Question 1

The nurse is teaching the mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex. Which of the following responses from his mother indicates a need for further teaching?

Accepted Answer

The statement "A product's label indicates whether it is latex-free" indicates a need for further teaching because not all products clearly label whether they contain latex. Parents and caregivers must be vigilant and may need to contact manufacturers or research products to ensure they are truly latex-free.

Question 2

The nurse is caring for an 8-year-old boy with myasthenia gravis and is teaching his parents about the signs of cholinergic crisis. Which of the following responses by the parents indicates a need for further teaching?

Accepted Answer

B

Question 3

The nurse is providing postoperative care for a 14-month-old girl who has undergone a myelomeningocele repair. The girl's mother is extremely anxious and tells the nurse she is afraid she will never learn how to care for her daughter at home. Which response by the nurse would be most appropriate?

Accepted Answer

The nurse's response of offering help and support is the most appropriate and empathetic, acknowledging the mother's anxiety while providing reassurance and a willingness to assist in her learning process.

Question 4

The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention would the nurse implement to best promote maximum chest expansion?

Accepted Answer

Upright positioning helps promote maximum chest expansion by allowing the diaphragm to move more freely and improving lung capacity, which is crucial for maintaining cardiopulmonary function in patients with Duchenne muscular dystrophy.

Question 5

A 6-year-old boy with cerebral palsy has been admitted to the hospital for some tests. His condition is stable. The boy's mother remains with her son, but she is obviously exhausted and stressed. Which response by the nurse would be most appropriate?

Accepted Answer

Encouraging the mother to go home and rest acknowledges her exhaustion and stress, while also reassuring her that her son is in good hands.

Question 6

A nurse is caring for a 14-year-old girl following myelography. Which of the following would be the priority nursing action?

Accepted Answer

Observing for signs of meningeal irritation is the priority nursing action following myelography because the procedure involves the injection of a contrast dye into the spinal canal, which can potentially irritate the meninges and lead to complications such as meningitis. Monitoring for symptoms like headache, fever, neck stiffness, and photophobia is crucial for early detection and intervention.

Question 7

The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury?

Accepted Answer

Raising the bed's side rails when a caregiver is not present is a practical measure to prevent falls without constant supervision, balancing safety with the child's independence and comfort. Continuous caregiver presence (B) is ideal but not always feasible, and the use of restraints (C) can be controversial and should be minimized. Raising side rails all the time (A) may not be necessary and could restrict the child's mobility more than needed.

Question 8

The nurse is caring for a child with a spinal cord injury and providing instruction to the parents on promoting skin integrity. Which response from the mother indicates a need for further teaching?

Accepted Answer

Monitoring skin at least twice a week is not sufficient for a child with a spinal cord injury. It is important to check the skin daily to prevent pressure ulcers and other skin integrity issues.

Question 9

The nurse is teaching a group of students about myelinization in a child. Which statement by the students indicates that the teaching was successful?

Accepted Answer

Myelinization occurs in a cephalocaudal (head-to-toe) and proximodistal (from the center of the body outward to the extremities) pattern. This process is crucial for the development of motor skills and coordination in children, as it enhances the speed and efficiency of nerve impulse transmission.

Question 10

When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely?

Accepted Answer

Skeletal traction is least likely to be used in the treatment plan for a child with cerebral palsy. Cerebral palsy primarily involves neurological and muscular issues, and treatments like physical therapy, orthotics, and occupational therapy are more directly beneficial in managing symptoms and improving function. Skeletal traction is more commonly used for fractures, dislocations, or orthopedic corrections, which are not the primary concerns in cerebral palsy management.

Question 11

A nurse is preparing a program for a group of parents about injury prevention. Which of the following would the nurse include as an important contributing factor for cervical spine injury in a child?

Accepted Answer

Increased mobility of the spine in children makes them more susceptible to cervical spine injuries compared to adults. This is due to the anatomical and physiological differences in children's spines, including more elastic ligaments and underdeveloped neck muscles, which can lead to a greater risk of injury when subjected to force.

Question 12

A child with Duchenne muscular dystrophy is to receive prednisone as part of his treatment plan. After teaching the child's parents about this drug, which statement by the parents indicates the need for additional teaching?

Accepted Answer

Prednisone can cause gastrointestinal irritation, so it is usually recommended to take it with food to minimize this side effect. The statement about giving the drug before eating suggests misunderstanding.

Question 13

Which of the following would the nurse expect to find initially in a child with Guillain- Barré syndrome?

Accepted Answer

The answer of Which of the following would the nurse...

Question 14

The nurse is assessing a newborn who was delivered after a prolonged labor due to an abnormal presentation. The newborn sustained a cranial nerve injury. The nurse would most likely expect to assess deficits related to which cranial nerve?

Accepted Answer

The facial nerve (cranial nerve VII) is most likely to be injured in cases of difficult labor or abnormal presentations, leading to facial paralysis or weakness, which can affect expressions and possibly feeding.

Question 15

A child with spastic cerebral palsy is to receive botulin toxin. The nurse prepares the child for administration of this drug by which route?

Accepted Answer

Botulinum toxin for spastic cerebral palsy is typically administered via intramuscular injection to target specific muscles affected by spasticity, helping to reduce muscle stiffness and improve mobility.

Question 16

The nurse is assessing the neuromusculoskeletal system of a newborn. Which of the following would the nurse identify as an abnormal finding?

Accepted Answer

Sluggish deep tendon reflexes in a newborn are considered abnormal because newborns typically have brisk reflexes. A decrease in reflex activity could indicate an underlying neuromuscular issue.

Question 17

The nurse is developing a teaching plan for the parents of a child with a myelomeningocele who will require clean intermittent catheterization. Which of the following would the nurse include?

Accepted Answer

The answer of The nurse is developing a teaching plan...

Question 18

A child with cerebral palsy has undergone surgery for placement of a baclofen pump. Which of the following would the nurse include when teaching the parents about caring for their child?

Accepted Answer

The answer of A child with cerebral palsy has undergone...

Question 19

A group of students are reviewing information about neuromuscular disorders. The students demonstrate understanding of the information when they identify which of the following as examples of autoimmune neuromuscular disorders? Select all answers that apply.

Accepted Answer

Guillain-Barré syndrome, Myasthenia gravis, and Dermatomyositis are autoimmune neuromuscular disorders. Guillain-Barré syndrome involves the immune system attacking the peripheral nervous system. Myasthenia gravis is characterized by weakness and rapid fatigue of any of the muscles under voluntary control, caused by an autoimmune attack on the neuromuscular junction. Dermatomyositis involves inflammation of the muscles and skin, also due to an autoimmune reaction. Cerebral palsy is a group of permanent movement disorders that appear in early childhood, not caused by autoimmune responses, and Spinal muscular atrophy is a genetic disorder affecting the control of muscle movement.

Question 20

A nursing instructor is preparing for a class discussion on spinal muscular atrophy (SMA). When describing type 2 SMA, which of the following would the instructor include? Select all answers that apply.

Accepted Answer

Type 2 SMA typically manifests after 6 months of age, so onset before 6 months (A) is more characteristic of Type 1 SMA. Type 2 SMA is characterized by muscle weakness that is more pronounced in the proximal muscles, such as the shoulders and hips (B), and it is a slowly progressing condition (D), unlike Type 1 SMA, which progresses more rapidly. Difficulty with swallowing (C) is more commonly associated with Type 1 SMA. SMA, including Type 2, is a genetic disorder with autosomal recessive inheritance (E), meaning that a child must inherit one copy of the defective gene from each parent to be affected.

Quiz 44: Nursing Care of the Child With an Alteration in Mobility/Neuromuscular or Musculoskeletal Disorder