73.
The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation?■ 1. Standard precautions.
■ 2. Contact precautions.
■ 3. Airborne precautions.
■ 4. Droplet precautions.
74.
The nurse manager on a pediatric fl oor is reviewing national sentinel event alerts and prepar- ing recommendations for the unit. Which strategy would help reduce pediatric medication errors?Select all that apply.
■ 1. Eliminate the pediatric satellite pharmacy.
■ 2. Increase the steps in the medication adminis- tration procedure.
■ 3. Utilize only oral syringes to administer oral medication.
■ 4. Limit the size of I.V. fl uid bags that can be hung on small children.
■ 5. Reduce the available concentrations or dose strengths of high alert medications to the minimum.
75.
The physician orders carbamazapine extended release (Tegretol-XR) for a client with a cerebral palsy who also has a seizure disorder.The client has a gastrostomy feeding tube, and carbamazapine is on the hospital’s “no crush” list.
In order to administer the medication, the nurse should:
■ 1. Cut the medication into four pieces that can be placed in the feeding tube.
■ 2. Dissolve the medication in 30 mL’s of juice.
■ 3. Ask the pharmacist for an oral suspension.
■ 4. Contact the primary care provider to change the order.
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and watched closely. However, the parents can fondle and stroke the neonate.
CN: Psychosocial adaptation;
CL: Synthesize
6.
1. Excessive cerebrospinal fl uid in the cranial cavity, called hydrocephalus, is the most common anomaly associated with myelomeningocele. Micro- encephaly, an abnormally small head, is associated with maternal exposure to rubella or cytomegalovirus.Anencephaly, a congenital absence of the cranial vault, is a different type of neural tube defect. Overriding of the sutures, possibly a normal fi nding after a vaginal delivery, is not associated with myelomeningocele.
CN: Physiological adaptation; CL: Apply
7.
1. Approximately one-third of infants diag- nosed with myelomeningocele are mentally retarded, but the degree of retardation is variable and it is diffi cult to predict intellectual functioning in neo- nates. The parents are asking for an answer now and should not be told to talk with the physician later.CN: Physiological adaptation;
CL: Synthesize
8.
2. The nurse places the neonate with myelomeningocele in an isolette shortly after birth to help to maintain the infant’s temperature.Because of the defect, the neonate cannot be bun- dled in blankets. Therefore, it may be diffi cult to prevent cold stress. The isolette can be maintained at higher than room temperature, helping to main- tain the temperature of a neonate who cannot be dressed or bundled. Body temperature readings, not arterial oxygen levels, are the best indicator. Typi- cally, an infant loses 5% to 10% of body weight before beginning to regain the weight.
CN: Reduction of risk potential;
CL: Analyze
9.
1, 3, 5. Prior to surgery, the neonate with a myelomeningocele should be placed in a prone position. The feet can hang over the edge of the mattress to prevent foot deformities. The neonate should rest on a soft surface to reduce pressure on the skin; the nurse can use a fl eece pad or foam over the mattress. The meningeal sac should not be cov- ered. The hips should be maintained in abduction using a diaper roll or small pillow.CN: Basic care and comfort;
CL: Synthesize
10.
2. Because of the potential for hip dislocation, the neonate’s legs should be slightly abducted, hips maintained in slight to moderate abduction, and feet maintained in a neutral position. The infant’s knees are fl exed to help maintain the hips in abduction.CN: Reduction of risk potential;
CL: Synthesize
2.
3. Before surgery, the infant is kept fl at in the prone position to decrease tension on the sac. This allows for optimal positioning of the hips, knees, and feet because orthopedic problems are com- mon. The supine position is unacceptable because it causes pressure on the defect. Flexing the knees when side lying will increase tension on the sac, as will placing the infant in semi-Fowler’s position, even though the chest and abdomen are elevated.CN: Physiological adaptation;
CL: Synthesize
3.
2, 3, 4. Prevention of urinary tract infections includes adequate fl uid intake, urine acidifi cation, frequent emptying of the bladder including the use of the Crede’s maneuver if needed. While the nurse should keep the skin clean and dry, this will not prevent urinary tract infections. Keeping urine close to the meatus with a tight-fi tting diaper would increase the risk for infection.CN: Reduction of risk potential;
CL: Create
4.
2. A Chiari malformation obstructs the fl ow of cerebral spinal fl uid resulting in hydrocephalus. This is a common problem in infants with myelomenin- gocele and will require surgical intervention with a shunt. A high-pitched cry is one sign of increased intracranial pressure that may indicate the presence of a Chiari malformation and requires further evalu- ation. Minimal movement of the lower extremities is an expected fi nding associated with spinal cord damage. Overfl ow voiding comes from a neurogenic bladder, not increased intracranial pressure. It is normal for the fontanel to bulge with crying.CN: Physiological adaptation;
CL: Analyze
5.
1. The parents should see the neonate as soon as possible, because the longer they must wait to see the neonate, the more anxiety they will feel.Because the parents are acutely aware of the defi cit, the nurse should emphasize the neonate’s normal and positive features during the visit. All parents, but especially those with a child who has a dis- ability or defect, need to hear positive comments and comments that refl ect how the infant is normal.
Although the parents need to discuss their fears and concerns, the priority on the fi rst visit is to empha- size the neonate’s normal and positive features.
Reinforcing the doctor’s explanation of the defect may be necessary later. Reinforcing the explanation at this initial visit emphasizes the defect, not the child. The parents should spend time with or care for the neonate after birth because parent-infant contact is necessary for attachment. The parents cannot feed the neonate before the defect is repaired because the repair typically occurs within 24 hours.
The infant will be prone in an isolette or warmed
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common. Asking about the skin rash is not a priority when a child is wheezing. Who brought the child to the emergency department is irrelevant at this time.
CN: Reduction of risk potential;
CL: Analyze
The Client with Hydrocephalus
15.
2. An infant with hydrocephalus is diffi cult to feed because of poor sucking, lethargy, and vomit- ing, which are associated with increased intracranial pressure. Small, frequent feedings given at times when the infant is relaxed and calm are tolerated best. Feeding an infant before any procedure is inap- propriate because the stress of the procedure may lead to vomiting. Ideally, the infant should be held in a slightly vertical position when feeding to pre- vent backfl ow of formula into the eustachian tubes and subsequent development of ear infections. Most infants are fed on demand every 3 to 4 hours.CN: Basic care and comfort;
CL: Synthesize
16.
4. For at least the fi rst 24 hours after insertion of a ventriculoperitoneal shunt, the child is posi- tioned supine with the head of the bed fl at to prevent too rapid a decrease in cerebrospinal fl uid pressure.Although elevating the head increases cerebrospinal fl uid drainage and reduces intracranial pressure, a rapid reduction in the size of the ventricles can cause subdural hematoma. Positioning on the opera- tive or right side is avoided because it places pres- sure on the shunt valve, possibly blocking desired drainage of the cerebrospinal fl uid. Elevating the foot of the bed could increase intracranial pressure.
With continued increased intracranial pressure, the child would be positioned with the head of the bed elevated to allow gravity to aid drainage. The child should be kept off the nonoperative side (side oppo- site the shunt), or the left side, to help prevent rapid decompression leading to a cerebral hematoma.
CN: Reduction of risk potential;
CL: Synthesize
17.
3. Monitoring the temperature allows the nurse to assess for infection, the most common and most hazardous postoperative complication after ventroperitoneal shunt placement. Typically, pain after insertion of a ventriculoperitoneal shunt is mild, requiring the use of mild analgesics. Usually narcot- ics are not administered because they alter the level of consciousness, making assessment of cerebral function diffi cult. Neither proteinuria nor glycosuria is associated with shunt placement. Cerebrospinal fl uid leakage commonly occurs with head injury. It is not usually associated with shunt placement.CN: Reduction of risk potential;
CL: Synthesize
11.
3. In a neonate with open cranial sutures, increasing head circumference is the predominant and earliest sign of increased intracranial pressure and the nurse should report this to the surgeon.Bulging fontanels also are seen. However, some neonates may exhibit bulging fontanels without head enlargement. Seizures and vomiting are associ- ated with hydrocephalus, but most often these are seen in an older child with closed cranial sutures.
Shortly after increasing head circumference and bulging fontanels occur, other signs and symp- toms, such as frontal bossing or enlargement with depressed eyes and the sunset sign (sclera visible above the iris), may develop. Although irritability is an early sign, a brief, shrill cry is a later sign of increasing intracranial pressure associated with the development of hydrocephalus.
CN: Physiological adaptation;
CL: Analyze
12.
4. The most important aspect of the dis- charge plan is to ensure that the parents understand what the daily care of their infant involves and to provide teaching related to carrying out this daily care. In addition to the routine care required by the infant, care also may include physical therapy to the lower extremities. Providing a list of available hospital services may be helpful to the parents, but it is not the most important aspect to include in the discharge plan. Usually, home health care is not needed because the parents are able to care for their child. A referral for counseling is initiated whenever the need arises, not just at discharge.CN: Reduction of risk potential;
CL: Synthesize
13.
3. Children with a myelomeningocele are prone to urinary tract infections (UTI) and foul smelling urine is one symptom of a UTI. Because of the level of defect, the child may be insensitive to pressure or heat. Using a heating pad may lead to thermal injury because the child may not be able to sense if the pad is too hot. Keeping the child away from other children is unnecessary and can retard social development. Using pillows as props increases the risk of sudden infant death syndrome.CN: Safety and infection control;
CL: Evaluate
14.
3. Children with myelomeningocele are at high risk for development of latex allergy because of repeated exposure to latex products during surgery and bladder catheterizations. Cross-reactions to food items such as bananas, kiwi, milk products, chestnuts, and avocados also occur. These allergic reactions vary in severity ranging from mild (such as sneezing) to severe anaphylaxis. While the child could have allergies to medications that caused the wheezing, the latex and food allergies are moreBillings_Part 2_Chap 2_Test 7.indd 287
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nutritious meals or letting the child play with more able children have not been supported by research as benefi cial in increasing intelligence. Vasodila- tor medications act to increase oxygenation to the tissues, including the brain. However, these medica- tions do not increase the child’s IQ.
CN: Health promotion and maintenance;
CL: Synthesize
23.
4. When teaching the parents of a child with Down syndrome, activities should focus on increas- ing the parents’ confi dence in their ability to care for the child. The parents must continue to work daily with their child. Most parents feel affection and a sense of responsibility for their child regardless of the child’s limitations. Parents usually understand the child’s disability on the cognitive level but have diffi culty accepting it on the emotional level.As the parents’ confi dence in their caring abilities increases, their understanding of the child’s disabil- ity also increases on all levels.
CN: Psychosocial adaptation; CL: Create
24.
4. When responding to a mother who becomes angry when someone calls her child mentally retarded instead of exceptional, the nurse should give the mother a chance to explore her feel- ings on the subject. Because the mother obviously has diffi culty with the term “retarded,” stressing the use of this term would cause further angry feelings.Apologizing, trying to use logic, and defending the comment are not effective ways to handle the situation because the mother’s feelings need to be addressed.
CN: Psychosocial adaptation;
CL: Synthesize
The Client with a Seizure Disorder
25.
3. Ease the child to the fl oor.
2. Clear the area of potentially harmful objects and pad the head.
4. Roll the child to the side.
1. Note the time.
The nurse should very quickly check the time the seizure begins to be able to determine its length. Sei- zure duration will determine the need for immediate additional interventions. Anyone who is standing or sitting needs to be lowered to the fl oor to prevent a fall injury. The next step is to prevent potential
18.
4. In a school-age child, irritability, lethargy, vomiting, diffi culty with eating, and decreased level of consciousness are signs of increased intracranial pressure caused by a blocked shunt. Decreased urine output with stable fl uid intake indicates fl uid loss from a source other than the kidneys. A tense fontanel and increased head circumference would be signs of a blocked shunt in an infant. Elevated temperature and redness around incisions might suggest an infection.CN: Reduction of risk potential;
CL: Evaluate
The Client with Down Syndrome
19.
1, 2, 3. The defi nition of mental retardation includes defi cits in intellectual functioning and behavior. The child’s IQ will be 70 or less and he will have diffi cult learning. The client cannot adapt to situations in a manner consistent with children with higher IQs. The client does not have a normal intellectual capacity to learn and develop from his experiences. The client may have behavioral prob- lems but these are not considered a result of mental retardation.CN: Health promotion and maintenance;
CL: Evaluate
20.
1. Watching the child relate to his teacher and school work is the best indication of how he is progressing. School involves interacting with a person who is not a relative and in a situation that is not totally familiar. Observing the client in situa- tions with family and friends shows social relation- ships but does not indicate how the child is learning new intellectual skills.CN: Health promotion and maintenance;
CL: Evaluate
21.
1. The goal in working with mentally retarded children is to train them to be as indepen- dent as possible, focusing on developmental skills.The child may not be capable of learning something new every day but needs to repeat what has been taught previously. Rather than encouraging more lenient behavior limits, the parents need to be strict and consistent when setting limits for the child.
Most children with Down syndrome are unable to achieve age-appropriate social skills due to their mental retardation. Rather, they are taught socially appropriate behaviors.
CN: Health promotion and maintenance;
CL: Synthesize
22.
4. Nonthreatening experiences that are stimulating and interesting to the child have been observed to help raise IQ. Practices such as servingBillings_Part 2_Chap 2_Test 7.indd 288
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30.
4. Most febrile seizures occur in the presence of an upper respiratory infection, otitis media, or tonsillitis. Febrile seizures typically occur during a temperature rise rather than after prolonged fever.There appears to be increased susceptibility to febrile seizures within families. Infrequently, febrile seizures may lead to respiratory arrest.
CN: Physiological adaptation;
CL: Analyze
31.
2. Shivering, the body’s defense against rapid temperature decrease, results in an increase in body temperature. Therefore the parents need to take measures to stop the shivering (and the result- ing increase in body temperature) by increasing the room temperature or the temperature of the child’s immediate environment (such as with blankets) until the shivering stops. Then, attempts are made to lower the temperature more slowly. Shivering does not necessarily correlate with being cold. Alcohol, a toxic substance, can be absorbed through the skin.Its use is to be avoided.
CN: Physiological adaptation;
CL: Evaluate
32.
3. Phenytoin sodium (Dilantin) is a known teratogenic agent, causing numerous fetal prob- lems. Therefore the adolescent should be advised to talk to the doctor about changing the medica- tion. Additionally, anticonvulsant requirements usually increase during pregnancy. Seizures can be controlled but cannot be cured. There is a familial tendency for seizure disorders. Seizure disorders and infertility are not related.CN: Pharmacological and parenteral therapies; CL: Synthesize
33.
3. A toxic effect of valproic acid (Depakene) is liver toxicity, which may manifest with jaundice and abdominal pain. If jaundice occurs, the client needs to notify the health care provider as soon as possible. Diarrhea and sore throat are not common side effects of this drug. Increased appetite is com- mon with this drug.CN: Pharmacological and parenteral therapies; CL: Analyze
The Client with Meningitis
34.
3. The current recommendation is that the MCV4 vaccine be given at the earliest opportunity after the age of 11. Therefore, it is quite possible that the client received the vaccine at a previous visit and did not remember. On a college campus, students living in dormitories are at highest risk, but because it is diffi cult to target that group col- leges may elect to require proof of vaccination for bodily harm by removing any item in the immediatearea that might present a danger and pad the head.
Finally, the child should be rolled to the side, if pos- sible, to protect the airway.
CN: Reduction of risk potential;
CL: Synthesize
26.
2. Diphenylhydantoin (Dilantin) can cause gingival hyperplasia. Children taking Dilantin should brush their teeth after every meal and at bedtime, and visit their dentist on a regular basis. Drinking plenty of fl uids is not required while taking Dilantin.A child on Dilantin does not need to be observed during waking hours because the seizures should be under control. Infections do not occur with an increased incidence in clients receiving Dilantin.
CN: Pharmacological and parenteral therapies; CL: Create
27.
3. During a generalized tonic-clonic seizure, the fi rst priority is to keep the child safe and pro- tect the child by removing any nearby objects that could cause injury. Although obtaining information about events surrounding the seizure is important, this information can be obtained later, once the child’s safety is ensured. During a seizure, the child should not be moved. Although providing privacy is important, the child’s safety is the priority. During a seizure, nothing should be forced into the client’s mouth because this can cause severe damage to the teeth and mouth.CN: Physiological adaptation;
CL: Evaluate
28.
3. Most children who develop seizures after infancy are intellectually normal. A child with a seizure disorder needs the same experiences and opportunities to develop intellectual, emotional, and social abilities as any other child. Activity limi- tation is not needed. Learning disabilities are not associated with seizures. The child is able to attend public school, and social stigma is a rarity.CN: Health promotion and maintenance;
CL: Create
29.
1. A child who has generalized seizures should not participate in activities that are poten- tially hazardous. Even if accompanied by a respon- sible adult, the child could be seriously injured if a seizure were to occur during rock climbing.Someone also should accompany the child during activities in the water. At summer camp, hiking and swimming would occur most commonly as group activities, so someone should be with the child. Ten- nis would be considered an appropriate, nonhazard- ous activity for a child with generalized seizures.
CN: Safety and infection control;
CL: Synthesize
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