Families Exam 4 Questions With All Correct &
Verified Answers
The nurse is closely monitoring a child with increased intracranial pressure who has been exhibiting
decorticate (flexor) posturing. The nurse notes that the child suddenly exhibits decerebrate
(extensor) posturing and interprets that this change in the child's condition indicates which finding?
A. An insignificant finding
B. An improvement in condition
C. Decreasing intracranial pressure
D. Deteriorating neurological function Correct answer-D. Deteriorating neurological function
Rationale:
The progression from decorticate to decerebrate posturing usually indicates deteriorating
neurological function and warrants health care provider notification. Options 1, 2, and 3 are
inaccurate interpretations.
The registered nurse (RN) is reviewing a plan of care developed by a nursing student for a child who
is being admitted to the pediatric unit with a diagnosis of seizures. The RN determines that the
student nurse needs further teaching and should revise the plan of care if which incorrect
intervention is documented?
A. Maintain the bed in a low position.
B. Restrain the child if a seizure occurs.
C. Place pads on the side rails of the bed.
D. Place the child in a side-lying lateral position if a seizure occurs. Correct answer-B. Restrain the
child if a seizure occurs.
Rationale:
Restraints are not to be applied to a child with a seizure because they could cause injury to the child.
The bed is maintained in low position to provide safety in the event that the child has a seizure. The
side rails of the bed are padded with blankets to prevent injury. Positioning the child on his or her
side will prevent aspiration as the saliva drains out of the child's mouth during the seizure.
Which finding would indicate the presence of Kernig's sign?
A. Calf pain when the foot is dorsiflexed
B. Pain when the chin is pulled down to the chest
C. The inability of the child to extend the legs fully when lying supine
D. The flexion of the hips when the neck is flexed from a lying position Correct answer-C. The
inability of the child to extend the legs fully when lying supine
Rationale:
Kernig's sign is the inability of the child to extend the legs fully when lying supine. Brudzinski's sign is
flexion of the hips when the neck is flexed from a supine position. Both of these signs are frequently
present in clients with bacterial meningitis. Nuchal rigidity is also present with bacterial meningitis,
and it occurs when pain prevents the child from touching the chin to the chest. Homans' sign is
elicited when pain occurs in the calf region when the foot is dorsiflexed.
,The nurse is reviewing the laboratory analysis of cerebrospinal fluid (CSF) obtained during a lumbar
puncture from a child who is suspected of having bacterial meningitis. Which result would most likely
confirm this diagnosis?
A. Clear CSF with low protein and low glucose
B. Cloudy CSF with low protein and low glucose
C. Cloudy CSF with high protein and low glucose
D. Decreased pressure and cloudy CSF with high protein Correct answer-C. Cloudy CSF with high
protein and low glucose
Rationale:
A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of
bacterial meningitis, findings usually include increased pressure and cloudy CSF with high protein
and low glucose. Therefore, options 1, 2, and 4 are incorrect.
The nurse receives a telephone call from the emergency department and is told that a 7-month-old
infant with febrile seizures will be admitted to the pediatric unit. What should the nurse anticipate
the need for when planning care for the admission of the infant?
A. Restraints at the bedside
B. A code cart at the bedside
C. Suction equipment and an airway at the bedside
D. A padded tongue blade taped to the head of the bed Correct answer-C. Suction equipment and
an airway at the bedside
Rationale:
Suctioning may be required during a seizure to remove secretions that obstruct the airway. An airway
should also be readily available. During a seizure, the infant should be placed in a side-lying position,
but he or she should not be restrained. It is not necessary to place a code cart at the bedside, but a
cart should be readily available on the nursing unit. A padded tongue blade should never be used; in
fact, nothing should be placed in the mouth during a seizure.
A nursing student is asked to conduct a clinical conference about autism. Which characteristic
associated with autism should the student plan to include?
A. Normal social play that ceases by age 5
B. Lack of social interaction and awareness
C. The consistent imitation of others' actions
D. Normal verbal but abnormal nonverbal communication Correct answer-B. Lack of social
interaction and awareness
Rationale:
Autism is a severe developmental disorder that begins in infancy or toddlerhood. A primary
characteristic is a lack of social interaction and awareness. Social behaviors in children with autism
include a lack of or abnormal imitations of others' actions and a lack of or abnormal social play.
Additional characteristics include a lack of or impaired verbal communication and marked abnormal
nonverbal communication.
The nurse is monitoring a nursing student who is caring for a child who sustained a head injury from
a fall. Which action by the nursing student indicates a need for further teaching?
,A. Forcing fluids
B. Performing neurological assessments
C. Keeping the child in a sitting-up position
D. Keeping the child awake as much as possible Correct answer-A. Forcing fluids
Rationale:
A child with a head injury is at risk for increased intracranial pressure (ICP). Forcing fluids may cause
fluid overload and increased ICP. Additionally, the nurse should not "force" the client to do
something. Neurological assessments must be performed to monitor for increased ICP. Sitting up will
decrease fluid retention in cerebral tissue and promote drainage. Keeping the child awake will assist
in accurate evaluation of any cerebral edema that is present and will detect early coma
The nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt
who will be discharged from the hospital. Which instruction should the nurse include in the plan of
care?
A. Expect an increased urine output from the shunt.
B. Call the health care provider if the infant is fussy.
C. Call the health care provider if the infant has a high-pitched cry.
D. Position the infant on the side of the shunt when the infant is put to bed. Correct answer-C. Call
the health care provider if the infant has a high-pitched cry.
Rationale:
If the shunt is broken or malfunctioning, the fluid from the ventricular part of the brain will not be
diverted to the peritoneal cavity, and the cerebrospinal fluid will build up in the cranial area. The
result is intracranial pressure, which then causes a high-pitched cry in the infant. This type of shunt
affects the gastrointestinal system rather than the genitourinary system, and an increased urinary
output is not expected. Option 2 is only a concern if other signs that are indicative of a complication
are occurring. The infant should not be positioned on the side of the shunt, because this will cause
pressure on the shunt as well as skin breakdown.
The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure
(ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this
assessment finding, which action should the nurse take?
A. Document the findings.
B. Lower the head of the bed.
C. Notify the health care provider immediately.
D. Place the infant on nothing per mouth (NPO) status. Correct answer-A. Document the findings.
Rationale:
The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and
flat in a normal infant and normally closes by 18 to 24 months of age. The posterior fontanel closes
by 2 to 3 months of age. A bulging or tense fontanel may result from crying or increased ICP. If the
nurse notes a bulging fontanel when the infant cries, this is a normal finding that should be
documented and monitored. It is not necessary to notify the health care provider for this finding.
Options 2 and 4 are inappropriate actions.
When providing care for a child in cervical traction with Crutchfield tongs, which actions should the
nurse take?
, A. Promote mobility.
B. Provide emotional support.
C. Monitor intake and output (I&O).
D. Maintain proper alignment and prevent infection. Correct answer-D. Maintain proper alignment
and prevent infection.
Rationale:
Caring for a child in traction includes ensuring that the child's body is in proper alignment.
Crutchfield tongs are a type of cervical skeletal traction that requires pin-site assessment and pin
care to prevent infection. Fluid balance (I&O) should not be affected by cervical traction.
Immobilization until bone healing occurs is an essential goal of cervical traction
An infant has been found to be human immunodeficiency virus (HIV) positive. When teaching the
infant's mother, which action should the nurse instruct the mother to take?
A. Check the anterior fontanel for bulging and the sutures for widening each day.
B. Feed the infant in an upright position with the head and chest tilted slightly back to avoid
aspiration.
C. Provide meticulous skin care to the infant and change the infant's diaper after each voiding or
stool.
D. Feed the infant with a special nipple and burp the infant frequently to decrease the tendency to
swallow air. Correct answer-C. Provide meticulous skin care to the infant and change the infant's
diaper after each voiding or stool.
Rationale:
Meticulous skin care helps protect the HIV-infected infant from secondary infections. Bulging
fontanels, feeding the infant in an upright position, and using a special nipple are unrelated to the
pathology associated with HIV.
The nurse provides home care instructions to the mother of a child with chickenpox about
preventing the transmission of the virus. Which instruction should the nurse include?
A. Isolate the child until the skin vesicles have dried and crusted.
B. Ensure that the child uses a separate bathroom for elimination.
C. Bring all household members to the clinic immediately for a varicella vaccine.
D. Ask the health care provider for a prescription for antibiotics for all household members. Correct
answer-A. Isolate the child until the skin vesicles have dried and crusted.
Rationale:
Chickenpox is caused by the varicella-zoster virus. The communicable period is from 1 to 2 days
before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed.
Transmission occurs by direct contact with secretions from the vesicles or contaminated objects, and
via respiratory tract secretions. It is not transmitted via urine or feces. The recommended
preventative schedule for receiving the varicella vaccine is at 12 to 15 months of age (first dose) and
4 to 6 years of age (second dose). It is not administered at the time of exposure to the virus.
Antibiotics are not used to treat a viral infection. Rather, they are used for treating bacterial
infections.
The nurse is performing an assessment on a 3-year-old child with chickenpox. The child's mother tells
the nurse that the child keeps scratching at night, and the nurse teaches the mother about measures
Verified Answers
The nurse is closely monitoring a child with increased intracranial pressure who has been exhibiting
decorticate (flexor) posturing. The nurse notes that the child suddenly exhibits decerebrate
(extensor) posturing and interprets that this change in the child's condition indicates which finding?
A. An insignificant finding
B. An improvement in condition
C. Decreasing intracranial pressure
D. Deteriorating neurological function Correct answer-D. Deteriorating neurological function
Rationale:
The progression from decorticate to decerebrate posturing usually indicates deteriorating
neurological function and warrants health care provider notification. Options 1, 2, and 3 are
inaccurate interpretations.
The registered nurse (RN) is reviewing a plan of care developed by a nursing student for a child who
is being admitted to the pediatric unit with a diagnosis of seizures. The RN determines that the
student nurse needs further teaching and should revise the plan of care if which incorrect
intervention is documented?
A. Maintain the bed in a low position.
B. Restrain the child if a seizure occurs.
C. Place pads on the side rails of the bed.
D. Place the child in a side-lying lateral position if a seizure occurs. Correct answer-B. Restrain the
child if a seizure occurs.
Rationale:
Restraints are not to be applied to a child with a seizure because they could cause injury to the child.
The bed is maintained in low position to provide safety in the event that the child has a seizure. The
side rails of the bed are padded with blankets to prevent injury. Positioning the child on his or her
side will prevent aspiration as the saliva drains out of the child's mouth during the seizure.
Which finding would indicate the presence of Kernig's sign?
A. Calf pain when the foot is dorsiflexed
B. Pain when the chin is pulled down to the chest
C. The inability of the child to extend the legs fully when lying supine
D. The flexion of the hips when the neck is flexed from a lying position Correct answer-C. The
inability of the child to extend the legs fully when lying supine
Rationale:
Kernig's sign is the inability of the child to extend the legs fully when lying supine. Brudzinski's sign is
flexion of the hips when the neck is flexed from a supine position. Both of these signs are frequently
present in clients with bacterial meningitis. Nuchal rigidity is also present with bacterial meningitis,
and it occurs when pain prevents the child from touching the chin to the chest. Homans' sign is
elicited when pain occurs in the calf region when the foot is dorsiflexed.
,The nurse is reviewing the laboratory analysis of cerebrospinal fluid (CSF) obtained during a lumbar
puncture from a child who is suspected of having bacterial meningitis. Which result would most likely
confirm this diagnosis?
A. Clear CSF with low protein and low glucose
B. Cloudy CSF with low protein and low glucose
C. Cloudy CSF with high protein and low glucose
D. Decreased pressure and cloudy CSF with high protein Correct answer-C. Cloudy CSF with high
protein and low glucose
Rationale:
A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of
bacterial meningitis, findings usually include increased pressure and cloudy CSF with high protein
and low glucose. Therefore, options 1, 2, and 4 are incorrect.
The nurse receives a telephone call from the emergency department and is told that a 7-month-old
infant with febrile seizures will be admitted to the pediatric unit. What should the nurse anticipate
the need for when planning care for the admission of the infant?
A. Restraints at the bedside
B. A code cart at the bedside
C. Suction equipment and an airway at the bedside
D. A padded tongue blade taped to the head of the bed Correct answer-C. Suction equipment and
an airway at the bedside
Rationale:
Suctioning may be required during a seizure to remove secretions that obstruct the airway. An airway
should also be readily available. During a seizure, the infant should be placed in a side-lying position,
but he or she should not be restrained. It is not necessary to place a code cart at the bedside, but a
cart should be readily available on the nursing unit. A padded tongue blade should never be used; in
fact, nothing should be placed in the mouth during a seizure.
A nursing student is asked to conduct a clinical conference about autism. Which characteristic
associated with autism should the student plan to include?
A. Normal social play that ceases by age 5
B. Lack of social interaction and awareness
C. The consistent imitation of others' actions
D. Normal verbal but abnormal nonverbal communication Correct answer-B. Lack of social
interaction and awareness
Rationale:
Autism is a severe developmental disorder that begins in infancy or toddlerhood. A primary
characteristic is a lack of social interaction and awareness. Social behaviors in children with autism
include a lack of or abnormal imitations of others' actions and a lack of or abnormal social play.
Additional characteristics include a lack of or impaired verbal communication and marked abnormal
nonverbal communication.
The nurse is monitoring a nursing student who is caring for a child who sustained a head injury from
a fall. Which action by the nursing student indicates a need for further teaching?
,A. Forcing fluids
B. Performing neurological assessments
C. Keeping the child in a sitting-up position
D. Keeping the child awake as much as possible Correct answer-A. Forcing fluids
Rationale:
A child with a head injury is at risk for increased intracranial pressure (ICP). Forcing fluids may cause
fluid overload and increased ICP. Additionally, the nurse should not "force" the client to do
something. Neurological assessments must be performed to monitor for increased ICP. Sitting up will
decrease fluid retention in cerebral tissue and promote drainage. Keeping the child awake will assist
in accurate evaluation of any cerebral edema that is present and will detect early coma
The nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt
who will be discharged from the hospital. Which instruction should the nurse include in the plan of
care?
A. Expect an increased urine output from the shunt.
B. Call the health care provider if the infant is fussy.
C. Call the health care provider if the infant has a high-pitched cry.
D. Position the infant on the side of the shunt when the infant is put to bed. Correct answer-C. Call
the health care provider if the infant has a high-pitched cry.
Rationale:
If the shunt is broken or malfunctioning, the fluid from the ventricular part of the brain will not be
diverted to the peritoneal cavity, and the cerebrospinal fluid will build up in the cranial area. The
result is intracranial pressure, which then causes a high-pitched cry in the infant. This type of shunt
affects the gastrointestinal system rather than the genitourinary system, and an increased urinary
output is not expected. Option 2 is only a concern if other signs that are indicative of a complication
are occurring. The infant should not be positioned on the side of the shunt, because this will cause
pressure on the shunt as well as skin breakdown.
The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure
(ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this
assessment finding, which action should the nurse take?
A. Document the findings.
B. Lower the head of the bed.
C. Notify the health care provider immediately.
D. Place the infant on nothing per mouth (NPO) status. Correct answer-A. Document the findings.
Rationale:
The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and
flat in a normal infant and normally closes by 18 to 24 months of age. The posterior fontanel closes
by 2 to 3 months of age. A bulging or tense fontanel may result from crying or increased ICP. If the
nurse notes a bulging fontanel when the infant cries, this is a normal finding that should be
documented and monitored. It is not necessary to notify the health care provider for this finding.
Options 2 and 4 are inappropriate actions.
When providing care for a child in cervical traction with Crutchfield tongs, which actions should the
nurse take?
, A. Promote mobility.
B. Provide emotional support.
C. Monitor intake and output (I&O).
D. Maintain proper alignment and prevent infection. Correct answer-D. Maintain proper alignment
and prevent infection.
Rationale:
Caring for a child in traction includes ensuring that the child's body is in proper alignment.
Crutchfield tongs are a type of cervical skeletal traction that requires pin-site assessment and pin
care to prevent infection. Fluid balance (I&O) should not be affected by cervical traction.
Immobilization until bone healing occurs is an essential goal of cervical traction
An infant has been found to be human immunodeficiency virus (HIV) positive. When teaching the
infant's mother, which action should the nurse instruct the mother to take?
A. Check the anterior fontanel for bulging and the sutures for widening each day.
B. Feed the infant in an upright position with the head and chest tilted slightly back to avoid
aspiration.
C. Provide meticulous skin care to the infant and change the infant's diaper after each voiding or
stool.
D. Feed the infant with a special nipple and burp the infant frequently to decrease the tendency to
swallow air. Correct answer-C. Provide meticulous skin care to the infant and change the infant's
diaper after each voiding or stool.
Rationale:
Meticulous skin care helps protect the HIV-infected infant from secondary infections. Bulging
fontanels, feeding the infant in an upright position, and using a special nipple are unrelated to the
pathology associated with HIV.
The nurse provides home care instructions to the mother of a child with chickenpox about
preventing the transmission of the virus. Which instruction should the nurse include?
A. Isolate the child until the skin vesicles have dried and crusted.
B. Ensure that the child uses a separate bathroom for elimination.
C. Bring all household members to the clinic immediately for a varicella vaccine.
D. Ask the health care provider for a prescription for antibiotics for all household members. Correct
answer-A. Isolate the child until the skin vesicles have dried and crusted.
Rationale:
Chickenpox is caused by the varicella-zoster virus. The communicable period is from 1 to 2 days
before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed.
Transmission occurs by direct contact with secretions from the vesicles or contaminated objects, and
via respiratory tract secretions. It is not transmitted via urine or feces. The recommended
preventative schedule for receiving the varicella vaccine is at 12 to 15 months of age (first dose) and
4 to 6 years of age (second dose). It is not administered at the time of exposure to the virus.
Antibiotics are not used to treat a viral infection. Rather, they are used for treating bacterial
infections.
The nurse is performing an assessment on a 3-year-old child with chickenpox. The child's mother tells
the nurse that the child keeps scratching at night, and the nurse teaches the mother about measures
