MCN REVIEWER PDF

32. The nurse prepares a teaching plan about the 36. Neonatal Intensive Care Unit nurse Janet teaches administration of ear drops for the parents of a handwashing techniques to the parents of an 6-year-old child. The nurse tells the parents that infant who is r...

32. The nurse prepares a teaching plan about the 36. Neonatal Intensive Care Unit nurse Janet teaches administration of ear drops for the parents of a handwashing techniques to the parents of an 6-year-old child. The nurse tells the parents that infant who is receiving antibiotic treatment for a when administering the drops, they should: neonatal infection. Nurse Janet determines that a. Pull the ear up and back the parents understand the purpose of b. Wear Gloves handwashing if they state that this is primarily c. Hold the child in a sitting position done to: d. Position the child so that the affected ear is a. Reduce their fears facing forward b. Minimize the spread of infection to other e. All of the above siblings c. Reduce the possibility of transmitting an 33. Following a cleft lip repair, the nurse instructs the environmental infection to their Infant parents about cleaning of the lip repair site. The d. Allow them an opportunity to communicate nurse uses which solution in demonstrating this with each other and staff procedure to the parents? e. All of the above a. Tap water b. Sterile water 37. A nurse is preparing to care for the mother of a c. Full-strength hydrogen peroxide preterm infant. The nurse plans to begin discharge d. Half-strength hydrogen peroxide planning: a. When the discharge date is set. 34. A nurse is providing home care instructions to the b. When the parents feel comfortable with and parents of an infant who had surgical repair of an can demonstrate adequate care of their inguinal hernia. The nurse instructs the parents to infant. do which of the following to prevent infection at c. When the mother is in labor. the surgical site? d. After stabilization of the infant in the early a. Change the diapers as soon as they become stages of hospitalization. damp e. None of the above b. Report a fever immediately c. Soak the infant in a tub bath twice a day for 38. A nurse provides home care instructions to a the next 5 days mother of an infant with a diagnosis of d. Restrict the infant's physical activity hydrocephalus. Which statement by the mother e. All of the above indicates an understanding of the care for the infant? 35. A nurse is teaching a mother with a DM who a. “I need to keep my infant's head in a delivered a Large for Gestational Age (LGA) male pushed-back position during sleep." infant about care of the infant. The nurse tells the b. “I need to feed my infant in a flat, side-lying mother that LGA infants appear to be more position.” mature because of the large size, and in reality, c. “I need to place my infant on Its stomach with these infants frequently need to be aroused to a towel under the neck for sleep." facilitate nutritional intake and attachment. Which d. “I need to support my infant's neck and statement by the mother indicates the need for head." additional information about care of the infant? e. All of the above. a. “I will talk to my baby when he is in a quiet alert state.” 39. Nurse Jen is preparing a teaching plan for the b. “I will watch my baby closely because I know parents of an infant with a ventricular peritoneum he may not be as mature in motor shunt who will be discharged from the hospital. development.” Nurse Jen plans to include which instruction the c. "I will breastfeed my baby every 2 1/2 to 3 plan of care. hours and will use arousing techniques." a. Call the physician if the infant is fussy d. "I will allow my baby to sleep through the b. Position the infant on the side of the shunt night because he needs his rest." when the infant is put to bed c. Expect an increased urine output from the shunt  d. Call the physician if the infant has a e. All of the above high-pitched cry e. None of the above 44. A nurse is planning care for an infant with a diagnosis of encephalocele located in the occipital 40. Nurse Jane has completed discharge teaching with area. Which item would the nurse use to assist in the parents of a child with glomerulonephritis. positioning the child to avoid pressure on the Which statement by the parents indicates that encephalocele? further teaching is necessary? a. Sheep skin a. “We'll check our child's blood pressure every b. Foam half donut day.” c. Feather pillows. b. "We'll be sure that our child eats a lot of d. Sand bags vegetables and does not add extra salt to e. None of the above food." c. “It'll be so good to have my child back in tap 45. A child with a diagnosis of hepatitis B is being dancing classes next week.” cared for at home. The mother of the child calls d. "We'll test our child's urine for albumin every the health care clinic and tells the nurse that the week.” jaundice seems to be worsening. The nurse which e. All of the above responded to the mother? a. "The hepatitis may be spreading.” 41. A nurse in the pediatric unit is caring for a b. "You need to bring the child to the health care 9-month-old child following cleft palate repair clinic to see the physician." who has elbow restraints applied. The mother c. "The jaundice may appear to get worse asks the nurse to remove the restraints. The nurse before it resolves." takes which appropriate action? d. "It is necessary to isolate the child from the a. Removes both restraints others." b. Tells the mother that the restraints cannot be e. All of the above removed c. Removes a restraint from one extremity 46. On assessment of a child, a nurse notes that the d. Loosens the restraints but tells the mother child's genitals are swollen. The nurse suspects that they cannot be removed that the child is being sexually abused. Which action by the nurse is of primary importance. 42. A nurse is caring for a term infant who is 24 hours a. Document the child's physical findings old who had a confirmed episode of hypoglycemia b. Report the case in which the abuse is at 1 hour of age. Which observation by the nurse suspected would indicate the need for further evaluation? c. Refer the family to appropriate support a. Blood glucose level of 40 mg/dI before the last groups feeding d. Assist the family in identifying resources and b. High-pitched cry, eating 10 to 15 ml of support system formula per feeding e. None of the above. c. Weight loss of 4 ounces and dry, peeling skin d. Breast- feeding for 20 minutes or greater, 47. A mother of a child with mumps called the health strong sucking care clinic to tell the nurse that the child has been e. None of the above lethargic and vomiting. The nurse most appropriate tells the mother: 43. A postpartum client has a nursing diagnosis of Risk a. To continue to monitor the child for Infection. A goal has been developed in those b. That lethargy and vomiting are normal states. "The client will remain free of infection manifestations of mumps during her hospital stay." Which assessment data c. To bring the child to the clinic to be seen by would support that the goal has been met? the physician a. Presence of chills d. That as long as there is no fever, there is b. Abdominal tenderness nothing to be concerned about c. Absence of fever e. All of the above d. Loss of appetite 48. A nurse in the newborn nursery prepares to admit 52. Jose had an open burn. What is the advantage of a newborn infant with spina bifida, an open burn? meningomyelocele type. Which nursing action is a. Allows frequent inspections of the site. most important in the care of this infant? b. Provides better protection from injury. a. Monitor blood pressure c. Does not require strict isolation to prevent b. Monitoring specific gravity of the urine infection. c. Inspecting the anterior fontanel for bulging d. None of the above d. Monitoring temperature Rationale: Keeping a burn wound open e. None of the above (without a dressing) allows healthcare providers to frequently inspect the burn site, 49. A nurse is preparing a plan of care for a child with monitor for signs of infection, and assess the leukemia who is scheduled to receive healing process. This can be particularly chemotherapy. Which intervention will the nurse important in a clinical setting where close include in the plan of care? monitoring is necessary. a. Monitor rectal temperatures every 4 hours b. Monitor mouth and anus each shift for signs 53. The condition of Jose's burned skin was red, of breakdown swollen, and blistered. What is the classification or c. Provide meticulous mouth care several times degree of burn he incurred? daily using an alcohol-based mouthwash and a a. First degree burn toothbrush b. Second degree burn d. Encourage the child to consume fresh fruits c. Third degree burn and vegetables to maintain nutritional status d. Fourth degree burn e. All of the above Rationale: Second-degree burns, also known as partial-thickness burns, affect both the 50. A nursing student is preparing to conduct a clinical outer layer (epidermis) and the underlying conference regarding cerebral palsy. Which layer (dermis) of the skin. These burns are characteristics related to this disorder will the characterized by redness, swelling, and student plan to include in the discussion? blistering. a. Cerebral palsy is a chronic disability characterized by a difficulty in controlling 54. After teaching the parents of a child with febrile muscles. seizures about methods to lower temperature b. Cerebral palsy is an infectious disease of the other than medication, which of the following central nervous system statements indicates successful teaching? c. Cerebral palsy is an inflammation of the brain a. We will add extra blankets when he complains as a result of a viral illness. of being cold. d. Cerebral palsy is a congenital condition that b. We will wrap him in a blanket if he starts results in moderate to severe retardation. shivering. e. None of the above. c. We will make the bath water cold enough to make him shiver. 51. What should the mother do for emergency d. We will use a solution of half alcohol and half management for minor burns? water when sponging him. a. The burn should not be covered with a topical antibiotic. Rationale: Shivering can increase the body's b. Rub sliced fresh tomatoes on the burn site. metabolic rate and subsequently raise body c. Immediately apply cool water to cool the temperature. Wrapping the child in a blanket skin. helps to stop shivering and prevent the body d. Apply toothpaste on the skin. from trying to generate more heat. Rationale: Applying cool (not cold) water to 55. Nurse Cali is planning to give a tepid tub bath to a the burn helps reduce the temperature of the child who has hyperthermia. The nurse plans to. burn area, minimizing tissue damage and a. Obtain isopropyl alcohol to add to the bath reducing pain. This is the recommended initial water. first aid treatment for minor burns.  b. Warm the water to the same body 58. Nurse Diane is describing the underlying cause of temperature of the child. trisomy 21 to a group of parents, integrating c. Have cool water available to add to the bath knowledge that the disorder is due to: water. a. Translocation d. Allow 5 minutes for the child to soak in the b. Duplication bath water. c. Nondisjunction Rationale: Using cool water can help lower d. Deletion the child's body temperature more effectively. Rationale: Nondisjunction is an error in cell The water should be tepid, which means division where the chromosomes do not lukewarm, and having cool water available separate properly, resulting in an extra copy of allows the nurse to adjust the temperature as chromosome 21. This extra chromosome needed to achieve a gradual and safe cooling leads to the characteristics and symptoms effect. associated with Down syndrome. 56. Nurse Bea is collecting a urine sample on a patient 59. The nurse at the Pediatric unit of UCSF Hospital is who is experiencing proteinuria due to nephrotic assessing a 7-year-old girl with down syndrome. syndrome. As the nurse, you know the urine will Which would the nurse be least likely to assess? appear: a. Inspection finds the nasal passages clear and a. Tea-colored open. b. Orange and frothy b. Palpation indicates that the child may be c. Dark and foamy constipated. d. Straw-colored c. Auscultation reveals a definite heart murmur. Rationale: Proteinuria, which is the presence d. The child is significantly underweight. of excess protein in the urine, often causes Rationale: Children with Down syndrome the urine to be foamy or frothy due to the often have anatomical differences that can presence of proteins. The color may vary, but lead to narrowed nasal passages and other it is often described as darker than usual due respiratory issues, making clear and open to the concentration of proteins. nasal passages less likely. 57. Nurse Instructor Dana is providing education to a 60. Baby Boy Adrian with a cleft lip and palate is group of nursing students about nephrotic scheduled for surgical repair. What is the primary syndrome. A student describes the signs and goal of the initial surgical intervention? symptoms of this condition. Which signs and a. Improve speech articulation symptoms verbalized by the student require you b. Enhance facial aesthetics to re-educate the student about this topic? c. Correct feeding difficulties Select-all-that-apply. d. Prevent middle ear infections a. Slight proteinuria Rationale: The initial surgery typically aims to b. Hypoalbuminemia address the most immediate concerns, which c. Tea-colored urine include improving the ability of the baby to d. Hypertension feed properly. While other goals such as Answer: A, C, D improving speech articulation, enhancing Rationale: For nephrotic syndrome, the signs facial aesthetics, and preventing middle ear and symptoms typically include significant infections are also important, they are often proteinuria, hypoalbuminemia, secondary and addressed in subsequent hyperlipidemia, and edema. The student's procedures as the child grows. description of slight proteinuria, tea-colored urine, and hypertension are not characteristic 61. A 3-month-old baby boy Carl with cleft palate of nephrotic syndrome and require presents with poor weight gain. Which feeding re-education. technique is most appropriate for this infant? a. Traditional bottle feeding b. Breastfeeding with a regular nipple c. Paced bottle feeding  d. Spoon feeding What cosmetic procedure may be considered to Rationale: Paced Bottle Feeding is a method improve scar aesthetics? of bottle feeding that allows the infant to be a. Rhinoplasty more in control of the feeding pace. This b. Scar revision surgery feeding method slows down the flow of milk c. Orthodontic treatment into the nipple and the mouth, allowing the d. Cheiloplasty baby to eat more slowly, and take breaks. Rationale: Scar revision surgery aims to 62. A child with repaired cleft lip and palate improve the appearance of a scar by experiences persistent nasal speech. Which minimizing its visibility and improving its healthcare professional is primarily responsible for texture. This procedure can be beneficial for assessing and managing this issue? individuals who are dissatisfied with the a. Pediatrician appearance of their scar following cleft lip b. Speech-language pathologist repair. c. Plastic surgeon d. Otolaryngologist 66. A child with cleft lip and palate requires Rationale: Speech-language pathologists multidisciplinary care. Who coordinates the specialize in the assessment and treatment of various aspects of the child's treatment plan? speech and language disorders. They are the a. Pediatrician primary professionals who manage issues b. Plastic surgeon related to speech articulation, resonance, and c. Care coordinator other communication difficulties, including d. Speech therapist nasal speech. Rationale: A care coordinator plays a crucial role in managing and coordinating the 63. A pregnant woman undergoes prenatal screening different healthcare providers and services and is informed of a possible cleft lip and palate in involved in the care of a child with cleft lip and her unborn child. Which intervention can be palate. helpful in preparing the parents for the child's care? 67. A teenager with repaired cleft lip and palate a. Genetic testing wishes to participate in contact sports. What b. Ultrasound imaging protective measure should be recommended? c. Genetic counseling a. Mouthguard d. Amniocentesis b. Tongue guard Rationale: Genetic counseling involves c. Shin guards providing information and support to d. Knee pads individuals and families who have genetic Rationale: A mouthguard helps protect the conditions or concerns about the risk of teeth, lips, cheeks, and tongue during contact inherited conditions. In the case of a possible sports. It can also help protect any surgical cleft lip and palate, genetic counseling can repairs done for cleft lip and palate, reducing provide detailed information about the the risk of injury to the mouth area. condition, its implications, treatment options, and what to expect after birth. 68. Rebecca, a 7-year-old child, with repaired cleft lip and palate requires speech therapy. Which speech 64. A child with untreated cleft palate is at risk of sound is commonly affected in individuals with developing: cleft palate? a. Vision problems a. /k/q b. Hearing loss b. /p/ c. Skin infections c. C)/m/ d. Respiratory infections d. /s/ Rationale: The reason /p/ (and sometimes 65. A teenager with a repaired cleft lip expresses /b/) is commonly affected is because these dissatisfaction with the appearance of their scar. sounds require a build-up of air pressure in the oral cavity, which can be difficult to  achieve due to the opening in the palate. This the intestine telescopes into another, causing opening can affect the child's ability to control obstruction. This obstruction leads to severe airflow and pressure necessary for producing abdominal pain, drawing up of legs, and clear /p/ sounds. episodes of crying due to pain. The sausage-shaped mass palpated in the abdomen can be the intussuscepted bowel 69. A pregnant woman inquires about the risk factors segment felt through the abdominal wall. for cleft lip and palate. Which factor is associated with an increased risk of cleft lip and palate? 72. A 4-year-old child with a history of cleft palate a. Maternal age repair presents with coughing and choking b. Maternal obesity episodes during meals. On examination, bubbles c. Paternal smoking are noted in the oral cavity when the child drinks d. Family history from a cup. What complication of cleft palate Rationale: A family history of cleft lip and repair is suspected? palate increases the risk for the condition in a. Gastroesophageal reflux disease (GERD) future generations. Genetic factors play a b. Tracheoesophageal fistula (TEF) significant role in the development of cleft lip c. Intestinal obstruction and palate, and having a close relative with d. Esophageal stricture the condition increases the likelihood of it Rationale: Tracheoesophageal fistula is a occurring in offspring. condition where there is an abnormal connection between the trachea (windpipe) 70. A 3-month-old infant presents with projectile and the esophagus. In children with repaired vomiting and abdominal distention. Upon further cleft palate, especially if there were evaluation, an upper gastrointestinal (GI) series complications or if the repair did not reveals a double-bubble sign. What is the most completely close the palate, a TEF can occur. likely diagnosis? This abnormal connection allows air to pass a. Intussusception from the trachea into the esophagus, leading b. Duodenal atresia to bubbles in the oral cavity when the child c. Hirschsprung's disease drinks. d. Meckel's diverticulum Rationale: Duodenal atresia is a congenital 73. A 2-month-old infant presents with bilious condition where there is a blockage or vomiting and abdominal distention. Abdominal complete closure of the duodenum (the first ultrasound reveals a "target sign". What is the part of the small intestine). The most likely diagnosis? double-bubble sign on imaging refers to the a. Intussusception appearance of two air-filled bubbles seen in b. Malrotation with volvulus the stomach and the proximal duodenum, c. Hirschsprung's disease which are dilated due to the obstruction. This d. Meckel's diverticulum sign is characteristic of duodenal atresia. Rationale: Malrotation with volvulus is a condition where there is abnormal rotation of 71. A 6-month-old infant presents with sudden, the intestines during fetal development, severe episodes of crying and drawing their legs leading to a volvulus (twisting) of the intestine toward the abdomen. On physical examination, a around its own mesentery. The "target sign" sausage-shaped mass is palpated in the right on imaging refers to the appearance of upper quadrant of the abdomen. What is the most concentric rings seen on ultrasound or other likely diagnosis? imaging modalities, which is characteristic of a. Appendicitis midgut volvulus. b. Volvulus c. Intussusception 74. Which of the following lifestyle modifications d. Meckel's diverticulum should the nurse encourage a teenager client with Rationale: Intussusception is a medical a hiatal hernia to include in their activities of daily emergency in infants where one segment of living?  a. Daily aerobic exercise. b. Increasing fluid intake. b. Eliminating smoking and alcohol use. c. Avoiding air swallowing with meals. c. Balancing activity and rest. d. Adding a bedtime snack to the dietary plan. d. Avoiding high-stress situations. Rationale: Eating small, frequent meals helps Rationale: Smoking and alcohol use can reduce the amount of food in the stomach at exacerbate symptoms of hiatal hernia by any given time, which can decrease the increasing stomach acid production and likelihood of reflux episodes. This approach relaxing the lower esophageal sphincter, helps prevent overfilling the stomach, which which can lead to acid reflux and discomfort. can contribute to increased pressure on the Therefore, eliminating these substances from lower esophageal sphincter (LES) and promote the teenager's lifestyle can help improve reflux. symptoms and prevent complications associated with hiatal hernia. 78. Which of the following maternal behaviors increases an infant's risk for hypertrophic pyloric 75. In developing a teaching plan for the client with a stenosis? hiatal hernia, the nurse's assessment of which a. Alcohol consumption work-related factors would be most useful? b. Consumption of fish high in mercury a. Number and length of breaks. c. Marijuana consumption b. Body mechanics used in lifting. d. Cigarette smoking c. Temperature in the work area. Rationale: Cigarette smoking by the mother d. Cleaning solvents used. during pregnancy has been identified as a risk Rationale: factor for hypertrophic pyloric stenosis (HPS) in infants. Studies have shown an association 76. The parent of a two-year old client asks the nurse between maternal smoking and an increased whether her child will need surgery to correct his incidence of HPS in newborns. hiatal hernia. Which reply by the nurse would be most accurate? 79. Which of the following clinical manifestations a. "Surgery is usually required, although medical suggests pyloric stenosis? treatment is attempted first." a. Regurgitation b. "Surgery is not performed for this type of b. Projectile vomiting hernia." c. Bloody stool c. "A minor surgical procedure to reduce the size d. Steatorrhea of the diaphragmatic opening will probably be Rationale: Projectile vomiting is a hallmark planned." symptom of pyloric stenosis. It typically occurs d. "Hiatal hernia symptoms can usually be shortly after feeding and is forceful, projecting successfully managed with diet a significant distance from the infant. This modifications, medications, and lifestyle occurs because the narrowed pyloric opening changes." obstructs the passage of food from the Rationale: In pediatric cases, hiatal hernias stomach to the small intestine, causing the often do not require surgical intervention stomach to forcefully eject its contents. unless they are severe or causing significant symptoms that cannot be managed with 80. A child with acute otitis media is put on conservative measures. For many children antibiotics. The caregivers ask when the child will with hiatal hernias, symptoms such as reflux be better. The nurse will explain that, when or regurgitation can often be controlled treated with antibiotics, an acute otitis media will through dietary adjustments, medications to begin to resolve in how many days? reduce stomach acid, and lifestyle changes. a. 2-3 b. 4-5 77. Which of the following dietary measures would be c. 7 useful in preventing esophageal reflux in patients d. 14 with pyloric stenosis? a. Eating small, frequent meals.  Rationale: Antibiotics are effective in treating c. Ventriculoperitoneal (VP) bacterial infections associated with acute d. Ventriculopleural otitis media. Improvement in symptoms such Rationale: most common type of shunt used as ear pain and fever can often be noticed for infants with hydrocephalus. The VP shunt within the first 2-3 days of starting antibiotic diverts the excess cerebrospinal fluid from the treatment. ventricles in the brain to the peritoneal cavity, where it can be absorbed by the body. 81. A nurse is assessing a new admission. The 6- 85. Which of the following clinical assessments would month-old infant displays irritability, bulging be included when caring for an infant with fontanels, and setting-sun eyes. The nurse would hydrocephalus? suspect? a. Ataxia a. Increased intracranial pressure b. Increased head circumference b. Hypertension c. Papilledema c. Skull fracture d. Vomiting d. Myelomeningocele Rationale: This is a key indicator of hydrocephalus in infants due to the expansion Rationale: Irritability, bulging fontanels (the of the ventricles and accumulation of soft spots on a baby's head), and setting-sun cerebrospinal fluid, which causes the head to eyes (downward deviation of the eyes) are enlarge. classic signs of increased pressure within the 86. Marlyn delivered a baby boy which was admitted skull. in the NICU. She observes that her baby is in a prone position and there is something protruding 82. Which of the following interventions would be from the baby's back, Nurse Evan informs her that included in the care plan to prevent the most her child has myelomeningocele and the one that serious shunt complication? she is seeing in the back is? a. Checking for inflammation at operative site a. There is usually no sign of a defect and shunt tracts b. The meninges b. Observing behavior, blood pressure, and pulse c. A layer of fat c. Positioning carefully, flat on operative side d. The meninges and the spinal cord care Rationale: In a myelomeningocele, which is a d. Providing meticulous skin type of neural tube defect, the spinal cord and Rationale: Prompt identification and the meninges (protective membranes treatment of infection can prevent further surrounding the spinal cord) protrude through complications and shunt failure. an opening in the vertebrae. This protrusion is typically visible on the baby's back as a sac-like structure. 83. When assessing children for early signs of 87. Nurse Evan is conducting his health teaching on increased intracranial pressure (ICP), the nurse pediatric disorders. He discusses spina bifida and monitors the child for which of the following? understands that the symptoms of spina a. Altered pupil reactivity Bifida/spinal injury include: b. Decreased level of consciousness (LOC) a. Loss or no bowel and bladder control c. Early morning headache b. Partial or complete paralysis d. Papilledema c. Weakness of hips, legs and feet Rationale: most appropriate sign to monitor d. All of the above for early detection of increased intracranial Rationale: Basta yan yung sagot HAHAHA pressure in children. 88. Nurse Jeremy shows how body moves involving injury to the cerebral cortex or motor pathways, 84. When planning the postoperative care of an infant he explains that this is what type of cerebral with hydrocephalus, which of the following would palsy? the nurse expect as the most common type of a. Athetoid CP shunt used? b. Spastic CP a. Ventricular bypass c. Ataxic CP b. Ventriculoatrial (AV) d. Intractable seizures  e. Speech disorders Rationale: most appropriate first step in Rationale: Spastic cerebral palsy is managing spasticity in a patient with cerebral characterized by increased muscle tone palsy. It emphasizes non-invasive and holistic (hypertonia) and stiffness, which can lead to approaches to improve muscle function and difficulty with movement and coordination. It mobility. is the most common type of cerebral palsy, 92. It is an Inflammation from the immune response affecting around 70-80% of individuals with that leads to fibrin deposits on the endocardium CP. and valves in particular the mitral valve, as well as 89. Marilou is taking care of her patient with spastic in the major body joints. Which of the following is cerebral palsy. She knows her patient will exhibit an autoimmune disease that occurs as a reaction the following except for one. to a group A beta-hemolytic streptococcal a. Cerebral palsy is a disorder of movement and infection. posture a. Rheumatic heart disease b. It is caused by a permanent and b. Rheumatic Fever non-progressive cerebral lesion acquired early c. Endocarditis in brain development d. None of the above c. The clinical picture changes as the child grows Rationale: Rheumatic fever is an autoimmune and develops disease that can develop as a complication d. There is a delay in appearance of primitive following a group A beta-hemolytic reflexes streptococcal throat infection, such as strep e. Tone may be reduced at first presentation throat. It is characterized by inflammation that Rationale: In spastic cerebral palsy, individuals can affect various parts of the body, including typically present with increased muscle tone the heart (leading to rheumatic heart disease (hypertonia) rather than reduced tone if untreated) and major joints (leading to (hypotonia). Spasticity refers to the increased arthritis). resistance to passive movement of muscles, 93. The source of streptococcal infections are the which is a hallmark feature of spastic cerebral following: EXCEPT palsy. a. Pharyngitis, tonsillitis 90. Karen has a child with cerebral palsy. She was b. Scarlet fever thinking about how she had a child with this c. Strep throat or impetigo condition. Upon visit in the clinical the d. Fever pediatrician tells her that the following puts her at Rationale: Fever is not a source of risk to have this kind of child except: streptococcal infection but rather a symptom a. Joint dislocation that can accompany these infections. b. Contractures 94. When assessing a child with Rheumatic Fever, the c. Poor growth following noticeable minor signs are; EXCEPT d. Epilepsy a. Fever Rationale: poor growth is not typically b. History of previous Rheumatic Fever, Elevated considered a risk factor for having a child with ESR cerebral palsy. The condition is primarily c. Carditis, Erythema marginatum related to prenatal, perinatal, or postnatal d. Arthralgia factors that affect brain development or cause Rationale: Major sign kasi yung carditis, brain injury. erythema marginatum 91. Jane was assigned to the pediatric unit and 95. Dave, an infant, was brought by his mother to the handles patients with CP she observed tahallis hospital after being circumcised in a clinic. The pastor What does Nurse Jane must do first. mother noticed that bleeding did not stop Upon a. Intramuscular botulinum toxin Assessments the nurse understand that the b. Intrathecal baclofen via a subcutaneous pump condition of the infant is called; infusion a. Hemophilia c. A program of exercises and postural b. Haemophilus influenza management c. Hemorrhage d. Vitamin supplements d. All of the above e. Lightweight splints  Rationale: Hemophilia often is recognized first a. 10% of Normal in the infant who bleeds excessively after b. 50% of Normal circumcision c. 50-80% of Normal 96. Management for hemophilia are the following; d. 100% of Normal EXCEPT Rationale: In patients with severe hemophilia a. Administration of factor VIII supplied by fresh A who have evident joint or intramuscular whole blood bleeding, the transient goal is to raise the b. Administration of fresh or frozen plasma factor VIII level to 100% of normal. This c. Administration of Concentrate of Factor VIII ensures adequate clotting factor activity to d. Concentrate of factor x IU control bleeding effectively. Rationale: D. lang yung wala sa notes 100. The student nurse asks the staff nurse what is 97. Hemophilia C, or plasma thromboplastin the cause of the hemophilia? What is the antecedent deficiency is caused by which of the appropriate reply of the nurse? following factor deficiency; a. Virus a. factor XI deficiency, transmitted as an b. Genetic Mutation autosomal recessive trait, and occurs in both c. Bacteria sexes. d. Unknown b. factor XX deficiency, transmitted as an Rationale: These genetic mutations are autosomal recessive trait, and occurs in both inherited in an X-linked recessive pattern, sexes. meaning the defective gene is located on the c. factor XI deficiency, transmitted as an X chromosome. Males are more commonly autosomal recessive trait and occurs in female affected because they have only one X sex. chromosome (XY), whereas females have two d. None of the above X chromosomes (XX) and are typically carriers Rationale: Hemophilia C, also known as factor unless they inherit two defective copies of the XI deficiency, is indeed caused by a deficiency gene. of factor XI, which is involved in the intrinsic pathway of blood coagulation. It is inherited as an autosomal recessive trait, meaning both copies of the gene (one from each parent) must be affected for the individual to have the disorder. It can affect both males and females. 98. Haemophilia is suspected in patients with recurrent bleeding, unexplained hemarthrosis, or a prolongation of the PPT. If hemophilia is suspected, PPT, PT, Platelet count, and clotting factor VIII and IX assay are obtained. Measure of which of the following can determine whether a female is a true carrier of hemophilia A? a. PPT b. PT c. Clotting factor VII d. Clotting factor IX Rationale: C tamang sagot if typo yan na dapat VIII 99. If symptoms suggest bleeding, treatment should begin immediately, even before diagnostic tests are completed. Replacement of the deficient factors is the primary treatment. If severe joints or intramuscular bleeding is already evident in patients with hemophilia A, the factor VIII level should be raised transiently to which of the following?