RICCI CHAPTER 44 - TEST BANK - 4TH
EDITION
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." - ✅✅ - 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." - ✅✅ - 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.
40. A pediatric client diagnosed with Duchenne muscular dystrophy is prescribed a
corticosteriod. Which statement by the caregiver indicates additional education by the
nurse is
needed?
A. "I will monitor my child for signs of infection."
B. "My child should take this medicine with food."
C. "I will call the primary health care provider if my child develops a moon-face."
D. "If I notice my child gain weight, I will stop the medication." - ✅✅ - Answer: D
Rationale: Corticosteriods may be prescribed to treat Duchenne muscular dystrophy for
their
anti-inflammatory and immunosuppressive actions. The nurse would provide additional
education if the caregiver stated the medication would be stopped. The nurse would
educate to
not stop treatment abruptly or acute adrenal insufficiency may occur. Corticosteriods
may mask
signs of infection; therefore, the child should be monitored for infection and the health
care
provider notified if any signs noted. The medication should be administer with food to
decrease
gastrointestinal upset. The caregiver should be taught to monitor for signs of Cushing
syndrome
(moon-face).
41. The school nurse has performed scoliosis screening. Based on this assessment,
which
children require the nurse to implement a referral to the healthcare provider? Select all
that
apply.
A. The child with asymetric shoulder elevation
B. The child with a limb length discrepancy
C. The child with a lateral curve of the spine
D. The child with a one-sided hump upon bending over
E. The child who's sibling had scoliosis surgically corrected
F. The child who has uneven balance - ✅✅ - Answer: A, B, C, D
Rationale: Scoliosis is defined by a lateral curve of the spine greater than 10
degrees.This curve
causes displacement of the ribs. The nurse would first inspect the back in a standing
position and
note any asymetric shoulder elevation, the prominence of one scapula, an uneven curve
at the
, waistline, or a rib hump on one side. While standing the nurse could also assess for leg
length
discrepancy and this could be measured. The nurse would then have the child bend
over and
observe for a pronounced hump on one side. The nurse should notify the parents and
refer the
child to the healthcare provider for evaluation if any of these symptoms are found. The
sibling
with a scoliosis repair would not be a concern unless it was known the family had a
genetic diagnosis. Most scoliosis is idiopathic. Uneven balance is not a sign of scoliosis.
The nurse
would have to complete further assessments for this child.
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 - ✅✅ - 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?" - ✅✅ - 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
EDITION
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." - ✅✅ - 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." - ✅✅ - 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.
40. A pediatric client diagnosed with Duchenne muscular dystrophy is prescribed a
corticosteriod. Which statement by the caregiver indicates additional education by the
nurse is
needed?
A. "I will monitor my child for signs of infection."
B. "My child should take this medicine with food."
C. "I will call the primary health care provider if my child develops a moon-face."
D. "If I notice my child gain weight, I will stop the medication." - ✅✅ - Answer: D
Rationale: Corticosteriods may be prescribed to treat Duchenne muscular dystrophy for
their
anti-inflammatory and immunosuppressive actions. The nurse would provide additional
education if the caregiver stated the medication would be stopped. The nurse would
educate to
not stop treatment abruptly or acute adrenal insufficiency may occur. Corticosteriods
may mask
signs of infection; therefore, the child should be monitored for infection and the health
care
provider notified if any signs noted. The medication should be administer with food to
decrease
gastrointestinal upset. The caregiver should be taught to monitor for signs of Cushing
syndrome
(moon-face).
41. The school nurse has performed scoliosis screening. Based on this assessment,
which
children require the nurse to implement a referral to the healthcare provider? Select all
that
apply.
A. The child with asymetric shoulder elevation
B. The child with a limb length discrepancy
C. The child with a lateral curve of the spine
D. The child with a one-sided hump upon bending over
E. The child who's sibling had scoliosis surgically corrected
F. The child who has uneven balance - ✅✅ - Answer: A, B, C, D
Rationale: Scoliosis is defined by a lateral curve of the spine greater than 10
degrees.This curve
causes displacement of the ribs. The nurse would first inspect the back in a standing
position and
note any asymetric shoulder elevation, the prominence of one scapula, an uneven curve
at the
, waistline, or a rib hump on one side. While standing the nurse could also assess for leg
length
discrepancy and this could be measured. The nurse would then have the child bend
over and
observe for a pronounced hump on one side. The nurse should notify the parents and
refer the
child to the healthcare provider for evaluation if any of these symptoms are found. The
sibling
with a scoliosis repair would not be a concern unless it was known the family had a
genetic diagnosis. Most scoliosis is idiopathic. Uneven balance is not a sign of scoliosis.
The nurse
would have to complete further assessments for this child.
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 - ✅✅ - 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?" - ✅✅ - 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
