4-year-old presented to the ER with the parents with complaints of bowel incontinence, extremity weakness and neck pain. Child has a history of Trisomy 21 with atlantoaxial stability. began having neck pain 24 hours ago after falling off the steps. No injuries reported

The nurse is caring for a client diagnosed with Down Syndrome and a history

of hypotonia and atlantoaxial instability. Which of the following symptoms require priority interventions? (Select All that Apply.)

Pain of the facial bones

Continuous neck pain

Lower extremity pain

Loss of established bladder control

Loss of established motor skills

Answer and Explanation

Correct Answer : C,D,E

A.   Although facial pain could be concerning, it is not the immediate priority when the child has a history of atlantoaxial instability and is presenting with signs that could indicate spinal cord compression. Facial pain does not suggest a direct threat to the spinal cord, which is a more critical concern in this case.
B.   Continuous neck pain in a child with atlantoaxial instability is a significant priority and requires immediate intervention. This could be a sign of spinal cord compression or injury to the cervical spine, which can occur after trauma such as a fall. Since this child has a predisposition for atlantoaxial instability, there is a high risk for neck instability and spinal cord injury, making this a top priority.
C.   While lower extremity pain may be concerning, it is not as high a priority as neck pain in this context. The primary concern here is potential spinal cord compression or neurological injury. If the child is able to move their extremities or does not have severe pain or weakness, this may not require as urgent intervention. However, it should still be monitored closely.
D.   Loss of bladder control is a red flag in children with suspected spinal cord injury. It can indicate nerve involvement in the spinal cord or cauda equina, which can be caused by injury or compression, particularly in a child with atlantoaxial instability. This requires priority intervention to prevent further damage and to initiate appropriate care (e.g., neurological assessment, imaging, and potentially surgical intervention).
E.   The loss of established motor skills is another concerning sign. In this child, it may indicate neurological impairment or spinal cord injury. Since the child has atlantoaxial instability, this is a critical symptom that suggests the possibility of spinal cord compression or injury, requiring immediate evaluation and intervention to prevent permanent neurological damage.

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Correct Answer is C

Explanation

A. While some form of restraint may be necessary, explaining the procedure first is important for reducing anxiety and helping the toddler understand what is going to happen.
B. Gathering supplies is essential but should come after preparing the child and ensuring they are mentally ready.
C. Explaining the procedure to the toddler helps ease anxiety and ensures they are informed, even at a young age.
D. Routine vital sign assessment is not necessary for a simple IM injection unless the child has a specific medical condition.

A. Promote quiet activities and rest B. Provide liquids with straws C. Closely monitor ABC D. Monitor and treat pain E. Apply ice collar as ordered

Correct Answer is ["A","C","D","E"]

Explanation

A. Quiet activities and rest should be promoted to ensure the child is not overstimulated and to allow for proper recovery.
B. Liquids should be given without straws to avoid potential injury to the surgical site.
C. Monitoring the airway, breathing, and circulation (ABC) is essential, particularly in the first few hours post-surgery.
D. Pain management is critical to ensure the child’s comfort and to help with healing.
E. Applying an ice collar can help reduce swelling and pain after a tonsillectomy.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an intramuscular (IM) injection to a toddler. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

A nurse is caring for a 5-year-old child who is 3 hours post-operative uncomplicated tonsillectomy. Which of the following actions are appropriate post op care? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is providing discharge teaching about nutrition to the parents of a 9-year-old child with cystic fibrosis (CF). The nurse should recognize that which statement made by the mother indicates understanding about nutrition?

A nurse is assessing a 6-week-old child for progressive weight loss and projectile vomiting. The nurse suspects pyloric stenosis. What other assessment finding should be expected?

A nurse is caring for a child post-operative tonsillectomy, what is the nursing priority when providing post-operative care?

A nurse is providing post-operative tonsillectomy instructions to the parents of a child. The nurse informs the parents that the greatest risk for postoperative hemorrhage can occur during which of the following time frames?

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson's theory of psychosocial development?

The nurse is teaching a group of parents about the benefits of immunizations. The nurse explains that which of the following immunizations are utilized in preventing the life-threatening disease epiglottis?

A nurse is caring for an infant with respiratory syncytial virus (RSV). Which of the following are appropriate nursing interventions when prioritizing care for an infant with RSV? (Select All that Apply.)

A nurse is caring for a female newborn with an apparent anorectal malformation. The nurse should assess the infant for which of the following other potential finding?