Final-Exam-NCM109 - It's all about chn things.pdf
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lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED...
lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS FINAL GRADING EXAM IN NCM 109 CARE OF MOTHER, CHILD AT RISK WITH PROBLEMS (ACUTE AND CHRONIC) Name: Year and Section: Direction: Choose the letter of the correct answer. 1. A nurse is caring for a child recently diagnosed with cerebral palsy, and the parents of the child ask the nurse about the disorder. The nurse bases her response on the understanding that cerebral palsy is: A. An infectious disease of the central nervous system B. An inflammation of the brain as a result of a viral illness C. A congenital condition that results in moderate to severe retardation D. A chronic disability characterized by impaired muscle movement and posture Ans. D Rationale: Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation. 2. A nurse performs an admission assessment on a child and suspects physical abuse. Based on this suspicion, the primary legal nursing responsibility is which of the following? a. Refer the family to the appropriate support groups. b. Assist the family in identifying resources and support systems. c. Report the case in which the abuse is suspected to the local authorities. d. Document the child’s physical assessment findings accurately and thoroughly. Ans. C Rationale: Abuse is the nonaccidental physical injury or the nonaccidental act of omission of care by a parent or person responsible for a child. It includes neglect and physical, sexual, and emotional maltreatment. The primary legal nursing responsibility when child abuse is suspected is to report the case. All states and provinces in North America have laws for mandatory reporting of child maltreatment. Suspected child abuse should be reported to the local authorities. Although documentation of assessment findings, assisting the family, and referring the family to appropriate resources and support groups are important, the primary legal responsibility is to report the suspected case 3. A mother arrives at an emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and a nurse checks the child’s airway status and assesses the child for signs of increased intracranial pressure (ICP). Which of the following is a late sign of increased ICP in this child? a. Nausea b. Bradycardia c. Bulging fontanel d. Dilated scalp veins Ans. B Rationale: Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased intracranial pressure (ICP). Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma. A bulging fontanel and dilated scalp veins Page 1 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS are early signs of increased ICP and would be noted in an infant, not a 5-year-old child. Nausea is an early sign of increased ICP. 4. A nurse is caring for an infant with a diagnosis of hydrocephalus. Preoperatively, a priority nursing intervention is to: a. Test the urine for protein. b. Reposition the infant frequently. c. Provide a stimulating environment. d. Assess blood pressure every 15 minutes. Ans. B Rationale: Hydrocephalus occurs as a result of an imbalance of cerebrospinal fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma. It results in head enlargement and increased intracranial pressure. In infants with hydrocephalus, the head grows at an abnormal rate, and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help prevent skin breakdown. Proteinuria is not specific to hydrocephalus. Stimulus should be kept at a minimum because of the increase in intracranial pressure. It is not necessary to check the blood pressure every 15 minutes. 5. A nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which of the following if this type of posturing is present? a. Flaccid paralysis of all extremities b. Adduction of the arms at the shoulders c. Rigid extension and pronation of the arms and legs d. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities Ans. C Rationale: Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing. 6. A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? a. Clear CSF, decreased pressure, and elevated protein level b. Clear CSF, elevated protein, and decreased glucose levels c. Cloudy CSF, elevated protein, and decreased glucose levels d. Cloudy CSF, decreased protein, and decreased glucose levels Ans. C Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing cerebrospinal fluid obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy cerebrospinal fluid; and elevated leukocyte, elevated protein, and decreased glucose levels. Page 2 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS 7. A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following should be included in the plan of care? a. Maintain enteric precautions. b. Maintain neutropenic precautions. c. No precautions are required as long as antibiotics have been started. d. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics. Ans. D Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. A major priority of nursing care for a child suspected to have meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child also is placed on respiratory isolation precautions for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Enteric precautions and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when a child has a low neutrophil count. 8. After a tonsillectomy, a child begins to vomit bright red blood. The initial nursing action is to: a. Notify the physician. b. Maintain NPO status. c. Turn the child to the side. d. Administer the prescribed antiemetic. Ans. C Rationale: After tonsillectomy, if bleeding occurs, the nurse immediately turns the child to the side to prevent aspiration and then notifies the physician. NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turn the child to the side. 9. A nurse is reviewing the laboratory results for a child scheduled for tonsillectomy. The nurse determines that which laboratory value is most significant to review? a. Creatinine level b. Prothrombin time c. Sedimentation rate d. Blood urea nitrogen level Ans. B Rationale: A tonsillectomy is the surgical removal of the tonsils. Because the tonsillar area is so vascular, postoperative bleeding is a concern. Prothrombin time, partial thromboplastin time, platelet count, hemoglobin and hematocrit, white blood cell count, and urinalysis are performed preoperatively. The prothrombin time results would identify a potential for bleeding. Creatinine level, sedimentation rate, and blood urea nitrogen would not determine the potential for bleeding. 10. A nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which appropriate position? A. Supine B. Side-lying C. High Fowler’s Page 3 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS D. Trendelenburg’s Ans B Rationale: A tonsillectomy is the surgical removal of the tonsils. The child should be placed in a prone or side-lying position after the surgical procedure to facilitate drainage 11. After a tonsillectomy, a nurse reviews the physician’s postoperative prescriptions. Which of the following physician’s prescriptions does the nurse question? A. Monitor for bleeding. B. Suction every 2 hours. C. Give no milk or milk products. D. Give clear, cool liquids when awake and alert. Ans B Rationale: A tonsillectomy is the surgical removal of the tonsils. After tonsillectomy, suction equipment should be available, but suctioning is not performed unless there is an airway obstruction because of the risk of trauma to the surgical site. Monitoring for bleeding is an important nursing intervention after any type of surgery. Milk and milk products are avoided initially because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding. Clear, cool liquids are encouraged. 12. A nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which of the following indicates that the child is bleeding? a. Frequent swallowing b. A decreased pulse rate c. Complaints of discomfort d. An elevation in blood pressure Ans. A Rationale: A tonsillectomy is the surgical removal of the tonsils. Frequent swallowing, restlessness, a fast and thready pulse, and vomiting bright red blood are signs of bleeding. An elevated blood pressure and complaints of discomfort are not indications of bleeding 13. Antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanostomy tubes. The nurse provides discharge instructions to the parents regarding the administration of the antibiotics. Which statement, if made by the parents, indicates that they understood the instructions? a. “Administer the antibiotics until they are gone.” b. “Administer the antibiotics if the child has a fever.” c. “Administer the antibiotics until the child feels better.” d. “Begin to taper the antibiotics after 3 days of a full course.” Ans A Rationale: A myringotomy is the insertion of tympanoplasty tubes into the middle ear to promote drainage of purulent middle ear fluid and to equalize pressure and keep the ear aerated. The nurse must instruct parents regarding the administration of antibiotics. Antibiotics need to be taken as prescribed, and the full course needs to be completed. Options 2, 3, and 4 are incorrect. Antibiotics are not tapered, but are administered for the full course of therapy. 14. A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. A nurse caring for the child monitors for which of the following, knowing that it indicates a worsening of the condition? a. Warm, dry skin Page 4 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS b. Decreased wheezing c. Pulse rate of 90 beats/min d. Respirations of 18 breaths/min Ans. B Rationale: Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A “silent chest” is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child’s condition is improving. Warm, dry skin indicates an improvement in the child’s condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats/min. The normal respiratory rate in a 10- year-old is 16 to 20 breaths/min 15. The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that the ibuprofen (Motrin) is not effective. The nurse should tell the mother to: a. Increase the dose of the ibuprofen. b. Increase the frequency of the ibuprofen. c. Encourage the child to lie on the left side. d. Encourage the child to lie on the right side. Ans.. D Rationale: Pneumonia is an inflammation of the pulmonary parenchyma or alveoli or both caused by a virus, mycoplasmal agents, bacteria, or aspiration of foreign substances. Splinting of the affected side by lying on that side may decrease discomfort. It would be inappropriate to advise the mother to increase the dose or frequency of the ibuprofen. Lying on the left side would not be helpful in alleviating discomfort. 16. A new mother expresses concern to a nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. The nurse appropriately tells the mother that the infant should be placed on the: a. Side or prone b. Back or prone c. Stomach with the face turned d. Back rather than on the stomach Ans. D Rationale: Sudden infant death syndrome (SIDS) is the unexpected death of an apparently healthy infant younger than 1 year for whom an investigation of the death and a thorough autopsy fails to show an adequate cause of death. Several theories are proposed regarding the cause, but the exact cause is unknown. Nurses should encourage parents to place the infant on the back (supine) for sleep. Infants in the prone position (on the stomach) may be unable to move their heads to the side, increasing the risk of suffocation. The infant may have the ability to turn to a prone position from the side-lying position 17. An emergency department nurse is caring for a child diagnosed with epiglottitis. Assessing the child, the nurse monitors for which indication that the child may be experiencing airway obstruction? a. The child exhibits nasal flaring and bradycardia. b. The child is leaning forward, with the chin thrust out. c. The child has a low-grade fever and complains of a sore throat. d. The child is leaning backward, supporting himself or herself with the hands and arms. Page 5 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS Ans. B Rationale: Epiglottitis is a bacterial form of croup. A primary concern is that it can progress to acute respiratory distress. Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward while supported by arms, chin thrust out, mouth open), nasal flaring, the use of accessory muscles for breathing, and the presence of stridor. Option 4 is an incorrect position. Options 1 and 3 are incorrect because epiglottitis causes a high fever and tachycardia. 18. A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. The appropriate nursing action is to: a. Tell the mother that the child must stay in the tent. b. Call the physician and obtain a prescription for a mild sedative. c. Place a toy in the tent to make the child feel more comfortable. d. Let the mother hold the child and direct the cool mist over the child’s face Ans. D Rationale: Laryngotracheobronchitis (croup) is the inflammation of the larynx, trachea, and bronchi and is the most common type of croup. Cool mist therapy may be prescribed to liquefy secretions and to assist in breathing. If the use of a tent or hood is causing distress, treatment may be more effective if the child is held by the parent and a cool mist is directed toward the child’s face. A mild sedative would not be administered to the child. Crying would increase hypoxia and aggravate laryngospasm, which may cause airway obstruction. Options 1 and 3 would not alleviate the child’s fear 19. A nurse is caring for a newborn infant with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which of the following is a clinical manifestation associated with this disorder? \ a. Bile-stained fecal emesis b. The passage of currant jelly–like stools c. Failure to pass meconium stool in the first 24 hours after birth d. Sausage-shaped mass palpated in the upper right abdominal quadrant Ans. C Rationale: Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum. During the newborn assessment, this defect should be identified easily on sight. A rectal thermometer or tube may be necessary, however, to determine patency if meconium is not passed in the CHAPTER 40 Gastrointestinal Disorderss483first 24 hours after birth. Other assessment findings include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum. Options 1, 2, and 4 are findings noted in intussusception. 20. A nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child’s record and expects to note which symptom of this disorder documented? a. Watery diarrhea b. Ribbon-like stools c. Profuse projectile vomiting d. Bright red blood and mucus in the stools Ans. D Rationale: Intussusception is a telescoping of one portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. A child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomiting may be present, but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly–like stools. Watery diarrhea and ribbon-like stools are not manifestations of this disorder Page 6 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS 21. A clinic nurse reviews the record of an infant and notes that the physician has documented a diagnosis of suspected Hirschsprung’s disease. The nurse reviews the assessment findings documented in the record, knowing that which symptom most likely led the mother to seek health care for the infant? A. Diarrhea B. Projectile vomiting C. Regurgitation of feedings D. Foul-smelling ribbon-like stools Ans. D Rationale: Hirschsprung’s disease is a congenital anomaly also known as congenital aganglionosis or aganglionic megacolon. It occurs as the result of an absence of ganglion cells in the rectum and other areas of the affected intestine. Chronic constipation beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foul- smelling is a clinical manifestation of this disorder. Delayed passage or absence of meconium stool in the neonatal period is also a sign. Bowel obstruction especially in the neonatal period, abdominal pain and distention, and failure to thrive are also clinical manifestations. Options 1, 2, and 3 are not associated specifically with this disorder 22. An infant has just returned to the nursing unit after a surgical repair of a cleft lip on the right side. The nurse places the infant in which best position at this time? a. Prone position b. On the stomach c. Left lateral position d. Right lateral position Ans. C Rationale: A cleft lip is a congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic development. After cleft lip repair, a nurse avoids positioning an infant on the side of the repair or in the prone position because these positions can cause rubbing of the surgical site on the mattress. The nurse positions the infant on the side lateral to the repair or on the back upright and positions the infant to prevent airway obstruction by secretions, blood, or the tongue. From the options provided, placing the infant on the left side immediately after surgery is best to prevent the risk of aspiration if the infant vomits 23. A child is hospitalized because of persistent vomiting. The nurse monitors the child closely for: a. Diarrhea b. Metabolic acidosis c. Metabolic alkalosis d. Hyperactive bowel sounds Ans. C Rationale: Vomiting causes the loss of hydrochloric acid and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea might or might not accompany vomiting. Hyperactive bowel sounds are not associated with vomiting 24. A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The school nurse provides instructions regarding how to prevent hypoglycemia during practice. The school nurse tells the child to: a. Eat twice the amount normally eaten at lunch time. b. Take half the amount of prescribed insulin on practice days. c. Take the prescribed insulin at noontime rather than in the morning. d. Eat a small box of raisins or drink a cup of orange juice before soccer practice. Page 7 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS Ans. D Rationale: Hypoglycemia is a blood glucose level less than 70 mg/dL and results from too much insulin, not enough food, or excessive activity. An extra snack of 15 to 30 g of carbohydrates eaten before activities such as soccer practice would prevent hypoglycemia. A small box of raisins or a cup of orange juice provides 15 to 30 g of carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be doubled 25. The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child’s urine and it was positive for ketones. The nurse instructs the mother to: A. Hold the next dose of insulin. B. Come to the clinic immediately. C. Administer an additional dose of regular insulin. D. Encourage the child to drink calorie-free liquids. Ans. D Rationale: When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink calorie-free liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses should not be adjusted or changed. 26.. A nurse is monitoring a child with burns during treatment for burn shock. The nurse understands that which of the following assessments provides the most accurate guide to determining the adequacy of fluid resuscitation? A. Skin turgor B. Neurological assessment C. Level of edema at burn site D. Quality of peripheral pulses Ans.. B Rationale: Sensorium is an accurate guide to determine the adequacy of fluid resuscitation. The burn injury itself does not affect the sensorium, so the child should be alert and oriented. Any alteration in sensorium should be evaluated further. A neurological assessment would determine the level of sensorium in the child. Options 1, 3, and 4 would not provide an accurate assessment of the adequacy of fluid resuscitation. 27. The mother of a child with juvenile idiopathic arthritis calls the clinic nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child can perform range-of-motion exercises at this time. The appropriate nursing response is: A. “Avoid all exercise during painful periods.” B. “Range-of-motion exercises must be performed every day.” C. “Have the child perform simple isometric exercises during this time.” D. “Administer additional pain medication before performing range-of-motion exercises.” Ans. C Rationale: Juvenile idiopathic arthritis is an autoimmune inflammatory disease affecting the joints and other tissues, such as articular cartilage. During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain. Although resting the extremity is appropriate, Page 8 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS beginning simple isometric or tensing exercises as soon as the child is able is important. These exercises do not involve joint movement 28. A nurse is caring for a child after spinal fusion for scoliosis treatment. The child complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. Based on these findings, the nurse should take which action? A. Notify the physician. B. Administer an antiemetic. C. Increase the intravenous fluids. D. Place the child in a Sims’ position. Ans. A Rationale: Scoliosis is a three-dimensional spinal deformity that usually involves lateral curvature, spinal rotation resulting in rib asymmetry, and hypokyphosis of the thorax. A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child’s abdominal contents, resulting from lengthening of the child’s body. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or children who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Options 2, 3, and 4 are incorrect 29. A nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instructions? A. “I will encourage my child to perform prescribed exercises.” B. “I will have my child wear soft fabric clothing under the brace.” C. “I should apply lotion under the brace to prevent skin breakdown.” D. “I should avoid the use of powder because it will cake under the brace.” Ans. C Rationale: A brace may be prescribed to treat scoliosis. Braces are not curative, but may slow the progression of the curvature to allow skeletal growth and maturity. The use of lotions or powders under a brace should be avoided because they can become sticky and cake under the brace, causing irritation. Options 1, 2, and 4 are appropriate interventions in the care of a child with a brace. 30. The mother of a 4-year-old child brings the child to a clinic and tells a pediatric nurse specialist that the child’s abdomen seems to be swollen. During further assessment of subjective data, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms’ tumor, would avoid which of the following during the physical assessment? A. Palpating the abdomen for a mass B. Assessing the urine for the presence of hematuria C. Monitoring the temperature for the presence of fever D. Monitoring the blood pressure for the presence of hypertension Ans. A Rationale: Wilms’ tumor is the most common intraabdominal and kidney tumor of childhood. If Wilms’ tumor is suspected, the tumor mass should not be palpated by the nurse. Excessive manipulation can cause seeding of the tumor and spread of the cancerous cells. Fever, hematuria, and hypertension are clinical manifestations associated with Wilms’ tumor Page 9 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS 31. The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 cells/mm3. Based on this laboratory result, which intervention would the nurse document in the plan of care? a. Monitor closely for signs of infection. b. Monitor the temperature every 4 hours. c. Initiate protective isolation precautions. d. Use a soft small toothbrush for mouth care. Ans. D Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). If a child is severely thrombocytopenic and has a platelet count less than 20,000 cells/mm3 , bleeding precautions need to be initiated because of the increased risk of bleeding or hemorrhage. Precautions include limiting activity that could result in head injury, using soft toothbrushes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories, enemas, and rectal temperatures are avoided. Options 1, 2, and 3 are related to the prevention of infection rather than bleeding. 32. A nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP? A. Excessive vomiting B. Bulging anterior fontanel C. Increasing head circumference D. Complaints of a frontal headache Ans. A Rationale: The brain, although well protected by the solid bony cranium, is highly susceptible to pressure that may accumulate within the enclosure. Volume and pressure must remain constant within the brain. 33. A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. The nurse responds to the grandmother by telling her: A. “I have a vase in the utility room, and I will get it for you.” B. “I will get the vase and wash it well before you put the flowers in it.” C. “The flowers from your garden are beautiful, but should not be placed in the child’s room at this time.” D. “When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible.” Ans.. C Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). 34. A adolescent client calls the emergency department and tells the nurse that he had been cleaning a wooded area in the backyard and came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot Page 10 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS see anything on the skin and asks the nurse what to do. Which of the following is the appropriate nursing response? A. “Come to the emergency department.” B. “Apply calamine lotion immediately to the exposed skin areas.” C. “Take a shower immediately, lathering and rinsing several times.” D. “It is not necessary to do anything if you cannot see anything on your skin.” Ans. C Rationale: When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area with alcohol and then shower immediately and to lather the skin several times and rinse each time in running water 35. When caring for a client with extensive burns, the nurse anticipates that pain medication will be administered via which route? A. Oral B. Intravenous C. Intramuscular D. Subcutaneous Ans.B Rationale: An extensive burn injury causes impairment of muscle and subcutaneous tissue. Additionally, the gastrointestinal tract has decreased perfusion related to the burn injury. Medications administered by mouth, intramuscularly, or subcutaneously are not absorbed consistently as a result of the burn injury. The client may not experience pain relief from these routes of administration and may also receive a sudden bolus of medication at some point after administration, when fluid shifts occur. Therefore options 1, 3, and 4 are incorrect. 36. The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which of the following does the nurse expect to note during the resuscitation/emergent phase of the burn injury? A. Decreased heart rate B. Increased urinary output C. Increased blood pressure D. Elevated hematocrit levels Ans. D Rationale: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, and renal perfusion and glomerular filtration are decreased, resulting in low urine output. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts. 37. The client arrives at the emergency department following a burn injury that occurred in the basement at home and an inhalation injury is suspected. Which of the following would the nurse anticipate to be prescribed for the client? A. 100% oxygen via an aerosol mask Page 11 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS B. Oxygen via nasal cannula at 15 L/min C. Oxygen via nasal cannula at 10 L/min D. 100% oxygen via a tight-fitting, non-rebreather face mask Ans. D Rationale: If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting non-rebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Options 1, 2, and 3 are incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion 38. The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial- thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which of the following would provide the most reliable indicator for determining the adequacy? A. Vital signs B. Urine output C. Mental status D. Peripheral pulses Ans. B Rationale: Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL 39. The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique? A. Using sterile sheets and linens B. Performing strict hand-washing technique C. Wearing gloves and a gown only when giving direct care to the client D. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron Ans C Rationale: Thorough handwashing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used because of the client’s high risk for infection. Protective garb, including gloves, cap, masks, shoe covers, gowns, and plastic apron need to be worn when in the client’s room and when directly caring for the client. 40. The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. Which of the following would the nurse anticipate to be prescribed for the client? A. Out of bed B. Bathroom privileges C. Immobilization of the affected leg D. Placing the affected leg in a dependent position Ans. C Rationale: Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Options 1, 2, and 4 are incorrect. Page 12 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS 41. is a group of nonprogressive disorders of upper motor neuron impairment that result in motor dysfunction? A. Cerebral Palsy B. Meningitis C. Hydro Cephalus D. Brain tumor Ans. A 42. The distorted and uncontrolled proliferation of WBCs (leukocytes) and is the most frequently occurring type of cancer in children A. Leukemia B. Bone Cancer C. Wilms Tumor D. Aplastic Anemia Ans. A 43. Tends to occur in children with atopy or those who tend to be hypersensitive to allergens. Mast cells release histamine and leukotrienes that result in diffuse obstructive and restrictive airway disease because of a triad of inflammation, bronchoconstriction, and increased mucus production A. Asthma B. Bronchitis C. Epiglottitis D. Tonsilitis Ans. A 44. anti-inflammatory effect diminishes inflammatory component of asthma and reduces airway obstruction; preferred controller medicine for all ages A. Corticosteroids B. H2 blocker C. Cephalosporin D. Beta Blocker Ans. A 45. formerly referred to as juvenile diabetes or insulin-dependent diabetes A. DM1 B. DM2 C. Hyperglycemia D. Hypoglycemia Ans. A 46. Inflammatory disease that affects the heart, joints, central nervous system, subcutaneous system. It follows infection with group B-hemolytic streptococcus pharyngitis in 2 – 6 weeks if untreated. A. Rheumatic Heart Disease B. Rheumatic fever C. Rheumatoid Arthritis D. Rheumatic carcinoma Page 13 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS Ans. B 47. is a disease in which there is inflammation (swelling) of the synovium in children aged 16 or younger? A. Juvenile Idiopathic Arthritis B. Rheumatoid Arthritis C. Rheumatic Fever D. None of the above Ans. A 48. Scoliosis is a lateral (sideways) curvature of the spine. It may involve all or only a portion of the spinal column. A. Spina Bifida B. Spina Occulta C. Scoliosis D. Lordosis Ans. C 49. disorder characterized by refusal to maintain a minimally normal body weight because of a disturbance in perception of the body's size or appearance A. Anorexia Nervosa B. Bulimia Nervosa C. Aphasia D. Loss of Appetite Ans. A 50. Therapeutic Management Therapy for patient with Candidiasis? A. Vaginal suppositories or cream applications of antifungal preparations such as miconazole (Monistat) or clotrimazole (Lotrimin), once a day for 3 to 7 days. B. removing a sample of the discharge from the vaginal wall C. An at-home test kit (Vagasil Screening Kit) is available that gives results instantly D. None of the above Ans. A 51. What should be a clinic nurse’s first action when a child tells the nurse of a sore throat? A. Examine the throat B. Have the child sent home C. Take the child’s temperature. D. Secure a prescription for a oral analgesic Ans: A Rationale: the priority is to assess the throat to determine the extent of inflammation. Signiant swelling can create the potential airway obstruction. 52. Range of motion exercise are prescribed for a child with juvenile idiopathic arthritis (JIA). What criterion should the nurse use to evaluate the effectiveness of the exercises? a. Pain is relieved b. Affected joints can flex and extend c. Pedal and radial pulses are diminished d. Subcutaneous nodules at the joints recedes. Page 14 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS Ans. B Rationale: exercises are done to preserve joint function. 53. A nurse is developing a plan of care for an 8-year-old patient who was recently diagnosed with diabetes mellitus type 1. What is the developmental characteristic of the child this age should the nurse consider? A. Child is in abstract level of cognition. B. Child’s dependence on peer influence has reached its peak. C. Child will welcome opportunities for participation in self-care D. Childs developmental stage involves achieving a sense of identity Ans. C Rationale: 8-year-old child is in the stage of industry VS inferiority and strives to complete assigned tasks. 54. When teaching an adolescent with type 1 Diabetes about dietary management, what should the nurse include? a. Meals should be eaten at home b. Foods should be weight on a gram scale. c. Ready source of glucose should be available. d. Specific foods should be cooked for an adolescent. Ans. C Rationale: an adolescent with type 1DM must carry a source of simple sugar to rapidly counteract the effect of hypoglycemia. 55. What treatment should a nurse suggest to an adolescent with type 1 diabetes if an insulin reaction is experienced while at the basketball game? a. Call the parents immediately b. Buy soda and hamburger to eat c. Administer insulin as soon as possible d. Leave the arena and rest until the condition subsides. Ans. B Rationale: the adolescent needs immediate and easily absorbable glucose. 56. A 13-year-old adolescent is diagnosed with idiopathic scoliosis. Because exercise and avoidance of fatigue are essential components of care, which sport should the nurse suggest will be most therapeutic for this condition. a. Golf b. Bowling c. Swimming d. Badminton Ans. C Rationale: hyperextension required in swimming aids in strengthening the back muscles and increases deeper respirations, both of which are necessary before the surgery and/or before wearing brace or cast. 57. To slow the progression of the curvature, the adolescent with scoliosis is fitted with a brace. ow should the nurse respond to the parents’ questions about when the brace will no longer be needed? a. After the cessation of bone growth b. After the curvature has straightened c. When the iliac crests are equal levels Page 15 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS d. When pain-free after prolonged standing Ans. A Rationale: continuing growth causes changes in muscle, bone structure, and position. The brace is worn for 6 months after physical maturity, which confirmed by radiographs showing cessation of bone growth 58. How can a nurse best communicate with adolescents? a. Using teen language b. Relating to peer level c. Establishing a relationship over time d. Interacting by using concrete concepts Ans. C Rationale: several meetings with an adolescent provide an opportunity to establish trust and relationship. 59. inflammation of the air cavities within the passages of the nose. A. Sinusitis B. Bronchitis C. Atelectasis D. Pneumonia Ans. A 60. The following are example of independent nursing intervention except? A. Give oxygen inhalation via nasal cannula for patient with difficulty of breathing. B. Assess respiratory status and breath sounds, noting nasal flaring, the use of accessory muscles, retractions, and the presence of stridor. C. Position the patient on high fowlers position if there is DOB D. Have resuscitation equipment available Ans. A 61..Signs of increase intracranial pressure include the following except? a. High blood pressure b. slow pulse c. rapid pulse d. Bulging fontanels Ans. C 62. Is caused by an imbalance in the production and absorption of cerebral spinal fluid (CSF) in the ventricular system a. Hydrocephalus b. Meningitis c. Septicemia d. Otitis Media Ans. A 63. A type of Hydrocephalus wherein the decreased absorption of the CSF is caused by post meningitis or intraventricular hemorrhage. Page 16 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS a. Communicating b. Non-communicating c. Brain Edema d. Meningitis Ans. A 64. The treatment for hydrocephalus is a. Ventriculoperitoneal Shunts b. Ventriculosubclavian shunts c. Ventrculopapulo shunts d. Ventriculoabdominal shunts Ans. A 65. Confirmatory diagnosis for meningitis is? a. Lumbar puncture b. Biopsy c. X-ray d. Ultrasound Ans. A 66. How to position a patient with hydrocephalus. a. Prone position b. left side lying c. On her abdomen d. Head of bed 30-45 degrees Ans. D 67. Treatment for otitis media a. Feeding techniques b. No bottle propping c. Myringotomy with Pressure Equalizing (PE) tubes d. Health Teaching Ans. C 68. for patient with meningitis a droplet precaution should be implemented for how many hours after the 1st dose of antibiotic. a. at least 48 hrs b. at least 24 hrs c. at least 42 hrs Page 17 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS d. at least 40 hrs Ans. A 69. Is a congenital brain malformation involving the cerebellum and the fluid-filled spaces around it. The key features of this syndrome are an enlargement of the fourth ventricle a partial or complete absence of the area of the brain between the two cerebellar hemispheres (cerebellar vermis), and cyst formation near the lowest part of the skull. a. Chiari malformation b. Dandy-Walker Syndrome c. Hydrocephalus d. Meningitis Ans. B 70. What is an essential nursing action when caring for a young child with severe diarrhea? * a. Maintain the IV b. Take daily weights c. Replace the lost calories d. Promote perianal skin integrity Ans. A 71. After closure of a newborn’s myelomeningocele, what essential nursing intervention must be included in the plan of care? a. Limiting leg movement b. Decreasing environmental stimuli c. Measuring Head circumference only d. Observing for serous drainage from the nares. Ans. C 72. The nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can: a. prepare the child by positive self-talk b. establish a time limit to get ready for the procedure. c. hold and rock him and give him a security object. d. count and sing with the child. Ans. C 73. The parents of an infant who has had a surgical repair of a myelomeningocele express concern about skin care and ask what they can do to avoid problems. The nurse should teach the parents that their infant: a. will require long-term multidisciplinary follow-up care b. should take prophylactic antibiotic therapy indefinitely Page 18 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS c. mut be kept dry by applying powder after each diaper change d. does not need anything more than routine cleansing and diaper changes. Ans. A 74. 5-month-old infant develops severe diarrhea and is given IV fluids. What is the rationale for the nurse to closely monitor the IV flow rate? a. Limiting output b. replacing loss fluids c. Avoid IV infiltration d. Preventing cardiac overload Ans. D 75. A nurse is caring for an infant with bacterial meningitis. The parents ask how their baby could have contracted the illness. What does the nurse consider as the most likely route of transmission to the central nervous system (CNS)? a. Genitourinary tract b. Gastrointestinal tract c. Skin or mucous membrane d. Cranial apertures or sinuses Ans. D 76. The following are chromosomal aberration EXCEPT: a. trisomy 21 b. tranlocation15/21 c. trisomy 15 d. mosaicism Ans. C 77. When teaching the parent of a school-age child about signs and symptoms of fever that require immediate notification of the physician, which of the following descriptions should the nurse include? a. Burning or pain with urination b. Complaints of a stiff neck c. Fever disappearing for longer than 24 hours, then returning History of febrile seizures Ans. B 78. For acute otitis media, the treatment is prompt antibiotic therapy. Delayed treatment may result to complications of; a. tonsilitis b. brain damage c. eardrum perforation Page 19 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS d. Infections Ans. B 79. A toddler is brought to the emergency department with sudden onset of abdominal pain, vomiting, and stools that look like red currant jelly. To confirm intussusception, the suspected cause of these findings, the nurse expects the physician to order: a. a barium enema. b. suprapubic aspiration. c. nasogastric (NG) tube insertion. d. indwelling urinary catheter insertion. Ans.A 80. During a visit to the well-baby clinic, a mother who's breast-feeding her 2-month-old infant expresses concern over the infant's bowel movements. Which statement by the mother would lead the nurse to believe that the infant's bowel movements are normal? a. "The baby's stools are yellow and semi formed." b. The baby's stools are dark green and sticky." c. "The baby's stools are green and watery." d. The baby's stools are bright yellow and sof Ans. D 81. A nurse who is caring for an infant with a clef lip is concerned about preventing an infection. Why does the cleft lip predispose the infant to infection? a. Waste products accumulate along the defect. b. There is inadequate circulation in the defective area. c. Nutrition is inadequate because of ineffective feeding d. Mouth breathing dries the oropharyngeal mucous membrane Ans. D 82. A 6 mos. old client is admitted with possible intussusceptions. which question during the nursing history is least helpful in obtaining information regarding this diagnosis. a. Cab you describe the pain b. What does his vomits look like c. Describe his usual diet d. Have noticed changes in his abdominal size? Ans. B 83. An infant is diagnosed with communicating hydrocephalus, the parents ask for clarification of the health care provider’s explanation of their baby’s problem. How should the nurse respond? a. “Too much spinal fluid is produced within the spaces (ventricles) of the brain”. b.. “The flow of the spinal fluid through the brain cells does not empty effectively into the spinal cord”. c. “The spinal fluid is prevented from adequate absorption by a blockage in the spaces (ventricles) of the brain”. Page 20 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS d. “There is a part of the brain surface that usually absorbs spinal fluid afer its production that is not functioning adequately”. Ans. D 84. The nurse formulates a nursing diagnosis of Risk for infection for a child with Down syndrome. Which condition typically seen in children with this syndrome supports this nursing diagnosis? a. Muscular hypotonicity b. Muscle spasticity c. Increased mucus viscosity d. Hypothyroidism Ans. A 85. What does a nurse determine is the most serious complication of meningitis in young children? a. Epilepsy b. Blindness c. Peripheral circulatory collapse d. Communicating hydrocephalus Ans.C 86. What should a nurse use to feed an infant born with unilateral cleft lip and palate? a. Plastic spoon b. Cross-cut nipple c. Parenteral infusion d. Rubber-tipped syringe Ans.D 87. Which assessment finding would the nurse find in a child with Hirschsprung’s Disease? a. Currant jelly stool b. Diarrhea c. Constipation d. Foul-smelling, fatty stool Ans.D 88. A 1-year-old infant has been admitted with a tentative diagnosis of bacterial meningitis. A lumbar puncture is performed to confirm the diagnosis. What laboratory report the spinal fluid supports this diagnosis? a. Decreased cell count b. Elevated protein level c. Increased glucose level d. Low spinal glucose level Ans. B Page 21 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS 89. An infant with myelomeningocele is admitted to the pediatric intensive care unit (PICU). While the infant is awaiting surgical correction of the defect, what is the most appropriate nursing intervention? a. Using disposable diaper b. Placing the infant in the prone position c. Performing neurologic checks above the site of the lesion d. washing the area below the defect with a nontoxic antiseptic Ans. B 90. A 10-month-old child with recurrent otitis media (middle ear inflammation) is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents: a. "Does water ever get into the baby's ears during shampooing?" b. "Do you give the baby a bottle to take to bed?" c. "Have you noticed a lot of wax in the baby's ears?" d. "Can the baby combine two words when speaking?" Ans.B 91. A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal? a. Preventing infection b. Ensuring adequate hydration c. Providing adequate nutrition d. Preventing contracture deformity Ans. A 92. What is the primary nursing intervention for an infant with a myelomeningocele before surgical correction? a. Minimize infection b. Prevent trauma to the sac c. Observe for increasing paralysis d. Assess the degree of bowel and bladder control. Ans. A 93. What should be the nursing care for an infant after the surgical repair of a cleft lip include? a. Preventing crying b. Placing in a semi-fowler position c. Keeping NPO for 1 day after surgery d. Feeding with a spoon for 2 days after surgery. Ans. A Page 22 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected]) lOMoARcPSD|26067655 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND Cabanatuan City, Nueva Ecija, Philippines ISO 9001:2015 CERTIFIED GENERAL TINIO CAMPUS 94. When developing a postoperative plan of care for an infant scheduled for cleft lip repair, the nurse should assign highest priority to which intervention? a. Comforting the child as quickly as possible b. Maintaining the child in a prone position c. Restraining the child's arms at all times, using elbow restraints d. Avoiding disturbing any crusts that form on the suture line Ans. A 95. Twenty-four hours after birth, a neonate hasn't passed meconium. The nurse suspects which condition? a. Hirschsprung's disease b. Celiac disease c. Intussusception d. Abdominal wall defect Ans. A 96. A baby boy has just had surgery to repair his cleft lip. Which nursing intervention is the most important during the immediate postoperative period? a. Clean the suture line carefully with a sterile solution afer every feeding. b. Lay the infant on his abdomen to help drain fluids from his mouth. c. Allow the infant to cry to promote lung re-expansion. d. Give the baby a pacifier to suck for comfort. Ans. A 97. The pedia nurse is caring for an infant with spina bifida. Which technique is most important in recognizing possible hydrocephalus? a. Magnetic resonance imaging (MRI) b. Obtaining skull X-ray c. Performing a lumbar puncture d. Measuring head circumference Ans. C 98. A nurse in the pediatric clinic is assessing an infant who had a revision of ventriculoperitoneal shunt. Hat clinical finding alerts the nurse that intracranial pressure has increased? a. Increased pulse rate b. Hypoactive reflexes c. decreased blood pressure d. Tension of the anterior fontanel Ans. D 99. A healthy infant has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client’s fluid intake because fluid overload may cause: Page 23 of 24 NEUST-AAF-F001 Transforming Communities through Science and Technology Rev.01 (10.15.2019) Downloaded by Go, J.R. ([email protected])
