T3P Chapter. 46 2024 Edition. Real Test Questions & Verified Correct Answers. Graded A+, Exams of Nursing

Download T3P Chapter. 46 2024 Edition. Real Test Questions & Verified Correct Answers. Graded A+ and more Exams Nursing in PDF only on Docsity! T3P Chapter: 46. 2024 Edition. Real Test Questions & Verified Correct Answers. Already Graded A+ . A 3-year-old child is hospitalized after a near-drowning accident. The childs mother complains to the nurse, This seems unnecessary when he is perfectly fine. The nurses best reply is: a. He still needs a little extra oxygen. b. Im sure he is fine, but the doctor wants to make sure. Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 780 c. The reason for this is that complications could still occur. d. It is important to observe for possible central nervous system problems - ANSANS: C All children who have a near-drowning experience should be admitted to the hospital for observation. Although many children do not appear to have suffered adverse effects from the event, complications such as respiratory compromise and cerebral edema may occur up to 24 hours after the incident. Stating that, He still needs a little extra oxygen does not respond directly to the mothers concern. Why is her child still receiving oxygen? The nurse should clarify that different complications can occur up to 24 hours later and that observations are necessary. . Which clinical manifestations would suggest hydrocephalus in a neonate? a. Bulging fontanel and dilated scalp veins b. Closed fontanel and high-pitched cry c. Constant low-pitched cry and restlessness d. Depressed fontanel and decreased blood pressure - ANSANS: A Bulging fontanel, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. Closed fontanel and high-pitched cry, constant low-pitched cry and restlessness, and depressed fontanel and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation. . Which statement best describes a neuroblastoma? a. Diagnosis is usually made after metastasis occurs. b. Early diagnosis is usually possible because of the obvious clinical manifestations. c. It is the most common brain tumor in young children. d. It is the most common benign tumor in young children. - ANSANS: A Neuroblastoma is a silent tumor with few symptoms. In more than 70% of cases, diagnosis is made after metastasis occurs, with the first signs caused by involvement in the nonprimary site. In only 30% of cases is diagnosis made before metastasis. Neuroblastomas are the most common malignant extracranial solid tumors in children. The majority of tumors develop in the adrenal glands or the retroperitoneal sympathetic chain. They are not benign; they metastasize. . Which type of seizure may be difficult to detect? a. Absence c. Simple partial b. Generalized d. Complex partial - ANSANS: A Absence seizures may go unrecognized because little change occurs in the childs behavior during the seizure. Generalized, simple partial, and complex partial seizures all have clinical manifestations that are observable. A 10-year-old boy has been hit by a car while riding his bicycle in front of the school. The school nurse immediately assesses airway, breathing, and circulation. The next nursing action should be to: a. Place on side. c. Stabilize neck and spine. b. Take blood pressure. d. Check scalp and back for bleeding. - ANSANS: C After determining that the child is breathing and has adequate circulation, the next action is to stabilize the neck and spine to prevent any additional trauma. The childs position should not be changed until the neck and spine are stabilized. Blood pressure is a later assessment. Less urgent, but an important assessment, is inspection of the scalp for bleeding. A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. Which statement made by the mother indicates a correct understanding of the teaching? a. I should expect my child to have a few episodes of vomiting. b. If I notice sleep disturbances, I should contact the physician immediately. c. I should expect my child to have some behavioral changes after the accident. d. If I notice diplopia, I will have my child rest for 1 hour - ANSANS: C The parents are advised of probably post-traumatic symptoms that may be expected, including behavioral changes. If the child has episodes of vomiting, sleep disturbances, or diplopia, they should be immediately reported for evaluation should be obtained as part of the assessment, but because of the severity of injury, analgesia should be provided as soon as possible. Analgesia can be used safely in individuals who have sustained head injuries and can decrease anxiety and resultant increased intracranial pressure. A toddler fell out of a second-story window. She had brief loss of consciousness and vomited four times. Since admission, she has been alert and oriented. Her mother asks why a computed tomography (CT) scan is required when she seems fine. The nurse should explain that the toddler: a. May have a brain injury. c. May start having seizures. b. Needs this because of her age. d. Probably has a skull fracture - ANSANS: A The childs history of the fall, brief loss of consciousness, and vomiting four times necessitate evaluation of a potential brain injury. The severity of a head injury may not be apparent on clinical examination but will be detectable on a CT scan. The need for the CT scan is related to the injury and symptoms, not the childs age, and is necessary to determine whether a brain injury has occurred A young childs parents call the nurse after their child was bitten by a raccoon in the woods. The nurses recommendation should be based on knowing that: a. The child should be hospitalized for close observation. Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 783 b. No treatment is necessary if thorough wound cleaning is done. c. Antirabies prophylaxis must be initiated. d. Antirabies prophylaxis must be initiated if clinical manifestations appear. - ANSANS: C Current therapy for a rabid animal bite consists of a thorough cleansing of the wound and passive immunization with human rabies immune globulin (HRIG) as soon as possible. Hospitalization is not necessary. The wound cleansing, passive immunization, and immune globulin administration can be done as an outpatient. The child needs to receive both HRIG and rabies vaccine. An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed. What type of head injury should the nurse suspect? a. Brainstem c. Subdural hemorrhage Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 778 b. Skull fracture d. Epidural hemorrhage - ANSANS: A Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are consistent with a brainstem injury. Skull fracture and subdural and epidural hemorrhages are not consistent with these signs. An appropriate nursing intervention when caring for an unconscious child should be to: a. Change the childs position infrequently to minimize the chance of increased intracranial pressure (ICP). b. Avoid using narcotics or sedatives to provide comfort and pain relief. c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema. d. Give tepid sponge baths to reduce fever because antipyretics are contraindicated - ANSANS: C Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema. The childs position should be changed frequently to avoid complications such as pneumonia and skin breakdown. Narcotics and sedatives should be used as necessary to reduce pain and discomfort, which can increase ICP. Antipyretics are the method of choice for fever reduction An important nursing intervention when caring for a child who is experiencing a seizure is to: a. Describe and record the seizure activity observed. b. Restrain the child when seizure occurs to prevent bodily harm. c. Place a tongue blade between the teeth if they become clenched. d. Suction the child during a seizure to prevent aspiration. - ANSANS: A Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 785 When a child is having a seizure, the priority nursing care is observation of the child and seizure. The nurse then describes and records the seizure activity. The child should not be restrained, and nothing should be placed in his or her mouth. This may cause injury. To prevent aspiration, if possible, the child should be placed on his or her side, facilitating drainage An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should be included in the childs postoperative care (Select all that apply)? a. Observe closely for signs of infection. b. Pump the shunt reservoir to maintain patency. c. Administer sedation to decrease irritability. d. Maintain Trendelenburg position to decrease pressure on the shunt. e. Maintain an accurate record of intake and output. f. Monitor for abdominal distention. - ANSANS: A, E, F Infection is a major complication of ventriculoperitoneal shunts. Observation for signs of infection is a priority nursing intervention. Intake and output should be measured carefully. Abdominal distention could be a sign of peritonitis or a postoperative ileus. Pumping the shunt reservoir, administering sedation, and maintaining Trendelenburg position are not interventions associated with this condition Clinical manifestations of increased intracranial pressure (ICP) in infants are (Select all that apply): a. Low-pitched cry. b. Sunken fontanel. c. Diplopia and blurred vision. d. Irritability. e. Distended scalp veins. f. Increased blood pressure - ANSANS: C, D, E Diplopia and blurred vision, irritability, and distended scalp veins are signs of increased ICP in infants. Low- pitched cry, sunken fontanel, and increased blood pressure are not clinical manifestations associated with ICP in infants. How should the nurse explain positioning for a lumbar puncture to a 5-year-old child? a. You will be on your knees with your head down on the table. b. You will be able to sit up with your chin against your chest. c. You will be on your side with the head of your bed slightly raised. d. You will lie on your side and bend your knees so that they touch your chin. - ANSANS: D The child should lie on his or her side with knees bent and chin tucked in to the knees. This position exposes the area of the back for the lumbar puncture. The knee-chest position is not appropriate for a lumbar puncture. An infant can be placed in a sitting position with the infant facing the nurse and the head steadied against the nurses body. A side-lying position with the head of the bed elevated is not appropriate for a lumbar puncture The Glasgow Coma Scale consists of an assessment of: a. Pupil reactivity and motor response. b. Eye opening and verbal and motor responses. c. Level of consciousness and verbal response. d. Intracranial pressure (ICP) and level of consciousness. - ANSANS: B Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 774 The Glasgow Coma Scale assesses eye opening and verbal and motor responses. Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. Level of consciousness and ICP are not c. Bulging anterior fontanel d. Weak cry e. Poor muscle tone - ANSANS: C, D, E Assessment findings in a neonate with meningitis include bulging anterior fontanel, weak cry, and poor muscle tone. Headache and photophobia are signs seen in an older child. The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as: a. Eye trauma. c. Severe brainstem damage. b. Neurosurgical emergency. d. Indication of brain death. - ANSANS: B The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain. One fixed and dilated pupil is not suggestive of brain death. The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased ICP in an infant (Select all that apply)? a. Tachycardia b. Alteration in pupil size and reactivity c. Increased motor response d. Extension or flexion posturing e. Cheyne-Stokes respirations - ANSANS: B, D, E Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes respirations. The nurse is performing a Glasgow Coma Scale (GCS) on a school-age child with a head injury. The child opens eyes spontaneously, obeys commands, and is oriented to person, time, and place. Which is the score the nurse should record? a. 8 c. 13 Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 787 b. 11 d. 15 - ANSANS: D The GCS consists of a three-part assessment: eye opening, verbal response, and motor response. Numeric values of 1 through 5 are assigned to the levels of response in each category. The sum of these numeric values provides an objective measure of the patients level of consciousness (LOC). A person with an unaltered LOC would score the highest, 15. The child who opens eyes spontaneously, obeys commands, and is oriented is scored at a 15. The nurse is preparing a school-age child for a computed tomography (CT) scan to assess cerebral function. When preparing the child for the scan, which statement should the nurse include? a. Pain medication will be given. Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 775 b. The scan will not hurt. c. You will be able to move once the equipment is in place. d. Unfortunately no one can remain in the room with you during the test - ANSANS: B For CT scans, the child will not be allowed to move and must be immobilized. It is important to emphasize to the child that at no time is the procedure painful. Pain medication is not required; however, sedation is sometimes necessary. Someone is able to remain with the child during the procedure. The nurse should recommend medical attention if a child with a slight head injury experiences: a. Sleepiness. c. Headache, even if slight. b. Vomiting, even once. d. Confusion or abnormal behavior. - ANSANS: D Medical attention should be sought if the child exhibits confusion or abnormal behavior; loses consciousness; or has amnesia, fluid leaking from the nose or ears, blurred vision, or unsteady gait. Sleepiness alone does not require evaluation. If the child is difficult to arouse from sleep, medical attention should be obtained. Vomiting more than three times requires medical attention. Severe or worsening headache or one that interferes with sleep should be evaluated. The priority nursing intervention when a child is unconscious after a fall is to: a. Establish an adequate airway. b. Perform neurologic assessment. c. Monitor intercranial pressure. d. Determine whether a neck injury is present - ANSANS: A Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishing an adequate airway is always the first priority. A neurologic assessment and determination of neck injury are performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 776 after airway, breathing, and circulation are maintained. The treatment of brain tumors in children consists of which therapies(Select all that apply)? a. Surgery b. Bone marrow transplantation c. Chemotherapy d. Stem cell transplantation e. Radiation f. Myelography - ANSANS: A, C, E Treatment for brain tumors in children may consist of surgery, chemotherapy, and radiotherapy alone or in combination. Bone marrow, stem cell, and myelographuy are transplantation therapies are not used to treat brain tumors in children The vector reservoir for agents causing viral encephalitis in the United States is: a. Tarantula spiders. c. Carnivorous wild animals. b. Mosquitoes and ticks. d. Domestic and wild animals. - ANSANS: B Viral encephalitis, not attributable to a childhood viral disease, is usually transmitted by mosquitoes and ticks. The vector reservoir for most agents pathogenic for humans and detected in the United States are mosquitoes and ticks; therefore, most cases of encephalitis appear during the hot summer months. Tarantulas, carnivorous wild animals, and domestic animals are not reservoirs for the agents that cause viral encephalitis. What action may be beneficial in reducing the risk of Reyes syndrome? a. Immunization against the disease b. Medical attention for all head injuries c. Prompt treatment of bacterial meningitis Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 782 d. Avoidance of aspirin and ibuprofen for children with varicella or those suspected of having influenza - ANSANS: D Although the etiology of Reyes syndrome is obscure, most cases follow a common viral illness, either varicella or influenza. A potential association exists between aspirin therapy and the development of Reyes syndrome; thus use of aspirin is avoided. No immunization currently exists for Reyes syndrome. Reyes syndrome is not correlated with head injuries or bacterial meningitis. When caring for the child with Reyes syndrome, the priority nursing intervention is to: a. Monitor intake and output. c. Observe for petechiae. b. Prevent skin breakdown. d. Do range-of-motion (ROM) exercises. - ANSANS: A state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion regarding time and plac Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? a. Coma c. Obtundation b. Stupor d. Persistent vegetative state - ANSANS: B Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex. Which test is never performed on a child who is awake? a. Oculovestibular response b. Dolls head maneuver c. Funduscopic examination for papilledema d. Assessment of pyramidal tract lesions - ANSANS: A The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a comatose child. The caloric test is painful and is never performed on a child who is awake or one who has a ruptured tympanic membrane. Dolls head maneuver, funduscopic examination, and assessment of pyramidal tract lesions can be performed on children who are awake Which type of fracture describes traumatic separation of cranial sutures? a. Basilar c. Diastatic b. Compound d. Depressed - ANSANS: C Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 777 Diastatic skull fractures are traumatic separations of the cranial sutures. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. A compound fracture has the bone exposed through the skin. A depressed fracture has the bone pushed inward, causing pressure on the brain Which type of seizure involves both hemispheres of the brain? a. Focal c. Generalized b. Partial d. Acquired - ANSANS: C Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 784 Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. Partial seizures are caused by abnormal electrical discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure