QUIZ #1 NUR104AB Flashcards
Assess ______ using observation of the child moving around the room.
Gait
Autonomic reflexes in infants are the _______ reflex, ______ reflex, and the ______ reflex.
palmar grasp
stepping
rooting
Regardless of age inspection is always the first assessment because it is the least _______.
Invasive
When do you do a head to toe assessment instead of a chest thorax assessment?
When assessing a school ager NOT a toddler, infant, or preschooler.
The Babinski reflex is a fanning of the ____.
toes
A 10 month old child cries when the parents leave this is an example of ________.
Separation anxiety
A five-year-old cries and screams before vaccinations. The nurse should tell the dad that all children have a fear of needles and at her age she believes that pain is a form of _________ for their behavior.
punishment
An 18-month-old child has a seizure and their jaw is clamped shut the _______ is maintaining a safe environment.
Nursing Priority
A 15 month old boy is in your office. The mom says the child has not started crawling yet. What would be the nursing priority?
Determining why the child has not reached this developmental milestone.
Study Tip: You notify the mom that 16 to 18 months is the normal average age that children begin walking.
A child’s weight at birth is 8 lbs. 2 oz.
The child is weight again at 1 year old and they weigh 18 lbs. 4 oz.
Is this the normal amount of weight gain for a child at one year?
Not it is below average.
Study Tip: Should be TRIPLE the birth weight by ONE YEAR!
Ortolani test or Ortolani Maneuver is a physical examination for congenital hip dysplasia or developmental hip dysplasia. Ortolani maneuver is performed before 2-3 months of age. The maneuver is DONE IN EARLY INFANCY ONLY because after 2-3 months the development of soft tissue contracture prevents the hip from being relocated, thus, no clicking or clunking sound will be assessed in children with congenital hip dysplasia. This test is used to detect the posterior dislocation of the hip. How do you perform this maneuver?
The maneuver is performed by abducting the infant’s hip an assessing for a clicking sound.
A positive Ortolani’s sign is noted when a clicking or distinctive “clunk” is heard when femoral head re-enters the acetabulum.
The ________ is a maneuver performed by bringing the thigh towards the midline of the body. Feeling of femoral head slipping out of the socket postolaterally, is considered as a positive sign.
Barlow Test
Study Tip: The Ortolani test is then used after to confirm that the hip is actually dislocated.
Encourage ________ in a eight-year-old girl by allowing her to help with HER OWN dressing change, SELF-CATHETERIZATION, administering her own BLOOD GLUCOSE checks, and encouraging doing HOMEWORK.
INDUSTRY
Study Tip: Industry Vs. Inferiority
What age group that is most at risk for acquiring meningitis and why?
Infants and small children because they can get it easily R/T decreased immunity.
A seven-month-old could have _________ if they still have a POSITIVE tonic neck REFLEX which usually goes away by 4 to 6 months.
Cerebral Palsy
Parents should talk to _____ about worries about bullying and how to handle the situation because they know how each student reacts, interacts, and the dynamics of the classroom.
Teachers
The patient has a VP shunt and they develop a high temperature and a high-pitched cry what is the nursing priority?
Assess for INFECTION.
Study Tip: Normally increased ICP would be the priority but a HIGH TEMP is not a complication of increased intracranial pressure so the nurse MUST determine the agent causing the FEVER.
Pre-Op:
Position on abdomen to protect against damage to the area of the spinal defect when the patient has a _________.
Myelomeningocele
The nurse can ease a patient’s anxiety about hospitalization using therapeutic _____.
Play
Meningitis can lead to death in under ____ hours.
4
Appropriate teaching for a 17 year old in regards to anticipatory guidance includes teaching about ______ and ________ poisoning.
alcohol and alcohol
What is the most important assessment after a child is injured?
A series of NEURO assessments
Study Tip: This is because the RN is going to need ongoing data to compare to the baseline to assess for any personality changes or any decrease in level of consciousness.
There may be an absence of external signs of injury. This is correct with what kind of injury?
Shaken Baby Syndrome
