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15 Cards in this Set
- Front
- Back
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An adolescent with scoliosis is being fitted for a brace. Which statement by the teen is most indicitative of successful teaching by the nurse?
A. "I am glad I will only have to wear the brace for for a couple of months." B. "I can take the brace off for special occasions like the prom C. "I should wear the brace all the time except for the one hour daily for bathing." D. "I am glad the brace will correct the curve." |
A. "I am glad I will only have to wear the brace for
for a couple of months." (Will be much longer than a couple of months) B. "I can take the brace off for special occasions like the prom." (Everything could be seen as special and a reason to take off the brace) C. "I should wear the brace all the time except for the one hour daily for bathing." (CORRECT, less than 23 hours a day will not keep consistent forces on the spine and prevent progression of the curve. The hour also gives them the opportunity for skin assessment and strengthening exercises) D. "I am glad the brace will correct the curve." (Will not correct, just limit the) progression |
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The nurse taking care of an infant with bacterial meningitis who is seizing. The nurse reviews the MAR for the baby's medication orders. She notes the child has an order for which of the following anticonvulsants PRN for seizures?
A. Depakene B. Ativan C. Phenytoin D. Diazepam |
A. Depakene for long term management of seizure disorders
B. Ativan for sedation and antianxiety C. Phenytoin CORRECT for control of and prevention of acute seizures D. Diazepam for anxiety disorders and pre-op sedation |
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The nurse documenting the mothers report of stool patterns in a 9 month old with Hirschsprung Disease is not surprised to have the mother report which pattern of stooling.
A. stools are watery and green B. stools are ribbon like and foul smelling C. stools are pasty and tan in color D. stools are streaked with old blood |
A. stools are watery and green (describes diarrhea)
B. stools are ribbon like and foul smelling (CORRECT stool has been in colon a long time and is squeezed past tight internal sphincter) C. stools are pasty and tan in color (nutritional deficit) D. stools are streaked with old blood (reflect possible GI bleed) |
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Upon return to the room from the OR, the nurse's priority assessment for a child who has had a colostomy done for Hirschsprung Disease would be:
A. assessment of bowel sounds B. patency of the nasogastric tube C. hydration status D. nutritional status |
A. assessment of bowel sounds (will indicate the return of gastric function but not immediately post op)
B. patency of the nasogastric tube (CORRECT following this surgery the patient will have no bowel activity, without gastric decompression the patient will become distended and vomit risking the possibility of aspiration) C. hydration status (this child will have an IV infusing post op and has no risk factors for dehydration) D. nutritional status (this is not an immediate concern) |
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The mother of an infant with Pyloric Stenosis tells the nurse, "I feel like such a failure. He vomits everything I feed him." The nurse's best response is:
A. "the vomiting will stop as soon as the baby has the surgery" B. "show me how you hold the baby to feed him and burp him" C. "does he vomit if his father or anyone else feeds him?" D. "you sound frustrated, let's talk about your feelings” |
A. "the vomiting will stop as soon as the baby has
the surgery" (while the vomiting “should” stop, there is no guarantee) B. "show me how you hold the baby to feed him and burp him" (feeding position and burping have nothing to do with this infant’s vomiting) C. "does he vomit if his father or anyone else feeds him?" (this would only lead the mother to think even more that it may he “her”) D. "you sound frustrated, let's talk about your feelings” (CORRECT, this mom needs to be encouraged to ventilate her concern and allow the nurse to provide information and reassurance) |
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In planning care for a toddler who is hospitalized, the nurse includes which of the following approaches in this child's care? Check all that apply
A. pay attention to the child's efforts to feed self B. maintain the same expectations for toilet training as at home C. provide opportunities for toddler to exercise their will D. maintain comsistency of care and provide a secure environment |
A. pay attention to the child's efforts to feed self (CORRECT this child is in the autonomy stage of development)
B. maintain the same expectations for toilet training as at home (not realistic, the stress of hospitalization may lead to regression) C. provide opportunities for toddler to exercise their will (CORRECT, this is what Autonomy is all about) D. maintain comsistency of care and provide a secure environment (CORRECT, the child needs to feel comfortable in an environment in which he can exert his growing independece) |
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The family of an infant with pyloric stenosis asks
the nurse to clarify some of the information the doctor told them. The nurse should include which of the following in the explanation? Check all that apply A. the exact cause of PS is unknown B. the emesis of the infant is typically green C. the pyloric muscle thickens and enlarges D. the baby is hungry and will want to eat in spite of the vomiting |
A. the exact cause of PS is unknown (CORRECT)
B. the emesis of the infant is typically green (no, the stomach contents have not reached the bile duct yet) C. the pyloric muscle thickens and enlarges (CORRECT the muscle is hypertrophic!) D. the baby is hungry and will want to eat in spite of the vomiting (CORRECT, this disorder is not accompanied by other signs of a gastrointestional disorder) |
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The nurse working with an infant immediately following the repair of a cleft lip places priority on which of the following?
A. pain relief B. family education C. protection of the suture line D. range of motion to extremities |
A. pain relief (important but safety first)
B. family education (this should have been done preoperatively) C. protection of the suture line (CORRECT, disruption of the sutures would require additional surgery) D. range of motion to extremities (restraints should be removed one at a time for range of motion, but this is not the priority) |
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The nurse is preparing to do the discharge teaching for the family of a 2 month old diagnosed with GER who has been started on Reglan (metoclopramide). The family questions the effects of this drug. The nurse responds:
A. this drug will increase stomach motility and enhance stomach emptying B. this drug will buffer the acid in the infants stomach and prevent irritation C. this drug will decrease the production of gastric acids that cause mucosal ulceration D. this drug will coat irritated areas of the gastric lining and promote healing |
A. this drug will increase stomach motility and enhance stomach emptying (CORRECT, Reglan is a dopamine blocker)
B. this drug will buffer the acid in the infants stomach and prevent irritation (not an antacid) C. this drug will decrease the production of gastric acids that cause mucosal ulceration (not a histamine blocker) D. this drug will coat irritated areas of the gastric lining and promote healing (not a gi protectant, antiulcer medication) |
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The definitive diagnosis to determine if a child has bacterial meningitis is based on which of the following findings in the CSF obtained by lumbar puncture?
A. white blood cell count B. gram stain and culture C. protein level D. glucose level |
A. white blood cell count (could also be indicitative of viral meningitis)
B. gram stain and culture (CORRECT will not only identify the organism, but determine the appropriate drug treatment) C. protein level (may be suggestive of bacterial meningitis, but not diagnostic) D. glucose level (often also decreased in viral meningitis) |
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A goal for an infant with bacterial meningitis is to prevent injury related to central nervous system irritability and seizures. This goal would best be achieved by doing which of the following?
A. tape a padded tongue blade to the head of the infant’s crib B. place the infant in a room away from the nurses’ station to minimize stimulation C. pad the side rails of the infant’s crib D. place the infant in High Fowlers position |
A. tape a padded tongue blade to the head of the infant’s crib (no longer suggested)
B. place the infant in a room away from the nurses’ station to minimize stimulation (infants with meningitis need to be placed close to the nurses’ station so they can be observed) C. pad the side rails of the infant’s crib (CORRECT, this will not prevent a seizure but would prevent injury to the infant during a seizure) D. place the infant in High Fowlers position (slight elevation of the head of the bed will help decrease intracranial pressure, but High Fowlers is not appropriate) |
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Communication with an adolescent can be enhanced by
A. realization that adolescents are not able to comprehend most adult concepts B. using concrete examples because adolescents do not understand hypothetical situations C. discourage conversations about trivial matters D. listen without showing surprise, disapproval or trivialization of matters discussed |
A. realization that adolescents are not able to comprehend most adult concepts (adolescents have mature cognitive reasoning)
B. using concrete examples because adolescents do not understand hypothetical situations (teens have the ability for abstract thinking) C. discourage conversations about trivial matters (may not be trivial to the adolescent) D. listen without showing surprise, disapproval or trivialization of matters discussed (CORRECT, the teen needs to be validated to support their developing sense of identity) |
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The nurse in the emergency room is admitting a child with 20 % TBSA burns to the chest and upper back, who has been found under the bed in a smoke filled room in a house fire. The nurse monitors the child closely for which priority nursing diagnosis for a potential complication of this type of burn injury?
A. ineffective airway clearance B. impaired skin integrity C. pain D. risk for infection |
A. ineffective airway clearance (CORRECT, hx of a closed space burn, consider the potential inhalation injury)
B. impaired skin integrity (yes, but not priority) C. pain (again a concern, but not above airway) D. risk for infection (again a concern, but not above airway) |
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The nurse knows that fluid resuscitation for a burn victim is vital what is the correct amount of fluid needed for a 9kg baby, with a 15% TBSA burn in the first 24 hours following the burn?
A. 810 mls B. 405 mls C. 270 mls D. 135 mls |
A. 810 mls this would be 6mls/kg/%tbsa "too much"
B. 405 mls CORRECT, this is 3mls/kg/ tbsa "remember start low and go up!" C. 270 mls this would be the upper limit for adult per kg, not enough for a child D. 135 mls this is also too low |
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The nurse would expect which of the following children and their families to have the greatest degree of anxiety concerning hospitalization
A. John the 3rd child in the family, one week old, admitted for phototherapy for high billirubin level B. Lindsey, age seven, admitted for regulation of blood sugar and evaluation for an insulin pump C. Tom, nine years old, who was hit by a car on his bike and was not wearing his helmet D. David, age thirteen, who has Cystic Fibrosis, admitted to the hospital for a “tune up” |
A. John the 3rd child in the family, one week old, admitted for phototherapy for high billirubin level (this is a veteran family with prior experience with infants)
B. Lindsey, age seven, admitted for regulation of blood sugar and evaluation for an insulin pump (this family is in a health seeking state with the potential for improving the health status of this child) C. Tom, nine years old, who was hit by a car on his bike and was not wearing his bike helmet (CORRECT, this family is likely in crisis mode and experiencing a sense of guilt surrounding the accident) D. David, age thirteen, who has Cystic Fibrosis, admitted to the hospital for a “tune up” (tune ups are elective hospitalizations for adjustment of the treatment plan, should not create significant anxiety ) |
