1. The nurse is caring for a toddler (key word) with special needs (key word) Which
developmental tasks related
to toddlerhood might be delayed in the child with special needs?
A) Developing body image
B) Developing peer relationships
C) Developing language and motor skills
D) Learning through sensorimotor exploration
Ans: C
Feedback:
In special needs children, developmental delays may occur in all stages. In particular,
motor and language skill development may be delayed if the toddler is not given
adequate opportunities to test his or her limits and abilities. This is actually Ericksons Autonomy
vs shame and doubt!!They are establishing independence which is harder to do with special
needs, therefor the delay in language and motor!
Development of body image
may be hindered in the preschooler due to painful exposures and anxiety. Development
of peer relationships may be delayed in the school-age and adolescent child. The infant's
ability to learn through sensorimotor exploration may be impaired due to lack of
appropriate stimulation, confinement to a crib, or increased contact with painful
experiences.
Here is one of those select alls…
2. The nurse is caring for infants having the condition failure to thrive (FTT). Which
infants would be at risk for this condition? Select all that apply.
A) A newborn baby with tetralogy of Fallot (cardiac)
B) An infant with a cleft palate(more difficult to eat)
C) An infant born to a diabetic mother
D) An infant born to an impoverished mother(decrease in resources)
E) An infant with bronchopulmonary dysplasia(chronic lung)
F) An infant born to a teenage mother
Ans: A, B, D, E
Feedback:
Infants and children with cardiac or metabolic disease, chronic lung disease
(bronchopulmonary dysplasia), cleft palate, or gastroesophageal reflux disease are at
particular risk for FTT. Also, poverty is the single greatest contributing risk factor
(Block et al., 2005). An infant born to a diabetic mother or an infant born to a teenage
mother does not have increased risk for FTT.
We know that disease conditions such as cardiac, cleft palate,
chronic lung make it more difficult for a child to put on weight,
absorb calories ect… I know most of you would want to pick
teenage mother because of her lack of knowledge. However, there
, is no where telling us that teenage mother = FTT infant. Some
teenage mothers are better than 30 somethings! The impoverished
mother would have fewer resources to adequately take care of her
baby!
3. The nurse is conducting a physical examination of a child with a suspected
cardiovascular disorder. Which finding would the nurse most likely expect to assess if
the child had transposition of the great vessels?
A) Significant cyanosis without presence of a murmur
B) Abrupt cessation of chest output with an increase in heart rate/filling pressure
C) Soft systolic ejection
D) Holosystolic murmur
Ans: A
Feedback:
Significant cyanosis without presence of a murmur is highly indicative of transposition.
Abrupt cessation of chest output accompanied by an increase in heart rate and filling
pressure is indicative of cardiac tamponade. A soft systolic ejection or holosystolic
murmur can be found with other disorders, such as hypoplastic left heart syndrome, but
is not highly suspicious of transposition
This is a definition question, so you have to know what you are looking for in transposition of
the great vessels! Knowledge of how an illness unfolds clinically is how you can answer these
questions!!
4. The nurse is caring for a 2-month-old infant who has been diagnosed with acute heart
failure. The nurse is providing teaching about nutrition. Which statement by the mother
indicates a need for further teaching?
A) "The baby may need as much as 150 calories/kg/day."
B) "Small, frequent feedings are best if tolerated."
C) "I need to feed him every hour to make sure he eats enough."
D) "Gavage feedings may be required for now."
Ans: C
Feedback:
Although offering small frequent feedings is appropriate if the infant tolerates them,
feeding every hour is not necessary. During the acute phase, continuous or intermittent
gavage feedings may be needed to help the infant maintain or gain weight. Due to the
increased metabolic demands, the infant may require as much as 150 calories/kg/day.
acute heart failure means the heart does not pump as much blood that is required for the
metabolism of the body. If this mom feeds this baby every hour, she would exhaust herself and
the baby!!!! So hourly is NOT necessary but more like 2, 2 ½ hrs would be more appropriate.
5. 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
developmental tasks related
to toddlerhood might be delayed in the child with special needs?
A) Developing body image
B) Developing peer relationships
C) Developing language and motor skills
D) Learning through sensorimotor exploration
Ans: C
Feedback:
In special needs children, developmental delays may occur in all stages. In particular,
motor and language skill development may be delayed if the toddler is not given
adequate opportunities to test his or her limits and abilities. This is actually Ericksons Autonomy
vs shame and doubt!!They are establishing independence which is harder to do with special
needs, therefor the delay in language and motor!
Development of body image
may be hindered in the preschooler due to painful exposures and anxiety. Development
of peer relationships may be delayed in the school-age and adolescent child. The infant's
ability to learn through sensorimotor exploration may be impaired due to lack of
appropriate stimulation, confinement to a crib, or increased contact with painful
experiences.
Here is one of those select alls…
2. The nurse is caring for infants having the condition failure to thrive (FTT). Which
infants would be at risk for this condition? Select all that apply.
A) A newborn baby with tetralogy of Fallot (cardiac)
B) An infant with a cleft palate(more difficult to eat)
C) An infant born to a diabetic mother
D) An infant born to an impoverished mother(decrease in resources)
E) An infant with bronchopulmonary dysplasia(chronic lung)
F) An infant born to a teenage mother
Ans: A, B, D, E
Feedback:
Infants and children with cardiac or metabolic disease, chronic lung disease
(bronchopulmonary dysplasia), cleft palate, or gastroesophageal reflux disease are at
particular risk for FTT. Also, poverty is the single greatest contributing risk factor
(Block et al., 2005). An infant born to a diabetic mother or an infant born to a teenage
mother does not have increased risk for FTT.
We know that disease conditions such as cardiac, cleft palate,
chronic lung make it more difficult for a child to put on weight,
absorb calories ect… I know most of you would want to pick
teenage mother because of her lack of knowledge. However, there
, is no where telling us that teenage mother = FTT infant. Some
teenage mothers are better than 30 somethings! The impoverished
mother would have fewer resources to adequately take care of her
baby!
3. The nurse is conducting a physical examination of a child with a suspected
cardiovascular disorder. Which finding would the nurse most likely expect to assess if
the child had transposition of the great vessels?
A) Significant cyanosis without presence of a murmur
B) Abrupt cessation of chest output with an increase in heart rate/filling pressure
C) Soft systolic ejection
D) Holosystolic murmur
Ans: A
Feedback:
Significant cyanosis without presence of a murmur is highly indicative of transposition.
Abrupt cessation of chest output accompanied by an increase in heart rate and filling
pressure is indicative of cardiac tamponade. A soft systolic ejection or holosystolic
murmur can be found with other disorders, such as hypoplastic left heart syndrome, but
is not highly suspicious of transposition
This is a definition question, so you have to know what you are looking for in transposition of
the great vessels! Knowledge of how an illness unfolds clinically is how you can answer these
questions!!
4. The nurse is caring for a 2-month-old infant who has been diagnosed with acute heart
failure. The nurse is providing teaching about nutrition. Which statement by the mother
indicates a need for further teaching?
A) "The baby may need as much as 150 calories/kg/day."
B) "Small, frequent feedings are best if tolerated."
C) "I need to feed him every hour to make sure he eats enough."
D) "Gavage feedings may be required for now."
Ans: C
Feedback:
Although offering small frequent feedings is appropriate if the infant tolerates them,
feeding every hour is not necessary. During the acute phase, continuous or intermittent
gavage feedings may be needed to help the infant maintain or gain weight. Due to the
increased metabolic demands, the infant may require as much as 150 calories/kg/day.
acute heart failure means the heart does not pump as much blood that is required for the
metabolism of the body. If this mom feeds this baby every hour, she would exhaust herself and
the baby!!!! So hourly is NOT necessary but more like 2, 2 ½ hrs would be more appropriate.
5. 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
