Child with Altered Mental Health, Neurological, Developmental, or Learning Disorders
A) To improve motor function
B) To reduce spasticity and loosen tight muscles
C) To improve cognitive function
D) To manage pain
B) To reduce spasticity and loosen tight muscles
A nurse is caring for a patient with sickle cell disease who is experiencing a vaso-occlusive crisis. Which of the following symptoms should the nurse expect to observe in this patient?
B) Immense pain and difficulty with distal perfusion.
Rationale: During a vaso-occlusive crisis, sickled red blood cells obstruct blood flow in small vessels, leading to immense pain due to tissue ischemia and difficulty with distal perfusion. Other symptoms such as mild headache, fatigue, or changes in appetite are not characteristic of a vaso-occlusive crisis.
A nurse is reviewing the laboratory results of a patient with sickle cell disease. The nurse notes an increase in reticulocyte count. What complication should the nurse be particularly concerned about with this finding?
B) Stroke.
Rationale: An increased reticulocyte count indicates that the body is producing more red blood cells, which can lead to increased blood viscosity in patients with sickle cell disease. This heightened viscosity raises the risk of vaso-occlusive events, including stroke. While other complications are also concerns in sickle cell disease, the immediate risk associated with increased reticulocytes is stroke.
The nurse is caring for a child with nephroblastoma. What is the most important nursing intervention prior to surgery?
C) Avoid palpating the abdominal mass.
Rationale: Palpating the tumor can increase the risk of rupture, so it is critical to avoid this intervention.
Which diagnostic procedure is considered the gold standard for confirming a diagnosis of bacterial meningitis?
Correct Answer:
C) Lumbar puncture (LP).
A nurse is preparing to perform a procedure on a child who has sensory sensitivities. Which of the following strategies should the nurse use to minimize the child’s anxiety and discomfort?
A) Explain the procedure in detail before starting.
B) Provide a warning before touching the child.
C) Encourage the child to be brave and not to cry.
D) Perform the procedure quickly without explanation.
Correct Answer: B
Rationale: Providing a warning before touching helps the child prepare and reduces anxiety related to unexpected contact.
A patient with sickle cell disease is admitted to the emergency department with a sequestration crisis. The nurse notes that the patient has an enlarged spleen and exhibits signs of anemia. What is the most appropriate initial intervention for this patient?
Correct Answer:
B) Prepare the patient for a blood transfusion.
Rationale: In a sequestration crisis, significant blood pooling in the spleen leads to anemia, necessitating preparation for a blood transfusion to restore hemoglobin levels and prevent complications. While pain relief and hydration are important, the immediate focus should be on addressing the anemia from the crisis.
A nurse is reviewing the components of a normal sinus rhythm with a group of nursing students. Which of the following components should the nurse identify as characteristic of a normal sinus rhythm? (Select all that apply)
Correct Answers:
A) P wave, B) QRS complex, C) T wave
Rationale: A normal sinus rhythm includes the P wave, which represents atrial depolarization, the QRS complex, which represents ventricular depolarization, and the T wave, which represents ventricular repolarization. The U wave and ST segment are not characteristic components of a normal sinus rhythm.
A nurse is providing education to the parents of a pediatric patient undergoing chemotherapy about preventing hemorrhagic cystitis. Which of the following recommendations should the nurse emphasize?
B) Ensure the child maintains adequate hydration throughout treatment.
After a lumbar puncture, the nurse is monitoring a child who requires flat bed rest for 4 hours. What is the primary reason for this intervention?
B) To prevent leakage of cerebrospinal fluid (CSF).
A child with ADHD is prescribed methylphenidate, a stimulant. Which statement by the parents suggests they need further education about the medication's side effects?
Correct answer: B) "We will administer the medication in the evening to help with concentration."
(Stimulants should be given in the morning to avoid insomnia.)
A nurse is reviewing the diagnosis of Tetralogy of Fallot with the parents of an infant. Which of the following are the four components of this congenital heart defect? (Select all that apply)
Correct Answers:
A) Ventricular septal defect (VSD), C) Pulmonary stenosis, D) Overriding aorta, E) Right ventricular hypertrophy
Rationale: Tetralogy of Fallot consists of four defects: VSD, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. ASD and PDA are not part of this condition.
A) Anticholinergics
B) Anti-inflammatory agents
C) Skeletal muscle relaxants
D) Steroids
A) Anticholinergics
How often are dressings for PICC lines changed?
Every 7 days
When caring for a newborn with spina bifida, which position is most appropriate to promote healing of the defect?
Correct Answer:
B) Prone with legs abducted and hips flexed.
9. The nurse is administering Baclofen to a child with cerebral palsy. Which common side effect should the nurse monitor for?
Correct answer: A) Sedation
A nurse is caring for a patient with polycythemia. What is the first priority intervention to prevent complications in this patient?
B) Encourage increased oral fluid intake to promote hydration.
Rationale: Hydration is the first priority in polycythemia to reduce blood viscosity and prevent complications like clotting. Other interventions, such as phlebotomy and anticoagulants, are important but hydration comes first.
2. The nurse is discussing stimulant medications used to treat ADHD. Which of the following are common side effects? (Select all that apply)
A nurse is caring for a child post-surgery for nephroblastoma. What complication should the nurse monitor for?
Correct Answer:
B) Small bowel obstruction.
Which statement by the nurse demonstrates an understanding of the importance of monitoring a child’s head circumference in the context of bacterial meningitis?
B) "Monitoring head circumference helps identify potential hydrocephalus."
Rationale: Monitoring head circumference is critical in identifying hydrocephalus, a potential complication of bacterial meningitis.
4. A child with ADHD is taking atomoxetine, a non-stimulant medication. Which side effects should the nurse teach the parents to monitor for? (Select all that apply)
Correct answers: A) Drowsiness, B) Fatigue, D) Dry mouth
(Bradycardia and hypotension are more common, but tachycardia is not a typical side effect for non-stimulants.)
Question: A nurse on a pediatric unit is assessing four children with different diagnoses. Which child should the nurse assess first?
A) A child with Tetralogy of Fallot who has mild cyanosis while crying.
B) A child with Ventricular Septal Defect (VSD) who has a soft systolic murmur but is otherwise stable.
C) A child with sickle cell anemia who is experiencing chest pain, dyspnea, and diaphoresis.
D) A child with Tetralogy of Fallot who is experiencing mild fatigue after physical therapy.
C) A child with sickle cell anemia who is experiencing chest pain, dyspnea, and diaphoresis.
The child with sickle cell anemia showing symptoms such as chest pain, dyspnea (difficulty breathing), and diaphoresis (sweating) is displaying signs of a potential medical emergency, which could indicate acute chest syndrome or a cardiac event.
A) A child with Tetralogy of Fallot who has mild cyanosis while crying could be concerning, but it is not necessarily an emergency unless the cyanosis worsens or persists.
Mild cyanosis in Tetralogy of Fallot (TOF) can occur during crying due to increased oxygen demand and decreased oxygen supply. However, if the child experiences a "Tet spell" (a severe hypoxic episode), it becomes an emergency. Mild cyanosis alone, especially if it resolves, is not as urgent as the symptoms in the child with sickle cell anemia.
A nurse is assessing four patients in a pediatric unit. Which patient should the nurse assess first?
Correct Answer:
A) A 2-month-old infant with a heart rate of 54 beats per minute.
Rationale: In infants, a heart rate below 60 beats per minute can indicate bradycardia, which is a critical condition that requires immediate assessment and intervention. The other patients present less urgent concerns that do not necessitate immediate intervention compared to the infant with bradycardia.
A nurse is educating parents about the signs and symptoms of neuroblastoma. Which of the following should be included in the teaching? (Select all that apply)
Correct Answers:
A) Firm, nontender, irregular mass that crosses the midline, C) Facial asymmetry, D) Urinary retention, E) Bruising around the eyes
The nurse is assessing a newborn with spina bifida for signs of hydrocephalus. Which of the following findings would indicate the need for further evaluation? (Select all that apply)
Correct Answers:
A) Increased head circumference, B) Decreased alertness and lethargy, C) Frequent vomiting, D) High-pitched crying.
Rationale: These findings may indicate increased intracranial pressure and warrant further evaluation.