Question 1

The nurse is caring for an infant with a diagnosis of hydrocephalus and is monitoring the infant for signs of increased intracranial pressure (ICP). The nurse suspects increased ICP if which of the following is noted?

Accepted Answer

A bulging anterior fontanel is a sign of increased intracranial pressure in infants, as the fontanel can bulge due to the pressure inside the skull.

Question 2

The nurse is caring for a child who has sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse monitors for the earliest sign of increased ICP by assessing for:

Accepted Answer

Changes in level of consciousness (LOC) are often the earliest sign of increased intracranial pressure (ICP) in a patient. This can manifest as confusion, drowsiness, or alertness changes, making it a critical early indicator for healthcare professionals to monitor in patients at risk of or suspected to have increased ICP.

Question 3

The nurse is providing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse includes which of the following instructions?

Accepted Answer

A high-pitched cry in an infant with a ventriculoperitoneal shunt can indicate increased intracranial pressure, which is a serious concern and requires immediate medical attention.

Question 4

The nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for:

Accepted Answer

Reye's syndrome can lead to serious complications, including increased intracranial pressure due to swelling of the brain. Monitoring for signs of increased intracranial pressure is crucial in managing and treating children with Reye's syndrome.

Question 5

The nurse is providing home care instructions to the mother of a child who is recovering from Reye's syndrome. Which of the following home instructions should the nurse provide to the mother?

Accepted Answer

Reye's syndrome can affect the liver, leading to jaundice. Monitoring for yellow discoloration of the skin and eyes is important to detect any liver issues.

Question 6

The nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure:

Accepted Answer

Safety is the primary concern when planning activities for any child, especially those with autism, who may have unique sensitivities or challenges that could affect their safety in various environments or activities.

Question 7

The nurse is providing instructions to an adolescent who is taking phenytoin (Dilantin) for the control of seizures. Which of the following statements, if made by the adolescent, indicates a need for further teaching regarding the medication?

Accepted Answer

Phenytoin (Dilantin) can cause gum hyperplasia, which is an overgrowth of the gums. Patients are advised to maintain good oral hygiene and see a dentist regularly, not to stop the medication. Stopping antiepileptic medication without medical advice can lead to uncontrolled seizures.

Question 8

The nurse is collecting data on a 7-year-old child who is suspected of having episodes of absence seizures. Which of the following questions to the mother will assist in providing information that will identify the symptoms associated with these types of seizures?

Accepted Answer

Absence seizures are characterized by brief, sudden lapses in attention and activity, often with a blank stare, rather than by muscle twitching. This makes option D the correct choice, as it directly inquires about a hallmark symptom of absence seizures.

Question 9

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing were present?

Accepted Answer

Decerebrate posturing is characterized by abnormal extension of the upper and lower extremities with some internal rotation, indicating severe brain injury.

Question 10

The nurse is assisting in developing a plan of care for a child who will be returning from the operating room following a tonsillectomy. The nurse plans to place the child in which of the following positions on return from the operating room?

Accepted Answer

The side-lying position is recommended for a child returning from a tonsillectomy to facilitate drainage and prevent aspiration of blood or secretions, enhancing airway clearance and safety.

Question 11

The nurse provides discharge instructions to the mother of a child following a myringotomy with insertion of tympanostomy tubes. Which of the following statements, if made by the mother, indicates a need for further education?

Accepted Answer

The statement "My child can swim in the lake as long as the water is not deep" indicates a need for further education because swimming in lakes or other bodies of untreated water can introduce bacteria into the ear canal, potentially causing infection. Depth of water does not mitigate this risk.

Question 12

The pediatric nurse in the ambulatory surgery unit is caring for a child following a tonsillectomy. The child is complaining of a dry throat. Which of the following items would the nurse offer to the child?

Accepted Answer

The answer of The pediatric nurse in the ambulatory surgery...

Question 13

The nurse is providing home care instructions to a mother of a 9-year-old child diagnosed with viral conjunctivitis. Antibiotic eye drops are prescribed for the child. The nurse would instruct the mother that the child:

Accepted Answer

Viral conjunctivitis is contagious, and while antibiotics are not effective against viruses, they may be prescribed to prevent bacterial superinfection. The child should be kept at home until the antibiotic eye drops have been administered for at least 24 hours to reduce the risk of spreading the infection.

Question 14

The nurse is providing instructions to a mother of a child with strabismus of the right eye. The physician has prescribed "patching" for the child, and the parent is instructed in the procedure. Which of the following, if stated by the parent, indicates an understanding of the procedure?

Accepted Answer

Patching is used to treat strabismus by covering the unaffected eye (in this case, the left eye) to encourage the affected eye (the right eye) to work harder and improve its function.

Question 15

The nurse is reviewing the physician's prescriptions on a child following a tonsillectomy. Which of the following physician prescriptions would the nurse question?

Accepted Answer

Suctioning in a child post-tonsillectomy should be avoided unless absolutely necessary because it can cause trauma to the surgical site and provoke bleeding. The other options are appropriate post-operative care measures.

Question 16

The nurse is caring for a 2-year-old child with an ear infection who requires the administration of antibiotic ear drops. The nurse observes the mother administering the ear drops to the child. Which of the following observations, if made by the nurse, indicates that the mother is performing the procedure correctly?

Accepted Answer

CFor a child under 3 years old, the correct technique for administering ear drops involves pulling the earlobe down and back to straighten the ear canal, which is indicated in choice A. Choice C is incorrect for a 2-year-old, as pulling the earlobe up and back is the technique used for children over 3 years and adults to straighten the ear canal. Gloves are not necessary for a parent to wear when administering ear drops to their own child, and while the child's position can help with administration, the specific technique of pulling the earlobe down and back is key for effectiveness in a 2-year-old.

Question 17

The ambulatory care nurse makes a follow-up telephone call to the mother of a child who underwent a myringotomy with insertion of tympanostomy tubes on the previous day. The mother of the child tells the nurse that the child is complaining of discomfort. The nurse would instruct the mother to:

Accepted Answer

After a myringotomy with insertion of tympanostomy tubes, it is common for children to experience some discomfort. Acetaminophen (Tylenol) is a safe and effective way to manage this pain. Aspirin is generally avoided in children due to the risk of Reye's syndrome, and there is usually no need to immediately contact a physician for expected post-operative discomfort or to seek stronger analgesics without physician guidance.

Question 18

The nurse is assisting in providing an educational session to new mothers regarding the methods that will decrease the risk of recurrent otitis media in infants. Which of the following statements, if made by a mother in the group, indicates a need for further instruction?

Accepted Answer

Breastfeeding is actually recommended to decrease the risk of otitis media in infants. Discontinuing breastfeeding does not decrease the risk; rather, it can increase it due to the protective antibodies found in breast milk.

Question 19

A nursing student is preparing a clinical conference. The topic of the discussion is caring for the child with cystic fibrosis (CF). Which of the following comments by the student would indicate that the student needs further review of information about cystic fibrosis?

Accepted Answer

Cystic fibrosis primarily causes the production of abnormally thick and sticky mucus, leading to blockages in the ducts, tubes, and passageways, especially in the lungs and pancreas. It does not cause dilation of the passageways of many organs; instead, it can lead to blockages.

Question 20

The nurse reviews the health record of a 2-year-old child and notes that the physician has documented that the results of a Mantoux test have indicated an area of induration measuring 5 mm. The nurse would interpret these results as:

Accepted Answer

A Mantoux test (tuberculin skin test) result of 5 mm of induration is considered negative in most populations, including healthy children without any risk factors for tuberculosis. Positive results typically require a larger area of induration, the size of which can depend on the individual's risk factors and health status.

Quiz 2: Child Health

The nurse is caring for an infant with a diagnosis of hydrocephalus and is monitoring the infant for signs of increased intracranial pressure (ICP) . The nurse suspects increased ICP if which of the following is noted?

The nurse is caring for a child who has sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP) . The nurse monitors for the earliest sign of increased ICP by assessing for: