Correct answer: C. Wash the face twice a day with mild soap and water.

Washing the face once or twice a day with a mild soap removes fatty acids from the skin. Acne is an inflammation of the sebaceous glands that produce sebum. Washing the face with mild soap and water keeps the sebaceous glands from becoming plugged. Excessive washing or squeezing the eruptions can cause rupture of these glands, spreading the sebum and causing further inflammation. Applying vitamin E to the lesions does not reduce the inflammation and, due to the greasiness of the preparation, may plug the ducts. Retin-A should be applied at night. Exposure to the sun can result in sunburn and an increased risk of skin cancer and should be avoided. Sunscreen with a sun protection factor of at least 15 must be applied before the client can be exposed to the sun.

Correct answer: B. Playing with the child every day.

The parents can best meet the needs of their 9-month-old infant by playing with the child every day. All infants need time with their parents to develop trust and thus attain optimal development. The parents of a child with a chronic problem may need more guidance to meet the child’s needs because of the focus on medical problems. The child’s lesions are secondarily infected and therefore should not be contagious. Siblings do not need to stay away. Even with lesions that are infected, the child can still attend day care, but the child needs attention from the parents as well. Playing video games for several hours is not appropriate for a 9-month-old infant.

Correct answer: B. "When my child gets out of the tub I just pat the skin dry."

Atopic dermatitis is a chronic pruritic dermatitis that usually begins in infancy. Many of the children diagnosed with it have a family history of eczema, allergies, or asthma. Atopic dermatitis is best treated with hydrating the skin, controlling the pruritus, and preventing secondary infection. Patting the skin dry removes less natural skin moisturizer and thus maintains skin hydration. Water has a drying effect on the skin. Playing in the tub for 30 minutes each night would deplete the skin of its natural moisturizers, thereby leading to increased pruritus and dry skin. Bubble baths are to be avoided in children with atopic dermatitis because they may act as an irritant, possibly exacerbating the condition. Also, bubble baths deplete the skin of its natural moisturizers. The issue is not whether the child bathes every night. Rather, the goal is to decrease dryness and itching.

Correct answer: B. Allow the child to go back to school after 24 hours of treatment.

Impetigo involving several superficial lesions is usually treated topically, including washing the affected areas, removing crusts, and applying antibiotic ointment several times a day. The child can return to day care or school after being treated for 24 hours. The lesions do not need to be covered, they can remain open to the air. There is no need for follow-up unless the lesions have not resolved or have become more severe.

Correct answer: B. The entire family should be treated.

Scabies is caused by the scabies mite, Sarcoptes scabiei. The mite burrows into the stratum corneum of the epidermis, where the female deposits eggs and fecal material. These burrows are linear. Scabies is highly contagious. The length of time from infestation to physical symptoms is 30 to 60 days, so everyone in close contact with the child will need to be treated. The bed linens and the child’s clothing should be washed in hot water and dried on the hot setting. It is not necessary to damp mop the floors to prevent the spread of scabies. The child should be held minimally until treatment is completed. Family members should wash their hands after contact with the child. Itching lasts for 2 to 3 weeks until the stratum corneum is replaced.

Correct answer: C. Apply cool water to the burned area.

To prevent further injury to the skin, the mother should apply cool water to the burn site. Doing so causes vasoconstriction, retards further damage to tissues, and decreases fluid loss. Keeping the child warm promotes vasodilation, increases fluid loss, and decreases blood pressure and, thus, circulation to the area. Applying ointment to the burn is contraindicated because it does not allow healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or chilling. If only the arm is burned, a call to 911 for emergency care is not necessary, but the mother should seek health care services immediately.

Correct answer: B. Allow the child to assist in removing the dressings and applying the cream.

Expressions of anger and combativeness are often the result of loss of control and a feeling of powerlessness. Some control over the situation is regained by allowing the child to participate in care. Although having parental support during the dressing changes may be helpful, this action does nothing to allow the child control. Giving the child permission to cry may help with verbalizing feelings, but doing so does nothing to provide the child with control over the situation. Although allowing the child to determine the time for dressing changes may provide a sense of control over the situation, doing so is inappropriate because the dressing changes need to be performed as prescribed to ensure effectiveness and healing.

Correct answer: B. Withholding dessert and treats unless meals are eaten.

Withholding certain foods until the child complies is punitive and rarely successful. Allowing the mother to feed the child, serving smaller and more frequent meals, and offering finger foods are all acceptable interventions for a 5-year-old child. This is true whether the child is well or ill.

Correct answer: D. Bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks.

Hypoproteinemia is common after severe burns. The child’s diet should be high in protein to compensate for protein loss and to promote tissue healing. The child will also require a diet that is high in calories and rich in iron. The menu of bacon, lettuce, and tomato sandwich; milk; and celery sticks is lacking in sufficient protein and calories.

Correct answer: D. Ensure the application of leg splints.

A child with moderate burns is at high risk for contractures. A position of comfort would encourage contracture formation. Therefore, splints need to be applied to maintain proper positioning and joint function, thereby preventing contractures and loss of function. Allowing the child to lie on the abdomen or with the hips and knees flexed often encourages contracture formation.

Correct answer: B. "The advantage of radioactive iodine is that I will not need future medication for my disease."

Most clients will need lifelong thyroid replacement after treatments with radioactive iodine. Most clients are treated as outpatients. To reduce the risk of exposure to radioactivity to others, clients are advised to avoid public places for at least 1 day and maintain a prudent distance from others for 2 to 3 days. Additionally, clients are advised to avoid close contact with pregnant women and children for 5 to 11 days. The use of radioiodine to treat Graves’ disease has not been found to affect long-term fertility. Clients are taught not to share food, utensils, and towels. Use of a private bathroom is desirable. Clients are also instructed to flush the toilet more than one time after each use.

Correct answer: D. Promote interactions with one friend instead of groups.

Children with hyperthyroidism experience emotional lability that may strain interpersonal relationships. Focusing on one friend is easier than adapting to group dynamics until the child’s condition improves. Because of their high metabolic rate, children with hyperthyroidism feel too warm. Bright sunshine may be irritating because of disease-related ophthalmopathy. Sweating is common and bathing should be encouraged.

Correct answer: C. 15 g of carbohydrate and retest the blood sugar in 15 minutes.

The 15-15 rule is a general guideline for treating hypoglycemia where the client consumes 15 g of carbohydrate and repeats testing the blood sugar in 15 minutes. Fifteen grams of carbohydrate equals 60 cal and is roughly equal to � cup of juice or soda, six to eight lifesavers, or a tablespoon of honey or sugar. The general recommendation is if the blood sugar is still low, the client may repeat the sequence. Fifteen milliliters of juice would only provide 15 cal. This would not be sufficient carbohydrates to treat the hypoglycemia. Protein does not treat insulin-related hypoglycemia; however, a protein-starch snack may be offered after the blood glucose improves. Fifteen ounces of juice would be 450 mL-almost four times the recommended 4 oz (120 mL) of juice.

Correct answer: A. Utilize a peer with type 2 diabetes to role model lifestyle changes.

Self-efficacy, or the belief that one can act in a way to produce a desired outcome, can be promoted through the observation of role models. Peers are particularly effective role models because clients can more readily identify with them and believe they are capable of similar behaviors. Providing a written plan alone does not promote self-efficacy. Having parents eliminate junk food and having the school nurse weigh the adolescent can be part of the plan, but these actions do not empower the client.

Correct answer: D. Increases insulin sensitivity.

Metformin is currently approved by the FDA and Health Canada to treat type 2 diabetes in children. The medication decreases glucogenesis in the liver and increases insulin sensitivity in the peripheral tissues. Only insulin can actually replace insulin. This treatment is reserved for clients with type 1 diabetes or those with type 2 who do not respond to diet, exercise, and an oral diabetic agent. Other oral medications used to treat diabetes augments insulin production or decreases carbohydrate absorption, but those medications are primarily used in adults.

Correct answer: B. Prevent late night hypoglycemia.

NPH insulin peaks in 6 to 8 hours, which would occur during sleep. A bedtime snack is needed to prevent late night hypoglycemia. The snack is not given to help regain weight. Milk contains fat and protein, which cause delayed absorption into the blood stream and maintains the blood glucose level at night when the NPH insulin will peak. The snack is not used to provide carbohydrates for immediate use because NPH insulin, unlike regular insulin, does not peak immediately. The snack has nothing to do with a diet.

Correct answer: C. More insulin.

The child needs more insulin during an illness, because the cells become more insulin resistant during illness and need more insulin to achieve a normal blood glucose level. During an acute illness, simple carbohydrates and fluids are usually tolerated best.

Correct answer: B. All of the above

Weakness, thirst, and dizziness are symptoms related to dehydration caused by excretion of large amounts of glucose and water in the urine. The nurse should notify the primary health care provider. Shakiness, hunger, headache, and irritability are related to hypoglycemia and result from the brain and other cells being starved for nutrients.

Correct answer: A. She introduces the nurse to her friends as "the one who taught me all about my diabetes."

The ability to talk about her diabetes indicates that the adolescent feels good enough about herself to share her problem with her peers. Asking for reference material does not specifically indicate that the client’s self-esteem has improved or that she has accepted her diagnosis. Saying that her friends will probably desert her if she tells them about the illness indicates that the adolescent still needs to work on her self-esteem and her feelings about the disease. Asking her friends what they think of someone with a lifelong illness would not indicate that the nurse’s interventions targeted toward improving self-esteem have been successful. Rather, this statement demonstrates the adolescent’s uncertainty about herself.

Correct answer: B. "Untreated PCOS will make getting pregnant impossible."

While pregnancy may be difficult for some clients, the nurse must work to prevent the false conception that a sexually active teen with PCOS does not need to use a reliable form of birth control. PCOS is associated with high levels of androgens and excessive insulin. It is the excess insulin that is thought to increase androgen production. Clients with PCOS are at risk for type 2 diabetes. Initial treatment focuses on weight management and exercise. These measures often reduce insulin production and restore normal menstrual cycles.

Correct answer: A. All of the above

PCOS is associated with obesity, increased body or facial hair (hirsutism), acne, and darkening of the skin usually in body folds (acanthosis nigricans). When a female has never had a menstrual cycle, it is referred to as primary amenorrhea. PCOS is associated with irregular menstrual cycles and/ or secondary amenorrhea, not primary amenorrhea. High androgen levels frequently lead to decreased versus enlarged breast size.

Correct answer: C. Increased insulin levels.

Metformin works by decreasing the production of glucose in the liver and improving insulin sensitivity. These two mechanisms reduce insulin and blood glucose level. Reducing insulin levels reduces androgens and helps to restore menstruation.

Correct answer: B. The organization’s privacy officer.

Confidentiality legislation specifies that institutions designate a "privacy officer" who is responsible for developing and implementing privacy policies. This would be the very best resource for the nurse to contact. Depending on the nurse manager’s experience, he or she may or may not know the answer and may have to consult the privacy officer. While primary care providers would have an understanding of confidentiality laws, it is unlikely they understand the specifics of nursing policies. The customer service representatives typically address client concerns or complaints. At this time, the family has not voiced a complaint.

Correct answer: C. Reassign the children to different rooms.

People of Arab descent most frequently practice Islam. Sleeping in the same room with a person of the opposite sex most likely would be viewed as a violation of their faith. If at all possible, the charge nurse should reassign the family to a different room. While it makes sense to have two clients with similar educational needs in the same room, it is likely that the arrangement would be sufficiently distressing enough to create a learning barrier. Offering the mother another place to sleep deprives the child of her parent at night. The customer service representative would only need to be involved if it became impossible to accommodate the mother’s needs.

Correct answer: C. Both of the above

Gowns, mask, and gloves are needed before the nurse or anyone can enter the room of a client who has chickenpox because the varicella virus is spread by air, droplets, and contact. It is very contagious, so a negative-air flow room is recommended. Contact isolation only includes a gown and gloves. Because varicella is spread by air and contact, a private room is needed. The child should remain in isolation until all lesions have crusted.

Correct answer: D. "What is it that concerns you about having the school know about your daughter’s condition?"

The nurse’s first response should be to obtain more information about the mother’s concerns. It is true that the child may have a diabetic reaction anywhere at school, and it is advisable that her teacher, classmates, and other adults know about her diabetes in order to help her; however, it is ultimately the client and her parents who will make the decision about informing the school. The nurse can facilitate a dialogue that will help the mother reach this decision. Dictating to the mother does not explain any rationale for the necessity of the information.

Correct answer: B. All of the above

Common shunt complications are obstruction, infection, and disconnection of the tubing. The signs presented by the child indicate increased intracranial pressure from a shunt malformation, which could be caused by an infection, such as peritonitis or meningitis. By listening to bowel sounds, the nurse will note if peritonitis might be a possibility. Palpating the fontanel would indicate increased intracranial pressure if it were bulging and taut. Obtaining vital signs would assess for signs of infection, such as elevated temperature or, possibly, Cushing’s triad (elevated blood pressure, slow pulse, and depressed respirations). A high-pitched cry is a sign of increased intracranial pressure. Weighing the child at this time would not be a priority, nor would it add to identifying the cause of the signs and symptoms.

Correct answer: B. Prone with hips in abduction.

Before surgery, the infant is kept flat in the prone position to decrease tension on the sac. This allows for optimal positioning of the hips, knees, and feet because orthopedic problems are common. The supine position is unacceptable because it causes pressure on the defect. Flexing the knees when side lying will increase tension on the sac, as will placing the infant in semi-Fowler’s position, even though the chest and abdomen are elevated.

Correct answer: A. All of the above

Prevention of urinary tract infections includes adequate fluid intake, urine acidification, frequent emptying of the bladder including the use of Crede’s maneuver if needed. While the nurse should keep the skin clean and dry, this will not prevent urinary tract infections. Keeping urine close to the meatus with a tight-fitting diaper would increase the risk for infection.

Correct answer: C. A high-pitched cry.

A Chiari malformation obstructs the flow of cerebral spinal fluid resulting in hydrocephalus. This is a common problem in infants with myelomeningocele and will require surgical intervention with a shunt. A high-pitched cry is one sign of increased intracranial pressure that may indicate the presence of a Chiari malformation and requires further evaluation. Minimal movement of the lower extremities is an expected finding associated with spinal cord damage. Overflow voiding comes from a neurogenic bladder, not increased intracranial pressure. It is normal for the fontanel to bulge with crying.

Correct answer: A. Emphasizing the infant’s normal and positive features.

The parents should see the neonate as soon as possible, because the longer they must wait to see the neonate, the more anxiety they will feel. Because the parents are acutely aware of the deficit, the nurse should emphasize the neonate’s normal and positive features during the visit. All parents, but especially those with a child who has a disability or defect, need to hear positive comments and comments that reflect how the infant is normal. Although the parents need to discuss their fears and concerns, the priority on the first visit is to emphasize the neonate’s normal and positive features. Reinforcing the doctor’s explanation of the defect may be necessary later. Reinforcing the explanation at this initial visit emphasizes the defect, not the child. The parents should spend time with or care for the neonate after birth because parent-infant contact is necessary for attachment. The parents cannot feed the neonate before the defect is repaired because the repair typically occurs within 24 hours. The infant will be prone in an isolette or warmed and watched closely. However, the parents can fondle and stroke the neonate.

Correct answer: C. Excessive cerebrospinal fluid within the cranial cavity.

Excessive cerebrospinal fluid in the cranial cavity, called hydrocephalus, is the most common anomaly associated with myelomeningocele. Microencephaly, an abnormally small head, is associated with maternal exposure to rubella or cytomegalovirus. Anencephaly, a congenital absence of the cranial vault, is a different type of neural tube defect. Overriding of the sutures, possibly a normal finding after a vaginal delivery, is not associated with myelomeningocele.

Correct answer: D. "About one-third have an intellectual disability, but it’s too early to tell about your child."

Approximately one-third of infants diagnosed with myelomeningocele are mentally retarded, but the degree of retardation is variable and it is difficult to predict intellectual functioning in neonates. The parents are asking for an answer now and should not be told to talk with the primary health care provider later.

Correct answer: A. The axillary temperature remains between 97°F and 98°F (36.1°C and 36.7°C).

The nurse places the neonate with myelomeningocele in an isolette shortly after birth to help to maintain the infant’s temperature. Because of the defect, the neonate cannot be bundled in blankets. Therefore, it may be difficult to prevent cold stress. The isolette can be maintained at higher than room temperature, helping to maintain the temperature of a neonate who cannot be dressed or bundled. Body temperature readings, not arterial oxygen levels, are the best indicator. Typically, an infant loses 5% to 10% of body weight before beginning to regain the weight.

Correct answer: B. Allowing the hips to be abducted.

Because of the potential for hip dislocation, the neonate’s legs should be slightly abducted, hips maintained in slight to moderate abduction, and feet maintained in a neutral position. The infant’s knees are flexed to help maintain the hips in abduction.

Correct answer: B. Placing the legs in adduction.

The most important aspect of the discharge plan is to ensure that the parents understand what the daily care of their infant involves and to provide teaching related to carrying out this daily care. In addition to the routine care required by the infant, care also may include physical therapy to the lower extremities. Providing a list of available hospital services may be helpful to the parents, but it is not the most important aspect to include in the discharge plan. Usually, home health care is not needed because the parents are able to care for their child. A referral for counseling is initiated whenever the need arises, not just at discharge.

Correct answer: D. "I will call the doctor if his urine has a funny smell."

Children with a myelomeningocele are prone to urinary tract infections (UTI) and foul-smelling urine is one symptom of a UTI. Because of the level of defect, the child may be insensitive to pressure or heat. Using a heating pad may lead to thermal injury because the child may not be able to sense if the pad is too hot. Keeping the child away from other children is unnecessary and can retard social development. Using pillows as props increases the risk of sudden infant death syndrome.

Correct answer: A. Giving the infant small, frequent feedings.

An infant with hydrocephalus is difficult to feed because of poor sucking, lethargy, and vomiting, which are associated with increased intracranial pressure. Small, frequent feedings given at times when the infant is relaxed and calm are tolerated best. Feeding an infant before any procedure is inappropriate because the stress of the procedure may lead to vomiting. Ideally, the infant should be held in a slightly vertical position when feeding to prevent backflow of formula into the eustachian tubes and subsequent development of ear infections. Most infants are fed on demand every 3 to 4 hours.

Correct answer: B. Supine, with the head of the bed flat.

For at least the first 24 hours after insertion of a ventriculoperitoneal shunt, the child is positioned supine with the head of the bed flat to prevent too rapid a decrease in cerebrospinal fluid pressure. Although elevating the head increases cerebrospinal fluid drainage and reduces intracranial pressure, a rapid reduction in the size of the ventricles can cause subdural hematoma. Positioning on the operative or right side is avoided because it places pressure on the shunt valve, possibly blocking desired drainage of the cerebrospinal fluid. Elevating the foot of the bed could increase intracranial pressure. With continued increased intracranial pressure, the child would be positioned with the head of the bed elevated to allow gravity to aid drainage. The child should be kept off the nonoperative side (side opposite the shunt), or the left side, to help prevent rapid decompression leading to a cerebral hematoma.

Correct answer: B. Monitoring for increased temperature.

Monitoring the temperature allows the nurse to assess for infection, the most common and the most hazardous postoperative complication after ventroperitoneal shunt placement. Typically, pain after insertion of a ventriculoperitoneal shunt is mild, requiring the use of mild analgesics. Usually narcotics are not administered because they alter the level of consciousness, making assessment of cerebral function difficult. Neither proteinuria nor glycosuria is associated with shunt placement. Cerebrospinal fluid leakage commonly occurs with head injury. It is not usually associated with shunt placement.

Correct answer: C. Irritability and increasing difficulty with eating.

In a school-age child, irritability, lethargy, vomiting, difficulty with eating, and decreased level of consciousness are signs of increased intracranial pressure caused by a blocked shunt. Decreased urine output with stable fluid intake indicates fluid loss from a source other than the kidneys. A tense fontanel and increased head circumference would be signs of a blocked shunt in an infant. Elevated temperature and redness around incisions might suggest an infection.

Correct answer: B. "I understand your concern; you may want to start your daughter on a birth control pill."

Children with Down syndrome range from severely retarded to low average intelligence, which questions the adolescent’s ability to make informed choices regarding sexual activity. Starting her on birth control pills will greatly reduce the risk of unwanted pregnancy. Most women with Down syndrome are fertile; however, children born to women with Down syndrome often have congenital defects.

Correct answer: D. At school with his teacher.

Watching the child relate to his teacher and school work is the best indication of how he is progressing. School involves interacting with a person who is not a relative and in a situation that is not totally familiar. Observing the client in situations with family and friends shows social relationships but does not indicate how the child is learning new intellectual skills.

Correct answer: B. Encouraging self-care skills in the child.

The goal in working with mentally retarded children is to train them to be as independent as possible, focusing on developmental skills. The child may not be capable of learning something new every day but needs to repeat what has been taught previously. Rather than encouraging more lenient behavior limits, the parents need to be strict and consistent when setting limits for the child. Most children with Down syndrome are unable to achieve age-appropriate social skills due to their mental retardation. Rather, they are taught socially appropriate behaviors.

Correct answer: C. Providing stimulating, nonthreatening life experiences.

. Nonthreatening experiences that are stimulating and interesting to the child have been observed to help raise IQ. Practices such as serving nutritious meals or letting the child play with more able children have not been supported by research as beneficial in increasing intelligence. Vasodilator medications act to increase oxygenation to the tissues, including the brain. However, these medications do not increase the child’s IQ.

Correct answer: B. Confidence in their ability to care for their child.

When teaching the parents of a child with Down syndrome, activities should focus on increasing the parents’ confidence in their ability to care for the child. The parents must continue to work daily with their child. Most parents feel affection and a sense of responsibility for their child regardless of the child’s limitations. Parents usually understand the child’s disability on the cognitive level but have difficulty accepting it on the emotional level. As the parents’ confidence in their caring abilities increases, their understanding of the child’s disability also increases on all levels.

Correct answer: B. Removing any nearby objects that could harm the child.

During a generalized tonic-clonic seizure, the first priority is to keep the child safe and protect the child by removing any nearby objects that could cause injury. Although obtaining information about events surrounding the seizure is important, this information can be obtained later, once the child’s safety is ensured. During a seizure, the child should not be moved. Although providing privacy is important, the child’s safety is the priority. During a seizure, nothing should be forced into the client’s mouth because this can cause severe damage to the teeth and mouth.

Correct answer: C. The child will likely have normal intelligence and be able to attend regular school.

Most children who develop seizures after infancy are intellectually normal. A child with a seizure disorder needs the same experiences and opportunities to develop intellectual, emotional, and social abilities as any other child. Activity limitation is not needed. Learning disabilities are not associated with seizures. The child is able to attend public school, and social stigma is a rarity.

Correct answer: D. Rock climbing.

A child who has generalized seizures should not participate in activities that are potentially hazardous. Even if accompanied by a responsible adult, the child could be seriously injured if a seizure were to occur during rock climbing. Someone also should accompany the child during activities in the water. At summer camps, hiking and swimming would occur most commonly as group activities, so someone should be with the child. Tennis would be considered an appropriate, nonhazardous activity for a child with generalized seizures.

Correct answer: B. The seizure occurred when the child had a respiratory infection.

Most febrile seizures occur in the presence of an upper respiratory infection, otitis media, or tonsillitis. Febrile seizures typically occur during a temperature rise rather than after prolonged fever. There appears to be increased susceptibility to febrile seizures within families. Infrequently, febrile seizures may lead to respiratory arrest.

Correct answer: A. "We’ll wrap him in a blanket if he starts shivering."

Shivering, the body’s defense against rapid temperature decrease, results in an increase in body temperature. Therefore, the parents need to take measures to stop the shivering (and the resulting increase in body temperature) by increasing the room temperature or the temperature of the child’s immediate environment (such as with blankets) until the shivering stops. Then, attempts are made to lower the temperature more slowly. Shivering does not necessarily correlate with being cold. Alcohol, a toxic substance, can be absorbed through the skin. Its use is to be avoided.

Correct answer: B. "When you decide to have children, talk to the doctor about changing your medication."

Phenytoin sodium (Dilantin) is a known teratogenic agent, causing numerous fetal problems. Therefore, the adolescent should be advised to talk to the doctor about changing the medication. Additionally, anticonvulsant requirements usually increase during pregnancy. Seizures can be controlled but cannot be cured. There is a familial tendency for seizure disorders. Seizure disorders and infertility are not related.

Correct answer: C. Jaundice.

A toxic effect of valproic acid (Depakene) is liver toxicity, which may manifest with jaundice and abdominal pain. If jaundice occurs, the client needs to notify the health care provider as soon as possible. Diarrhea and sore throat are not common side effects of this drug. Increased appetite is common with this drug.

Correct answer: D. Administering acetaminophen (Tylenol).

Instituting droplet precautions is the priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be ordered, but administering it does not take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit do not take priority.

Correct answer: B. Keeping extraneous noise to a minimum.

A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Although treatments need to be completed as quickly as possible to prevent overstressing the child, they should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.

Correct answer: C. Hemorrhagic skin rash.

Disseminated intravascular coagulation is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition. Heparin therapy is often used to interrupt the clotting process. Edema would suggest a fluid volume excess. Cyanosis would indicate decreased tissue oxygenation. Dyspnea on exertion would suggest respiratory problems, such as pulmonary edema.

Correct answer: D. Middle ear infection.

Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the body by vascular dissemination from a middle ear infection. The meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumococcus. A chronically draining ear is also frequently found. Bladder infections commonly are caused by Escherichia coli, unrelated to the development of pneumococcal meningitis. Pneumococcal meningitis is unrelated to a fractured clavicle or to septic arthritis, which is commonly caused by Staphylococcus aureus, group A streptococci, or Haemophilus influenzae.

Correct answer: B. Protect the image of an intact body.

Preschool-age children worry about having an intact body and become fearful of any threat to body integrity. Allowing the child to participate in required care helps protect her image of an intact body. Development of trust is the task typically associated with infancy. Additionally, allowing the child to apply a dressing over the intravenous insertion site is unrelated to the development of trust. Finding diversional activities is not a priority need for a child in this age group. Separation anxiety is more common in toddlers than in preschoolers.

Correct answer: B. All of the above

Antibiotics are indicated for the treatment of bacterial meningitis. Clients with bacterial meningitis often have increased ICP. It is necessary to maintain adequate hydration. However, infusing fluids at 1 � maintenance can increase ICP, further risking neurologic damage due to cerebral edema. Most children with meningitis are sensitive to sound, light, and stimulation. Decreasing environmental stimuli and keeping the room dim and quiet are essential. Frequent neurologic checks are necessary to monitor any changes in the child’s level of consciousness. Anticonvulsants are not indicated unless the child experiences seizures as a result of the meningitis.

Correct answer: B. All of the above

Irritability, bulging fontanel, and emesis are all signs of increased ICP in an infant. A headache may be present in an infant with increased ICP; however, the infant has no way of communicating this to the parent. A headache is an indication of increased ICP in a verbal child. An infant cannot exhibit mood swings; this is indicative of increased ICP in a child or adolescent.

Correct answer: A. Pounding on a pegboard.

The child is angry and needs a positive outlet for expression of feelings. An emotionally tense child with pent-up hostilities needs a physical activity that will release energy and frustration. Pounding on a pegboard offers this opportunity. Listening to a story does not allow the child to express emotions. It also places the child in a passive role and does not allow the child to deal with feelings in a healthy and positive way. Activities such as painting and stacking a tower of blocks require concentration and fine movements, which could add to frustration. However, if the child then knocks the tower over, doing so may help to dispel some of the anger.

Correct answer: D. Hypoxia.

Hypoxia is the primary problem because it results in brain cell damage. Irreversible brain damage occurs after 4 to 6 minutes of submersion. Hypothermia occurs rapidly in infants and children because of their large body surface area. Hypothermia is more of a problem when the child is in cold water. Although fluid aspiration occurs in most drownings and results in atelectasis and pulmonary edema, further aggravating hypoxia, hypoxia is the primary problem. Cutaneous capillary paralysis is not a problem.

Correct answer: C. Administer oxygen.

Near-drowning victims typically suffer hypoxia and mixed acidosis. The priority is to restore oxygenation and prevent further hypoxia. Here, the client has blunted sensorium, but is not unconscious; therefore, delivery of supplemental oxygen with a mask is appropriate. Warming protocols and fluid resuscitation will most likely be needed to help correct acidosis, but these interventions are secondary to oxygen administration. Intubation is required if the child is comatose, shows signs of airway compromise, or does not respond adequately to more conservative therapies

Correct answer: C. "Tell me a little bit more about your feelings of guilt."

Guilt is a common parental response. The parents need to be allowed to express their feelings openly in a nonthreatening, nonjudgmental atmosphere. Telling the parents that these things happen does not allow them to verbalize their feelings. Telling the parents that they should not have taken their eyes off the child blames them, possibly further contributing to their guilt. Telling the parents that they shouldn’t feel guilty denies the parents’ feelings of guilt and is inappropriate. Telling the parents that they are lucky that the child will be okay does not remove the feelings of guilt.

Correct answer: A. Difficulty swallowing.

Most children with sore throat have some difficulty swallowing, so it is important for the nurse to determine the extent of difficulty to aid in determining what action is necessary. Typically a sore throat precedes the paralysis of this disorder. Muscle tenderness is an initial symptom. Distal muscle weakness follows proximal muscle weakness, ultimately progressing to paralysis. Diet history and difficulty urinating will not contribute to assessment of the cause of a sore throat or difficulty swallowing. After determining the extent of difficulty swallowing, the nurse can obtain information about exposure to illness.

Correct answer: C. Evaluating the child’s bilateral muscle strength.

With Guillain-Barr� syndrome, progressive ascending paralysis occurs. Therefore, the nurse should assess the child’s muscle strength bilaterally to determine the extent of involvement and progression of the illness. Assessing the child’s ability to follow simple commands evaluates brain function. Range-of-motion exercises are an important part of treatment, but they are not a priority initially. Although the child may need diversional activities later, they also are not an initial priority.

Correct answer: D. Involvement of facial and cranial nerves.

In a child with Guillain-Barr� syndrome, decreased volume and clarity of speech and decreased ability to cough voluntarily indicate ascending progression of neural inflammation, specifically affecting the cranial nerves. Inflammation of the larynx and epiglottis is manifested by hoarseness, stridor, and dyspnea. A child with laryngeal inflammation still retains the ability to cough. Irritability, behavior changes, headache, and vomiting are common signs of increased intracranial pressure in a school-age child. Regression would be manifested by being more dependent and less able to care for self.

Correct answer: A. Ineffective breathing pattern related to neuromuscular impairment.

An ineffective breathing pattern caused by the ascending paralysis of the disorder interferes with the child’s ability to maintain an adequate oxygen supply. Therefore, this nursing diagnosis takes precedence. Additionally, as the neurologic impairment progresses, it will probably have an effect on the child’s ability to maintain respirations. An increased risk for infection related to an altered immune system is not associated with Guillain-Barr� syndrome. Although impaired swallowing and incontinence may occur with the ascending paralysis of this disorder, oxygenation is the priority.

Correct answer: A. Turn the child slowly and gently from side to side to prevent respiratory complications.

Even in the absence of respiratory problems or distress, the child must be turned frequently to help prevent the cardiopulmonary complications associated with immobility, such as atelectasis and pneumonia. Maintaining the child in a supine position is unnecessary. Doing so does not prevent unnecessary nerve stimulation. In addition, maintaining a supine position may lead to stasis of secretions, placing the child at risk for pneumonia. Transferring the child to a chair will not prevent postural hypotension. However, doing so will increase vascular tone and help prevent respiratory and skin complications. During the acute disease phase, vigorous physiotherapy is contraindicated because the child may experience muscle pain and be hypersensitive to touch. Careful and gentle handling is essential.

Correct answer: C. "I take her to the pool where she can exercise with other children."

Developmentally appropriate activities and therapeutic play should be used as rehabilitation modalities. Taking the child to the pool to exercise with other children indicates that the child is participating in exercise as well as engaging with other children, thus fostering development. Arguing with the sister does not address the discharge plan. Inappropriate rewards or threats should not be used to coerce a child into compliance. Although the mother is attempting to comply with the discharge plan, bribery is an inappropriate technique to foster compliance. Missing therapy sessions delays recovery. The parents need to help set the child’s schedule to ensure that she gets adequate rest to be able to follow her treatment plan.

Correct answer: A. Administer IV mannitol (Osmitrol).

An ICP level greater than 15?mm Hg is abnormal. This child’s vital signs indicate increased ICP. Mannitol is an osmotic diuretic and will decrease the child’s ICP. Suctioning the child will increase the ICP. Encouraging the parent to talk to the child may be comforting but will not decrease the ICP. The priority for this child is decreasing the ICP to avoid further brain injury. The fever is likely due to the head injury and will not decrease with Tylenol. A cooling blanket is the most effective means of reducing a fever in a client with a head injury.

Correct answer: B. Decompress the stomach.

For the child with serious head trauma, a nasogastric tube is inserted initially to decompress the stomach and to prevent vomiting and aspiration. Medications would be administered intravenously in the initial period. The tube will not be used to obtain gastric specimens. Nutrition is not a priority initially. Later on, the tube may be used to administer feedings.

Correct answer: B. Ask for the prescription to be changed to oral gastric tube.

Because a basilar skull fracture can involve the frontal and ethmoid bones, inserting a nasogastric tube carries the risk of introducing the tube into the cranial cavity through the fracture. An oral gastric tube is preferred for a client with a basilar skull fracture. The tube would not be placed into the duodenum. Gastric aspirate is not routinely tested for blood unless there is an indication to suggest bleeding, such as a falling hemoglobin or visible blood in the drainage.

Correct answer: B. "It’s hard to tell this early, but we’ll keep you informed of the progress."

As a rule, children demonstrate more rapid and more complete recovery from coma than do adults. However, it is extremely difficult to predict a specific outcome. Reassuring the parents that they will be kept informed helps open lines of communication and establish trust. Telling the parents that children do not do well would be extremely negative, destroying any hope that the parents might have. Telling the parents that children recover rapidly may give the parents false hopes. Telling the parents to talk to the doctor ignores the parents’ concerns and interferes with trust-building.

Correct answer: A. Level of consciousness.

The level of consciousness (LOC) is the best indicator of brain function. If the child’s condition deteriorates, the nurse would notice changes in LOC before any other changes and should notify the primary health care provider that these changes are occurring. Changes in vital signs and pupils typically follow changes in LOC. Motor strength is primarily assessed as a voluntary function. With changes in levels of consciousness, there may be motor changes.

Correct answer: A. Lying on the side, with the head of the bed elevated.

The unconscious child is positioned to prevent aspiration of saliva and minimize intracranial pressure. The head of the bed should be elevated, and the child should be in either the semiprone or the side-lying position. Lying prone with hips and knees slightly elevated increases intracranial pressure, as does lying on the back in the Trendelenburg position. The semi-Fowler’s position with arms at the side is not the best choice.

Correct answer: C. Decreased intracranial pressure.

Mannitol is an osmotic diuretic used to reduce intracranial pressure. The use of the drug is controversial and should be reserved to cases that do not respond to other treatments or when brain herniation is likely. Children this sick should be on intracranial pressure (ICP) monitoring. The best indicator that the drug has produced the desired results is a reduction in the ICP. Improved levels of consciousness should follow reduced ICP. While the drug will cause increased urine output, that measurement in and of itself does not indicate successful treatment. Because the drug is being used for head injuries, not to improve urine output in acute renal failure, the child may not have visible edema.

Correct answer: D. All of the above

Concussion recovery can be complicated by any previous brain injury, such as a previous concussion. Recovery can also be complicated by the presence of other neurologic problem, such as migraines, ADHD, and depression. Asthma and obesity have not been linked to concussion recovery.

Correct answer: A. Inability to hop.

The inability to hop is not concerning because it is a milestone for a 4-year-old not a 3-year-old. Lack of interest in toys, changes in eating habits, and increased temper tantrums that persist several weeks all require an evaluation by a neurologist or other specialist.

Correct answer: C. "Time is the most important factor in my recovery."

While recovery from a concussion takes time, adequate rest and limiting exertion facilitate recovery. Both physical and cognitive exertion can cause the reemergence of symptoms and delay recovery. As symptoms resolve, clients may slowly return to previous levels of activity.

Correct answer: C. Notify the primary health care provider.

A decreasing level of consciousness, decerebrate positioning, or Cushing’s triad (elevated systolic blood pressure, decreased pulse, and decreased respiratory rate) indicates that there is pressure on the brain stem and the client could require intubation and cardiac resuscitation unless the primary health care provider can prescribe a medication or surgical procedure to reduce the intracranial pressure. Raising the head of the bed could offer some reduction in the intracranial pressure by increasing venous blood return from the head, but it is not the priority at this time. An analgesic administered at this time would mask the sign of decreasing level of consciousness and hinder assessment. An oximeter would measure the oxygen level in the blood, but not necessarily in the brain.

Correct answer: B. Encourage meticulous handwashing by client and visitors.

A WBC of 2,000?mm3 (2 � 109/L) is low and increases risk for infection. Meticulous handwashing is a universal precaution and the first line of defense in combating infection. A platelet count of 150,000 ?L (150 � 109/L) is normal, so there is no need for a platelet transfusion. Mouth care will help decrease the risk of infection. However, handwashing is the priority as it will have the greatest impact on diminishing the risk of infection. An Hgb of 12.5?g/dL (125 g/L) and an HCT of 36.8% (0.37) are within normal range, so there is no need to transfuse packed red blood cells.

Correct answer: A. Make an appointment with the adolescent’s primary health care provider.

A child who has symptoms of vomiting, headaches, and problems walking needs to be evaluated by a health care provider to determine the cause. Unexplained headaches and vomiting along with difficulty walking (eg, ataxia) may suggest a brain tumor. Evaluation by an eye doctor would be appropriate once a complete medical evaluation has been accomplished. Psychological counseling may be indicated for this adolescent, but only after medical evaluation to determine that she is physically healthy. Meeting with the child’s teachers would be appropriate after medical evaluation.

Correct answer: D. All of the above

Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor. Polydipsia is rare with a brain tumor. It is more often a sign of diabetes insipidus following a closed head injury. Increased appetite occurs during a growth spurt and is not necessarily a sign of a brain tumor. Increased pulse is a nonspecific sign and can occur with many illnesses, cardiac anomalies, fever, or exercise.

Correct answer: B. Side-lying.

After surgery for an infratentorial tumor, the child is usually positioned flat on either side, with the head and neck in midline and the body slightly extended. Pillows against the back, not the head, help maintain position. Such a position helps avoid pressure on the operative site. Placing the child in a prone or semi-Fowler’s position will cause pressure on the operative site. The Trendelenburg position is usually contraindicated because keeping the head below the level of the heart increases intracranial pressure as well as the risk of hemorrhage.

Correct answer: A. Lower the arousal level.

Hypercapnia, hypoxia, and acidosis are potent cerebral vasodilating mechanisms that can cause increased intracranial pressure. Lowering the carbon dioxide level and increasing the oxygen level through hyperventilation is the most effective short-term method of reducing intracranial pressure. Although ensuring a patent airway is important, this is not accomplished by manual hyperventilation. Manual hyperventilation does not lower the arousal level; in fact, the arousal level may increase. Manual hyperventilation is used to reduce hypoxia, not produce it.

Correct answer: C. Ask the child if she’d like to wear a hat.

It is not uncommon for a child to be concerned about a change in appearance when the entire head or only part of the head has been shaved. The child should be encouraged to participate in decisions about her care when possible. Asking her if she would like to wear a hat is one way to encourage this participation. Reassuring the child that her hair will grow back does not address the immediate change in appearance, and it ignores the child’s current feelings. Explaining that this type of reaction is normal does not address the child’s feelings. The child needs to be able to express feelings and be involved in care as much as possible. Buying the child a wig as a surprise does not address the child’s feelings and does not allow her to participate in decision making. Rather, the parents should ask the child if she would like a wig and then work with the child to determine what kind of wig she would like.

Correct answer: D. "After this, I’ll never let her out of my sight again."

Parents of a child who has undergone neurosurgery can easily become overprotective. Yet the parents must foster independence in the convalescing child. It is important for the child to resume age-appropriate activities, and parents play an important role in encouraging this. Statements about going back to school would be expected. Parents want the child to return to normal activities after a serious illness or injury as a sign that the child is doing well.

Correct answer: B. Leave the adolescent as he is, staying close by.

The adolescent’s signs and symptoms suggest a spinal cord injury. A client with suspected spinal cord injury should not be moved until the spine has been immobilized. Removing the helmet could further aggravate a spinal cord injury. The nurse could assess for abdominal trauma, but only if it can be done without moving the adolescent.

Correct answer: A. Paralytic ileus.

A thoracic spinal cord injury involves the muscles of the lower extremities, bladder, and rectum. Paralytic ileus often occurs as a result of decreased gastrointestinal muscle innervation. The nurse evaluates this by auscultating the abdomen. Because the client has a thoracic spinal cord injury, the client may not feel abdominal cramping. Additionally, auscultation would provide no evidence of cramping. Hyperactive bowel sounds would be evidenced with increased peristalsis; peristalsis would probably be diminished with this injury. Profuse diarrhea, resulting from increased peristalsis, would not be an expected finding. Diarrhea would be more commonly associated with a gastrointestinal infection.

Correct answer: B. Hyperactive reflexes.

Spinal shock causes a loss of reflex activity below the level of the injury, resulting in bladder atony and flaccid paralysis. When the reflex arc returns, it tends to be overactive, resulting in spasticity. The reflexes and bladder become hypertonic during this phase of spinal shock resolution; sensation does not return. A widened pulse pressure is not associated with resolution of spinal shock.

Correct answer: A. A stage of grief reaction.

After a catastrophic injury, individuals commonly experience grief. Initially, the person experiences denial, the most common response. With gradual awareness of the situation, anger commonly occurs. The child is demonstrating anger, not rebellion, as he gradually becomes aware of his situation. Rebellion is the child’s way to maintain autonomy and individuality. It is a reaction to rigid rules. Examples include refusing to follow a treatment protocol when the child had no input and running away. Sensory overload would cause the child to be irritable and tired and to have difficulty sleeping. Too much attention usually would lead to irritability, difficulty sleeping, and mood swings.

Correct answer: C. Droplet precautions.

Bacterial meningitis is caused by one of three organisms, H. influenzae type b, Neisseria meningitidis, or Streptococcus pneumoniae. All three organisms may be transmitted through contact with respiratory droplets. These droplets are heavy and typically fall within 3 feet (91.4 cm) of the client. Droplet precautions require, in addition to standard (routine) precautions, that health care providers wear masks when coming into close contact with the client. Standard or routine precautions, previously referred to as universal precautions, are general measures used for all clients. Contact precautions are used when direct or indirect contact with the client causes disease transmission. Gowns and gloves are needed but not masks. Airborne precautions differ from droplet in that the particles are smaller and may stay suspended in the air for longer periods of time. These clients require negative pressure rooms and all heath care workers must wear respirators.

Correct answer: C. All of the above

Using only oral syringes to administer oral medications reduces the chance that the medication will be given intravenously. The use of smart pumps alone is not enough to prevent IV fluid administration. An additional measure that pediatric floors can institute to prevent accidental fluid overload is to use smaller IV fluid bags, such as 250?mL. Whenever a medication comes in multiple concentrations and doses, there is risk of administering the wrong dose. The use of pediatric satellite pharmacies with pediatric pharmacists greatly increases the safety of medication administration. Any time steps are added to the medication administration process, there is one more place where an error might occur.

Correct answer: A. Contact the primary care provider to change the prescription.

The coating on an extended-release medication helps assure slow absorption of the medication. If the nurse crushes the medication, the medication may enter the client’s system too quickly and result in toxic levels. The only appropriate action is to contact the prescriber and ask that the prescription be changed. Cutting the medication or trying to dissolve a whole tablet would have similar results as crushing it. Carbamazapine comes as an oral suspension, but it is not extended release. Therefore, a prescription would be needed to address dosing if switching to this form.

Correct answer: C. Create a poster presentation on the topic with a required post test.

A poster presentation is an eye-catching way to disseminate information that can be used to educate nurses on all shifts. The addition of the post test will verify that the poster information has been received. Because of the large volume of emails the typical employee receives, information sent this way may be overlooked. If several nurses are observed not using the most current practice, it is quite possible many more do not understand it. Thus, a larger scale plan is needed. Posting an article will not alone assure that the information is read.

Correct answer: C. Lumbar puncture.

The child is exhibiting signs and symptoms of increased intracranial pressure (ICP). A lumbar puncture is contraindicated in children with increased ICP due to the risk of herniation. Magnetic resonance imaging and a computerized tomography scan are indicated in children with suspected increased ICP. Radiology studies will allow visualization of the cause of the increased ICP such as inflammation, a tumor, or hemorrhage. An arterial blood draw is not indicated in this client. However, there is no contraindication for performing an arterial blood draw on a child with increased ICP.

Correct answer: B. Rectal diazepam.

IV lorazepam is the benzodiazepine of choice for treating prolonged seizure activity. IV benzodiazepines act to potentiate the action of the gamma-aminobutyric acid (GABA) neurotransmitter; stopping seizure activity. If an IV is not available, rectal diazepam is the benzodiazepine of choice. The child does have a low-grade fever; however, this is likely caused by the excessive motor activity. The primary goal for the child is to stop the seizure in order to reduce neurologic damage. Benzodiazepines are used for the initial treatment of prolonged seizures. Once the seizure has ended, a loading dose of fosphenytoin or phenobarbital is given.

Correct answer: A. Coordinate outpatient physical therapy.

Physical therapy is the most important part of the child’s plan of care. Most cases of torticollis respond to gentle stretching exercises, which the parents perform daily. Regular physical therapy is needed to monitor the infant’s progress. Botox injections are not approved for children under the age of 2 and would not be an appropriate first-line treatment for an infant. Surgery is only done if physical therapy is not successful after several months. The use of wedges to position children during sleep is not recommended because they increase the risk of SIDS.

Correct answer: A. Avoidance of weight bearing on the head of the affected femur.

Legg-Calv�-Perthes disease, also known as coxa plana or osteochondrosis, is characterized by aseptic necrosis at the head of the femur when the blood supply to the area is interrupted. Avoidance of weight bearing is especially important to prevent the head of the femur from leaving the acetabulum, thus preventing hip dislocation. Devices such as an abduction brace, a leg cast, or a harness sling are used to protect the affected joint while revascularization and bone healing occur. Surgical procedures are used in some cases. Although pain control measures may be appropriate, pain is not necessarily more acute at night. Initial therapy involves rest and non-weight bearing to help restore motion. Preventing flexion is not necessary.