Check My Twitter Account @nursetopia or IG @nursetopia1 For More Nursing Test Banks, Sample Exam, Reviewers, and Notes

Check my twitter account @nursetopia or IG @nursetopia1
for more nursing test banks, sample exam, reviewers, and notes.
Chapter 27
Question 1
Type: MCSA
A child has been diagnosed with epilepsy and is on daily phenytoin (Dilantin). Client
education should include
1. Fluid intake.
2. Good dental hygiene.
3. A decrease in vitamin D intake.
4. Taking the medication with milk.
Correct Answer: 2
Rationale 1: Because phenytoin (Dilantin) can cause gingival hyperplasia, good dental
hygiene should be encouraged. Fluid intake does not affect the drugs effectiveness, an
adequate intake of vitamin D should be encouraged, and phenytoin (Dilantin) should not be
taken with dairy products.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: LO 03. Differentiate between the signs of a seizure and status
epilepticus in infants and children, and plan appropriate nursing care for each condition.
Question 2
Type: MCSA
A 2-year-old starts to have a tonic-clonic seizure while in a crib in the hospital. The childs
jaws are clamped. The most important nursing action at this time is to
1. Place a padded tongue blade between the childs jaws.
2. Stay with the child and observe the respiratory status.
3. Prepare the suction equipment.
4. Restrain the child to prevent injury.
Correct Answer: 2
Rationale 1: During a seizure the nurse remains with the child, watching for
complications. The childs respiratory rate should be monitored. Be sure nothing is placed in
the childs 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.
Global Rationale:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: LO 03. Differentiate between the signs of a seizure and status
epilepticus in infants and children, and plan appropriate nursing care for each condition.
Question 3
Type: MCSA
A lumbar puncture is being done on an infant suspected of having meningitis. If the infant
has bacterial meningitis, the nurse would expect the cerebral spinal fluid to show
1. Elevated white blood cell count.
2. Elevated red blood cell count.
3. Normal glucose.
4. Decreased white blood cell count.
Correct Answer: 1
Rationale 1: The lumbar puncture is done to obtain cerebral spinal fluid (CSF). Elevated
white blood cell count is seen with bacterial meningitis. The red blood cell count is not
elevated, and the glucose is decreased in meningitis.
Global Rationale:
Cognitive Level: Analyzing
Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: LO 04. Differentiate between signs of bacterial meningitis, viral
meningitis, encephalitis, Reye syndrome, and Guillain-Barr syndrome in infants and
children.
Question 4
Type: MCSA
The nurse is planning care for a school-age child with bacterial meningitis. Which of the
following should be included?
1. Keep environmental stimuli at a minimum.
2. Avoid giving pain medications that could dull sensorium.
3. Measure head circumference to assess developing complications.
4. Have child move head side to side at least every two hours.
Correct Answer: 1
Rationale 1: A quiet environment should be maintained because noise can disturb a child
with meningitis. Pain medications are appropriate to give and should be used when needed.
Measuring head circumference would only be appropriate for a child less than 2 years.
Excessive head movement should be avoided because it can increase irritation of the
meninges.
meninges.
meninges.
meninges.
Global Rationale:
Client Need Sub:
children.
Question 5
Type: MCSA
A nurse is doing a postoperative assessment on an infant who has just had a

ventriculoperitoneal shunt placed for hydrocephalus. Which assessment would indicate a
malfunction in the shunt?
1. Incisional pain.
2. Movement of all extremities.
3. Negative Brudzinskis sign.
4. Bulging fontanel.
Correct Answer: 4
Rationale 1: A bulging fontanel would be an abnormal finding and could indicate that the
shunt is malfunctioning. Incisional pain, movement of all extremities, and negative
Brudzinskis sign are all normal findings after a ventriculoperitoneal shunt has been placed.
Global Rationale:
Client Need Sub:
Learning Outcome: LO 05. Plan the nursing care for the child with myelodysplasia and
hydrocephalus and family.
Question 6
Type: MCSA
An important nursing intervention when caring for an infant with a myelomeningocele in the
preoperative stage would be to
1. Place infant supine to decrease pressure on the sac.
2. Apply a heat lamp to facilitate drying and toughening of the sac.
3. Measure head circumference every shift to identify developing hydrocephalus.
4. Apply a diaper to prevent contamination of the sac.
Correct Answer: 3
Rationale 1: 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.
Global Rationale:
Client Need Sub:
Question 7
Type: MCSA
A child with myelomeningocele, corrected at birth, is now 5 years old. What is a priority
nursing diagnosis for a child with corrected spina bifida at this age?
1. Risk for Altered Nutrition.
2. Risk for Impaired Tissue PerfusionCranial.
3. Risk for Altered Urinary Elimination.
4. Risk for Altered Comfort.
Correct Answer: 3
Rationale 1: 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.

Global Rationale:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Question 8
Type: MCSA
The nurse should suspect a child has cerebral palsy if the parent says,
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.
Correct Answer: 2
Rationale 1: 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.
walks at 12 months.
walks at 12 months.
walks at 12 months.
Global Rationale:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: LO 06. Plan the nursing care for the child with cerebral palsy and
family in a community setting.
Question 9
Type: MCSA
A nurse is caring for a child who has recently been diagnosed with cerebral palsy. The
major goals of therapy for this child will include
1. Reversal of 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.
Correct Answer: 4
Rationale 1: 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.
Global Rationale:
Client Need: Safe Effective Care Environment
Client Need Sub:
Learning Outcome: LO 06. Plan the nursing care for the child with cerebral palsy and
family in a community setting.
Question 10
Type: MCMA
A child has sustained a traumatic brain injury and is being monitored in the pediatric
intensive-care unit. The nurse is using the Glasgow Coma Scale to assess the child. What
will the nurse be assessing for this scale?
Standard Text: Select all that apply.
1. Eye opening.
2. Verbal response.
3. Motor response.
4. Head circumference.
5. Pulse oximetry.
Correct Answer: 1,2,3
Rationale 1: 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.
Global Rationale:
Client Need Sub:
Learning Outcome: LO 07. Contrast the initial nursing management for mild and severe
traumatic brain injury.
Question 11
Type: MCMA
A child with a mild traumatic brain injury is being sedated with a mild sedative so that pain
and anxiety are minimized. The nurse should
Standard Text: Select all that apply.
1. Place a continuous-pulse oximetry monitor on the child.
2. Place the child in a room near the nurses station.
3. Allow for several visitors to remain at the childs bedside.
4. Use soft restraints if the child becomes confused.
5. Use sedation around the clock to decrease agitation.
Correct Answer: 1,2
Rationale 1: When a child is sedated, respiratory status should be monitored with a pulse-
oximetry machine. The child should be close to the nurses station so that frequent
monitoring can be done. Several visitors at the bedside would increase the childs anxiety.
Soft restraints may increase agitation. Sedation around the clock is not recommended due
to the need to evaluate the neurologic system.
Global Rationale:
Client Need Sub:
Question 12
Type: MCSA
A child has sustained a basilar skull fracture. The priority symptom the nurse should watch
for is
1. Cerebral-spinal-fluid leakage from the nose or ears.
2. Headache.
3. Transient confusion.
4. Periorbital ecchymosis.
Correct Answer: 1
Rationale 1: Cerebral-spinal-fluid leakage could be present from the nose or ears and if it
persists may indicate that surgical repair will be needed. Headache, transient confusion,
and periorbital ecchymosis are findings that commonly present with a basilar skull fracture
but do not indicate that surgical repair will be needed.
Global Rationale:
Client Need Sub:
Question 13
Type: MCSA
A child has experienced a near-drowning episode and is admitted to the pediatric intensive-
care unit. The parents express guilt over the near drowning of their child. The nurses best
response is
1. You will need to watch the child more closely.
2. Tell me more about your feelings related to the accident.
3. The child will be fine, so dont worry.
4. Why did you let the child almost drown?
Correct Answer: 2
Rationale 1: In near-drowning cases the nurse should be nonjudgmental and provide a
forum for parents to express guilt. Telling the parents to watch the child more closely or
asking them why they let the child almost drown is judgmental. Saying the child will be fine
may not be true. The nurse should reassure the parents that the child is receiving all
possible medical treatment.
Global Rationale:
Client Need: Psychosocial Integrity
Client Need Sub:
Learning Outcome: LO 08. Discuss initiatives to prevent drowning in children.
Question 14
Type: MCSA
With a group of new parents, the nurse is reviewing treatment for viral illness such as
influenza. The nurse knows teaching was understood when a parent states:
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.
Correct Answer: 1
Rationale 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.
Global Rationale:
Client Need Sub:
children.
Question 15
Type: MCSA
A 10-year-old child is transported to the emergency room by ambulance from the scene of
a car accident. He is alert and oriented 3; his pulse, respirations, and blood pressure are
stable; and his neck and back are immobilized on a backboard. The nurse sees no obvious
bleeding. The child states, I cant feel or move my legs. What injury is most likely?
1. Traumatic brain injury.
2. Ruptured spleen.
3. Traumatic shock.
4. Spinal-cord injury.
Correct Answer: 4
Rationale 1: Spinal-cord injury results in paralysis and anesthesia of the affected body
parts below the level of the lesion. Altered levels of consciousness may indicate traumatic
brain injury. The child may have a ruptured spleen, but it is not evident from the data
given. Traumatic shock results in initially increasing then decreasing pulse and respirations
and falling blood pressure.
Global Rationale:
Client Need Sub:
Question 16
Type: MCSA
A child is being discharged 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 12 hours.
2. Every 34 hours.
3. Every 68 hours.
4. Every 1012 hours.
Correct Answer: 2
Rationale 1: To decrease the incidence of bladder or urinary tract infections,
catheterization should occur every 34 hours.
Global Rationale:
Client Need Sub:
Ball/Bindler/Cowen, Principles of Pediatric Nursing 5th Ed. Test Bank
Copyright 2012 by Pearson Education, Inc.

Check My Twitter Account @nursetopia or IG @nursetopia1 For More Nursing Test Banks, Sample Exam, Reviewers, and Notes

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Copyright 2012 by Pearson Education, Inc.

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