Chapter 23: The Child With a Sensory or Neurological Condition My Nursing Test Banks

Chapter 23: The Child With a Sensory or Neurological Condition

Elsevier items and derived items 2007 by Saunders, an imprint of Elsevier Inc.

MULTIPLE CHOICE

1. A parent comments that her infant has had several ear infections in the past few months. The nurse understands that infants are more susceptible to otitis media because:

a.

Infants are in a supine or prone position most of the time.

b.

Sucking on a nipple creates middle ear pressure.

c.

They have increased susceptibility to upper respiratory tract infections.

d.

The eustachian tube is short, straight, and wide.

ANS: D

An infants eustachian tubes are shorter, wider, and straighter, allowing microorganisms easy access to the middle ear.

DIF: Cognitive Level: Knowledge REF: 511 OBJ: 2

TOP: Otitis Media KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse determines a mother understands instructions about administering an oral antibiotic for otitis media when the mother verbalizes that she will:

a.

Continue using the medication until symptoms are relieved.

b.

Share the medicine with siblings if their symptoms are the same.

c.

Give the medication with a glass of milk.

d.

Administer prescribed doses until all the medication is used.

ANS: D

Antibiotic therapy for otitis media is continued until the prescribed amount has been completed, even if symptoms are alleviated.

DIF: Cognitive Level: Application REF: 522 OBJ: 2

TOP: Otitis Media KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

3. The situation in which the nurse would be suspicious about a hearing impairment is:

a.

A 3-month-old infant with a positive Moro reflex

b.

A 15-month-old toddler who is babbling

c.

An 18-month-old toddler who is speaking one-syllable words

d.

A 24-month-old toddler who communicates by pointing

ANS: D

The child who is not making verbal attempts by 18 months should undergo a complete physical examination.

DIF: Cognitive Level: Analysis REF: 523 OBJ: 3

TOP: Hearing Impairment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

4. The best way for the nurse to communicate with a 10-year-old child who has a hearing impairment would be to:

a.

Use gestures and signs as much as possible.

b.

Let the childs parents communicate for her.

c.

Face the child and speak clearly in short sentences.

d.

Recognize that the childs ability to communicate will be on a 6-year-old level.

ANS: C

The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality.

DIF: Cognitive Level: Application REF: 523 OBJ: 3

TOP: Hearing Impairment KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. The nurse planning postoperative teaching for a child who has had a tympanostomy with insertion of tubes would include:

a.

Keep the infant flat after feeding.

b.

Give over-the-counter anticongestants.

c.

Avoid getting water in the ears.

d.

Clean the ear canal with cotton-tipped applicators.

ANS: C

Following a tympanostomy, care should be taken to avoid getting water in the ears.

DIF: Cognitive Level: Comprehension REF: 522 OBJ: 2

TOP: Postoperative Care of Tympanostomy

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk

6. The school nurse would suspect amblyopia when the child:

a.

Has a reddened sclera in one eye

b.

Covers one eye to read the board

c.

Complains of a headache

d.

Has copious tears while watching TV

ANS: B

Indicators of amblyopia include covering one eye to see, tilting the head to see, missing objects in attempts to pick them up. Although headaches may be associated with amblyopia, it is too vague to point suspicion to any disorder.

DIF: Cognitive Level: Analysis REF: 526 OBJ: 4

TOP: Amblyopia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

7. The nurse explains that a common treatment for amblyopia is:

a.

Patching the good eye to force the brain to use the affected eye

b.

Patching the affected eye to allow the refractory muscles to rest

c.

Using glasses that will slightly blur the image for the good eye

d.

Using corticosteroids to treat inflammation of the optic nerve

ANS: A

Early detection and treatment are essential for the child with amblyopia. Treatment includes patching the good eye and using glasses to correct refractive errors.

DIF: Cognitive Level: Knowledge REF: 526 OBJ: 4

TOP: Amblyopia KEY: Nursing Process Step: N/A

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

8. The school nurse recognizes the cardinal sign of a hyphema when she assesses:

a.

Opacity of the lens

b.

A yellow-white reflex on the pupil

c.

A dark-red spot in front of the iris

d.

Inflamed mucous membranes of the eyelids

ANS: C

A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury.

DIF: Cognitive Level: Knowledge REF: 527 OBJ: N/A

TOP: Retinoblastoma KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

9. The nurse is planning to teach parents about prevention of Reyes syndrome. What information would the nurse include in this teaching?

a.

Use aspirin instead of acetaminophen for children with viral illness.

b.

Advise parents to have their children immunized against Reyes syndrome.

c.

Avoid giving salicylate-containing medications to a child who has viral symptoms.

d.

Get the child tested for Reyes syndrome if the child exhibits fever, vomiting, and lethargy.

ANS: C

Prevention of Reyes syndrome includes educating parents not to give aspirin-containing medication to children with viral symptoms.

DIF: Cognitive Level: Application REF: 529 OBJ: 11

TOP: Reyes Syndrome KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

10. The nurse caring for a 5-month-old with viral influenza suspects the development of Reyes syndrome when the child:

a.

Has respirations drop from 18 to 14 breaths/min

b.

Goes to sleep after feeding

c.

Suddenly vomits

d.

Develops a macular rash

ANS: C

A child with a viral infection is at risk for Reyes syndrome, the onset of which is effortless vomiting, lethargy, and a change in LOC. A 5-month-old child that sleeps after eating is normal.

DIF: Cognitive Level: Application REF: 529 OBJ: 11

TOP: Reyes Syndrome KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

11. The nurse explains that febrile seizures:

a.

Occur when the body temperature exceeds 103F

b.

Can be prevented by anticonvulsant medication

c.

Usually lead to the development of epilepsy

d.

Occur when the temperature rises quickly

ANS: D

Febrile seizures occur in response to a rapid rise in temperature, often above 102F (38.8C).

DIF: Cognitive Level: Comprehension REF: 533 OBJ: 9

TOP: Febrile Seizures KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. A parent reports that her child experiences episodes where he appears to be staring into space. This behavior is characteristic of which type of seizure?

a.

Absence

b.

Akinetic

c.

Myoclonic

d.

Complex partial

ANS: A

Absence seizures are characterized by transient loss of consciousness where the child appears to stare blankly, and which may last only a few seconds.

DIF: Cognitive Level: Analysis REF: 534, Table 23-2

OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. An adolescent has just had a generalized seizure lasting 1 minute. Following the seizure, the nurse should:

a.

Help the patient to sit upright

b.

Turn on the side

c.

Offer ice chips

d.

Assist to ambulate

ANS: B

During the tonic phase of a generalized seizure, the head, legs, and back stiffen.

DIF: Cognitive Level: Analysis REF: 534, Table 23-2

OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

14. When a child is experiencing a generalized tonic-clonic seizure, an appropriate nursing action would be to:

a.

Guide the child to the floor if the child is standing, and then go for help.

b.

Move objects out of the childs immediate area.

c.

Stick a padded tongue blade between the childs teeth.

d.

Manually restrain the child.

ANS: B

During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury.

DIF: Cognitive Level: Application REF: 534, Table 23-2

OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

15. A child had a generalized tonic-clonic seizure that lasted 90 seconds. After a generalized tonic-clonic seizure, the nurse would expect that the child might be:

a.

Restless

b.

Sleepy

c.

Nauseated

d.

Anxious

ANS: B

Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness.

DIF: Cognitive Level: Analysis REF: 535 OBJ: 9

TOP: Epilepsy KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. The nurse would include in a teaching plan pertinent to the long-term administration of Dilantin that:

a.

The medication should be given with food to reduce gastrointestinal distress.

b.

Behavioral changes are a possible side effect.

c.

Gums should be massaged regularly to prevent hyperplasia.

d.

Blood pressure should be closely monitored.

ANS: C

Dilantin can cause gum overgrowth, which can be minimized by regular massaging.

DIF: Cognitive Level: Application REF: 536 OBJ: 9

TOP: Epilepsy KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

17. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy?

a.

Athetoid

b.

Ataxic

c.

Spastic

d.

Mixed

ANS: C

Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles jerky and uncoordinated.

DIF: Cognitive Level: Analysis REF: 536 OBJ: 10

TOP: Cerebral Palsy KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. The assessment finding that should be reported immediately if observed in a child with meningitis is:

a.

Irregular respirations

b.

Tachycardia

c.

Slight drop in blood pressure

d.

Elevated temperature

ANS: A

Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported immediately because they could indicate increased intracranial pressure.

DIF: Cognitive Level: Analysis REF: 530 OBJ: 15

TOP: Meningitis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

19. The nurse observes a childs position is supine with his arms and legs rigidly extended and the hands pronated. The nurse recognizes this posture as:

a.

Correct anatomical position

b.

Decorticate

c.

Decerebrate

d.

Opisthotonos

ANS: C

In decerebrate posturing, arms are extended along the side of the body and hands are pronated. This posture indicates brainstem function only.

DIF: Cognitive Level: Analysis REF: 542 OBJ: 14

TOP: Posturing KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. The nurse giving instructions for acute conjunctivitis would teach parents to:

a.

Apply cool compresses to the affected eye several times a day.

b.

Instill topical steroid eye drops for 1 week.

c.

Clear away drainage from the inner to the outer aspect of the eye.

d.

Keep the eye patched until the inflammation resolves.

ANS: C

Eye secretions are always cleared from the inner canthus downward and away from the opposite eye (inner to outer direction).

DIF: Cognitive Level: Application REF: 526 OBJ: N/A

TOP: Conjunctivitis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

21. A child is brought to the emergency department after he fell and hit his head on the ground. The nursing assessment that suggests the child has a concussion is:

a.

Sleepy but easily arousable

b.

Complaining of a stiff neck

c.

Cannot remember what happened to him

d.

Pupils react sluggishly to light

ANS: C

A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness. It is accompanied often by a loss of memory of the events that occurred immediately before, during, or after the injury.

DIF: Cognitive Level: Analysis REF: 543 OBJ: N/A

TOP: Head Injury KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

22. A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks she has had headaches that are worse in the morning with vomiting. The nurse would suspect:

a.

Meningitis

b.

Reyes syndrome

c.

Brain tumor

d.

Encephalitis

ANS: C

The signs and symptoms of a brain tumor are related to its size and location. Most tumors create increased ICP with the hallmark symptoms of headache, vomiting, drowsiness, and seizures.

DIF: Cognitive Level: Analysis REF: 532 OBJ: 15

TOP: Brain Tumor KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

1. The pediatric nurse is alerted to the probability of an ear infection in a 6-month-old child when the baby:

Select all that apply.

a.

Is hypersensitive to noise

b.

Is irritable

c.

Has a reddened ear canal

d.

Rolls head from side to side

e.

Spikes a temperature of 103F

ANS: B, D, E

Infants signal ear infections by being irritable, spiking a temperature, rolling their heads from side to side, and pulling at or rubbing their ears.

DIF: Cognitive Level: Application REF: 521 OBJ: 2

TOP: Indications of Ear Infection KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

2. The nurse cautions parents that hearing impairment can affect the childs:

Select all that apply.

a.

Speech clarity

b.

Language development

c.

Emotional stability

d.

Personality development

e.

Academic achievement

ANS: A, B, C, D, E

All the options are areas in which a hearing impairment could interfere with normal development.

DIF: Cognitive Level: Comprehension REF: 522 OBJ: 2

TOP: Hearing Impairment KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. The nurse, preparing air travel instructions to prevent barotraumas in infants, would include:

Select all that apply.

a.

Using ear plugs during takeoff

b.

Holding baby upright during flight

c.

Omitting the meal just before takeoff

d.

Letting the baby nurse during descent

e.

Applying ear drops before takeoff

ANS: D

Encouraging an infant to swallow reduces the pressure in the ears during descent.

DIF: Cognitive Level: Comprehension REF: 524 OBJ: 2

TOP: Barotrauma KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

4. The nurse caring for a child with infectious meningitis, would include in the care:

Select all that apply.

a.

Isolation precautions

b.

Provision of dimly lit room

c.

Observation for increasing intracranial pressure

d.

Preparation for spinal tap

e.

Seizure precautions

ANS: A, B, C, D, E

All elements of nursing care listed in the options would be part of comprehensive care of a child with meningitis.

DIF: Cognitive Level: Application REF: 531 OBJ: 12

TOP: Nursing Care of Child With Meningitis

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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