is teaching a mother of an infant who has been diagnosed with failure to thrive (FTT) about the treatment for the condition.Which statement by the nurse is appropriate?

A nurse is caring for a pregnant client who has a history of depression.When including information to decrease the client's risk for having an infant diagnosed with failure to thrive (FTT) ,which of the following rationales is appropriate?

Which of the following best describes the relationship of nutrition,immunity,and geriatric failure to thrive (GFTT) ?

The nurse is planning care for a family with five children,one of whom has been diagnosed with cerebral palsy (CP) .The child is being cared for in the home,has a tracheostomy,and is on a home ventilator.Which intervention best supports the needs of needs of the family?

Which of the following sets of symptoms would the nurse identify in an infant exhibiting hypotonia?

Which statement made by a parent would cause the nurse to suspect that the infant may have a developmental condition like cerebral palsy (CP) ?

The nurse caring for a child recently diagnosed with cerebral palsy (CP) is discussing the plan of care with the parents.Which should the nurse identify as a major goal of therapy for this child?

Which of the following would the nurse anticipate observing in the client with geriatric failure to thrive (GFTT) ?

Which of the following statements should the nurse include in a teaching session for an adult client with cerebral palsy (CP) ?

During a home visit,the nurse suspects that a newborn is at risk for failure to thrive (FTT) .Which statement by the child's mother supports this assessment?

A child with cerebral palsy (CP) is scheduled for casting of the lower extremities.When instructing the parents about the purpose of the casts,which of the following will the nurse include in the teaching session? Select all that apply.

The nurse sees several adult clients between the ages of 30 and 40 for annual checkups,one of whom has CP.Which of the following client statements represents a common consequence of the stress state caused by CP?

The nurse suggests that the mother of an infant with failure to thrive (FTT) see a lactation specialist to assist with breastfeeding.Which goal is appropriate when planning care for this family?

The nurse is caring for a child with intellectual deficits who has been diagnosed with failure to thrive (FTT) .The family is expressing difficulty with managing the child's care needs.Which nursing diagnosis would be appropriate for this situation?

While conducting a well-child assessment,the nurse suspects that a 2-month-old has failure to thrive (FTT) .Which of the following height and weight measurement parameters should the nurse use to help diagnose this health problem?