Peds: Final Exam Test Bank

Peds: Final Exam Test Bank

1) Which assessment finding for a 4-month-old infant would require further action by the nurse?

• The posterior fontanel is open.
• The infant has good head control when held upright.
• The infant is able to roll only from abdomen to back.

4. The anterior fontanel is open and soft. correct answer: 1. The

posterior fontanel is open.2) The nurse is providing care for a pediatric client in the emergency department (ED) with a diagnosis of decreased level of consciousness (LOC) secondary to increased intracranial pressure (ICP). Which healthcare provider order should the nurse question?

• Passive range-of-motion exercises to promote hip flexion
• Oxygen at 2 L nasal cannula to keep saturation above 95%
• Hourly vital signs and neurologic checks

4. Elevate head of bed 30 degrees correct answer: 1. Passive

range-of-motion exercises to promote hip flexion 3) A 4-year-old client with intractable seizures has been on a ketogenic diet for the last 6 months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. Which possible complication to this diet does the nurse suspect? 1 / 4

• Appendicitis
• Bowel obstruction
• Urinary tract infection

4. Kidney stones correct answer: 4. Kidney stones

4) A child with a history of seizures arrives in the emergency department (ED) in status epilepticus. Which is the priority nursing action?

• Take vital signs.
• Establish an intravenous line.
• Perform rapid neurologic assessment.

4. Maintain patent airway. correct answer: 4. Maintain patent

airway.5) The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child is prescribed valproic acid (Depakote) for control of seizures. Which parental statement indicates the need for further education?

• "I will not use carbonated beverages to dilute his medication."
• "I will give his medicine on an empty stomach so he will

absorb it better."

• "I will not let him chew his tablet."
• "I will bring him to the physician's office for regular blood

work to check bleeding times." correct answer: 2. "I will give

his medicine on an empty stomach so he will absorb it better." 6) A young child admitted to the pediatric unit has fever, irritability, and vomiting with suspected bacterial meningitis. 2 / 4

Which cerebrospinal fluid (CSF) result should the nurse anticipate based on these data?

• Decreased protein count
• Clear, straw-colored fluid
• Positive for red blood cells (RBCs)

4. Decreased glucose level correct answer: 4. Decreased

glucose level 7) Which is the priority nursing diagnosis when planning care for a pediatric client who is diagnosed with bacterial meningitis?

• Impaired Gas Exchange
• Risk for Infection
• Anxiety (parental)

4. Acute Pain correct answer: 1. Impaired Gas Exchange

8) The nurse is caring for a 9-month-old infant who just returned from the postanesthesia care unit (PACU) after a shunt placement for hydrocephalus. Which healthcare provider prescription should the nurse question?

• Vital signs and neurologic checks hourly
• Small, frequent formula feedings
• Elevate head of bed

4. Daily head circumference correct answer: 3. Elevate head of

bed 9) A neonate with a meningomyelocele is to have surgery in the morning. Which nursing action is appropriate for this neonate? 3 / 4

• Applying a diaper to prevent contamination of sac
• Positioning the newborn in a side-lying position
• Encouraging the mother to hold the newborn because she will

not be able to pick him up after surgery

4. Positioning the newborn in a prone position correct answer:

• Positioning the newborn in a prone position

10) Which should the nurse include in the plan of care for a hospitalized school-age child with meningomyelocele? Select all that apply.

• Implementing interventions for a client of normal intelligence
• Using latex precautions when providing client care
• Allowing the client to self-catheterize
• Ensuring that the client has a low-fiber diet
• Encouraging the client to shift positions hourly when in the

wheelchair correct answer: 1. Implementing interventions for a

client of normal intelligence

• Using latex precautions when providing client care
• Allowing the client to self-catheterize
• Encouraging the client to shift positions hourly when in the

wheelchair 11) Which side effect should the nurse include in the parent teaching for a child who is prescribed a baclofen pump for cerebral palsy?

• Diarrhea
• Hypertonia
• Hypotonia

4. Restlessness correct answer: 3. Hypotonia

• / 4