Maternity and Pediatric Nursing 4th ed Chapter 38 Test Bank
(203) questions and 100% verified correct answers
The nurse is caring for a child hospitalized with Reye syndrome who is in the acute
stage of
the illness. The nurse would assess the child most carefully for what finding?
A. Indications of increased intracranial pressure
B. An increase in the blood glucose level
C. A decrease in the liver enzymes
D. A presence of protein in the urine - Correct Answer Answer: A
Rationale: Reye syndrome is characterized by brain swelling, liver failure, and death in
hours if
treatment is not initiated. Therefore, increased intracranial pressure could occur. Liver
enzyme
levels typically increase. Blood glucose levels and protein in the urine are not
characteristic of
this illness.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial
Regulation/Neurologic
Disorder
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 1363
The physician has ordered rectal diazepam for a 2-year-old boy with status epilepticus.
Which
instruction is essential for the nurse to teach the parents?
A. Monitor their child's level of sedation.
B. Watch for fever indicating infection.
C. Gradually reduce the dosage as seizures stop.
D. Monitor for an allergic reaction to the medication. - Correct Answer Answer: A
Rationale: Diazepam is useful for home management of prolonged seizures and
requires that the
parents be educated on its proper administration. Monitoring the child's level of sedation
is key
when giving diazepam because it slows the central nervous system. Parents need to
monitor the
overall health of the child, including temperature when needed, but that has nothing to
do with
the diazepam. When the use of an anticonvulsant is stopped, gradual reduction of the
dosage is
necessary to prevent seizures or status epilepticus. This is not done without a
physician's order.
, Monitoring for allergic reactions is necessary when any medications have been
prescribed, but is
not specific to diazepam.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial
Regulation/Neurologic
Disorder
Cognitive Level: Apply
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Reference: p. 1342
A 4-year-old boy has a febrile seizure during a well-child visit. What action would be a
priority?
A. Hyperextending the child's head while placing him on his side
B. Using a tongue blade to pry open the child's jaw
C. Loosening the child's clothing to ensure a patent airway
D. Protecting the child from harm during the seizure - Correct Answer Answer: D
Rationale: During a seizure, the child should not be held down in a specific position.
Protecting
the child's head and body during the seizure is the priority. Ensuring a patent airway is
an
important intervention but is not accomplished by loosening the child's clothing or
hyperextending his head. The child should be placed on his side and nothing should be
inserted
into his mouth to forcibly open the jaw.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial
Regulation/Neurologic
Disorder
Cognitive Level: Apply
Client Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process
Reference: p. 1348-1349
The nurse has developed a teaching plan for the family of a 2-year-old boy who holds
his
breath when he gets frustrated. What will be most important to include in this plan?
A. Provide cuddle time whenever the child begins to act out.
B. Explain the child's behavior to the parents.
C. Encourage the parents to interact more with the child.
D. Stay close to prevent injury when he gets frustrated. - Correct Answer Answer: D
Rationale: Encourage the parents to maintain a safe environment when an episode is
occurring,
but to avoid giving extra attention to the child after the event since this could encourage
(203) questions and 100% verified correct answers
The nurse is caring for a child hospitalized with Reye syndrome who is in the acute
stage of
the illness. The nurse would assess the child most carefully for what finding?
A. Indications of increased intracranial pressure
B. An increase in the blood glucose level
C. A decrease in the liver enzymes
D. A presence of protein in the urine - Correct Answer Answer: A
Rationale: Reye syndrome is characterized by brain swelling, liver failure, and death in
hours if
treatment is not initiated. Therefore, increased intracranial pressure could occur. Liver
enzyme
levels typically increase. Blood glucose levels and protein in the urine are not
characteristic of
this illness.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial
Regulation/Neurologic
Disorder
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 1363
The physician has ordered rectal diazepam for a 2-year-old boy with status epilepticus.
Which
instruction is essential for the nurse to teach the parents?
A. Monitor their child's level of sedation.
B. Watch for fever indicating infection.
C. Gradually reduce the dosage as seizures stop.
D. Monitor for an allergic reaction to the medication. - Correct Answer Answer: A
Rationale: Diazepam is useful for home management of prolonged seizures and
requires that the
parents be educated on its proper administration. Monitoring the child's level of sedation
is key
when giving diazepam because it slows the central nervous system. Parents need to
monitor the
overall health of the child, including temperature when needed, but that has nothing to
do with
the diazepam. When the use of an anticonvulsant is stopped, gradual reduction of the
dosage is
necessary to prevent seizures or status epilepticus. This is not done without a
physician's order.
, Monitoring for allergic reactions is necessary when any medications have been
prescribed, but is
not specific to diazepam.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial
Regulation/Neurologic
Disorder
Cognitive Level: Apply
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Reference: p. 1342
A 4-year-old boy has a febrile seizure during a well-child visit. What action would be a
priority?
A. Hyperextending the child's head while placing him on his side
B. Using a tongue blade to pry open the child's jaw
C. Loosening the child's clothing to ensure a patent airway
D. Protecting the child from harm during the seizure - Correct Answer Answer: D
Rationale: During a seizure, the child should not be held down in a specific position.
Protecting
the child's head and body during the seizure is the priority. Ensuring a patent airway is
an
important intervention but is not accomplished by loosening the child's clothing or
hyperextending his head. The child should be placed on his side and nothing should be
inserted
into his mouth to forcibly open the jaw.
Question format: Multiple Choice
Chapter 38: Nursing Care of the Child With an Alteration in Intracranial
Regulation/Neurologic
Disorder
Cognitive Level: Apply
Client Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process
Reference: p. 1348-1349
The nurse has developed a teaching plan for the family of a 2-year-old boy who holds
his
breath when he gets frustrated. What will be most important to include in this plan?
A. Provide cuddle time whenever the child begins to act out.
B. Explain the child's behavior to the parents.
C. Encourage the parents to interact more with the child.
D. Stay close to prevent injury when he gets frustrated. - Correct Answer Answer: D
Rationale: Encourage the parents to maintain a safe environment when an episode is
occurring,
but to avoid giving extra attention to the child after the event since this could encourage
