Chapter 28: Caring for the Child With a Neurological or Sensory Condition Nursing School Test Banks

Chapter 28: Caring for the Child With a Neurological or Sensory Condition

MULTIPLE CHOICE

1. The student nurse studying the neurological system learns that areas of gray matter are found deep in the brain. To determine damage to the basal ganglia, what will the nurse assess?
A. Blood pressure
B. Homeostasis
C. Movement
D. Sensory impulses
ANS: C
Areas of gray matter are found deep in the brain. These areas include the basal ganglia (affect movement), the hypothalamus (maintains homeostasis and regulates blood pressure, heart rate, and temperature), and the thalamus (processes sensory impulses and sends them to the cerebral cortex).

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

2. The pediatric nurse explains to the parents of a comatose child that which structure controls the childs level of consciousness?
A. Basal ganglia
B. Brainstem
C. Central nervous system
D. Reticular activating system
ANS: D
Level of consciousness is controlled by the reticular activating system and the cerebral hemispheres of the brain. Cognitive cerebral function cannot occur without an active reticular activating system.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

3. The pediatric nurse carefully monitors a patients status by assessing the childs level of consciousness. The nurse understands that the Glasgow Coma Scale provides clues to which of the following?
A. Encephalitis
B. Irreversible coma
C. Neurological impairment
D. Neurological status
ANS: D
The childs level of consciousness and the use of the Pediatric Glasgow Coma Scale, pupil response, and overall activity provide clues to the childs neurological status

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

4. The pediatric nurse caring for patients in a trauma center examines a patient who has increased intracranial pressure as a result of a motor vehicle crash. The nurse is aware that secondary brain injuries can result from which factor?
A. Acidosis
B. Ischemia
C. Infections
D. Reduced oxygen
ANS: B
Primary brain injury is irreversible, immediate, and can result from traumatic injuries (e.g., a blow to the head) or nontraumatic injuries (e.g., a tumor or infection). Secondary brain injuries include ischemia from hypoxia, hypercapnia, hypotension, acidosis, and reduced oxygen delivery.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

5. The pediatric nurse caring for a patient with encephalitis explains to the parents that the most common origin of encephalitis is which of the following?
A. Bacterial
B. Fungal
C. Parasitic
D. Viral
ANS: D
Encephalitis is usually viral in origin and occurs with an acute febrile illness that is characterized by cerebral edema and infection of surrounding meninges. Less common etiologies are fungal, bacterial, and parasitic infections; exposure to toxins or drugs; and cancer.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

6. A pediatric nurse performs a physical examination on a neonate and notes a spinal lesion with the meninges protruding through the defect that contains spinal cord elements. The nurse documents which condition as being present?
A. Hydrocephalus
B. Meningitis
C. Meningocele
D. Myelomeningocele
E. Spina bifida occulta
ANS: D
A myelomeningocele is the most severe form of spina bifida and is evident on delivery. The meninges protrude through the defect, and they contain spinal cord elements. It appears as a very pronounced skin defect, usually covered by a transparent membrane, and neural tissue may be attached to the inner surface.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Communication and Documentation
Difficulty: Easy

PTS: 1

7. An ophthalmologist examining the eyes of a patient explains to the nurse that the patient has an irregular curvature or uneven contour of the eye, resulting in impaired light refraction that causes blurred vision at all distances. Which condition does the nurse inform the parents about?
A. Astigmatism
B. Hyperopia
C. Myopia
D. Strabismus
ANS: A
In myopia, light rays do not reach the retina, causing blurred vision at a far range and clear vision at a close range. In hyperopia, vision is unclear at a close range and is clearer at a far range. Strabismus, or crossed-eye appearance, results in misalignment of the eyes. Astigmatism may be present at birth or acquired. Light rays are unevenly distributed in the eyes, causing blurred vision at all distances. This condition is associated with birth hyperopia and myopia.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

8. A nurse is caring for a child with suspected epilepsy. Which diagnostic test does the nurse facilitate as the priority for this child?
A. Cerebral angiogram
B. Electrocardiogram (ECG)
C. Electroencephalogram (EEG)
D. Lumbar puncture (LP)
ANS: C
The EEG is the gold standard diagnostic test for a seizure disorder.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

9. A hospitalized child is having a seizure. Which action by the nurse takes priority?
A. Apply oxygen and oximeter.
B. Give anti-seizure medications.
C. Pad the side rails of the bed.
D. Turn the child on his or her side.
ANS: D
All actions are appropriate when a patient has a seizure. The priority, however, is on maintaining the childs airway. Placing the child in a side-lying position decreases the risk of aspiration and airway obstruction.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

10. A nurse admits a 5-year-old child with bacterial meningitis to the pediatric intensive care unit. Which information obtained by the nurse during the intake history is most helpful for the nurse to document?
A. Fell off swing hitting head 2 months ago
B. History of recent sinus infection
C. Mother with history of herpes simplex
D. Sibling with upper respiratory infection
ANS: B
In a child this age, common causes of bacterial meningitis include septicemia, surgical procedures involving the CNS, penetrating wounds, otitis media, sinusitis, cellulitis of the scalp or face, dental cavities, pharyngitis, and orthopedic diseases. Blunt trauma from falling off a swing and a sibling with a URI are noncontributory. Herpes simplex is an important cause of neonatal viral meningitis.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

11. A nurse admits a child experiencing drowsiness and vomiting who has had a seizure at home. The parents state the child was healthy until 2 weeks ago when she had a viral illness. Which diagnostic testing does the nurse facilitate as a priority?
A. Complete blood count
B. Liver biopsy
C. Lumbar puncture
D. Serum glucose
ANS: B
This child has manifestations of Reye syndrome. The definitive diagnosis of this disease is made via a liver biopsy.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

12. A neonate receives a diagnosis of hydrocephalus. The pediatric nurse assesses for congenital anomalies related to this condition. Which condition is inconsistent with the nurses knowledge of hydrocephalus?
A. Aqueductal stenosis
B. Chiari I and II malformations
C. Dandy-Walker malformation
D. Folic acid deficiency
ANS: D
Hydrocephalus develops when an impedance to cerebrospinal fluid (CSF) flow or absorption is present. It rarely occurs as a result of the overproduction of CSF. Congenital anomalies, including Chiari I and II malformations, Dandy-Walker malformation, and aqueductal stenosis, are the most common causes of hydrocephalus during the neonatal and early infancy periods. Acquired hydrocephalus occurs after birth and in infancy, usually resulting from intraventricular hemorrhage due to prematurity. Folic acid deficiency is related to neural tube deficits.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

13. A child is prescribed baclofen (Lioresal) via intrathecal pump to treat severe muscle spasms related to cerebral palsy. What teaching does the nurse provide the child and parents?
A. Do not let this prescription run out.
B. The medication may cause gingival hyperplasia.
C. Periodic serum drug levels are needed.
D. Watch for excessive facial hair growth.
ANS: A
Abrupt discontinuation of intrathecal baclofen can cause drastic effects, such as high fever, altered mental status, and exaggerated rebound spasticity and muscle rigidity. The parents should ensure there is a supply of this drug on hand at all times to avoid these effects. Gingival hyperplasia and hirsutism are side effects of phenytoin (Dilantin). Serum drug levels are not obtained with an intrathecal medication.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Difficulty: Difficult

PTS: 1

14. A school-aged child wishes to learn embroidery from her grandmother, but the grandmother reports that the child can only concentrate on the projects for a short time and seems frustrated. What action by the nurse is the most appropriate?
A. Advise that the child needs more physical activity.
B. Explain that the child is too young for this project.
C. Suggest that the child have a routine vision exam.
D. Teach behavior modification to the grandmother.
ANS: C
The most common refractive disorder in children is hyperopia (farsightedness). Symptoms include reports of objects being unclear at close range and clearer at a distance. Younger children may have trouble focusing on a project that requires close vision work. The nurse should suggest that the child have a routine eye examination. The other options may or may not be beneficial, but do not address the potential visual problem.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

15. The pediatric nurse caring for hearing-impaired children teaches parents the recommended guidelines for communicating with their children. Which instruction is inconsistent with current guidelines?
A. Ignoring any related stigmas
B. Obtaining the childs attention before speaking
C. Positioning yourself at the childs eye level
D. Talking slowly and loudly to the child
ANS: A
The following guidelines are used when communicating with the hearing-impaired child: obtain the childs attention prior to speaking, face the child when talking, position yourself at the childs eye level, talk slowly and loudly, modify the environment to reduce noise, and offer emotional support because the child may face stigmas related to his or her hearing loss.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

16. The student nurse studying anatomy and physiology understands which of the following to be the function of axons?
A. Bringing information to the brain
B. Maintaining myelin sheaths on nerves
C. Protecting sensory and motor pathways
D. Taking information away from the brain
ANS: D
Axons take information away from the brain.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

17. A student nurse is tutoring another student on anatomy and physiology. What does the tutor explain is the function of myelin sheaths on certain nerves?
A. Allow rapid transmission of nerve impulses
B. Assist in long-term storage of memories
C. Prevent cross-communication between nerves
D. Protect the nerves from temperature changes
ANS: A
White matter in the brain consists of nerves coated with myelin sheaths, which allow nerve impulses to travel rapidly.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

18. What would the nurse assess for in a child with a disturbance in the basal ganglia?
A. Ataxia
B. Hyperthermia
C. Hypotension
D. Incontinence
ANS: A
Ataxia, or uncoordinated movements, may been seen in a child with a problem of the basal ganglia, which controls movement. Changes in temperature and blood pressure are more likely related to problems with the hypothalamus, and incontinence could signify a spinal cord problem.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

19. A nurse is caring for a child who only awakens to painful stimuli and produces no verbal responses. Which term is the most appropriate when documenting this childs status?
A. Lethargy
B. Obtundation
C. Persistent vegetative state
D. Stupor
ANS: D
A child who is stuporous only responds to painful stimuli and has verbal responses that are either absent or slow. A lethargic patient opens his or her eyes to loud voices and appears confused and falls asleep without continued stimulation. Obtundation is demonstrated when a person is aroused by tactile stimulation, such as gentle shaking, but does not show great interest in surroundings. A persistent vegetative state is a coma-like condition that has lasted for over 4 weeks.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

20. A nurse is caring for a child who has intracranial pressure (ICP) monitoring. The nurse assesses the child and notes that the ICP is 9 mm Hg. Which action by the nurse is most appropriate?
A. Activate the rapid response team.
B. Document the finding in the chart.
C. Hyperventilate the patient.
D. Prepare to administer mannitol (Osmotrol).
ANS: B
A normal ICP is 010 mm Hg. This finding is normal and the nurse needs only to document it and continue monitoring. No other actions are needed.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

21. A student nurse is confused about the Monroe-Kelly doctrine. How does the registered nurse explain it to the student?
A. Compensation for an increase in one of the skulls components
B. Hypothesis about the length of a coma determining the outcome
C. Immunomodulatory theory of an inborn resistance to rabies
D. Theory that seizures change the neurons and provoke more seizures
ANS: A
The brain consists of three components: brain matter, cerebral spinal fluid (CSF), and blood. Because the skull is a hard vault (after fontanels have closed), an increase in one of the components is not tolerated. The Monroe-Kelly doctrine states that in order to compensate for an increase in one of the components, there must be an equitable decrease in the other two components in order to prevent brain injury.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

22. A nurse is caring for four patients in the pediatric intensive care unit with head injuries or brain infections. Which child should the nurse see first?
A. Blood pressure change from 110/58 to 134/40 mm Hg in a child with brain injury
B. Child with brain injury who has vomited twice in 12 hours, now sleeping
C. Child with meningitis who is irritable, complaining of a bad headache
D. Oral temperature of 100.4F (38C) in a child with meningitis
ANS: A
Hypertension (with widening pulse pressure), bradycardia, and changes in respiratory pattern are components of Cushings triad, a late sign of increased intracranial pressure, indicative of impending herniation. The change in the childs blood pressure, including the widened pulse pressure (difference between systolic and diastolic pressures), is worrisome. A child with a head injury and minimal vomiting is not alarming. A child with a brain infection who is irritable with a headache needs attention, but not over the child with possible herniation. An oral temperature of 100F would be expected in a child with a brain infection.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

23. A nurse is caring for a 10-year-old child with a brain injury. On assessing the child, the nurse finds the following data: opens eyes only to pain, mutters inappropriate words, has abnormal extension to stimulation. Which action by the nurse takes priority?
A. Alert the operating room for emergent surgery.
B. Document the findings; reassess in 15 minutes.
C. Notify the provider; prepare for intubation.
D. Raise the head of the childs bed to 45.
ANS: C
A child with a Glasgow Coma Score of less than 8 needs to be intubated and mechanically ventilated. This childs score is 7 (eye opening = 2, verbal response = 3, motor response = 2). The child may need an invasive procedure due to the increased intracranial pressure, but this would not take priority over managing the airway and providing adequate oxygenation. The findings need to be documented, but further action is needed. Raising the head of the bed may or may not be beneficial, but does not take priority over intubation.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

24. A student nurse is preparing to give a 48.5-lb(22-kg) child IV mannitol (Osmitrol). What action by the student causes the nursing instructor to intervene?
A. Assesses childs pain including report of headache
B. Confirms the dose of 66 g in a 20% solution
C. Double-checks childs urine output for the shift
D. Explains to the child that nausea may occur
ANS: B
Mannitol is an osmotic diuretic often used to decrease intraocular pressure. The correct dose is 12 g/kg, so the safe dose range is 2244 g. The nurse would intervene if the student prepared to administer 66 g. The other actions are appropriate.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Communication and Documentation
Difficulty: Difficult

PTS: 1

25. A child who is intubated and mechanically ventilated has an intracranial pressure monitoring device in place. The child is agitated. Which medication order would the nurse question based on the assessment data?
A. Fentanyl (Sublimaze)
B. Lorazepam (Ativan)
C. Methylprednisolone (Solu-Medrol)
D. Morphine (Astramorph)
ANS: C
Pain and agitation are treated aggressively because they both can increase intracranial pressure. Appropriate drug choices include fentanyl, lorazepam, and morphine. Corticosteroids do not treat either pain or agitation and their use in cerebral edema is controversial.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

26. A child has an invasive intracranial pressure monitoring device in place. Which assessment finding indicates that goals for a priority nursing diagnosis have been met?
A. Daily weight equals admission weight.
B. Joints move freely during range of motion.
C. No signs of infection are present at the insertion site.
D. Skin is intact without redness or breakdown.
ANS: C
All indications show that goals for various nursing diagnoses have been met; however, the priority here would be preventing infection at the intracranial pressure monitoring site, which would have a direct route to the brain.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Evaluation
Difficulty: Easy

PTS: 1

27. A child has had an episode of lip smacking while staring into space, but did not seem to lose consciousness. She was confused afterward but said her hands felt tingly before the other symptoms started. How should the nurse document this event?
A. Alteration in consciousness
B. Convulsion
C. Focal seizure
D. Generalized seizure
ANS: C
A focal seizure involves only one part of the brain and manifests with involuntary movements, sensory symptoms, possible staring into space, no loss of consciousness, and confusion afterward. Alteration in consciousness is too vague in this case to be a useful description. Convulsion is an outdated term. A generalized seizure involves both hemispheres of the brain and manifestations usually include loss of consciousness and tonic-clonic movements.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

28. A child has been admitted with bacterial meningitis. Which action by the nurse takes priority?
A. Administering broad-spectrum antibiotics
B. Assessing and treating pain aggressively
C. Facilitating blood cultures and lumbar puncture
D. Maintaining a quiet, nonstimulating environment
ANS: C
All actions are appropriate for the child with acute bacterial meningitis. However, the priority is obtaining cultures so that appropriate therapy can be identified. After cultures are obtained, the nurse will administer broad-spectrum antibiotics until the culture and sensitivity results are known.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

29. During assessment of a 6-year-old child with meningitis, the nurse places the child supine and attempts to put the childs chin on her chest. The child cries out in pain and flexes her knees. How does the nurse document this assessment finding in the medical record?
A. Absent Moro reflex
B. Exaggerated Grey-Turner sign
C. Negative Kernig sign
D. Positive Brudzinski sign
ANS: D
Two assessment tests are used in evaluating a patient with meningitis: the Kernig sign and the Brudzinski sign. The nurse has demonstrated a positive Brudzinski sign. The Kernig sign is elicited by placing the patient supine with hips flexed and raising and straightening the leg. Pain behind the knee and resistance are abnormal findings possibly indicative of meningitis. The Moro reflex is done on infants. The Grey-Turner sign is bruising of the flanks, often accompanying pancreatitis.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

30. A nurse is preparing to discharge a 10-year-old child who was diagnosed with bacterial meningitis. Which action by the nurse takes priority?
A. Arrange home health-care visits for antibiotic infusions.
B. Consult with physical therapy about a home exercise plan.
C. Ensure the parents can plan high-protein meals.
D. Make a social work referral for long-term care placement.
ANS: A
Children with bacterial meningitis are often discharged with a PICC line in place for home IV antibiotic infusions. Depending on the needs of the child, the other options may or may not be appropriate.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

31. A nurse is caring for a child who had a sudden onset of muscle weakness beginning in the legs and progressing in an ascending fashion, but who otherwise appears healthy. Which laboratory result would confirm the nurses suspicion about the origin of this problem?
A. Elevated CSF protein
B. Increased liver enzymes
C. Leukocytosis
D. Low hemoglobin
ANS: A
This child has manifestations of Guillain-Barr syndrome. Elevated CSF protein in the absence of infection supports this diagnosis.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

32. A nurse is caring for an 8-year-old with Guillain-Barr Syndrome (GBS). On hourly rounds, the nurse assesses that the childs lung sounds are diminished, respiratory rate is 8 breaths/min and shallow, and pulse oximeter is 88%. What action by the nurse takes priority?
A. Administer high-flow oxygen by mask.
B. Call the rapid response team; prepare for intubation.
C. Encourage the patient to take slow, deep breaths.
D. Have the patient use the incentive spirometer.
ANS: B
In GBS, respiratory muscles can be affected, leading to respiratory failure. The nurse needs to prepare for intubation. The childs muscles are too weak for oxygen or the spirometer to help her, and she may be too weak to use the spirometer or to take deep breaths.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

33. A health-care provider administers edrophonium (Tensilon) to a school-age child with new onset of muscle weakness. The child is able to hold her eyes open for the duration of the drugs half-life. Which information does the nurse plan to teach the child and parents?
A. Muscle weakness will progress in an ascending fashion.
B. Pain control will be an important aspect of the childs care.
C. This disease is a result of a previous viral infection.
D. Weakness and fatigue will probably be worse during the day.
ANS: D
A positive result to a Tensilon test is diagnostic for myasthenia gravis, an autoimmune disease uncommon in children. Muscle weakness is the main symptom, and the weakness is particularly pronounced in muscles used for eye movement, chewing, swallowing, and breathing. Weakness is usually worse during the day or during times of stress. It is not painful, muscle weakness does not progress in ascending fashion as in Guillain-Barr syndrome, and the cause is unknown.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

34. A nurse is teaching a parent group about caring for their infants and toddlers. What does the nurse teach to prevent a serious neurological problem in infants?
A. Always treat any temperature elevation to prevent seizures.
B. Avoid vaccinations with live, attenuated viruses.
C. Do not use artificial sweeteners in your babys food.
D. Never give honey to a child less than 1 year of age.
ANS: D
Infant botulism can be caused by feeding honey to a child less than 12 months of age, so the nurse teaches parents to avoid this. The other statements are inaccurate.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

35. The high school nurse is teaching a healthy living class to high school seniors. One student asks why she should take folic acid now when she is not planning to become pregnant. Which response by the nurse is the most appropriate?
A. It is a good habit to get into while you are young and can develop good habits.
B. Most people in this country have a serious deficiency of vitamins and folic acid.
C. Neural tube defects occur so early that you might not know you are even pregnant.
D. There are no foods that contain folic acid so you have to take a supplement.
ANS: C
Neural tube defects (NTDs) generally occur between the 18th and 28th days of pregnancy, often before the woman knows she is pregnant. All women of childbearing age should get 400 g/day of folic acid to help prevent NTDs. It is a good habit to get into prior to contemplating pregnancy, but this answer does not give specific information. Most people do not have a serious deficiency of folic acid; however, pregnant women (and those who could be pregnant) need to have a minimal amount of folic acid. Several foods are good sources of folic acid, including green leafy vegetables, liver, legumes, orange juice, and fortified breakfast cereals; it is also contained in multivitamins.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

36. A woman is considering a second pregnancy, but tells the nurse she is not sure she wants to get pregnant again because her first child was born with spina bifida. She is taking folic acid on the advice of her health-care provider. Which information can the nurse provide this woman?
A. Alpha-fetoprotein testing can be done in pregnancy.
B. Genetic testing is available for this condition.
C. It is rare for two children in one family to be affected.
D. Usually spina bifida affects only female children.
ANS: A
During pregnancy, testing of maternal blood for elevated alpha-fetoprotein is available for an early indication of spina bifida. The other options are incorrect.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

37. An infant born with spina bifida with a repaired myelomeningocele is brought the emergency department, where the parents report that the infant is very fussy and is feeding poorly. Which nursing action takes priority?
A. Assess the babys fontanels for bulging.
B. Attach a cardiac and respiratory monitor.
C. Obtain and document the babys vital signs.
D. Try feeding the baby with sucrose water.
ANS: A
Poor feeding and irritability are signs of increased intracranial pressure (ICP) in infants. A child with spina bifida is at risk for hydrocephalus, which can lead to increased ICP. A corroborating sign would be bulging fontanels. The nurse should quickly palpate the infants fontanels. Monitoring the child and obtaining vital signs are important actions too, but palpating the fontanels can be done quickly as the nurse handles the child and performs other procedures. The nurse should not attempt to feed this baby now.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

38. A 6-week-old baby is brought to the clinic for a follow-up visit after having surgical repair of a myelomeningocele. His head circumference was 33 cm (12 inches) at birth. Now the nurse assesses his head circumference at 36 cm (14.1 inches). What action by the nurse is most appropriate?
A. Assess the child for signs of hydrocephalus.
B. Document the measurement in the childs chart.
C. Educate the parents on possible shunt placement.
D. Inquire about signs of increased intracranial pressure.
ANS: B
Increasing head circumference is a sign of possible hydrocephalus. The average head circumference of an infant at birth is 3338 cm (1214 inches) and increases by 2 cm/month (0.75 inches/month). This childs head circumference is normal and the nurse should document the information; no other actions are needed.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

39. A nurse in a well-child clinic notes that a 5-month-old is not able to hold her head up. Which action by the nurse is the most appropriate?
A. Ask about other developmental milestones .
B. Document the finding in the childs chart.
C. Measure the childs head circumference.
D. Obtain the childs length and weight.
ANS: C
Difficulty holding the head up by an appropriate age is a manifestation of hydrocephalus. Another sign of this disorder is an enlarging head, so the nurse measures the childs head and compares it to age-related norms. The other actions are appropriate, but not as specifically associated with hydrocephalus as measuring head circumference.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

40. A new nurse is caring for a child who had a ventriculoperitoneal shunt placed 2 days ago for hydrocephalus. Which action by the new nurse causes the experienced nurse to intervene?
A. Administers IV antibiotics
B. Asks for medication to treat nausea
C. Palpates the shunt tract with assessments
D. Raises the head of the bed to 30
ANS: B
Peritonitis is a complication of this procedure and manifestations of this include rebound tenderness, abdominal muscle rigidity, nausea, and vomiting. The new nurse should conduct a more thorough abdominal assessment instead of asking for anti-nausea medication. The other actions are appropriate and do not require the experienced nurse to intervene.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

41. A nurse is caring for a child and notes Battles sign during the assessment. Which action by the nurse is the most appropriate?
A. Assist with obtaining laboratory studies.
B. Document the findings in the childs chart.
C. Measure the childs abdominal girth.
D. Notify the provider and facilitate a CT or an MRI.
ANS: D
Battles sign is indicative of a basilar skull fracture. The child will need a head CT or an MRI. The other actions are not needed as a result of this finding.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

42. A pediatric nurse reads the diagnosis SCIWORA on a childs chart. Which assessment finding does the nurse anticipate to correlate with this condition?
A. Altered level of consciousness
B. Diplopia and visual disturbances
C. Inability to hold his head up
D. Weakness/paralysis of muscles
ANS: D
SCIWORA stands for spinal cord injury without radiographic abnormality. Common manifestations of spinal cord injury include increased muscle tone, loss of normal bowel and bladder function, numbness, sensory changes, pain, and weakness or paralysis of muscles.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

43. An adolescent has frequent headaches accompanied by nausea and vomiting. What item is most appropriate for the nurse to include in the teaching plan for this adolescent patient?
A. How to give him- or herself an injection of medication
B. The maximum daily dose of acetaminophen (Tylenol)
C. Ways to manage temporary ptosis or rhinorrhea
D. What to do in case of a seizure during the headache
ANS: A
These symptoms are characteristic of a migraine. Migraines can be treated with a variety of medications, including injectable sumatriptan (Imitrex). The nurse would determine if this medication was included in the treatment plan and offer related education. The child might also take Tylenol, in which case he or she needs to know the maximal daily dose, but that is not as specific for migraines as sumatriptan is. Ptosis and rhinorrhea are characteristic of cluster headache. Headaches are not generally accompanied by seizures.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

44. A child has been examined by a pediatric ophthalmologist, and findings indicate a dulled red reflex and cloudy lens. Which treatment plan does the nurse educate the parents on based on these findings?
A. Occlusion therapy to the affected eye for 6 months
B. Periodic administration of IV mannitol (Osmotrol)
C. Surgery to remove the cataract and placement of a lens
D. Use of eyedrops for the rest of the childs life
ANS: C
These manifestations are characteristic of cataracts, which can be congenital or acquired. Typical treatment includes surgical removal of the cataract and lens implant. The other options are not part of the treatment for cataracts.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

45. A childs chart indicates he has leukocoria and a hyphema in the right eye. Which teaching does the nurse implement for the child and parents?
A. Application of antibiotic ointment and eye patch
B. Possibility of other children having this genetic disorder
C. Surgery, possible enucleation, possible chemotherapy
D. Wearing appropriate eye protection during sports
ANS: C
Leukocoria (cats eye reflex) and hyphema (blood in the anterior chamber of the eye) are manifestations of retinoblastoma, a rare and aggressive tumor of the retina. Treatment is vigorous and may include surgery (including enucleation), radiation, chemotherapy, laser, or cryotherapy.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Difficult

PTS: 1

46. A nurse is working with a teen who has epilepsy treated with carbamazepine (Tegretol). Laboratory results indicate a serum drug level of 2 g/mL. Which action by the nurse is the most appropriate?
A. Assess the teen for noncompliance.
B. Document the results in the chart.
C. Have the teen continue the regimen.
D. Tell the teen to cut the dose in half.
ANS: A
The therapeutic level of carbamazepine is 512 g/mL. The nurse should assess the teen for noncompliance because this level is too low. It is also possible that the teen has grown since the last drug level was obtained and that he or she simply now needs a higher dose. The results should be documented, but the nurse should take other action. Because the level was too low, it is not appropriate to continue the drug regimen or to cut the dose in half.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

47. A camp nurse reads on a medical history form that a camper has drop attacks. What does the nurse understand about this condition?
A. Atonic seizure activity
B. Fainting spells
C. Loss of consciousness
D. Sudden muscle weakness
ANS: A
Drop attack is an old term for atonic seizure activity.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

48. A child is brought to the pediatric clinic by her mother, who reports redness, swelling, and pain around the childs right eye. Which information does the nurse give the mother?
A. A steroid injection may be needed to reduce swelling.
B. Intravenous antibiotic treatment for 7 days is usually curative.
C. See an ophthalmologist to assess for any corneal damage.
D. Use warm wet compresses to remove any crusting.
ANS: B
This child has the manifestations of periorbital cellulitis, which is treated with a week of IV antibiotics. Steroid injections may be used for a chalazion. An ophthalmologist needs to assess the child with keratitis to assess for corneal damage. Warm moist soaks are used in conjunctivitis.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

MULTIPLE RESPONSE

1. A nurse assesses an infant for signs of increased intracranial pressure. Which signs would lead the nurse to notify the rapid response team? (Select all that apply.)
A. Bulging fontanels
B. Change in LOC
C. Irregular respirations
D. Posturing
E. Seizures
ANS: A, C, D
Bulging fontanels, irregular respirations, and posturing are among the late signs of increased intracranial pressure and would lead the nurse to intervene quickly by notifying the health-care provider or by activating the rapid response team. The other signs are early indicators of increased intracranial pressure.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment; Management of Care
Integrated Process: Communication and Documentation
Difficulty: Difficult

PTS: 1

2. The pediatric nurse is caring for a child with increased intracranial pressure (ICP). The nurse places priority on completing which interventions? (Select all that apply.)
A. Administering mannitol (Osmitrol)
B. Lowering the head of the bed
C. Maintaining a patent airway
D. Performing vigorous suctioning
E. Preventing hyperthermia
ANS: A, C, E
Hyperthermia is to be avoided because brain metabolic needs will be greatly increased. The nurse may use a hypothermic blanket if the childs temperature is over 102F (39C). The head of the bed can be elevated 15 to 30 to promote venous blood return, but a side effect of elevating the head is that the pressure of blood being delivered to the brain decreases, resulting in inadequate blood supply and perfusion. A priority nursing intervention is maintenance of a patent airway. Inadequate oxygenation or excess carbon dioxide causes cerebral blood vessels to dilate, resulting in increased intracranial pressure (ICP). The nurse may administer medications to decrease cerebral edema. A drug frequently prescribed is mannitol (Osmitrol). The patient should be suctioned if needed, but suctioning can increased ICP and should be done gently and only when necessary.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

3. A nurse is caring for a 1-year-old child who was admitted for seizures. The parents ask what could have caused the childs seizure. The nurse explains that seizures can be caused by which problems? (Select all that apply.)
A. Brain injury
B. Central nervous system infection
C. Hypertension
D. Renal failure
E. Unknown cause
ANS: A, B, E
Seizures can be caused by many things, including traumatic brain injury, infection in the central nervous system, ingestion of toxins, endocrine dysfunction, atrial-venous malformation, or anoxia. The etiology may also be unknown.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

4. A nurse is preparing discharge teaching for an adolescent with a new diagnosis of epilepsy. What information should the nurse provide? (Select all that apply.)
A. Driving is not allowed while taking anti-seizure drugs.
B. Participating in sports again in the future is possible.
C. Several drugs will be tried at once, then reduced over time.
D. Wearing a Medic-Alert bracelet is not needed for seizures.
E. You should check the schools seizure action plan.
ANS: B, E
Once drug levels are therapeutic and the child has been seizure-free for several months (usually at least 6 months), he or she can return to participating in sports. School nurses should be aware of a childs diagnosis of a seizure disorder and treatment plan; the parents should check on the schools seizure action plan so they are aware of actions that will be taken if their child has a seizure on campus. Driving is allowed (depending on state law) with therapeutic drug levels and a certain period of seizure-free time. Monotherapy is the optimal treatment plan, but if a single drug does not work to control seizures, other drugs may be added to the regimen. Anyone with epilepsy or a seizure disorder should wear a Medic-Alert bracelet or necklace.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

5. The pediatric nurse prepares a care plan for a patient admitted to the intensive care unit for meningitis. Which nursing interventions does the nurse include in the care plan for this patient? (Select all answers that apply.)
A. Assess and treat pain as needed.
B. Implement transmission-based precautions.
C. Initiate and maintain IV access.
D. Monitor vital signs every 4 hours.
E. Monitor neurological status and symptoms.
ANS: A, B, C, E
The nurse should initiate transmission-based precautions to help prevent transmission of infection. The nurse should initiate and maintain intravenous access (specify fluids and rate) as ordered. The nurse should monitor vital signs every 1 to 4 hours (depending on severity of symptoms) and place the patient on a cardiac monitor as indicated. The nurse should monitor neurological status and symptoms closely, comparing with baseline values for the child. Patients with meningitis often have pain, especially headaches, and the nurse should be prepared to assess and treat.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

6. The nurse is admitting an adolescent with known myasthenia gravis to the intensive care unit with respiratory failure. Which questions would be most important for the nurse to ask to attempt to find the cause of the problem? (Select all that apply.)
A. Could your child have skipped doses of his medication?
B. Do you know if your child uses drugs or drinks alcohol?
C. Has your child been sick or overly fatigued recently?
D. How long has your child been diagnosed with myasthenia gravis?
E. Is it possible that your child took too much medication?
ANS: A, C
This child appears to be in a myasthenic crisis, which is usually caused by underdosing or skipping medication and illness, infection, or fatigue. The other questions will not help identify the cause of the crisis.

Cognitive Level: Applying/Application
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

7. The nurse is preparing discharge teaching for the parents of a 7-year-old boy with hydrocephalus and a ventriculoperitoneal shunt. Which information does the nurse include in the discharge teaching? (Select all that apply.)
A. After the shunt site has healed, contact sports are permitted
B. How to accurately take the childs temperature when needed
C. Monitoring for shunt infection is always a priority action.
D. Report any nausea, vomiting, or change in behavior.
E. Shunt removal can occur after hydrocephalus has been controlled.
ANS: B, C, D
Parents are taught how to care for their child after shunt placement. They need to know common signs of infection (fever, nausea, vomiting, change in behavior), how to take a temperature, and that contact sports are not permitted. Because hydrocephalus is a lifelong condition, monitoring for infection is ongoing and the shunt stays in place permanently.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

8. The pediatric nurse caring for a 3-year-old child with cerebral palsy (CP) prepares a home care teaching plan for the caregivers on discharge. Which items will the nurse include in the teaching plan? (Select all that apply.)
A. Apply splints and braces to facilitate muscle control.
B. Buy toys that are appropriate for the childs abilities.
C. Encourage the child to perform self-care tasks.
D. Ensure the clothing has buttons to stimulate dexterity.
E. Use skeletal muscle relaxants for short-term control.
ANS: A, B, C, D
The child with CP has some degree of muscular dysfunction. The nurse encourages the child to perform self-care tasks. The child may exhibit muscular hypotonia (low tension) or hypertonia (high tension). Splints and braces may be necessary to facilitate muscle control and to improve body functioning. Clothing should be easy to manipulate. Skeletal muscle relaxants may be used for short-term control with older children and adolescents.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

9. A pediatric nurse caring for patients in an emergency room performs an assessment of a child who survived a drowning incident. Which does the nurse assess when using the Orlowski scale on this child? (Select all that apply.)
A. Arterial pH < 7.10
B. Comatose on admission to the emergency room
C. No resuscitation efforts for more than 10 minutes after rescue
D. Submersion time > 20 minutes
E. Used for children who are 10 years of age or older
ANS: A, B, C
According to the Orlowski scale, each item is assigned one point: 3 years of age or older, submersion time greater than 5 minutes, no resuscitation efforts for > 10 minutes after rescue, comatose on admission to the emergency room, and arterial pH < 7.10. If a child has a score of 2 or less, there is a 90% likelihood of a complete recovery. If a child has a score of 3 or more, there is a 5% rate of survival.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

10. The clinic nurse is providing community education to a parent group. The topic is over-the-counter medications containing aspirin or aspirin compounds. Which products does the nurse advise the parents to avoid? (Select all that apply.)
A. Kaopectate (bismuth subsalicylate)
B. Lamictal (limotragine)
C. Pedia-profen (ibuprofen)
D. Pepto-Bismol (bismuth subsalicylate)
E. Ventolin (albuterol)
ANS: A, D
Common over-the-counter products containing aspirin include Kaopectate and Pepto-Bismol. Lamictal is not an over-the-counter drug. The other three medications do not contain aspirin compounds.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

COMPLETION

1. The nurse is providing care for a child in the intensive care unit who requires intracranial monitoring. The childs blood pressure is 100/42 mm Hg and his ICP is 10 mm Hg. Your calculation indicates that the childs cerebral perfusion pressure (CPP) is ____________________.

ANS:
51.3 mm Hg
CPP = MAP ICP
MAP = systolic blood pressure + 2(diastolic blood pressure); 100 + 2(42)/3 = 61.3
61.3 10 = 51.3

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

2. A nurse assesses a 1-month olds Glasgow Coma Scale (GCS) and finds the following: opens eyes to pain, irritable cry, localizes pain. Your calculation indicates that this childs GCS is ____________________.

ANS:
11 (eyes = 2, vocal = 4, motor = 5; total = 11)

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

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