244 OBJ: 3 TOP: Intracranial Hemorrhage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort... 248 OBJ: 6 TOP: One-way Pressure Valve KE
Trang 1Link full download:
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Test Bank for Pediatric Nursing An Introductory Text 11th Edition
by Price Chapter 13: Neurologic and Sensory Disorders
a Are twice that of the adult
b Are scant due to rapid physical growth
c Fluctuate dependent on growth cycles
d Are impossible to measure
ANS: A
In the first several years of the child’s life, cerebral blood flow and oxygen
consumption are almost twice that of the adult Brain growth is measured by head circumference
DIF: Cognitive Level: Comprehension REF: p 243 OBJ: 2
Trang 2TOP: Brain Growth KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2 The newborn nursery nurse takes special care in feeding a child with a possible intracranial hemorrhage because these children:
a Will be likely to engorge themselves
b Need more nutrients than other babies
c Have a poor sucking reflex
d Need cuddling and nurturing
DIF: Cognitive Level: Application REF: p 244 OBJ: 3
TOP: Intracranial Hemorrhage KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
Trang 3
The nurse recognizes this posture in a child with a head injury as being indicative of injury to the:
DIF: Cognitive Level: Application REF: p 245 OBJ: 3
TOP: Decerebrate Posturing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4 A 12-year-old is admitted to the emergency department after a head injury His admission vital signs are: T: 98.2°, P: 68, BP: 96/56, and R: 16 Select the set of vital signs that would indicate to the nurse that there is increasing intracranial pressure (ICP):
a T: 98.2°, P: 66, BP: 100/60, R: 18
Trang 4DIF: Cognitive Level: Analysis REF: p 246 OBJ: 3
TOP: Increasing Intracranial Pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
of Disease
5 The mother of a 3-year-old who received a mild concussion during a fall from his tricycle the previous day tells the home health nurse that she is worried about his temperature elevation of 100° The nurse’s best response will be based on the knowledge that the temperature elevation:
a Is an indication of an infection
b Suggests that there is increasing intracranial pressure
Trang 5c Could be a sign that there is an intracranial bleed
d Is not uncommon during the first 2 days after trauma
DIF: Cognitive Level: Application REF: p 247 OBJ: 2
TOP: Elevated Temperature KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6 When the mother of a child who has just received a ventriculoperitoneal (VP) shunt for the relief of hydrocephalus asks the nurse what happens to all the fluid that is pumped into the peritoneal space, the nurse bases the response
on the knowledge that the fluid is:
a Absorbed into the circulating volume and excreted
b Taken up by the fat cells in the abdomen
c Ultimately stored in the liver
Trang 6d Stored in the lymphatic system
DIF: Cognitive Level: Comprehension REF: p 248 OBJ: 6
TOP: Ventriculoperitoneal Shunt KEY: Nursing Process Step:
a Placement of a one-way pressure valve
b A system of locks along the shunt tubing
c Organ movement in peritoneal space
d Gravity
ANS: A
Trang 7A one-way pressure valve that responds to a preset intraventricular pressure allows the fluid to be removed under its own pressure, but does not allow back-flow
DIF: Cognitive Level: Comprehension REF: p 248 OBJ: 6
TOP: One-way Pressure Valve KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
8 The nurse includes in the plan of care for a 5-month-old hydrocephalic baby
an intervention to prevent hypostatic pneumonia, which would be:
a Monitor oxygen per nasal cannula
b Keep the baby hydrated by offering water between
feedings
c Change the baby’s position every 2 hours
d Position the baby in an upright position
Trang 8TOP: Hypostatic Pneumonia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
9 The nurse is aware that the most appropriate position for 1-day
post-operative child with a ventriculoperitoneal (VP) shunt is:
DIF: Cognitive Level: Application REF: p 249 OBJ: N/A
TOP: Post-operative Ventriculoperitoneal Shunt
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
Trang 9
10 The nurse clarifies that the difference between a myelomeningocele and a meningocele is that the cyst of a myelomeningocele contains:
DIF: Cognitive Level: Comprehension REF: p 250 OBJ: 7
TOP: Myelomeningocele KEY: Nursing Process Step:
Trang 10DIF: Cognitive Level: Knowledge REF: p 250 OBJ: N/A
TOP: Folic Acid KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
12 The nurse takes special caution in positioning the infant with a
myelomeningocele in order to:
a Protect the sac
b Support the back
c Facilitate feeding
Trang 11d Prevent vomiting
ANS: A
The primary preoperative focus in the nursing care of a child with a
myelomeningocele is to protect the sac
DIF: Cognitive Level: Comprehension REF: p 251 OBJ: 7
TOP: Positioning KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
Trang 12The petechiae over the trunk is an indicator of meningococcal infection
DIF: Cognitive Level: Comprehension REF: p 252 OBJ: 8
TOP: Petechiae KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
of Disease
14 The nurse explains to the mother of a child with meningitis that the child will remain in isolation until the child has:
a Received at least 24 hours of antibiotic therapy
b A normal temperature for 24 hours
c Spinal fluid that is clear
d Been free of upper respiratory symptoms
DIF: Cognitive Level: Comprehension REF: p 252 OBJ: 8
TOP: Isolation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
Trang 13DIF: Cognitive Level: Comprehension REF: p 254 OBJ: N/A
TOP: Febrile Seizures KEY: Nursing Process Step:
Trang 14
DIF: Cognitive Level: Application REF: p 255 OBJ: 9
TOP: Seizures KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
17 Most epileptic generalized seizures are preceded by:
a A period of physical activity
b A high temperature
Trang 15DIF: Cognitive Level: Knowledge REF: p 256 OBJ: 1
TOP: Aura KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
18 The nurse is aware that in an absence seizure the patient will:
a Have an aura
b Be fully aware during the seizure
c Have a sudden cessation of motor activity
d Have a lengthy post-ictal period
ANS: C
Trang 16Absence seizures have no aura or post-ictal stage The person has a sudden
cessation of motor activity lasting 5 to 10 seconds and then returns to full activity
DIF: Cognitive Level: Comprehension REF: p 255 OBJ: 9
TOP: Absence Seizures KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation
DIF: Cognitive Level: Comprehension REF: p 259 OBJ: 11
TOP: Near-Drowning KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
Trang 17DIF: Cognitive Level: Comprehension REF: p 259 OBJ: 11
TOP: Near-Drowning KEY: Nursing Process Step:
Trang 18a Does not babble unintelligible sounds
b Does not cry when startled by an extremely loud
sound
c Does not turn the head toward a sound
d Frequently pulls at the ears
DIF: Cognitive Level: Application REF: p 260 OBJ: 12
TOP: Hearing Loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
Trang 19DIF: Cognitive Level: Knowledge REF: p 244 OBJ: 1
TOP: Opisthotonos KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2 The nurse is aware that the earliest indicator of increasing intracranial
pressure (ICP) is the _
ANS:
Level of consciousness (LOC)
The level of consciousness is the earliest indicator of increasing ICP
DIF: Cognitive Level: REF: p 244 OBJ: 3
TOP: Increasing Intracranial Pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
Trang 20DIF: Cognitive Level: Analysis REF: p 247 OBJ: 5
TOP: Pediatric Coma Scale KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
of Disease
4 The child with hydrocephalus is found to have an obstruction in the
subarachnoid space Based on this finding, the child has type of hydrocephalus
DIF: Cognitive Level: Comprehension REF: p 247 OBJ: 6
TOP: Communicating Hydrocephalus KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
5 The nurse caring for a child with meningitis would plan care to minimize disturbing the child unnecessarily as these children are extremely sensitive to stimuli that may initiate a
Trang 21DIF: Cognitive Level: Comprehension REF: p 253 OBJ: 8
TOP: Reduction of Stimuli KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk
6 The nurse understands that when the lab report shows a very low glucose count in spinal fluid of the child with meningitis, the invading pathogen is
DIF: Cognitive Level: Analysis REF: p 252 OBJ: 8
TOP: Spinal Fluid KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
Trang 22
1 The nurse explains that a baby’s cranial characteristics allow the brain to
grow and enlarge These include: (Select all that apply.)
a Open anterior fontanel
b Fused cranium around the brain
c Open posterior fontanel
DIF: Cognitive Level: Application REF: p 244 OBJ: 2
TOP: Cranial Differences KEY: Nursing Process Step:
Trang 23DIF: Cognitive Level: Application REF: p 244 OBJ: 2
TOP: Intracranial Hemorrhage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3 If a seizure occurs in a newborn who suffered an intracranial hemorrhage, the
nurse should record: (Select all that apply.)
a Parts of the body and limbs that were involved
Trang 24b Witnesses to the seizure
c Whether movements were unilateral or bilateral
d Severity of the seizure
e Length of time of the seizure
DIF: Cognitive Level: Application REF: p 244 OBJ: 3
TOP: Seizures KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4 The nurse assigned to a 4-month-old hydrocephalic child anticipates that
assessments of this child will reveal: (Select all that apply.)
a Bulging fontanels
b Widened cranial sutures
Trang 25c Strong muscle tone
DIF: Cognitive Level: Application REF: p 248 OBJ: 6
TOP: Hydrocephalic Signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5 In feeding the child with hydrocephalus, the nurse would include in the plan
of care to: (Select all that apply.)
a Feed the child in a calm, unhurried manner
b Dim the lights in the room to reduce stimulation
c Give firm support to the head and neck
Trang 26d Burp the baby often
e Feed rapidly to prevent swallowing air
of vomiting
DIF: Cognitive Level: Comprehension REF: p 249 OBJ: N/A
TOP: Feeding the Hydrocephalic Child KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6 In caring for an infant who has had a ventriculoperitoneal (VP) shunt, the
nurse will include in the plan of care: (Select all that apply.)
a Taking daily head measurements
b Taking daily abdominal measurements
c Positioning on the stomach if fontanels are bulging
Trang 27d Positioning on the opposite side from surgery
e Changing the position every 4 hours
DIF: Cognitive Level: Comprehension REF: p 249 OBJ: N/A
TOP: Post-shunt Care KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7 The nurse is aware that the child with a myelomeningocele may also have
problems with: (Select all that apply.)
a Lower limb paralysis
b Mental retardation
c Poor bladder control
Trang 28DIF: Cognitive Level: Comprehension REF: p 250 OBJ: 7
TOP: Myelomeningocele KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8 The nurse caring for a 1-month-old child with a myelomeningocele will take
into consideration when positioning the baby to: (Select all that apply.)
a Place the baby in prone position
b Maintain hip abduction
c Counteract hip subluxation
d Maintain a neutral foot position
Trang 29e Maintain upper limb alignment
ANS: A, B, C, D
The positioning of an infant prior to the repair of a myelomeningocele would focus
on protecting the sac and preventing postural deformities The baby should be placed in the prone position with a towel roll between the legs to maintain hip abduction and counteract hip subluxation, and another small roll to maintain a neutral foot position
DIF: Cognitive Level: Application REF: p 251 OBJ: N/A
TOP: Positioning KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
Pediatric Nursing An Introductory Text 11th Edition Test Bank – Price