Rules Everyone must participate – meaning attempt to answer questions.
When assessing a newborn admitted to the pediatric unit with upper lumbar myelomeningocele, which of the following would the nurse anticipate finding? 1.Minimal movement of the lower extremities. 2.Upper extremity paralysis. 3.Urinary bladder prolapse. 4.Respiratory problems.
Answer and Rationale 1. Clinical manifestations of myelomeningocele are related to the anatomic level of the defect and the nerves involved.
2. When developing the plan of care for an infant diagnosed with myelomeningocele and the parents who have just been informed of the infant’s diagnosis, which of the following would the nurse include as the priority when the parents visit the infant for the first time? 1.Emphasizing the infant’s normal and positive features. 2.Encouraging the parents to discuss their fears and concerns. 3.Reinforcing the doctor’s explanation of the defect. 4.Having the parents feed their infant.
Answer and Rationale 1. The parents should see the neonate as soon as possible, because the longer they must wait to see him/her, the more anxiety they will feel. The nurse should emphasize the neonate’s normal and positive features during the visit.
3. A mother of a newborn with myelomeningocele asks if her baby is likely to have any other defects. The nurse responds based on the understanding that myelomeningocele is frequently associated with which of the following? 1.Excessive cerebrospinal fluid within the cranial cavity. 2.Abnormally small head 3.Congenital absence of the cranial vault. 4.Overriding of the cranial sutures.
Answer and Rationale 1 = hydrocephalus and the most common anomaly associated with myelomeningocele.
4. The parents of an infant with myelomeningocele ask the nurse about their child’s future mental ability. Which of the following would be the nurse’s best response? 1.“About one-third are mentally retarded, but it’s too early to ell about your child.” 2.“About two-thirds are significantly retarded, and you’ll know soon if this will occur.” 3.“Your child will probably be of normal intelligence since he demonstrates signs of it now.” 4.“You’ll need to talk with the doctor about that, but you can ask later.”
Answer and Rationale 1 = Approximately 1/3 of infants diagnosed with myelomeningocele are mentally retarded, but the degree of retardation is variable and it is difficult to predict intellectual functioning in neonates.
5. After placing an infant with myelomeningocele in an isolette shortly after birth, which of the following would the nurse use as the best indicator to determine the effectiveness of this intervention? 1.The arterial PO2 remains between 945 and 100mm/Hg. 2.The axillary temp remains between 97 & 98 F. 3.The bilirubin level remains stable. 4.Weight increases by about 1 oz per day.
Answer and Rationale 2= Placing a neonate in an isolette helps maintain the infant’s temp.
6. When positioning the neonate with an unrepaired myelomeningocele, which of the following positions would be most appropriate? 1.Supine with the hips at 90-degree flexion. 2.Right side-lying position with knees flexed. 3.Prone with hips in abduction. 4.Semi-Fowler’s position with chest and abdomen elevated.
Answer and Rationale 3 = before surgery, the infant is kept flat in the prone position to decrease tension on the sac. This allows for optimal positioning of the hips, knees and feet because orthopedic problems are common.
12. Before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is irritable, lethargic, and difficult to feed. To maintain the infant’s nutritional status, which of the following actions would be most important? 1.Feeding the infant just before doing any procedures. 2.Giving the infant small, frequent feedings. 3.Feeding the infant in a horizontal position. 4.Scheduling the feedings every 6 hours.
Answer and Rationale 2= An infant with hydrocephalus is difficult to feed because of poor sucking, lethargy, and vomiting, which are associated with increased ICP.
13. A 4 y/o with hydrocephalus is scheduled to have a VP shunt in the right side of the head. When developing the child’s postoperative care, the nurse would expect to place the preschooler in which of the following positions immediately after surgery? 1.On the right side, with the foot of the bed elevated. 2.On the left side, with the head of the bed elevated. 3.Prone, with the head of the bed elevated. 4.Supine, with the head of the bed flat.
Answer and Rationale 13= For at least the first 24 hours after insertion of a VP shunt, the child is positioned supine with the head of the bed flat to prevent too rapid a decrease in CSF pressure.
14. Which of the following would the nurse do when providing postoperative nursing care to a child after insertion of a VP shunt? 1.Administer narcotics for pain control. 2.Check the urine for glucose and protein. 3.Monitoring for increased temp. 4.Test CSF leakage for protein.
Answer and Rationale 3=monitoring for temp allows the nurse to assess for infection, the most common and most hazardous postop complication after shunt placement.
15. The nurse evaluates the discharge teaching as successful when the parents of a school-aged child with a VP shunt insertion identify which of the following as signaling a blocked shunt? 1.Decreased urine output with stable intake. 2.Tense fontanel and increased head circumference. 3.Elevated temp. and reddened incisional site. 4.Irritability and increasing difficulty with eating.
Answer and Rationale 4=In a school-aged child, irritability, lethargy, vomiting, difficulty with eating, and decreased level of consciousness are signs of increased intracranial pressure caused by a blocked shunt.
28. During the acute stage of meningitis, a 3 y/o child is restless and irritable. Which of the following would be most appropriate to institute? 1.Limiting conversation with the child. 2.Keeping extraneous noise to a minimum. 3.Allowing the child to play in the bathtub. 4.Performing treatments quickly.
Answer and Rationale 2=a child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light.
29. Which of the following would lead the nurse to suspect that a child with meningitis has developed DIC? 1.Hemorrhagic skin rash. 2.Edema 3.Cyanosis 4.Dyspnea on exertion
Answer and Rationale 1=DIC is characterized by petechiae and purpuric skin rash caused by spontaneous bleeding into the tissues.
31. A preschooler with pneumonococci meningitis is receiving IV AB tx. When discontinuing the IV tx, the nurse allows the child to apply a dressing to the area where the needle is removed. The nurse’s rationale for doing so is based on the interpretation that a child in this age group has a need to accomplish which of the following? 1.Trust those caring for her. 2.Find diversional activities. 3.Protect the image of an intact body. 4.Relieve the anxiety of separation from home.
Answer and Rationale 3= Preschool aged children worry about having an intact body.
30. When interviewing the parents of a 2 y/o child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? 1.Bladder infection. 2.Middle ear infection. 3.Fractured clavicle. 4.Septic arthritis.
Answer and Rationale 2=organisms that cause bacterial meningitis such as pneumococci or meningococci are commonly spread by vascular dissemination from a middle ear infection.
37. Which of the following assessments would be most important for the nurse to make initially in a school-aged child being seen in the clinic for c/o sore throat, muscle tenderness, arms feeling weak, and generally not feeling well. 1.Difficulty swallowing. 2.Diet intake for the last 24 hours. 3.Exposure to illnesses. 4.Difficulty urinating.
Answer and Rationale 1=Most children with sore throat have some difficulty swallowing, so it is important for the nurse to determine the extent of difficulty to aid in determining what action is necessary.
38. Which of the following actions would be the priority when caring for a school-aged child admitted to the pediatric unit with the dx of GB? 1.Assessing the child’s ability to follow simple commands. 2.Evaluating the child’s bilateral muscle strength. 3.Making a game of the ROM exercises. 4.Providing the child with a diversional activity.
Answer and Rationale 2=with GB, progressive ascending paralysis occurs.
39. The nurse asks the school-aged child with GB to cough and also assess the child’s speech for decreased volume and clarity. The underlying rationale for these assessments is to determine which of the following? 1.Inflammation of the larynx and epiglottis. 2.Increased ICP. 3.Involvement of facial and cranial nerves. 4.Regression to an earlier developmental phase.
Answer and Rationale 3=In a child with GB, decreased volume and clarity of speech and decreased ability to cough voluntarily indicate ascending progression of neural inflammation, specifically affecting the cranial nerves.
40. Assmt of a school-aged child with BG reveals absent gag and cough reflexes. Which of the following nursing dx would receive the highest priority during the acute phase? 1.Risk for Infection due to altered immune system. 2.Ineffective breathing pattern r/t neuromuscular impairment. 3.Impaired swallowing r/t neuromuscular impairment. 4.Total urinary incontinence r/t fluid losses.
Answer and Rationale 2-ineffective breathing pattern caused by the ascending paralysis of the disorder interferes with the child’s ability to maintain an adequate oxygen supply.
7-13. Which of the following is the most appropriate nursing intervention for a child with increased intracranial pressure? 1.Keep the child’s head turned to the side so that the airway will remain open if the child vomits. 2.Perform ROM q 4hr while awake to prevent nuchal rigidity from bed rest. 3.Perform airway sx at the same time vital signs are taken so that the child will have undisturbed rest. 4.Play gentle, soothing background music in the room.
Answer and Rationale 4-soothing music may help.
7-33. A child with spastic CP is admitted for surgery. The most appropriate nsg dx for this child is: 1.Potential impaired swallowing 2.Altered tissue perfusion – cerebral 3.Decreased cardiac output. 4.Potential fluid volume deficit.
Answer and Rationale 1=tight muscles of spastic cerebral palsy can include those associated with effecive swallowing. Furthermore, the child’s surgery, anesthesia and analgesia can affect muscle use and coordination.
7-35. A 7 y/o is suspected of having meningitis. What are the classic symptoms of meningitis for which you will assess? (choose all that apply). 1.Fever 2.Severe HA 3.Increased pulse pressure 4.Bradycardia 5.Nuchal rigidity
Answer and Rationale 1,2,5-fever, severe HA, and nuchal rigidity are the three classic symptoms of meningitis. Irritability, nausea, and vomiting can be symptomatic for a variety of illnesses.
Answer and Rationale An instrument used for measuring intraocular pressure.
7-42. To confirm a tentative diagnosis of myasthenia gravis, the drug neostigmine will be administered. Should the client have mg, the action of this drug will cause: 1.An immediate decrease in bp. 2.An escalation of symptoms. 3.A temporary increase in muscle strength. 4.A temporary drying of the mouth and throat.
Answer and Rationale 3-A client receives temporary muscle strength following the administration of neostigmine (Prostigmin), it will confirm that the client has mg.
7-48. A 4 y/o with average intelligence and spastic cerebral palsy is to be admitted to the pediatrics unit. The plan of care most likely to be included in the nursing diagnoses is: 1.Decreased cerebral tissue perfusion. 2.Gas exchange impaired. 3.Sensory/perceptual alteration. 4.Sleep pattern disturbance.
Answer and Rationale 3-The most likely nursing diagnosis would include sensory/perceptual alteration that can affect swallowing, vision, and speech.
7-49. A newborn with a myelomeningocele is to have a surgical repair 24-48 hours after birth. The most important ongoing assessment in the preoperative period is assessment for: 1.Fontanel status. 2.Hip dysplasia 3.Bowel incontinence. 4.Pain sensation below the defect.
Answer and Rationale 1=preoperative assessment should include ongoing fontanel status. Hydrocephalus is a common condition developing pre- or postoperatively with children who have a myelomeningocele. Ongoing fontanel assessment, along with HC would help monitor.
7-50. The most appropriate nursing intervention for an infant with possible bacterial meningitis is to: 1.Measure weight and head circumference each shift. 2.Monitor behavior at each encounter. 3.Evaluate Kernig’s sign each shift. 4.Monitor fontanel tenseness daily.
Answer and Rationale 2=meningitis causes an inflammation of the meninges of the brain and spinal cord due to bacteria or viruses. The infant’s behavior should be monitored at each encounter. Behavior is a good indicator of intracranial pressure and is often an early sign of changes in ICP.
1. T or F: Trigeminal neuralgia affects the sensory branches of the trigeminal nerve while Bell’s palsy affects the motor branches of the facial nerve.
28-44. The vector reservoir for agents causing viral encephalitis in the U.S. is which of the following: 1.Tarantula spiders 2.Mosquitoes and ticks 3.Carnivorous wild animals 4.Domestic wild animals.
Answer and Rationale B- mosquitoes and ticks (p 1095 wong)
28-45. Which of the following may be beneficial in reducing the risk of Reye syndrome? 1.Immunization against disease 2.Medical attention for all head injuries. 3.Prompt treatment of bacterial meningitis. 4.Avoidance of aspirin for children with varicella or those suspected of having influenza.