Question 1

Which should the nurse expect to find in the cerebral spinal fluid (CSF) results of a child with Guillain-Barré syndrome (GBS)? (Select all that apply.)

Accepted Answer

A)   Decreased protein concentration
B)   Normal glucose
C)   Fewer than 10 white blood cells (WBCs/mm³) 
D)   Elevated red blood cell (RB
C)   count B, C

Question 2

The nurse is preparing to admit a newborn with myelomeningocele to the neonatal intensive care nursery. Which describes this newborn's defect?

Accepted Answer

A)   Fissure in the spinal column that leaves the meninges and the spinal cord exposed
B)   Herniation of the brain and meninges through a defect in the skull
C)   Hernial protrusion of a saclike cyst of meninges with spinal fluid but no neural elements
D)   Visible defect with an external saclike protrusion containing meninges, spinal fluid, and nerves D

Question 3

What should be administered to a child with tetanus?

Accepted Answer

A)   Nonsteroidal antiinflammatory drugs (NSAIDs)  to reduce inflammation.
B)   Muscle stimulants to counteract muscle weakness.
C)   Bronchodilators to prevent respiratory complications.
D)   Tetanus immunoglobulin therapy. D

Question 4

Which clinical manifestations in an infant would be suggestive of spinal muscular atrophy (Werdnig-Hoffmann disease)?

Accepted Answer

A)   Hyperactive deep tendon reflexes
B)   Hypertonicity
C)   Lying in the frog position
D)   Motor deficits on one side of body

Question 5

A 4-year-old child has just been diagnosed with pseudohypertrophic (Duchenne) muscular dystrophy. The management plan should include which action?

Accepted Answer

A)   Recommend genetic counseling.
B)   Explain that the disease is easily treated.
C)   Suggest ways to limit use of muscles.
D)   Assist family in finding a nursing facility to provide child's care.

Question 6

Which assessment findings should the nurse note in a school-age child with Duchenne muscular dystrophy (DMD)? (Select all that apply.)

Accepted Answer

A)   Lordosis
B)   Gower sign
C)   Kyphosis
D)   Scoliosis
E)   Waddling gait

Question 7

The nurse is talking to a parent with a child who has a latex allergy. Which statement by the parent would indicate a correct understanding of the teaching?

Accepted Answer

A)   "My child will have an allergic reaction if he comes in contact with yeast products."
B)   "My child may have an upset stomach if he eats a food made with wheat or barley."
C)   "My child will probably develop an allergy to peanuts."
D)   "My child should not eat bananas or kiwis."

Question 8

How much folic acid is recommended for women of childbearing age?

Accepted Answer

A)   1.0 mg
B)   0.4 mg
C)   1.5 mg
D)   2.0 mg

Question 9

A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Nursing care for this child includes which action(s)? (Select all that apply.)

Accepted Answer

A)   Monitoring and maintaining systemic blood pressure
B)   Administering corticosteroids
C)   Minimizing environmental stimuli
D)   Discussing long-term care issues with the family
E)   Monitoring for respiratory complications

Question 10

The nurse is conducting reflex testing on infants at a well-child clinic. Which reflex finding should be reported as abnormal and considered as a possible sign of cerebral palsy?

Accepted Answer

A)   Tonic neck reflex at 5 months of age
B)   Absent Moro reflex at 8 months of age
C)   Moro reflex at 3 months of age
D)   Extensor reflex at 7 months of age

Question 11

A toddler is admitted to the hospital with a possible diagnosis of tetanus. The health care provider has prescribed lorazepam (Ativan) intravenously 0.05 mg/kg/dose every 6 hours prn as a muscle relaxant. The child weighs 22 pounds. How many milligrams of Ativan should the nurse administer per dose? (Record your answer using one decimal place.)

Accepted Answer

The answer of A toddler is admitted to the hospital...

Question 12

The nurse is admitting a school-age child with suspected Guillain-Barré syndrome (GBS). Which is a priority in the care for this child?

Accepted Answer

A)   Monitoring intake and output
B)   Assessing respiratory efforts
C)   Placing on a telemetry monitor
D)   Obtaining laboratory studies

Question 13

The nurse is caring for a neonate born with a myelomeningocele. Surgery to repair the defect is scheduled the next day. Which describes the most appropriate way to position and feed this neonate?

Accepted Answer

A)   Prone and tube-fed
B)   Prone, head turned to side, and nipple-fed
C)   Supine in an infant carrier and nipple-fed
D)   Supine, with defect supported with rolled blankets, and nipple-fed

Question 14

The nurse is conducting discharge teaching to parents of a preschool child with myelomeningocele, repaired at birth, being discharged from the hospital after a urinary tract infection (UTI). Which should the nurse include in the discharge instructions related to management of the child's genitourinary function? (Select all that apply.)

Accepted Answer

A)   Continue to perform the clean intermittent catheterizations (CI
C)   at home.
B)   Administer the oxybutynin chloride (Ditropan)  as prescribed.
C)   Reduce fluid intake in the afternoon and evening hours.
D)   Monitor for signs of a recurrent urinary tract infection.
E)   Administer furosemide (Lasix)  as prescribed.

Question 15

The nurse is conducting a staff in-service on common problems associated with myelomeningocele. Which common problem is associated with this defect?

Accepted Answer

A)   Hydrocephalus
B)   Craniostenosis
C)   Biliary atresia
D)   Esophageal atresia

Question 16

A home care nurse is caring for an adolescent with a T1 spinal cord injury. The adolescent suddenly becomes flushed, hypertensive, and diaphoretic. Which intervention should the nurse perform first?

Accepted Answer

A)   Place the adolescent in a flat right side-lying position.
B)   Place a cool washcloth on the adolescent's forehead and continue to monitor the blood pressure.
C)   Implement a standing prescription to empty the bladder with a sterile in and out Foley catheter.
D)   Take a full set of vital signs and notify the health care provider.

Question 17

The nurse is planning a staff in-service on childhood spastic cerebral palsy. What characterizes spastic cerebral palsy?

Accepted Answer

A)   Hypertonicity and poor control of posture, balance, and coordinated motion
B)   Athetosis and dystonic movements
C)   Wide-based gait and poor performance of rapid, repetitive movements
D)   Tremors and lack of active movement

Question 18

Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which action?

Accepted Answer

A)   Avoid using any latex product.
B)   Use only nonallergenic latex products.
C)   Administer medication for long-term desensitization.
D)   Teach family about long-term management of asthma.

Question 19

The nurse is admitting a child with Werdnig-Hoffmann disease (spinal muscular atrophy type 1). Which signs and symptoms are associated with this disease?

Accepted Answer

A)   Spinal muscular atrophy
B)   Neural atrophy of muscles
C)   Progressive weakness and wasting of skeletal muscle
D)   Pseudohypertrophy of certain muscle groups

Question 20

A child steps on a nail and sustains a puncture wound of the foot. Which is the most appropriate method for cleansing this wound?

Accepted Answer

A)   Wash wound thoroughly with chlorhexidine.
B)   Wash wound thoroughly with povidone-iodine.
C)   Soak foot in warm water and soap.
D)   Soak foot in solution of 50% hydrogen peroxide and 50% water.

Exam 30: The Child with Neuromuscular or Muscular Dysfunction

Which should the nurse expect to find in the cerebral spinal fluid (CSF) results of a child with Guillain-Barré syndrome (GBS) ? (Select all that apply.)