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1. 1. The nurse is teaching the mother of a 5-year-old boy with a
myelomeningo- cele who has developed a sensitivity to latex. Which of
the following responses 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.":
Ans: C Feedback:
The Food and Drug Administration (FDA) requires that all medical supplies be labeled if they contain
latex, but this is not the case with consumer products. The mother must be familiar with products that
contain latex. The Spina Bifida Association of America maintains an updated list of latex-containing
products. Getting a medical alert identification, talking with his caregivers, and avoiding all contact with latex
are correct.
2. 2. The nurse is caring for an 8-year-old boy with myasthenia gravis
and is
teaching his parents about the signs of cholinergic crisis. Which of the
following responses by the parents indicates a need for further
teaching?
A) "Low blood pressure is a sign of crisis."
B) "He might have difficulty swallowing."
C) "He may start to sweat a lot."
D) "More saliva in the mouth is a common sign.":
Ans: B Feedback:
Dysphagia is a sign of myasthenic crisis. Increased salivation, hypotension, and increased sweating
are signs and symptoms of cholinergic crisis.
3. 3. 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."
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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.": Ans: A Feedback:
The nurse needs to empower families to become the experts on their child's needs and conditions via
education and
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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.
4. 4. 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
.: Ans: B
Feedback:
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
5. 5. A 6-year-old boy with cerebral palsy has been admitted to the
hospital for some tests. His condition is stable. The boy's mother
remains with her son, but she 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 son."
C) "He's in good hands; consider going home to get some sleep."
D) "Are you planning to spend the night or to go home?":
Ans: C Feedback:
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 mother that her son is in good hands and urge her to go home. Asking her
whether she is planning to stay might make the mother feel obligated to stay. Asking if she wants a
blanket or pillow does not encourage the mother to leave the hospital.
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Telling the mother she is doing a good job is nice, but does not encourage her to take a break.
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