16.

A 2-year old child with croup suffering respiratory distress may show which of the following
signs on initial assessment?
A. Capillary refill time <3 sec
B. Elevated temperature
C. Grunting or nasal flaring
D. Respiratory rate of 28 bpm

Answer: C - R: Grunting and nasal flaring is seen in a child in respiratory distress. Croup is
characterized by a brassy or “barking” cough and hoarseness.Within 1-2 days, the characteristic
signs of hoarseness, barking cough, and inspiratory stridor develop, often suddenly, along with
a variable degree of respiratory distress. Signs and symptoms of croup stem from inflammation
within the lining of the trachea and larynx, which narrows the airways. When croup progresses
to upper airway obstruction, the patient may have an increased respiratory rate, nasal flaring,
and suprasternal, infrasternal, and intercostal retractions along with continuous stridor.

A - A capillary refill time of <3 seconds is a normal finding.

B - The child's temperature may be elevated if infection is present.
C. A respiratory rate of 28 breaths/ minute is a normal finding.

17. Which of the following is the best intervention for parents to take if their child is experiencing
an episode of “midnight croup” or acute spasmodic laryngitis?
A. Give warm liquids
B. Raise the heat on the thermostat
C. Take child out to breathe cool breeze
D. Increase fluid intake

Answer: C - High humidity with cool mist, such as the cool and fresh breeze outside, provides
the best and safest form of relief for a pediatric patient with croup. Because dry and warm air
may further cause secretions to adhere to the airway wall. It also provides a mist that may be
helpful to moisten and decrease the viscosity of airway secretions and may also decrease
laryngeal spasm.

A - Cool liquids would be best for the child. A child with croup is usually encouraged to drink
‘cold’ fluids. Children with croup usually have a ‘sore throat’, and this may help to soothe it.
B - Raising the heat on the thermostat will result in dry, warm air, which may cause secretions to
adhere to the airway wall.
D - Although drinking cool fluids would somehow soothe the patient to alleviate spasmodic
laryngitis, increasing fluid intake is not the best intervention to immediately relieve patient’s
condition.

18. A nurse is giving discharge instructions to parents of a child who had tonsillectomy?
A. The child should drink extra milk for nutrition
B. The child should not drink from straw
 C. Orange juice should be given to mask taste of pain medication
D. The child’s mouth should be rinsed with salt and water

Answer: B - A child who just had undergo tonsillectomy should emphasize about not giving the
child straws for up to 2 weeks, or as directed by his healthcare provider. Drinking from a straw
may increase a child's risk for bleeding.
A - Generally, there are no food restrictions (other than milk products) after surgery. Milk
products should be avoided in the first 24 hours after surgery. Milk products may increase
mucus secretions
C - Do not give a child who had tonsillectomy citrus juices, such as orange juice or grapefruit
juice, because they may irritate his throat.
D - Rinsing the mouth with saline (salt water) solution three or four times a day (one teaspoon of
salt to one quart of warm tap water)is given also as a discharge instruction to help alleviate pain
and bad breath. This may be a discharge instruction but the the choice that needs higher priority
is the one that impose risk for bleeding of patient. This answer is basically focused on promoting
healing.

19. Which of the following characteristics is true of cerebral palsy?

A. Reversible
B. Progressive
C. Results in mental retardation
D. Appears at birth or during the first 2 years of life

Answer: D - The signs of cerebral palsy usually appear in the early months of life, although
specific diagnosis may be delayed until age two years or later. The full extent of the disorder
may be recognizable only when the child is older and attempts more complex motor skills, such
as walking. However, all infants need careful neurologic assessment during the first year of life,
so the small signs of impairment can be tracked and also so that the child can be monitored
closely for further testing and assessment.

A - Cerebral palsy is an irreversible, nonprogressive disorder that results from damage to the
developing brain during the prenatal, perinatal, or postnatal period.
B - Cerebral palsy is a nonprogressive disorder
C - Although some children with cerebral palsy are mentally retarded, many have normal
intelligence

20. For which of the following symptoms will the nurse assess a neonate diagnosed with
bacterial meningitis?
A. Temperature instability, irritability and poor feeding
B. Positive Babinski reflex, mottling, and pallor
C. Headache, nuchal rigidity, and developmental delays
D. Positive Moro reflex, hyperthermia, and sunken fontanel
Answer: A - The clinical appearance of a neonate with meningitis is different from that of a child
or an adult. Neonates may be either hypothermic or hyperthermic. The irritation to the meninges
causes the neonates to be irritable and to have a decreased appetite.
B - They may be pale and mottled with a bulging, full fontanel but normal neonates manifests
positive Babinski reflex
C - Older children and adults with meningitis are the ones who have clinical manifestations of
headaches, nuchal rigidity, and hyperthermia, not neonates.
D - A neonate diagnosed with bacterial meningitis could either have hypothermia or
hyperthermia and have full and bulging fontanel. Moreover, a positive Moro reflex is present on
normal neonate.