Ricci Chapter 44 - Test Bank - 4th Edition
UPDATED ACTUAL Exam Questions and
CORRECT Answers
1. The nurse is teaching the mother of a 5-year-old boy with a myelomeningocele who has
developed a sensitivity to latex. Which response from his mother indicates a need for further
teaching?
A. "He needs to get a medical alert identification."
B. "I will need to discuss this with his caregivers."
C. "A product's label indicates whether it is latex-free."
D. "He must avoid all contact with latex." - CORRECT ANSWER - 1. The nurse is
teaching the mother of a 5-year-old boy with a myelomeningocele who has
developed a sensitivity to latex. Which response from his mother indicates a need for further
teaching?
A. "He needs to get a medical alert identification."
B. "I will need to discuss this with his caregivers."
C. "A product's label indicates whether it is latex-free."
D. "He must avoid all contact with latex."
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 -
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 - 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 -
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 - 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 - 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
UPDATED ACTUAL Exam Questions and
CORRECT Answers
1. The nurse is teaching the mother of a 5-year-old boy with a myelomeningocele who has
developed a sensitivity to latex. Which response from his mother indicates a need for further
teaching?
A. "He needs to get a medical alert identification."
B. "I will need to discuss this with his caregivers."
C. "A product's label indicates whether it is latex-free."
D. "He must avoid all contact with latex." - CORRECT ANSWER - 1. The nurse is
teaching the mother of a 5-year-old boy with a myelomeningocele who has
developed a sensitivity to latex. Which response from his mother indicates a need for further
teaching?
A. "He needs to get a medical alert identification."
B. "I will need to discuss this with his caregivers."
C. "A product's label indicates whether it is latex-free."
D. "He must avoid all contact with latex."
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 -
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 - 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 -
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 - 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 - 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
