Chapter 13: Neurological Disorders and Sensory Disorders My Nursing Test Banks

Chapter 13: Neurological Disorders and Sensory Disorders

Multiple Choice

1. The autonomic nervous system is responsible for:

1. Digesting a meal of hotdogs and chips.

2. Monitoring the heart rate while running.

3. Causing the body to perspire in the hot sun.

4. All of the above are part of the autonomic nervous system.

ANS: 4

Feedback
1. The ANS helps with the digestion of food.
2. The heart is regulated by the ANS.
3. Perspiration occurs because of the ANS for the purpose of thermoregulation.
4. The ANS helps with the digestion of food. The heart is regulated by the ANS. Perspiration occurs because of the ANS for the purpose of thermoregulation.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

2. The responsibilities of the central nervous system include:

1. Deciding to walk instead of run.

2. Helping to understand a math problem.

3. Digesting the food in the stomach.

4. Keeping the hand on a hot stove.

ANS: 1

Feedback
1. The brain is part of the CNS, which helps make decisions about body movements.
2. The CNS does not help with cognitive abilities.
3. Food digestion is part of the ANS.
4. The CNS would tell the hand to move.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

3. The blood-brain barrier of an infant is:

1. Less permeable than that of an adult.

2. Impermeable for glucose.

3. Permeable for large proteins.

4. Permeable for large molecules.

ANS: 4

Feedback
1. There is no difference between the adult and infant blood-brain barrier.
2. Glucose is permeable for the blood-brain barrier.
3. Large proteins are impermeable for the blood-brain barrier.
4. Large molecules are able to cross the blood-brain barrier.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

4. The first assessment a child receives to identify neurological development is:

1. APGAR scores.

2. Scoliosis testing.

3. The Denver II study.

4. Kindergarten testing.

ANS: 1

Feedback
1. APGAR stands for Appearance, Pulse, Grimace, Activity, Respiration, indicating responses of the neurological system. This testing is done right after birth.
2. Scoliosis testing does not occur until the child is a preteen.
3. The Denver II test is not used until the infant is older.
4. Kindergarten testing occurs later in the childs life.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

5. Questions about neurological function are raised when a child:

1. Snores.

2. Shows aggression when previously none was shown.

3. Wants attention from a parent.

4. Refuses to follow adult instruction.

ANS: 2

Feedback
1. Snoring presents a concern for the airway, not neurological functioning.
2. Changes in personality are signs of abnormal behaviors and should be investigated.
3. Attention-seeking behaviors indicate psychosocial need, not a neurological change.
4. This is normal behavior for a child and does not qualify as a neurological issue.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

6. A neonate is born with anencephaly. The prognosis for a neonate with this condition is:

1. A normal outcome.

2. A high risk for hydrocephaly.

3. Can be death.

4. Mental handicap.

ANS: 3

Feedback
1. The neonate will not have a brain, thus this is not a normal outcome.
2. The child lacks brain tissue, and hydrocephaly is not common.
3. Death is inevitable for a neonate with anencephaly because of the lack of brain structure.
4. A child with anencephaly has a very short life span, and evaluation for mental handicap is not needed.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

7. A child with severe mental and physical handicaps is at risk for:

1. Developing neurocutaneous lesions.

2. A dysmorphic nose and ears.

3. Abnormal cranial nerve function.

4. All of the above are correct.

ANS: 4

Feedback
1. Neurocutaneous lesions occur because of high risk for lack of physical movement.
2. Bone structure may be dysmorphic because of chronic abnormal muscle movements and contractures.
3. Because of neurological dysfunction, cranial nerve function will be abnormal.
4. Neurocutaneous lesions occur because of high risk for lack of physical movement. Bone structure may be dysmorphic because of chronic abnormal muscle movements and contractures. Because of neurological dysfunction, cranial nerve function will be abnormal.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 13 | Type: Multiple Choice

8. Neural tube defects can be linked to:

1. A mothers drug habit while pregnant.

2. A mothers lack of folic acid while pregnant.

3. A fetuss exposure to environmental toxins.

4. A mothers alcohol consumption while pregnant.

ANS: 2

Feedback
1. Drug habits can be linked to neurological damage and growth retardation.
2. Folic acid is needed for neural tube closure and should be taken as a prenatal vitamin.
3. Exposure to toxins can cause various cognitive and physical anomalies.
4. Alcohol can cause cognitive and physical anomalies if taken while pregnant.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

9. A nurse is attempting to position a newborn with a myelomeningocele in the lower lumbar region. The best position for the newborn would be:

1. Prone.

2. Laying the newborn on his/her side with support provided to the myelomeningocele.

3. Supine.

4. Any position is acceptable for a neonate with a myelomeningocele.

ANS: 2

Feedback
1. Prone does not allow for support of the sac.
2. Laying the newborn on his/her side will provide support for the sac and decrease the chance of a rupture.
3. Supine places too much pressure on the sac and increases the risk for a rupture.
4. Laying the newborn on his/her side will provide the most support for the sac and decrease the chance of a rupture.

KEY: Content Area: Neurological | Integrated Processes: Care | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

10. A neonate was born to a 28-year-old mother with an uneventful pregnancy two hours ago. The baby was delivered via cesarean section and taken directly to the neonatal intensive care unit because of an encephalocele. The mother is coming to see the baby. The nurse should:

1. Be prepared to answer questions about the babys care and condition.

2. Leave the room and give the family time with the neonate.

3. Prepare the mother prior to entering the room about the dysmorphic features and discuss the supportive care being provided.

4. Not let the mother see the child at this point.

ANS: 3

Feedback
1. The nurse should be ready to answer questions and needs to prepare the mother for the appearance of her neonate.
2. Time with the neonate is important, but support is the priority for parents at this time.
3. Prior information before seeing the child can help reduce the shock and foster more acceptance of the neonate.
4. The mother needs to see the neonate to help create a bond.

KEY: Content Area: Neurological | Integrated Processes: Care | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

11. A child born with Dandy Walker malformation is receiving palliative care in the pediatric unit. A nurse should:

1. Provide the parents, patient, and family members with supportive care during this time.

2. Ask the parents to be part of the plan of care as much as possible.

3. Attempt to provide a primary nurse for this particular patient on each shift.

4. All of the above are correct.

ANS: 4

Feedback
1. Family support is important in order to provide a high quality of life in a limited amount of time.
2. Parental involvement will create a bond with the child and empower the parents.
3. A primary nurse is able to form a bond with the family and understand the needs of the child because of frequent interactions.
4. Family support is important in order to provide a high quality of life in a limited amount of time. Parental involvement will create a bond with the child and empower the parents. A primary nurse is able to form a bond with the family and understand the needs of the child because of frequent interactions.

KEY: Content Area: Neurological | Integrated Processes: Care | Client Need: Psychological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

12. A head circumference is being measured at a 4 month olds well-baby checkup. It is noted that the head circumference has not grown since the previous assessment. The nurse should:

1. Ask the mother about the childs nutrition.

2. Notify the doctor.

3. Re-measure the head circumference, check developmental milestones, assess the nutritional status, and discuss the findings with the doctor.

4. Document the normal findings.

ANS: 3

Feedback
1. Nutritional assessment is important, but not the priority intervention at this time.
2. The doctor will receive the information after a re-measurement is taken to validate the findings.
3. Re-measurement is needed to validate findings, and assessing milestones will indicate the cognitive and physical abilities of the child. Nutritional information will indicate if adequate nutrition is being given. The doctor will be able to prescribe the best course of action after this information is reported.
4. The findings are abnormal, and further investigation is needed.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 13 | Type: Multiple Choice

13. A child with a diagnosis of schizencephaly is assigned to a new nurse on the pediatric floor. The new nurse has not worked with a child with this diagnosis before. A career nurse discusses the plan of care needed for the child with the new nurse. It will be important to:

1. Assess the side of the body that has paralysis for any lesions or sores.

2. Let the patient do as much as possible for activities of daily.

3. Discourage the patient to move the paralyzed side of the body.

4. Provide full care for the patient.

ANS: 1

Feedback
1. Skin breakdown can occur because of the lack of mobility for the affected side of the body.
2. The child may be lower functioning and not be able to understand how to do ADLs or have the physical ability to do them.
3. Movement is important, but not the priority.
4. Encouragement to do as much as possible is important for independence, but the child will need supervision.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

14. A nurse is assessing a 6-month-old boys suture lines. The nurse notes that the baby has craniosynostosis. The nurse should be concerned because:

1. The suture line closure will not allow the brain to grow.

2. This can lead to hydrocephalus.

3. The child will have immediate developmental delays because of the lack of space for the brain to grow.

4. The child will not require surgery.

ANS: 1

Feedback
1. Early closure of the sutures will inhibit brain growth.
2. Fluid buildup is not a concern at this time.
3. A progression of developmental delay, rather than immediate delay, will occur.
4. Surgery may be needed to relieve pressure and allow for growth to occur.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

15. A child that had a shunt placed four years ago for hydrocephalus is in the emergency room complaining of a rapid onset of vomiting and increased lethargy. The nurse knows that the child will need:

1. Nothing, as this is a normal complication and not an emergency.

2. To be placed on IV fluids to help maintain an electrolyte balance.

3. Small amounts of fluids until the vomiting has subsided.

4. To consider this a neurological medical emergency and check the childs head circumference.

ANS: 4

Feedback
1. This should be considered a neurological emergency, and the child should be checked.
2. Electrolyte imbalances are more apt to occur when fluid is removed.
3. The history of having a shunt needs to be addressed first to prevent any neurological damage.
4. Measuring the head circumference will give an indication as to the amount of fluid not draining with the shunt and should be considered a medical emergency.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 13 | Type: Multiple Choice

16. Night terrors can occur in adolescents because of:

1. Emotional stress.

2. Alcohol use.

3. Bullying.

4. All of the above can trigger night terrors in adolescents.

ANS: 4

Feedback
1. Emotional stress can cause increased thoughts and trigger night terrors.
2. Alcohol causes a disturbance to the chemical balance in the brain, causing the night terrors.
3. Bullying can be an emotional stressor, causing the night terrors.
4. Emotional stress can cause increased thoughts and trigger night terrors. Alcohol causes a disturbance to the chemical balance in the brain, causing the night terrors. Bullying can be an emotional stressor, causing the night terrors.

KEY: Content Area: Mental Health | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

17. When speaking with a family about their 9-year-old daughters nightmares, it is important to ask:

1. If the child has a history of daytime napping.

2. What medications the child takes during the day.

3. How often the child consumes caffeine.

4. All of the above should be part of the assessment.

ANS: 4

Feedback
1. Daytime napping can cause a sleep disturbance pattern because the child is not reaching the REM cycle.
2. Medications can have a side effect of nightmares for children.
3. Caffeine causes sleep disturbance because it is a stimulant.
4. Daytime napping can cause a sleep disturbance pattern because the child is not reaching the REM cycle. Medications can have a side effect of nightmares for children. Caffeine causes sleep disturbance because it is a stimulant.

KEY: Content Area: Neurological | Integrated Processes: Communication/Documentation | Client Need: Physiological Integrity | Cognitive Level: Evaluation | REF: Chapter 13 | Type: Multiple Choice

18. A quality of a partial seizure is:

1. Status epilepticus.

2. Tonic movements.

3. Fluttering eyelids.

4. Clonic movements.

ANS: 4

Feedback
1. This occurs after a grand mal seizure.
2. Tonic movements occur with a grand mal seizure.
3. Fluttering eyelids are noted in grand mal seizures.
4. Clonic movements occur in partial seizures and can occur in grand mal seizures.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

19. A mother is asking the nurse why her daughter continues to have temporal lobe seizures even though she is on medication. The nurse knows this is occurring because:

1. The medication may not be in the therapeutic range.

2. Temporal lobe seizures do not respond well to medications.

3. The daughter may be missing doses of her medication.

4. The food her daughter eats may have a negative reaction with the medication, causing more seizures.

ANS: 2

Feedback
1. Medication regulation is difficult with temporal lobe seizures.
2. Temporal lobe seizures have a poor response rate to medications.
3. Missing doses of medication can lead to seizures, but temporal lobe seizures dont respond well to medications.
4. Foods do not have an influence on temporal lobe seizures.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 13 | Type: Multiple Choice

20. Which of the following types of epilepsy are photosensitive?

1. Juvenile myoclonic epilepsy

2. Temporal lobe epilepsy

3. Febrile seizures

4. Childhood absence epilepsy

ANS: 1

Feedback
1. Photosensitivity is common with Juvenile myoclonic epilepsy.
2. Photosensitivity does not usually occur in temporal lobe epilepsy.
3. Febrile seizures are triggered by fevers, not photosensitivity.
4. Childhood absence epilepsy is not influenced by photosensitivity.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

21. A child who had a seizure one hour ago is exhibiting signs of paralysis on the left side of the body. The nurse understands the child is exhibiting signs of:

1. Lethargy due to previous seizure activity.

2. Postictal paralysis.

3. Permanent paralysis of the left side of the body.

4. Major brain damage that is going to have long-term effects.

ANS: 2

Feedback
1. Neurological fatigue can occur after a seizure, but it is not the reason for the paralysis.
2. Postictal paralysis will resolve within the next few hours.
3. The paralysis caused by the seizure will resolve within the next few hours.
4. Serial seizures cause brain damage. One seizure will not.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 13 | Type: Multiple Choice

22. A child with a known history of Benign Rolandic Epilepsy is having a seizure during lunch at the middle school. The school nurse is called to the cafeteria. What is the school nurses priority at this time?

1. Prevent a possible choking incident by checking the students mouth for food.

2. Lay the child down on the floor and make sure the area is safe.

3. Call the EMTs for help.

4. Notify the parents that their daughter is having a seizure.

ANS: 1

Feedback
1. This is the priority because the child is in the lunch room.  The nurse must check for food to decrease the chance of choking.
2. Making the area safe is important, but not the priority at this time.
3. EMTs are not needed for this situation because this is a common occurrence for the diagnosis.
4. The parents should be notified after the child is safe.

KEY: Content Area: Neurological | Integrated Processes: Care | Client Need: Safe and Effective Care Environment | Cognitive Level: Evaluation | REF: Chapter 13 | Type: Multiple Choice

23. An 18 month old is having a seizure when the nurse is assessing him. The nurse notes that the child is fluttering his eyes and smacking his lips. The nurse should document this seizure as:

1. An absence seizure.

2. A tonic-clonic seizure.

3. A myoclonic seizure.

4. A febrile seizure.

ANS: 1

Feedback
1. Eye fluttering and lip smacking are common characteristics of an absence seizure.
2. A tonic-clonic seizure has stiffening of the muscles. This child is not exhibiting this characteristic.
3. The child is not exhibiting muscle rigidity that is common with myoclonic seizures.
4. The child does not have a fever to cause the seizure.

KEY: Content Area: Neurological | Integrated Processes: Communication/Documentation | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

24. A 9 month old is admitted to the pediatric unit for seizures of unknown origin. The child has an EEG performed for several hours. The EEG notes several seizures occurring at different intervals. The nurse knows this child:

1. Will develop at the same rate as his peers.

2. May have severe mental and physical challenges due to the frequent seizure activity.

3. May exhibit a slight cognitive delay as he grows.

4. Will grow out of having seizures.

ANS: 2

Feedback
1. The continual seizure activity can cause hypoxia to the brain.
2. The frequency of the seizures causes hypoxia to the brain, increasing the chance for mental and physical challenges.
3. The frequency of the seizures will increase the level of cognitive delays.
4. Because of the type of seizures, the child will not grow out of having seizures.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 13 | Type: Multiple Choice

25. A child has been status epileptics for the last 20 minutes. The child has Depakote, Valporic Acid, and Diazepam gel ordered. The nurse should prepare which medication for administration at this time?

1. Depakote

2. Valporic acid

3. Diazepam

4. None of the medications. The child will stop on his own.

ANS: 3

  Feedback
1. The Depakote is needed on a regular, scheduled basis to help keep the level adequate in the body.
2. Valporic acid needs to be given on a regular schedule to keep the adequate levels in the body.
3. Diazepam can be used as needed to help stop the brain activity for seizures.
4. The seizure activity needs to be stopped because of the hypoxia that is occurring to the brain.

KEY: Content Area: Pharmacology | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 13 | Type: Multiple Choice

26. Care for a child during status epilepticus should include all of the following except:

1. Turn the patient to the right side.

2. Loosen tight clothes.

3. Move toys out of the area to prevent injury.

4. Stay with the patient until the seizure has stopped.

ANS: 1

Feedback
1. Turning the patient to the right side increases the risk for aspiration because of the positioning of the bronchioles.
2. Loosening clothes helps the person move freely and reduces the chance of injury.
3. Moving objects out of the area decreases the chance for injury as the patient moves during the seizure.
4. It is important to make sure the patient stays safe.

KEY: Content Area: Neurological | Integrated Processes: Care | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

27. The nurse is identifying the difference between primary headaches to secondary headaches. Secondary headaches can occur:

1. Because of stress.

2. In relation to low blood pressure.

3. Because of concussions.

4. Because of migraines.

ANS: 3

Feedback
1. Stress is a primary cause for headaches.
2. Low blood pressure is a primary cause for headaches.
3. Concussions are a cause of secondary headaches because an injury has previously occurred to the brain tissue.
4. Migraines are a primary cause for headaches.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 13 | Type: Multiple Choice

28. Cyclic vomiting may:

1. Last for days.

2. Require SSRIs to stop hurting.

3. Not be associated with a headache.

4. Requires pain medication and Zofran.

ANS: 3

Feedback
1. Usually short lived
2. SSRIs are not an effective method of pain control for the vomiting.
3. The vomiting can occur for random reasons, but a headache is not a symptom.
4. Pain medication is not usually required to stop the vomiting.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

29. A child that has rhythmic, repetitive, involuntary movements is exhibiting:

1. Tremors.

2. Dystonia.

3. Contractures.

4. Tics.

ANS: 2

Feedback
1. Tremors are involuntary and have random movements.
2. Twisting and repetitive, involuntary movements are common with dystonia.
3. Contractures can be a permanent placement of the body because of muscle and ligament rigidity.
4. Tics are not rhythmic in nature.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

30. Identify a therapeutic management technique for a child with a tic disorder.

1. Behavioral modification to suppress the tics

2. Administer anti-psychotic medications to reduce the tics

3. Education and support for the child and the family

4. Genetic counseling for the family

ANS: 3

Feedback
1. Behavior modification does not aid in stopping tics form occurring.
2. Tics do not respond to antic-psychotic medications.
3. Support and education are important so that people understand that tics are involuntary.
4. There is little research to prove that tics are genetic in nature.

KEY: Content Area: Neurological | Integrated Processes: Care | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

31. Identify a true statement about Tourettes Syndrome (TS) is that:

1. Manifestations rarely change once developed.

2. Children with TS do not have obsessive compulsive disorders.

3. The tics of TS can lead to mental deterioration.

4. The tics are involuntary, and the person cannot control the behavior.

ANS: 4

Feedback
1. Manifestations change related to the stress level and various other factors.
2. There is a strong correlation between TS and obsessive compulsive disorders.
3. The tics do not affect the cognitive ability of a child.
4. The tics are involuntary, and public education about this is important so that the child is not harassed about the behaviors.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

32. The assessment a nurse performed on a 12-year-old boy demonstrated a positive Kernigs sign and a Brudzinskis sign. Identify the priority for the nurses next action.

1. Document the findings and note as normal.

2. Further assess the neurological function of the child and call the doctor with a report.

3. Explain to the patient that the assessment was abnormal and there is no a cause for concern.

4. Prepare the child for a lumbar puncture.

ANS: 2

Feedback
1. These findings are abnormal and need further neurological testing.
2. Further assessment is needed because these signs should not be present in a 12-year-old child.
3. Explaining the situation to the patient is important, but there is s possible neurological issue that needs to be addressed with further diagnostic testing.
4. A lumbar puncture is invasive, and other tests should be done before the procedure.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 13 | Type: Multiple Choice

33. Results from cerebrospinal fluid that was tested for meningitis have been received by the nurse. The results indicate bacterial meningitis. The nurse knows this because the results show:

1. A low protein count and a low glucose count.

2. A low red blood cell count.

3. An elevated protein count and a low glucose level.

4. A normal protein count and a high glucose count.

ANS: 3

Feedback
1. Does not indicate infection
2. Some red blood cells may show in the specimen if the lumbar puncture was not a clean catch.
3. Results indicate bacterial meningitis.
4. Results indicate viral meningitis.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 13 | Type: Multiple Choice

34. Identify the false statement about bacterial meningitis.

1. Bacterial meningitis can be fatal if not treated.

2. Bacterial meningitis can spread quickly.

3. Bacterial meningitis cannot be effectively treated with antibiotics.

4. Bacterial meningitis can cause hearing loss in children.

ANS: 3

Feedback
1. The illness can cause death if not treated.
2. The illness can spread quickly and be fatal without treatment.
3. Antibiotic therapy can stop the progression of the illness.
4. Because of the bacteria, the illness attacks the ear drum, creating hearing loss in children if not treated early.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

35. The nurse is assessing a 6-month-old boy. Which of the following would be an abnormal finding, indicating possible cerebral palsy?

1. The infant can pull to a sitting position while holding onto an adults hand.

2. The infant does not exhibit a Moro reflex.

3. The infant does not exhibit a Babinskis reflex.

4. The infant has an obligatory tonic neck flexion.

ANS: 4

Feedback
1. A 6-month-old should be able to pull up with aid from another person.
2. A Moro reflex should not be present after the newborn period.
3. The Babinskis reflex should not be present after the first few weeks of life.
4. A tonic neck flexion can indicate neurological damage because this is not a normal position for an infant.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 13 | Type: Multiple Choice

36. A multidisciplinary meeting is being conducted for a 4-year-old boy with cerebral palsy. A goal for managing this childs condition would be:

1. Assistance with motor control of voluntary muscles.

2. Maximizing the childs capabilities.

3. Surgically correcting deformities.

4. Waiting to place the child in school.

ANS: 2

Feedback
1. It is important to have the child be as independent as possible to maintain optimum function.
2. Concentrating on the capabilities can help the child modify other areas of weakness to have a better quality of life.
3. Surgery is used only in extreme conditions.
4. Planning for school will be important, but the priority is to maximize the capabilities so the child is as independent in school as possible.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Synthesis | REF: Chapter 13 | Type: Multiple Choice

37. A common trait of Beckers Muscular Dystrophy is:

1. Progressive weakness in the trunk and arms over time.

2. A quick rate of deterioration of the body.

3. Cardiomyopathy.

4. Usually diagnosed by the age of 3.

ANS: 3

Feedback
1. This type of dystrophy has weakening in the legs and pelvis areas.
2. This particular type of muscular dystrophy has a longer life expectancy than most other types of muscular dystrophy.
3. Cardiomyopathy occurs because of abnormality in the protein dystrophin in the body.
4. First diagnosis usually does not occur until between the ages 5 and 15.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

38. Brian, a 4-year-old boy, is demonstrating the Gowers sign, and his mother is wondering why her child is making this movement. The child is doing this because:

1. The weakness of his arms requires his legs to do more work.

2. The weakness in his hips and thighs requires help from his arms to stand.

3. Weakening trunk and back muscles require the legs and arms to help keep an upright position.

4. Weakening of the trunk requires this movement to help breath.

ANS: 2

Feedback
1. The weakness is in the hips and thighs, not the arms.
2. The weakness in the hips and thighs makes it difficult to stand, thus requiring the arms to help provide stability.
3. The trunk and back muscles are weak, but are not the reason for the Gowers sign.
4. The Gowers sign is seen when attempting to stand.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

39. When assessing a 10-year-old child with myasthenia gravis, the nurse notes ptosis and drooping facial expressions. The nurse knows this disease will require all of the following except:

1. Supportive care, as there is no cure for the disease.

2. Administering beta blockers to improve the muscle tone.

3. Check the child for a depressive state due to body image issues.

4. Explain procedures to the child as needed and provide emotional support.

ANS: 2

Feedback
1. The lack of a cure will require education and support for the family and patient.
2. Administration of cholinesterase inhibitors is the common drug used to help keep the acetylcholine receptors from being blocked.
3. Because of the physical changes, an assessment of emotional and psychosocial issues is important.
4. Education and explanations will allow the child to feel involved in his/her care.

KEY: Content Area: Neurological | Integrated Processes: Care | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 13 | Type: Multiple Choice

40. Infantile spinal muscular atrophy contains all of the following characteristics except:

1. Muscle wasting of voluntary muscles.

2. Type 1 can begin in utero.

3. Inability to suck occurs early in life.

4. It is associated with children who are intellectually slower.

ANS: 4

Feedback
1. Muscle wasting is noted in these dystrophies.
2. Type 1 may start with the fetus.
3. Suckling is the strongest at the earliest points of life. As time progresses, the muscle weakens, making feeding difficult.
4. Children with the disease show cognitive delays.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

41. What should the nurse anticipate when reviewing laboratory results of a patient with Guillain-Barre syndrome?

1. Elevated CBC

2. High protein in a cerebral spinal fluid tap

3. Creatinine phosphokinase elevated

4. Sensory nerve conduction time increased

ANS: 2

Feedback
1. The CBC should be within normal ranges.
2. The high protein in the cerebral spinal fluid is because of the inflammation to the area.
3. The laboratory results should be within normal limits.
4. The nerve conduction time is decreased.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 13 | Type: Multiple Choice

42. A common treatment for a person with Guillain-Barre syndrome is:

1. Broad spectrum antibiotics.

2. Intravenous gamma globulins.

3. Antihistamines.

4. Acyclovir.

ANS: 2

Feedback
1. Broad spectrum antibiotics are not an effective treatment for the disease.
2. IGg is given to help the body naturally fight the syndrome.
3. Antihistamines are not an effective treatment for the disease.
4. Acyclovir will not treat the illness.

KEY: Content Area: Pharmacology | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

43. After a seizure, a 2-year-old boy would exhibit what type of reaction with the Babinskis reflex?

1. Positive

2. Negative

3. Will be positive one time and negative the next

4. Not a reliable test at this age

ANS: 4

Feedback
1. A Babinskis reflex is not reliable at this age. It should only be done with infants.
2. A Babinskis reflex is not reliable at this age. It should only be done with infants.
3. There will not be accurate results
4. Because of the childs age, the results will not be accurate.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 13 | Type: Multiple Choice

44. A teenage boy has received a concussion while playing hockey. A cardinal sign of a concussion is:

1. Confusion.

2. Altered level of consciousness.

3. Loss of consciousness.

4. Fainting.

ANS: 3

Feedback
1. Confusion is not a cardinal sign, but may be present.
2. A change in the level of consciousness is not considered a cardinal sign.
3. A loss of consciousness is a cardinal sign for a concussion, and the child should be examined by a professional.
4. Fainting rarely occurs with a concussion.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

45. Tiagabine must be monitored when given to teens because:

1. It is less effective during puberty.

2. It has a high incidence of suicidal tendencies in teens.

3. It needs to be titrated with the teens growth pattern.

4. It is known to be sold as a street drug.

ANS: 2

Feedback
1. The drug can be effective during puberty.
2. The high level of suicidal rates makes monitoring the teens behavior a priority.
3. Titration to the growth is not a priority at this time.
4. The medication is not a common street drug.

KEY: Content Area: Mental Health | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

46. Which cranial nerve may be assessed by noting the strength of an infants suck?

1. Cranial nerve VII

2. Cranial nerve V

3. Cranial nerve III

4. Cranial nerve II

ANS: 2

Feedback
1. Cranial never VII assess acoustic ability.
2. Cranial nerve V, the Trigeminal nerve, controls mastication and facial sensation.
3. Cranial nerve III assesses oculomotor reflex.
4. Cranial nerve II assesses the optic area.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

47. Which cranial nerve may be assessed by noting the symmetry of the facial expression during crying or smiling?

1. Cranial nerve VII

2. Cranial nerve V

3. Cranial nerve III

4. Cranial nerve VI

ANS: 1

Feedback
1. Cranial nerve VII, the facial nerve, is responsible for symmetrical facial muscle movement.
2. Cranial nerve V, the Trigeminal nerve, controls mastication and facial sensation.
3. Cranial nerve III assesses oculomotor reflex.
4. Cranial nerve VI assesses the trochlear area.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

48. Which cranial nerves are involved in sending impulses that are responsible for autonomic functions, like heart beat and the gag reflex?

1. Cranial nerves VII and IX

2. Cranial nerves IX, X, and XI

3. Cranial nerves IX and X

4. Cranial nerves X and XII

ANS: 3

Feedback
1. Cranial nerves IX, the Glossopharyngeal, and X, the Vagus, send impulses to the heart and throat.
2. Cranial nerve XI assesses the Spinal Accessory.
3. Cranial nerve X assesses the Vagus.
4. Cranial Nerve X  assesses the Vagus, and Cranial Nerve XII assesses the Hypoglossal.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

49. Which, if any is not true about the brainstem?

1. It contributes to the regulation of the heart rate and respirations, as well as the bodys ability to manage consciousness and sleep patterns.

2. It controls autonomic behaviors necessary for the body to survive.

3. It connects with the spinal cord and houses the connections between the motor and sensory portions of the brain to the rest of the body.

4. It houses the cranial nerves.

ANS: 4

Feedback
1. The brainstem aids in the regulation of patterns in the body.
2. The brainstem is responsible for controlling the autonomic behaviors of the body.
3. The brainstem connects the spinal cord to the motor-sensory portions of the brain.
4. The brainstem houses 10 of the 12 pairs of cranial nerves.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

50. The brain is divided into two sections, called hemispheres. The hemispheres behave in a particular fashion in sending messages to the body. How do the hemispheres communicate information to the body?

1. The hemispheres relay messages in a direct route.

2. The hemispheres relay messages in a random fashion.

3. The hemispheres relay messages in a contralateral fashion.

4. The hemispheres relay messages in a unilateral route.

ANS: 3

Feedback
1. The hemispheres relay messages in a contralateral fashion.
2. The hemispheres relay messages in a contralateral fashion.
3. The hemispheres relay messages in a contralateral fashion. The right hemisphere sends messages to the left side of the body, and the left hemisphere sends messages to the right side of the body.
4. The hemispheres relay messages in a contralateral fashion.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

51. Neural tube defects occur in the brain and spinal cord in the fetal period. When do these defects occur?

1. Within the first trimester

2. Within the first 6 weeks

3. When the egg is fertilized

4. Within the first 28 days after fertilization

ANS: 4

Feedback
1. This answer is not specific enough.
2. This is outside of the range.
3. Development of the neural tube is minimal at this point.
4. Neural tube defects occur within the first 28 days of fertilization, before the woman knows that she is pregnant.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

52. In the neural tube defect spina bifida, which of the following problems can the nurse expect the child to exhibit?

1. Problems walking

2. Partial or complete paralysis of the legs

3. Problems with bowel or bladder control

4. All of the above

ANS: 4

Feedback
1. There are different types of spina bifida, and the degree of severity will depend on how severely the child is affected.
2. There are different types of spina bifida, and the degree of severity will depend on how severely the child is affected.
3. There are different types of spina bifida, and the degree of severity will depend on how severely the child is affected.
4. There are different types of spina bifida, and the degree of severity will depend on how severely the child is affected.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

53. When measuring head circumference in an infant, what equipment should the nurse select to perform the task?

1. Cloth tape measure

2. Electronic measure

3. Paper tape measure

4. Metal tape measure

ANS: 3

Feedback
1. Cloth tape measures can stretch over time and yield an inaccurate measure of the infants head.
2. An electronic measure is not realistic for use with infants.
3. The nurse should use a paper tape measure because paper tape is more sanitary and can be discarded after each use.
4. A metal tape measure will not conform to the infants head to yield an accurate measurement.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

54. Which is true about microcephaly?

1. Microcephaly is defined as the condition when the circumference of the head is more than two standard deviations below normal.

2. Microcephaly is defined as the condition when the circumference of the head is more than three standard deviations below normal.

3. Microcephaly is defined as the condition when the circumference of the head is more than one standard deviation below normal.

4. Microcephaly is defined as the condition when the circumference of the head is more than two standard deviations above normal.

ANS: 1

Feedback
1. Microcephaly occurs when the brain has not developed properly or has stopped growing, and is often associated with cognitive, motor, and speech delays.
2. Microcephaly occurs when the brain has not developed properly or has stopped growing, and is often associated with cognitive, motor, and speech delays.
3. Microcephaly occurs when the brain has not developed properly or has stopped growing, and is often associated with cognitive, motor, and speech delays.
4. Microcephaly occurs when the brain has not developed properly or has stopped growing, and is often associated with cognitive, motor, and speech delays.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

55. Which is not true about the assessment of primitive reflexes in infants?

1. Primitive reflexes are assessed immediately after the baby is born.

2. Primitive reflexes are assessed at every well-child visit until the age of 6 months.

3. Absent primitive reflexes can indicate prematurity or lesions in the motor neurons.

4. Some primitive reflexes remain throughout life, such as blinking.

ANS: 2

Feedback
1. Primitive reflexes are assessed immediately after birth in the APGAR scoring.
2. Assessment of primitive reflexes should continue through the age of 12 months in normal infants.
3. Absent reflexes can indicate prematurity or lesions in the motor neurons.
4. Some primitive reflexes remain for life.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

56. Developmental delay occurs when a child does not meet age appropriate milestones in which area(s) of development?

1. Fine motor skills

2. Gross motor skills

3. Language

4. All of the above

ANS: 4

Feedback
1. Delays can occur in this area and others as well.
2. Delays can occur in this area and others as well.
3. Delays can occur in this area and others as well.
4. Developmental delay, a descriptive term, can be related to an individual milestone delay or a mixed milestone delay.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

57. When assessing for a developmental delay, which element(s) of the childs history would have a significant impact on reaching developmental milestones?

1. Poverty

2. Neglectful parenting

3. Cultural differences

4. All of the above

ANS: 4

Feedback
1. The childs socioeconomic status has a direct impact on the childs ability to meet developmental milestones.
2. Lack of parental interaction has a direct impact on the childs ability to meet developmental milestones.
3. Cultures each have a set of norms and values which have a direct impact on the childs ability to meet developmental milestones.
4. The childs socioeconomic status, parental connections, and culture have a direct impact on the childs ability to meet developmental milestones.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

58. Hydrocephalus occurs when cerebrospinal fluid collects in an abnormal pattern in the brain, causing an enlargement in the ventricles. What feature of young infants helps to compensate for the increased pressure caused by the collection of the cerebrospinal fluid?

1. They are too young to perceive pain.

2. They have open fontanels and sutures in the skull to allow for the expansion of the fluid.

3. Infants grow quickly, so the ventricles accommodate for the fluid.

4. All of the above

ANS: 2

Feedback
1. Pain is perceived at any age.
2. Open fontanels and sutures help to compensate for increases in intracranial pressure. The nurse should gently palpate the fontanel and be alert to changes, such as a tense and bulging fontanel.
3. Infant ventricle growth does not occur fast enough to compensate for the extra fluid.
4. One answer applies.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

59. What are the symptoms of increased intracranial pressure in infants and children?

1. Vomiting, sunsetting eyes, lethargy

2. Vomiting, irritability, decline in academic performance

3. Headache, diarrhea, insomnia

4. Excitability, anorexia, regression in language skills

ANS: 1

Feedback
1. Increased intracranial pressure causes depression of brain function, which results in lethargy. The sunsetting eyes phenomenon occurs when there is pressure on the nerves of the eyes from the increased cerebrospinal fluid, causing the eyes to look downward. The increased intracranial pressure sends signals to other body functions as well, causing vomiting.
2. Academic performance is not assessed for the increased intracranial pressure, as this can have a quick onset.
3. Diarrhea is not a symptom of increased intracranial pressure.
4. The depression of brain function decreases the excitability of the brain.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

60. Which of the following is not a symptom of autism spectrum disorder?

1. Lack of expressive language

2. Enjoys change in routine

3. Lack of social skills

4. Engages in repetitive behavior

ANS: 2

Feedback
1. Children with autism spectrum disorder will exhibit this symptom.
2. Children with autistic spectrum disorder are disturbed or intolerant of changes in daily routines and rituals.
3. Children with autism spectrum disorder will exhibit this symptom.
4. Children with autism spectrum disorder will exhibit this symptom.

KEY: Content Area: Behavioral | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

61. What are characteristics of a seizure?

1. Loss of awareness

2. Twitching movements of a part of the body

3. Rhythmic jerking movements of an extremity

4. All of the above

ANS: 4

Feedback
1. Symptom of a seizure
2. Symptom of a seizure
3. Symptom of a seizure
4. Seizures can take many forms, including staring, blinking, twitching, drooling, rigidity, atonic muscles, eye deviation and convulsions.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

62. Which of the following is not true about sleepwalking?

1. Sleepwalking occurs in REM sleep.

2. Sleepwalking tends to run in families.

3. When sleepwalking, a child looks awake and his/her eyes are open.

4. Sleepwalking is most common between the ages of 4 and 8.

ANS: 1

Feedback
1. Sleepwalking occurs in non-REM sleep.
2. Sleepwalking does run in families.
3. The childs eyes may be open and appear awake, or they may be closed during sleepwalking.
4. This range is the most common for sleepwalking.

KEY: Content Area: Sleep Patterns | Integrated Processes: Nursing Process | Client Need: Physiological Adaptation | Cognitive Level: Comprehension | REF: Chapter13 | Type: Multiple Choice

63. Which of the following statements about temporal lobe epilepsy are true?

1. Temporal lobe epilepsy is the most common partial seizure epilepsy.

2. Temporal lobe seizures are often resistant to treatment.

3. Temporal lobe epilepsy is often associated with a specific lesion in the temporal lobe, called hippocampal sclerosis.

4. All of the above

ANS: 4

Feedback
1. The  most common partial seizure for epilepsy is temporal lobe.
2. Temporal lobe seizures have a high rate of resistance to treatment.
3. The hippocampal sclerosis can sometimes be surgically removed, which can stop or diminish seizure activity.
4. The hippocampal sclerosis can sometimes be surgically removed, which can stop or diminish seizure activity.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Adaptation | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

64. Which of the following is not a feature of Benign Rolandic Epilepsy?

1. It is more common in girls than boys.

2. The child has twitching, numbness, or tingling in the face and tongue. The child also remains fully conscious.

3. Tonic-clonic seizures may occur during sleep.

4. The EEG has a specific pattern of spikes, called centrotemporal spikes.

ANS: 1

Feedback
1. Benign Rolandic Epilepsy, also called Benign Childhood Epilepsy with Centrotemporal Spikes or BCECTS, is more common in boys than in girls.
2. The symptoms are common in children.
3. Tonic-clonic seizures are common during sleep.
4. This is a symptom of Benign Rolandic Epilepsy.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Adaption | Cognitive Level: Comprehension | REF: Chapter 13 | Type: Multiple Choice

65. When a child suffers generalized seizures, it is important for the nurse to do all of the following except:

1. Turn the child on his/her side in order to allow fluid to flow from his/her mouth.

2. Time the seizure length

3. Monitor his/her airway and placing a plastic airway or padded tongue blade in his/her mouth if necessary to keep the airway open.

4. Protect the child from injury as the body convulses.

ANS: 3

Feedback
1. The nurse should monitor the airway and place the child on his/her side, but should never place anything in the airway of a child having a seizure.
2. The nurse should monitor the airway and time the seizure, but should never place anything in the airway of a child having a seizure.
3. Do not place anything in a childs mouth during a seizure.
4. Protecting the child from injury is important during a seizure.

KEY: Content Area: Neurological | Integrated Processes: Nursing Assessment | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter13 | Type: Multiple Choice

66. Headaches and migraines are common in children and adolescents. In assessing the severity of the headaches in children, the nurse must understand the ability of the child to describe his/her symptoms. What would be an incorrect step for a nurse to take when assessing headache pain in a young child?

1. Use an approved pain scale, such as the Wong-Baker Faces Pain Rating Scale.

2. Note the mother or caregivers report.

3. Note the childs behavior.

4. Note the nurses own beliefs about childrens perception of pain.

ANS: 4

Feedback
1. Pain scales enable the patient to describe the level of pain for documentation and therapy purposes.
2. Caregivers and parents of children are the best sources for information because they know the child the best and can more accurately assess the pain.
3. A child in pain will exhibit irritability and want to pull away from any painful stimulus.
4. Pain is a subjective phenomenon. Young children are often unable to verbalize their symptoms and must be helped when describing their feelings by use of approved pain scales and words that they can understand.

KEY: Content Area: Pain | Integrated Processes: Caring | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

67. Which of the following is a symptom of tension headaches?

1. A feeling of tightness or pressure around the head

2. Unilateral throbbing or pounding head pain

3. Nausea, vomiting, anorexia

4. Sensitivity to light and/or noise

ANS: 1

Feedback
1. The pain is usually mild to moderate and does not usually prevent children from participating in activities.
2. Tension headaches usually have a tightness or pressure around the head, not unilateral throbbing or pounding.
3. This is not noted in tension headaches.
4. This is not noted in tension headaches. This is more often noted in migraine headaches

KEY: Content Area: Pain | Integrated Processes: Nursing Assessment | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

68. Migraine headaches in children can be debilitating and can be triggered by all of the following except:

1. Too much or too little sleep.

2. Overhydration.

3. Skipping meals.

4. Unusual stress or the childs inability to cope with stressors.

ANS: 2

Feedback
1. Sleep is a factor for migraines in children.
2. Inadequate hydration is a factor for migraines in children, not overhydration.
3. Skipping meals is a factor in migraines for children.
4. Stress is a factor in migraines for children.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 13 | Type: Multiple Choice

69. Which is the following is not a characteristic of Tourettes Syndrome?

1. Complex motor tics

2. The child is unaware of his/her behavior

3. Present for more than one year

4. Present before the 18th birthday

ANS: 2

Feedback
1. Common symptom of Tourettes syndrome
2. The child is aware of his/her behavior and often tries to suppress it unsuccessfully.
3. Tourettes Syndrome can be a life-long issue.
4. Tourettes Syndrome usually occurs in school-age children.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

70. Meningitis is assessed by which of the following after blood tests and a physical assessment are completed?

1. Lumbar puncture

2. Urine tests

3. Kernigs sign and Brudzinskis sign

4. Physical examination

ANS: 2

Feedback
1. Usually done after blood tests and a physical assessment
2. Blood tests are done prior to the lumbar puncture. Urine tests are not.
3. Usually the second assessment done for the disease
4. Usually the first assessment done for the disease

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: Multiple Choice

True /False

71. Neurofibromatosis Type 1 is the most common neurofibromatosis in children.

ANS: T

Feedback
1. Neurofibromatosis Type 1 is the most common neurofibromatosis in children.
2. Neurofibromatosis Type 1 is the most common neurofibromatosis in children.

KEY: Content Area: Neurological | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 13 | Type: True /False

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