Neuro and Musculoskeletal practice questions

Question 1

The nurse is caring for a 6-month-old infant with a diagnosis of hydrocephalus.
Which of the following signs best indicates increased ICP in this child?

1. Sunken anterior fontanel.
2. Complaints of blurred vision.
3. High-pitched cry.
4. Increased appetite

Answer 1

3. A high-pitched cry is often indicative of

increased ICP in infants.

Question 2

The nurse is preparing to give preoperative teaching to the parents of an infant with
hydrocephalus. The nurse knows that the most common treatment for hydrocephalus
includes the surgical placement of a shunt connecting which of the following?

1. The ventricle of the brain to the peritoneum.
2. The ventricle of the brain to the right atrium of the heart.
3. The ventricle of the brain to the lower esophagus.
4. The ventricle of the brain to the small intestin

Answer 2

1. The ventriculoperitoneal is the most common shunt used to treat hydrocephalus.

Question 3

The nurse receives a phone call from the parents of a 9-year-old female who is complaining of a headache and blurry vision. The child has been healthy but has a history of hydrocephalus and received a ventriculoperitoneal shunt at the age of 1 month.
The parents also state that she is not acting like herself, is irritable, and sleeps more
than she used to. They ask the nurse what they should do. Select the nurse’s best
response.

1. “Give her some acetaminophen, and see if her symptoms improve. If they do not
   improve, bring her to the pediatrician’s office.”
2. “It is common for girls to have these symptoms, especially prior to beginning
   their menstrual cycle. Give her a few days, and see if she improves.”
3. “You are probably worried that she is having a problem with her shunt. This is
   very unlikely as it has been working well for 9 years.”
4. “You should immediately bring her to the emergency room as these may be
   symptoms of a shunt malfunction.”

Answer 3

4. These are symptoms of a shunt malfunction

and should be evaluated immediately

Question 4

The nurse is working in the PICU caring for an infant who has just returned from
having a ventriculoperitoneal shunt placed. Which position initially will be most
beneficial for this child?
1. Semi-Fowler in an infant seat.
2. Flat in the crib.
3. Trendelenburg.
4. In the crib with the head elevated to 90 degrees.

Answer 4

2. Flat in the crib is the position usually used initially, with the angle gradually increasing as the child tolerates

Question 5

The nurse is providing education concerning Reye syndrome to a mothers’ group.
She knows that further education is needed when a mother states:
1. “I will have my children immunized against varicella and influenza.”
2. “I will make sure not to give my child any products containing aspirin when my
child is ill.”
3. “Because I do not give my child aspirin, my child will probably never get
Reye syndrome, but if that happens, it will be a very mild case.”
4. “Children with Reye syndrome are admitted to the hospital.”

Answer 5

2. The administration of aspirin or products containing aspirin have been associated with the development of
   Reye syndrome.

Question 6

The nurse is caring for a child with Reye syndrome in the PICU. At noon, the nurse
notes that the child is comatose with sluggish pupils. When stimulated, the child
demonstrates decerebrate posturing. At 2 p.m., the nurse notes that the child remains
unchanged except that the child now demonstrates decorticate posturing when
stimulated. The nurse concludes that:
1. The child’s condition is worsening and progressing to a more advanced stage of
Reye syndrome.
2. The child’s condition is worsening, and the child may likely experience cardiac
and respiratory failure.
3. The child’s condition is improving and progressing to a less advanced stage of
Reye syndrome.
4. The child’s condition remains unchanged as posturing reflexes are similar.

Answer 6

3. Progressing from decerebrate to
   decorticate posturing usually
   indicates an improvement in the child’s condition

Question 7

The nurse is working in the emergency room when an ambulance arrives with a
9-year-old male who has been having a generalized seizure for 35 minutes. The
paramedics have provided blow-by oxygen and monitored vital signs. The patient
does not have intravenous access yet. Which of the following medications should the nurse anticipate administering first?

1. Establish an intravenous line, and administer intravenous lorazepam.
2. Administer rectal diazepam.
3. Administer an oral glucose gel to the side of the child’s mouth.
4. Place a nasogastric tube, and administer oral diazepam.

Answer 7

2. Rectal diazepam is first administered in an attempt to stop the seizure long enough to establish an IV, and then IV medication is administered.

Question 8

The nurse is providing discharge teaching to the parents of a toddler who has
experienced a febrile seizure. The nurse knows that clarification is needed when the mother says:

1. “My child will likely have another seizure.”
2. “My child’s 7-year-old brother is also at high risk for a febrile seizure.”
3. “I’ll give my child acetaminophen when ill to prevent the fever from rising too
   high too rapidly.”
4. “Most children with febrile seizures do not require seizure medicine.”

Answer 8

2. Most children over the age of 5 years do not have febrile seizures.

Question 9

The nurse is providing discharge instructions to the parents of a 13-year-old girl who has been diagnosed with epilepsy. Her parents ask if there are any activities that she should avoid. Select the nurse’s best response.

1. “She should avoid swimming, even with a friend.”
2. “She should avoid being in a car at night.”
3. “She should avoid any strenuous activities.”
4. “She should not return to school right away as her peers will likely cause her to
   feel inadequate.”

Answer 9

2. The rhythmic reflection of other car lights can trigger a seizure in some children.

Question 10

An 8-year-old child is attending a Cub Scout camp picnic. He has a history of
epilepsy and has had generalized seizures since the age of 3. The child falls to the ground and has a generalized seizure. Which of the following is the best action for the nurse to take during the child’s seizure?

1. Administer the child’s rescue dose of oral valium.
2. Loosen the child’s clothing, and call for help.
3. Place an oral tongue blade in the child’s mouth to prevent aspiration.
4. Carry the child to the infirmary to call 911 and start an intravenous line

Answer 10

2. The nurse should remain with the child and observe the seizure. The child should be protected from his environment, and clothing should be loosened

Question 11

The nurse is caring for a child who has sustained a closed-head injury. The nurse
knows that brain damage can be caused by which of the following factors?
1. Increased perfusion to the brain and increased metabolic needs of the brain.
2. Decreased perfusion to the brain and decreased metabolic needs of the brain.
3. Increased perfusion to the brain and decreased metabolic needs of the brain.
4. Decreased perfusion of the brain and increased metabolic needs of the brain.

Answer 11

4. Decreased perfusion of the brain and increased metabolic needs of the brain

Question 12

The emergency room nurse is caring for a 5-year-old child who fell off his bike and
sustained a closed-head injury. The child is currently awake and alert, but his mother
states that he “passed out” for approximately 2 minutes. The mother appears highly
anxious and is very tearful. The child was not wearing a helmet. Which of the
following statements is a priority for the nurse at this time?
1. “Was anyone else injured in the accident?”
2. “Tell me more about the accident.”
3. “Did he vomit, have a seizure, or display any other behavior that was unusual
when he woke up?”
4. “Why was he not wearing a helmet?”

Answer 12

3. Asking specific questions will give the nurse the information needed to determine the level of care for the child.

Question 13

The emergency room nurse is caring for an unconscious 6-year-old girl who has had
a severe closed-head injury and notes the following changes in her vital signs. Her
heart rate has dropped from 120 to 55, her blood pressure has increased from 110/44
to 195/62, and her respirations are becoming more irregular. After calling the physician,
which of the following should the nurse expect to do?
1. Call for additional help, and prepare to administer mannitol.
2. Continue to monitor the patient’s vital signs, and prepare to administer a bolus of
isotonic fluids.
3. Call for additional help, and prepare to administer an antihypertensive.
4. Continue to monitor the patient, and administer supplemental oxygen.

Answer 13

1. Cushing triad is characterized by a
   decrease in heart rate, an increase in blood pressure, and changes in respirations.
   The triad is associated with
   severely increased ICP. Mannitol is an osmotic diuretic that helps decrease
   the increased ICP.

Question 14

A 2-month-old infant is brought to the emergency room after experiencing a seizure. The nurse notes that the infant appears lethargic with very irregular respirations and periods of apnea. The parents report that the child is no longer interested in feeding and that, prior to the seizure, the infant rolled off the couch. What additional testing
should the nurse immediately prepare for?

1. Computed tomography scan of the head and dilation of the eyes.
2. Computed tomography scan of the head and EEG.
3. Close monitoring of vital signs.
4. X-rays of all long bones.

Answer 14

1. A computed tomography scan of the head will reveal trauma. Dilating the
   eyes is performed to check for retinal hemorrhages that are seen in an infant who has experienced SBS.

Question 15

An infant is born with a sac protruding through the spine. The sac contains CSF, a portion of the meninges, and nerve roots. The nurse knows that this is referred to as:

1. Meningocele.
2. Myelomeningocele.
3. Spina bifida occulta.
4. Anencephaly.

Answer 15

2. A myelomeningocele is a sac that contains a portion of the meninges, the CSF, and the nerve roots.

Question 16

The nurse is caring for a neonate who has just been diagnosed with a meningocele. The parents ask what to expect. Which of the following is the nurse’s best response?

1. “After initial surgery to close the defect, most children experience no neurological
   dysfunction.”
2. “Surgery to close the sac will be postponed until the infant has grown and has
   enough skin to form a graft.”
3. “After the initial surgery to close the defect, the child will likely have motor and
   sensory deficits.”
4. “After the initial surgery to close the defect, the child will likely have future
   problems with urinary and bowel continence.”

Answer 16

1. Because a meningocele does not contain any nerve endings, most children experience no neurological problems after surgical correction.

Question 17

The nurse is caring for an infant with a myelomeningocele. The parents ask the nurse why the nurse keeps measuring the baby’s head circumference. Select the
nurse’s best response:

1. “We measure all babies’ heads to ensure that their growth is on track.”
2. “Babies with myelomeningocele are at risk for hydrocephalus, which can show up
   with an increase in head circumference.”
3. “Because your baby has an opening on the spinal cord, your infant is at risk for
   meningitis, which can show up with an increase in head circumference.”
4. “Many infants with myelomeningocele have microcephaly, which can show up
   with a decrease in head circumference.”

Answer 17

2. Children with myelomeningocele are
   at increased risk for hydrocephalus, which can be manifested with an increase
   in head circumference.

Question 18

The most common complication associated with myelomeningocele is:

1. Learning disability.
2. Urinary tract infection.
3. Hydrocephalus.
4. Decubitus ulcers and skin breakdown

Answer 18

2. Urinary tract infections are the most common complication of
   myelomeningocele. Nearly all children with myelomeningocele have a neurogenic bladder that leads to incomplete
   emptying of the bladder and subsequent urinary tract infections. Frequent
   catheterization also increases the risk of urinary tract infection

Question 19

The nurse is caring for a newborn infant who has just been diagnosed with a
myelomeningocele. Which of the following is included in the child’s plan of care?

1. Place the child in the prone position with a sterile dry dressing over the defect.
   Slowly begin oral gastric feeds to prevent the development of necrotizing
   enterocolitis.
2. Place the child in the prone position with a sterile dry dressing over the defect.
   Begin intravenous fluids to prevent dehydration.
3. Place the child in the prone position with a sterile moist dressing over the defect.
   Slowly begin oral gastric feeds to prevent the development of necrotizing
   enterocolitis.
4. Place the child in the prone position with a sterile moist dressing over the defect.
   Begin intravenous fluids to prevent dehydration.

Answer 19

4. The child is placed in the prone position to avoid any pressure on the defect.
   A sterile moist dressing is placed over the defect to keep it as clean as
   possible. Intravenous fluids are begun after the surgery.

Question 20

The parents of a 12-month-old female with a neurogenic bladder ask the nurse if
their child will always have to be catheterized. Select the nurse’s best response.
1. “Your child will never feel when her bladder is full, so she will always have to be
catheterized. Because she is female, she will always need assistance.”
2. “As your child ages, she will likely be able to sense when her bladder is full and
will be able to empty it on her own.”
3. “Although your child will not be able to feel when her bladder is full, she can
learn to urinate every 4 to 6 hours and therefore not require catheterizations.”
4. “Your child will never be able to completely empty her bladder spontaneously, but
there are other options to traditional catheterization. An opening can be made
surgically through the abdomen, thus allowing the parents and child to be able to
place a catheter into the opening.”

Answer 20

4. A vesicostomy is an example of an option for children with myelomeningoceles
   where alternatives to traditional catheterizations are created

Question 21

The nurse is caring for a 9-year-old with myelomeningocele who has just had surgery to release a tight ligament to the lower extremity. Which of the following does the
nurse include in the child’s postoperative plan of care?

1. Encourage the child to resume a regular diet, beginning slowly with bland foods
   that are easily digested, such as bananas.
2. Encourage the child to blow balloons to increase deep breathing and avoid
   postoperative pneumonia.
3. Assist the child to change positions to avoid skin breakdown.
4. Provide education on dietary requirements to prevent obesity and skin
   breakdown.

Answer 21

3. Preventing skin breakdown is important in the child with myelomeningocele, as
   pressure points are not felt easily

Question 22

The nurse is caring for a child with CP. The nurse knows that since the 1960s
the incidence of CP has:

1. Increased.
2. Decreased.
3. Remained the same.
4. Has decreased due to early misdiagnosis

Answer 22

1. The incidence of CP has increased partly due to the increased survival
   of extreme low-birth-weight and premature infants.

Question 23

The nurse is caring for several children. She knows that which of the following
children is at increased risk for CP?
1. An infant born at 34 weeks with an Apgar score of 6 at 5 minutes.
2. A 17-day-old infant with sepsis.
3. A 24-month-old child who has experienced a febrile seizure.
4. A 5-year-old with a closed-head injury after falling off a bike.

Answer 23

2. Any infection of the central nervous system increases the infant’s risk of CP.

Question 24

The nurse is working in the pediatric developmental clinic. Which of the children
requires continued follow-up because of behaviors suspicious of CP?
1. A 1-month-old who demonstrates the startle reflex when a loud noise is heard.
2. A 6-month-old who always reaches for toys with the right hand.
3. A 14-month-old who has not begun to walk.
4. A 2-year-old who has not yet achieved bladder control during waking hours.

Answer 24

2. The clinical characteristic of hemiplegia can be manifested by the early preference
   of one hand. This may be an
   early sign of CP.

Question 25

The nurse is caring for a 13-month-old with meningitis. The child has experienced
increased ICP and multiple seizures. The child’s parents ask if the child is likely to
develop CP. Select the nurse’s best response.
1. “When your daughter is stable, she’ll undergo computed tomography and
magnetic resolution imaging. The physicians will be able to let you know if
she has CP.”
2. “Most children do not develop CP at this late age.”
3. “Your child will be closely monitored after discharge, and a developmental
specialist will be able to make the diagnosis.”
4. “Most children who have had complications of meningitis develop some
amount of CP.”

Answer 25

3. The child will be given a chance to recover and will be monitored closely before a diagnosis is made

Question 26

The nurse is caring for a 2-month-old male infant who is at risk for CP due to
extreme low birth weight and prematurity. There is a multidisciplinary team caring
for him. His parents ask why there is a speech therapist involved in his care. Select
the nurse’s best response.
1. “Your child is likely to have speech problems because of his early birth. Involving
the speech therapist at this point will ensure vocalization at a developmentally
appropriate age.”
2. “The speech therapist will help with tongue and jaw movements to assist with
babbling.”
3. “The speech therapist will help with tongue and jaw movements to assist with
feeding.”
4. “It is the hospital routine to involve as many members of the health-care team in
your child’s care so that we will know if he has any unmet needs.”

Answer 26

3. It is important to involve speech therapy to strengthen tongue and jaw
   movements to assist with feeding. The infant who is at risk for CP may have
   weakened and uncoordinated tongue and jaw movements.

Question 27

The nurse is giving morning medications to a 4-year-old female who has just had a
surgical procedure to release her hamstrings. The child has a history of CP. When
the nurse prepares to administer baclofen, the child’s parents ask what the medication
is for. Select the nurse’s best response.
1. “It is a medication that will help decrease the pain from her surgery.”
2. “It is a medication that will prevent her from having seizures.”
3. “It is a medication that will help control her spasms.”
4. “It is a medication that will help with bladder control.”

Answer 27

3. Baclofen is given to help control the spasms associated with CP.

Question 28

A 3-year-old male with CP has just been fitted for braces and is beginning physical
therapy to assist with ambulation. His parents ask why he needs the braces when he
was crawling without any assistive devices. Select the nurse’s best response:
1. “The CP has progressed, and he now needs more assistance to ambulate.”
2. “As your child ages and grows, the CP can manifest in different ways, and
different muscle groups can need more assistance.”
3. “Most children with CP need braces to help with ambulation.”
4. “We have found that when children with CP use braces, they are less
likely to fall.”

Answer 28

2. CP can be manifested in different ways as the child grows. It does not progress, but its clinical manifestations may change.

Question 29

The parents of a 2-year-old with CP are learning how to feed their child and avoid
aspiration. When reviewing the teaching plan, the nurse should question which of
the following?
1. Place the food on the tip of the tongue, as the child will be less likely to choke.
2. Place the child in an upright position during feedings.
3. Feed the child soft and blended foods.
4. Feed the child slowly

Answer 29

1. The food should be placed far back in the mouth to avoid tongue thrust.

Question 30

The nurse is caring for a 5-year-old male with CP. His weight is in the fifth
percentile, and he has been hospitalized for aspiration pneumonia. His parents are
anxious and state that they do not want a G-tube put in. Which of the following
would be the nurse’s best response?
1. “A G-tube will help your son gain weight and reduce his risk for future
hospitalizations due to pneumonia.”
2. “G-tubes are very easy to care for and will make feeding time easier for your
family.”
3. “Are you concerned that you will not be able to care for his G-tube?”
4. “Tell me your thoughts about G-tubes.”

Answer 30

4. An open-ended question will encourage family members to share what
   they know and potentially clear any misconceptions.

Question 31

The nurse is caring for a 4-month-old infant who was diagnosed with a

neuroblastoma. The nurse knows that this particular child’s prognosis is:
1. Excellent, as a neuroblastoma is always cured.
2. Excellent, as infants with a neuroblastoma have the best prognosis.
3. Poor, as infants with a neuroblastoma rarely survive.
4. Variable, depending on where the site of origin is.

Answer 31

2. Infants younger than 1 year have the best prognosis

Question 32

The nurse is caring for a 3-year-old with neuroblastoma. The child’s parents ask the
nurse what the typical signs and symptoms are at first. Select the nurse’s best answer.
1. “Most children complain of abdominal fullness and difficulty urinating.”
2. “Many children in the early stages of a neuroblastoma have joint pain and walk
with a limp.”
3. “The signs and symptoms vary depending on where the tumor is located, but
typical symptoms include weight loss, abdominal distention, and fatigue.”
4. “The signs and symptoms are fairly consistent regardless of the location of the
tumor. They include fatigue, hunger, weight gain, and abdominal fullness.”

Answer 32

3. The signs and symptoms vary depending on where the tumor is located, but typical symptoms include
   weight loss, abdominal distention, and fatigue.

Question 33

The parents of a preschooler diagnosed with muscular dystrophy are asking questions
about the course of their child’s disease. The nurse should tell them which of
the following?
1. Muscular dystrophies are disorders associated with progressive degeneration of
muscles, resulting in relentless and increasing weakness.
2. The weakness that the child is currently experiencing will probably not increase.
3. The child will be able to function normally and require no special accommodations.
4. The extent of degeneration depends on performing daily physical therapy

Answer 33

1. Muscular dystrophies are progressive
   degenerative disorders. The most common
   is Duchenne muscular dystrophy,
   which is an X-linked recessive disorder.

Question 34

The nurse is teaching the parents of a child with Duchenne (pseudohypertrophic)
muscular dystrophy. The nurse should tell them that some of the progressive
complications include which of the following?
1. Dry skin and hair, hirsutism, protruding tongue, and mental retardation.
2. Anorexia, gingival hyperplasia, and dry skin and hair.
3. Contractures, obesity, and pulmonary infections.
4. Trembling, frequent loss of consciousness, and slurred speech.

Answer 34

3. The major complications of muscular
dystrophy include contractures, disuse
atrophy, infections, obesity, respiratory
complications, and cardiopulmonary
problems.

Question 35

A 5-year-old has been diagnosed with pseudohypertrophic muscular dystrophy.
Which of the following nursing interventions would be appropriate?
1. Discuss with the parents the potential need for respiratory support.
2. Explain that this disease is easily treated with medication.
3. Suggest exercises that will limit the use of muscles and prevent fatigue.
4. Assist the parents in finding a nursing facility for future care.

Answer 35

1. Muscles become weaker, including those
   needed for respiration, and a decision
   will need to be made about whether respiratory
   support will be provided

Question 36

The nurse is discussing nutrition with the parents of a child with Duchenne muscular
dystrophy. The nurse tells the parents that which of the following foods would be
best for their child?
1. High-carbohydrate, high-protein foods.
2. No special food combinations.
3. Extra protein to help strengthen muscles.
4. Low-calorie foods to prevent weight gain.

Answer 36

4. As the child becomes less ambulatory,
moving the child will become more of a
problem. It is not good for the child to
become overweight for several health
reasons in addition to decreased
ambulation.

Question 37

Which of the following will help a school-aged child with muscular dystrophy stay
active longer?
1. Normal activities, such as swimming.
2. Using a treadmill every day.
3. Several periods of rest every day.
4. Using a wheelchair on getting tired.

Answer 37

1. Children who are active are usually
able to postpone use of the wheelchair
longer. It is important to keep using
muscles for as long as possible, and
aerobic activity is good for a child.

Question 38

The nurse is teaching family members of a child newly diagnosed with muscular
dystrophy about early signs. The nurse knows that teaching was successful when a
parent states that which of the following signs may indicate the condition early?
1. Increased muscle strength.
2. Difficulty climbing stairs.
3. High fevers and tiredness.
4. Respiratory infections and obesity

Answer 38

2. Difficulty climbing stairs, running, and
   riding a bicycle are frequently the first
   symptoms of Duchenne muscular
   dystrophy.

Question 39

The nurse is caring for a school-aged child with Duchenne muscular dystrophy in
the elementary school. Which of the following would be an appropriate nursing
diagnosis?
1. Anticipatory grieving.
2. Anxiety reduction.
3. Increased pain.
4. Activity intolerance

Answer 39

4. The child would not be able to keep up
   with peers because of weakness, progressive
   loss of muscle fibers, and loss
   of muscle strength.

Question 40

The nurse knows that teaching has been successful when the parent of a child with
muscle weakness states that the diagnostic test for muscular dystrophy is which of the
following?
1. Electromyelogram.
2. Nerve conduction velocity.
3. Muscle biopsy.
4. Creatine kinase level.

Answer 40

3. Muscle biopsy confirms the type of

myopathy that the patient has.

Question 41

A nurse is receiving an infant with myelomeningocele from an outside hospital.
Which of the following priority items should be placed at the newborn’s bedside?
1. A bottle of normal saline.
2. A rectal thermometer.
3. Extra blankets.
4. A blood pressure cuff

Answer 41

1. Before the surgical closure of the sac,
the infant is at risk for infection. A
sterile dressing is placed over the sac
to keep it moist and help prevent it
from tearing.

Question 42

The nurse is caring for an infant with myelomeningocele who is going to surgery
later today for closure of the sac. Which of the following would be a priority nursing
diagnosis before surgery?
1. Alteration in parent-infant bonding.
2. Altered growth and development.
3. Risk of infection.
4. Risk for weight loss.

Answer 42

3. A normal saline dressing is placed over
the sac to prevent tearing, which would
allow the cerebrospinal fluid to escape
and microorganisms to enter and cause
an infection.

Question 43

The parent of a 6-year-old with a repaired myelomeningocele is in the clinic for her
child’s regular examination. The child has frequent constipation and has been crying
at night because of pain in the legs. After an MRI, the diagnosis of a tethered cord is
made. Which of the following should the nurse tell the parent?
1. Tethered cord is a postsurgical complication.
2. Tethered cord occurs during times of slow growth.
3. Release of the tethered cord will be necessary only once.
4. Offering laxatives and acetaminophen daily will help control these problems.

Answer 43

1. Tethered cord is caused by scar tissue
formation from the surgical repair of
the myelomeningocele and may affect
bowel, bladder, or lower extremity
functioning.

Question 44

The nurse is caring for a newborn with a myelomeningocele who will have a surgical
repair tomorrow. The nurse should do which of the following?
1. Offer formula every 3 hours.
2. Turn the infant back to front every 2 hours.
3. Place a wet dressing on the sac.
4. Provide pain medication every 4 hours.

Answer 44

3. Priority care for an infant with a
   myelomeningocele is to protect the
   sac. A wet dressing keeps it moist with
   less chance of tearing.

Question 45

Which of the following should the nurse do first when caring for an infant who just
had a repair of a myelomeningocele?
1. Weigh diapers for 24-hour urine output.
2. Measure head circumference.
3. Offer clear fluids.
4. Assess for infection.

Answer 45

2. Hydrocephalus occurs in about 90% of
infants with myelomeningocele, so
measuring the head circumference
daily and watching for an increase
are important. Accumulation of cerebrospinal
fluid can occur after closure
of the sac.

Question 46

A newborn is diagnosed with a myelomeningocele at L2. Which of the following
should be the priority nursing diagnosis for this infant at 12 hours of age?
1. Altered bowel elimination related to neurological deficits.
2. Potential for infection related to the physical defect.
3. Altered nutrition related to neurological deficit.
4. Disturbance in self-concept related to physical disability.

Answer 46

2. Because this infant has not had a repair,
the sac is exposed. It could rupture,
allowing organisms to enter the
cerebrospinal fluid, so this is the
priority.

Question 47

A 2-month-old has had a myelomeningocele repair and has been brought in by a
parent for the well-child checkup and shots. Over the last week, the baby has had a
high-pitched cry and has been irritable. Height, weight, and head circumference have
been at the 50th percentile. Today height is at the 50th percentile, weight is at the
70th percentile, and head circumference is at the 90th percentile. The nurse should
do which of the following?
1. Tell the parent this is normal for an infant with a repaired myelomeningocele.
2. Tell the parent this might mean the baby has increased intracranial pressure.
3. Suspect the baby’s intracranial pressure is low because of a leak.
4. Refer the baby to the neurologist for follow-up care.

Answer 47

2. The increase in head size is one of the
   first signs of increased intracranial
   pressure; other signs include highpitched
   cry and irritability.

Question 48

Which of the following should the nurse tell the parent of an infant with spina bifida?
1. Bone growth will be more than that of babies who are not sick, because your baby
will be less active.
2. Physical and occupational therapy will be helpful to stimulate the senses and
improve cognitive skills.
3. Nutritional needs for your infant will be calculated based on activity level.
4. Fine motor skills will be delayed because of the disability.

Answer 48

2. Children with decreased activity due to
   illness or trauma are helped by physical
   and occupational therapy. The varied
   activities stimulate the senses.

Question 49

A 3-month-old with spina bifida is admitted to the nurse’s unit. Which of the
following gross motor skills should the nurse assess at this age?
1. Head control.
2. Pincer grasp.
3. Sitting alone.
4. Rolling over.

Answer 49

1. A 3-month-old has good head control

Question 50

A 15-year-old with spina bifida is seen in the clinic for a well-child checkup. The
teen uses leg braces and crutches to ambulate. Which of the following nursing
diagnoses takes priority?
1. Potential for infection.
2. Alteration in mobility.
3. Alteration in elimination.
4. Potential body image disturbance

Answer 50

4. As an adolescent on crutches and wearing
   braces, the teen would have the issue
   of body image disturbance, which
   must be addressed. This is a priority

Question 51

Following surgical repair and closure of a myelomeningocele shortly after birth,
which of the following is true of an infant?
1. The infant will not need any long-term management and should be
considered cured.
2. The infant will no longer be at risk of urinary tract infections or movement problems.
3. The infant will have continual drainage of cerebrospinal fluid, needing frequent
dressing changes.
4. The infant will need lifelong management of urinary, orthopedic, and
neurological problems

Answer 51

4. Although immediate surgical repair decreases
infection, morbidity, and mortality
rates, these children will require
lifelong management of neurological,
orthopedic, and elimination problems

Question 52

A newborn with a repaired myelomeningocele is assessed for hydrocephalus. What
would the nurse expect if the infant has hydrocephalus?
1. Low-pitched cry and depressed fontanel.
2. Low-pitched cry and bulging fontanel.
3. Bulging fontanel and downwardly rotated eyes.
4. Depressed fontanel and upwardly rotated eyes.

Answer 52

3. An alteration in the circulation of the
cerebrospinal fluid causes hydrocephalus.
The anterior fontanel bulges
because of an increase in cerebrospinal
fluid, and an increase in intracranial
pressure causes a high-pitched cry in
infants and downward deviation of the
eyes, also called sunset eyes. With
sunset eyes the sclera can be seen
above the iris.

Question 53

The nurse is developing a plan of care for a child recently diagnosed with CP. Which
of the following should be the nurse’s priority goal?
1. Ensure the ingestion of sufficient calories for growth.
2. Decrease intracranial pressure.
3. Teach appropriate parenting strategies for a special-needs child.
4. Ensure that the child reaches full potential.

Answer 53

4. The priority for all children is to

develop to their full potential

Question 54

The nurse knows that teaching of parents of a child newly diagnosed with CP is
successful when the parents state that CP is which of the following?
1. Inability to speak and drooling.
2. Poor dentition due to poor hygiene.
3. Involuntary movements of upper extremities only.
4. An increase in muscle tone and deep tendon reflexes

Answer 54

4. The primary disorder is of muscle
tone, but there may be other
neurological disorders such as seizures,
vision disturbances, and impaired intelligence.
Spastic CP is the most common
type and is characterized by a
generalized increase in muscle tone,
increased deep tendon reflexes, and
rigidity of the limbs on both flexion
and extension.

Question 55

The parent of a toddler newly diagnosed with CP asks the nurse what caused it. The
nurse should answer which of the following?
1. Most cases are caused by unknown prenatal factors.
2. It is commonly caused by perinatal factors.
3. The exact cause is not known.
4. The exact cause is known in every instance

Answer 55

1. At least 80% of cases of CP result from

unknown prenatal factors.

Question 56

Which of the following developmental milestones should the nurse be concerned
about if a 10-month-old could not do it?
1. Crawl.
2. Cruise.
3. Walk.
4. Have a pincer grasp.

Answer 56

1. Most infants are able to crawl

unassisted by 8 months

Question 57

The parent of an infant asks the nurse what to watch for to determine if the infant
has CP. The nurse should reply which of the following?
1. If the infant cannot sit up without support before 8 months.
2. If the infant demonstrates tongue thrust before 4 months.
3. If the infant has poor head control after 2 months.
4. If the infant has clenched fists after 3 months.

Answer 57

4. Clenched fists after 3 months of age

may be a sign of CP

Question 58

The parent of a young child with CP brings the child to the clinic for a checkup.
Which of the parent’s following statements indicates an understanding of the child’s
long-term needs?
1. “My child will need all my attention for the next 10 years.”
2. “Once in school, my child will catch up and be like the other children.”
3. “My child will grow up and need to learn to do things independently.”
4. “I’m the one who knows the most about my child and do the most for my child.”

Answer 58

3. This statement indicates that the parent
   understands the long-term needs
   of the child.

Question 59

A child with spastic CP had an intrathecal dose of baclofen in the early afternoon.
What is the expected result 31/2 hours post dose that suggests the child would
benefit from a baclofen pump?
1. The ability to self-feed.
2. The ability to walk with little assistance.
3. If the spasticity were decreased.
4. If the spasticity were increased.

Answer 59

3. If baclofen were going to work for this
   patient, one could tell because spasticity
   would be decreased

Question 60

A child is admitted to the pediatric unit with spastic CP. Which of the following
would the nurse expect this child to demonstrate? Select all that apply.
1. Increased deep tendon reflexes.
2. Decreased muscle tone.
3. Scoliosis.
4. Contractures.
5. Scissoring.
6. Good control of posture.
7. Good fine motor skills.

Answer 60

1. Children with spastic CP have
increased deep tendon reflexes.
3. Children with spastic CP have scoliosis.
4. Children with spastic CP have contractures
of the Achilles tendons, knees,
and adductor muscles.
5. Children with spastic CP have
scissoring when walking.

Question 61

A 3-year-old child with CP is admitted for dehydration following an episode of diarrhea.
The nurse’s assessment follows: awake, pale, thin child lying in bed, multiple
contractures, drooling, coughing spells noted when parent feeds. T 97.8°F (36.5°C),
P 75, R 25, weight 7.2 kg, no diarrheal stool for 48 hours. Which of the following
nursing diagnoses is most important?
1. Potential for skin breakdown: lying in one position.
2. Alteration in nutrition: less than body requirements.
3. Potential for impaired social support: mother sole caretaker.
4. Alteration in elimination: diarrhea

Answer 61

2. This is the priority nursing diagnosis
for this severely underweight child.
Weight is average for a 4-month-old.
The coughing episodes while feeding
may indicate aspiration. The parent
needs help to learn how to feed so less
coughing occurs.

Question 62

The parent of an infant with CP asks the nurse if the infant will be mentally

retarded. Which of the following is the nurse’s best response?
1. “Children with CP have some amount of mental retardation.”
2. “Approximately 20% of children with CP have normal intelligence.”
3. “Many children with CP have normal intelligence.”
4. “Mental retardation is expected if motor and sensory deficits are severe.”

Answer 62

3. Many children with CP have normal intelligence.

Question 63

The nurse is assessing a 2-week-old for signs of DDH. The nurse should expect the
infant to have which of the following?
1. Excessive hip abduction.
2. Femoral lengthening of an affected leg.
3. Asymmetry of gluteal and thigh folds.
4. Pain when lying prone.

Answer 63

3. In DDH, asymmetrical thigh and gluteal

folds are frequently present.

Question 64

An infant is in a Pavlik harness for treatment of DDH. While instructing the parents
on preventing skin breakdown, the nurse should stress which of the following?
1. Put socks on over the foot pieces of the harness to help stabilize the harness.
2. Use lotions or powder on skin to prevent rubbing of straps.
3. Remove harness during diaper changes for ease of cleaning diaper area.
4. Check under the straps at least two to three times daily for red areas.

Answer 64

4. Checking under straps frequently is

suggested to prevent skin breakdown.

Question 65

Which of the following conditions can occur in untreated DDH? Select all that apply.

1. Duck gait.
2. Pain.
3. Osteoarthritis in adulthood.
4. Osteoporosis in adulthood.
5. Increased flexibility of the hip joint in adulthood

Answer 65

1. Due to abnormal hip joint function, the
   patient’s gait is stiff and waddling.
2. Due to abnormal femoral head placement,
   the patient may experience pain
   and decreased flexibility in adulthood.
3. Due to abnormal femoral head placement,
   the patient may experience osteoarthritis
   in the hip joint in adulthood

Question 66

The nurse is teaching about congenital clubfoot in infants. The nurse evaluates the
teaching as successful when the parent states that clubfoot is best treated when?
1. Immediately after diagnosis.
2. At age 4 to 6 months.
3. Prior to walking (age 9 to 12 months).
4. After walking is established (age 15 to 18 months).

Answer 66

1. The best outcomes for clubfoot are seen
   if casting begins as soon as the diagnosis
   is made.

Question 67

The nurse tells the parent that other conditions can be associated with congenital
clubfoot? Select all that apply.
1. Myelomeningocele.
2. Cerebral palsy.
3. Diastrophic dwarfism.
4. Breech position in utero.
5. Prematurity.
6. Fetal alcohol syndrome.

Answer 67

1. There is an association between
myelomeningocele and congenital
clubfoot.
2. There is an association between some
forms of cerebral palsy and congenital
clubfoot.
3. There is an association between diastrophic
dwarfism and congenital clubfoot

Question 68

A child has had surgery to correct bilateral clubfeet, and the cast has been removed.
While instructing the parents about their child’s future, the nurse should include
which of the following statements? Select all that apply.
1. “Your child will need to wear a brace on the feet 23 hours a day for at least
2 months.”
2. “Your child should see an orthopedic surgeon regularly until the age of 18 years.”
3. “Your child will not be able to participate in sports that require a lot of running.”
4. “Your child may have a recurrence of clubfoot in a year or more.”
5. “Most children treated for clubfeet develop feet that appear and function
normally.”
6. “Most children treated for clubfeet require surgery at puberty.”

Answer 68

1. After the final casting, bracing is
required for 23 to 24 hours per day
for 2 months. This decreases the
likelihood of a recurrence.
2. Because clubfoot can recur, it is important
to have regular follow-up with the
orthopedic surgeon until age 18 years.
4. Even with proper bracing, there may
be a recurrence.
5. Most children treated for clubfeet
develop normally appearing and
functioning feet.

Question 69

The parent of a 3-week-old states that the infant was recasted this morning for
clubfoot and has been crying for the past hour. Which of the following interventions
should the nurse suggest the parent do first?
1. Give pain medication.
2. Reposition the infant in the crib.
3. Check the neurocirculatory status of the foot.
4. Use a cool blow-dryer to blow into the cast to control itching.

Answer 69

3. Checking the neurocirculatory status

of the foot is the highest priority.

Question 70

A 12-year-old diagnosed with scoliosis is to wear a brace for 23 hours a day. What is
the most likely reason the child will not wear it for that duration?
1. Pain from the brace.
2. Difficulty in putting the brace on.
3. Self-consciousness about appearance.
4. Not understanding what the brace is for.

Answer 70

3. Children this age are very conscious of
   their appearance and of fitting in with
   their peers, so they might be very
   resistant to wearing a brace.

Question 71

A 13-year-old just returned from surgery for scoliosis. What nursing interventions
are appropriate in the first 24 hours? Select all that apply.
1. Assess for pain.
2. Logroll to change positions.
3. Get the teen to the bathroom 12 to 24 hours after surgery.
4. Check neurological status.
5. Monitor blood pressure.

Answer 71

1. General postoperative nursing interventions
   include assessing for pain.
2. Specific to scoliosis surgery, logrolling
   is the means of changing positions.
3. It is essential to check neurological
   status in a patient who just had
   scoliosis surgery.
4. General postoperative nursing interventions
   include assessing vital signs.

Question 72

A 9-year-old is in a spica cast and complains of pain 1 hour after receiving
intravenous opioid analgesia. What should the nurse do first?
1. Give more pain medication.
2. Perform a neuromuscular assessment.
3. Call the surgeon for orders.
4. Tell the child to wait another hour for the medication to work.

Answer 72

2. The nurse looks for the source of the
   pain by performing a neuromuscular
   assessment

Question 73

After the birth of an infant with clubfoot, the nursery nurse should do which of the
following when instructing the parents? Select all that apply.
1. Speak in simple language about the defect.
2. Avoid the parents unless providing direct care so they can grieve privately.
3. Keep the infant’s feet covered at all times.
4. Present the infant as precious; emphasize the well-formed parts of the body.
5. Tell the parent that defects could be much worse.
6. Be prepared to answer questions multiple times.

Answer 73

1. The parents will likely be shocked
immediately after the birth of the child.
To facilitate their understanding, the
nurse should speak in simple terms
4. The baby should be shown to the
parents like all newborns, emphasizing
the well-formed parts of the body
6. Information may need to be repeated
as the family begins to absorb the
information.

Question 74

When teaching parents about osteosarcoma, the nurse knows instruction has been
successful when a parent says that this type of cancer is common in which age group?
1. Infancy.
2. Toddlers.
3. School-age children.
4. Adolescents.

Answer 74

4. Osteosarcoma is a common cancer of

adolescents

Question 75

A 13-year-old with osteosarcoma is going to have an amputation of the affected limb.
Which of the following is most important to discuss with a teenage patient?
1. Pain.
2. Spirituality.
3. Body image.
4. Lack of coping.

Answer 75

3. Body image is a developmental issue
   for adolescents and influences their acceptance
   of themselves and by peers

Question 76

A nurse is caring for a 5-year-old who has a fracture of the tibia involving the growth

plate. When providing information to the parents, the nurse should indicate that:
1. This is a serious injury that could cause long-term growth issues.
2. The fracture usually heals within 6 weeks without further complications.
3. The child will never be able to play contact sports.
4. Fractures involving the growth plate require pain medication.

Answer 76

1. Fractures of the growth plate are
   serious, as they can disrupt the
   growth process.

Question 77

A toddler-age client has a tonic-clonic seizure while in a crib in the hospital. The client’s jaw is clamped. Which nursing action is the priority?

1. Place a padded tongue blade between the child’s jaws.
2. Stay with the child and observe the respiratory status.
3. Prepare the suction equipment.
4. Restrain the child to prevent injury.

Answer 77

2: During a seizure, the nurse remains with the child, watching for complications. The child’s respiratory rate should be monitored. Be sure nothing is placed in the child’s mouth during a seizure. Suction equipment should already be set up at the bedside before a seizure begins. The child should not be restrained during a seizure.

Question 78

A nurse is conducting a postoperative assessment on an infant who has just had a ventriculoperitoneal shunt placed for hydrocephalus. Which assessment finding would indicate a malfunction in the shunt?

1. Incisional pain
2. Movement of all extremities
3. Negative Brudzinski sign
4. Bulging fontanel

Answer 78

4: A bulging fontanel would be an abnormal finding and could indicate that the shunt is malfunctioning. Incisional pain, movement of all extremities, and negative Brudzinski sign are all normal findings after a ventriculoperitoneal shunt has been placed.

Question 79

Which nursing intervention is most appropriate when caring for an infant with a myelomeningocele in the preoperative stage?

1. Placing infant supine to decrease pressure on the sac
2. Appling a heat lamp to facilitate drying and toughening of the sac
3. Measuring head circumference every shift to identify developing hydrocephalus
4. Appling a diaper to prevent contamination of the sac

Answer 79

3: The infant should be monitored for developing hydrocephalus, so the head circumference should be monitored daily. The infant will be placed prone, not supine, and the defect will be protected from trauma or infection. Therefore, applying heat and a diaper around the defect would not be recommended. A sterile saline dressing may be used to cover the sac to maintain integrity.

Question 80

A child with myelomeningocele, corrected at birth, is now 5 years old. Which is the priority nursing diagnosis for a child with corrected spina bifida at this age?

1. Risk for Altered Nutrition
2. Risk for Impaired Tissue Perfusion—Cranial
3. Risk for Altered Urinary Elimination
4. Risk for Altered Comfort

Answer 80

3: A child with spina bifida will continue to have a risk for altered urinary elimination because the bowel and bladder sphincter controls are affected. Urinary retention is a problem, so bladder interventions are initiated early to prevent kidney damage. Risk for Altered Nutrition, Impaired Tissue Perfusion, and Altered Comfort are not problems once surgery has been performed to close the defect.

Question 81

Which statement made by a parent during a well-child visit would cause the nurse to suspect the child has cerebral palsy?

1. “My 6-month-old baby is rolling from back to prone now.”
2. “My 3-month-old seems to have floppy muscle tone.”
3. “My 8-month-old can sit without support.”
4. “My 10-month-old is not walking.”

Answer 81

2: Children with cerebral palsy are delayed in meeting developmental milestones. The infant with hypotonia is showing a clinical manifestation of cerebral palsy. A baby rolls over from back to prone at 6 months, sits without support at 8 months, and walks at 12 months.

Question 82

A nurse is caring for a child who is diagnosed with cerebral palsy. Which goal of therapy is most appropriate for the nurse to include in the plan of care?

1. Reversing the degenerative processes that have occurred
2. Curing the underlying defect causing the disorder
3. Preventing the spread to individuals in close contact with the child
4. Promoting optimum development

Answer 82

4: Recognition of the disorder is important so that optimal development can be maintained. Cerebral palsy cannot be reversed or cured. It is not caused by a contagious process, so there is no risk of spread.

Question 83

A child sustains a traumatic brain injury and is monitored in the pediatric intensive-care unit (PICU). The nurse is using the Glasgow Coma Scale to assess the child. Which items will the nurse assess when using this tool?

Select all that apply.

1. Eye opening
2. Verbal response
3. Motor response
4. Head circumference
5. Pulse oximetry

Answer 83

1, 2, 3: The Glasgow Coma Scale for infants and children scores parameters related to eye opening, verbal response, and motor response. The maximum score is 15, indicating the highest level of neurological functioning. Head circumference and pulse oximetry are not included on the scale

Question 84

A child diagnosed with a mild traumatic brain injury is being sedated with a mild sedative so that pain and anxiety are minimized. Which nursing interventions are appropriate for this child?

Select all that apply.

1. Place a continuous-pulse oximetry monitor on the child.
2. Place the child in a room near the nurse’s station.
3. Allow for several visitors to remain at the child’s bedside.
4. Use soft restraints if the child becomes confused.
5. Use sedation around the clock to decrease agitation.

Answer 84

1,2
When a child is sedated, respiratory status should be monitored with a pulse-oximetry machine. The child should be close to the nurse’s station so that frequent monitoring can be done. Several visitors at the bedside would increase the child’s anxiety. Soft restraints may increase agitation. Sedation around the clock is not recommended due to the need to evaluate the neurologic system.

Question 85

With a group of new parents, the nurse is reviewing treatment for viral illnesses such as influenza. Which statement by the parents indicates appropriate understanding of the teaching session?

1. “Some over-the-counter medications contain aspirin.”
2. “Acetaminophen is good for treatment of fevers in young children.”
3. “I can use ibuprofen as needed when my child has aches and pains.”
4. “Aspirin is acceptable if my child does not have a virus.”

Answer 85

1: Reye syndrome is a serious consequence of aspirin use in children with viral illnesses. Over-the-counter medications should be checked to see whether they contain aspirin before being used. Aspirin is avoided in children. Ibuprofen and acetaminophen are acceptable to use in children.

Question 86

A child is ready for discharge after surgery for a myelomeningocele repair. Before discharge, the nurse works with the parents to establish a catheterization schedule to prevent urinary tract infection. With what frequency should the nurse instruct the parents to catheterize the child?

1. Every 1–2 hours
2. Every 3–4 hours
3. Every 6–8 hours
4. Every 10–12 hours

Answer 86

2: To decrease the incidence of bladder or urinary tract infections, catheterization should occur every 3–4 hours.

Question 87

The nurse educator is describing the pediatric differences associated with the anatomy and physiology of the neurologic system to a group of nursing students. Which statements made by the class indicate appropriate understanding of this topic after the teaching session?

Select all that apply.

1. The bones of the cranium are connected by connective tissue to allow for brain growth.
2. The spine of infants is excessively mobile due to immature neck muscles and incompletely developed vertebral bodies.
3. Maturation of the nerves continues until age 10.
4. Myelination is complete at birth,
5. Myelination proceeds in a cephalocaudal direction.

Answer 87

1,2,5

There are several pediatric differences associated with the anatomy and physiology of the neurological system and include: the bones of the cranium are connected by connective tissue to allow for brain growth; the spine of infants is excessively mobile due to immature neck muscles and incompletely developed vertebral bodies; and myelination proceeds in a cephalocaudal direction. Maturation of the nerves continues until the age of 4, not 10. Myelination is incomplete at birth.

Question 88

The nurse completes parent education related to treatment for a pediatric client with congenital clubfoot. Which statement by the parents indicates the need for further education?

1. “We’re happy this is the only cast our baby will need.”
2. “We’ll watch for any swelling of the feet while the casts are on.”
3. “We’ll keep the casts dry.”
4. “We’re getting a special car seat to accommodate the casts.”

Answer 88

1: Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every one to two weeks. Parents should be watching for swelling while the casts are on, keeping the casts dry, and using a car seat to accommodate the casts.

Question 89

An infant returns from surgery for correction of bilateral congenital clubfeet. The infant has bilateral long-leg casts. The toes on both feet are edematous, but there is color, sensitivity, and movement to them. Which action by the nurse is the most appropriate?

1. Call the healthcare provider to report the edema.
2. Elevate the legs on pillows.
3. Apply a warm, moist pack to the feet.
4. Encourage movement of toes.

Answer 89

2: The legs should be elevated on a pillow for 24 hours to promote healing and help with venous return. Some amount of swelling can be expected, so it would not be appropriate to notify the healthcare provider, especially if the color, sensitivity, and movement remain normal to the toes. Ice should be applied, not heat. An infant would not be able to follow directions to move toes, and in this case it would not be as effective as elevating the legs on pillows.

Question 90

The nurse in the newborn nursery is performing the admission assessment on a neonate. Which assessment finding indicates the neonate may have congenital hip dysplasia?

1. Asymmetry of the gluteal and thigh fat folds
2. Trendelenburg sign
3. Telescoping of the affected limb
4. Lordosis

Answer 90

1: A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat folds. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia. Lordosis does not occur with hip dysplasia.

Question 91

The nurse is teaching family members how to care for their infant in a Pavlik harness to treat congenital developmental dysplasia of the hip. Which statement will the nurse include in the teaching session?

1. “Apply lotion or powder to minimize skin irritation.”
2. “Put clothing over the harness for maximum effectiveness of the device.”
3. “Check at least two or three times a day for red areas under the straps.”
4. “Place a diaper over the harness, preferably using a thin, superabsorbent, disposable diaper.”

Answer 91

3: The brace should be checked two or three times for red areas under the straps. Lotion or powder can contribute to skin breakdown. A light layer of clothing should be under the brace, not over. The diaper should also be under the brace.

Question 92

The nurse has completed discharge teaching for the family of a child diagnosed with Legg-Calve-Perthes disease. Which statement by the family indicates the need for further education?

1. “We’re glad this will only take about six weeks to correct.”
2. “We understand swimming is a good sport for Legg-Calve-Perthes.”
3. “We know to watch for areas on the skin the brace may rub.”
4. “We understand that abduction of the affected leg is important.”

Answer 92

1: The treatment generally takes approximately two years. Swimming is a good activity to increase mobility. A brace may be worn, so skin irritation should be monitored. The leg should be kept in the abducted position.

Question 93

A school health nurse is screening school-age students for scoliosis. Which assessment findings indicate the need for further evaluation for scoliosis?

Select all that apply.

1. Uneven shoulders and hips
2. A one-sided rib hump
3. Prominent scapula
4. Lordosis
5. Pain

Answer 93

1,2,3

The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. Lordosis and pain are not present with scoliosis.

Question 94

An adolescent client must wear a brace for the correction of scoliosis. Which nursing diagnosis is most appropriate for this client?

1. Risk for Impaired Skin Integrity
2. Risk for Altered Growth and Development
3. Risk for Impaired Mobility
4. Risk for Impaired Gas Exchange

Answer 94

1: The skin should be monitored for breakdown in any area the brace may rub. The other diagnoses would not be a priority and should be corrected by the wearing of the brace.

Question 95

A nurse is assessing a child after an open reduction of a fractured femur. Which assessment findings would indicate that the child is experiencing compartment syndrome?

Standard Text: Select all that apply.

1. Pink, warm extremity
2. Pain not relieved by pain medication
3. Dorsalis pedis pulse present
4. Prolonged capillary-refill time with paresthesia
5. Skin appears tense

Answer 95

2,4,5

The major serious complication post-fracture reduction is compartment syndrome. A prolonged capillary-refill time with loss of paresthesia, pain not relieved by medication, and skin that appears tense are signs of compartment syndrome. Pink, warm extremity; pain relieved by medication; and a present dorsalis pedis pulse would all be normal findings post-fracture reduction.

Question 96

A nurse is assessing a new admission. The 6 month old infant displays irritability, bulging fontanels, and setting-sun eyes. What condition would the nurse suspect based on these manifestations?

1. Increased intracranial pressure
2. Hypertension
3. Skull fracture
4. Myelomeningocele

Answer 96

1

Question 97

An 8 year old child with a VP shunt was admitted for shunt malfunction. He presents with symptoms of increased ICP. The mechanism of the development of his symptoms is most probably related to which mechanism related to the CSF?

1. Increased flow of CSF
2. Increased reabsorption of CSF
3. Obstructed flow of CSF
4. Decreased production of CSF

Answer 97

3

Question 98

A child with a myelomeningocele is started on a bowel management plan. The childs’ mother questions why this is being done. What would the nurse use as a basis for a response?

1. Lack of innervation to the colon predisposes the child to diarrhea.
2. Lack of innervation to the anal sphincter predisposes the child to being incontinent
3. Chronic immobility increases the gastric-colic reflex
4. Chronic immobility decreases the need for regular bowel movements

Answer 98

2

Question 99

A child is being treated for ICP. What should the nurse provide as part of the prescribed plan of care to decrease ICP? Select all that apply.

1. Keep head of bed at a 30 degree angle
2. Provide supplemental oxygen
3. Turn head to one side
4. Administer IV osmotic diuretics
5. Promote fluid intake

Answer 99

1, 2, 4

Question 100

A young child has just been diagnosed with spastic cerebral palsy. The nurse is teaching the parents how to meet their child’s dietary needs. The nurse would explain that children with cerebral palsy frequently have special dietary needs or feeding challenges for which reason?

1. The paralysis of their muscles decreases their caloric need.
2. The spascisity of their muscles increases their caloric need.
3. The hypotonic muscles make eating difficult.
4. The child’s inactivity increases the risk of obesity

Answer 100

2

Question 101

An 18 month old child is observed having a seizure. The nurse notes that the child’s jaws are clamped. What is the priority responsibility of the nurse at this time>

1. Start oxygen via mask
2. Insert padded tongue blade
3. Restrain child to prevent injury to soft tissue
4. Protect the child from harm from the environment

Answer 101

4

Question 102

The nurse is providing discharge instructions for a child who has suffered a head injury within the last four hours. The nurse determines there is a need for additional teaching when the mother makes which statement?

1. “I will call my doctor immediately if my child starts vomiting.”
2. “I won’t give my child anything stronger than Tylenol for headache.”
3. “My child should sleep for at least 8 hours without arousing after we get home.”
4. “I recognize that continued amnesia about the injury is not uncommon.”

Answer 102

3

Question 103

A 2 year old child is admitted to the neurosurgical unit following a head injury. The nurse is using the Glascow Coma Scale to measure neurological functioning. Which assessment finding indicates the lowest level of functioning for this child?

1. Confusion
2. Irritable and cries
3. Eyes open only to pain
4. No response to painful stimuli

Answer 103

4

Question 104

Upon performing a physical assessment of a 7 month old child, the nurse notes the following findings. The nurse concludes that which finding is abnormal and could suggest cerebral palsy?

1. No head lag when pulled to a sitting position
2. No Moro or startle reflex
3. Positive tonic neck reflex
4. Absence of tongue extrusion

Answer 104

3

Question 105

A 4 year old is being evaluated for hydrocephalus. The nurse notes which of the following as early signs of hydrocephalus in this child? Select all that apply.

1. Bulging fontanels
2. Rapid enlargement of the head
3. Shrill, high-pitched cry
4. Early morning headache
5. Vomiting upon arising

Answer 105

4, 5

Question 106

A 6 year old child has a cast applied for a fractured radius. The nurse completes an orthopedic assessment on this child. Which manifestation requires immediate attention and should be reported to the physician? Select all that apply.

1. Cap refill of 5 seconds in the affected hand
2. Edema in the affected fingers that resolves with elevation
3. Child describes feeling of the affected hand being “asleep”
4. Skin surrounding the cast is warm
5. Pain that increases with elevation of the hand

Answer 106

1, 3, 5

Question 107

A 5 month old infant is being evaluated for developmental dysplasia of the hip. The nurse assess for which signs and symptoms hat are exhibited with this disorder? Select all that apply

1. Ortolani sign
2. A limp
3. Allis sign
4. Trendelenburg sign
5. Asymmetric thigh and gluteal folds.

Answer 107

3, 5

Question 108

A nurse who is admitting a newborn to the newborn nurse is assessing for congenital defects. In addition to the abnormal position of the foot, the nurse would note which of the following if clubfoot is present?

1. Affected foot is larger and longer.
2. Affected limb is longer
3. There is calf atrophy of the affected limb
4. Affected foot is cooler

Answer 108

3

Question 109

The physician has written the following orders for a child with Duchenne Muscular Dystrophy hospitalized for a respiratory infection. The nurse should question the order for which of the following?

1. Physical therapy
2. Antibiotic therapy
3. Passive range of motion exercises
4. Strict bedrest

Answer 109

4

Question 110

The parents of an unborn infant have just learned that based on ultrasound, their infant has clubfoot. They ask the nurse how clubfoot is treated. Which treatment should the nurse discuss with the parents?

1. Weekly cast changes with manipulation
2. Probably surgery on the affected limb
3. Abduction device to keep the hip in full abduction
4. Use of a Denis Browne splint to achieve correction

Answer 110

1

Question 111

An infant is placed in a Pavlik harness for developmental dysplasia of the hip. The nurse has completed parent teaching, but the parents seem to be overwhelmed by the condition. Which statements made by the parents indicate that more instruction is needed? Select all that apply.

1. “The straps of the harness should be placed next to the skin.”
2. “The harness should be worn for six hours a day.”
3. “It will take a long time for my child to walk and crawl.”
4. “I should not lift the baby by his legs when changing his diaper.”
5. “Because my child’s defect was caught early, treatment will not usually require surgery.”

Answer 111

1, 2, 3

Question 112

A child is admitted to the hospital unit with a diagnosis of Legg-Calve-Perthes disease. The nurse would assess for which symptoms of this disease? Select all that apply.

1. Swelling of the involved joint(s)
2. Redness of the involved joint
3. Insidious limp after activities
4. Referred pain to the knee
5. Stiffness in the morning or after rest.

Answer 112

3, 4, 5

Question 113

An adolescent is diagnosed with idiopathic structural scoliosis describes all of the following symptoms. Which one would the nurse conclude is not associated with this diagnosis?

1. Back pain
2. Skirts that hang unevenly
3. Unequal shoulder height
4. Uneven waist level

Answer 113

1

Question 114

An adolescent is returning to the hospital unit after surgical spinal fusion for scoliosis. The nurse would include which of the following in the immediate postoperative care of this client? Select all that apply.

1. Oral analgesics for pain.
2. Logrolling every 2 hours as ordered.
3. Nasogastric intubation
4. Straight cath every 4 hours
5. IS every 2 hours while awake

Answer 114

2, 3, 5

Question 115

A 3 year old is suspected of having Duchenne’s Muscular Dystrophy. Which assessment findings by the nurse would support this diagnosis?

1. History of delayed crawling
2. Outward rotation of the hips
3. Difficulty climbing stairs
4. Wasted muscle appearance

Answer 115

3