A 7 month old is being evaluated in the emergency department for a possible head injury following a reported fall from the parent's bed. What would the
... [Show More] nurse consider when evaluating the fontanels for evidence of increased intracranial pressure?
Choose One
1. The anterior fontanel should be open at 7 months of age.
2. The anterior fontanel closes at 2 to 4 months of age.
3. The posterior fontanel should be open at 7 months of age.
4. The posterior fontanel closes at 4 to 6 months of age.
1
Rationale
1. Correct: The anterior fontanel closes between 12 to 18 months of age. The nurse could assess the anterior fontanel in this 7 month old with a normal finding being soft and flat. A bulging anterior fontanel would be indicative of increased intracranial pressure.
2. Incorrect: The anterior fontanel does not close until 12 to 18 months of age. Closure before this time would be considered premature closure which could affect brain growth.
3. Incorrect: The posterior fontanel should be closed in this client. The posterior fontanel is expected to close at 2 to 3 months of age. Therefore, the posterior fontanel would not be useful for assessing for increased intracranial pressure in this 7 month old.
4. Incorrect: The posterior fontanel closes at 2 to 3 months of age, not 4 to 6 months, and would be expected to be closed in this 7 month old infant.
The nurse provided a community safety presentation for parents and included car seat safety. Which would demonstrate to the nurse that the parents correctly understood the teaching for a 2 month old weighing 10 pounds (4.55 kg)?
Choose One
1. The car seat is placed upright in the rear facing position in the front passenger seat.
2. Padding is placed under the young infant's head in the semi-reclined car seat in a rear facing position.
3. The car seat is secured in the side of the rear seat in a reclined, front-facing position.
4. The car seat is placed semi-reclined in the middle of the back seat in a rear-facing position.
4
Rationale
4. Correct: The guideline for infants < 20 pounds (9kg) is to place them in the middle of the back seat in a rear-facing, semi-reclined car seat. This provides the best protection for their heavy head and weak neck.
1. Incorrect: Infants and young children should never be placed in the front passenger seat, regardless of the direction that the car seat is facing.
2. Incorrect: Padding should not be placed under or behind an infant or child in the car seat because this could become compressed during a crash and cause slackness in the car seat harness. The infant or child could then be ejected from the car seat.
3. Incorrect: Although the car seat is in the back seat, it should be rear-facing, not front-facing, for this 2 month old infant. Also, the middle of the back seat is preferable for car seat placement.
A parent voices concern because the 6 year child has not been eating as much in the last 3 months. What response from the nurse would be appropriate?
Choose One
1. "You need to make the child eat more frequent meals to avoid becoming anorexic."
2. "This is not unusual in this age child because the growth rate has slowed down."
3. "Try providing high calorie foods that the child likes to increase the calories to 3500 per day."
4. "You are just being overly cautious. There is no need to worry about how much the child eats."
2
Rationale
2. Correct: Think about normal growth and development here. Remember that the growth rate slows down in the school age child between 6 and 12 years of age. Therefore, they may not seem as hungry as they are during periods of growth spurts.
1. Incorrect: Forcing a child to eat can cause aversions to foods. There is nothing in the stem to indicate that the child is losing an abnormal amount of weight or is showing signs of anorexia. Although it can start this early, anorexia is not a problem that is generally seen in this age child.
3. Incorrect: This 6 year old child needs foods that are healthy but yet provide the calories needed. However, since the growth rate has slowed, the caloric needs at this age is about 2400 calories per day. Giving high calorie foods and increasing this to 3500 calories per day could lead to unhealthy weight gain and poor overall nutrition.
4. Incorrect: This response dismisses the parent's concern and does not address the issue. The parent should be provided with an explanation that this age child's appetite often decreases in relation to a decrease in the growth rate. However, the parent should be told that if weight loss or other problems begin to be noted, further evaluation may be needed.
A nurse is preparing to obtain vital signs on a 2 year old. What should the nurse consider when preparing to perform this task?
Choose One
1. The blood pressure should be obtained first to get an accurate reading.
2. Count the RR and HR for 30 seconds to avoid prolonged disturbance.
3. If the child becomes upset, record the behavior with the measurements.
4. The axillary route is the most reliable route for checking the temperature.
3
Rationale
3. Correct: Infants, toddlers, and young children often become anxious or upset during procedures, such as vital sign measurement, and we know that this activity could affect the vital sign results. Nurses or other healthcare providers would need this information to consider when evaluating the results.
1. Incorrect: We want to obtain the least invasive vital sign first. Start with observation before touching the child. What vital sign can you get by observing? Yes! Respirations!
2. Incorrect: In infants and toddlers, it is important to count the RR and HR for one full minute because of irregularities due to their immature nervous system regulation.
4. Incorrect: The rectal route is considered the most reliable route for assessing the temperature in infants and children.
A 5 year old girl is upset and saying she is to blame for her brother getting hit by a car on his bike because she was mad at him earlier and wanted to hit him. What does the nurse recognize this type thinking to be in a child?
Choose One
1. Abstract
2. Egocentric
3. Animism
4. Magical
4
Rationale
4. Correct: Magical thinking is common in young children and is the belief that the world around them can be influenced or impacted by their own thoughts, desires, or wishes. Therefore, when something happens that is related to their thoughts, the child may perceive that it occurred because of those thoughts. This child may have connected the thoughts of being upset with the brother and the desire to hit him with the aspect of the car hitting him later. Other times, this magical thinking may be linked to a desire to make positive things happen by their thoughts. The interesting part about magical thinking is that young children may believe that they can make things or events in life be anything or anyway they want them to be.
1. Incorrect: Abstract thinking is the ability to think about objects, ideas, and principles that do not physically exist. It is the ability to understand relationships, critically think or reason, and think symbolically using a symbol to substitute for an object or idea. It is a higher level of thinking that begins in adolescence but does not fully mature until adulthood.
2. Incorrect: Egocentric thinking is where the child thinks the world revolves around them. "It's all about me, me, me!"
3. Incorrect: Animism is the child's way of thinking in which they believe that inanimate objects have feelings, thoughts, and abilities like living things. They think that non-living things behave just like humans.
A child, admitted to the emergency department is noted to be drooling and has dysphagia. No cough is noted, and the child appears worse than the sound indicates. The parent states the child seemed "fine" when put to bed. History reveals that the child has not received some of the recommended immunizations. What should the nurse anticipate as part of the care for this child?
Choose One
1. Placement in the lateral, supine position.
2. Prompt initiation of respiratory syncytial virus immune globulin.
3. Transfer to OR for placement of ET tube.
4. Oral dose of dexamethasone.
3
Rationale
3. Correct: Did you recognize these symptoms as being characteristic of epiglottitis? Yes! It is considered a medical emergency in which there can be rapid progression to severe respiratory distress due to airway occlusion. An endotracheal tube (ET) may be needed, but it is best for the child to be in the OR where anesthesia can be administered, and an emergency trach can be performed if the airway is too occluded for the passage of the ET tube.
1. Incorrect: Did you pick the lateral, supine position because there is drooling present? Don't let that trick you here. The drooling occurs because of the degree of inflammation affecting the epiglottis. Because of the potential for rapid progression of respiratory distress, we want to promote ease of respirations, minimize agitation, and allow the child to be in the position of comfort. A great position is to be upright being comforted in the parent's arms.
2. Incorrect: Respiratory syncytial virus immune globulin is not used for the treatment of epiglottitis.
4. Incorrect: Although steroids may be used in the treatment of epiglottitis, you would never want to try to administer anything by mouth to this child who has drooling and dysphagia. The child can't swallow effectively! IV medication administration would be the route of choice in the acute period.
A 7 month old infant is brought to the emergency department with a sudden onset of inconsolable crying and currant jelly-like stools. The infant is drawing up the knees toward the abdomen and grimacing. What diagnosis should the nurse anticipate?
Choose One
1. Intussusception
2. Hirschsprung's Disease
3. Pyloric Stenosis
4. Meconium Ileus
1
Rationale
1. Correct: Intussusception is a condition in which a piece of the bowel telescopes in on itself, forming an obstruction. This causes a sudden onset of cramping and abdominal pain. The client tends to be inconsolable and draws the knees upward in response to the pain. The stool may appear normal at first and then currant jelly-like stools may be noticed as blood and mucus become mixed with the stool.
2. Incorrect: Hirschsprung's disease, known as aganglionic megacolon is a congenital anomaly in which there is an absence of nerves in a portion of the bowel, typically the sigmoid colon. This results in mechanical obstruction. Here, you would see constipation and abdominal distention. If stools are passed, they are often ribbon-like that have a foul smell.
3. Incorrect: Pyloric Stenosis is a condition in which there is enlargement of the pylorus. Symptoms include projectile vomiting due to the pressure that increases in the stomach as a result of the inability of the food to pass through the enlarged pylorus to the small intestine.
4. Incorrect: Meconium ileus is a bowel obstruction that results when the first infant stools (meconium) are thicker and stickier than normal. This blockage typically occurs in the ileum of the small intestines, and the cause of most cases of a meconium ileus in infants is cystic fibrosis.
A teen male was diagnosed with infectious mononucleosis. What would be of most concern for the nurse when performing a history on this client?
Choose One
1. Rides a bicycle three times a week
2. Plays on the varsity football team
3. Member of the swim team
4. Dances with the performing arts group
2
Rationale
2. Correct: With infectious mononucleosis, the liver and spleen are often enlarged. Therefore, participation in contact sports should be limited to prevent injury. We worry about splenic rupture with contact sports such as football.
1. Incorrect: Although many activities are reduced in the acute phase due to fatigue and general malaise, riding a bicycle would not be as potentially dangerous as contact sports.
3. Incorrect: Swimming is considered a low impact sport. The client may be on bedrest or have limited activity due to fatigue. The client may need to delay swimming activities during the acute phase, but this would not be as dangerous as participation in contact sports.
4. Incorrect: Dancing can be strenuous. The client may be on bedrest or have limited activity due to fatigue. The client may need to delay strenuous activities during the acute phase, but this would not be as dangerous as participation in contact sports.
A child is admitted in a sickle cell crisis. What treatment should the nurse anticipate being most helpful in reducing the painful crisis?
Choose One
1. Antibiotics
2. Oxygen
3. Hydration
4. Bedrest
3
Rationale
3. Correct: Hydration is crucial with a sickle cell crisis. It helps minimize the vaso-occlusive process that is causing the pain as it pushes the sickled cells apart, allowing them to flow through the vessels more freely.
1. Incorrect: Antibiotics may be needed if an infection is present, but this is not the most beneficial in reducing the painful crisis.
2. Incorrect: Oxygen does not reverse the sickling process and does not help improve circulation of the sickled cells that is occluding the vessels and causing the pain. It may be given to help improve hypoxia and prevent further sickling.
4. Incorrect: Bedrest is needed to help conserve O2. In addition, activity can lead to increased pain. However, it is not the treatment that is most helpful in reducing the blockage from the sickled cells that leads to the painful episodes. [Show Less]