Exercise 2

1. A nurse is performing an admission assessment on a 6-month-old infant with

a diagnosis of hydrocephalus. The nurse assess for the major sign associated
with hydrocephalus when the nurse
a. Tests the urine for protein.
b. Takes the apical pulse.
c. Palpates the anterior fontanel.
d. Takes the blood pressure
2. A nurse has provided discharge instructions to the parents of an infant who
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. If my infant has a high-pitched cry, I should call the doctor.
b. I should position my infant on the side with the shunt when sleeping.
c. My infant will pass urine more often now that the shunt is in place.
d. I should call my doctor if my infant refuses baby food.
3. A nurse is performing an admission assessment of a newborn with a
diagnosis of spina bifida (meningomyelocele). The nurse assesses for a major
symptom associated with this type of spina bifida when the nurse
a. Checks the capillary refill of the nailbeds of the upper extremities
b. Tests the urine for blood
c. Palpates the abdomen for masses.
d. Checks for responses to painful stimuli from the torso downward.
4. A mother arrives at an emergency room with her 5-year-old child. 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 that would indicate a late sign of
increased ICP in this child?
a. Buldging of the fontanel
b. Dialted scalp vein
c. Nausea
d. Widened pulse pressure
5. A nurse is caring for a newborn infant with spina bifida (meningomyelocele
type) who is scheduled for surgical closure of the sac. In the preoperative
period the priority nursing action would be to monitor the
a. Blood pressure
b. Moisture of the saline dressing covering the sac
c. Specific gravity of the urine
d. Anterior fontanel for depression
6. A child is diagnosed with Reyes syndrome. A nurse develops a nursing care
plan for the child and includes which intervention in the plan?
a. Providing a quiet atmosphere with dimmed lighting
b. Assessing hearing loss

c. Monitoring urine output

d. Changing body position every 2 hours
7. A day care nurse is observing a 2-year-old child. The nurse suspects that the
child may have strabismus. Which of the following observations made by the
nurse indicate this condition?
a. The child consistently tilts the head to see.
b. The child consistently turns the head to see.
c. The child does not respond when spoken to.
d. The child has difficulty hearing.
8. A nurse prepares a teaching plan for a mother of a child diagnosed with
bacterial conjunctivitis. Which of the following, if stated by the mother, would
indicate a need for further education?
a. I need to wash my hands frequently.
b. I need to clean the eye as prescribed.
c. I need to give the eye drops as prescribed.
d. It is okay to share towels and washcloths.
9. Antibiotics are prescribed for a child after myringotomy with insertion of
tympanostomy tubes. The nurse provides discharge instructions to the
parents regarding the administration of the antibiotics.
Which of the
following statements, if made by the parents, indicates that they understood
the instructions?
a. Administer the antibiotics if the child has a fever.
b. Administer the antibiotics until the child feels better.
c. Administer antibiotics until they are gone.
d. Begin to taper the antibiotics after 3 days of full course.
10.The mother of a child who underwent a myringotomy with insertion of
tympanostomy tubes calls a nurse and reports that the child is complaining of
discomfort. Which of the following is the most appropriate response?
a. Give the child childrens aspirin for the discomfort.
b. Give the child acetaminophen (Tylenol) for the discomfort.
c. You need to speak to the physician because the child should not be
having any discomfort.
d. I will speak to the physician so that a narcotic can be prescribed.