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Which intervention(s) should the nurse include in the child's plan of care immediately following insertion of a ventriculoperitoneal (VP) shunt for treatment of hydrocephalus?
- A. Maintain the head of the bed in an elevated position.
- B. Ensure that the child minimizes movement of the extremities.
- C. Provide a pressure dressing over the cephalic insertion site.
- D. Maintain a flat position and reposition the child every 2 hours.
Correct Answer: D
Rationale: Maintaining a flat position and repositioning every 2 hours helps prevent complications and ensures shunt function post-VP shunt insertion.
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The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first?
- A. Assess the nailbeds for capillary refill time.
- B. Remove the client's clothing from the arm.
- C. Call radiology for a STAT x-ray of the extremity.
- D. Prepare the client for the application of a cast.
Correct Answer: A
Rationale: Assessing capillary refill evaluates neurovascular status, the priority in arm injury to detect compromise. Clothing removal, x-rays, and casting follow assessment.
Which most immediate treatment by the HCP should the nurse anticipate for a child with a dislocated kneecap?
- A. Open surgical intervention to repair the kneecap
- B. Arthroscopy to surgically repair the torn cartilage
- C. Realignment of the kneecap by sliding it back into position
- D. Application of a cast to the affected leg until the kneecap heals
Correct Answer: C
Rationale: Immediate treatment for a dislocated kneecap involves manual realignment to restore position.
What should the nurse emphasize when preparing to teach the child and family about the treatment for Legg-Calvé-Perthes disease?
- A. Once treatment starts, it will likely continue for about 6 months.
- B. The treatment goal is a pain-free joint with full range of motion.
- C. Activities requiring hip adduction are encouraged for joint placement.
- D. Most of the treatments will be completed while the child is hospitalized.
Correct Answer: B
Rationale: The primary goal of treatment for Legg-Calvé-Perthes disease is to achieve a pain-free joint with full range of motion.
Which nursing intervention is most appropriate for preventing a pathological fracture?
- A. Encouraging a high fluid intake
- B. Providing a nutritional diet
- C. Supporting the limb during movement
- D. Relieving pressure on bony prominences
Correct Answer: C
Rationale: Supporting the limb prevents stress on weakened bone, reducing fracture risk.
What is the goal of therapy for a child newly diagnosed with scoliosis as explained by the nurse?
- A. Limit or stop progression of the curvature of the spine.
- B. Prepare the child for surgical correction at a later date.
- C. Minimize the complications of prolonged immobilization.
- D. Develop a pain management plan to minimize complications.
Correct Answer: A
Rationale: The primary goal of scoliosis treatment is to halt or limit the progression of spinal curvature.