Question 1

A nurse is teaching the parent of a child who has a new diagnosis of absence seizures.  Which statement by the parent indicates understanding of the teaching?

Accepted Answer

Absence seizures occur in children age 4-12 and usually disappear at puberty. Clinical manifestations include a brief loss of consciousness and an appearance of inattention or daydreaming (the absence attack) without loss of postural body tone. However, slight loss of tone may lead to dropping objects held in hands. Most absence seizures last less than 10 seconds and often go unrecognized. Following an attack, behavior and awareness return immediately to normal. The child does not experience a postictal period but usually has no recollection that a seizure has occurred. A child may have multiple absence seizures each day. Treatment includes the use of anticonvulsant medication(s). (Options A, B, and D) Altered sensory perceptions (eg, awareness of odors [aura]), postictal confusion, and incontinence are clinical manifestations of complex partial or tonic-clonic seizures. Educational objective: Absence seizures are characterized by a brief loss of consciousness and an appearance of inattention or daydreaming without loss of postural tone. Most absence seizures last less than 10 seconds. The seizures occur in children age 4-12, and multiple seizures may occur daily.

Question 2

A nurse is caring for a 3-month-old infant who has bacterial meningitis. Which clinical findings support this diagnosis? Select all that apply.

Accepted Answer

Bacterial meningitis is an inflammation of the meninges in the brain and spinal cord that is caused by specific types of bacteria, including group B streptococcal, meningococcal, or pneumococcal pathogens. Clinical manifestations of bacterial meningitis in infants age <2 include: Fever or possible hypothermia Irritability, frequent seizures High-pitched cry Poor feeding and vomiting Nuchal rigidity Bulging fontanelle possible but not always present One of the most common acute complications of bacterial meningitis in children is hydrocephalus. Long-term complications include hearing loss, learning disabilities, and brain damage. Due to the severity of potential complications, prompt identification and immediate treatment are vital for any client with suspected bacterial meningitis. (Option A) Infants with bacterial meningitis may have bulging fontanelles due to an increase in intracranial pressure. Depressed fontanelles indicate severe dehydration. (Option E) The Babinski reflex can be present up to 1-2 years and is a normal expected finding; it does not indicate meningitis. Educational objective: Bacterial meningitis is inflammation of the meninges in the brain and spinal cord caused by bacterial infection. Key characteristics of bacterial meningitis in infants under age 2 include frequent seizures, a high-pitched cry, poor feeding, nuchal rigidity, and possible bulging fontanelles.

Question 3

The nurse taught the caregiver of a child with a ventriculoperitoneal (VP) shunt about when to contact the health care provider (HCP).  The caregiver shows understanding of the instructions by contacting the HCP about which symptom?

Accepted Answer

11ecbb05_caee_2da0_b433_f3613394b210_MD0009_00 The caregiver of a child with a VP shunt must understand symptoms of increased intracranial pressure (ICP), which indicate shunt malfunction. Vomiting may be a sign of increased ICP and would require that the HCP be contacted. (Option A) Fever may indicate shunt infection, but a temperature of 99 F (37 C) remains within acceptable parameters. Contacting the HCP is not indicated. (Option B) Memory lapse or changes in mental status may indicate increased ICP. The inability to remember one meal would not indicate a change of mental status. (Option D) A VP shunt is tunneled under the scalp and can be palpated. Educational objective: Increased ICP may occur with VP shunt malfunctions. The caregiver must recognize symptoms of vomiting, headaches, vision changes, and changes in mental status. Early intervention by the HCP will decrease the risk of damage to the brain tissue.

Question 4

The nurse assesses a pediatric client who was diagnosed with diarrhea caused by Escherichia coli. The nurse is most concerned with which finding?

Accepted Answer

Hemolytic uremic syndrome (HUS) is a life-threatening complication of Escherichia coli diarrhea and results in red cell hemolysis, low platelets, and acute kidney injury. Hemolysis results in anemia, and low platelets manifest as petechiae or purpura. Therefore, the presence of petechiae in this client could indicate underlying HUS and needs further assessment. (Option A) E coli bacteria infect people through contaminated food or water and attack the digestive system. Blood-streaked stool due to intestinal irritation is a common symptom associated with this illness. Treatment is aimed at preventing dehydration, and clients usually improve in about a week. (Option B) Fruit juices are discouraged in acute diarrhea as they have high sugar (osmolality) and low electrolyte content. Continuing the client's normal diet (solid foods) is encouraged as it shortens the duration and severity of the diarrhea. (Option C) Dry mucous membranes are a sign of dehydration, a common complication of any persistent diarrhea. Dehydration should be treated promptly, especially in children; however, as long as fluid is replenished, the condition is not life-threatening. Educational objective: Hemolytic uremic syndrome is a life-threatening complication of Escherichia coli diarrhea. Clinical features include anemia (pallor), low platelets (petechiae and purpura), and acute kidney injury (low urine output).

Question 5

The nurse receives new prescriptions for a 6-month-old client with bacterial meningitis. Which action is the priority of care?

Accepted Answer

Bacterial meningitis is an inflammation of the membranes covering the brain and spinal cord (ie, meninges) caused by a bacterial infection. The inflammatory process and bacterial growth within the meninges lead to increased volumes of cerebrospinal fluid and, subsequently, increased intracranial pressure (ICP). Without intervention, increased ICP may lead to nerve ischemia, permanent functional impairment (eg, hearing loss, visual impairment, paralysis), brain damage, herniation, and death. The initial priority of nursing care is protecting other clients and staff from exposure, as bacterial meningitis is highly contagious and transmitted by droplets. After isolating the client, the nurse should initiate prescribed antibiotics as quickly as possible, as bacterial meningitis can progress rapidly and lead to death without treatment (Option A). (Options B and C) Clients with meningitis are at increased risk for seizures. Implementation of a low-stimulation environment (eg, low lighting, minimal noise, uninterrupted rest periods) and seizure precautions (eg, padded side rails) are important interventions. However, initiating antibiotic therapy is the priority. (Option D) An increasing head circumference may indicate increasing volumes of cerebrospinal fluid and increased ICP. Monitoring for new or worsening signs of increased ICP is important but may be performed after initiating prescribed antibiotics. Educational objective: Bacterial meningitis is an inflammation of the membranes covering the brain and spinal cord that can lead to severe complications (eg, hearing loss, brain damage) or death without treatment. To reduce the risk of complications, the nurse should prioritize initiation of prescribed antibiotic therapy as soon as possible.

Question 6

When performing developmental screenings in the well-child clinic, the registered nurse understands that which child is at highest risk of developing autism spectrum disorder?

Accepted Answer

Although the cause of autism spectrum disorder (ASD) is unknown, numerous studies indicate that it has a strong genetic component. The underlying genetic source is unknown in the majority of cases; however, researchers hypothesize that genetic factors predispose to an autism phenotype and that genetic expression is influenced by environmental factors. (Option A) A 2-year-old with a vocabulary of a few words only is a concern; however, there are a number of factors and/or conditions that could cause language or overall developmental delay. (Option B) There is no scientific evidence that the measles, mumps, and rubella vaccine or thimerosal-containing vaccines (eg, influenza) are linked to ASD. (Option D) Retrospective studies have linked parents of older age to autism; however, this association is inconclusive. Educational objective: There is strong scientific evidence of a genetic component to autism spectrum disorder (ASD). As a result, parents who have a child with ASD are at higher risk of having another child with this disorder. There is no evidence that supports a link between vaccines and ASD, and studies on associations between advanced parental age and the disorder are inconclusive.

Question 7

The nurse has assessed 4 children. Which finding requires immediate follow-up with the health care provider?

Accepted Answer

11ecbb05_caf3_36b3_b433_2b05f5757cb1_MD0009_00 Hypospadias is a congenital defect in which the urethral opening is on the underside of the penis. Except in very mild cases, the condition is typically corrected around age 6-12 months by surgically redirecting the urethra to the penis tip. Circumcision is delayed so the foreskin can be used to reconstruct the urethra. If not corrected, clients may have toilet-training difficulties, more frequent urinary tract infections, and inability to achieve erections later in life. Postoperatively, the client will have a catheter or stent to maintain patency while the new meatus heals. Urinary output is an important indication of urethral patency. Fluids are encouraged, and the hourly output is documented. Absence of urinary output for over an hour indicates that a kink or obstruction may have occurred and requires immediate follow-up (Option A). (Option B) Absence seizures are brief moments of staring accompanied by a lapse in awareness. These seizures often go undetected and do not cause physical injury. (Option C) Small amounts of blood-tinged sputum are normal after bronchoscopy; however, frank bleeding or clots should be reported. (Option D) Electrolyte disturbances commonly occur with gastroenteritis due to prolonged or heavy vomiting and diarrhea. This client's sodium and temperature are slightly abnormal but not critical. Educational objective: Hypospadias, a condition in which the urethral opening is on the underside of the penis, is surgically corrected by rerouting the urethra and inserting a temporary stent to aid healing. Urinary output is closely monitored postoperatively to ensure patency.

Question 8

The emergency department triage nurse is assessing 4 pediatric clients. Which client is a priority for further diagnostic workup and definitive care?

Accepted Answer

A ventriculoperitoneal shunt is used to treat hydrocephalus and is usually placed at age 3-4 months. Blockage and infection are complications of shunt placement. Blockage results in signs of increased intracranial pressure (ICP). The normal pulse range for a 1-year-old is 100-160/min. A pulse of 78/min is considered bradycardia, a part of Cushing's triad (bradycardia, slowed respiration, widened pulse pressure). (Option B) Meningocele is a saclike protrusion through a bony defect that contains meninges and cerebrospinal fluid; it is corrected with surgery. In some children, residual bowel and bladder incontinence can result despite surgery. If bowel and bladder control is obtained but incontinence reoccurs, the child should be evaluated for infection (a common complication). Although the child with ear pain (eg, otitis media) may need antibiotics, this is not urgent and the client with neurological signs is the priority. (Option C) Muscular dystrophy is an inherited condition of muscle fiber degeneration and muscle wasting. Respiratory and cardiac problems are the leading causes of mortality. These clients should take precautions to prevent respiratory infections (eg, pneumococcal and influenza vaccination, avoiding contact with infected individuals). This client is the second priority after the client with increased ICP and possible brain herniation. (Option D) Cerebral palsy is a permanent disorder of movement, with abnormal muscle tone, lack of physical coordination, spasticity, and compromised posture development causing activity limitation. Clonus is a series of involuntary, rhythmic, muscular contractions and relaxations. Spasticity/clonus is an expected finding in a client with cerebral palsy. Foot injury in this client is not a priority. Educational objective: A ventriculoperitoneal shunt is used to treat hydrocephalus. Complications include blockage (with signs of increased intracranial pressure [ICP]) and infection. The normal pulse range for a 1-year-old is 100-160/min; bradycardia can be a sign of increased ICP.

Question 9

A child with autism spectrum disorder is being admitted to an acute care unit. Which is the most important nursing action?

Accepted Answer

Children with autism spectrum disorder (ASD) often exhibit sensory processing problems; they may be hyper- or hypo-sensitive to sounds, lights, movement, touch, taste, and smells. A calming environment with minimal stimulation should be provided; a private room away from the nurses' station is the best location. The nurse can also facilitate a calming environment by: Using a quiet or monotone voice when speaking to the child Using eye contact and gestures carefully Moving slowly Limiting visual clutter Maintaining minimal lighting Providing the child with a single object to focus on (Option B) A private room is an appropriate placement; however, the noise and activity from the playroom may be distracting to the child with ASD. (Option C) A semi-private room near the nurses' station is likely to have a stimulating environment due to the noise, lighting, and work pace in the area. (Option D) Placing the child in a semi-private room with another child with ASD does not promote a calming environment. Educational objective: Because children with autism spectrum disorder often exhibit sensory processing problems, they need a calming environment with minimal stimulation.

Question 10

The clinic nurse performs assessments on four infants. The nurse should alert the health care provider to see which client first?

Accepted Answer

11ecbb05_caeb_bc9c_b433_9fbbd1508312_MD0009_00 Hydrocephalus is an increase in intracranial pressure (ICP) that results from obstruction of cerebrospinal fluid flow. Increased ICP can progress to brain damage and death. Signs of increased ICP in children include bulging fontanelles, increasing head circumference, and sunset eyes (or setting-sun sign) (sclera visible above the iris). Sunset eyes occur when periaqueductal structures are compressed from increased ICP, paralyzing the upward gaze. This is a late sign of increased ICP that requires timely treatment (eg, shunt placement) and is the priority (Option B). (Option A) Positional plagiocephaly (flat head syndrome) occurs when an infant is placed in the same position (eg, supine) for an extended period of time and the pliable skull molds to the surface (flattens). Parents can intervene to avoid or correct plagiocephaly (eg, periodically repositioning the head during sleep, tummy time). Minor skull deformation is not a priority. (Option C) Eight wet diapers in 24 hours is within the normal range (6-10 diapers/day or approximately 1 diaper every 4 hours), indicating that the infant is likely producing >1 mL/kg/hr urine output and is not dehydrated, despite vomiting. (Option D) The Babinski reflex (ie, toes fan outward and the big toe dorsiflexes with stimuli) is expected in infants and is a normal finding up to age 1 year. However, its presence beyond this age can indicate neurologic disease. Educational objective: The presence of sunset eyes (sclera visible above the iris) is a late sign of increased intracranial pressure and a priority to report to the health care provider.

Question 11

A client diagnosed with acute glomerulonephritis has pitting edema in both lower extremities, blood pressure of 170/80 mm Hg, and proteinuria. When developing a plan of care for this client, the nurse should include which most accurate indicator of fluid loss or gain?

Accepted Answer

The most accurate indicator of fluid loss or gain in an acutely ill client is weight, as accurate intake and output and assessment of insensible losses may be difficult (Option C). A 2.2-lb (1-kg) weight gain is equal to 1,000 mL of retained fluid. (Option A) Blood pressure measures the amount of pressure exerted on the arterial walls due to factors such as peripheral artery constriction or dilation, not just fluid volume status. (Option D) Pitting edema is not an accurate indicator as the fluid may shift from intravascular to interstitial spaces without an overall change in fluid gain or loss throughout the body. Educational objective: The most accurate indicator of fluid loss or gain in an acutely ill client is daily weight.

Question 12

A newborn has a large myelomeningocele. What nursing intervention is priority?

Accepted Answer

11ecbb05_caed_df7f_b433_7d541a12b7cd_MD0009_00 Myelomeningocele occurs when the neural tube fails to fuse properly during fetal development. An outpouching of spinal fluid, spinal cord, and nerves covered by only a thin membrane occurs, typically in the lumbar area. The newborn is at high risk for infection at this area. A priority nursing intervention is to cover the area with a sterile, moist dressing to decrease the risk of infection until surgical repair can occur. (Option A) Assessing for an anal wink will assist in the assessment of the level of neurologic deficit but is not a priority intervention. (Option C) Myelomeningocele may decrease the absorption of cerebrospinal fluid, which would place the newborn at risk for hydrocephalus from the excess cerebrospinal fluid. An occipital frontal circumference is needed as a baseline measurement but is not a priority. (Option D) The newborn would be placed in the prone position (with face turned to the side) to prevent rupture of the myelomeningocele. Educational objective: The newborn with a myelomeningocele is at risk for infection. Covering the myelomeningocele with a sterile, moist dressing is indicated to decrease the risk of infection at the site. The infant should be placed on the abdomen (prone) with the face turned to the side.

Question 13

A 7-month-old infant is admitted to the unit with suspected bacterial meningitis after receiving an initial dose of antibiotics in the emergency department. Frequent assessment of which of the following is most important in the plan of care?

Accepted Answer

Bacterial meningitis is inflammation of the meninges of the brain and spinal cord caused by infection. General manifestations in infants and children age <2 include fever, restlessness, and a high-pitched cry. One common acute complication of bacterial meningitis is hydrocephalus, an increase in intracranial pressure (ICP) resulting from obstruction of cerebrospinal fluid flow. Increased ICP can progress to permanent hearing loss, learning disabilities, and brain damage. Bulging/tense fontanels and increasing head circumference are important early indicators of increased ICP in children. Frequent assessment for developing complications is vital for any client with suspected bacterial meningitis. (Option A) The Babinski reflex can be present up to age 1-2 years and is a normal, expected finding; it does not indicate meningitis. (Option C) Pulse pressure is the difference between systolic and diastolic blood pressures. Widening of pulse pressure is one of the signs of Cushing's triad (systolic hypertension with widened pulse pressure, bradycardia, respiratory depression). These signs occur very late if increased ICP is not treated. Fontanel assessment provides an earlier indication of increased ICP. (Option D) Because meningitis clients are sensitive to light (photophobia), frequent assessment of pupillary light response will be uncomfortable. Severely increased ICP may alter pupillary response; however, this is a late complication of hydrocephalus. Fontanel assessment provides an earlier indication of a developing problem. Educational objective: Infants with bacterial meningitis can develop hydrocephalus. Bulging/tense fontanels and increasing head circumference are important early indicators of increased ICP in children and should be monitored to prevent long-term complications.

Question 14

The nurse is admitting a 4-year-old diagnosed with Wilms tumor. The child is scheduled for a right nephrectomy in the morning. Which action is a priority in the preoperative care plan?

Accepted Answer

11ecbb05_caf2_c182_b433_1d126018a315_MD0009_00 Wilms tumor (nephroblastoma) is a kidney tumor that usually occurs in children age <5. Most often it involves only one kidney, and the prognosis is good if the tumor has not metastasized. Wilms tumor is usually diagnosed after caregivers observe an unusual contour in the child's abdomen. Once the diagnosis is suspected or confirmed, the abdomen should not be palpated, as this can disrupt the encapsulated tumor. It is important to post the sign "DO NOT PALPATE ABDOMEN" at the bedside. It is also essential that the child be handled carefully during bathing. (Option A) Assessment of a child's development level and emotional maturity will help determine the appropriate approach to use during the many painful procedures that the child will undergo in rapid succession. However, this assessment is not a priority. (Option B) If the tumor has metastasized, adventitious sounds may be present. Auscultating for them is not a priority. (Option D) Some clients may have hypertension due to excess production of renin, and this will require monitoring. However, it is not as important as ensuring that the abdomen is not palpated. Educational objective: Wilms tumor is discovered when caregivers note an unusual bulging/swelling on one side of a child's abdomen. The abdomen should not be palpated until after the diagnosis is suspected or confirmed as this can disrupt the tumor and cause dissemination of tumor cells.

Question 15

A nurse is teaching the parent of an 8-month-old infant who had a febrile seizure about management of future fevers.  Which instruction is appropriate to include in the teaching?

Accepted Answer

Febrile seizures are an alarming experience for parents. They most commonly occur in children between ages 6 months to 6 years, with the peak of incidence occurring at age 18 months. The etiology is unknown. Simple febrile seizure management typically involves reassurance regarding the benign nature of most febrile seizures, and education about the risk of recurrence and seizure safety precautions (eg, side-lying positioning, removal from harmful environments). Parents should use antipyretics such as acetaminophen or ibuprofen (in children age >6 months) to control fever and make the child more comfortable (Option A). However, there is no evidence that antipyretics reduce the risk of future febrile seizures. After the administration of antipyretics, additional cooling methods that may be beneficial for reducing fever include applying cool, damp compresses to the forehead; increasing air circulation in the room; and wearing loose or minimal clothing. (Options B and D) Bathing an infant in tepid water and placing ice bags under the arms and around the neck are not recommended techniques as these induce shivering, increase metabolic activity, have no antiseizure effects, and cause discomfort for the child. (Option C) Parents should be instructed to call 911 and seek medical assistance for a seizure lasting more than 5 minutes. Neurologic damage can occur with frequent and prolonged seizures. Educational objective: Febrile seizures, although alarming, are generally benign. Parents should be instructed on appropriate cooling methods (eg, antipyretics, cool compresses), seizure safety precautions, and the avoidance of shivering.

Question 16

The nurse is planning care for an 8-year-old client with mild cognitive impairment who is hospitalized for diagnostic testing. Which of the following interventions are appropriate to include in the plan of care? Select all that apply.

Accepted Answer

Clients with cognitive impairment (intellectual disability) are diagnosed prior to adulthood and have limited levels of intellectual functioning and adaptive skills for their chronological age. Manifestations may include a decreased ability to perform abstract or logical reasoning, interpret complex ideas, and learn by experience. Cognitive impairment results in developmental delays of varying levels (eg, mild, moderate) and types (eg, cognitive, physical, social, emotional, behavioral) and requires the nurse to assess the client's skills and abilities and provide individualized care. Appropriate nursing interventions for a client with cognitive impairment include: Promoting the staff's understanding of client behavior/needs and maintaining a familiar environment for the client by consistently assigning the same staff (eg, nurse) for care (Option A) Fostering playtime by providing toys that are developmentally appropriate, not necessarily age appropriate (Option C) Preventing self-injury by reinforcing the parents' limit-setting measures (eg, time-outs) and positively reinforcing good behavior (Option D) Facilitating communication and learning by using visual demonstration (eg, picture board) rather than complex explanations (Option E) (Option B) The nurse should involve parents in preprocedural education but avoid excluding the client; explaining procedures using methods appropriate for the client's cognitive ability is encouraged. Educational objective: Appropriate nursing interventions when caring for a pediatric client with cognitive impairment include providing consistency in staff assignments, providing toys appropriate for the client's developmental (not chronological) age, preventing self-injurious behavior (eg, reinforce parental limit setting), and using visual demonstration (eg, picture board) and simple explanations to facilitate communication and learning.

Question 17

A child is scheduled to have an electroencephalogram (EEG).  Which statement by the parent indicates understanding of the teaching?

Accepted Answer

11ecbb05_caec_f51e_b433_01cd26b465c6_MD0009_00 An electroencephalogram (EEG) is a diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the brain, which may result in a seizure disorder. The EEG can be done in a variety of ways, such as with the child asleep or awake with or without stimulation. Teaching for the parent includes the following: Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be removed. Hair may need to be washed after the procedure to remove electrode gel. Avoid caffeine, stimulants, and central nervous system depressants prior to the test. The test is not painful, and no analgesia is required. (Option A) Food and liquids are not restricted prior to an EEG except for caffeinated beverages. Cocoa contains caffeine. (Option C) This test (EEG) is not painful as it only records brain electrical activity. Electrode gel is nonirritating to the skin. (Option D) A routine EEG is not performed under sedation, and so the child should remember the procedure. Educational objective: An EEG is used to diagnose the presence of a seizure disorder. Electrodes are secured to the scalp to observe for abnormal electrical discharges in the brain. Preprocedure teaching includes avoiding stimulants and CNS depressants and washing the hair.

Question 18

A nurse is caring for a child with acute glomerulonephritis. Frequent monitoring of which of the following is a priority?

Accepted Answer

Acute glomerulonephritis (AGN) in children is an immune complex disease most commonly induced by prior group A beta-hemolytic streptococcal infection of the skin or throat. A latent period of 2-3 weeks occurs between the streptococcal infection (eg, pharyngitis) and the symptoms of AGN. Clinical manifestations include periorbital and facial/generalized edema, hypertension, and oliguria, which are primarily due to fluid retention (decreased kidney filtration). The urine is tea-colored and cloudy due to the presence of protein and blood. Although most clients recover spontaneously within days, severe hypertension is an anticipated complication that must be identified early. Monitoring and control of blood pressure are most important as they prevent further progression of kidney injury and development of hypertensive encephalopathy or pulmonary edema. (Option B) Hematuria is common with AGN. It is usually minimal and resolves spontaneously. Monitoring is important but not a priority. (Option C) The most important measure of fluid status is a daily weight as it identifies fluid retention and response to treatment. Monitoring intake and output is important but is not the priority action over hypertension monitoring and control. (Option D) Monitoring for edema is important but not the priority. Moderate sodium restriction is needed, especially if hypertension and edema are present. Otherwise, avoiding high-sodium foods and having no added salt in the diet may be adequate measures. Educational objective: Acute glomerulonephritis is most often caused by recent streptococcal infection. Nursing care is focused on monitoring vital signs (particularly blood pressure) and fluid status, avoiding salt in the diet, and conserving energy.

Question 19

The nurse is preparing for the admission of a 9-year-old client with new-onset tonic-clonic seizures. It is important for the nurse to ensure that what is in the room? Select all that apply.

Accepted Answer

11ecbb05_caec_31cd_b433_c595d7bd484e_MD0009_00 Client safety is a priority when caring for a client with seizure activity. Protecting the airway and improving oxygenation includes turning the client on the side and providing oxygen and oral suctioning as needed. Padding the bed siderails provides the client protection and decreases the potential for injury from the metal in the event that the head or extremities hit the siderails during seizure activity. (Option A) During seizure activity, nothing should be placed in the client's mouth. Placing objects in the mouth could result in injury to the client or health care provider. Maintaining an open airway is important and can be accomplished by turning the client on the side and providing oral suctioning to the inside of the cheeks as necessary. (Option D) A client should never be restrained during seizure activity. Restraints could cause muscle or tissue injury. Educational objective: Turning the client on the side, providing oxygen and suctioning as needed, and padding the siderails or removing objects that are near the client can decrease the risk for injury during a seizure. Avoid restraints.

Question 20

The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture.  What is the appropriate nursing intervention?

Accepted Answer

11ecbb05_caf0_5081_b433_278fe8bbc10d_MD0009_00 The optimal position for access during a lumbar puncture is to have the client's head and knees tucked in and the back rounded out. This provides the most room for the health care provider (HCP) to perform the procedure and allows for a good hold to keep the client still. A lumbar puncture is a sensitive procedure, and it is important to keep the child from moving during needle insertion. (Option A) Unless the client has improper air exchange, oxygen administration is not needed. The nasal cannula will most likely bother the child and lead to unnecessary movement during needle placement. (Option B) The HCP performing the lumbar puncture will feel the spine for correct needle placement and then sterilize and prepare the chosen area for needle insertion. (Option D) Unless the client is unstable, there is no need to record vital signs every 15 minutes. The client should be awake and alert, and the procedure should be fairly short in duration. Educational objective: Performing a lumbar puncture on a child is a very sensitive procedure that requires accuracy. The correct position and ability to hold the child still are important to achieve the best result and minimize the risk for complications.

Exam 2: Child Health

A nurse is teaching the parent of a child who has a new diagnosis of absence seizures. Which statement by the parent indicates understanding of the teaching?

A nurse is caring for a 3-month-old infant who has bacterial meningitis. Which clinical findings support this diagnosis? Select all that apply.

The nurse taught the caregiver of a child with a ventriculoperitoneal (VP) shunt about when to contact the health care provider (HCP) . The caregiver shows understanding of the instructions by contacting the HCP about which symptom?

The nurse assesses a pediatric client who was diagnosed with diarrhea caused by Escherichia coli. The nurse is most concerned with which finding?

The nurse receives new prescriptions for a 6-month-old client with bacterial meningitis. Which action is the priority of care?

When performing developmental screenings in the well-child clinic, the registered nurse understands that which child is at highest risk of developing autism spectrum disorder?

The nurse has assessed 4 children. Which finding requires immediate follow-up with the health care provider?

The emergency department triage nurse is assessing 4 pediatric clients. Which client is a priority for further diagnostic workup and definitive care?

A child with autism spectrum disorder is being admitted to an acute care unit. Which is the most important nursing action?

The clinic nurse performs assessments on four infants. The nurse should alert the health care provider to see which client first?

A client diagnosed with acute glomerulonephritis has pitting edema in both lower extremities, blood pressure of 170/80 mm Hg, and proteinuria. When developing a plan of care for this client, the nurse should include which most accurate indicator of fluid loss or gain?

A newborn has a large myelomeningocele. What nursing intervention is priority?

A 7-month-old infant is admitted to the unit with suspected bacterial meningitis after receiving an initial dose of antibiotics in the emergency department. Frequent assessment of which of the following is most important in the plan of care?

The nurse is admitting a 4-year-old diagnosed with Wilms tumor. The child is scheduled for a right nephrectomy in the morning. Which action is a priority in the preoperative care plan?

A nurse is teaching the parent of an 8-month-old infant who had a febrile seizure about management of future fevers. Which instruction is appropriate to include in the teaching?

The nurse is planning care for an 8-year-old client with mild cognitive impairment who is hospitalized for diagnostic testing. Which of the following interventions are appropriate to include in the plan of care? Select all that apply.

A child is scheduled to have an electroencephalogram (EEG) . Which statement by the parent indicates understanding of the teaching?

A nurse is caring for a child with acute glomerulonephritis. Frequent monitoring of which of the following is a priority?

The nurse is preparing for the admission of a 9-year-old client with new-onset tonic-clonic seizures. It is important for the nurse to ensure that what is in the room? Select all that apply.

The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention?