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32 Cards in this Set
- Front
- Back
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A child is admitted with a diagnosis of acute glomerulnephritis (AGN) When performing a physical assessment, the nurse should expect to find?
1. Anorexia, hematuria, protienuria +1 and decreased blood pressure 2. Normal blood pressure, anorexia, protienuria +1 and glycosuria 3. Lowered blood pressure, periorbital edema, protienuria +! and decreased specific gravity ( 1.001) Moderately elevated blood pressure, protienuria +4 and increased specific gravity (1.030) |
4. Rational: The glomecular filtration rate is reduced resulting in sodium retention, protien loss, and fluid accumulation producing these signs
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When planning care for a 5 year old client with glomerculonephritis, the nurse realizes that the child needs help in understanding the necessary restrictions one of which:
1. Daily doses of penicilin 2. A bland diet high in protien 3. Bed rest for 4 weeks 4. Isolation from other children with infections |
4. Rational: During the acute stage, anorexia and loss of protien lower the child's resitstance to infection
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The parents of a child with acute glomerulnephritis are very concerned about the activity restrictions after discharge. The nurse bases the answer to them on the fact that after the urinary findings are normal:
1. Activity must be limited for four weeks 2. The child must not play active games 3. the clild must remain in bed for two weeks 4. Activity does not affect the course of the disease |
4. Rational: When urinary findings are normal, such as no evidence of hematuria, or protienuria, the child may resume perillness activities
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The mother of a child with acute glomerulnephritis asks why the child is being weighed every morning. The nurses best answer would be:
1. It is the best way to mesure your child's fluid balance 2. When weight loss stops, it indicated the disease process is over. 3. It gives the doctors a good idea on how much protien is lost 4. The dietitan plans the daily c aloric intake, according to the daily weight |
1. Rational: Daily changes in weight are indicators of fluid changes; loss or gain of muscle and fat do not cause daily fluctuations in weight.
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The most important nursing intervention for the 3 year-old child with a diagnosis of nephrotic syndrome is:
1. Encouraging fluids 2. Regulating the diet 3. Preventing infection 4. Maintaining bed rest |
3. Rational: infection is a constant threat because of poor general state of nutrition, a tendancy toard skin breakdow in edematous areas, corticosteroids thearpy, and lowered immunoglobulin levels
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During a clinic visit, a child with nephrotic syndrome has a muddy, pale appearence and complains of not wanting to eat and feeling tired. Thr nurse suspects that the child is:
1. in impending renal failure 2. Being too active in school 3. Developing a viral infection 4. Not taking ordered meds |
1. Rational: Poor appetite and decreased enegry are associated with accumulation of toxic wastes; anemia accounts for the pallor
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The nurse explains to a parent group that the most important complication of mumps in postopubertal males is:
1. sterility 2. Hypopituitaryism 3. Decrease in libido 4. Decrease in androgen |
1. Rational: Mumps can cause Orchitis (inflammation of the ovaries) in females. Although rare, both can render the postpubertal child sterile.
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When performing a physical assessment of a newborn with down's syndrome the nurse should carefully evaluate the infant's
1. heart sounds 2. Anterior fontanel 3. Pupillary reaction 4. Lower extremities |
1. Rational: Cardiac anmoalies often accompany genetic problems such as downs syndrome; 30% to 40% of these infants have congenital heart defects
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A female toddler has a tonic-clonic seziure r/t a high fever. During the tonic clonic stage of the seziure the nurse's priority should be to:
1 Turn her on her side 2. Protect her from injury 3. Call for additional help 4. Establish a patent airway |
2 Rational: This, together with observation and recording of seziure activity, is the primary nursing care for a child with a tonic-clonic seziure
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When explaning the occurance of febrile seziures to a parent's class the nurse should include the fact that:
1. They may occur in minor illnesses 2. They cause is usually readily identified 3. They usually occur after the first year of life 4. The frequency of occurance is greater in females than males |
1. Rational: Febrile seziures usually are not associated with major neurologic problems. from 95% to 98% of these children do not develop epilepsy or other neurologic problems
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A mother indicates that her 3 year-old son has had a fever for several days and is now vomitting. While instituting nursing measures to reduce the child's fever the nurse recgonizes that it is important to:
1. Restrict oral fluids 2. Measure output every hour 3. Limit exposure to prevent shivering 4. Monitor vital signs q 10mins |
3. Rational: shivering increases metabolic rate which intensifies the body's need for oxygen and raises the body temperature.
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A 2 year old had been admitted to rule out a seziure disorder. The nurse should establish the highest priority nursing diagnosis as
1. disturbed body image 2. Disturbed sersory perception 3. Feeding self-care deficit 4. Risk for injury |
4 Rational: A child who has a seziure may be injured unless precautions are taken
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A child sitting in a chair in a playroom begins a tonic-clonic seziure with a clenched jaw. The nurses best initial action would be to:
1. Phone for assistance 2. Attempt to lower the jaw 3. Lower the child to the floor 4. Place a large pillow under the child's head |
3. Rational: this limits the danger of falling and striking the head
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During a visit to the neurology clinic for follow up of a seziure disorder, a school-age child questions when the medicines can be stopped. The child has not had a seziure in the past 2 years. The nurse's best explanation is:
1. A gradual reduction in seziure medicine can be considered 2. Seziure disorders are lifelong problems and will require medications for the rest of your life 3. Enough time has passed since the 1st seziure. The medication will be discontinued this visit 4. A minimum of 10 years without seziures is necessary before discontinuation of medications can be considered |
1. specific protocols are designed to gradually reduce the dosage of seziure medications, after being seziure free, provided that the EEG is within acceptable limits. The child is observed for seziure activity because or the recurrence is greatest within the first year after drug withdral
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Nursing care of a baby with increased intracranial pressure should include:
1. Weighing the infant daily before feeding. 2. Evaluating the infant's head higher than the hips. 3.Checking the infant's reflexes q 15 minutes 4. Stimulating the infant frequently to monitor consciousness |
1. Rational: Bradycardia is a classic sign of increased intracranial pressure
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at the age of 7 years, a child with cerebral palsy is admitted to the hospital for a tendon-legnthening procedure. While in bed after the surgery, the child must wear braces and shoes for at least 8 hours a day. This is to:
1. Encourage ambluation as soon as possible 2. Continue the child's acceptance of physical restraints 3. Maintain hip and knee alignment 4. Stretch the child's ligaments and strengthen the muscle tone |
2. Elevation of the head helps decrease intracranial pressure by gravity
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When planning long term care for a child with cerebral palsy, it is important for the nurse to recgonize that the:
1. Illness is not progressively degenerative 2. Child probally has some degree of mental retardation 3. Effects of cerebral palsy are unstable and unpredictable 4. Child should have genetic counsuling before planning a family. |
3. Rational: Braces are used to enable the spastic child to control motions. They also prevent deformities from poor alignment.
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The exact sociocultral reason for lead posioning in children is:
1. Considered to be an enviorment with lead available for oral exploration. 2. attributed to an indigent and passive mother who fails to supervise children 3. Clearly understood to be caused by the child's ingestion of nonfood substances 4. Unknown, but groups at high risk include children with pica and those exposed to enviormental hazards |
4. Rational: The exact reason is unknown, but three factors appear to influence it; a child prone to pica, lead in the enviorment, and a high fat diet
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Although lead posioning affects various organ systems; its irreversible effects are exerted on the
1. Urinary system 2. Skeletal system 3. Hematologic System 4. CNS system |
4. Damaged nerve cells do not regenerate. Once mental retardation has occured, it is not reversible.
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For a child with a diagnosed with lead posioning, the nursing diagnosis with the highest priority would be:
1. Constipation r/t ingestion of lead 2. Risk for injury r/t ingestion of lead 3. Delayed growth and development r/t inadequate parenting. 4. Imbalanced nutrition, less than body requirements, r/t decreased iron intake |
2. Irreversible neurologic and intellectul damage are the most serous consquences of lead intoxication because of cortical atrophy and lead encephalopathy. Protecting the child from injury is the priority.
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A child with diminished sensation in the legs because of cerebral palsy should be taught special saftey percautions, including:
1. Testing the tempature of water in any water related activity 2. setting the clock two times during the night to change positions 3. Tightening straps and buckles more than usual on braces while ambluating 4. Looking down at the lower extremities when crutch walking to determine proper positioning of the legs |
1. Rational: Individuals whose thermoreceptors are impaired are unable to detect changes or degrees of tempature. They must be taught to first test the water tempature to prevent scalding and burning
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The nurse should maintain isolation of a child diagnosed with bacterial menningitis:
1. 12 hours after admission 2. Until cultures are negative 3. Until antibotic thearpy is completed 4. 48 hours after ABX thearpy begins |
4. Rational: Most children are no longer contagious after 24-48 hours when receiving IV ABX
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A 2 year old had be admitted with a suspected diagnosis of meningitis. A lumbar puncture is done to confirm the diagnosis. The nurse correctly interperts that bacterial meningitis is present with the report of the spinal fluid indicates:
1. Increased protien 2. Increased gluclose 3. Decreased cell count 4.Decreased specific gravity |
1. Rational: The blood brain barrier is affected, which permits the passage of protien into the cerebral spinal fluid.
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When caring for a child with meningococcal menigitis, the nurse should observe for the:
1. Identifying pururic skin rash 2. Low-grade nature of the fever 3. Presence of severe glossitis 4. Continual tremors in the extremities. |
1. Rational: Meningoccal meningitis is identified by its epidermic nature and purpuric rash.
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To identify possible increasing intracranial pressure, the nurse should monitor a 2-year old child with the diagnosis of meningitis for:
1. Restlessness, anorexia, rapid respirations 2. Vomiting, seziures, complaints of head pain 3. Anorexia, irratibility, subnormal tempature. 4. Buldging fontanels, decreased blood pressure, and elevated tempature |
2. Rational: because cranial sutures are closed by this age, increased cranial pressure could cause headache. Irritation of cerebral tissue would cause seziures, and pressure on vital centers would cause vomiting.
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The most serious complication of meningitis in young children is:
1. Epilepsy 2. Blindness 3. Peripheal circulatory collapse 4. Communicating hydocephalus |
3. Rational: Peripheral circulatory collapse is a serious complication of meningococcal menigitis caused by bilateral adrenal hemorrhage. This results in acute adrenal insufficiency causing profound shock, petechiae, ecchymotic lesions, vomiting, prostration, and hypertension
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In monocular strabisums in children is not corrected early enough:
1. Dyslexia will develop 2. Peripheal vision will develop 3. Amblyopia develops in the weaker eye 4. Vision in both eyes will diminish. |
3. Rational: Amblyopia is reduced visual activity that may occur when an eye weakened by strabismus is not forced into function
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The nurse explains to parents of a toddler with strabismus, that if this condition is not corrected in early childhood, it can lead to:
1. Glaucoma 2. Refractive errors 3. Partial loss of sight 4. Childhood cataracts |
3. Rational: If the strabismus is not corrected, sight in the affected eye would be lost due to the lack of use
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A child with a leg fracture of suspicious origin is brought into the emergency department by his mother's boyfriend. It is the child's first visit to this hospital. After assessing the child, the nurse suggests that the physician order a skeletal survey because it:
1. Will pinpoint the exaact location and the extent of the fracture 2. Is more cost effective than ordering three seperate xrays of the leg and hip. 3. Is the first step toward a complete assessment before a CT or an MRI scan 4. Will provide a skeletal history of current fractures and any previous healing or healed fractures |
4. Rational: Abusive parents may "shop" for hospitals that do not have a previous record of their child; The skeletal survey would provide a revealing injury history if there were abuse.
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A 7-year old girl has recently been diagnosed with rheumatoid arthritis. The parents are concerned about the lifelong effects of the disease. Their daughter is already hving difficuty going to school in the morning. The parents investigating other therapies to use with medications. The nurse should recommend a referral for:
1. Physical therapy 2. Special education 3. Nutritional thearpy 4. Herbal supplements |
1. Rational: A physical thearpist can prescribe an excerise protocol to keep the joints as mobile as possible; a routine can be developed to help the child alleviate morning stiffness.
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References:
Nugent,P. Pelikan, P. Saxton, D. Mosby's Comprehensive Review for the NCLEX-RN Examination. 18th edition. 2006. |
Jeremy Sherwin
October 7 2009 |
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References:
Nugent,P. Pelikan, P. Saxton, D. Mosby's Comprehensive Review for the NCLEX-RN Examination. 18th edition. 2006. |
Jeremy Sherwin
October 7 2009 |
