evolve Flashcards
Cerebral palsy (CP) may result from a variety of causes. It is now known that the most common cause of CP is
birth asphyxia neonatal diseases cerebral trauma prenatal brain abnormalities
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The major goal of therapy for children with cerebral palsy (CP) is
reversing degenerative processes that have occurred. curing the underlying defect causing the disorder. preventing spread to individuals in close contact with the children. recognizing the disorder early and promoting optimal development.
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A 3-year-old has cerebral palsy (CP) and is hospitalized for orthopedic surgery. The child’s mother states the child has difficulty swallowing and cannot hold a utensil to self-feed. The child is slightly underweight for height. What is the most appropriate nursing action related to feeding?
Bottle-feed or tube-feed the child with a specialized formula until sufficient weight is gained. Stabilize the child’s jaw with one hand (either from a front or side position) to facilitate swallowing. Correct Place the child in a well-supported, semireclining position to make use of gravity flow. Place the child in a sitting position with the neck hyperextended to make use of gravity flow.
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An 8-year-old has been diagnosed with moderate cerebral palsy (CP). The child recently began participation in a regular classroom for part of the day. The child’s mother asks the school nurse about joining the after-school Scout troop. The nurse’s response should be based on knowledge that
most activities such as Scouts cannot be adapted for children with CP. after-school activities usually result in extreme fatigue for children with CP. trying to participate in activities such as Scouts leads to lowered self-esteem in children with CP. after-school activities often provide children with CP with opportunities for socialization and recreation. Correct
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A neural tube defect that is not visible externally in the lumbosacral area would be called
meningocele. myelomeningocele. spina bifida cystica. spina bifida occulta. Correct
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A woman who is 6 weeks pregnant tells the nurse that she is worried her baby might have spina bifida because of a family history. What should the nurse’s response be based on?
There is no genetic basis for the defect. Prenatal detection is not possible yet. Chromosomal studies done on amniotic fluid can diagnose the defect prenatally. The concentration of α-fetoprotein in amniotic fluid can potentially indicate the presence of the defect prenatally. Correct
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A 6-year-old child born with a myelomeningocele has a neurogenic bladder. The parents have been performing clean intermittent catheterization. What should the nurse recommend?
Teach the child to do self-catheterization. Correct Teach the child appropriate bladder control. Continue having the parents do the catheterization. Encourage the family to consider urinary diversion.
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What most accurately describes bowel function in children born with a myelomeningocele?
Incontinence cannot be prevented. Enemas and laxatives are contraindicated. Some degree of fecal continence can usually be achieved. Correct A colostomy is usually required by the time the child reaches adolescence.
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What is important when caring for a child with myelomeningocele in the preoperative stage?
Place the child on one side to decrease pressure on the spinal cord. Apply a heat lamp to facilitate drying and toughening of the sac. Keep the skin clean and dry to prevent irritation from diarrheal stools. Measure the head circumference and examine the fontanels for signs that might indicate developing hydrocephalus. Correct
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A child with spina bifida has developed a latex allergy from numerous bladder catheterizations and surgeries. A priority nursing intervention is to
recommend allergy testing. provide a latex-free environment. Correct use only powder-free latex gloves. limit the use of latex products as much as possible.
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Which statement best describes pseudohypertrophic (Duchenne) muscular dystrophy (DMD)?
DMD is inherited as an autosomal dominant disorder. DMD is characterized by weakness of the proximal muscles of both the pelvic and shoulder girdles. DMD is characterized by muscle weakness, usually beginning at about age 3 years. Correct The onset of DMD occurs in later childhood and adolescence
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An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome). When explaining this disease process to the parents, what should the nurse consider?
Paralysis is progressive, with little hope for recovery. Muscle function will gradually return, and recovery is possible in most children. Correct Guillain-Barré syndrome results from an apparently toxic reaction to certain medications. Guillain-Barré syndrome is inherited as an autosomal recessive, sex-linked gene.
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Which statement is most accurate in describing tetanus?
Acute infectious disease caused by an exotoxin produced by an anaerobic, gram-positive bacillus Correct Inflammatory disease that causes extreme, localized muscle spasm Acute infection that causes meningeal inflammation, resulting in symptoms of generalized muscle spasm Disease affecting the salivary gland with resultant stiffness of the jaw
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What is associated with infant botulism?
Contaminated soil Honey and corn syrup Correct Commercial infant cereals Improperly sterilized bottles
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A 15 year-old is admitted to the intensive care unit (ICU) with a spinal cord injury. The most appropriate nursing interventions for this adolescent are (select all that apply)
monitoring neurologic status.Correct administering corticosteroids.Correct monitoring for respiratory complications.Correct discussing long-term care issues with the family.Incorrect monitoring and maintaining hemodynamic status.Correct
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psychosocial
erikson
cognitive
piaget
moral
kolhberg
sexual
freud
spiritual
fowler
What is a secondary effect when a child experiences decreased muscle strength, tone, and endurance from immobilization?
Increased metabolism Increased venous return Increased cardiac output Decreased exercise tolerance Correct
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Which measure is important in managing hypercalcemia in a child who is immobilized?
Promote adequate hydration Correct Change position frequently Encourage a diet high in calcium Provide a diet high in protein and calories
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he nurse is caring for an immobilized preschool child. What is helpful during this period of immobilization?
Encourage the child to wear pajamas. Let the child have few behavioral limitations. Keep the child away from other immobilized children if possible. Take the child for a "walk" by wagon outside the room. Correct
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What is the rationale for elevating an extremity after a soft tissue injury such as a sprained ankle?
Elevation increases the pain threshold. Elevation increases metabolism in the tissues. Elevation produces deep tissue vasodilation. Elevation reduces edema formation. correct
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hat is characteristic of fractures in children?
Fractures rarely occur at the growth plate site because it absorbs shock well. Rapidity of healing is inversely related to the child's age. Correct Pliable bones of growing children are less porous than those of adults. The periosteum of a child's bone is thinner, is weaker, and has less osteogenic potential compared with that of the adult.
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The callus that develops at a fracture site is important because it provides
use of the injured part. sufficient support for weight bearing. means for adequate blood supply. means for holding bone fragments together. Correct
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A 3-year-old has just returned from surgery in a hip spica cast. The priority nursing intervention is to
elevate the head of the bed. offer sips of water. check circulation, sensation, and motion of toes. Correct turn the child to the right side, then the left side every 4 hour
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An adolescent has had a lower leg amputation secondary to a motorcycle accident and is complaining of pain in the missing extremity. The nurse should recognize that this is
indicative of narcotic addiction indicative of the need for psychological counseling abnormal and suggests nerve damage normal and called phantom limb sensation Correct
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An infant is born with one lower limb deficiency. When is the optimum time for the child to be fitted with a prosthetic device?
As soon as possible after birth When the infant is developmentally ready to stand up Correct At about age 12 to 15 months, when most children are walking At about 4 years, when the healthy limb is not growing so rapidly
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Which statement is true concerning osteogenesis imperfecta (OI)?
OI is easily treated. OI is an inherited disorder. Correct With a later onset, the disease usually runs a more difficult course. Braces and exercises are of no therapeutic value.
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What is an appropriate nursing intervention when caring for the child with chronic osteomyelitis?
Provide active range-of-motion exercises of the affected extremity. Administer pain medication with meals. Encourage frequent ambulation. Move and turn the child carefully and gently to minimize pain. Correct
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Which statement is the most descriptive of rhabdomyosarcoma?
The most common sites are the head and neck. Correct It is a common hereditary neoplasm of childhood. It is the most common bone tumor of childhood. It is a benign tumor and unusual in children.
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What are considered major goals of the therapeutic management of juvenile rheumatoid arthritis (JRA)?
Prevent joint discomfort; regain proper alignment. Prevent loss of joint function; achieve cure. Prevent physical deformity; preserve joint function. Correct Prevent skin breakdown; relieve symptoms.
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Therapeutic management of the patient with systemic lupus erythematosus (SLE) includes
application of cold salts to suppress the inflammatory process. a high-protein, low-salt diet. a rigorous exercise regimen to build up muscle strength and endurance. administration of corticosteroids to control inflammation. Correct
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A nurse is caring for an infant with developmental dysplasia of the hip (DDH). Based on the nurses knowledge of DDH, which clinical manifestation should the nurse expect to observe? (Select all that apply.)
LordosisIncorrect Negative Babinski sign Incorrect Asymmetric thigh and gluteal folds Correct Positive Ortolani and Barlow tests Correct Shortening of limb on affected side Correct
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The school nurse is conducting an assessment for pediculosis capitis (head lice) on a group of school-age children. Which describes a child with a positive head check?
Maculopapular lesions behind the ears White, flaky particles throughout the entire scalp area Lesions in the scalp extending from the hairline to the neck White sacs attached to the hair shafts in the occipital area Correct
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Which factor promotes wound healing?
Antiseptics Eschar formation Dry wound environment Moist, crust-free wound environment Correct
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A toddler has a deep laceration contaminated with dirt and sand. Before suturing, the nurse should irrigate the wound with
alcohol. normal saline. Correct hydrogen peroxide. povidone-iodine.
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An occlusive dressing, is applied to a large abrasion. This is advantageous because the dressing will
provide an antiseptic for the wound. deliver vitamin C to wound. maintain a moist environment for healing. Correct promote mechanical friction for healing.
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