NCLEX Reviewer Download about Pediatric Nursing (76-80)

NCLEX Reviewer Download about Pediatric Nursing

76. An emergency room nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion?

a) poor hygiene
b) fear of the parents
c) difficulty walking
d) bald spots on the scalp  

77. A nurse is performing an assessment of a 7-year old child who is suspected of having episodes of absence seizures. Which assessment question to the mother will assist in providing information that will identify the symptoms associated with this type of seizure?

a) does twitching occur in the face and neck?
b) does the muscle twitching occur on one side of the body?
c) does the muscle twitching occur on both sides of the body?
d) does the child have a blank expression during these episodes?

78. A nurse has provided discharge instructions to the parents of an infant who has had a ventriculoperitoneal shunt procedure performed for the treatment of hydrocephalus. Which statement, if made by the parents, indicates an accurate understanding of the presence of a shunt complication?

a) I should call my doctor if my infant refuses baby food
b) if my infant has a high-pitched cry, I should call the doctor
c) my infant will pass urine more often now that the shunt is in place
d) I should position my infant on the side with the shunt when sleeping

79. A nurse is performing an admission assessment on a newborn infant with a diagnosis of spina bifida (myelomeningocele). A priority nursing assessment for this newborn is:

a) pulse rate
b) palpation of the abdomen
c) specific gravity of the urine
d) head circumference measurement

80. A mother arrives in an emergency room with her 5-year old child and the mother states that the child fell off a bunk bed. A head injury is suspected, and a nurse is assessing the child continuously for signs of increased intracranial pressure (ICP). Which of the following is a late sign of increased ICP in this child?

a) nausea
b) bradycardia
c) bulging fontanel
d) dilated scalp veins





NCLEX Reviewer Download about Pediatric Nursing:
ANSWERS AND RATIONALE

76) C
- the most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genitals, or anal area. Poor hygiene may indicate physical neglect. Bald spots on the scalp and fear of the parents most likely are associated with physical abuse.

77) D
- Absence seizures are brief episodes of altered awareness. No muscle activity occurs except eyelid fluttering or twitching. The child has a blank facial expression. These seizures last only 5 to 10 seconds, but they may occur one after another several times a day. Myoclonic seizures are brief random contractions of a muscle group that can occur on one or both sides of the body. Simple partial seizures consist of twitching of an extremity, face, or neck, or the sensation of twitching or numbness in an extremity or face or neck.

78) B
- If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is increased intracranial pressure, which then causes a high-pitched cry in the infant. The infant should not have pressure placed on the shunt side. Skin breakdown and possible compressions to the apparatus could result. This type of shunt affects the gastrointestinal system, not the genitourinary system. Option A is only a concern if the infant becomes malnourished or dehydrated, which then could raise the body temperature. Otherwise, the infant’s refusing baby food has no direct relationship to the shunt functioning.

79) D
- Newborn infants with spina bifida (myelomeningocele type) are at risk for hydrocephalus; therefore, the head circumference should be measured to obtain a baseline. Options A, B, and C are incorrect because pulse rate will not be affected with this disorder, the specific gravity can indicate hydration status but it is not priority at this time, and abdominal masses do not occur with this disorder.

80) B
- Late signs of increased intracranial pressure (ICP) include a significant decrease in level of consciousness, bradycardia, and fixed and dilated pupils. A bulging fontanel and dilated scalp veins are early signs of increased ICP and would be noted in an infant, not a 5-year-old child. Nausea is an early sign of increased ICP. 


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