The nurse is caring for an infant with an acyanotic defect. WHy must the nurse continue to monitor this infant's mucous membranes, fingers, and toes? a-bc it explains hemodynamics involved d-children with traditional named acyontic defects may be slightly cyanotic and children with traditionally classified cyanotic defects may appear pink, although they may eventually become cyanotic. The beneficial effect of performing surgery for PDA is to prevent which complication? a-pulmonary infection d-PDA allows blood flow from the aorta (high pressure) to the pulmonary artery (low pressure). If the PDA stays open, increased pulmonary congestion can occur Which condition is classified as a mixed blood cardiac defect? a-PS d-TGA allows the mixing of blood in the heart Which of the characterisitic of fractures in children? a-speed with healing occurs is inversely related to the age of the child a-fractures heal in children inless time than they do in adults. As the child ages, the healing time increases A child returned from surgery in a hip spica cast. What is the priority nursing intervention? a-check lower extremity circulation a-chief concern is that the extremity may continue to swell, compartment syndrome Which statement best describes DMD? a-its inherited as an
autosomal dominant disorder d-usually children with DMD reach the early developmental milestones but the muscular weakness is usually observed in third year of life A young child with tetralogy of Fallot may assume a posturing position as a compensatory mechanism. What position is automatically assumed by the child? A) Low Fowler's D. The squatting or knee-chest position decreases the amount of blood returning to the heart and allows the child time to compensate. Which sign would alert the nurse that congestive heart failure could be developing? A. Tachypnea is one of the early signs that should be identified. Tachycardia at rest, dyspnea, retractions, and activity intolerance are other physical signs and symptoms. As part of the treatment for congestive heart failure, a child is taking the diuretic furosemide (Lasix). As part of the discharge teaching plan, what should the nurse explain as the function of furosemide (Lasix)? A) It is a diuretic, which means that it eliminates extra fluid from the body. a-Furosemide (Lasix) is a diuretic used to eliminate excess water and salt to prevent reaccumulation of the fluid. The nurse is preparing to administer digoxin (Lanoxin) orally to a 9-month-old infant. The nurse checks the dose and prepares to draw up 4 mL of the drug.
What are the most appropriate nursing actions? B. Digoxin is often prescribed in micrograms. Rarely is more than 1 mL administered to an infant. Because it is a potentially dangerous drug, administration guidelines are very precise. Pediatric medication dosages should be checked with another licensed professional before administration. What is included in nursing care of the infant or child with congestive heart failure? D. The child needs to be well rested before feeding. The child's needs should be met as quickly as possible to minimize crying. The nurse must organize care to facilitate a decrease in the child's energy expenditure which is known as clustering care. What is the primary therapy for secondary hypertension in children? C. Secondary hypertension is a result of an underlying disease process or structural abnormality. It is usually necessary to treat the problem before the hypertension will be controlled. A 3-week-old neonate has been admitted to the hospital because inability to feed well and not growing as expected. What actions should the nurse implement when caring for this infant with suspected heart failure? (Select all that apply.) A. Allowing extra time to feed the infant should help the
nurse provide a relaxed environment which this infant needs. Knowing that 30 minutes should be allocated for each feeding helps the nurse with time management. The nurse would check the lab reports of which two electrolytes prior to administering digoxin (Lanoxin) because of the risk for digoxin toxicity? potassium and magnesium (Hypokalemia and hypomagnesemia can increase the risk for digoxin toxicity. In children with altered renal function, the dose needs to be decreased.) A child is being discharged home on a regimen of oral corticosteroids. What information is most important for the nurse to explain to the parents? D. If the child becomes ill, the physician who ordered the medication should be notified because of the increased stress. Supplemental glucocorticoids might be necessary during times of increased stress to prevent adrenal insufficiency. Which is a secondary effect when a child has decreased muscle strength, tone, and endurance from immobilization? D. Muscle disuse leads to tissue breakdown and loss of muscle mass. It may take weeks or months to recover. Which measure is important in managing hypercalcemia in a child who is immobilized? A. Hydration is extremely important to help remove the excess calcium from the body. This can help prevent hypercalcemia The nurse is providing care for a child with a sprained ankle. What is the rationale for the nurse to elevate the extremity after this soft tissue injury? D. Elevating the extremity uses gravity to
facilitate venous return to reduce edema An infant is born with one lower limb deficiency. What is the optimum time for the child to be fitted with a prosthetic device? C. When the infant begins sitting up and can maintain balance is the most optimum time for the child to be fitted with a prosthetic device. The child is ready to stand, and the prosthetic device will be integrated into his or her capabilities Which statement best describes pseudohypertrophic (Duchenne) muscular dystrophy?
d-Usually children with Duchenne muscular dystrophy reach the early developmental milestones, but the muscular weakness is usually observed in the third year of life. A nurse is caring for an immobilized preschool child. Which would be helpful during this period of immobilization while in the hospital? C. It is important for children to have activities outside of the room if possible. This increases environmental stimuli and provides social contact with others. The nurse is caring for a child in skeletal traction because of multiple fractures from an accident. What nursing interventions are essential in the care of this child? (Select all that apply.)
C. The position of the weights, knots and pulleys should
be checked whenever the nurse is in the room. It takes a brief glance to make sure the alignment is proper and the equipment is in proper position. A diagram with the amount of weight at the time can be placed on the traction near the foot of the bed. A 16-year-old female is being discharged tomorrow after a spinal fusion with rods has been done for correction of her scoliosis. What information should the nurse include during the teaching session? (Select all that apply.) A) Continue oral pain medication as needed for the next few weeks. A. Oral pain medication can be used for the next few weeks and tapered as healing occurs. When explaining the destruction of pancreatic beta cells, which produce insulin, to a parent whose child is running high glucose levels, the nurse is explaining what happens to cause which problem? A. Type 1 diabetes is characterized by destruction of the insulin-producing pancreatic beta cells. The mother of a child with type 1 diabetes mellitus asks why her child cannot avoid all those "shots" and take pills as an uncle does. What is the most appropriate response by the nurse? C. In type 1 diabetes the beta cells have been destroyed. It is necessary to supply the insulin no longer produced by the beta cells. During the summer many children are more physically active. What changes in the management of the child with diabetes would the camp nurse expect as a result of more exercise? A. Food intake should be increased in the summer when the child is more active. Exercise lowers blood glucose and hypoglycemia needs to be prevented. A 17-year-old boy with diabetes mellitus tells the school nurse that he has recently started drinking alcohol with his friends on weekends. What is the most appropriate action by the nurse? C. The nurse is taking a proactive approach. The adolescent is provided with information to facilitate the correct management of his illness. Which of the following is a clinical
manifestation of increased intracranial pressure in infants? A. Irritability is one of the changes that may indicate increased intracranial pressure. The temperature of an adolescent who is unconscious is 105º F(ax). What is the priority
nursing action? B. Brain damage can occur at temperatures this high. It is extremely important to institute temperature-lowering interventions, such as hypothermia blankets and tepid water baths.
A nurse is caring for a comatose child with multiple injuries. The nurse should recognize that pain C. Because the child cannot communicate pain through one of the standard pain rating scales, the nurse must be focused on physiologic and behavioral manifestations. A nursing intervention to prevent increased intracranial pressure (ICP) in an unconscious child includes A) Suctioning any secretions frequently. D. Nursing interventions should focus on assessments and interventions that minimize pain. The activities in the other options can cause the intracranial pressure to increase. A nurse is caring for a toddler status post surgery for a brain tumor. During an assessment the nurse notes that the toddler is becoming irritable and that the pupils are unequal and sluggish. What is the most appropriate nursing action?
A. The worsening of symptoms may indicate that the ICP is increasing. The physician should be notified immediately. The nurse is
admitting a young child to the hospital with possible bacterial meningitis. What is the major priority of nursing care? B. Administration of antibiotic therapy as soon as it is ordered is the priority action. Antibiotics are begun as soon as possible to prevent death and avoid resultant disabilities. The nurse is planning care for a school-age child with bacterial meningitis. Which of nursing actions should be included? A. Children with meningitis are sensitive to noise, bright lights, and other external stimuli. The nurse should keep the room as quiet as possible, with a minimum of external stimuli. A young child is having a
seizure that has lasted 35 minutes with loss of consciousness. What type of seizure would the nurse document? B. Status epilepticus is a generalized seizure that lasts more than 30 minutes. What are two of the most common causes
of cerebral palsy? C. Cerebral palsy results from faulty development (brain anomalies) during the prenatal period or from damage during the perinatal period, including brain anoxia and cerebral trauma during delivery and prematurity. What is a major goal of therapy for children with cerebral palsy? D. Because cerebral palsy is, so far as is known, a permanent disorder, the goal of therapy is to promote optimal development. This is done through early recognition and beginning of therapy. What is a neural tube defect that may not be visible externally in the lumbosacral area called? A) A meningocele D. Spina bifida occulta is completely enclosed. Often this defect will not be noticed. A woman 6 weeks pregnant tells the nurse that she is worried the baby might have spina bifida because of a family history. What response would be most helpful to the patient? A) “There is no definite genetic basis for the defect.” D. Fetal ultrasonography and elevated concentrations of alpha-fetoprotein in amniotic fluid may indicate the presence of neural tube defects. A child has a myelomeningocele at the L2 level. What degree of bowel control would be anticipated when toilet training is complete? A) Periodic incontinence C. Total fecal continence should be present with the defect at the L2 level. Which nursing intervention is important when caring for an infant with myelomeningocele in the preoperative stage? D. Hydrocephalus is frequently associated with myelomeningocele. Assessment of the fontanels and daily measurements of head circumference will aid in early detection. A child with spina bifida has a latex allergy from exposure to numerous bladder catheterizations and surgeries. What is a priority
nursing intervention in this child’s care? B. Providing a latex-free environment is the most important nursing intervention. From birth on, the limitation of exposure to latex is essential in an attempt to minimize sensitization
A school-age child begins to have a tonic-clonic seizure in bed as the nurse walks into her room. What actions should the nurse take? (Select all that apply.) B. The side should be placed on her side. A nurse caring for a child who has absence seizure. Which of the following findings can the nurse expect? (select all that apply) a-loss of consciousness b-appearence of daydreaming c-dropping held objects d-falling to the floor e-having a piercing cry a-loss of consciousness b-appearence of daydreaming c-dropping held objects A nurse caring for a child who just experienced a generalized seizrue. which of the following is the priopity action for the nurse to take? a-maintain inside-lying position b-monitor vital signs c-reorient the child to the environment d-assess for injuries a-maintain inside-lying position A nurse teaching a group of parents about the risk factors for seizures. which of the following should be included in the teaching? (select all that apply) a-febrile episodes b-hypoglycemia c-sodium imbalances d-low serum lead levels e-presence of diphtheria a-febrile episodescan cause tonic-clonic b-hypoglycemia late manifestation c-sodium imbalances is a manifestation of hypo-Na & hyper-Na A nurse caring for an adolescent who has susutained a closed head injury, which of th following are the clincal manifestation of IICP? (select all that apply) a-report of headache b-aleration in pupillary response c-increased motor response d-increased sleeping e-increased sensory response a-report of headache b-aleration in pupillary response d-increased sleeping A nurse caring for a child who has IICP, which of the following are appropriate actions by the nurse? (select all that apply) a-suction the endotracheal tube Q2 b-maintain a quiet environment c-use 2 pillows to elevate the head d-administer a stool softener e-maintain body alignment b-maintain a quiet environment d-administer a stool softener e-maintain body alignment A nurse caring for a child who has a concussion, which of the following are clinincal manifestations of a minor head injury? (select all that apply) a-vomiting b-delayed pupillary c-drowsiness d-pallor e-confusion a-vomiting c-drowsiness d-pallor e-confusion A 16 y/o boy has a dx of new onset of diabetes. The child is meeting with the nurse educator regarding changes that will need to be made in his diet, what would be the most influence? a-parents & their dietary choices b-cultural background c-peers & their dietary choices d-TV & other forms of media influences c-peers & their dietary choices A nurse caring for a 5y/o who has a fracture of the tibia innvolvinnng growth plate; when involvinnnnng info to parents nurse indicate? a-serious injusy that could cause long-term growth
issues a-fracture of the growth plate are serious |