Unit 9 Flashcards
The nurse is teaching the mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex. Which response from his mother indicates a need for further
teaching? abirb.com/test A. “He needs to get a medical alert identification.”
B. “I will need to discuss this with his caregivers.”
C. “A product’s label indicates whether it is latex-free.”
D. “He must avoid all contact with latex.” abirb.com/test
c
The nurse is providing postoperative care for a 14-month-old girl who has undergone a myelomeningocele repair. The girl’s mother is extremely anxious and tells the nurse she is afraid she will never learn how to care for her daughter at home. Which response by the nurse would be most appropriate?
A. “I will help you become comfortable in caring for your daughter.” om/test B. “You must learn how to care for your daughter at home.”
C. “You will need to learn to collaborate with all the caregivers.”
D. “There is a lot to learn, and you need a positive attitude.”
A
The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention would the nurse implement to best promote maximum chest expansion?
A. Deep-breathing exercises abirb.com/test B. Upright positioning
C. Coughing
D. Chest percussion
B
. A 6-year-old child with cerebral palsy has been admitted to the hospital for some tests. The child’s condition is stable. A parent remains with the child, but the parent is obviously exhausted and stressed. Which response by the nurse would be most appropriate? /test
A. “Would you like me to bring you a blanket and pillow?” B. “You are doing such a wonderful job with your child.”
C. “Your child is in good hands; consider going home to get someisleep.”st D. “Are you planning to spend the night or to go home?”
C
A nurse is caring for a 14-year-old girl following myelography. What is the priority nursing action?
A. Monitoring for a decrease in spasticity abirb.com/test B. Observing for signs of meningeal irritation
C. Assessing motor function
D. Observing for mental confusion or hallucinations
B
The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury? abirb.com/test
A. Recommend the bed’s side rails be raised throughout the day and night. B. Suggest a caregiver be present continuously to prevent falls from bed. C. Encourage a loose restraint to be used when he is in bed. abirb.com/test D. Recommend raising the bed’s side rails when a caregiver is not present
D
The nurse is caring for a 2-month-old with cerebral palsy. The infant is limp and flaccid with uncontrolled, slow, worm-like, writhing, and twisting movements. What word would the nurse use when documenting these observations?
A. Spastic abirb.com/test B. Athetoid
C. Ataxic
D. Mixed
B
The nurse is teaching a group of students about myelinization in ra child. Which statement by the students indicates that the teaching was successful?
A. Myelinization is completed by 4 years of age.
B. The process occurs in a head-to-toe fashion. abirb.com/test C. The speed of nerve impulses slows as myelinization occurs.
D. Nerve impulses become less specific in focus with myelinization.
B
When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely?
A. Skeletal traction B. Physical therapy C. Orthotics
D. Occupational therapy
A
A nurse is preparing a program for a group of parents about injury prevention. What would the nurse include as an important contributing factor for cervical spine injury in a child?
A. Exposure to teratogens while in utero
B. Immaturity of the central nervous system abirb.com/test C. Increased mobility of the spine
D. Incomplete myelinization
C
. A child with Duchenne muscular dystrophy is to receive prednisone/ast part of his treatment plan. After teaching the child’s parents about this drug, which statement by the parents indicates the need for additional teaching?
A. “We should give this drug before he eats anything.” B. “We need to watch carefully for possible infection.”
C. “The drug should not be stopped suddenly.”
D. “He might gain some weight with this drug.”
A
What information would the nurse include in the preoperative plan of care for an infant with myelomeningocele?
A. Positioning supine with a pillow under the buttocks
B. Covering the sac with saline-soaked nonadhesive gauze
C. Wrapping the infant snugly in a blanket D. Applying a diaper to prevent fecal soiling of the sac
B
. The nurse is assessing a newborn who was delivered after a prolonged labor due to an abnormal presentation. The newborn sustained a cranial nerve injury. The nurse would most likely expect to assess deficits related to which cranial nerve?
A. Optic B. Facial
C. Acoustic
D. Trigeminal
B
A child with spastic cerebral palsy is to receive botulin toxin. The nurse prepares the child for administration of this drug by which route?
A. Oral
B. Subcutaneous injection
C. Intramuscular injection D. Intravenous infusion
C
The nurse is assessing the neuromusculoskeletal system of a newborn. What is an abnormal assessment finding?
A. Sluggish deep tendon reflexes B. Full range of motion in extremities
C. Absence of hypotonia
D. Lack of purposeful muscular control
A
A child with cerebral palsy has undergone surgery for placement of a baclofen pump. Which instruction would the nurse include when teaching the parents about caring for their child?
A. Wait 48 hours before allowing the child to take a tub bath. B. Do not allow the child to sleep on the left side for about 4 weeks.
C. Call the helath care provider if the child’s temperature is over 100.5°F (38°C). D. Discourage the child from stretching or bending forward for 4 weeks.est
D
A nursing instructor is preparing for a class discussion on spinal muscular atrophy (SMA). When describing type 2 SMA, which information would the instructor include? Select all that apply.
A. Onset before 6 months of age
B. Weakness most severe in shoulders and hips C. Difficulty with swallowing
D. Slowly progressing condition
E. Genetic disease with autosomal recessive inheritance
B D E
An 8-year-old girl was diagnosed with a closed fracture of the radius at approximately 2 p.m. The fracture was reduced in the emergency department and her arm placed in a cast. At 11 p.m. her mother brings her back to the emergency department due to unrelenting pain that has not been relieved by the prescribed narcotics. Which action would be the priority?
A. Notifying the doctor immediately B. Applying ice
C. Elevating the arm
D. Giving additional pain medication as ordered
A
The nurse is caring for an active 14-year-old boy who has recently been diagnosed with scoliosis. He is dismayed that a “jock” like himself could have this condition, and is afraid it will impact his spot on the water polo team. Which response by the nursecwould best address the boy’s concerns?
A. “If you wear your brace properly, you may not need surgery.”
B. “The good news is that you have very minimal curvature of your spine.”
C. “Let’s talk to another boy with scoliosis, who is winning trophies for his swim team.”
D. “Let’s talk to the doctor about your treatment options.”
C
The nurse is caring for a female infant with torticollis and is providing instructions to the parents about how to help their daughter. Which statement by the parents indicates a need for further teaching?
A. “We must encourage our daughter to turn her head both ways.” B. “Flatness on one side of the head is a common side effect.”
C. “We must apply firm pressure and stretching every other day.”birb.com/test D. “We will do a daily stretching regimen with multiple sessions.”
C
. The nurse is caring for a 10-year-old in traction. While performing at skin assessment, the nurse notices that the skin over the calcaneus appears slightly red and irritated. Which action would the nurse take first?
A. Reposition the child’s foot on a pressure-reducing device.
B. Apply lotion to his foot to maintain skin integrity.
C. Make sure the skin is clean and dry.
D. Gently massage his foot to promote circulation.
A
The nurse is caring for a 14-month-old boy with rickets who was recently adopted from overseas. His condition was likely a result of a diet very low in milk . products. The nurse is providing teaching regarding treatment. Which response by the parents indicates a need for further teaching?
A. “We must give him calcium and phosphorus with food every morning.”t
B. “He must take vitamin D as prescribed and spend some time in the sunlight.”
C. “He must take calcium at breakfast and phosphorus at bedtime.”
D. “We should encourage him to have fish, dairy, and liver if he will eat it.”
A
. The nurse is caring for a 14-year-old client in traction prior to surgery. The client has been in the hospital for 2 weeks and will require an additional 10 days in the hospital following surgery. The client states, “I feel isolated and I am refusing any more treatment.” Which response by the nurse is most appropriate?
A. “I know it is boring here, but the best place for you to remain immobile is the hospital.” B. “I will see if you can have friends come spend a few nights with you.”
C. “Let’s come up with things for you to do and see if your friendsi can come visit.”
D. “If you refuse further treatment, your condition will only get worse.”/test
C
. The nurse is caring for a 2-year-old girl in a bilateral brace with tibia vara. Her parents are
upset by their toddler’s limited mobility. Which response by the nurseowould be most appropriate?
A. “If you don’t follow the therapy, your daughter could develop severe bowing of her legs.” B. “It’s important to use the brace or your daughter may need surgery.”
C. “You are doing a great job. Let’s put our heads together on howi to keep ther busy.” D. “You’ll need to accept this since treatment may be required for several years.”
C
The nurse is conducting a physical examination of a child with suspected developmental dysplasia of the hip. Which finding would help confirm this diagnosis? /test
A. Abduction occurs to 75 degrees and adduction to within 30 degrees (with stable pelvis). B. A distinct “clunk” is heard with Barlow and Ortolani maneuvers.
C. A high-pitched “click” is heard with hip flexion or extension.
D. The thigh and gluteal folds are symmetric.
B
The nurse is caring for an infant with osteogenesis imperfecta and is providing instruction on how to reduce the risk of injury. Which response from the mother indicates a need for further teaching?
A. “I need to avoid pushing or pulling on an arm or leg.” B. “I must carefully lift the baby from under the armpits.”
C. “I should not bend an arm or leg into an awkward position.”
D. “We must avoid lifting the legs by the ankles to change diapers.”.
B
The nurse is developing a teaching plan for a child who is to have his cast removed. What instruction would the nurse most likely include?
A. Applying petroleum jelly to the dry skin
B. Rubbing the skin vigorously to remove the dead skin C. Soaking the area in warm water every day
D. Washing the skin with dilute peroxide and water
C
. When teaching a group of parents about the skeletal development in children, what
information is most helpful? A. The growth plate is made up of the epiphysis.
B. A young child’s bones commonly bend instead of break with an injury. C. The infant’s skeleton has undergone complete ossification by birth.
D. Children’s bones have a thin periosteum and limited blood supply.om/test
B
The school nurse is presenting a class to a group of students about common overuse disorders. Which disorder would the school nurse include?
A. Dislocated radial head
B. Transient synovitis of the hip C. Osgood-Schlatter disease
D. Scoliosis
C
