Test BANK ALL (55 Q& A) COMPLTE
SOLUTIONS
1) Which assessment finding for a 4-month-old infant would require further
action by the nurse?
1. The posterior fontanel is open.
2. The infant has good head control when held upright.
3. The infant is able to roll only from abdomen to back.
4. The anterior fontanel is open and soft. - ANSWER>>1. The posterior
fontanel is open.
2) The nurse is providing care for a pediatric client in the emergency
department (ED) with a diagnosis of decreased level of consciousness
(LOC) secondary to increased intracranial pressure (ICP). Which
healthcare provider order should the nurse question?
1. Passive range-of-motion exercises to promote hip flexion
2. Oxygen at 2 L nasal cannula to keep saturation above 95%
3. Hourly vital signs and neurologic checks
4. Elevate head of bed 30 degrees - ANSWER>>1. Passive range-of-
motion exercises to promote hip flexion
3) A 4-year-old client with intractable seizures has been on a ketogenic diet
for the last 6 months, with a decrease in seizure activity. This child is now
admitted to the pediatric unit with left-sided pain. Which possible
complication to this diet does the nurse suspect?
1. Appendicitis
2. Bowel obstruction
3. Urinary tract infection
4. Kidney stones - ANSWER>>4. Kidney stones
4) A child with a history of seizures arrives in the emergency department
(ED) in status epilepticus. Which is the priority nursing action?
,1. Take vital signs.
2. Establish an intravenous line.
3. Perform rapid neurologic assessment.
4. Maintain patent airway. - ANSWER>>4. Maintain patent airway.
5) The nurse is teaching a mother of a young child with a newly diagnosed
seizure disorder. The child is prescribed valproic acid (Depakote) for
control of seizures. Which parental statement indicates the need for further
education?
1. "I will not use carbonated beverages to dilute his medication."
2. "I will give his medicine on an empty stomach so he will absorb it better."
3. "I will not let him chew his tablet."
4. "I will bring him to the physician's office for regular blood work to check
bleeding times." - ANSWER>>2. "I will give his medicine on an empty
stomach so he will absorb it better."
6) A young child admitted to the pediatric unit has fever, irritability, and
vomiting with suspected bacterial meningitis. Which cerebrospinal fluid
(CSF) result should the nurse anticipate based on these data?
1. Decreased protein count
2. Clear, straw-colored fluid
3. Positive for red blood cells (RBCs)
4. Decreased glucose level - ANSWER>>4. Decreased glucose level
7) Which is the priority nursing diagnosis when planning care for a pediatric
client who is diagnosed with bacterial meningitis?
1. Impaired Gas Exchange
2. Risk for Infection
3. Anxiety (parental)
4. Acute Pain - ANSWER>>1. Impaired Gas Exchange
8) The nurse is caring for a 9-month-old infant who just returned from the
postanesthesia care unit (PACU) after a shunt placement for
hydrocephalus. Which healthcare provider prescription should the nurse
question?
, 1. Vital signs and neurologic checks hourly
2. Small, frequent formula feedings
3. Elevate head of bed
4. Daily head circumference - ANSWER>>3. Elevate head of bed
9) A neonate with a meningomyelocele is to have surgery in the morning.
Which nursing action is appropriate for this neonate?
1. Applying a diaper to prevent contamination of sac
2. Positioning the newborn in a side-lying position
3. Encouraging the mother to hold the newborn because she will not be
able to pick him up after surgery
4. Positioning the newborn in a prone position - ANSWER>>4. Positioning
the newborn in a prone position
10) Which should the nurse include in the plan of care for a hospitalized
school-age child with meningomyelocele? Select all that apply.
1. Implementing interventions for a client of normal intelligence
2. Using latex precautions when providing client care
3. Allowing the client to self-catheterize
4. Ensuring that the client has a low-fiber diet
5. Encouraging the client to shift positions hourly when in the wheelchair -
ANSWER>>1. Implementing interventions for a client of normal intelligence
2. Using latex precautions when providing client care
3. Allowing the client to self-catheterize
5. Encouraging the client to shift positions hourly when in the wheelchair
11) Which side effect should the nurse include in the parent teaching for a
child who is prescribed a baclofen pump for cerebral palsy?
1. Diarrhea
2. Hypertonia
3. Hypotonia
4. Restlessness - ANSWER>>3. Hypotonia
12) A 9-month-old infant who is not sitting independently has been
diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations
would the nurse expect to see in the baby?