ATI LPN
Wong's Essentials of Pediatric Nursing 11th Edition Test Bank
Chapter 30 : The Child with Neuromuscular or Muscular Dysfunction Questions
Question 1 of 5
A 12-year-old child with Guillain-Barré syndrome (GBS) is admitted to the pediatric intensive care unit. She tells you that yesterday her legs were weak and that this morning she was unable to walk. After the nurse determines the current level of paralysis, which should the next priority assessment be?
Correct Answer: A
Rationale: Assessing swallowing ability is critical in GBS due to potential pharyngeal and respiratory involvement, risking aspiration or the need for ventilatory support. Parental involvement, consciousness, and viral history are secondary to immediate physiologic risks.
Question 2 of 5
What statement is most accurate in describing tetanus?
Correct Answer: C
Rationale: Tetanus, caused by Clostridium tetani?s exotoxins, affects the central nervous system, causing muscle stiffness and spasms, starting with the jaw (lockjaw). It?s not inflammatory, doesn?t affect salivary glands, and isn?t caused by meningeal inflammation.
Question 3 of 5
An adolescent whose leg was crushed when she fell off a horse is admitted to the emergency department. She has completed the tetanus immunization series, receiving the last tetanus toxoid booster 8 years ago. What care is necessary for therapeutic management of this adolescent to prevent tetanus?
Correct Answer: A
Rationale: A tetanus toxoid booster is required for tetanus-prone wounds like crush injuries, despite a booster 8 years ago, as prophylaxis is needed for such injuries. Immunoglobulin isn?t needed with prior immunization, and boosters are protective for 10 years in clean wounds.
Question 4 of 5
During a well-child visit, the mother tells the nurse that her 4-month-old infant is constipated, is less active than usual, and has a weak-sounding cry. The nurse suspects botulism and questions the mother about the childs diet. What factor should support this diagnosis?
Correct Answer: C
Rationale: Honey ingestion is a known risk factor for infant botulism in children under 1 year, supporting the diagnosis given symptoms like constipation and weakness. Breastfeeding and formula have minimal risk, and bottle sterilization issues are unrelated to botulism.
Question 5 of 5
An adolescent has just been brought to the emergency department with a spinal cord injury and paralysis from a diving accident. The parents keep asking the nurse, How bad is it? The nurses response should be based on which knowledge?
Correct Answer: C
Rationale: Spinal cord injury extent and severity are unclear initially due to physiologic responses, with improvement possible over weeks or months. Immediate loss doesn?t predict long-term outcomes, and while tests are done, prognosis requires time. Gradual information helps, but extent is the key issue.