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 4-month-old with significant head lag meets the criteria for floppy infant syndrome. A diagnosis of progressive infantile spinal muscular atrophy (Werdnig-Hoffmann disease) is made. What should be included in the nursing care for this child?
Correct Answer: A
Rationale: An infant stimulation program with frequent position changes and sensory input is vital for Werdnig-Hoffmann disease to support development. Contractures are not a concern due to muscle atrophy, sensation is normal, and genetic counseling is needed, not encouragement for more children.
Question 2 of 5
An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome [GBS]). When explaining this disease process to the parents, what should the nurse consider?
Correct Answer: D
Rationale: GBS involves progressive paralysis with recovery of muscle strength starting within 2-3 weeks, with most children regaining full strength, especially younger ones. It?s immune-mediated, not inherited or medication-induced, and has a good prognosis.
Question 3 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 4 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 5 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.