1) Which assessment finding for a 4-month-old infant would require further action by the nurse?
1. The posterior fontanel is open.
2. The infant has good head control when held upright.
3. The infant is able to roll only from abdomen to back.
4. The anterior fontanel is open and soft. correct...
Peds: Final Exam Test Bank
1) Which assessment finding for a 4-month-old infant would require further action by the nurse?
1. The posterior fontanel is open.
2. The infant has good head control when held upright.
3. The infant is able to roll only from abdomen to back.
4. The anterior fontanel is open and soft. correct answer: 1. The posterior fontanel is open.
2) The nurse is providing care for a pediatric client in the emergency department (ED) with a diagnosis of decreased level of consciousness (LOC) secondary to increased intracranial pressure (ICP). Which healthcare provider order should the nurse question?
1. Passive range-of-motion exercises to promote hip flexion
2. Oxygen at 2 L nasal cannula to keep saturation above 95%
3. Hourly vital signs and neurologic checks
4. Elevate head of bed 30 degrees correct answer: 1. Passive range-of-motion exercises to promote hip flexion
3) A 4-year-old client with intractable seizures has been on a ketogenic diet for the last 6 months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. Which possible complication to this diet does the
nurse suspect? 1. Appendicitis
2. Bowel obstruction
3. Urinary tract infection
4. Kidney stones correct answer: 4. Kidney stones
4) A child with a history of seizures arrives in the emergency department (ED) in status epilepticus. Which is the priority nursing action?
1. Take vital signs.
2. Establish an intravenous line.
3. Perform rapid neurologic assessment.
4. Maintain patent airway. correct answer: 4. Maintain patent airway.
5) The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child is prescribed valproic acid (Depakote) for control of seizures. Which parental statement indicates the need for further education?
1. "I will not use carbonated beverages to dilute his medication."
2. "I will give his medicine on an empty stomach so he will absorb it better."
3. "I will not let him chew his tablet."
4. "I will bring him to the physician's office for regular blood work to check bleeding times." correct answer: 2. "I will give his medicine on an empty stomach so he will absorb it better."
6) A young child admitted to the pediatric unit has fever, irritability, and vomiting with suspected bacterial meningitis. Which cerebrospinal fluid (CSF) result should the nurse anticipate based on these data?
1. Decreased protein count
2. Clear, straw-colored fluid
3. Positive for red blood cells (RBCs)
4. Decreased glucose level correct answer: 4. Decreased glucose level
7) Which is the priority nursing diagnosis when planning care for a pediatric client who is diagnosed with bacterial meningitis?
1. Impaired Gas Exchange
2. Risk for Infection
3. Anxiety (parental)
4. Acute Pain correct answer: 1. Impaired Gas Exchange
8) The nurse is caring for a 9-month-old infant who just returned
from the postanesthesia care unit (PACU) after a shunt placement for hydrocephalus. Which healthcare provider prescription should the nurse question?
1. Vital signs and neurologic checks hourly
2. Small, frequent formula feedings
3. Elevate head of bed
4. Daily head circumference correct answer: 3. Elevate head of bed
9) A neonate with a meningomyelocele is to have surgery in the morning. Which nursing action is appropriate for this neonate? 1. Applying a diaper to prevent contamination of sac
2. Positioning the newborn in a side-lying position
3. Encouraging the mother to hold the newborn because she will not be able to pick him up after surgery
4. Positioning the newborn in a prone position correct answer: 4. Positioning the newborn in a prone position
10) Which should the nurse include in the plan of care for a hospitalized school-age child with meningomyelocele? Select all
that apply.
1. Implementing interventions for a client of normal intelligence
2. Using latex precautions when providing client care
3. Allowing the client to self-catheterize
4. Ensuring that the client has a low-fiber diet
5. Encouraging the client to shift positions hourly when in the wheelchair correct answer: 1. Implementing interventions for a client of normal intelligence
2. Using latex precautions when providing client care
3. Allowing the client to self-catheterize
5. Encouraging the client to shift positions hourly when in the wheelchair
11) Which side effect should the nurse include in the parent teaching for a child who is prescribed a baclofen pump for cerebral palsy?
1. Diarrhea
2. Hypertonia
3. Hypotonia
4. Restlessness correct answer: 3. Hypotonia
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