Siena Kathleen V.

Placino BSN-IV

SEMI-FINAL EXAM (NURSING ENHANCEMENT PROGRAM)

1. A newborn with cleft lip is feed with a special nipple. To minimized regurgitation of feedings the
nurse should instruct the mother to:
a. hold and burp the baby frequently while feeding
b. give the baby thickened formula
c. lay the baby on the side with the bottle firmly propped
d. feed the baby while in infant seat

2. A mother asked the nurse why she needs to wait for 12 – 18 months for the repair of her child with
cleft palate. The nurse best response would be:
a. waiting leaves time for other birth defects to be detected
b. the cleft requires plastic surgery
c. the doctors will separate the operation to minimize complication
d. to allow teething and development of speech

Situation: The nurse is taking care of Alban, 3 year old child admitted with severe diarrhea. Questions 3-
5 refer to this situation.

3. Which of the following nursing diagnosis would be appropriate for the nurse to identify as a
priority for an infant just admitted to the hospital with moderate to severe diarrhea?
a. Pain related to repeated episodes of vomiting
b. Impaired parenting related to infants loss of fluid
c. Fluid volume deficit related to excessive losses from severe diarrhea
d. Impaired urinary elimination pattern related to increase fluid intake

4. Another mother calls the clinic to report that her 9 month old infant has mild diarrhea. Upon further
questioning, the nurse discovers that the infant has no vomiting and no signs of dehydration. Which
of the following advice is most appropriate to give to the mother?
a. continue your baby’s normal feedings
b. feed your baby liquids only
c. call back if your baby has 10 stools in one day
d. notify your baby’s day care of his illness

5. Which of the following parameters should the nurse closely monitored while taking care of Alban?
a. temperature
b. body weight
c. eating pattern
d. sleeping pattern

Situation: The nurse is taking care of various clients in the gastro unit. Among her client are neonates
born with tracheoesophageal fistula and atresia. Please refer to this condition in answering questions 6-
12

6. A neonate born several hours ago shows sign of Tracheoesophageal fistula. During the initial
assessment, what does the nurse expect to find?
a. Diaphragmatic hernia c. sow response to stimuli
b. continuous drooling d. frothy meconium

7. The client is admitted to the emergency room with abdominal distention. Upon bronchial
endoscopy it was found out that there is an obstruction to the esophagus and it is not connected to
the stomach. The nurse should realize that this is:
a. Tracheoesophageal atresia
b. Tracheobronchitis
c. esophageal cancer
d. Tracheoesophageal fistula

8. Which of the following statement best describe tracheoesophageal fistula?

a. there is an obstruction to the trachea
b. there is an obstruction to the esophagus
c. there is an opening created between the esophagus and trachea
d. esophagus end in a blind pouch

9. Which of the following condition or factors s the major cause of esophageal atresia and fistula?
a. unknown c. poor nutrition during pregnancy
b. Prematurity d. genetic
Siena Kathleen V. Placino BSN-IV

10. After repair of Tracheoesophageal fistula and atresia the nurse should expect that the client will be
feed via:
a. nasogastric tube c. gastrostomy tube
b. orogastric tube d. intravenous route

11. A nurse is taking care of the patient post tracheoesophageal fistula repair. Which of the following
assessment by the nurse indicates that the client needs suctioning?
a. Slight irritability c. regurgitation of undigested foods
b. poor weight gain by the client d. moderate signs of dehydration

12. Which of the following nursing diagnosis would the nurse identify as priority for the infant with
tracheoesophageal fistula?
a. Risk for injury related to increased potential for aspiration
b. Impaired parenting related to newborn illness
c. Ineffective breathing pattern elated to a weak diaphragm
d. Imbalance nutrition less than body requirements related to poor sucking

Situation: Leslie an 8 year old client presents to the clinic with her mother for a follow up appointment
after diagnostic test show that she has Gastroesophageal reflux disease. Questions 13-17 refer to this
situation.

13. Which instruction should the nurse provide to Leslie’s mother regarding the eating pattern of the
child?
a. lie down and rest after meal
b. avoid alcohol and caffeine intake
c. drink a lot of water with each meal
d. eat three well balance meal everyday

14. Which of the following definition best described Gastroesophageal reflux disease?
a. hypertrophy of the canal between the stomach and duodenum
b. mechanical obstruction from inadequate motility of the intestine
c. telescoping of one portion of the bowel into another
d. relaxation or incompetent cardiac sphincter

15. Upon initial assessment of Leslie, which of the following should the nurse expect?
a. regurgitation of stomach content and emesis
b. olive shape mass at the epigastrium right of the umbilicus
c. abdominal distention and excessive flatus
d. currant jelly like stools with blood and mucus

16. While caring for a client with Gastroesophageal reflux disease, which of the following intervention
is appropriate to decrease regurgitation?
a. give a liquid or thin formula c. place on low fowlers after feeding
b. limit burping frequency d. give small frequent feedings

17. If surgery is prescribed for client with Gastroesophageal reflux disease, which of the following
procedure should the nurse expect:
a. Fundoplication c. esophagorhaphy
b. Pyloromyotomy d. jannetta procedure

Situation: A mother brings her 4 month old son into the emergency department because he’s been crying
for several hours as if in pain. The nurse notes that he is crying uncontrollably and his knees are pulled to
his chest. She learns from the mother that the child has been vomiting almost all feedings and he has a
strange looking stool just before coming to the emergency department.

18. The nurse suspect Intussusception and asked the mother to describe the stool. Which description
does the nurse expect?
a. Pale, colored almost white
b. Very frothy, foul smelling
c. Bright green, loose
d. dark red with little seeds similar to currant

19. Which of the following definition best describes Intussusception?

a. herniation of the umbilical content into the umbilical ring
b. connection that forms between the trachea and esophagus
c. telescoping of one portion of the bowel into another
d. narrowed pathway between the stomach and duodenum
Siena Kathleen V. Placino BSN-IV

20. When assessing a 4 month old diagnosed with possible Intussusception, the nurse would expect the
mother to relate which of the following about the infants crying and episodes of pain?
a. constant accompanied by leg extension
b. intermittent with knees drawn to the chest
c. shrill during ingestion of solids
d. intermittent while being held in the mothers arms

Situation: A nursery nurse is doing an admission care of a client that was born 2 days ago. Baby boy A
was diagnosed to have PKU and Baby boy B is under observation.

21. Nursing assessment reveals that twenty four hours after birth baby boy B was not able to passed
meconium. The nurse suspects which condition?
a. Diarrhea c. Hirschprung’s disease
b. Intussusception d. pyloric stenosis

22. Assessment of the stool of the children with Hirschprung’s disease will reveal which of the
following characteristics?
a. ribbon like and foul smelling c. well formed with large amount of mucus
b. liquid in consistency d. liquid with slight amount of blood

23. When teaching the parents of an infant diagnosed with PKU, the nurse should plan to include the
fact that
a. mental retardation occurs if PKU is untreated
b. treatment for PKU includes lifelong medication
c. PKU is transmitted by an autosomal dominant gene
d. The infant is tested for PKU immediately after birth

24. Dietary treatment of children with PKU includes:

a. protein free diet
b. low phenylalanine
c. phenylalanine free diet
d. dietary supplement of phenylalanine

25. A test that is done to all neonates to detect PKU is:

a. Phenistix test
b. Guthrie blood test
c. Ferric chloride uric test
d. Clinitest serum phospopyruvic acid

Situation: A registered nurse together with a pediatric cardiologist is discussing to a group of nursing
students the common congenital heart defects.

26. A disorder following a streptococcal infection characterized by swollen joints, fever, and the
possibility of endocarditis and death is:
a. Tetanus c. measles
b. rheumatic fever d. whooping cough

27. A common finding in most children with cardiac anomalies is:

a. mental retardation
b. delayed physical growth
c. clubbing of fingertips
d. family history of cardiac anomalies

28. The nurse highlighted that children with cardiac problems who are awaiting corrective surgery are
placed on long term antibiotic prophylaxis to prevent which of the following complication?
a. Myocarditis c. pericarditis
b. upper respiratory infection d. sub-acute bacterial endocarditis

29. After discussion with the pediatric cardiologist, the parents of an infant asked the nurse to explain
once again what patent ductus arteriosus is:
a. narrowing of the pulmonary artery
b. an enlarge aorta and pulmonary artery
c. an open connection between aorta and pulmonary artery
d. an abnormal opening between the right and left ventricles

30. A 1 year old child was diagnosed with atrial septal defect. Cardiologist explain that surgery is the
treatment of choice for this client because of which of the following reasons?
a. the aorta is receiving unoxygenated blood
Siena Kathleen V. Placino BSN-IV

b. the blood is shunting from right to left side of the heart

c. to prevent the risk of infection
d. to allow the ductus arteriosus to remain patent

31. A concern student asked. Which of the following cardiovascular disorders is considered acyanotic?
The nurse reply that one of this is:
a. Patent ductus arteriosus
b. Tetralogy of Fallot
c. Transposition of great vessels
d. Truncus arteriosus

32. One of the students was asked by the nurse to describe ventricular septal defect. As a student, you
will answer that it is:
a. narrowing of the aortic arch
b. failure of the septum to develop completely between the atria
c. narrowing of the valve at the entrance of pulmonary artery
d. failure of the septum to develop completely between the ventricles

33. In a newborn diagnosed with coarctation of aorta, which of the following condition occurs?
a. absent of tricuspid valve
b. narrowing in the area of the aortic valve
c. localized constriction or narrowing of the aortic wall
d. narrowing at some location along the right ventricular outflow tract

34. Congenital Heart Defects leads to a various disturbances in the normal blood circulation. Which of
the following defect causes an increase in pulmonary blood flow?
a. atrial septal defect, ventricular septal defect and pulmonic stenosis
b. atrial septal defect, ventricular septal defect, and tricuspid atresia
c. patent ductus arteriosus, ventricular and atrial septal defects
d. coarctation of aorta, patent ductus arteriosus and pulmonic stenosis

35. A newly admitted neonate was diagnosed to have aortic stenosis. The pediatrician ordered a 12 lead
echocardiography. The nurse should expect the findings to reveal:
a. right ventricular hypertrophy c. absent of femoral pulse
b. left ventricular hypertrophy d. portal hypertension

36. The nurse is admitting a newborn diagnosed with transposition of great vessels. A mother
concerned asked the nurse about information regarding the disease. The nurse should tell the
mother that in this kind of defect involves:
a. pulmonary vein that returns to the right atrium
b. aorta arises from the right ventricle instead of left ventricle
c. VSD and right ventricular hypertrophy
d. Pulmonary artery arises from the right ventricle

37. A mother delivered her first born child and is diagnosed with Tetralogy of Fallot. This defect
involves four structural abnormalities which include:
a. pulmonary stenosis, VSD, overriding aorta, left ventricular hypertrophy
b. right ventricular hypertrophy, overriding aorta, VSD, pulmonic stenosis
c. right ventricular hypertrophy, ASD, overriding aorta, pulmonic stenosis
d. left ventricular hypertrophy, ASD, overriding aorta, pulmonic stenosis

38. Which of the following statement about tricuspid atresia is incorrect?

a. the valve between the right and left atria is completely closed
b. the child with this defect have adequate oxygenation as long as ductus arteriosus is open
c. prostaglandin E is administered to allow closure of the ductus arteriosus
d. infant has cyanosis, tachycardia and dyspnea

39. A child with Tetralogy of Fallot may assume which position of comfort during exercise?
a. Prone b. Semi-Fowler c. Side-lying d. Squat

40. A child with Tetralogy of Fallot has clubbing of the fingers and toes, a finding related to which of
the following conditions?
a. Polycythemia c. Pansystolic murmur
b. Chronic hypoxia d. abnormal growth and development

41. Which of the following characteristics can be noted during the assessment of a child with tricuspid
atresia?
Siena Kathleen V. Placino BSN-IV

a. Cyanosis c. Decreased respiratory rate

b. Machine-like murmur d. Capillary refill more than 2 seconds

42. Which of the following operations is recommended to correct tricuspid atresia?

a. Blalock-Tausig operation c. Jatene procedure
b. Fontan procedure d. Patch closure

43. Which of the following assessments is expected when assessing a child with Tetralogy of Fallot?
a. Machine-like murmur
b. Eisenmenger’s complex
c. Increasing cyanosis with crying or activity
d. Higher pressures in the upper extremities than with the lower extremities

44. Which of the following statements is correct for a child with Tetralogy of Fallot?
a. The condition is commonly referred to as “blue tets”
b. They experience hypercyanotic, or “tet”, spells.
c. They experience frequent respiratory infections
d. They experience decreased or absent pulses in the lower extremities

45. The nurse should give which of the following instruction as most appropriate for a child with aortic
stenosis.
a. restrict exercise c. avoid prostaglandin E
b. avoid digoxin and diuretics d. allow the child to exercise freely

46. Prior to discharge from the newborn nursery at 48 hours old, the nurse knows that murmurs are
frequently assessed and are most often due to which factor:
a. ventricular septal defects
b. heart diseases of the newborn period
c. transition from fetal to pulmonic circulation
d. cyanotic heart diseases of the newborn

47. Which of the following cardiac anomalies produces a left-to-right shunt?

a. Atrial septal defect c. Tetralogy of Fallot
b. Pulmonic stenosis d. Total anomalous pulmonary venous return

48. Which of the following curative surgical interventions is recommended for a child with ventricular
septal defect?
a. Surgery with pulmonary artery banding
b. Defect repair through cardiac catheterization
c. Surgery with purse-string suture or Dacron patch repair
d. Surgery when severe pulmonary hypertension is noted

49. One hour after delivery, a newborn admitted to the neonatal care unit develop signs and symptoms
of coarctation of aorta. Which of the following findings will lead the nurse to conclude that the
newborn is suffering from this defect?
a. hypertrophy of the right ventricle c. lower extremity hypotension
b. bounding femoral pulse b. absence of heart murmur

50. While taking care of the newborn with transposition of great vessels, the nurse noticed cyanosis
and mild clubbing of fingers. The nurse should base on her knowledge that this occurs due to:
a. inadequate oxygen that is being pump by the left ventricle
b. mixing of blood from the pulmonary and systemic circulation
c. narrowed lumen of the descending aorta
d. pulmonary vein that arises from the superior vena cava

Situation: Alden’s mother brings him to the pediatric clinic and complains that the child has malaise,
weakness, lethargy, anorexia, headaches and smoky urine

51. When taking the nursing history, the nurse asked the mother whether Alden has.
a. pain in the shoulders and knees
b. recent weight loss of at least 2
c. streptococcal infection within the last 2weeks
d. rash n the palms and feet with in the last 3 weeks

52. The nurse is aware that in order to confirm the diagnosis of acute glomerolunephritis in Alden , the
test that the physician will order will include:
a. routine urinalysis, chest x-ray c. routine urinalysis, ASO titer
Siena Kathleen V. Placino BSN-IV

b. Routine urinalysis, heterophil antibody test d. 24 hour urine specimen and blood
chemistry

53. Alden was admitted to the pediatric unit with a diagnosis of acute glomerolunephritis. The nursing
action that has priority is:
a. assessing for dysuria c. observing for jaundice
b. monitoring for jaundice d. testing vomitus for occult blood

54. Alden’s mother is fearful that her other child may get the disease. To allay the fears of the mother,
the nurse should tell her that:
a. the cause of acute glomerolunephritis is unknown, so it is difficult to know how to
prevent it
b. acute glomerolunephritis is inherited by autosomal recessive trait but usually occurs only
in males
c. acute glomerolunephritis is caused by a clot formation secondary to systemic infection
d. acute glomerolunephritis is caused by antigen antibody response secondary to group
A beta hemolytic streptococcus

55. When assessing the child with glomerulonephritis in the case of Alden, the nurse should expect to
find:
a. a decrease in joint mobility c. an increase in urine volume
b. the presence of peri-orbital edema d. the occurrence of intermittent fever

56. When testing the urine and assessing the condition of Alden, a child with acute glomerulonephritis,
the nurse would not be surprised to note:
a. anorexia, normal blood pressure
b. hematuria, increase blood pressure
c. periorbital edema, proteinuria
d. fever, hematuria

57. When caring for a child, with acute glomerulonephritis, the nurse plans to:
a. maintain bed rest encourage fluid, meticulous skin care
b. maintain bed rest, low sodium diet, isolate the patient
c. prevent chilling, provide no sodium diet
d. promote rest, monitor child’s intake and output, weigh the child daily, and provide
a regular diet with no added salt

58. When teaching Alden’s mother how to prevent recurrences of acute glomerulonephritis, which of
the following instruction should the nurse include?
a. avoid physical activity
b. strain all urine
c. seek early treatment for respiratory infection
d. monitor urine specific gravity everyday

59. When planning nursing care for a child with acute glomerulonephritis, the nurse realizes that the
nurse needs help in understanding the necessary restriction, one of which is:
a. daily doses of I.M penicillin
b. a bland diet high in protein
c. bed rest for at least 4 weeks
d. isolation from other children with infection

Situation: A 5 year old male is admitted to the medical surgical unit with a diagnosis of nephrotic
syndrome

60. When admitting a 5 year-old child with nephrotic syndrome to the hospital, the nurse should assess
for:
a. severe lethargy c. chronic hypertension
b. dark, frothy urine output d. flushed, ruddy complexion

61. When planning nursing care for a child with nephrotic syndrome, the nurse includes:
a. provision of meticulous skin care
b. a diet low in carbohydrates and protein
c. restriction of fluids to 500 ml each shift
d. laboratory test for blood type and crossmatch

62. The adaptation that indicates that a child may have nephrotic syndrome rather than
glomerulonephritis is the presence of:
a. Edema c. lethargy
Siena Kathleen V. Placino BSN-IV

b. Protein in the urine d. slightly decreased blood pressure

63. Which of the following is a hallmark of this syndrome?

a. osmotic diuresis b. edema c. hypolipidemia d. hyperproteinemia

64. The most important nursing intervention for a 3 year old child with the diagnosis of nephrotic
syndrome is:
a. encouraging fluids b. regulating the diet c. preventing infection d. maintaining
bed rest

65. The nurse realizes that the parents of a child with nephrotic syndrome need further discharge
instructions when they state, “We will:
a. Ignore any weight gain since it is normal.”
b. Look at our child’s eyelid every morning.”
c. Need to test our child’s urine for specific gravity.”
d. Give our child the prednisone with meals or milk.”

Situation: The nurse is doing an admission care of Dave, a neonate born with hypospadias.

66. The nurse should explain to Dave’s parents that hypospadias refers to which of the following
conditions”
a. absence of a urethral opening
b. penis shorter than usual for age
c. urethral opening along dorsal surface of penis
d. urethral opening along ventral surface of penis

67. Which of the following reasons explains why surgical repair of a hypospadias is done as early as
possible?
a. prevent separation anxiety c. prevent urinary complications
b. promote acceptance of hospital d. promote development of normal body image

68. The nurse should counsel Dave’s parents to postpone which of the following actions until after their
son’s hypospadias has been repaired?
a. Circumcision c. infant baptism
b. getting hepatitis B vaccine d. checking blood for inborn errors of metabolism

69. When explaining to the parents the optimum time for repair of hypospadias, the nurse should
indicate which of the following as the age of choice?
a. 1 week c. 6 to 18 months
b. 2 years d. 4 years

70. When providing discharge instruction to the parents of a child who has hypospadias repair, which
of the following shouldn’t be avoided
a. finger painting c. playing in sandboxes
b. increased fluid intake d. playing with the family pet

71. Which of the following intervention by the nurse would be most helpful when discussing
hypospadias with the parents of an infant with this defect?
a. refer the parent to a counselor
b. be there to listen to the parents concern
c. notify the primary health care provider and have him talk to the parents
d. suggest a support group of other parents who have gone through this experience

72. Which of the following nursing diagnoses would be most appropriate for Dave?
a. deficient fluid volume c. impaired urinary elimination
b. delayed growth and development d. risk for infection

73. Dave’s mother is asking about the difference between hypospadias and epispadias. The nurse
should reply that it is defined by which of the following boundaries?
a. the difference between the defect is the length of the urethra
b. epispadias defects can only occur in males
c. hypospadias is an abnormal opening on the ventral side of the penis, epispadias is an
abnormal opening on the dorsal side
d. hypospadias is an abnormal opening on the dorsal side of the penis, epispadias is an
abnormal opening on the ventral side

Situation: The nurse is discussing common musculoskeletal disorders to a group of client in the out
patient department. Questions 74-79 refer to this situation.
Siena Kathleen V. Placino BSN-IV

74. The mother of a neonate with clubfoot feels guilty because she believes she did something to cause
the condition. The nurse should explain that the cause of clubfoot in neonate is due to which of the
following factors?
a. Unknown c. hereditary
b. restricted movement in utero d. anomalous embryonic development

75. A client with structural scoliosis has been fitted for a Milwaukee brace. How many hours a day
should the nurse tell the client that the brace must be worn?
a. 8 hours b. 2 hours c. 23 hours d. 24 hours

76. Scoliosis can be best described by which of the following definitions?

a. an increase in lumbar lordosis
b. a decrease in thoracic kyphosis
c. lateral curves in the spinal column describe as left or right concavities
d. lateral curves in the vertebral column

77. Non-structural scoliosis can be cause by which of the following complications?

a. proper exercise c. tumor
b. poor posture d. trauma to the lumbar spine

78. Which of the following complications should the nurse stress that may occur due to severe
scoliosis?
a. increase vital capacity c. increase oxygen uptake
b. diminished vital capacity d. decrease residual volume

79. The nurse should explain to the audience that diagnosis of congenital hip dislocation can be best
confirmed by which of the following techniques?
a. X-ray c. Positive Ortolani’s sign
b. Positive Trendelenburg gait d. Audible clicking with adduction

Situation: A 12-year-old diagnosed with muscular dystrophy is hospitalized secondary to fall. Surgery is
necessary as well as skeletal traction

80. Which of the following definitions best describes muscular dystrophy?

a. A demyelinating disease c. Lesions of the brain cortex
b. Upper motor neuron lesions d. Degeneration of muscle fibers

81. Which of the following forms of muscular dystrophy is the most common?
a. Duchenne’s c. Becker’s
b. Limb girdle d. Myotonic

82. Through which of the following mechanisms is Duchene’s muscular dystrophy acquired?
a. Virus c. hereditary
b. autoimmune factors d. environmental toxins

83. Which of the following complications would be of greatest concern to the nursing staff if a child
with muscular dystrophy is put on skeletal traction?
a. skin integrity c. infection of pin sites
b. respiratory infection d. nonunion healing of the fracture

84. Which of the following definitions best describes Gower’s sign?

a. A transfer technique c. A waddling-type gait
b. The pelvis position during gait d. Muscle twitching present during a quick stretch

Situation: The outpatient clinic nurse is caring for Mon, a 7-year-old child with sickle cell anemia. The
child’s history includes having a splenectomy at age five.

85. At this time the nurse’s priority of care for Mon would be:
a. assessing for jaundice c. monitoring serial hematocrit readings
b. frequent assessments of the abdomen d. keeping the child away from infectious
contacts

86. A child with sickle cell anemia has a sequestration crisis. The nurse is aware that this type of crisis
is characterized by:
a. distal ischemia and pain c. diminished red blood cell production
b. accelerated red blood cell destruction d. decreased blood volume and signs of shock
Siena Kathleen V. Placino BSN-IV

87. The nurse is caring for a child with sickle cell anemia. To prevent thrombus formation in
capillaries, as well as other problems from stasis and clotting of blood in the sickling process, the
nurse should:
a. administer oxygen c. administer prescribes anticoagulants
b. encourage the child to maintain bed rest d. increase fluids by mouth and use a
humidifier

88. Mon is in sickle cell crisis (pain episode) is complaining of right-knee pain. The best nursing
intervention would be to:
a. decrease IV fluids c. wrap the right knee in a cold pack
b. apply a warm soak to the right knee d. give morphine sulfate 0.5mg as ordered

89. A week after discharge Mon was readmitted with a vaso-occlusive crisis. Priority nursing concerns
should be:
a. Nutrition and hydration c. Nutrition and infection
b. Pain management and infection d. Hydration and pain management

Situation: A toddler has been diagnosed with classic hemophilia and has a subcutaneous venous port
inserted. The child’s mother is being taught to administer Factor VIII prophylactically 3 times a week.

90. To receive the most benefit from this therapy, the mother should be taught to administer the factor:
a. Whenever a bleed is suspected
b. In the morning on scheduled days
c. On a regular schedule at the mother’s convenience
d. At bedtime when the child will be lying in bed quietly

91. To control bleeding in a child with hemophilia A, the nurse would expect to give:
a. Albumin c. fresh frozen plasma
b. factor II, VII, IX, X complex d. factor VIII concentrate

92. When discussing hemophilia with the parents of a child recently diagnosed with this disorder, the
nurse should explain that:
a. Hemophilia is an autosomal dominant disorder in which the woman carries the trait
b. Hemophilia follows regular laws of Mendelian inherited disorders such as sickle cell
anemia
c. This disorder can be carried by either males or females but occurs in the sex opposite that
of the carrier
d. Hemophilia is an X-linked disorder in which the mother is usually the carrier of the
illness but is not affected by it

93. The parents of a 10-year-old boy with hemophilia are very worried about their other children, two
girls and another boy. They want to know what chances are concerning the other children having
the disorder or being carriers. An appropriate answer top this question would be that:
a. “Neither of the girls will be affected, but the other son will be a carrier.”
b. “Both of the girls will be carriers, but half of the boys will be affected.”
c. “Each son has a 50% chance of being either affected or a carrier, and the girls will all be
carriers.”
d. “Each son has a 50% chance of being affected, and each daughter a 50% chance of
being a carrier.”

94. A child comes to the emergency department feeling feverish and lethargic. Which of the following
assessment findings suggest Reye’s syndrome?
a. Fever, profoundly impaired consciousness, and hepatomegaly
b. Fever, splenomegaly, and hyperactive reflexes
c. Afebrile, intractable vomiting, and rhinorrhea
d. Malaise, cough, and sore throat

95. Which of the following aspects is most important for successful management of the child with
Reye’s syndrome?
a. early diagnosis c. initiation of antibiotics
b. isolation of the child d. staging of the illness

96. Which of the following group of laboratory results, along with the clinical manifestations,
establishes a diagnosis of Reye’s syndrome?
a. Elevated liver enzymes and prolonged prothrombin and partial thromboplastin
times
b. Increased serum glucose and insulin levels
Siena Kathleen V. Placino BSN-IV

c. Increased bilirubin and alkaline phosphate levels

d. Decreased serum glucose and ammonia levels

97. Which of the following assessment changes would indicate increased intracranial pressure (ICP) in
a child acutely ill with Reye’s syndrome?
a. Irritability and quick pupil response
b. Increased blood pressure and decreased heart rate
c. Decreased blood pressure and increased heart rate
d. Sluggish pupil response and decreased blood pressure

98. A client with Reye’s syndrome is exhibiting signs of increased intracranial pressure (ICP). Which
of the following nursing interventions would be contraindicated for this client?
a. mouth care c. scheduled cluster care
b. suctioning and chest physiotherapy d. positioning to avoid neck vein compression

99. Which of the following medications has been connected with the development of Reye’s
syndrome?
a. Acetaminophen (Tylenol) c. Aspirin
b. Ibuprofen (Motrin) d. Guaifenesin (Robitussin)

100. Which of the following nursing diagnosis is most applicable to a child diagnosed with Reye’s
syndrome?
a. Ineffective breathing pattern related to increased intracranial pressure
b. Risk for aspiration related to vomiting
c. Interrupted family process related to situational crisis
d. Risk for injury related to disorientation and impaired coagulation