Ricci Chapter 44 - Test Bank - 4th Edition || 100% Correct
Solutions.
2. The nurse is providing postoperative care for a 14-month-old girl who has undergone a
myelomeningocele repair. The girl's mother is extremely anxious and tells the nurse she is afraid
she will never learn how to care for her daughter at home. Which response by the nurse would be
most appropriate?
A. "I will help you become comfortable in caring for your daughter."
B. "You must learn how to care for your daughter at home."
C. "You will need to learn to collaborate with all the caregivers."
D. "There is a lot to learn, and you need a positive attitude." Correct Answer: A
Rationale: The nurse needs to empower families to become the experts on their child's needs and
conditions via education and participation in care. The most positive approach is to let the
mother know the nurse will support her and help her become an expert on her daughter's care.
Telling the mother that she must learn how to care for her daughter or that she must have a
positive attitude is not helpful. Telling her that she needs to collaborate with the caregivers is
true, but does not address her fears.
3. The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan
of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention
would the nurse implement to best promote maximum chest expansion?
A. Deep-breathing exercises
B. Upright positioning
C. Coughing
D. Chest percussion Correct Answer: B
Rationale: The nurse should emphasize that the child's position should be arranged to promote
maximum chest expansion. This is usually in the upright position. Deep-breathing exercises are
for strengthening/maintaining respiratory muscles. Coughing helps clear the airways. Chest
percussion helps loosen secretions in lungs.
4. A 6-year-old child with cerebral palsy has been admitted to the hospital for some tests. The
child's condition is stable. A parent remains with the child, but the parent is obviously exhausted
and stressed. Which response by the nurse would be most appropriate?
A. "Would you like me to bring you a blanket and pillow?"
B. "You are doing such a wonderful job with your child."
C. "Your child is in good hands; consider going home to get some sleep."
D. "Are you planning to spend the night or to go home?" Correct Answer: C
Rationale: Providing daily, intense care can be quite demanding and tiring. When a child with
cerebral palsy is admitted to the hospital, this may serve as a time of respite for family and
primary caregivers. The nurse should remind the parent that the child is in good hands and urge
the parent to go home. Asking whether the parent is planning to stay might make the parent feel
obligated to stay. Asking if the parent wants a blanket or pillow does not encourage the parent to
leave the hospital. Telling the parent he or she is doing a good job is nice, but does not encourage
the parent to take a break.
5. A nurse is caring for a 14-year-old girl following myelography. What is the priority nursing
, action?
A. Monitoring for a decrease in spasticity
B. Observing for signs of meningeal irritation
C. Assessing motor function
D. Observing for mental confusion or hallucinations Correct Answer: B
Rationale: Following myelography, the nurse should carefully observe for signs of meningeal
irritation because of what is involved in this procedure. Monitoring for a decrease in muscle
spasticity, assessing motor function, and observing for mental confusion or hallucinations is
appropriate following an intrathecal test dose of baclofen.
6. The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was
recently injured when he fell out of bed at home. Which intervention would the nurse suggest to
prevent further injury?
A. Recommend the bed's side rails be raised throughout the day and night.
B. Suggest a caregiver be present continuously to prevent falls from bed.
C. Encourage a loose restraint to be used when he is in bed.
D. Recommend raising the bed's side rails when a caregiver is not present. Correct Answer: D
Rationale: The nurse should recommend that side rails on the bed be elevated when a caregiver is
not present. The use of restraints should be avoided if at all possible. Suggesting that a caregiver
be present at all times places undue stress on the family. Close observation is more appropriate.
Recommending side rails be elevated at all times may be upsetting to the child and make him
feel like a "baby."
7. The nurse is caring for a 2-month-old with cerebral palsy. The infant is limp and flaccid with
uncontrolled, slow, worm-like, writhing, and twisting movements. What word would the nurse
use when documenting these observations?
A. Spastic
B. Athetoid
C. Ataxic
D. Mixed Correct Answer: B
Rationale: Athetoid cerebral palsy is characterized by abnormal, involuntary movement. It
affects all four extremities with possible involvement of the face, neck, and tongue. The
movements increase in periods of stress. Dysarthria and drooling may be present as well. Spastic
cerebral palsy is characterized by poor control of posture, balance, and movement; exaggeration
of deep tendon reflexes; and hypertonicity of affected extremities. Ataxic is characterized by
poor coordination, unsteady gait, and wide-based gait.
8. The nurse is teaching a group of students about myelinization in a child. Which statement by
the students indicates that the teaching was successful?
A. Myelinization is completed by 4 years of age.
B. The process occurs in a head-to-toe fashion.
C. The speed of nerve impulses slows as myelinization occurs.
D. Nerve impulses become less specific in focus with myelinization. Correct Answer: B
Rationale: Myelinization occurs in a cephalocaudal, proximodistal manner and is completed by 2
years of age. As myelinization proceeds, nerve impulses become faster and more accurate.
Solutions.
2. The nurse is providing postoperative care for a 14-month-old girl who has undergone a
myelomeningocele repair. The girl's mother is extremely anxious and tells the nurse she is afraid
she will never learn how to care for her daughter at home. Which response by the nurse would be
most appropriate?
A. "I will help you become comfortable in caring for your daughter."
B. "You must learn how to care for your daughter at home."
C. "You will need to learn to collaborate with all the caregivers."
D. "There is a lot to learn, and you need a positive attitude." Correct Answer: A
Rationale: The nurse needs to empower families to become the experts on their child's needs and
conditions via education and participation in care. The most positive approach is to let the
mother know the nurse will support her and help her become an expert on her daughter's care.
Telling the mother that she must learn how to care for her daughter or that she must have a
positive attitude is not helpful. Telling her that she needs to collaborate with the caregivers is
true, but does not address her fears.
3. The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan
of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention
would the nurse implement to best promote maximum chest expansion?
A. Deep-breathing exercises
B. Upright positioning
C. Coughing
D. Chest percussion Correct Answer: B
Rationale: The nurse should emphasize that the child's position should be arranged to promote
maximum chest expansion. This is usually in the upright position. Deep-breathing exercises are
for strengthening/maintaining respiratory muscles. Coughing helps clear the airways. Chest
percussion helps loosen secretions in lungs.
4. A 6-year-old child with cerebral palsy has been admitted to the hospital for some tests. The
child's condition is stable. A parent remains with the child, but the parent is obviously exhausted
and stressed. Which response by the nurse would be most appropriate?
A. "Would you like me to bring you a blanket and pillow?"
B. "You are doing such a wonderful job with your child."
C. "Your child is in good hands; consider going home to get some sleep."
D. "Are you planning to spend the night or to go home?" Correct Answer: C
Rationale: Providing daily, intense care can be quite demanding and tiring. When a child with
cerebral palsy is admitted to the hospital, this may serve as a time of respite for family and
primary caregivers. The nurse should remind the parent that the child is in good hands and urge
the parent to go home. Asking whether the parent is planning to stay might make the parent feel
obligated to stay. Asking if the parent wants a blanket or pillow does not encourage the parent to
leave the hospital. Telling the parent he or she is doing a good job is nice, but does not encourage
the parent to take a break.
5. A nurse is caring for a 14-year-old girl following myelography. What is the priority nursing
, action?
A. Monitoring for a decrease in spasticity
B. Observing for signs of meningeal irritation
C. Assessing motor function
D. Observing for mental confusion or hallucinations Correct Answer: B
Rationale: Following myelography, the nurse should carefully observe for signs of meningeal
irritation because of what is involved in this procedure. Monitoring for a decrease in muscle
spasticity, assessing motor function, and observing for mental confusion or hallucinations is
appropriate following an intrathecal test dose of baclofen.
6. The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was
recently injured when he fell out of bed at home. Which intervention would the nurse suggest to
prevent further injury?
A. Recommend the bed's side rails be raised throughout the day and night.
B. Suggest a caregiver be present continuously to prevent falls from bed.
C. Encourage a loose restraint to be used when he is in bed.
D. Recommend raising the bed's side rails when a caregiver is not present. Correct Answer: D
Rationale: The nurse should recommend that side rails on the bed be elevated when a caregiver is
not present. The use of restraints should be avoided if at all possible. Suggesting that a caregiver
be present at all times places undue stress on the family. Close observation is more appropriate.
Recommending side rails be elevated at all times may be upsetting to the child and make him
feel like a "baby."
7. The nurse is caring for a 2-month-old with cerebral palsy. The infant is limp and flaccid with
uncontrolled, slow, worm-like, writhing, and twisting movements. What word would the nurse
use when documenting these observations?
A. Spastic
B. Athetoid
C. Ataxic
D. Mixed Correct Answer: B
Rationale: Athetoid cerebral palsy is characterized by abnormal, involuntary movement. It
affects all four extremities with possible involvement of the face, neck, and tongue. The
movements increase in periods of stress. Dysarthria and drooling may be present as well. Spastic
cerebral palsy is characterized by poor control of posture, balance, and movement; exaggeration
of deep tendon reflexes; and hypertonicity of affected extremities. Ataxic is characterized by
poor coordination, unsteady gait, and wide-based gait.
8. The nurse is teaching a group of students about myelinization in a child. Which statement by
the students indicates that the teaching was successful?
A. Myelinization is completed by 4 years of age.
B. The process occurs in a head-to-toe fashion.
C. The speed of nerve impulses slows as myelinization occurs.
D. Nerve impulses become less specific in focus with myelinization. Correct Answer: B
Rationale: Myelinization occurs in a cephalocaudal, proximodistal manner and is completed by 2
years of age. As myelinization proceeds, nerve impulses become faster and more accurate.
