MATERNITY AND PEDIATRIC NURSING 4TH ED CHAPTER 38 TEST BANK (203)EXAM QUESTIONS, Exams of Nursing

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MATERNITY AND PEDIATRIC NURSING 4TH ED

CHAPTER 38 TEST BANK (203)EXAM QUESTIONS

1. The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for what finding? A. Indications of increased intracranial pressure B. An increase in the blood glucose level C. A decrease in the liver enzymes D. A presence of protein in the urine: Answer: A Rationale: Reye syndrome is characterized by brain swelling, liver failure, and death in hours if treatment is not initiated. Therefore, increased intracranial pressure could occur. Liver enzyme

levels typically increase. Blood glucose levels and protein in the urine are not characteristic of this illness. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 1363

2. The physician has ordered rectal diazepam for a 2-year-old boy with status epilepticus. Which instruction is essential for the nurse to teach the parents? A. Monitor their child's level of sedation. B. Watch for fever indicating infection.

C. Gradually reduce the dosage as seizures stop. D. Monitor for an allergic reaction to the medication.: Answer: A Rationale: Diazepam is useful for home management of prolonged seizures and requires that the parents be educated on its proper administration. Monitoring the child's level of sedation is key when giving diazepam because it slows the central nervous system. Parents need to monitor the overall health of the child, including temperature when needed, but that has nothing to do with the diazepam. When the use of an anticonvulsant is stopped, gradual reduction of the dosage is necessary to prevent seizures or status epilepticus. This is not done without a physician's order. Monitoring for allergic reactions is necessary when any medications have been prescribed, but is

not specific to diazepam. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 1342

3. A 4-year-old boy has a febrile seizure during a well-child visit. What action would be a priority? A. Hyperextending the child's head while placing him on his side B. Using a tongue blade to pry open the child's jaw C. Loosening the child's clothing to ensure a patent airway D. Protecting the child from harm during the seizure: Answer: D

Rationale: During a seizure, the child should not be held down in a specific position. Protecting the child's head and body during the seizure is the priority. Ensuring a patent airway is an important intervention but is not accomplished by loosening the child's clothing or hyperextending his head. The child should be placed on his side and nothing should be inserted into his mouth to forcibly open the jaw. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 1348- 1349

4. The nurse has developed a teaching plan for the family of a 2-year-old boy who holds his breath when he gets frustrated. What will be most important to include in this

plan? A. Provide cuddle time whenever the child begins to act out. B. Explain the child's behavior to the parents. C. Encourage the parents to interact more with the child. D. Stay close to prevent injury when he gets frustrated.: Answer: D Rationale: Encourage the parents to maintain a safe environment when an episode is occurring, but to avoid giving extra attention to the child after the event since this could encourage repetition of the behavior. It is important for the parents to understand what is happening, but rewarding the child with cuddle time when he is misbehaving provides incorrect reinforcement of behaviors. Encouraging the parents to interact more with the child may be helpful, but the

priority is safety for the child. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 1371

5. The nurse is caring for an 8-year-old boy who has chronic epilepsy. What would be most important to address when teaching the child and parents about living with this condition? A. Multiple corrective surgeries to slowly remove diseased parts of his brain B. Physical, occupational, and speech therapy to maximize his potential C. Support for maintaining self-esteem because of his altered lifestyle

D. Hyperventilation therapy to counteract the periods of decreased oxygena- tion: Answer: C Rationale: The effects of living with a seizure disorder can be devastating, and it is essential for the child to receive support to maintain self-esteem. While corrective surgery is possible, it would only be performed once. Physical, occupational, speech, and hyperventilation therapy are not indicated for treatment of epilepsy. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 1348

6. What finding would lead the nurse to suspect that a child is beginning to develop increased intracranial pressure? A. Bradycardia B. Cheyne-Stokes respirations C. Fixed, dilated pupils D. Projectile vomiting: Answer: D Rationale: Projectile vomiting is an early sign of increased intracranial pressure. Bradycardia, Cheyne-Stokes respirations, and fixed dilated pupils are late signs of increased intracranial pressure. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Apply

Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 1333

7. A nurse is talking with the parents of a child who has had a febrile seizure. The nurse would integrate an understanding of what information into the discussion? A. The child's risk for cognitive problems is greatly increased. B. Structural damage occurs with febrile seizure. C. The child's risk for epilepsy is now increased. D. Febrile seizures are benign in nature.: Answer: D Rationale: Parents need reassurance that febrile seizures, although frightening, are benign in nature. Children who experience one or more febrile seizures are at no greater risk of developing epilepsy than the general population. No evidence exists that febrile seizures cause structural

damage or cognitive declines. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 1349

8. A nurse is preparing a school-aged child for a lumbar puncture. The nurse would expect to position the child in which manner? A. On her side with the head flexed forward and knees flexed to the abdomen B. Sitting upright with the head flexed forward to the chest C. Supine with arms and legs pronated and extended D. Prone with the arms flexed under the chest: Answer: A

Rationale: When a lumbar puncture is performed on a child, the child is placed on his or her side with the head flexed forward and knees flexed to the abdomen. An infant would be positioned sitting upright with the head flexed forward. A supine position with the arms and legs pronated and extended suggests decerebrate posturing. A prone position is not used for a lumbar puncture. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 1334

9. A group of nursing students are reviewing information related to seizures that occur in infants and children. The students demonstrate a need for additional review when they identify which type as common in neonates? A. Tonic B. Focal clonic C. Multifocal clonic D. Myoclonic: Answer: D Rationale: Five major types of seizures have been recognized in the neonatal period: subtle, tonic, focal clonic, multifocal clonic, and myoclonic. Of these, myoclonic seizures rarely occur during the neonatal period. Subtle seizures affect preterm and full-term neonates. Tonic seizures

primarily occur in preterm neonates. Focal clonic and multifocal clonic are more common in full-term neonates. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 1349

10. A child is brought to the emergency department after sustaining a concus- sion. The child is to be discharged home with his parents. What would the nurse include in the child's discharge instructions? A. "Expect his headache to get worse initially and then disappear."

B. "Wake him every 2 hours to check his movement and responses." C. "Call your medical provider if he vomits more than five times." D. "Any watery fluid draining from his ears is normal.": Answer: B Rationale: The nurse should instruct the parents to wake the child every 2 hours to ensure that he moves normally and wakes enough to recognize and respond appropriately to them. The parents should be instructed to call the physician or nurse practitioner or bring the child back to the emergency department if he experiences a constant headache that gets worse, vomits more than two times, or has oozing of blood or watery fluid from his ears or nose. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder

Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 1365

11. A group of students are reviewing information about head injuries in children. The students demonstrate understanding of this information when they identify what as the most common type of skull fracture in children? A. Linear B. Depressed C. Diastatic D. Basilar: Answer: A Rationale: The most common type of skull fracture in children is a linear skull fracture, which can result from minor head injuries. Other, less common types of skull fractures in children

include depressed, diastatic, and basilar. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 1364

12. During class, a student states, "I didn't think children could have strokes. I thought this only occurred in older adults." When responding to the student, what would be most important for the instructor to integrate into the response? A. Strokes in children often have an identifiable cause. B. The signs and symptoms in children are different from an adult.

C. Research has identified specific treatments for children. D. Ischemic strokes are more common than hemorrhagic strokes.: Answer: D Rationale: In children, ischemic strokes are more common than hemorrhagic strokes. However, the cause of the stroke in many children remains unidentified. Signs and symptoms are similar to those in adults and will vary based on age; underlying cause, if known; and location of the stroke. Historically, children have been excluded from adult stroke studies and thus, many treatments used have had to be adapted from adult studies. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Apply

Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 1369

13. A 10-month-old infant is brought to the emergency department by the parents after they found the infant face down in the bathtub. The parent states, "I just left the bathroom to answer the phone. When I came back, I found my infant." Which nursing action is priority? A. Assess the client's respiratory rate B. Start cardiopulmonary resusitative measures C. Determine how long the client was face down in the water D. Apply a heart monitor to the client: Answer: A Rationale: With a submersion injury, hypoxia is the primary problem. Therefore, assessment of airway and breathing are priority. Based on this assessment, the nurse would determine if

resuscitative measures were needed. Other actions such as applying a heart mon- itor and obtaining additional information about the event would be done once the infant's airway and breathing are assessed and emergency interventions are instituted. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 1368

14. A hospitalized child is scheduled for magnetic resonance imaging (MRI) with contrast. What

nursing intervention(s) will the nurse complete to ensure safety during the examination? Select all that apply. A. Place child in clothing with no metal B. Connect the child to a heart monitor C. Assess the IV site for patency D. Review any prescriptions for sedation E. Assess for a latex allergy: Answer: A, C, D Rationale: When preparing a child for an MRI procedure, it is important the child and parent are aware of the test procedure. No metal can be used in the MRI scanner room so all clothing, jewelry, etc. need to be removed before testing. IV contrast may be used so the IV needs to be patent and in good working order. If the child is to be sedated the nurse should review the

sedation prescription and identify any discrepanies before the child goes for the examination. If the child is to be sedated a heart monitor will be used, but it is not necessary for the nurse on the unit to connect the child. A special monitor compatible with the MRI scanner will be used. If sedated the child may also receive oxygen just as a prevention because the exam take a long time in a confined space. Having a latex allergy is not a contraindication for receiving gadolinium, the MRI contrast used during testing. Question format: Multiple Select Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Apply

Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 1335

15. Phenytoin IV has been prescribed by health care provider for a child who has experienced a seizure. Before administering the drug what should the nurse do? A. Determine the IV fluid infusing is normal saline B. Assess the child's vital signs C. Monitor the electrolyte levels D. Start another IV with a large bore needle: Answer: A Rationale: The drug phenytoin can be administered PO or IV. If it is to be adminis- tered IV, the fluids needs to be normal saline solution. Any other type of fluid will cause the drug to percipitate in the IV tubing.There is no need to start an additional peripheral IV. The drug can be

administered via a secondary set through the IV pump. The vital signs can be monitored after the drug is infusing. The electrolyte levels can be monitored, but treatment of the seizure is the priority. Fosphenytoin is another form of phenytoin and may be tolerated better. It can be administered through all IV fluids without precipitaion. Question format: Multiple Choice Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regula- tion/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 1346

16. A child with a seizure disorder will be discharged home from the hospital on the drug