Exam 3

Question 1

Why is a child at risk for shaken baby syndrome?

Answer 1

The head is disproportionate and the neck is not supported

Question 2

What should the nurse do if a client who has a hip spica cast and complains of pain for 1 hour after receiving intravenous opioid analgesics?

Answer 2

Complete a neuromuscular assessment

Question 3

What should the nurse do if a client who has been re-casted for clubfoot has been crying for an Hour?

Answer 3

Make sure blood is circulating.

Complete another neuro assessment of the foot

Question 4

How long should a child with meningitis remain in isolation?

Answer 4

24 hours on antibiotics in isolation

Question 5

What nursing actions are appropriate to prevent skin break down for a client with a spinal cord injury?

Answer 5

Turn / reposition Q2

Question 6

What lab value should the nurse report to the provider before initiating amphotericin B (an anti fungal that can cause kidney damage)

Answer 6

BUN > 20 (55 is high)

Question 7

What is beneficial in reducing the risk of Reye syndrome?

Answer 7

Avoid aspirin

Question 8

What assessment should the nurse include on a child who had acute rheumatic fever?

Answer 8

Heart sounds

Question 9

What should a nurse expect from a child who has heart failure?

Answer 9

Orthopnea

Question 10

What comfort medication can be given to a child who just had cardiac catheterization?

Answer 10

Tylenol

Question 11

What is a normal apical heart rate for a 6 month old ?

Answer 11

90-180

(Hold Dig if heart rate is <90)

Question 12

What supplement can be added to a babies formula to increase calories in an infant with heart failure?

Answer 12

Polycose

Question 13

What data or medical information would clue to the nurse that a child might have rheumatic fever?

Answer 13

If anyone else in the family has had strep throat recently

Question 14

What defect is associated with increased pulmonary blood flow?

Answer 14

PDA (congenital)

Question 15

What should the nurse monitor for a child who has Kawasaki disease?

Answer 15

Lymph nodes
Cardiac

Question 16

What should the nurse expect of a client has arteriosclerosis and increased peripheral vascular resistance?

Answer 16

Increase in systolic portion of BP

Question 17

What manifestations should the nurse monitor first for or are priority for a client with infective endocarditis?

Answer 17

Respiratory
Trouble feeding
Fever
Murmur
Weight loss
Hemorrhage under nails

Question 18

What venous access device should the nurse identify as appropriate for the client with bacterial endocarditis?

Answer 18

PICC

Question 19

What nursing interventions should be included in the care following a cardiac catheterization

Answer 19

Monitor the cranial nerves

Prevent bleeding, maintain affected extremity in straight position for 4-6 hours

Question 20

What does baclofen do in a child with cerebral palsy?

Answer 20

Controls muscle spasms

Question 21

What manifestations would indicate that a shunt revision is necessary due to hydrocephalus?

Answer 21

Check LOC

Question 22

What manifestations should the nurse assess for Cushing’s triad?

Answer 22

Widened pulse pressure
Decreased respiratory
Bradycardia

Question 23

What should the nurse include in the child’s care plan who has an acute head injury ?

Answer 23

Elevate HOB
Assess LOC

Question 24

What should the nurse test for a client with clear drainage coming out of the clients right nostril that was sustained from a nasal skull fracture ?

Answer 24

Glucose

Question 25

What cerebrospinal fluid results support the diagnosis of bacterial meningitis

Answer 25

Decreased glucose Increased protein Cloudy

Question 26

If a child has a fever of 103, what type of isolation should the child be in?

Answer 26

Droplet precaution

Question 27

What is the manifestations of a child having hydrocephalus?

Answer 27

Distended scalp veins Bulging fontanel Vomiting Irritability

Question 28

What seizure precautions should be implemented by the nurse if the child is experiencing a seizure?

Answer 28

Time seizure Stay with the patient Protect head Loosen clothing Remove furniture

Question 29

What is the nurses priority who has a tonic clinic seizure?

Answer 29

Side laying position

Question 30

What type/route temperature on an infant who has myelomeningocele ?

Answer 30

Auxiliary

Question 31

What should the nurse include in the plan of care for an infant who has spina bifida?

Answer 31

No latex gloves

Question 32

How often should a child who has legg-calve-parthesis and is in a buck extension traction be moved?

Answer 32

Q2 hours

Question 33

What plan of care should be included for a client who is postoperative following scoliosis repair?

Answer 33

PCA pump for pain management

Question 34

What type of position should a patient be placed in who is postoperative following a ventricularperitoneal shunt replacement ?

Answer 34

On the opposite side of the surgical incision

Question 35

What should be included in a plan of care for a child who has hemiplegic cerebral palsy?

Answer 35

Maintain activity level in a modified environment

Question 36

What type of position should a client be placed in who is having a seizure?

Answer 36

Side lying

Question 37

What action should the nurse take when assessing cranial nerve 3?

Answer 37

PERLA, pupil reaction to light

Question 38

What type of assessment should the nurse do on a client who has a newly applied fiberglass cast for a fractured tibia?

Answer 38

Neuromuscular assessment

Question 39

What type of assessment should a nurse do on a client with myelomeningocele

Answer 39

Protect sac

Question 40

What manifestations are seeing with a client who is hydrocephalus?

Answer 40

Dilated scalp things

Question 41

What is unnecessary in the child’s plan of care who has bacterial meningitis?

Answer 41

Measuring the head circumference, if they’re older than 18 months

Question 42

What is a manifestation of a client who has increased ICP

Answer 42

Cushing’s triad

Question 43

How should a nurse proceed with a child who will be getting a cast?

Answer 43

Use a toy to demonstrate

Question 44

What findings should the nurse observe first on a client with a leg cast?

Answer 44

Color of the toes, pallor is bad

Question 45

What should the nurse check first in a client who has a cast in place for a fractured tibia?

Answer 45

Cap refill

Question 46

What should be a nursing priority for a client who has osteomyelitis?

Answer 46

Antibiotics

Question 47

What should the nurse also include in the care plan of a seizure patient following a seizure

Answer 47

Side lying Assess cranial nerves?

Question 48

What is Brudzinski’s sign

Answer 48

Passively flex neck and involuntary flex in both legs

Question 49

What medication should the nurse be ready to administer to a client who has a traumatic head injury and is having ICP

Answer 49

Mannitol 25%

Question 50

What is the purpose of administering an osmotic diuretics IV to a client with ICP

Answer 50

To reduce edema in the brain

Question 51

How should a patient be position who has ICP?

Answer 51

Semi Fowler 15 to 30%

Question 52

Which manifestations would be related to having a leaking cerebral aneurysm?

Answer 52

Headache Disoriented Slurred speech

Question 53

What type of action should the nurse take when caring for a client with increased ICP following a head injury

Answer 53

Log roll Keep their head midline, elevate HOB

Question 54

What should a nurse monitor for an infant following a car crash?

Answer 54

Sleepiness Temperature Respirations ICP : bulging, fontanelle, increase head, circumference, high scream, distended veins, irritability, bradycardia, decreased respirations

Question 55

What is the purpose of a halo fixation device?

Answer 55

To immobilized keep straight

Question 56

What is the function of cranial nerve three?

Answer 56

Oculomotor Response to light

Question 57

What action should the nurse take first for a client who has a short leg cast to treat at ankle fracture?

Answer 57

Notify the PCP if the patient cannot flex their toes

Question 58

What complication might be suspected if the client has a cast that feels warm to the touch?

Answer 58

Check for infection / restlessness (possible ICP)??? Compartment syndrome? *my notes said compartment syndrome, but class told me otherwise